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Articles by K. Khunti
Total Records ( 29 ) for K. Khunti
  K. Khunti , J. Camosso-Stefinovic , M. Carey , M. J. Davies and M. A. Stone

Aims  To conduct a systematic review to determine the scope of published assessments of educational initiatives for South Asians with Type 2 diabetes living in Western countries and to consider the effectiveness of reported interventions.

Methods  A range of electronic databases was searched using Medical Subject Headings (MeSH) and free text terms; papers published up to the end of 2007 were considered. Two researchers independently reviewed titles and abstracts and the full text of selected citations. Reference list review and consultation with experts in the field were used to check for completeness of the final sample of studies prior to data extraction.

Results  Only nine studies, including five randomized controlled trials with a combined total of 1004 cases, met our inclusion criteria. The quality of reporting in some studies was limited, e.g. omission of detailed information about ethnicity. Selected studies included a range of group and one-to-one interventions with varied knowledge, psychological and biomedical outcome measures. The effectiveness of the interventions was also variable, and the low number and heterogeneity of the studies made identification of factors linked to effectiveness difficult and meta-analysis inappropriate. However, it appeared that improvements in knowledge levels may be easier to achieve than positive biomedical outcomes, and the need for tailored approaches was suggested.

Conclusions  Our findings confirm the difficulty of designing, assessing and achieving an impact through educational interventions for migrant South Asians with Type 2 diabetes and emphasize the need for good-quality studies in these high-risk populations

  T. C. Skinner , M. E. Carey , S. Cradock , H. M. Dallosso , H. Daly , M. J. Davies , Y. Doherty , S. Heller , K. Khunti and L. Oliver

Aims  To determine whether differences in the amount of time educators talk during a self-management education programme relate to the degree of change in participants` reported beliefs about diabetes.

Method  Educators trained to be facilitative and non-didactic in their approach were observed delivering the DESMOND self-management programme for individuals newly diagnosed with Type 2 diabetes. Observers used 10-s event coding to estimate the amount of time educators spoke during different sessions in the programme. Facilitative as opposed to didactic delivery was indicated by targets for levels of educator talk set for each session. Targets were based on earlier pilot work. Using the revised Illness Perceptions Questionnaire (IPQ-R) and the Diabetes Illness Representations Questionnaire (DIRQ), participants completed measures of: perceived duration of diabetes (timeline IPQ-R), understanding of diabetes (coherence IPQ-R), personal responsibility for influencing diabetes (personal responsibility IPQ-R), seriousness of diabetes (seriousness DIRQ) and impact on daily life (impact DIRQ), before and after the education programme.

Results  Where data from the event coding indicated educators were talking less and meeting targets for being less didactic, a greater change in reported illness beliefs of participants was seen. However, educators struggled to meet targets for most sessions of the programme.

Conclusion  The amount of time educators talk in a self-management programme may provide a practical marker for the effectiveness of the education process, with less educator talk denoting a more facilitative/less didactic approach. This finding has informed subsequent improvements to a comprehensive quality development framework, acknowledging that educators need ongoing support to facilitate change to their normal educational style.

  C. Millett , K. Khunti , J. Gray , S. Saxena , G. Netuveli and A. Majeed

AimTo examine associations between obesity, ethnicity and intermediate clinical outcomes in diabetes.

MethodsPopulation-based, cross-sectional study using electronic primary care medical records of 7300 people with diabetes from White, Black and south Asian ethnic groups.

ResultsThe pattern of obesity differed within ethnic groups, with rates significantly higher in younger when compared to older Black (women, 63% vs. 44%, P=0.002; men, 37% vs. 20%, P=0.005) and south Asian (women, 47% vs. 27%,P=0.01; men, 21% vs. 13%, P=0.05) people. Obese people with diabetes were significantly less likely to achieve an established target for blood pressure control (adjusted odds ratio 0.50, 95% confidence interval 0.42, 0.59). Differences in mean systolic blood pressure in obese and normal weight persons were significant in the White group but not in the Black groups or south Asian groups (6.9 mmHg, 1.9 mmHg and 2.7 mmHg, respectively). Differences in mean diastolic blood pressure between obese and normal weight persons were 4.8 mmHg, 3.6 mmHg and 3.4 mmHg in the White, Black and south Asian groups. Mean HbA1c and achievement of an established treatment target did not differ significantly with obesity in any ethnic group.

ConclusionsObesity is more prevalent amongst younger people than older people with diabetes in ethnic minority groups. The relationship between obesity and blood pressure control in diabetes differs markedly across ethnic groups. Major efforts must be implemented, especially in young people, to reduce levels of obesity in diabetes and improve long-term outcomes.

  M. A. Stone , A. C. Burden , M. Burden , R. Baker and K. Khunti

Aims  To assess the acceptability of and satisfaction with near patient testing for glycated haemoglobin in primary care in patients and health professionals.

Methods  A questionnaire survey and qualitative study were nested within a randomized controlled trial conducted in eight general practices in Leicester-shire, UK. Satisfaction with diabetes care was compared in the intervention group (near patient test) and in the control subjects (usual laboratory test), using the Diabetes Clinic Satisfaction Questionnaire. Semistructured interviews were conducted with a purposive sample of patients and healthcare professionals and analysed using thematic coding and framework charting.

