published_or_final_version / Medicine / Master / Master of Philosophy

Non-insulin diabetes mellitus (NIDDM) is a major health problem affecting U.S. Mexicans. A population of Southwestern Arizona, near the U.S.-Mexico border, was studied to assess the biocultural environment in which disease develops, and to determine risk factors affecting the population. This geographic area is home to a high percentage of farmworkers of Mexican origin or ancestry. A global overview of macro- and micro-level issues was used to provide the context in which the population lives, and where the disease emerges and is maintained. The discussion of historical, economic, demographic, and social issues provide the background for the understanding of the natural and the social environments. Anthropological methods and techniques were used to assess and analyze numerous factors to determine the most useful for the identification of NIDDM risk. Methods used for data gathering included anthropometric measurements, survey instruments, ethnographic interviews, life history, and participant observation. Fifty-seven households participated in the study. A total of 212 subjects were measured; a sub-sample of 79 adults was also interviewed. The study identified 17 diabetics (12 females, 5 males). Prevalence of NIDDM for the sampled population was calculated at 8.2 percent. The rate was higher among females than among males. Diabetics were older than 45 years of age, were in poor health, had more than one source of income, and depended on social safety net assistance; high parity was characteristic of diabetic females. Diabetics' blood glucose (B.G.) levels were higher than those of non-diabetics, regardless of the variables tested. Known risk factors for NIDDM were not found to be significantly strong in the determination of diabetic status nor of B.G. levels. However, the ethnographic and quantitative data suggested that physiological variables may be affected by work and occupational related risks, diluting the prediction strength of known NIDDM risk factors. The yearly cycles of farm work and the physiological demands of the tasks involved are probably the most salient risk factors in farmworkers' lives. Recommendations are provided for the incorporation of anthropological theory, methods and techniques to the study of disease processes, and for the design of public health strategies.

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M.Fam.Med. Faculty of Health Sciences, University of the Witwatersrand, 2009. / Worldwide, obesity prevalence is rapidly rising. Doctors have poor understanding of what patients experience and expect from them regarding weight-loss management. This qualitative study explored what obese patients with Non-insulin Dependent Diabetes Mellitus experience and expect from their primary care doctors concerning weight-loss management. Free attitude interviews were conducted with eight participating patients. The findings showed that doctors encouraged and counselled patients regarding weight-loss, mainly giving dietary advice, but did not routinely weigh them. Patients accepted responsibility for losing weight, trusted their doctors, valued their advice highly and did not want referrals to gymnasiums or dieticians. They expected doctors to advise them practically about exercise, diet and weight-loss goals, weigh them regularly and communicate effectively. They believed that doctor-patient relationships and interaction are important in weight-loss management, patients should be treated on an individual basis and the process should be empowering. Medical intervention costs were not problematic for this group. Generally patients were satisfied with their doctors but there were areas concerning patients’ expectations that primary care doctors should take cognisance of.

Gao, Zhibo. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 147-157). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.

Liu, Xin. / Thesis (Ph.D.)--Chinese University of Hong Kong, 2013. / Includes bibliographical references (leaves 157-164). / Electronic reproduction. Hong Kong : Chinese University of Hong Kong, [2012] System requirements: Adobe Acrobat Reader. Available via World Wide Web. / Abstract also in Chinese.

Fok, Tsz Nam = 香港二型糖尿病併發症風險評估模型 / 霍梓楠. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2011. / Includes bibliographical references (p. 71-72). / Abstracts in English and Chinese. / Fok, Tsz Nam = Xianggang er xing tang niao bing bing fa zheng feng xian ping gu mo xing / Huo Zinan. / Abstract --- p.i / 概要 --- p.iii / Acknowledgements --- p.iv / Chapter 1 --- Introduction --- p.1 / Chapter 2 --- Dataset Information --- p.3 / Chapter 3 --- Background and Literature Review --- p.9 / Chapter 3.1 --- The Idea of Risk Model --- p.9 / Chapter 3.2 --- Discrimination Problem --- p.10 / Chapter 3.3 --- Receiver Operating Characteristic (ROC) Curve --- p.11 / Chapter 3.4 --- Summary Indices of the ROC Curve --- p.13 / Chapter 3.4.1 --- Area Under ROC Curve (AROC) --- p.14 / Chapter 3.4.2 --- Maximum Vertical Distance --- p.16 / Chapter 3.5 --- Discrimination Performance in Prognostic Model --- p.18 / Chapter 3.5.1 --- Survival Data --- p.18 / Chapter 3.5.2 --- Survival Function --- p.20 / Chapter 3.5.3 --- Time-dependent ROC Curve for Censored Data --- p.21 / Chapter 3.6 --- Earlier Work on Diabetic Complications Risk Models --- p.22 / Chapter 3.6.1 --- Maximization of the AROC --- p.28 / Chapter 4 --- Model Development --- p.29 / Chapter 4.1 --- Overview --- p.29 / Chapter 4.2 --- Estimating the ROC curve and the AROC --- p.29 / Chapter 4.3 --- Choosing Suitable Risk Factors --- p.30 / Chapter 4.4 --- Mixing Risk Factors and Optimizing Coefficients --- p.31 / Chapter 4.5 --- Validation of Risk Equations Using Test Set --- p.33 / Chapter 5 --- Results and Validation --- p.34 / Chapter 5.1 --- Performance of the Risk Factor Candidates --- p.34 / Chapter 5.2 --- Estimation of the Coefficients --- p.37 / Chapter 5.3 --- Checking the Uniqueness of the Solution --- p.41 / Chapter 5.4 --- Validation Using Test Set --- p.46 / Chapter 5.5 --- Comparison of AROC-optimized and MVD-optimized Risk Equations --- p.56 / Chapter 6 --- Comparison of our Results with Earlier Work --- p.58 / Chapter 7 --- "Discussion, Outstanding Issues and Future Works" --- p.66 / Chapter 7.1 --- Comparison Between the AROC and the MVD --- p.66 / Chapter 7.2 --- Applications of Risk Models --- p.68 / Chapter 7.3 --- Limitations of the study --- p.69 / Chapter 7.4 --- Outstanding Issues and Future Works --- p.69 / Chapter 7.4.1 --- The Estimation of Error Due to Sampling Variance --- p.69 / Chapter 7.4.2 --- Time-dependent Coefficients --- p.69 / Chapter 7.4.3 --- Extending the Idea to other Datasets --- p.70 / Chapter 7.5 --- Conclusion --- p.70 / Bibliography --- p.71

