Thesis submitted in fulfilment of the requirements for the degree Masters of Technology: Radiography in the Faculty of Health and Wellness Sciences at the Cape Peninsula University of Technology / BACKGROUND: Diabetic patients are at increased risk of cardiovascular events and stroke, and its prevention is therefore the desired goal. In the arsenal of available techniques, ultrasound plays a vital role in primary healthcare. It is reliable, cost-effective and a noninvasive diagnostic tool that may prove beneficial for screening individuals at risk of cardiovascular disease (CVD) and stroke in SA. OBJECTIVE: To determine the interrelationships between carotid ultrasound findings with glycaemia status and contributing risk factors of atherosclerosis in the selected population. METHODS: Initially blinded by the glycaemia status, blood results, contributing risks and patient demographics, both carotid arteries were evaluated with duplex ultrasound (DUS), during July 2010 – July 2011. Using graphs, figures, frequency tables, means and standard deviations for the selected study population, univariate, multivariate and stepwise regression analysis was done to determine the association between ultrasound findings and risk factors for atherosclerosis. The hypothesis tested in this study was to determine if there is an increased incidence of carotid artery intima-media thickening (CIMT), plaque formation and stenosis in patients diagnosed with T2DM and hyperglycaemia in a very specific sub-population of mixedancestory, residing in Bellville South Africa (BSA). RESULTS: Of 534 subjects, 375 were of mixed ancestry and ≥35yrs of age, which met the inclusion criteria for the carotid ultrasound substudy. The glycaemic status for each individual was established, and 44% (165/375) were diagnosed hyperglycaemic, of which 66.7% (110/165) were diabetic (T2DM) and 33.3% (55/165) were pre-diabetic (Pre-DM). Majority (56%:265/375) had a normal glycaemic status. The ultrasound measurement of the carotid wall thicknesses (Mean Rt. and Lt. CIMT) revealed a statistically significant rise from normal glycaemia status to DM status for both the males (p = 0.0115*; p = 0.0259*) and females (p < 0.0001**; p < 0.0001**) respectively. In terms of plaques and internal carotid artery (ICA) stenosis (124/375), when grouped into normal and hyperglycaemic sub-groups, indicated plaque presence and some form of narrowing. A <50% stenotic ratio noted in 61% (76/124) of the hyperglycaemic group, that was 1.6 times higher than those with normal glycaemia (48/124). Predisposing factors demonstrated significantly higher levels in the females than in the males. The univariate multiple regression analysis after adjusted R² of 0.3247 for all independent variables (predisposing /contributing risk factor markers) of age (yrs.), SBP (mmHg), hs-CRP (mg/L), S-Cotinine (ng/mL) and LDL (mmol/L) showed statistically significant positive associations with dependent variable of the mean carotid wall thickness (p < 0.0001**, p< 0.0001**, p = 0.0033*, p = 0.0409* and p = 0.0044)* respectively. Statistically significant positive differences and standard error (SE), for every unit of change (1yr.) of age (yrs.), as a contributing factor for herosclerosis, there was a change in the mean carotid wall thickness as predicted according to this model. The total contribution of independent risk factors to CIMT ultrasound measurements were calculated as 34.5% (Adjusted R² = 0.3247). In the multivariate stepwise regression analysis, the independent variables of age (p< 0.0001) ** and systolic blood pressure (p < 0.0001) ** showed the strongest positive association with carotid wall thickeness changes. The hs-CRP (mg/L) inflammatory markers (p = 0.0014)* and LDL (mmol/L) (p = 0.0208)* were the 2nd and 3rd highest positive associated contributory risk factors for carotid artery wall thickening. The hip circumference (p = 0.0008)* and waist circumference (p = 0.0 555) + risk factors related to obesity was significant and approached significance, respectively, with the predicted increase of carotid artery wall thickening. CONCLUSION: Subjects diagnosed with T2DM and hyperglycaemia had increased levels of CIMT, plaques and carotid artery stenosis, compared to those subjects without T2DM. Age and systolic blood pressure, inflammatory (raised hs-CRP) and LDL cholesterol changes, and central (truncal) waist circumference adiposity, were positively associated with increased carotid intima media thickness. Smoking (S-Cotinine) and gender also reflected a direct relationship with CIMT changes. The hip circumference adiposity and diastolic blood pressure measurements were not directly associated with an increase in CIMT, which are in keeping with hypertension and obesity formulas. These findings confirm the association of thickened CIMT, plaques and stenosis with ‘unhealthy’ T2DM subjects at higher risk of CVD and stroke. The total contribution of independent risk factors to CIMT measurements were calculated as 34.5% (Adjusted R² =0.3247). The gathered information, discussion of results, and concluding statements thereby supports the recommendation of carotid artery ultrasound evaluation, for screening and diagnosis in primary health care, for ‘flagging’ high risk individuals at risk of stroke, so that lifestyle changes and appropriate management is early adopted.