Results  Questionnaire data for 344 patients were analysed and interviews were conducted with 15 patients and 11 health professionals. Interviews indicated that the near patient test was highly acceptable to patients and staff and confirmed that there may be potential benefits such as time saving, reduced anxiety and impact on patient management and job satisfaction. However, both the survey and the interviews identified high pre-existing levels of satisfaction with diabetes care in both intervention and control group patients and survey results failed to confirm increased patient satisfaction as a result of rapid testing. Limited patient understanding of glycated haemoglobin testing was noted.

Conclusions  We were unable to confirm actual rather than potential advantages of the near patient test. Widespread adoption in primary care cannot be recommended without further evidence of benefit.

  S. A. Mostafa , M. J. Davies , D. Webb , L. J. Gray , B. T Srinivasan , J. Jarvis and K. Khunti
  Aims There are calls to simplify the diagnosis of Type 2 diabetes mellitus (T2DM) to reduce the burden of undiagnosed disease. Glycated haemoglobin (HbA1c) is therefore being considered as a preferred diagnostic tool to replace the need for an oral glucose tolerance test (OGTT), considered by many as cumbersome and inconvenient. The aim of this study was to examine the potential impact of the preferred use of HbA1c as a diagnostic tool on the prevalence and phenotype of T2DM.
Methods Analysis of the Leicester Ethnic Atherosclerosis and Diabetes Risk (LEADER) cohort for previously undiagnosed individuals between 40 and 75 years of age who had OGTT, repeated if within the diabetes range, and HbA1c results. We compared the prevalence and phenotype of subjects with T2DM based on either HbA1c≥6.5% or OGTT using 1999 World Health Organization criteria.
Results From the total population of 8696, we detected 291 (3.3%) with T2DM from using an OGTT, and 502 (5.8%) had HbA1c≥6.5%. Of those diagnosed with T2DM by OGTT, 93 (1.2%) had HbA1c <6.5% and therefore would not have been classified as having T2DM using proposed criteria. Using HbA1c criteria resulted in 304 (3.5%) additional cases of T2DM, approximately doubling the prevalence. Of these 304 additional people, 172 (56.7%) had impaired glucose tolerance/impaired fasting glycaemia according to 1999 World Health Organization criteria. Using HbA1c criteria there was an increase of 2.2- and 1.4-fold in south Asians and white Europeans detected, respectively.
Conclusions Within this multi-ethnic cohort, we found that introducing HbA1c≥6.5% as the preferred diagnostic test to diagnose T2DM significantly increased numbers detected with T2DM; however, some people were no longer detected as having T2DM.
  T. Yates , M. J. Davies , T. Gorely , D. Talbot , F. Bull , N. Sattar and K. Khunti
  Aims To investigate whether an exercise intervention programme, with or without pedometer use, is effective at reducing chronic low-grade inflammation in those with impaired glucose tolerance. Methods Using baseline and 12 month data from the Pre-diabetes Risk Education and Physical Activity Recommendation and Encouragement (PREPARE) programme randomized controlled trial, we investigated whether the pedometer or the standard version of the PREPARE programme is associated with reduced chronic low-grade inflammation. Outcomes included interleukin-6, C-reactive protein, fasting and 2 h post-challenge glucose values and objectively measured ambulatory activity. Results Sevety-four participants (31% female; mean age, 65 years; body mass index, 29.3 ± 4.8 kg/m2) were included, of which 26 were in the control group and 24 were in each intervention group. At 12 months there was an increase in ambulatory activity of 1351 and 1849 steps/day in the standard and pedometer group, respectively, compared with control conditions; however, there was no significant change in markers of chronic low-grade inflammation. Across the pooled study sample, change in ambulatory activity was significantly correlated with change in interleukin-6 (r = –0.32, P = 0.01) after adjustment for group, age, sex, ethnicity, aspirin and statin medication, baseline body mass index and change in body mass index. Change in interleukin-6 was also significantly correlated with change in 2 h glucose after adjustment for the same variables (r = 0.26, P = 0.03). Conclusions This study failed to show reductions in markers of chronic low-grade inflammation following an intervention that promoted modest increases in ambulatory activity; however, across the study sample, increased ambulatory activity was associated with reduced interleukin-6, independent of obesity.
  S. De Lusignan , K. Khunti , J. Belsey , A. Hattersley , J. Van Vlymen , H. Gallagher , C. Millett , N. J. Hague , C. Tomson , K. Harris and A. Majeed
  Aims: Incorrect classification, diagnosis and coding of the type of diabetes may have implications for patient management and limit our ability to measure quality. The aim of the study was to measure the accuracy of diabetes diagnostic data and explore the scope for identifying errors.Method: We used two sets of anonymized routinely collected computer data: the pilot used Cutting out Needless Deaths Using Information Technology (CONDUIT) study data (n=221958), which we then validated using 100 practices from the Quality Improvement in Chronic Kidney Disease (QICKD) study (n=760588). We searched for contradictory diagnostic codes and also compatibility with prescription, demographic and laboratory test data. We classified errors as: misclassified-incorrect type of diabetes; misdiagnosed-where there was no evidence of diabetes; or miscoded-cases where it was difficult to infer the type of diabetes.Results: The standardized prevalence of diabetes was 5.0 and 4.0% in the CONDUIT and the QICKD data, respectively: 13.1% (n=930) of CONDUIT and 14.8% (n=4363) QICKD are incorrectly coded; 10.3% (n=96) in CONDUIT and 26.2% (n=1143) in QICKD are misclassified; nearly all of these cases are people classified with Type 1 diabetes who should be classified as Type 2. Approximately 5% of T2DM in both samples have no objective evidence to support a diagnosis of diabetes. Miscoding was present in approximately 7.8% of the CONDUIT and 6.1% of QICKD diabetes records.Conclusions: The prevalence of miscoding, misclassification and misdiagnosis of diabetes is high and there is substantial scope for further improvement in diagnosis and data quality. Algorithms which identify likely misdiagnosis, misclassification and miscoding could be used to flag cases for review.
  K. Khunti , T. C. Skinner , S Heller , M. E Carey , H. M. Dallosso and M. J Davies
  Aims  To describe the characteristics of newly diagnosed people with Type 2 diabetes (T2DM) and compare these with published studies.

