Abstract Type 2 diabetes mellitus is a disease that has trebled in incidence over the last 25 years, affecting both adults and increasingly children. The rapid increase of the disease mirrors the gradients of social position and income distribution, and parallels the accelerated environmental changes witnessed with the rise of neoliberal capitalism. This research situates neoliberal capitalism as a collection of political and economic policies that form an ideology suited to protect discrete elite interests. The current ideology has permeated all social aspects of society, including education and healthcare. Therefore, it is argued that the practice of healthcare and the education of healthcare students are shaped by the sociopolitical environment in which they exist. Ten best-selling postsecondary textbooks in pathology, pathophysiology, and disease processes were selected for content analysis to determine if the interpretation of type 2 diabetes in pathophysiology textbooks reflects neoliberal thinking. The data were interpreted within the tradition of critical discourse analysis and theoretically enriched using Foucault’s descriptions of governmentality, biopolitics, and discursive formations. The results indicate that notions consistent with neoliberal capitalism permeate pathology textbooks in the understandings of type 2 diabetes. Consistent with how neoliberal thought embodies and explicates social conditions, type 2 diabetes is described in a way that stresses iii self-responsibility and culpability for falling ill. The texts also impart the importance of biomedical industry interventions for the treatment of the sick and the surveillance of the healthy. Finally, in a way that substantiates the degradation of the environment and retrenchment of social welfare policies, the textbooks fail to make any reference to the ecological factors that contribute to type 2 diabetes, including urbanisation and the propagation of food deserts, environmental toxins, income inequality, the steepening of the social gradient, and the deleterious effects of globalisation on human nutrition.

Type 2 diabetes mellitus (T2DM) has become a major health problem worldwide. The St. Vincent declaration emphasized the urgent need to improve the epidemiological knowledge of this disease in Europe. Within Europe, research on the link between socioeconomic position (SEP) and type 2 diabetes is scarce. The objective of this thesis was to conduct an extensive review of the current literature on socioeconomic inequalities in type 2 diabetes within European countries, while analyzing the relationship between, incidence, prevalence and mortality due to T2DM and SEP. In addition, we also analyzed trends on SEP inequalities in the prevalence of T2DM in Spain (1983-2006). Finally, we also assessed the appropriate use of health surveys with self-reported diagnosis in order to further analyze the relation between SEP and T2DM. Different sources of information were used throughout the study. The systematic review was completed using the PUBMED database while the empirical studies used data of two European projects, the EUROTHINE, SHARE and the Spanish National Health Survey (study of trends in SEP inequalities in T2DM) along with the Catalonia health surveys (study of validation). The thesis consists of 5 papers that attempt to respond to the different objectives. The studies included in this thesis suggest that socio-economic position (SEP) inequalities affect the incidence, prevalence and mortality by T2DM in Europe. These SEP inequalities are partly explained for body mass index, diet and physical activity. Moreover, these inequalities seemed to have remained constant or increased over time. Finally, health interview surveys with self-reported T2DM seems to be a good instrument to evaluate SEP inequalities in T2DM. / La Diabetis Mellitus Tipus 2 (DM2) ha esdevingut un dels principals problemes de salut a nivell mundial. La declaració de ST VINCENT emfatitzava la necessitat i la urgència de millorar-ne el coneixement epidemiològic a nivell Europeu. Els estudis a nivell europeu sobre les desigualtats per Posició Socioeconòmica (PSE) en la DM2 eren força escassos. L’objectiu d’aquesta tesi era fer una revisió extensa dels estudis publicats sobre desigualtats per PSE en la DM2 a Europa, així com analitzar la relació entre la incidència, la prevalença i la mortalitat per DM2 i la PSE. Un altre objectiu també era analitzar la tendència de les desigualtats per PSE en la prevalença de DM2 a Espanya (1983-2006). Finalment, com a objectiu també hi figurava el valorar l’ús adequat de les enquestes de salut amb auto - declaració de DM2 per tal d’avaluar les desigualtats per PSE en la DM2. Per tal de dur a terme els objectius es van emprar diferents fonts d’informació. Per tal de dur a terme la revisió sistemàtica es va emprar la base de dades de PUBMED mentre que pels estudis empírics es van utilitzar les dades de dos projectes europeus com són el projecte EUROTHINE i el SHARE i les enquestes nacionals de salut d’Espanya (per la tendència de diabetis) i de Catalunya (per la validació). La tesi consta de 5 articles que intenten donar resposta als diferents objectius. Els estudis inclosos en aquesta tesi suggereixen que existeixen desigualtats per posició socioeconòmica (SEP) en la DM2, tant en la incidència, en la prevalença com en la mortalitat a Europa. Aquestes desigualtats per PSE s’expliquen en part per l’índex de massa corporal, la dieta o l’activitat física. A més a més, aquestes desigualtats sembla que s’han mantingut constants o han crescut al llarg del temps. Finalment, s’ha vist que les enquestes de salut amb la pregunta d’auto-declaració de la diabetis són un bon instrument per avaluar les desigualtats per PSE en la DM2.