Although considered a substanially preventable disease, Type 2 diabetes is reaching epidemic status within the Maori population. This study sought to investigate factors that positively and negatively influenced levels of physical activity for Maori within Otepoti/Dunedin, and to discuss ideas and potential initiatives that could increase levels of physical activity and aid in the prevention of Type 2 diabetes. Eighteen Maori (9 males; 9 females) from this rohe (area) participated in a four hour focus group interview (groups of three) and were also invited to attend an evaluation hui. A Maori-centered research orientation was used throughout the research process. Individual transcripts from focus groups, debriefing discussion and content from the evaluation hui were inductively analysed to identify the main themes. The 'active' participants were physically active because of the benefits they attained for health and longevity, and to undertake task-oriented activity such as gathering kai. Barriers to physical activity (i.e., family, work), a contemporary societal shift towards inactivity, and negative personal attitudes and perceptions towards physical activity detrimentally affected levels of physical activity. Initiatives to increase levels of physical activity included community, educational and work-based initiatives. A key element of each proposed initiative was a 'by Maori for Maori' approach, with a focus on strengthening whānau and iwi networks, a comfortable environment and social support. While education was believed to be a key component for Type 2 diabetes prevention, an avoidance barrier and fatalistic attitudes could negatively affect any attempt to prevent Type 2 diabetes and increase levels of physical activity. The results indicated that to strengthen Maori identity, increase levels of physical activity and prevent Type 2 diabetes, positive changes (taking responsibility for health), cultural changes (a shift towards a stronger identity and belief in the taonga [treasure] of being Maori), societal changes ( a more positive view of Maori, better role models and education), and social economic changes (better access to exercise facilities, healthy food and education for those in the lower deprivation indices) were needed.

Despite the medical advances in recent decades, cardiovascular disease (CVD) remains one of the leading causes of mortality in most developing countries. Ongoing efforts have been focused on evaluating new strategies targeting on novel risk factors. Vitamin D deficiency, a previously neglected condition, has recently attracted much attention from the scientific community with its potential extra-skeletal effects. There is accumulating evidence from epidemiological studies that a suboptimal 25-hydroxyvitamin D [25(OH)D] level is associated with all-cause and cardiovascular mortality, increased risk of coronary heart disease, stroke and peripheral vascular disease, and various traditional CVD risk factors including hypertension, diabetes mellitus (DM) and metabolic syndrome. Several theories have been proposed to explain these relationships but none receive universal recognition. There is recent laboratory evidence that vitamin D may exert specific effects in patients with DM. However, relationships between vitamin D deficiency and supplementation on vascular function in this group of patients are unclear. In this dissertation, I sought to explore the effects of vitamin D deficiency on vascular function in patients with type II DM in a cross-sectional study. In the later part, the results of a randomized controlled trial investigating the effects of daily vitamin D supplementation in type II DM patients are presented and discussed. The cross-sectional study (Chapter 3) investigated the association of vitamin D status with endothelial function as measured by brachial flow-mediated dilation (FMD) and circulating endothelial progenitor cell (EPC) numbers in 280 patients with type II DM. The results showed that suboptimal vitamin D status was more common among patients with DM. Furthermore, patients with vitamin D deficiency had significantly lower brachial FMD (mean difference = -1.43%, 95% CI: -2.31 to -0.55, P = 0.001) and CD133/KDR+ EPC counts (mean difference = -0.12%, 95% CI: -0.21 to -0.02, P = 0.022) than those with sufficient vitamin D after adjustment for age, sex and cardiovascular risk factors, including HbA1c levels. Based on these positive results, the objectives of the randomized controlled trial (Chapter 4) were to study and confirm the effects of daily oral vitamin D supplementation on the vascular function in this group of patients. Over a 12-week period, 100 DM patients with suboptimal vitamin D status were randomized to receive 5,000 IU/day vitamin D or placebo. There were no reported adverse events including hypercalcemia, although a slight increase in serum ionized calcium (treatment effect 0.037 mmol/L, P = 0.018) was recorded in the vitamin D group. Despite a significant improvement in serum 25(OH)D in the treatment group, supplementation of vitamin D did not result in any significant improvement in vascular function as determined by FMD, circulating EPC count or arterial stiffness (all P > 0.05). Furthermore, the serum level of high-sensitivity C-reactive protein, oxidative stress markers, low- and high-density lipoprotein and glycated haemoglobin were also similar between two groups (all P > 0.05). The results of this study did not support a therapeutic role of supplementation with vitamin D for cardiovascular benefits. In conclusion, the results of these studies demonstrated that deficiency of vitamin D was associated with worse vascular function in patients with type II DM. However, vitamin D supplementation did not result in any significant benefits on vascular function or improvement in traditional CVD risk factors in DM patients. Further large clinical trials on vitamin D supplementation in patients with DM using clinical outcomes rather than surrogate CVD markers are necessary to confirm its benefits. / published_or_final_version / Medicine / Master / Master of Research in Medicine

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