Methods  Baseline data of participants recruited to the DESMOND randomized controlled trial conducted in 13 sites across England and Scotland were used. Biomedical measures and questionnaires on psychological characteristics were collected within 4 weeks of diagnosis.

Results  Of 1109 participants referred, 824 consented to participate (74.3%). Mean (± sd) age was 59.5 ± 12 years and 54.9% were male. Mean HbA1c was 8.1 ± 2.1% and did not differ by gender. Mean body mass index (BMI) was significantly higher in women (33.7 vs. 31.3 kg/m2; P < 0.001); 69% of women and 54% of men were obese (BMI > 30 kg/m2). Total cholesterol was significantly higher in women (5.6 vs. 5.2 mmol/l; P < 0.001). Overall, 14.7% reported smoking. Percentages reporting recommended levels of vigorous activity (≥ 3 times/week) and moderate activity (≥ 5 times/week) were 10.6 and 16.0%, respectively, and were lower in women. Specific illness beliefs included 73% being unclear about symptoms and only 54% believing diabetes is a serious condition. Symptoms indicative of depression were reported by significantly more women than men (16.1% vs. 8.2%; P = 0.001).

Conclusion  Data from this large and representative cohort of newly diagnosed people with T2DM show that many have modifiable cardiovascular risk factors. Comparison with the literature suggests that the profile of the newly diagnosed may be changing, with lower HbA1c and higher prevalence of obesity. Many expressed beliefs about and poor understanding of their diabetes that need to be addressed in order for them to engage in effective self-management.

  M. A. Stone , J. Camosso-Stefinovic , J. Wilkinson , S. De Lusignan , A. T. Hattersley and K. Khunti
  Aims  To conduct a systematic review to identify types and implications of incorrect or incomplete coding or classification within diabetes or between diabetes and other conditions; also to determine the availability of evidence regarding frequency of occurrence.

Methods  Medical Subject Headings (MeSH) and free-text terms were used to search relevant electronic databases for papers published to the end of August 2008. Two researchers independently reviewed titles and abstracts and, subsequently, the full text of potential papers. Reference lists of selected papers were also reviewed and authors consulted. Three reviewers independently extracted data.

Results  Seventeen eligible studies were identified, including five concerned with distinguishing between Type 1 and Type 2 diabetes. Evidence was also identified regarding: the distinction between diabetes and no-diabetes, failure to specify type of diabetes, and diagnostic errors or difficulties involving maturity-onset diabetes of the young, latent autoimmune diabetes in adults, pancreatic diabetes, persistence of foetal haemoglobin and acquired immune deficiency syndrome (AIDS). The sample was too heterogeneous to derive accurate information about frequency, but our findings suggested that misclassification occurs most commonly in young people. Implications relating to treatment options and risk management were highlighted, in addition to psychological and financial implications and the potential impact on the validity of quality of care evaluations and research.

Conclusions  This review draws attention to the occurrence and implications of incorrect or incomplete coding or classification of diabetes, particularly in young people. A pragmatic and clinically relevant approach to classification is needed to assist those involved in making decisions about types of diabetes.

  L. J. Gray , N. A. Taub , K. Khunti , E. Gardiner , S. Hiles , D. R. Webb , B. T. Srinivasan and M. J. Davies
  Aims  Risk assessment scores identify those at high risk of impaired glucose regulation and Type 2 diabetes mellitus. To date no risk assessment scores that can be completed by a lay person have been developed and validated specifically for multiethnic populations in the UK.

Methods  We used data on 6186 subjects aged 40-75 years from a multiethnic UK screening study (73% white European, 22% South Asian). All participants were given a 75 g oral glucose tolerance test. We developed logistic regression models for predicting current impaired glucose regulation (impaired fasting glycaemia/impaired glucose tolerance) or Type 2 diabetes mellitus using data from anthropometric measurements and self-reported questionnaires. Using the best-fitting model, we developed the Leicester Risk Assessment score. We externally validated the score using data from 3171 subjects aged 40-75 years from a separate screening study.

Results  The components of the final model are age, ethnicity [white European vs. other (predominantly South Asian)], sex, first degree family history of diabetes, antihypertensive therapy or history of hypertension, waist circumference and body mass index. The score ranges from 0 to 47. Validating this model using the data from the second screening study gave an area under the receiver operator characteristic curve of 72% (95% confidence interval, 69-74%). A cut point of 16 had a sensitivity of 81% and a specificity of 45%.

