Background Several prospective studies have evaluated the association between body mass index (BMI) and death risk among patients with diabetes; however, the results have been inconsistent. Methods and Results We performed a prospective cohort study of 19,478 African American and 15,354 white patients with type 2 diabetes. Cox proportional hazards regression models were used to estimate the association of different levels of BMI stratification with all-cause mortality. During a mean follow up of 8.7 years, 4,042 deaths were identified. The multivariable-adjusted (age, sex, smoking, income and type of insurance) hazard ratios (HRs) for all-cause mortality associated with BMI levels (18.5–22.9, 23–24.9, 25–29.9, 30–34.9 [reference group], 35–39.9, and ≥40 kg/m2) at baseline were 2.12 (95% confidence interval [CI] 1.80–2.49), 1.74 (1.46–2.07), 1.23 (1.08–1.41), 1.00, 1.19 (1.03–1.39), and 1.23 (1.05–1.43) for African Americans, and 1.70 (1.42–2.04), 1.51 (1.27–1.80), 1.07 (0.94–1.21), 1.00, 1.07 (0.93–1.23), and 1.20 (1.05–1.38) for whites, respectively. When stratified by age, smoking status, patient types or use of anti-diabetic drugs, a U-shaped association was still present. When BMI was included in the Cox model as a time-dependent variable, the U-shaped association of BMI with all-cause mortality risk did not change. Conclusions The current study indicated a U-shaped association of BMI with all-cause mortality risk among African American and white patients with type 2 diabetes. A significantly increased risk of all-cause mortality was observed among African Americans with BMI<30 kg/m2 and BMI ≥35 kg/m2, and among whites with BMI<25 kg/m2 and BMI ≥40 kg/m2 compared with patients with BMI 30–34.9 kg/m2.

This systematic review examines the characteristics and psychometric properties of the instruments used to assess self-care behaviors among persons with type 2 diabetes. Electronic databases were searched for relevant studies published in English within the past 20 years. Thirty different instruments were identified in 75 articles: 18 original instruments on type 2 diabetes mellitus self-care, 8 translated or revised version, and 4 not specific but relevant to diabetes. Twenty-one instruments were multidimensional and addressed multiple dimensions of self-care behavior. Nine were unidimensional: three focusing exclusively on medication taking, three on diet, one on physical activity, one on self-monitoring of blood glucose, and one on oral care. Most instruments (22 of 30) were developed during the last decade. Only 10 were repeated more than once. Nineteen of the 30 instruments reported both reliability and validity information but with varying degrees of rigor. In conclusion, most instruments used to measure self-care were relatively new and had been applied to only a limited number of studies with incomplete psychometric profiles. Rigorous psychometric testing, operational definition of self-care, and sufficient explanation of scoring need to be considered for further instrument development.

BackgroundThe Diabetes Impact Study followed up a large national population-based screening study to estimate the use of and expenditures for medical care caused by diabetes in China and to ascertain the use and cost of essential basic medicines and care.MethodsIn 2009–10, the study team interviewed 1482 adults with diabetes and 1553 adults with glucose tolerance in the normal range from population-based random samples at 12 sites in China. The response rate was 67%.FindingsAfter adjusting for age, sex, and urban/rural location, people with diabetes received 1.93 times more days of inpatient treatment, 2.40 times more outpatient visits, and 3.35 times more medications than people with normal glucose tolerance (all p<0.05). Adjusted expenditures for medical care were 3.38 times higher among people with diabetes than among people with normal glucose tolerance (p<0.01, unadjusted 3.97). Persons who were diagnosed with ≥10 years prior to the survey paid 3.75 times as much for medical care as those with ≤5 years of diagnosed diabetes. Among persons with diabetes, 45.2% took medication to control blood sugar, 21.1% took an antihypertensive medicine, 22.4% took daily aspirin, and 1.8% took a statin. Over the three months before the interview, 46.1% of persons with diabetes recalled seeing a doctor, 48.9% recalled a blood pressure measurement, and 54.5% recalled a blood sugar test. Over the year preceding the interview, 32.1% recalled a retinal screening and 17.9% recalled a foot examination.ConclusionsIn China, health care use and costs were dramatically higher for people with diabetes than for people with normal glucose tolerance and, in relative terms, much higher than in industrialized countries. Low-cost generic medicines that would reduce diabetes expenditures were not fully used.