El texto completo de este trabajo no está disponible en el Repositorio Académico UPC por restricciones de la casa editorial donde ha sido publicado. / Revisión por pares / INTRODUCCIÓN: Los pacientes con diabetes mellitus tipo 2 son más propensos a una baja calidad de vida, discapacidad e incluso muerte. También, tienen una mayor predisposición a la depresión en comparación con los pacientes no diabéticos; así como una evolución favorable producto de la evaluación e intervención de su salud mental. OBJETIVOS: El objetivo de este estudio fue explorar la presencia de síntomas depresivos en una población ambulatoria con diagnóstico de diabetes mellitus tipo 2 y filiación militar. También examinar los factores asociados a la presencia de síntomas depresivos. MÉTODOS: Realizamos un estudio transversal en 108 personas con diabetes mellitus tipo 2, durante enero de 2012 en una muestra ambulatoria de un hospital de las fuerzas armadas. Los síntomas depresivos se evaluaron con el test autoaplicado de Zung. Usamos la prueba de Chi-cuadrado para examinar las asociaciones entre síntomas depresivos y los factores asociados de interés. Usamos modelos lineales generalizados crudos y ajustados para estimar las Razones de Prevalencia (RP) de la asociación entre las características clínicas y sociodemográficas con la presencia de síntomas depresivos. RESULTADOS: La prevalencia de sintomatología depresiva fue de 56,5% (intervalo de confianza 95%: 46,6-66,0%). El análisis bivariado mostró como significativa la asociación entre la presencia de síntomas depresivos con las variables: sexo, edad y complicaciones clínicas de la diabetes. En los análisis ajustados, la retinopatía diabética [RP: 1,3; intervalo de confianza 95%: 1,1-1,7], y la neuropatía diabética [RP: 1,4; intervalo de confianza 95%: 1,1-1,7] se asociaron a una mayor presencia de síntomas depresivos luego de considerar el sexo de los participantes. CONCLUSIONES: Observamos una elevada presencia de síntomas depresivos en la población de estudio, especialmente en los pacientes geriátricos o del sexo femenino. También en aquellos con complicaciones tardías de la diabetes mellitus tipo 2, y que probablemente representen la repercusión de la enfermedad en la calidad de vida del paciente. Un abordaje multidisciplinario, con enfoque físico y mental, debe ser considerado ya que podría beneficiar a la evolución de los pacientes con esta concomitancia en Perú.

Diabetes is a chronic, complex illness with a risk for acute and long-term complications. The aim of this quality improvement project on prevention of type 2 diabetes was to increase self-management behaviors in patients at high risk of type 2 diabetes, decrease the financial burden of type 2 diabetes, and decrease the incidence of complications that can occur from type 2 diabetes. The primary outcome of this project was each participant reporting at least one lifestyle modification that would be helpful in preventing type 2 diabetes after attending two group education sessions. A pretest posttest design was used for this project. Three completed the initial questionnaires, and two attended the educational sessions and completed the posttest questionnaires. Of the total number of participants, one reported a decrease in hot/cold cereal, regular soda, sugar or honey in coffee/tea, other potatoes, tomato sauces, chocolate, doughnuts, and cookies, cake, pies, brownies. Two participants reported a decrease in fruit juice, fried potatoes, and pizza. One participant had an increase in physical activity while the other participant had no change in physical activity. The landmark Diabetes Prevention Program (DPP) Trial demonstrated that counseling on a healthy diet and moderate physical activity reduced the incidence of type 2 diabetes. The two participants in this project reported they made some helpful changes in diet after two education sessions. It is vital to the success of a prevention program to convey the significance of preventing a chronic disease such as type 2 diabetes