Conclusions  The Leicester Risk Assessment score can be used to identify those at high risk of impaired glucose regulation and Type 2 diabetes mellitus in UK multiethnic populations. The score is simple (seven questions) and non-invasive.

  N. Aujla , T. C. Skinner , K. Khunti and M. J. Davies
  Aims  To compare the identification of prevalent depressive symptoms by the World Health Organization-5 Wellbeing Index (WHO-5) and Centre for Epidemiological Studies Depression Scale (CES-D) for South Asian and white European people, male and female, attending a diabetes screening programme, and to explore the adequacy of the screening tools for this population. An additional aim was to further explore associations of depressive symptoms with impaired glucose regulation (IGR) and Type 2 diabetes mellitus (Type2 DM).

Methods  Eight hundred and sixty-four white European (40-75 years old) and 290 South Asian people (25-75 years old) underwent an oral glucose tolerance test (OGTT), detailed history and anthropometric measurements and completed the WHO-5 and CES-D. Depressive symptoms were defined by a WHO-5 score ≤ 13, and CES-D score ≥ 16.

Results  Unadjusted prevalence of depressive symptoms with the WHO-5, for people with Type2 DM was 42.3% (47.4% in white European; 28.6% in South Asian) and for IGR 30.7% (26% in white European; 45.8% in South Asian). With the CES-D, the prevalence in Type2 DM was 27.2% (25.4% in white European; 31.8% in South Asian) and for IGR 30.7% (27.8% in white European; 40.7% in South Asian). Statistically significant differences in the prevalence of depressive symptoms for sex or ethnicity were not identified. Odds ratios adjusted for age, sex and ethnicity showed no significant association of depression with Type2 DM or IGR, with either WHO-5 or CES-D. Agreement was moderate (κ = 0.48, 95% confidence intervals 0.42-0.54), and reduced when identifying depressive symptoms in people with Type2 DM. For this group, a WHO-5 cut-point of ≤ 10 was optimal.

Conclusions  Depressive symptoms, identified by WHO-5 or CES-D, were not significantly more prevalent in people with Type2 DM or IGR. The WHO-5 and CES-D differed in their identification of depressive symptoms in people with Type2 DM, though discrepancies between sex and ethnicity were not identified.

  T. C. Skinner , M. E. Carey , S. Cradock , H. M. Dallosso , H. Daly , M. J. Davies , Y. Doherty , S. Heller , K. Khunti and L. Oliver
  Aims  To describe the course of depressive symptoms during the first year after diagnosis of Type 2 diabetes.

Methods Post hoc analysis of data from a randomized controlled trial of self-management education for 824 individuals newly diagnosed with Type 2 diabetes. Participants completed the Depression scale of the Hospital Anxiety and Depression Scale after diagnosis and at 4, 8 and 12 months follow-up. Participants also completed the Problem Areas in Diabetes scale at 8 and 12 months follow-up. We present descriptive statistics on prevalence and persistence of depressive symptoms. Logistic regression is used to predict possible depression cases, and multiple regression to predict depressive symptomatology.

Results  The prevalence of depressive symptoms in individuals recently diagnosed with diabetes (18-22% over the year) was not significantly different from normative data for the general population (12%) in the UK. Over 20% of participants indicated some degrees of depressive symptoms over the first year of living with Type 2 diabetes; these were mostly transient episodes, with 5% (1% severe) reporting having depressive symptoms throughout the year. At 12 months post diagnosis, after controlling for baseline depressive symptoms, diabetes-specific emotional distress was predictive of depressive symptomatology.

Conclusions  The increased prevalence of depressive symptoms in diabetes is not manifest until at least 1 year post diagnosis in this cohort. However, there are a significant number of people with persistent depressive symptoms in the early stages of diabetes, and diabetes-specific distress may be contributing to subsequent development of depressive symptoms in people with Type 2 diabetes.

  N. Aujla , M. J. Davies , T. C. Skinner , L. J. Gray , D. R. Webb , B. Srinivasan and K. Khunti
  Aim  To investigate associations between anxiety and measures of glycaemia in a White European and South Asian population attending community-based diabetes screening.

Methods  In total, 4688 White European and 1353 South Asian participants (aged 40-75 years) without a previous diagnosis of Type 2 diabetes underwent an oral glucose tolerance test and HbA1c measurement, detailed history, anthropometric measurements and completed the short-form Spielberger State Trait Anxiety Inventory.

Results  Anxiety was significantly higher in South Asian participants (mean 34.1; sd 0.37) compared with White European participants (mean 29.8; sd 0.13). Significant correlations were not identified between anxiety and fasting (r = −0.01, P = 0.75), 2-h glucose (r = −0.10, P = 0.24) or HbA1c (r = 0.01, P = 0.40).

Conclusions  Anxiety levels at screening were greater among South Asian people. Fasting, 2-h plasma glucose and HbA1c are not affected by anxiety during screening tests for diabetes. Current and proposed screening methods for diagnosis of diabetes are not affected by anxiety at screening.

  T. Yates , M. J. Davies , S. Sehmi , T. Gorely and K. Khunti
  Objective  To determine whether improvements in glucose regulation following the PREPARE structured education programme were sustained at 24 months.