OBJECTIVEClinical trials to date have not provided definitive evidence regarding the effects of glucose lowering with coronary heart disease (CHD) risk among diabetic patients.RESEARCH DESIGN AND METHODSWe prospectively investigated the association of HbA1c at baseline and during follow-up with CHD risk among 17,510 African American and 12,592 white patients with type 2 diabetes.RESULTSDuring a mean follow-up of 6.0 years, 7,258 incident CHD cases were identified. The multivariable-adjusted hazard ratios of CHD associated with different levels of HbA1c at baseline (<6.0 [reference group], 6.0–6.9, 7.0–7.9, 8.0–8.9, 9.0–9.9, 10.0–10.9, and ≥11.0%) were 1.00, 1.07 (95% CI 0.97–1.18), 1.16 (1.04–1.31), 1.15 (1.01–1.32), 1.26 (1.09–1.45), 1.27 (1.09–1.48), and 1.24 (1.10–1.40) (P trend = 0.002) for African Americans and 1.00, 1.04 (0.94–1.14), 1.15 (1.03–1.28), 1.29 (1.13–1.46), 1.41 (1.22–1.62), 1.34 (1.14–1.57), and 1.44 (1.26–1.65) (P trend <0.001) for white patients, respectively. The graded association of HbA1c during follow-up with CHD risk was observed among both African American and white diabetic patients (all P trend <0.001). Each one percentage increase of HbA1c was associated with a greater increase in CHD risk in white versus African American diabetic patients. When stratified by sex, age, smoking status, use of glucose-lowering agents, and income, this graded association of HbA1c with CHD was still present.CONCLUSIONSThe current study in a low-income population suggests a graded positive association between HbA1c at baseline and during follow-up with the risk of CHD among both African American and white diabetic patients with low socioeconomic status.

Background: Mobile health interventions may support risk factor management and are readily scalable in healthcare systems. We aim to evaluate the efficacy of a text messaging–based intervention to improve glycemic control in patients with coronary heart disease and diabetes mellitus in China. Methods and Results: The CHAT-DM study (Cardiovascular Health and Texting-Diabetes Mellitus) was a parallel-group, single-blind, randomized clinical trial that included 502 patients with both coronary heart disease and diabetes mellitus from 34 hospitals in China. The intervention group (n=251) received 6 text messages per week for 6 months in addition to usual care. Messages were theory driven and culturally tailored to provide educational and motivational information on glucose monitoring, blood pressure control, medication adherence, physical activity, and lifestyle. The control group (n=251) received usual care and 2 thank you messages per month. The primary outcome was change in glycated hemoglobin (HbA 1C [hemoglobin A 1C ]) from baseline to 6 months. Secondary outcomes were change in proportion of patients achieving HbA 1C <7%, fasting blood glucose, systolic blood pressure, LDL (low-density lipoprotein) cholesterol, body mass index, and physical activity from baseline to 6 months. The end points were assessed using analyses of covariance. The follow-up rate was 99%. When compared with control group at 6 months, the intervention group had a greater reduction in HbA 1C (−0.2% versus 0.1%; P =0.003) and a greater proportion of participants who achieved HbA 1C <7% (69.3% versus 52.6%; P =0.004). Change in fasting blood glucose was larger in the intervention group (between-group difference: −0.6 mmol/L; 95% CI, −1.1 to −0.2; P =0.011), but no other outcome differences were observed. Nearly all participants reported that messages were easy to understand (97.1%) and useful (94.1%). Conclusions: A text message intervention resulted in better glycemic control in patients with diabetes mellitus and coronary heart disease. While the mechanism of this benefit remains to be determined, the results suggest that a simple, culturally sensitive mobile text messaging program may provide an effective and feasible way to improve disease self-management. Clinical Trial Registration: URL: http://www.clinicaltrials.gov . Unique identifier: NCT02883842.