Abstract Background: Individuals with type 2 diabetes mellitus (T2D) face many challenges in self-management of their current disease state. Nutrition education has been identified as a key component in managing metabolic control in individuals diagnosed with T2D. The purpose of this study is to investigate the effect of a 4-week nutrition intervention on glycated hemoglobin (HbA1c) and nutrition knowledge by food security status in individuals with T2D who attend the Family Health Centers of Georgia (FHCGA) located in West Atlanta. Methods: Subjects enrolled in the study (n=6) completed a nutrition knowledge survey at the beginning of the intervention and had their HbA1c values extracted from the FHCGA medical record. Subjects then entered a 4-week group nutrition intervention program. The program consisted of four lessons that focused on the basic diet for diabetes, food label reading, grocery store shopping and eating out with diabetes. Subjects took a nutrition knowledge survey after the intervention and were asked to return to have a follow-up blood draw for HbA1c levels. Results: Two out of six subjects completed the entire protocol. The HbA1c for this subject was higher after the nutrition intervention. An additional two subjects completed all of the lessons and the post survey, but did not have a follow-up HbA1c drawn. The mean nutrition knowledge score pre-intervention (72.33 + 5.13) was lower than the mean post-intervention score (78.67 + 4.04) but was not significantly different. When subdivided by food security status, subjects with a higher food security status had a lower baseline HbA1c. Conclusion: Nutrition knowledge scores increased after nutrition education but not significantly. The effect of nutrition education on HbA1c by food security status could not be determined due to low participation. Future studies with a larger sample size and incentives for compliance are needed to investigate how group nutrition education influences metabolic control in food insecure and secure people with T2D.

Background: A marked increase of type 2 diabetes and associated morbidity and mortality rate over the last 10 years has been recorded in Malaysia. Ineffective diabetes management and a lack of self-care practice among type 2 diabetic patients have been identified as the major reasons for this problem. Research in other countries has highlighted a range of factors influencing effective self-care of type 2 diabetes including patients' perspectives of diabetes, sociocultural issues, religious beliefs and support from healthcare. Nevertheless, there is paucity of research conducted in Malaysia. Therefore, the exploration of self-care practice and self-care support provision in patients with type 2 diabetes in Malaysia is needed to understand the problem. Aims: To understand the self-care practice of patients with type 2 diabetes in Malaysia and the factors that influence the patients' self-care practice. To understand the type 2 diabetes’ self-care support provision in Malaysia from the perspective of patients, healthcare professionals, and healthcare system. Methods: A qualitative, single embedded case study design was utilised. Eighteen patients with type 2 diabetes and 19 healthcare professionals (physicians, diabetes educators, nurse, pharmacist and dietician), involved in self-care support provision primary- and secondary-care settings in Kuala Lumpur and Putrajaya, Malaysia, participated in in-depth semi-structured interviews between November 2012 and June 2013. In addition, data were collected through participant-observation of clinic consultations, and analysis of relevant documents used in the provision of diabetes management in the respective clinics. The framework technique supported analysis of data. Data were stored and managed using Nvivo 9 software. Findings: The findings indicate that patients with type 2 diabetes had a good understanding of diabetes and self-care, but a lack of self-care support meant that effective self-care was difficult to sustain. Healthcare professionals’ (HCPs’) provision of self-care support was restricted due to several factors, including lack of opportunity to provide self-care support, unsuitable clinic environment and a fragmented management within primary and secondary care. Additionally, barriers in patient–HCP communication, a combination of the personal, interpersonal and inter-professional HCP factors, and a traditional medical model adopted by Malaysian healthcare system, seem to have influenced the practice and quality of the service delivered. Conclusion: It is clear that the increased incidence of uncontrolled type 2 diabetes is not merely due to poor self-care practice by patients, but also due to constraints in service delivery and underdevelopment of self-care support provision. The evidence generated can assist in the development of strategies to improve the quality of care and facilitate changes in the self-care support provision in Malaysia.

