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Background and aims: Carotenoids may reduce diabetes risk, due to their antioxidant properties. However, the association between dietary carotenoids intake and type 2 diabetes risk is still unclear. Therefore, the objective of this study was to examine whether higher dietary carotenoid intakes associate with reduced type 2 diabetes risk. Methods and results: Data from 37,846 participants of the European Prospective Investigation into Cancer and Nutrition-Netherlands study were analyzed. Dietary intakes of beta-carotene, alpha-carotene, beta-cryptoxanthin, lycopene, lutein & zeaxanthin and the sum of these carotenoids were assessed using a validated food frequency questionnaire. Incident type 2 diabetes was mainly self-reported, and verified against general practitioner information. Mean +/- SD total carotenoid intake was 10 + 4 mg/day. During a mean +SD follow-up of 10 + 2years, 915 incident cases of type 2 diabetes were ascertained. After adjustment for age, sex, diabetes risk factors, dietary intake, waist circumference and BMI, higher beta-carotene intakes associated inversely with diabetes risk [Hazard Ratio quartile 4 versus quartile 1 (HRQ4): 0.78 (95%CI:0.64,0.95), P-linear trend 0.01]. For alpha-carotene, a borderline significant reduced risk was observed, with a HRQ4 of 0.85 (95%CI:0.70,1.03), and P-linear trend 0.05. beta-cryptoxanthin, lycopene, lutein & zeaxanthin, and the sum of all carotenoids did not associate with diabetes risk. Conclusions: This study shows that diets high in beta-carotene and alpha-carotene are associated with reduced type 2 diabetes in generally healthy men and women. (C) 2015 Elsevier B.V. All rights reserved.

Aims: To study whether microalbuminuria, endothelial dysfunction and low-grade inflammation are associated with the presence and progression of diabetic retinopathy. Methods: Patients with Type 2 diabetes (n = 328) attending a diabetes clinic were followed for 10 years and examined annually during the last 7 years. Retinopathy was assessed after pupillary dilatation by direct ophthalmoscopy (baseline) and two-field 60°fundus photography (follow-up). Urinary albumin excretion, and markers of endothelial function (von Willebrand factor, tissue-type plasminogen activator, soluble E-selectin (sE-selectin), and soluble vascular cell adhesion molecule 1) and inflammatory activity (C-reactive protein and fibrinogen) were determined. Results: The prevalence of retinopathy was 33.8%. The median diabetes duration at baseline was 7 years (interquartile range 2-12 years). The highest tertiles of baseline urinary albumin excretion and glycated haemoglobin (HbA1c) were associated with prevalent retinopathy: odds ratio (OR) 95% confidence interval (CI) 2.80 (1.44-5.46) and 2.19 (1.11-4.32), respectively. Progression of retinopathy occurred in 188 patients. The second and third tertiles of baseline sE-selectin were associated with progression of retinopathy [1.44 (1.04-2.01) and 1.61 (1.19-2.18)] but not independently of HbA1c. None of the other markers was significantly associated with the presence or progression of retinopathy. High baseline HbA1c was significantly associated with progression of retinopathy: 1.65 (1.21-2.25). Conclusions: In this population of patients with Type 2 diabetes who attended a diabetes clinic, there was some evidence for a role of endothelial dysfunction in the progression of retinopathy. We could not demonstrate a role for low-grade inflammation. Our study emphasizes the importance of glycaemic control in the development and progression of retinopathy. © 2007 The Authors.

Objective— To explore to what extent homocysteine, S-adenosylmethionine (SAM), S-adenosylhomocysteine, total folate, 5-methyltetrahydrofolate (5-MTHF), vitamin B12, and vitamin B6 are associated with endothelium-dependent, flow-mediated vasodilation (FMD), and whether these associations are stronger in individuals with diabetes or other cardiovascular risk factors. Methods and Results— In this population-based study of 608 elderly people, FMD and endothelium-independent nitroglycerin-mediated dilation (NMD) were ultrasonically estimated from the brachial artery (absolute change in diameter [μm]). High SAM and low 5-MTHF were significantly associated with high and low FMD, respectively (linear regression coefficient, [95% confidence interval]): 48.57 μm (21.16; 75.98) and −32.15 μm (−59.09; −5.20), but high homocysteine was not (−15.11 μm (−42.99; 12.78). High SAM and low 5-MTHF were also significantly associated with high and low NMD, respectively. NMD explained the association of 5-MTHF with FMD but not of SAM. No interactions were observed for diabetes or cardiovascular risk factors. Conclusions— In this elderly population, both SAM and 5-MTHF are associated with endothelial and smooth muscle cell function. The effect of homocysteine on endothelial function is relatively small compared with SAM and 5-MTHF. The relative impact of SAM, 5-MTHF, and homocysteine, and the mechanisms through which these moieties may affect endothelial and smooth muscle cell function need clarification.

