Thesis (Ph. D.) in Individualized in Adult Health Education--University of Maine, 2003. / Includes vita. Includes bibliographical references (leaves 211-229).

Thesis (Ph. D.)--University of Texas at Austin, 2003. / Vita. Includes bibliographical references. Available also from UMI Company.

Thesis (M.S.)--West Virginia University, 2004. / Title from document title page. Document formatted into pages; contains v, 51 p. Vita. Includes abstract. Includes bibliographical references (p. 36-38).

Thesis (M.D. Sc)--University of Queensland, 2002. / Includes bibliographical references.

Thesis (M.P.H.)--University of Queensland, 2002. / Includes bibliographical references.

Thesis (M. Med. Sc.)--University of Hong Kong, 2002. / Includes bibliographical references (leaves 74-83).

Thesis (Ph. D.)--Ohio State University, 2003. / Title from first page of PDF file. Document formatted into pages; contains xviii, 233 p.: ill. Includes abstract and vita. Advisor: Douglas E. Crews, Dept. of Anthropology. Includes bibliographical references (p. 209-233).

Introduction: Historically, type 2 diabetes (T2DM) has been regarded as a progressive and degenerative disease and only minority of patients can have disease remission with conventional treatment. It was noticed that gastrointestinal surgery could induce complete remission of T2DM in most of morbidly obese patients. Compared to the West, the development of bariatric and metabolic surgery is slow in Hong Kong. It is unknown whether the knowledge and attitudes of medical doctors and patients towards surgical treatment for T2DM have impacts on the development in this field. The novel procedure sleeve gastrectomy (SG) had been shown to be effective in inducing T2DM remission in obese human. Duodenal jejunal bypass (DJB) and ileal transposition (IT) were reported to be effective for ameliorating T2DM in non-obese diabetic animal model. The anti-diabetic potency of DJB and IT is unknown in comparing to SG particularly in non-obese subjects. Currently, SG is the main procedure for morbidly obese patients with or without T2DM in the authors’ institution. Aims: The aims of the present thesis were to investigate the knowledge and attitudes of medical doctors and patients toward using surgery as a treatment for T2DM, to compare the anti-diabetic effect of SG, DJB and IT in non-obese T2DM animal model, and lastly, to review of outcomes of morbidly obese patients who underwent SG in authors’ institution. Methods: Survey was conducted using questionnaire for interview of both doctors and patients to investigate their knowledge and attitudes toward surgical treatment of T2DM. The anti-diabetic effects of novel surgical procedures SG, DJB and IT were compared using non-obese T2DM animal model (Goto Kakizaki rats). The outcomes were evaluation by measuring fasting glucose and glycosylated haemoglobin (HbA1c) levels. Other parameters including alteration in gut hormones and lipid profile were also analyzed. The outcomes of morbidly obese patients who underwent laparoscopic SG in last 5 years in the authors’ institution were retrospectively reviewed. Results: The knowledge of bariatric and metabolic surgery was inadequate both in medical doctors and patients. The attitude and pattern of referral from medical doctors depends on the amount of knowledge. Patients’ attitudes were positive and they accept surgery as a treatment option for T2DM as long as they were provided with adequate information. This implies that tremendous educational works are required both for medical doctors and patients for the development of bariatric and metabolic surgery in Hong Kong. All 3 procedures (SG, DJB and IT) significantly improved glucose homeostasis and the effect was more potent and durable in DJB and IT than SG. The improved glucose homeostasis in IT was resulted from increased GLP-1 and PYY secretion (hindgut theory). In DJB, GIP, GLP-1 and PYY were raised and the anti-diabetic effect could be explained both by the foregut and hindgut theories. SG reduced the diet triglyceride absorption. DJB reduced cholesterol absorption whereas IT reduced cholesterol but increase triglyceride absorption. The outcomes of SG for T2DM for morbidly obese patients were promising. More than 90% patients had T2DM ameliorated and 70% had complete remission. SG can effectively control the body weight of morbidly obese patients. Conclusion: Education, both to doctors and patients, was crucial to overcome the potential obstacles for the development of this newly specialty. The anti-diabetic effects of DJB and IT were more potent than SG in non-obese diabetic animal model. The lipid absorption varied in different surgical procedures. Application of these procedures in non-obese T2DM patients warrants individual consideration and further investigation. SG in the authors’ institution was effective to induce T2DM remission in morbidly obese patients. / published_or_final_version / Surgery / Doctoral / Doctor of Philosophy