La prévalence croissante du diabète de type II et les risques cardiovasculaires associés, sont maintenant considérés comme un enjeu majeur de santé publique. L'agrégation du polypeptide amyloïde humain des îlots (hIAPP) est liée à une dégénérescence des cel-lules β pancréatiques et à la pathogénèse du diabète de type II. Le mécanisme de la toxi-cité de hIAPP et la nature des espèces concernées (oligomères et/ou fibres) sont loin d'être élucidés, bien que de récentes études ont montré que les oligomères formés lors des étapes précoces du processus pourraient être les plus toxiques. Très peu de tech-niques permettent à l’heure actuelle de suivre cette oligomérisation en temps réel et d’évaluer des inhibiteurs de ce processus pathologique. Au cours de cette thèse, nous avons exploré la CE et l’IMS-MS comme techniques permettant de suivre l’oligomérisation de hIAPP in vitro en temps réel. Une méthode de CE a été développée, permettant d’évaluer de nouveaux inhibiteurs envers cette oligomérisation. Une méthode d’IMS-MS a également été développée pour décrire les interactions formées entre hIAPP et un inhibiteur.Des inhibiteurs peptidomimétiques ont été rationnellement conçus et syn-thétisés afin de déstabiliser les structures β formées lors de l’oligomérisation de hIAPP. L’évaluation de ces composés a permis de mettre en évidence la relation entre leurs structures et leurs activités inhibitrices. Des études de viabilité cellulaire sont en cours afin d’améliorer la compréhension de l’activité de ces molécules. / The rising prevalence of type II diabetes, and associated adverse cardiovascular risks, is now considered as a major public health challenge. The aggregation of human islet amyloid polypeptide (hIAPP) is linked to beta-cell degeneration and to the pathogenesis of type II diabetes. The mechanism of hIAPP toxicity and the species involved (oligomers and/or fibrils) are far to be elucidated, although recent studies have shown that early formed species could be the most toxic species. Very few techniques are currently available to monitor in real time this oligomerization and to evaluate inhibitors of this pathological process. During this PhD project, we investigated CE and IMS-MS as potential techniques to monitor in vitro and in real time the oligomerization of hIAPP. A CE-UV method has been developed, which allows the activity evaluation of new inhibitors. An IMS-MS method has also been developed to investigate the interactions formed between hIAPP and the inhibitors. Peptidomimetics inhibitors have been rationally designed and synthesized in order to destabilize beta-sheets structures formed during the oligomerization process of hIAPP. The evaluation of those compounds revealed a relation between their structures and their inhibitory activities. Cellular viability tests are on-going to get more insights on those molecules activity.

Type 2 diabetes mellitus (T2DM) is a widespread metabolic disorder that continues to grow in prevalence both in the United States and worldwide. T2DM is an immense public health crisis and has been declared an epidemic by the United States Centers for Disease Control and Prevention. T2DM is a heterogeneous disease that is characterized by chronic hyperglycemia that is caused by dysfunction of the insulin transduction pathway. Particularly in T2DM, individuals with the disease experience a progressive loss of insulin production by pancreatic β cells in the setting of peripheral insulin resistance. Due to the dysfunction of insulin’s actions, glucose in circulation is unable to enter insulin’s target cells and remains in the bloodstream. Formerly known as adult-onset diabetes, T2DM has recently become more commonplace in youthful populations, particularly in adolescents during puberty. Several risk factors have been identified for T2DM, which defines a population of study to determine the underlying pathogenesis of T2DM and possible therapeutic interventions. While extensive research on T2DM has been performed, the heterogeneous nature of the disease makes it difficult to understand the relationship between genetic susceptibility and environmental triggers. The trend of reaching younger populations is extremely worrying as the loss of glycemic control in T2DM is associated with various medical complications. The most commonly seen complications in T2DM include neuropathy, nephropathy, retinopathy, and cardiovascular disease. These complications come with a significant burden that greatly increases mortality and reduces one’s quality of life. One of the underlying causes of the growing prevalence of youth-onset T2DM is the growing pediatric obese population. The increasing prevalence of pediatric obesity, in turn, is likely tied to adolescents getting less sleep, having diets high in carbohydrates, and having insufficient physical activity. Compared to T2DM that precipitates later in life, youth-onset T2DM appears to have a more aggressive nature, where glycemic control is quickly lost, and complications arise sooner in the disease course than adults. Unfortunately, compared to the various drug classes available to adults, options for youths with T2DM are limited. Currently, the only pharmacologic therapies available to youths are metformin and insulin and given that youths quickly lose metabolic control, new therapies are desperately needed to combat this epidemic. Lifestyle interventions are also widely used in pediatric populations, but success with lifestyle monotherapy is limited. Adherence to treatment plans is a barrier to positive outcomes in youthful populations, which may be improved by having patients and their families attend diabetes education programs. The aggressive nature of youth-onset T2DM and the limited amount of available therapies make it difficult to maintain control diabetes in this youthful population, which is concerning given the huge costs associated with diabetes for both individuals and health care systems. To combat this epidemic of youth-onset T2DM, aggressive monitoring is needed to identify high-risk populations and to prevent and delay T2DM in these populations. Reducing the prevalence of youth-onset T2DM will require efforts to increase the physical activity of youths and to reduce the consumption of foods that greatly increase blood sugar. Additionally, efforts should be made to ensure that youths are getting adequate amounts of sleep. Bariatric surgery has been demonstrated positive results in remission of T2DM in youths, but such an invasive procedure may be an extreme solution in a vulnerable population.