Patients and methods  Ninety-eight overweight or obese individuals with impaired glucose tolerance were randomized to receive: (1) advice leaflet, (2) 3-h structured education programme aimed at promoting physical activity, (iii) 3-h structured education with personalized pedometer use. The primary outcome was change in 2-h post-challenge plasma glucose.

Results  Seventy-three (74%) individuals were included for analysis at 24 months; age 65 ± 8 years, BMI 29.3 ± 4.8 kg/m2, South Asian ethnicity 21%. A statistically significant reduction in 2-h glucose of −1.6 mmol/l (-0.4 to -2.7) was seen in the education-with-pedometer group compared with the control group. There is no significant difference in the education-only group.

Conclusion  Improvements in glucose regulation following a pragmatic group-based structured education with pedometer use were sustained at 24 months.

  M. van den Donk , A. Sandbaek , K. Borch-Johnsen , T. Lauritzen , R. K. Simmons , N. J. Wareham , S. J. Griffin , M. J. Davies , K. Khunti and G. E. H. M. Rutten
  Aims  To describe and compare attendance rates and the proportions of people identified with Type 2 diabetes mellitus in people with previously unknown diabetes who participated in screening programmes undertaken in general practice in the UK, Denmark and the Netherlands as part of the ADDITION-Europe study.

Methods  In Cambridge, routine computer data searches were conducted to identify individuals aged 40-69 years at high risk of Type 2 diabetes using the Cambridge Diabetes Risk Score. In Denmark, the Danish Diabetes Risk Score was mailed to individuals aged 40-69 years, or completed by patients visiting their general practitice. In the Netherlands, the Hoorn Symptom Risk Questionnaire was mailed to individuals aged 50-69 years. In these three centres, high-risk individuals were invited to attend subsequent steps in the screening programme, including random blood glucose, HbA1c, fasting blood glucose and/or oral glucose tolerance test. In Leicester, eligible people aged 40-69 years were invited directly for an oral glucose tolerance test. In all centres, Type 2 diabetes was defined according to World Health Organization 1999 diagnostic criteria.

Results  Attendance rates ranged from 20.2% (oral glucose tolerance test in Leicester without pre-stratification) to 95.1% (random blood glucose in opportunistic screening in Denmark in high-risk people). The percentage of people with newly detected Type 2 diabetes from the target population ranged from 0.33% (Leicester) to 1.09% (the Netherlands).

Conclusions  Screening for Type 2 diabetes was acceptable and feasible, but relatively few participants were diagnosed in all participating centres. Different strategies may be required to increase initial attendance and ensure completion of screening programmes.

  S. de Lusignan , N. Sadek , H. Mulnier , A. Tahir , D. Russell-Jones and K. Khunti
  Aims  To determine the effectiveness of self-audit tools designed to detect miscoding, misclassification and misdiagnosis of diabetes in primary care.

Methods  We developed six searches to identify people with diabetes with potential classification errors. The search results were automatically ranked from most to least likely to have an underlying problem. Eight practices with a combined population of 72 000 and diabetes prevalence 2.9% (n = 2340) completed audit forms to verify whether additional information within the patients' medical record confirmed or refuted the problems identified.

Results  The searches identified 347 records, mean 42 per practice. Pre-audit 20% (n = 69) had Type 1 diabetes, 70% (n = 241) had Type 2 diabetes, 9% (n = 30) had vague codes that were hard to classify, 2% (n = 6) were not coded and one person was labelled as having gestational diabetes. Of records, 39.2% (n = 136) had important errors: 10% (n = 35) had coding errors; 12.1% (42) were misclassified; and 17.0% (59) misdiagnosed as having diabetes. Thirty-two per cent (n = 22) of people with Type 2 diabetes (n = 69) were misclassified as having Type 1 diabetes; 20% (n = 48) of people with Type 2 diabetes (n = 241) did not have diabetes; of the 30 patients with vague diagnostic terms, 50% had Type 2 diabetes, 20% had Type 1 diabetes and 20% did not have diabetes. Examples of misdiagnosis were found in all practices, misclassification in seven and miscoding in six.

Conclusions  Volunteer practices successfully used these self-audit tools. Approximately 40% of patients identified by computer searches (5.8% of people with diabetes) had errors; misdiagnosis is commonest, misclassification may affect treatment options and miscoding in omission from disease registers and the potential for reduced quality of care.

  K. Khunti , N. Taub , D. Webb , B. Srinivasan , J. Stockman , S. J. Griffin , R. K. Simmons and M. J. Davies
  Aims  To investigate validity of waist circumference measurements obtained by self-report and self-measurement with non-verbal pictorial instructions among a multi-ethnic population.

Methods  Five hundred and twenty-six individuals aged 40-75 years (91 South Asian, 430 White European and five other), who attended a screening programme for Type 2 diabetes, estimated their waist circumference and measured their waist with a paper tape measure. Participants were also provided with simple pictorial instructions for measurement of waist circumference in their preferred language and remeasured their waist circumference. We calculated 95% limits of agreement with measures undertaken by a healthcare professional unaware of prior measures.