The association of estimated GFR with cardiovascular diseases risk among type 2 diabetes patients was unclear. We prospectively investigated the race-specific association of estimated GFR with the risk of coronary heart disease and stroke among 11 940 White and 16 451 African American patients. During mean follow up of 6.1–6.8 years, 6 647 coronary heart disease and 2 750 stroke incident cases were identified. Age- and sex-adjusted hazard ratios of coronary heart disease associated with baseline estimated GFR (≥90, 75–89, 60–74, 30–59, and 15–29 mL/min/1.73 m2) were 1.00, 1.04 (95% CI 0.95–1.14), 1.13 (1.02–1.26), 1.37 (1.22–1.53), and 2.07 (1.58–2.71) (Ptrend<0.001) for African Americans, and 1.00, 1.09 (0.99–1.19), 1.10 (0.99–1.21), 1.31 (1.18–1.46), and 2.18 (1.66–2.85) (Ptrend<0.001) for whites, respectively. Significantly increased stroke risk was observed among both African American and white participants with estimated GFR<60 mL/min/1.73 m2. When using the updated mean values of estimated GFR, these significant associations became stronger. Participants with mildly decreased estimated GFR (60–89 mL/min/1.73 m2) during follow-up were also at significantly higher risk of coronary heart disease and stroke. The present study demonstrated that even mildly reduced estimated GFR at baseline (<75 mL/min/1.73 m2) and during follow-up (<90 mL/min/1.73 m2) increased risk of incident coronary heart disease and stroke among both African American and white type 2 diabetes patients.

Aims/hypothesis Sex differences in macrovascular disease, especially in stroke are observed across studies of epidemiology. We studied a large sample of patients with type 2 diabetes to better understand the relationship between glycemic control and stroke risk. Methods We prospectively investigated the sex-specific association between different levels of HbA1c and incident stroke risk among 10,876 male and 19,278 female patients with type 2 diabetes. Results During a mean follow up of 6.7 years, 2,949 incident cases of stroke were identified. The multivariable-adjusted hazard ratios (HRs) of stroke associated with different levels of HbA1c at baseline (<6.0%, 6.0–6.9% [reference group], 7.0–7.9%, 8.0–8.9%, 9.0–9.9%, and ≥10.0%,) were 0.96 (95% confidence interval [CI] 0.80, 1.14), 1.00, 1.04 (0.85, 1.28), 1.11 (0.89, 1.39), 1.10 (0.86, 1.41), and 1.22 (0.92, 1.35) (P trend =0.66) for men, and 1.03 (0.90, 1.18), 1.00, 1.09 (0.94, 1.26), 1.19 (1.00, 1.42), 1.32 (1.09, 1.59), and 1.42 (1.23, 1.65) (P trend <0.001) for women, respectively. The graded association of HbA1c during follow-up with stroke risk was observed among women (P trend=0.066). When stratified by race, with glucose-lowering agents or not, this graded association of HbA1c with stroke was still present among women. When stratified by age, the adjusted HRs were significantly higher in women older than 55 years compared to younger women. Conclusions/interpretation The current study suggests a graded association between HbA1c and the risk of stroke among women with type 2 diabetes. Poor control of blood sugar has a stronger effect in diabetic women older than 55 years.

Aims To assess the efficacy and safety of twice‐daily insulin degludec/insulin aspart (IDegAsp) versus biphasic insulin aspart 30 (BIAsp 30) twice daily, both ± metformin, in Chinese adults ( N = 543) with type 2 diabetes (T2D) inadequately controlled on premixed/self‐mixed or basal insulin ± metformin. Materials and methods We conducted a 26‐week, phase III, open‐label, treat‐to‐target, 2:1 randomized trial. Hierarchical testing was used with non‐inferiority of glycated haemoglobin (HbA1c) change from baseline to week 26 as the primary endpoint and superiority for the confirmatory secondary endpoints which were as follows: change from baseline in fasting plasma glucose (FPG); nocturnal confirmed hypoglycaemic episodes (12:01–5:59 am , inclusive); total confirmed hypoglycaemic episodes (severe or plasma glucose <3.1 mmol/L with/without symptoms); body weight; and percentage of responders (HbA1c <53 mmol/mol [<7.0%]) without confirmed hypoglycaemic episodes. Results Non‐inferiority for change from baseline to week 26 in HbA1c and superiority of IDegAsp twice daily versus BIAsp 30 twice daily for change in FPG, nocturnal confirmed and total confirmed hypoglycaemic episodes, was demonstrated. Estimated rates of nocturnal confirmed and total confirmed hypoglycaemic episodes were 47% and 43% lower, respectively, with IDegAsp twice daily versus BIAsp 30 twice daily. Superiority for change in body weight was not confirmed. Participants were more likely to reach the HbA1c goal of <53 mmol/mol (<7.0%) without confirmed hypoglycaemia with IDegAsp twice daily versus BIAsp 30 twice daily by trial end. No new safety signals were identified. Conclusions The efficacy and safety of IDegAsp in Chinese patients with T2D was demonstrated, confirming results from international trials.