Type 2 diabetes is a global health problem. Evidence indicates that type 2 diabetes can lead to serious complications, such as a cardiac event, which usually require critical nursing care. Patients with type 2 diabetes and with a history of cardiac disease are at greater risk of a further cardiac event requiring readmission to hospital. Evidence indicates that improved diabetes management assists patients with type 2 diabetes to manage their condition efficiently, reduces risks of a further cardiac event, and therefore reduces hospitalisations. However, there is limited information found regarding a diabetes management program specifically for patients who have already had cardiac complications. Difficulties in developing patients' skills in managing and modifying their daily lives also present a challenge to coronary care staff. Therefore, there is a real need to develop a special diabetes management program for patients with diabetes who have experienced a critical cardiac event, which will be commenced in the Coronary Care Unit (CCU). The aim of this research is to gain a greater understanding of the characteristics, secondly to obtain in-depth understanding of needs and experiences of patients with type 2 diabetes hospitalised for a critical cardiac event. A further aim is to develop and pilot test a diabetes management program, specific to the patients with diabetes in the context of the CCU. The design of this research employed three studies: Study I was an exploratory study, which obtained patients' demographic and disease characteristics from the hospital records of all patients with diabetes admitted to the CCU of one public hospital between 1 January 2000 to 31 December 2003. Study II used a qualitative interpretative approach and aimed to gain an in-depth understanding of the perspectives of patients with type 2 diabetes who have experienced a critical cardiac event in managing their everyday lives with both diabetes and cardiac conditions. Study III included two parts. The first utilised the information from the first two studies and the literature (self-efficacy theory) to develop a diabetes self-management program specifically for patients with diabetes who have had a critical cardiac event. The second part pilot tested the newly-developed diabetes self-management program for patients with diabetes admitted to CCU following a critical cardiac event. The pilot study used a randomised controlled trial research design to evaluate the efficacy of the program. Study I collected data from one hospital's records retrospectively from 2000 to 2003. The results of Study I showed there were 233 (14.7%) patients admitted to CCU that had diabetes out of the total 1589 CCU admissions during the study period. More than 22% of CCU patients with diabetes were readmitted to hospital within 28 days, compared to 6% of CCU patients without diabetes. Patients with diabetes who had a longer CCU stay were more likely to be readmitted. These results indicate that a significant proportion of a CCU population had type 2 diabetes and is more likely to be readmitted to hospital. Study II used an interpretive approach comprising open-ended interviews to collect data from patients with type 2 diabetes experiencing a cardiac event who had a CCU admission in 2000-2003. The findings revealed that patients with diabetes who had a critical cardiac event experienced considerable feelings of hopelessness and fatigue. Patients also had concerns in the areas of self-confidence and confidence in health professionals. Patients indicated that greater self-confidence and confidence in health professionals would help their ability to manage their daily lives. Therefore, it is very important that intervention programs for these at-risk patients need to improve patients' confidence levels, and reduce their feelings of hopelessness and fatigue. The information gathered from Study I and Study II provided important insight into the development of an effective diabetes self-management specifically designed for patients with type 2 diabetes following a critical cardiac event, which is presented in Study III in this thesis. Study III also provided a preliminary evaluation of the newly developed program. The evaluation used a randomised controlled trial research design for the new program and the current educational program provided in the CCU. The results of the program indicate the feasibility of commencing the new diabetes self-management program in the CCU, and to be continued in wards or at home. The results also showed significant improvements in patients' knowledge in the experimental group, but not in other outcome variables (self-efficacy, vitality and mental health levels). However, as a small sample size was used in this pilot study, a larger study is needed to ensure adequate testing of the intervention. Future research is also recommended to incorporate the new diabetes self-management program into the current cardiac education program. Staff's further professional development in providing such a program also needs to be examined. Improvements in quality of care, and patients' quality of life are expected in the future.