Aims To examine the impact of the diagnosis of Type 2 diabetes on psychological well-being and perceived health status in subjects who participated in a targeted population-screening programme. Methods This study was conducted within the framework of a screening project in the general (aged 50–75 years) Dutch population. The final study population consisted of 259 subjects with a high-risk score on the Symptom Risk Questionnaire; 116 of whom were subsequently detected with Type 2 diabetes and 143 who were non-diabetic. The impact was assessed approximately 2 weeks (shortly) and 6 and 12 months after the diagnosis, using the 12-item Well-Being Questionnaire (W-BQ12) and the Medical Outcomes Study Short Form 36 (SF-36), respectively. Analyses of co-variance (ancova) were used. Results Approximately 2 weeks after the diagnosis, no significant mean differences were found on either the W-BQ12 or the SF-36, between the screening-detected Type 2 diabetes subjects and the non-diabetic subjects. Six months after the diagnosis, we found lower scores in the screening-detected Type 2 diabetes subjects compared with the non-diabetic subjects on the SF-36 dimensions Role Physical (mean difference (95% CI); −8.2 (−16.2; −0.1); P = 0.046) and Role Emotional (mean difference (95% CI); −7.9 (−15.3; −0.5); P = 0.038). One year after the test results, no significant mean differences were found between both groups on either instrument (W-BQ12; SF-36). Conclusions The diagnosis of Type 2 diabetes has no substantial adverse or positive effect on psychological well-being and perceived health status, shortly, and 6 and 12 months after the diagnosis.

Prevalence of macrovascular disease amongst type 2 diabetic patients detected by targeted screening and patients newly diagnosed in general practice: the Hoorn Screening Study.Spijkerman AM, Henry RM, Dekker JM, Nijpels G, Kostense PJ, Kors JA, Ruwaard D, Stehouwer CD, Bouter LM, Heine RJ.Institutes for Research in Extramural Medicine, VU University Medical Center, Amsterdam, The Netherlands. amw.spijkerman@vumc.nlOBJECTIVES: Screening for type 2 diabetes has been recommended and targeted screening might be an efficient way to screen. The aim was to investigate whether diabetic patients identified by a targeted screening procedure differ from newly diagnosed diabetic patients in general practice with regard to the prevalence of macrovascular complications. DESIGN: Cross-sectional population-based study. SETTING: Population study, primary care. SUBJECTS: Diabetic patients identified by a population-based targeted screening procedure (SDM patients), consisting of a screening questionnaire and a fasting capillary glucose measurement followed by diagnostic testing, were compared with newly diagnosed diabetic patients in general practice (GPDM patients). Ischaemic heart disease and prior myocardial infarction were assessed by ECG recording. Peripheral arterial disease was assessed by the ankle-arm index. Intima-media thickness of the right common carotid artery was measured with ultrasound. RESULTS: A total of 195 SDM patients and 60 GPDM patients participated in the medical examination. The prevalence of MI was 13.3% (95% CI 9.3-18.8%) and 3.4% (1.0-11.7%) in SDM patients and GPDM patients respectively. The prevalence of ischaemic heart disease was 39.5% (95% CI 32.9-46.5%) in SDM patients and 24.1% (15.0-36.5%) in GPDM patients. The prevalence of peripheral arterial disease was similar in both groups: 10.6% (95% CI 6.9-15.9%) and 10.2% (4.7-20.5%) respectively. Mean intima-media thickness was 0.85 mm (+/-0.17) in SDM patients and 0.90 mm (+/-0.20) in GPDM patients. The difference in intima-media thickness was not statistically significant. CONCLUSIONS: Targeted screening identified patients with a prevalence of macrovascular complications similar to that of patients detected in general practice, but with a lower degree of hyperglycaemia

OBJECTIVE—To assess the performance of the Cambridge Risk Score (CRS) to predict undiagnosed hyperglycemia in Caribbean and South Asian people living in the U.K. RESEARCH DESIGN AND METHODS—The CRS uses routinely available data from primary care records to identify people at high risk for undiagnosed type 2 diabetes. The sensitivity, specificity, and area under the receiver operator characteristic (ROC) curve for the CRS cut point of 0.199 were 77, 72, and 80% (95% CI 68–91), respectively. The risk score was calculated for 248 Caribbean and 555 South Asian participants aged 40–75 years in the 1999 Health Survey for England. Undiagnosed hyperglycemia was considered present if fasting plasma glucose was ≥7.0 mmol/l or HbA1c was ≥6.5%. Sensitivity, specificity, and predictive values were calculated for various cut points of the risk score, and ROC curves were constructed. RESULTS—The area under the ROC curve was 67% (59–76) and 72% (67–78) for Caribbeans and South Asians, respectively. The optimal cut point in Caribbean participants was 0.236, sensitivity was 63% (46–77), and specificity was 63% (56–69). In the South Asian population, the optimal cut point was and 0.127, sensitivity was 69% (60–78), and specificity was 64% (60–69). CONCLUSIONS—The CRS, using routinely available data, can be used in a strategy to detect undiagnosed hyperglycemia in Caribbean and South Asian populations. The existence of ethnic group–specific cut points must be further established in future studies.