Results  Mean age was 56.8 years (sd 9.0), mean BMI 30.0 kg/m2 (sd 5.6) and mean waist circumference 98.4 cm (sd 14.1). Seventy-nine per cent had high waist circumference according to International Diabetes Federation criteria. The mean of participants' self-reported value was 6.8 cm lower than the healthcare professional measure (sd 8.8; 95% limits of agreement -10.4 to 24.0 cm), with significant differences by sex and ethnicity (South Asian men 7.5 cm, South Asian women 0.1 cm, White European men 7.8 cm, White European women 7.0 cm, P < 0.001). Compared with healthcare professional measures, mean self-measured waist circumference was very similar, both with instructions (0.4 cm higher; sd 5.5 cm; -11.1 to 10.4 cm) and without instructions (0.5 cm lower; sd 5.6; -10.4 to 11.4 cm), but with significant differences by sex and ethnicity (P < 0.001).

Conclusions  There was systematic underestimation of self-reported waist circumference in this multi-ethnic UK population. The magnitude of underestimation might reduce the performance of risk scores; however, this can be corrected through self-measurement with pictorial instructions.

  A.-R. Sadek , J. van Vlymen , K. Khunti and S. de Lusignan
  Aims  To develop a computer processable algorithm, capable of running automated searches of routine data that flag miscoded and misclassified cases of diabetes for subsequent clinical review.

Method  Anonymized computer data from the Quality Improvement in Chronic Kidney Disease (QICKD) trial (= 942 031) were analysed using a binary method to assess the accuracy of data on diabetes diagnosis. Diagnostic codes were processed and stratified into: definite, probable and possible diagnosis of Type 1 or Type 2 diabetes. Diagnostic accuracy was improved by using prescription compatibility and temporally sequenced anthropomorphic and biochemical data. Bayesian false detection rate analysis was used to compare findings with those of an entirely independent and more complex manual sort of the first round QICKD study data (= 760 588).

Results  The prevalence of definite diagnosis of Type 1 diabetes and Type 2 diabetes were 0.32% and 3.27% respectively when using the binary search method. Up to 35% of Type 1 diabetes and 0.1% of Type 2 diabetes were miscoded or misclassified on the basis of age/BMI and coding. False detection rate analysis demonstrated a close correlation between the new method and the published hand-crafted sort. Both methods had the highest false detection rate values when coding, therapeutic, anthropomorphic and biochemical filters were used (up to 90% for the new and 75% for the hand-crafted search method).

Conclusions  A simple computerized algorithm achieves very similar results to more complex search strategies to identify miscoded and misclassified cases of both Type 1 diabetes and Type 2 diabetes. It has the potential to be used as an automated audit instrument to improve quality of diabetes diagnosis.

  D. R. Webb , K. Khunti , L. J. Gray , B. T. Srinivasan , A. Farooqi , N. Wareham , S. C. Griffin and M. J. Davies
  Aims  To compare the effects of intensive multifactorial cardiovascular risk intervention with standard care in screen-detected Type 2 diabetes.

Methods  Twenty general practices randomly invited 30 950 adults without diagnosed diabetes for screening (World Health Organization, 1999). In a cluster randomized controlled trial, screen-detected cases were assigned by practice allocation to receive intensive protocol-driven cardiovascular risk management (n = 146) or standard care (n = 199) according to local guidelines. Intensive intervention was designed to achieve an HbA1c of 48 mmol/mol (6.5%), blood pressure < 130/80 mmHg and total cholesterol < 3.5 mmol/l. Primary outcome was modelled 5-year coronary heart disease risk (UKPDS-CHD). Analysis was via intention to treat.

Results  After 1.1 years 339 (98%) individuals were still participating. There were significant reductions in HbA1c, blood pressure and total cholesterol from baseline in both groups [mean change for total study population −27.7 mmol/mol (−0.62%), −11.64/10.01 mmHg, −1.11 mmol/l]. After adjustment for baseline and clustering, significant inter-group differences were observed in mean changes from baseline for HbA1c{−28.5 mmol/mol [−0.7% (1.4)] vs. −27.5 mmol/mol [−0.6% (1.6)], P = 0.001}, blood pressure [systolic −16.2 (19.6) vs. −8.4 (18.6) mmHg, P < 0.001], total cholesterol [−1.3 (1.3) vs. −1.0 (1.2) mmol/l, P < 0.001] and weight [−3.8 (5.5) vs. −2.2 (5.5) kg, P = 0.01] in favour of intensive treatment. UKPDS 5-year coronary heart disease risk was reduced by 3.2% and 2.3%, respectively (P < 0.0001). Intensive intervention was associated with more lipid-lowering and anti-hypertensive but not hypoglycaemic medication use [odds ratios 2.5 (1.4-4.4), 5.5 (2.4-11.5), 1.6 (0.8-2.3); compared with standard care, P < 0.001, P = 0.003, P = 0.65]. Treatment satisfaction responses were superior with intensive intervention, with no increase in self-reported hypoglycaemia.

Conclusion  Intensive intervention in patients with diabetes identified through systematic non-risk-factor-based screening significantly reduces modelled coronary heart disease risk. This is achieved predominantly with lipid-lowering and anti-hypertensive treatments with no adverse effect on quality of life or hypoglycaemia.