Adiponectin is an adipose-derived protein (adipocytokine) that is secreted by adipose tissue. It has insulin-sensitizing, anti-inflammatory and cardio-protective properties, and is thought to be protective against obesity-related diseases such as type 2 diabetes. Humans and cats are two species that commonly develop type 2 diabetes associated with insulin resistance, impaired beta cell function and spontaneous islet amyloid deposition. The domestic cat (Felis catus) has recently been proposed as an animal model for human type 2 diabetes. However, little is known about the physiology of adiponectin in cats. Therefore, we set out to investigate the association of adiponectin profiles with dietary carbohydrate intake, feeding, body weight, fat mass, and insulin sensitivity in healthy young adult cats (n=32; 2-4 years old; gender ratio 1:1; body condition 4-5/9). Cats were fed a moderate carbohydrate diet (37% ME) at maintenance energy requirements for four weeks. Cats were then assigned to either receive a low (19% ME) or high (52% ME) carbohydrate diet and fed at maintenance energy requirements for another four weeks, followed by ad-libitum feeding for eight weeks to facilitate weight gain. Adiponectin profiles including total circulating adiponectin and its distribution [low molecular weight (LMW) and high molecular weight (HMW) adiponectin], and proportion of adiponectin that is HMW (SA) were measured by ELISA and velocity sedimentation using sucrose gradients, followed by Western blotting, respectively. We demonstrated inter-animal variation in total adiponectin concentration at baseline (0.6 to 15.0 g/mL), with the adiponectin present in both LMW and HMW forms. Feeding with a high carbohydrate diet for four weeks at maintenance energy requirements resulted in increased total adiponectin concentration, which was associated with an increased concentration of LMW adiponectin. In contrast, feeding with a low carbohydrate diet for four weeks at maintenance energy requirements resulted in increased concentration of HMW adiponectin, decreased LMW adiponectin concentration, and increased SA, without a change in total adiponectin concentration. In cats fed the high carbohydrate diet, total adiponectin and HMW adiponectin concentrations become lower at six hours after feeding, as compared to the fasting concentrations. This phenomenon was not observed in cats fed a low carbohydrate diet, indicating a diet-dependent postprandial effect. There was no effect of gender on any of the adiponectin profiles in cats. Unlike other studies in humans and mice in which adiponectin concentrations decreased as fat mass increased, our data indicate that a moderate weight gain achieved by ad libitum feeding of a low carbohydrate diet for eight weeks correlated with increased adiponectin concentrations. Total adiponectin concentration (mirrored by HMW adiponectin) was positively correlated with body weight gain and fat mass gain (but not absolute fat mass) in our overweight cats. Furthermore, the fat mass-related increases in plasma adiponectin over eight weeks correlated with insulin sensitivity (higher adiponectin concentration corresponded to greater insulin sensitivity in overweight cats). These data hint at the possibility that in overweight animals, adiponectin is similar to other adipokines that rise concomitantly with increased of moderate fat mass gain and thus increases insulin sensitivity. Overall, the knowledge in this study therefore provides useful information to veterinarians and cat food manufacturers, and forms a foundation for future studies to extend our knowledge of adiponectin in cats. Data gathered in cats may also be applicable to humans and could therefore inform research using cats as an animal model of human obesity and type 2 diabetes.

