Rozprawy doktorskie na temat „Diabetes in India”

Introducción: Una proporción de pacientes con diabetes de la edad adulta, que inicialmente no requieren insulina, presentan autoanticuerpos contra la decarboxilasa del ácido glutámico (GADA) en el suero y diferencias fenotípicas con la diabetes clásica tipo 2 (DM2). Se ha propuesto la designación de diabetes autoinmune latente del adulto (LADA) para esta categoría. Objetivos de la investigación: La diabetes autoinmune de la edad adulta es heterogénea. Este hecho ha sido demostrado en Europa y ciertos países no europeos. Los estudios epidemiológicos han encontrado variaciones en la prevalencia de LADA. En el sur de Asia, los datos sobre LADA son escasos. Se ha observado una discrepancia muy marcada en la frecuencia de LADA en la población de la India, entre 2.6% y 58%, que no puede atribuirse a diferencias étnicas o ambientales; más bien a metodologías conflictivas/distintas. El diagnóstico precoz de LADA es importante por sus implicaciones terapéuticas. Con el fin de caracterizar adecuadamente LADA y evaluar su prevalencia real se requiere un criterio de diagnóstico fiable con procedimientos validados. Métodos: Se realizó una investigación transversal en la región norte de la India en 139 sujetos. Los criterios de reclutamiento incluyeron: a) diagnóstico de diabetes; b) edad al diagnóstico, 30-70 años; c) duración conocida de la enfermedad entre 6 meses y 5 años. Se determinaron en muestras de suero/plasma, tras un ayuno de más de 10 horas, las concentraciones de glucosa, hemoglobina glicosilada, perfil lipídico, creatinina, péptido C y GADA. Los pacientes con positividad a GADA insulinizados desde el diagnóstico, o antes de un mes desde el diagnóstico, se definieron como DM1. Los individuos con resultado negativo en la determinación de GADA fueron diagnosticados como DM2. El grupo de sujetos con diabetes y positividad a GADA que no requirieron insulina durante al menos 6 meses tras diagnóstico fueron definidos como LADA. Resultados y Conclusiones: 1- LADA representó el 6.5% de los casos entre las personas adultas con diagnóstico de diabetes, frecuencia considerablemente superior a la informada en estudios previos para esta población. En sujetos diabéticos diagnosticados a los 31-40 años de edad, la frecuencia de LADA fue del 13,9%. El estudio sugirió una tendencia decreciente de LADA con el aumento de edad. 2- LADA fue el subtipo prevalente de diabetes autoinmune de inicio en la edad adulta, dato que convendría contrastar con observaciones previas publicadas de una menor prevalencia de DM-1A entre niños y adolescentes en el norte de la India. En esta población investigada, la prevalencia de LADA fue considerablemente inferior a la informada en el sur de la India. 3- El grupo de sujetos con diagnóstico de LADA es más joven y presenta niveles inferiores de circunferencia abdominal, péptido C sérico y triglicéridos en ayunas, que el grupo de sujetos con DM2 de la misma zona del norte de la India. 4- Los pacientes con LADA con títulos más elevados de GADA en el momento del diagnóstico eran preferentemente varones, más delgados, y necesitaban tratamiento insulínico, presentando menor riesgo de hipertensión sistólica y síndrome metabólico. 5- Los pacientes con LADA con títulos bajos de GADA eran preferentemente mujeres, y no mostraron diferencias fenotípicas con las pacientes con DM-2, en concordancia con datos publicados en la población asiática china, y en contradicción con los publicados para la población europea. 6- En el presente estudio, los niveles séricos de péptido C en ayunas al diagnóstico fueron inferiores en los pacientes LADA que en los pacientes con DM2. Esta diferencia se mantuvo durante 36 meses, contrariamente a los datos del Estudio LADA en España.
Introduction: A significant proportion of diabetic patients with adult‐onset diabetes, initially non requiring insulin treatment, have glutamic decarboxylase autoantibodies (GADA) in their sera and display a different clinical phenotype from classical type 2 diabetes (DM2) without GADA. A new subclass of diabetes with the designation of latent autoimmune diabetes of adult‐onset (LADA) has been proposed for this category of subjects. Research Objectives: Adult-onset autoimmune diabetes is heterogeneous consisting of various groups. This observation has been intensively investigated in Europe and needs a comprehensive search in India. Epidemiological studies have reported varied prevalence of LADA. In South Asia, data on LADA are sparse. Significant discrepancy in the frequency of LADA has been observed in earlier studies on Indian population ranging from 2.6% to 58%. Such variation in the results may be attributed to local differences and conflicting methodology adopted by various authors. Diagnosing LADA early in the disease process is important as it may have therapeutic implications. In order to assess the true prevalence and characterize LADA in various populations, a standardised diagnostic criterion is required. The adoption of standard criterion and valid methods to define LADA would facilitate the rational comparison of the disease between different populations and a more efficient management for all health providers. Methods: We performed a cross-sectional investigation in the Northern region of India that included 139 subjects. Inclusion criteria were: a) diagnosis of diabetes by standard criteria; b) age at diagnosis of diabetes, 30 – 70 years; c) duration of disease between 6 months to 5 years. The concentrations of glucose, glycosylated hemoglobin, lipid profile, creatinine, C-peptide, and GADA were measured in serum/plasma samples after fasting for more than 10 hours. Subjects with GADA in whom insulin was started at diagnosis or within one month of diagnosis were defined as DM1. All antibody negative subjects were diagnosed as DM2. LADA patients were defined as patients who did not require insulin for at least 6 months after diagnosis and depicted GADA at their sera. Results and Conclusions: 1- LADA represents 6.5% of cases among all adult-onset diabetes in a region of Northern India, considerably a higher frequency than reported in two previous studies. In diabetic subjects diagnosed at 31-40 years of age, the frequency of LADA was 13.9%. A decreasing trend of LADA with increasing age was suggested, similar to reports from Chinese and European publications. 2- In our study, LADA was the prevalent subtype of adult-onset autoimmune diabetes, in agreement with earlier reports showing lower prevalence of DM-1A among children and adolescents in Northern India. In this investigated population, the prevalence of LADA was much lower than previously reported in Southern India. 3- The group of subjects with diagnosis of LADA were younger, and presented lower abdominal circumference, serum C-peptide and triglycerides levels at fasting than the group of subjects with DM2 from the same area of Northern India. 4- In our study, LADA patients depicting high titers of GADA in their sera at the time of diagnosis were more likely to be male, leaner, and insulin- treated, and less likely to display systolic hypertension and the metabolic syndrome. 5- In the same investigated population, LADA patients depicting low titers of GADA in their sera were mostly females, and they did not show phenotypic differences than DM-2 patients, similar to data reported for Asian Chinese population, in contradiction to the data reported for European population. 6- In comparison to subjects with DM2, serum C-peptide levels at fasting at the time of diagnosis were lower in LADA patients in the current study. This difference remained after 36 months, contrary to data of Spanish LADA Study.