The use of telehealth in healthcare has grown in recent years; however, little is known about the effectiveness of this delivery method in the management of Type 2 diabetes mellitus (T2DM). Guided by the chronic care model and telehealth in chronic disease model, the purpose of this systematic literature review was to explore evidence related to lowering hemoglobin A1c levels and managing T2DM using telehealth in the outpatient setting. The practice-focused questions explored telehealth interventions used in T2DM management and their effectiveness. The Joanna Briggs Institute (JBI) method for conducting systematic literature reviews was the process, and data were compiled using the PRISMA evidence-based minimum set for reporting. Eighteen studies met the inclusion criteria for this project. Data were extracted, analyzed, and synthesized using JBI tools for data extraction and critical appraisal. Article appraisals revealed numerous telehealth interventions for management of T2DM including telephone, Internet-based, clinical video, remote monitoring, and smart phones/applications. Overall, telehealth interventions showed statistically significant improvement in the hemoglobin A1c levels of participants compared to traditional outpatient care. Success of the interventions is associated with components of evidenced-based diabetes management such as education, self-management, support, and feedback loop. The implications of this project for positive social change include the integration of telehealth interventions in the outpatient setting to manage T2DM with enhanced access to care, reduction in health disparities, and improved health outcomes for society.

No description available.

Adolescent type 2 diabetes (T2D) diagnoses are on the rise. Consistent with the adult literature, preliminary evidence in adolescents suggests that T2D is associated with reduced brain volume and white matter microstructural integrity. As part of the Cognitive Performance in Adolescents with T2D (CPAT2D) study, this project aimed to test whether T2D diagnosis is associated with poorer cognitive performance in adolescents. Five adolescents with obesity and T2D (60% female; body mass index [BMI] percentile 98.2 ± 2.0; age 16.7 ± 1.1 years) were recruited and matched to two control adolescents with obesity but without T2D (50% female; BMI percentile 99.9 ± 0.2; age 15.9 ± 1.3 years) on at least three of the following characteristics: age, sex, pubertal stage and habitual sleep duration. All participants wore a wrist actigraphy device for seven consecutive nights to measure sleep at home and then completed two neuromotor cognitive tasks at a laboratory testing session assessing motor preparation (simple reaction time task) and executive functioning (affective shifting task [AST]). Control data were available through the Sleep Manipulation in Adolescents at Risk of Type 2 Diabetes (SMART2D) study. Premotor reaction time outcomes in either task and proportions of commission and omission error trials in the AST were subsequently analyzed. Based on this preliminary participant sample, there is no evidence to suggest that adolescents with compared to without T2D perform differently on the neuromotor cognitive tasks. The results should be confirmed once the intended sample size is reached. In the meantime, clinicians should monitor for changes in cognitive function in adolescents with T2D, perhaps by asking about academic achievement. The majority of our sample exhibited sub-optimal movement behaviours; to preserve overall health, adolescents with obesity and/or T2D should strive to meet sleep, physical activity and screen time recommendations for their age group.