[Formulae and special characters can only be approximated here. Please see the pdf version of the Abtract for an accurate reproduction.] Type 2 diabetes at least doubles the risk of cardiovascular disease. This can partly be explained by the increased prevalence of risk factors such as hypertension, dyslipidaemia and obesity. However, the underlying abnormality of insulin resistance and the presence of more recently identified risk factors including endothelial dysfunction, increased inflammation, and increased oxidative stress might also contribute towards the heightened cardiovascular risk. Fish oil, which contains eicosapentaenoic acid (EPA, 20:5 n-3), has wide-ranging beneficial effects on these and other abnormalities, and has reduced cardiovascular mortality in secondary prevention studies. Animal and human studies have recently established that in addition to EPA, docosahexaenoic acid (DHA, 22:6 n-3) also has beneficial effects, and furthermore, may have less detrimental effects than EPA on glycaemic control which has worsened in some fish and fish oil studies involving Type 2 diabetic subjects. Study 1 : This intervention study aimed to determine the independent effects of EPA and DHA on cardiovascular risk factors and glycaemic control in individuals with Type 2 diabetes receiving treatment for hypertension. In a double-blind placebo-controlled trial of parallel design, 59 subjects in good to moderate glycaemic control (HbA1c < 9%) were recruited from media advertising and randomised to 4 g/day of EPA, DHA or olive oil (placebo) for 6 weeks. Thirty-nine men and 12 post-menopausal women aged 61.2±1.2 yrs completed the study. Relative to placebo, and with Bonferroni adjustments for multiple comparisons, serum triglycerides fell by 19% (p=0.022) and 15% (p=0.022) in the EPA and DHA groups respectively. There were no changes in serum total cholesterol, or LDL- and HDL-cholesterol, although HDL2-cholesterol increased 16% with EPA (p=0.026) and 12% with DHA (p=0.05). HDL3-cholesterol fell by 11% (p=0.026) with EPA supplementation and LDL particle size increased by 0.26±0.10 nm (p=0.02) with DHA. Urinary F2-isoprostanes, an in-vivo marker of oxidative stress was reduced by 19% following EPA (p=0.034) and by 20% following DHA. DHA but not EPA supplementation reduced collagen-stimulated platelet aggregation (16.9%, p=0.05) and thromboxane release (18.8%, p=0.03), but there were no significant changes in PAF-stimulated platelet aggregation. Fasting glucose rose by 1.40±0.29 mmol/l (p=0.002) following EPA and 0.98±0.29 mmol/l (p=0.002) following DHA. Neither EPA nor DHA had any significant effect on HbA1c, fasting serum insulin or C-peptide, insulin sensitivity, stimulated insulin secretion, 24-hr ambulatory blood pressure and heart rate, markers of inflammation, and fibrinolytic or vascular function. Study 2 : This study aimed to examine the influence and causes of increased inflammation on vascular function in subjects recruited for Study 1. Compared with healthy controls (n=17), the diabetic subjects (n=29) had impaired flow-mediated dilatation (FMD) (3.9±3.0% vs 5.5±2.4%, p=0.07) and glyceryl-trinitrate mediated dilatation (GTNMD) (11.4±4.8% vs 15.4±7.1%, p=0.04) of the brachial artery. They also had higher levels of the inflammatory markers C-reactive protein (2.7±2.6 mg/l vs 1.4±1.1 mg/l, p=0.03), fibrinogen (3.4±0.7 g/l vs 2.7±0.3 g/l, p<0.001) and tumor necrosis factor-alpha (20.9±13.4 pg/l vs 2.5±1.7 pg/l, p<0.001). In diabetic subjects, after adjustment for age and gender, leukocyte count was an independent predictor of FMD (p=0.02), accounting for 17% of total variance. Similarly, leukocyte count accounted for 23% (p<0.001) and IL-6 for 12% (p=0.03) of variance in GTNMD. Von Willebrand factor, a marker of endothelial cell activation was correlated with leukocyte count (r=0.38, p=0.04), FMD (r=-0.35, p=0.06) and GTNMD (r=-0.47, p=0.009), whilst P-selectin, a marker of platelet activation was correlated with fibrinogen (r=0.58, p=0.001). Conclusion : EPA and DHA have similar beneficial effects on triglycerides, HDL2 cholesterol and oxidative stress in individuals with Type 2 diabetes and hypertension. However, DHA also increases LDL particle size and reduces collagen-stimulated platelet aggregation and thromboxane release, thus offering more potential than EPA as an anti-thrombotic agent. The beneficial effects of both oils were potentially offset by deterioration in glycaemic control. Neither oil affected blood pressure or vascular function. Longer-term studies with major morbidity and mortality as the primary outcome measures are required to assess the overall benefits and risks of EPA and DHA. The cross-sectional observations from Study 2 are consistent with the hypothesis that impaired vascular function in individuals with Type 2 diabetes and hypertension is at least in part secondary to increased inflammation, with associated endothelial and platelet activation.