Background: Gestational diabetes mellitus (GDM) is carbohydrate intolerance resulting in hyperglycemia of variable severity with onset or first recognition during pregnancy. Although GDM is asymptomatic in most patients, it will lead to adverse perinatal outcomes such as macrosomia and postpartum hemorrhage, birth injury and increased cesarean section rate. Identifying populations at high risk of GDM will allow for proper interventions and may thus improve the adverse perinatal outcomes. In 2010, the International Association of Diabetes and Pregnancy Study Groups (IADPSG) developed new diagnostic criteria for GDM. Mild hyperglycemia according to the previous criteria such as the WHO criteria and NDDG criteria is now categorized as GDM by the IADPSG Criteria. However, there are more and more controversies on the effectiveness of the IADPSG Criteria since it was implemented. China has relatively high prevalence of GDM, and the prevalence will be much higher by using the IADPSG Criteria. Given the uncertainty of the effectiveness of the IADPSG Criteria, it is important to examine the potential harms or benefits of the IADPSG Criteria in China by examining the adverse perinatal outcomes. Objectives:(1) To assess the difference in pregnancy outcomes in a cohort of Chinese women before and another cohort after implementing the IADPSG Criteria.(2) To examine whether the intervention to the mild hyperglycemia group improved pregnancy outcomes. Setting: Guangzhou Women and Children’s Medical Center (GZWCMC). Methods: A historical cohort study was conducted to investigate the difference of adverse pregnancy outcomes of the GDM patients after the IADPSG Criteria was adopted in the GZWCMC. 114 pregnant women with overt diabetes and 244 pregnant women with mild hyperglycemia in 2010 were sampled from the cohort of 2010 when the IADPSG Criteria had not been applied. 121 pregnant women with overt diabetes and 195 pregnant women with mild hyperglycemia were sampled from the cohort of 2012 when the IADPSG Criteria had been applied. Data was collected from the medical records in the medical center. Comparison of adverse pregnancy outcomes between the overt diabetes patients in 2010 and in 2012 was performed to examine the variation of GDM outcomes over time. Comparison of adverse pregnancy outcomes between the mild hyperglycemic subjects in 2010 and 2012 was performed to examine the effectiveness of the interventions to the mild hyperglycemic subjects, because mild hyperglycemic subjects in 2010 did not receive interventions. Primary outcomes were large for gestational infant (LGA) and primary cesarean section. Binary logistic regression model was used to examine the differences of adverse outcomes with adjustment for potential confounders. Odds ratios (ORs) and P-values were used to demonstrate the relative risk and the significance of the results. Results: Baseline characteristics varied between the cohort of 2010 and cohort of 2012. Subjects in the 2012 cohort had lower body mass index (BMI), lower blood glucose and were diagnosed earlier. No differences of primary outcomes between the overt diabetes patients in 2010 and in 2012 were found after adjustment for maternal age, BMI, parity and gestational age at oral glucose tolerance test (OGTT). The OR for LGA and primary cesarean was 0.58 (95% confidence interval (CI):0.10-3.35, P=0.54) and 0.68 (95% CI: 0.33-1.39,P=0.29), respectively, suggesting that LGA and primary cesarean in overt diabetes patients did not vary over time. No differences of LGA and primary cesarean between the mild hyperglycemic subjects in 2010 and 2012 were observed after adjustment for maternal age, BMI, parity and gestational age at OGTT. The OR for LGA and primary cesarean section was 1.25 (95% CI: 0.46-3.40, P=0.66) and 0.78 (95% CI: 0.47-1.29, P=0.33), respectively. Compared with those with mild hyperglycemia in 2010, a lower risk for postpartum hemorrhage in those with mild hyperglycemia in 2012 was found (OR=0.05, 95% CI: 0.01-0.41). Conclusions: Our study has provided some evidence that the risks for most of the adverse pregnancy outcomes except postpartum hemorrhage, including LGA, primary cesarean, gestational hypertension, preterm birth, macrosomia and mean birth weight in pregnant women with mild hyperglycemia did not have significant differences before and after the IADPSG Criteria was adopted. Given the small sample size of the current study, we have yet to draw a definite conclusion that intervention to pregnant women with mild hyperglycemia improved adverse pregnancy outcomes from the results. Further large studies are needed to examine both the benefits and harms of implementing the IADPSG Criteria. / published_or_final_version / Public Health / Master / Master of Public Health

Objective: To review in the literature on the association between diabetes and background exposure of dioxins among general population. Method: Systematic review on studies the association of background dioxin exposure and diabetes among general population, published from January 1960 to July 2013 in PubMed, and from January 1979 to July 2013 in China National Knowledge Infrastructure (CNKI). Result: A total of nine articles (including seven cross-sectional studies, one longitudinal study and one cohort study) out of 111 articles from PubMed and 5 articles from CNKI were included in the systematic review. Five out of nine studies found a positive association between background exposure to dioxins or dioxins-like compounds and the risk of diabetes whilst two studies reported an inverse association between dioxins and insulin concentrations or IGF-I serum levels. Two studies reported positive significant relation of dioxins and diabetes in women but not in men. Discussion: Based on this systematic review, the association of background dioxins exposure and diabetes among general population remains unclear. Given the crosssection design of the studies, causal relation between dioxin exposure and diabetic risks cannot be drawn. / published_or_final_version / Public Health / Master / Master of Public Health