Every day, India sees the addition of 5,000 new cases of diabetes to its current diabetic population of 65 million people. This number is projected to cross the 100 million mark in 15 years. The emerging pandemic scale of diabetes growth is straining India's already-overburdened public healthcare resources. India is home to several well-established native and adapted foreign traditions of medicine that are widely practiced. These traditions include Ayurveda, yoga and naturopathy, unani, siddha, and homeopathy. The modern and traditional medicine approaches are extensively used as independent systems. The purpose of this qualitative research case study was to evaluate the use of an integrative approach to address the multiple challenges posed by diabetes in India. The research design for the case study was based on the theoretical framework of participatory action research. The research questions evaluated how the modern and traditional medicine systems can be jointly used to contain the spread, scale, and immensity of diabetes in India and examined the barriers and challenges in combining various systems of medicine. Data were collected from interviews with 30 modern and traditional medical practitioners and 6 policy makers identified through a stratified purposeful sampling process. The transcribed data were coded thematically and objectively analyzed. The trustworthiness of interpretations was bolstered with triangulation through records from notes and observations. In evaluating the feasibility of a synergistic and integrative approach, the study filled a gap in scholarly literature. The study contributes to social change by adding to the existing body of knowledge available to physicians and patients in preventing and containing the diabetes pandemic.