  P. Chester and K. Khunti
  Not available
  N. Gholap , M. J. Davies , S. A. Mostafa , I. Squire and K. Khunti
  Glucose intolerance is common but often remains undiagnosed and untreated in people with acute coronary syndrome. The best approach to screening for glucose intolerance post-acute coronary syndrome remains debated. The World Health Organization has recently advocated the use of HbA1c in diagnosing Type 2 diabetes. A screening strategy using HbA1c as the preferred test would be pragmatic and improve early detection and management of glucose intolerance in acute coronary care practice. In this commentary, we discuss the relevant literature and guidelines in this area and propose a simple and pragmatic algorithm based on the use of HbA1c to screen for glucose intolerance during and after admission with acute coronary syndrome.

  N. Patel , M. A. Stone , A. Chauhan , M. J. Davies and K. Khunti
  Aim  To explore barriers to prescribing of insulin, particularly delays in initiation, from the perspective of healthcare professionals involved in managing Type 2 diabetes in a multi-ethnic setting.

Methods  The study was carried out in a UK population with high numbers of people of South Asian (mainly Indian) origin. Semi-structured interviews were conducted with 14 healthcare professionals from primary and secondary care. Analysis involved exploring interview transcripts in terms of themes and sub-themes identified through a process of progressive focusing.

Results  Initiation of insulin therapy was described as challenging in all patients irrespective of ethnicity, but some barriers were perceived to be accentuated because of language needs and lower levels of understanding about diabetes and insulin. Additionally, some South Asians were viewed as more likely than their white European counterparts to be influenced by negative observations and experiences about insulin therapy within community networks. Time restrictions were seen as a barrier that was accentuated in the management of South Asian patients. Participants suggested strategies for overcoming patient barriers; with South Asians these included involvement of families and patient peers and availability of South Asian healthcare providers.

Conclusion  The challenge for healthcare providers is to how to address the tension between the optimal clinical time for commencing insulin therapy and the time when the patient feels psychologically ready. To help make these two time points coincide, our findings suggest the need to adopt a holistic approach involving consideration of the cultural context of patients, including their ethnic background.

  K. Khunti and M. J. Davies
  Not available
  S. I. Makda , M. J. Davies , E. Wilmot , J. Bankart , T. Yates , E. M. Varghese , H. Fisher , A. Anwar and K. Khunti


To describe contraception use and the prescription of drugs that are either not recommended in pregnancy or are potentially teratogenic by diabetes type in women of child-bearing age.


Retrospective, cross-sectional chart review undertaken in 22 general practices in Warwickshire, UK. Demographic, anthropometric, medical history, medication and contraception data were extracted from women aged 14 to 49 years with pre-existing diabetes. Independent sample t-test, Mann-Whitney test and χ2-test were used to test for univariable associations and multiple logistic regression was used to adjust for confounders.


Four hundred and seventy eligible women were identified; the majority had a diagnosis of Type 2 diabetes (67%). Thirty-six per cent and 64% of women with Type 1 and Type 2 diabetes, respectively, were prescribed drugs not recommended for use in pregnancy (P < 0.001). Less than half were using concomitant contraception (P < 0.001). No significant difference of contraception use was observed between women who were and were not taking drugs not recommended for use in pregnancy (40 vs. 41%, P = 0.4).


Use of drugs not recommended during pregnancy in women with diabetes of child-bearing age is common but is not associated with increased use of contraception. There is need to identify and overcome barriers to effective contraception use for this population group in order to facilitate optimal management of cardiovascular risk.

  M. J. Davies , J. J. Gagliardino , L. J. Gray , K. Khunti , V. Mohan and R. Hughes


To identify real-world factors affecting adherence to insulin therapy in patients with Type 1 or Type 2 diabetes mellitus.


A literature search was conducted in PubMed and EMBASE in November 2011 to identify studies reporting factors associated with adherence/non-adherence to insulin therapy in adults with Type 1 or Type 2 diabetes.


Seventeen studies were identified; six used self-reported measures and 11 used calculated measures of adherence. Most (13/17) were conducted exclusively in the USA. Four categories of factors associated with non-adherence were identified: predictive factors for non-adherence, patient-perceived barriers to adherence, type of delivery device and cost of medication. For predictive factors and patient-perceived barriers, only age, female sex and travelling were associated with non-adherence in more than one study. Fear of injections and embarrassment of injecting in public were also cited as reasons for non-adherence. Conversely, adherence was improved by initiating therapy with, or switching to, a pen device (in four studies), and by changing to an insurance scheme that lowered the financial burden on patients (in two studies).


Adherence to insulin therapy is generally poor. Few factors or patient-perceived barriers were consistently identified as predictive for non-adherence, although findings collectively suggest that a more flexible regimen may improve adherence. Switching to a pen device and reducing patient co-payments appear to improve adherence. Further real-world studies are warranted, especially in countries other than the USA, to identify factors associated with non-adherence and enable development of strategies to improve adherence to insulin therapy.

  E. G. Wilmot , C. L. Edwardson , S. J. H. Biddle , T. Gorely , J. Henson , K. Khunti , M. A. Nimmo , T. Yates and M. J. Davies


Rising rates of obesity have led to an increasing prevalence of Type 2 diabetes mellitus in young people. Uncertainty exists over the utility of screening younger adults for Type 2 diabetes, as existing data sets have focused on mature (> 40 years) cohorts. The aim of this study was to determine the prevalence of impaired glucose metabolism in higher risk younger adults.