Lic.-avh. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 2 uppsatser.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2005. / Härtill 5 uppsatser.

Thesis (Ph. D.)--University of Washington, 2004. / Vita. Includes bibliographical references (leaves 183-207).

Made available in DSpace on 2015-05-14T12:56:01Z (GMT). No. of bitstreams: 1 parte 1.pdf: 286274 bytes, checksum: 680b6739458bd32bbb943941a13dc712 (MD5) Previous issue date: 2007-12-05 / Coordenação de Aperfeiçoamento de Pessoal de Nível Superior - CAPES / Diabetes mellitus is an endocrine disease, which causes alteration in assimilation, metabolism and balance of the blood glucose concentration. It is believed that the high level of blood glucose is linked to the development of buccal alterations; however, there is some controversy in the studies that aim to compare the concentration of blood and salivary glucose in diabetic patients. The objective of this paper is to comparatively evaluate the concentration of blood and salivary glucose as well as the salivary flow and xerostomia in type 2 diabetic and non-diabetic patients. Eighty adult subjects of both sexes have been selected, being 40 adults diabetic of the experimental type and 40 adults non-diabetic belonging to control. The total in-rest and stimulated salivary flow has been determined as well as the concentration of peripheral blood and salivary glucose. Descriptive analysis was carried out and Mann-Whitney and qui-square tests were applied considering significant values of p<0,05. The average value of salivary glucose in diabetic patients was 14,03±16,76 mg/dl and in the control group, 6,35±6,02 mg/dl, with p= 0,036. The capillary blood glucose in diabetic patients presented an average value equivalent to 213,23±87,98 mg/dl and, in non-diabetic patients it was equivalent to 99,15±13,72 mg/dl, with p= 000. The average value for the in-rest salivary flow was 0,21±0,16 ml/min in diabetic patients and 0,33±0,20 ml/min in the control group with p= 0,002. The stimulated salivary flow was lower in the group of diabetic patients, with an average of 0,63±0,43 ml/min, in relation to the control group, which presented an 1,20±0,70 ml/min average, with p= 0,00. Out of the diabetic patients, 45% had hyposalivation contrasting to 2,5% out of the non-diabetic patients, with p=0,00. Xerostomia was reported in 12,5% of diabetic patients and 5% of non-diabetic patients, with p=0,23. We can conclude that the salivary glucose concentration was significantly higher in the experimental group and that there was no correlation between the salivary and blood glucose concentration in diabetic patients. The total salivary flows were significantly reduced in diabetic patients and there was no significant difference as to the presence of xerostomia in both groups. / O diabetes mellitus é uma doença endócrina que causa alteração na assimilação, metabolismo e equilíbrio da concentração da glicose sanguínea. Acredita-se que o elevado nível de glicose sangüínea esteja associado ao desenvolvimento de alterações bucais, porém, existe controvérsia nos estudos que objetivam comparar a concentração de glicose sanguínea e salivar em pacientes diabéticos. O objetivo do presente estudo foi avaliar comparativamente a concentração de glicose salivar e sanguínea, o fluxo salivar e a xerostomia em pacientes diabéticos tipo 2 e não diabéticos. Foram selecionados 80 indivíduos adultos, de ambos os sexos, sendo 40 adultos diabéticos pertencentes ao experimental e 40 adultos não diabéticos pertencentes ao controle. Determinou-se o fluxo salivar total em repouso e estimulado, a concentração de glicose salivar e sanguínea periférica. Realizou-se análise descritiva e aplicaram-se