Every day, India sees the addition of 5,000 new cases of diabetes to its current diabetic population of 65 million people. This number is projected to cross the 100 million mark in 15 years. The emerging pandemic scale of diabetes growth is straining India's already-overburdened public healthcare resources. India is home to several well-established native and adapted foreign traditions of medicine that are widely practiced. These traditions include Ayurveda, yoga and naturopathy, unani, siddha, and homeopathy. The modern and traditional medicine approaches are extensively used as independent systems. The purpose of this qualitative research case study was to evaluate the use of an integrative approach to address the multiple challenges posed by diabetes in India. The research design for the case study was based on the theoretical framework of participatory action research. The research questions evaluated how the modern and traditional medicine systems can be jointly used to contain the spread, scale, and immensity of diabetes in India and examined the barriers and challenges in combining various systems of medicine. Data were collected from interviews with 30 modern and traditional medical practitioners and 6 policy makers identified through a stratified purposeful sampling process. The transcribed data were coded thematically and objectively analyzed. The trustworthiness of interpretations was bolstered with triangulation through records from notes and observations. In evaluating the feasibility of a synergistic and integrative approach, the study filled a gap in scholarly literature. The study contributes to social change by adding to the existing body of knowledge available to physicians and patients in preventing and containing the diabetes pandemic.

Background Rural Andhra Pradesh is a developing region in India with reported high prevalence of diabetes mellitus and blood lipid levels. This is consistent with a worldwide transition of mortality and morbidity towards predominantly non-communicable conditions such as heart disease, stroke and diabetes. Detecting and monitoring these changes in less accessible regions of the world is a difficult task. Methods Three cross sectional studies examining cardiovascular risk factors in the Godavari region of rural Andhra Pradesh were done in 2005 (Andhra Pradesh Rural Health Initiative, APRHI), 2010 (Gates Grand Challenge 13, GC13) and 2014 (Systematic Medical Appraisal Referral and Treatment Health, SMARThealth). Diabetes prevalence from all three studies and blood lipid levels from 2005 and 2010 were compared to assess the trend. The data were further divided into a primary analysis including only fasting plasma glucose measurements and a secondary analysis which allowed for other methods of diabetes diagnosis. A systematic review and meta-analysis of the use of dried blood spots (DBS) for cardiometabolic risk factor analysis was also conducted. Findings Sixteen studies were included in the meta-analysis of the use of dried blood spots, 12 of which reported necessary data for haemoglobin A1c (HbA1c), one for triglycerides, two for both triglycerides and total cholesterol and one for HbA1c, total cholesterol and high density lipoprotein (HDL). Study sizes ranged from 30 to 613 participants. For HbA1c the summary regression (DBS = 0.9858Venous + 0.3809) showed close agreement between analyses based upon the venous and DBS sampling methods. The summary regression line for total cholesterol (DBS = 0.6807Venous + 1.151) indicates a requirement for moderate adjustment of values based upon analyses of DBS samples to obtain estimates equivalent to standard analyses based upon venous samples. For triglycerides, the summary regression for the three contributing studies showed a close association between the results obtained for the two methods (DBS = 0.9557Venous + 0.1427). The primary analyses of dysglycaemia (diabetes and prediabetes) were based upon 3243 individuals from APRHI and 749 individuals from SMARThealth for whom fasting plasma glucose samples were available. The estimated prevalence of dysglycaemia was 53.7% (51.8 - 55.7, 95% CI) in 2005 and 62.0% (58.5 - 65.4, 95% CI) in 2014 (p<0•001). The primary difference in population characteristics across the two surveys was a more than one unit rise in mean BMI driven by an approximate 1.7kg rise in mean weight. For the secondary analyses there were 3333 individuals aged 40 to 85 included from the APRHI study in 2005; 2200 individuals included from the GC13 survey done in 2010; and 62 254 participants included from the SMARThealth survey in 2014. For the secondary analyses the estimated prevalence of dysglycaemia was 53•9% (52•0 - 55•9, 95% CI) in 2005, 50•5% (46.1 - 54.9, 95% CI) in 2010, and 41.3% (40.9 - 41.7, 95% CI) in 2014 with the data suggesting a decline across the three time points (p<0.001). There were significant increases observed between 2005, 2010, and 2014 for both body mass index (BMI) (p<0.001) and weight (p<0.001). Mean total cholesterol decreased from 4.6mM in 2005 to 3.4mM in 2010 while mean low density lipoprotein decreased from 2.9mM to 1.5mM during the same period. Conclusions The use of dried blood spots as a method of reporting HbA1c levels appears justified but further studies are required to confirm the suitability of blood lipid level measurements based upon dried blood spots. Every estimate of dysglycaemia was high suggesting that dysglycaemia is a major problem in this part of Andhra Pradesh. Further, the upward trend in dysglycaemia observed in the primary analyses and the corresponding adverse trend in obesity measures suggests that the problem is getting worse not better. The differences in observed trends between the primary and secondary analyses are almost certainly attributable to the variable assay methods used across the data included in the secondary analyses. The steep changes in lipid levels are likely incorrect and have been biased by the study methods.