Overweight (with an additional risk factor) or obese adults (18-40 years) were recruited for the Sedentary Time And Diabetes (STAND) randomized controlled trial. Measures included an oral glucose tolerance test, HbA1c, biochemical and anthropometric data.


One hundred and ninety-three individuals (68% female; median age 33.8 years; median BMI 33.9 kg/m2) were recruited. Forty-three per cent had a first-degree family history of Type 2 diabetes. Previously undiagnosed Type 2 diabetes was present in 4.7% (n = 9). Of participants, 18.1% (n = 35) had impaired glucose metabolism: 4.7% (n = 9) HbA1c ≥ 48 mmol/mol (6.5%); 9.3% (n = 18) HbA1c 42-46 mmol/mol (6.0-6.4%); 3.1% (n = 6) Type 2 diabetes on oral glucose tolerance test; 6.2% (n = 12) isolated impaired glucose tolerance; 2.1% (n = 4) isolated impaired fasting glucose; 1% (n = 2) both impaired fasting glucose and impaired glucose tolerance. Of participants, 58.5% (n = 113) had dyslipidaemia, 28.0% (n = 54) had hypertension, 31.1% (n = 60) were vitamin D deficient and 7.3% (n = 14) had abnormal liver function.


This study identified a high prevalence of Type 2 diabetes and impaired glucose regulation in overweight and obese younger adults. These findings require confirmation in a larger, representative, population.

  L. J. Gray , T. Leigh , M. J. Davies , N. Patel , M. Stone , M. Bonar , R. Badge and K. Khunti
  Not available
  J. A. Black , S. J. Sharp , N. J. Wareham , A. Sandbaek , G. E. H. M. Rutten , T. Lauritzen , K. Khunti , M. J. Davies , K. Borch-Johnsen , S. J. Griffin and R. K. Simmons


Little is known about the long-term effects of intensive multifactorial treatment early in the diabetes disease trajectory. In the absence of long-term data on hard outcomes, we described change in 10-year modelled cardiovascular risk in the 5 years following diagnosis, and quantified the impact of intensive treatment on 10-year modelled cardiovascular risk at 5 years.


In a pragmatic, cluster-randomized, parallel-group trial in Denmark, the Netherlands and the UK, 3057 people with screen-detected Type 2 diabetes were randomized by general practice to receive (1) routine care of diabetes according to national guidelines (1379 patients) or (2) intensive multifactorial target-driven management (1678 patients). Ten-year modelled cardiovascular disease risk was calculated at baseline and 5 years using the UK Prospective Diabetes Study Risk Engine (version 3β).


Among 2101 individuals with complete data at follow up (73.4%), 10-year modelled cardiovascular disease risk was 27.3% (sd 13.9) at baseline and 21.3% (sd 13.8) at 5-year follow-up (intensive treatment group difference -6.9, sd 9.0; routine care group difference -5.0, sd 12.2). Modelled 10-year cardiovascular disease risk was lower in the intensive treatment group compared with the routine care group at 5 years, after adjustment for baseline cardiovascular disease risk and clustering (-2.0; 95% CI -3.1 to -0.9).


Despite increasing age and diabetes duration, there was a decline in modelled cardiovascular disease risk in the 5 years following diagnosis. Compared with routine care, 10-year modelled cardiovascular disease risk was lower in the intensive treatment group at 5 years. Our results suggest that patients benefit from intensive treatment early in the diabetes disease trajectory, where the rate of cardiovascular disease risk progression may be slowed.

  E. G. Wilmot , M. Leggate , J. N. Khan , T. Yates , T. Gorely , D. H. Bodicoat , K. Khunti , J. P. A. Kuijer , L. J. Gray , A. Singh , P. Clarysse , P. Croisille , M. A. Nimmo , G. P. McCann and M. J. Davies


A pilot study to phenotype young adults (< 40 years) with Type 2 diabetes mellitus.


Twenty people with Type 2 diabetes (aged 18-40 years), 10 lean and 10 obese control subjects underwent detailed assessment, including tagged cardiac magnetic resonance imaging, inflammatory proteins, lipids, vitamin D and maximal oxygen uptake. Outcomes were compared between the group with Type 2 diabetes and the control group.


Mean (standard deviation) age, Type 2 diabetes duration and BMI in the group with Type 2 diabetes were 31.8 (6.6) years, 4.7 (4.0) years and 33.9 (5.8) kg/m2 respectively. Compared with lean control subjects, those with Type 2 diabetes had more deleterious profiles of hyperlipidaemia, vitamin D deficiency, inflammation and maximal oxygen uptake relative to body mass. However, there was no difference between the group with Type 2 diabetes and the obese control group. The group with Type 2 diabetes had a higher left ventricular mass and a trend towards concentric remodelling compared with the lean control group (P = 0.002, P = 0.052) but not the obese control group (P > 0.05). Peak early diastolic strain rate was reduced in the group with Type 2 diabetes [1.51 (0.24)/s] compared with the lean control [1.97 (0.34)/s, P = 0.001] and obese control [1.78 (0.39)/s, P = 0.042] group.


Young adults with Type 2 diabetes and those with obesity have similar adverse cardiovascular risk profiles, higher left ventricular mass and a trend towards left ventricular concentric remodelling. In addition, those with Type 2 diabetes demonstrate diastolic dysfunction, a known risk marker for future heart failure and mortality.

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