AIMS: To determine health-related quality of life (HRQoL) in the first year following diagnosis of Type 2 diabetes among newly diagnosed patients in general practice compared with patients detected by targeted population screening.METHODS: The study population consisted of 49 newly diagnosed patients in general practice and 116 screening-detected patients. HRQoL was operationalized as symptom distress, perceived health status and emotional well-being, that were assessed prospectively approximately 2 weeks, 6 months and 12 months after the diagnosis of Type 2 diabetes, with the Type 2 Diabetes Symptom Checklist (DSC-type 2), the Short Form 36 (SF-36) and the Well-Being Questionnaire (W-BQ12), respectively.RESULTS: The DSC-type 2 total score (range 0-4) improved significantly within newly diagnosed patients in general practice (median at approximately 2 weeks, 6 months and 12 months; 0.56, 0.21, 0.26; P = 0.000) and not within screening-detected patients (0.24, 0.24, 0.29; P = 0.093). Descriptives showed that newly diagnosed patients in general practice compared with screening-detected patients had consistently worse mean scores on all SF-36 mental health subscales Social Functioning, Role Emotional, Mental Health, Vitality, and all W-BQ12 scales at each time point. The differences were statistically significant for Role Emotional, Mental Health, Vitality (SF-36), and General well-being (W-BQ12). The SF-36 General Health (F = 3.7, P = 0.028) and Vitality (F = 4.5, P = 0.012) scores of newly diagnosed patients in general practice improved significantly over time, compared with screening-detected patients.CONCLUSIONS: Newly diagnosed patients in general practice compared with screening-detected patients reported more diabetes-related symptom distress shortly after the diagnosis, and a consistently worse mental health status at each time point. Improved Vitality scores in newly diagnosed patients in general practice in the first year following diagnosis of Type 2 diabetes suggest a positive effect of diabetes treatment on HRQoL.

Background Evidence is accumulating that lifestyle factors influence the incidence of fatal and non-fatal cardiovascular diseases (CVD). A healthy diet, being physically active, moderate alcohol consumption and not smoking are associated with a lower CVD risk. In addition to these lifestyle factors, recent research suggests that poor sleep may also be a risk factor of CVD. In this thesis, we focussed on a Mediterranean style diet, specific leisure time physical activities, and sleep duration and quality as risk factors for CVD. Methods Our analyses are based on the prospective Doetinchem Cohort Study (N ~ 3 400), the Monitoring Project on Risk Factors for Chronic Diseases (MORGEN) Study (N ~ 20 400) and the Dutch contribution to the European Prospective Investigation into Cancer and Nutrition (EPIC-NL) (N ~ 34 700). These studies included men and women aged 20-65 years when examined between 1993 and 1997. Diet was assessed with the validated EPIC food frequency questionnaire and operationalized with the Mediterranean Diet Score (MDS, range: 0-9). Physical activity was estimated with the validated EPIC physical activity questionnaire, with an emphasis on different leisure time activities. In addition, information was collected on duration and quality of sleep by two questions. Cardiovascular morbidity and mortality were ascertained through linkage with national registers. Multivariable Cox models were used to estimate the strength of the associations and 95% confidence intervals. Results During 12 years of follow-up, 206 CVD cases occurred in the Doetinchem Cohort Study, 1 486 cases in the MORGEN Study and 4 881 cases in the EPIC-NL Study. In the study on diet, a two unit increment in MDS was associated with a 22% lower risk of fatal CVD, and a 5% lower risk of total CVD. For specific CVDs, a 14% lower risk of myocardial infarction, a 12% lower risk of stroke, and a 26% lower risk of pulmonary embolism was observed. The MDS was not related to incident angina pectoris, transient ischemic attack and peripheral arterial disease. The use of multiple measurements of the MDS increased the strength of the associations with CVD and narrowed the confidence intervals. For leisure time physical activity, we showed that cycling was associated with an 18% lower risk of total CVD, sports with a 26% lower risk, and those who both cycled and performed sports had a 34% lower risk. Walking and gardening were not associated with CVD risk. Short sleep duration was associated with a 15% higher risk of total CVD, whereas long sleep duration and sleep quality separately were not associated. Short sleepers with a poor sleep quality had a 63% higher risk of total CVD compared to those with a normal sleep duration and good sleep quality. Finally, the combination of a healthy diet, sufficient physical activity, moderate alcohol consumption and non-smoking was associated with a 57% lower risk of composite CVD and a 67% lower risk of fatal CVD. The addition of sufficient sleep duration to these four traditional healthy lifestyle factors resulted in a 65% lower risk of composite CVD and an 83% lower risk of fatal CVD. Conclusions In this thesis, we showed that the strength of the association between dietary patterns and CVD incidence is likely underestimated because most studies used only the baseline measurement of diet. Furthermore, leisure time physical activities should be of at least moderate intensity to contribute to lower CVD risk. We also observed that sufficient sleep is a factor that should be taken into consideration in the prevention of CVD, in combination with a healthy diet, sufficient physical activity, moderate alcohol consumption and not smoking. Our results underscore the importance of a healthy lifestyle for CVD prevention.