testes de Mann-Whitney e qui-quadrado, considerando significantes valores de p<0,05. O valor médio de glicose salivar nos diabéticos foi 14,03±16,76 mg/dl e, no grupo controle, 6,35±6,02 mg/dl, com p= 0,036. A glicose sanguínea capilar nos diabéticos apresentou valor médio equivalente a 213,23±87,98 mg/dl e, nos não diabéticos, a 99,15±13,72 mg/dl, com p= 000. O valor médio para o fluxo salivar em repouso foi de 0,21±0,16 ml/min nos diabéticos e 0,33±0,20 ml/min no grupo controle, com p= 0,002. O fluxo salivar estimulado foi inferior no grupo dos diabéticos, com média de 0,63±0,43 ml/min, em relação ao grupo controle que apresentou média 1,20±0,70 ml/min, com p= 0,00. Entre os diabéticos, 45% apresentaram hipossalivação, contrastando com os 2,5% entre os não diabéticos, com p=0,00. A xerostomia foi referida em 12,5% dos diabéticos e 5% dos não diabéticos, com p=0,23. Pode-se concluir que concentração de glicose salivar foi significativamente maior no grupo experimental e que não houve correlação entre a concentração da glicose salivar e glicose sanguínea nos indivíduos diabéticos. Os fluxos salivares totais mostraram-se significativamente reduzidos nos pacientes diabéticos e não houve diferença significativa quanto à presença de xerostomia em ambos os grupos.

Bakgrund: Typ 2 diabetes är ett globalt hälsoproblem som kan ge allvarliga komplikationer. Livsstilsförändringar inom fysisk aktivitet och kost kan minska risken för komplikationer och leda till viktnedgång hos patienter med övervikt eller fetma. Motiverande samtal (MI) har som syfte att öka patientens motivation. MI används som ett hjälpmedel inom hälso-och sjukvården för att motivera patienter till livsstilsförändring. Inom rådgivning har sjuksköterskan en viktig hälsofrämjande arbetsroll att motivera patienter till livsstilsförändringar avseende ökad fysisk aktivitet och kostvanor. Syfte: Att sammanställa aktuell forskning om betydelsen av MI avseende livsstilsförändringar hos patienter med typ 2 diabetes. Metod: Designen är en litteraturöversikt som grundar sig på 15 vetenskapliga artiklar. Datainsamlingen har genomförts via PubMed och Cinahl. Resultat: Tre huvudkategorier med tillhörande subkategorier framtogs. Huvudkategorierna var: Betydelsen av MI avseende kost, betydelsen av MI avseende viktnedgång och betydelsen av MI avseende fysisk aktivitet. Konklusion: Samtalsmetoden MI gav olika resultat avseende kost och fysisk aktivitet samt viktnedgång. En gemensam faktor som identifierades var att MI gav förståelse för deltagarnas aktuella livsstil tillsammans med ökad motivation. / Background: Type 2 diabetes is a global health problem that can cause complications. Lifestyle changes in physical activity and diet can reduce the risk of complications and lead to weight loss in patients with overweight or obesity. Motivational Interviewing (MI) aims to increase motivation for behavioral change. MI can be used in healthcare counseling to motivate patients for lifestyle change. Aim: To compile current research about the importance of MI regarding lifestyle changes in patients with type 2 diabetes. Methods: The design is a literature review based on 15 scientific articles. The data collection was made in PubMed and Cinahl databases. Results: Three main categories with subcategories were implemented. The main categories were: The importance of MI regarding diet, the importance of MI regarding weight loss and the importance of MI regarding physical activity. Conclusions: The communication model MI gave different results regarding diet and physical activity as well as weight loss. A common factor identified was that MI gave an understanding of the participants' acute lifestyle together with increased motivation.