Every day, India sees the addition of 5,000 new cases of diabetes to its current diabetic population of 65 million people. This number is projected to cross the 100 million mark in 15 years. The emerging pandemic scale of diabetes growth is straining India's already-overburdened public healthcare resources. India is home to several well-established native and adapted foreign traditions of medicine that are widely practiced. These traditions include Ayurveda, yoga and naturopathy, unani, siddha, and homeopathy. The modern and traditional medicine approaches are extensively used as independent systems. The purpose of this qualitative research case study was to evaluate the use of an integrative approach to address the multiple challenges posed by diabetes in India. The research design for the case study was based on the theoretical framework of participatory action research. The research questions evaluated how the modern and traditional medicine systems can be jointly used to contain the spread, scale, and immensity of diabetes in India and examined the barriers and challenges in combining various systems of medicine. Data were collected from interviews with 30 modern and traditional medical practitioners and 6 policy makers identified through a stratified purposeful sampling process. The transcribed data were coded thematically and objectively analyzed. The trustworthiness of interpretations was bolstered with triangulation through records from notes and observations. In evaluating the feasibility of a synergistic and integrative approach, the study filled a gap in scholarly literature. The study contributes to social change by adding to the existing body of knowledge available to physicians and patients in preventing and containing the diabetes pandemic.

BACKGROUND:India has the second largest diabetic population (61 million) and tobacco users (275 million) in the world. Data on smoking cessation among diabetic patients are limited in low and middle income countries. The objective of the study was to document the effectiveness of diabetic specific smoking cessation counseling by a non-doctor health professional in addition to a cessation advice to quit, delivered by doctors.METHODS:In our parallel-group randomized controlled trial, we selected 224 adult diabetes patients aged 18 years or older who smoked in the last month, from two diabetes clinics in South India. Using a computer generated random sequence with block size four
the patients were randomized equally into intervention-1 and intervention-2 groups. Patients in both groups were asked and advised to quit smoking by a doctor and distributed diabetes specific education materials. The intervention-2 group received an additional diabetes specific 30 minutes counseling session using the 5As (Ask, Advise, Assess, Assist and Arrange), and 5 Rs (Relevance, Risks, Rewards, Roadblocks and Repetition) from a non-doctor health professional. Follow up data were available for 87.5% of patients at six months. The Quit Tobacco International Project is supported by a grant from the Fogarty International Centre of the US National Institutes of Health (RO1TW005969-01).The primary outcomes were quit rate (seven day smoking abstinence) and harm reduction (reduction of the number of cigarettes / bidis smoked per day > 50% of baseline use) at six months.RESULTS:In the intention to treat analysis, the odds for quitting was 8.4 95% confidence interval (CI): 4.1-17.1] for intervention-2 group compared to intervention-1 group. Even among high level smokers the odds of quitting was similar. The odds of harm reduction was 1.9 (CI: 0.8-4.1) for intervention-2 group compared to intervention-1 group.CONCLUSIONS:The value addition of culturally sensitive diabetic specific cessation counseling sessions delivered by non-doctor health professional was an impressive and efficacious way of preventing smoking related diabetic complications.TRIAL REGISTRATION:Clinical Trial Registry of India (CTRI/2012/01/002327)

Background: Type 2 diabetes is among the fastest growing diseases in the world, especially in India where the prevalence is 9 percent and expected to rise significantly. Managing diabetes involves a substantial portion of self-care and lifestyle changes for the patient. Hence, the nursing care to patients needs to be focused on promoting self-care and empowerment. Objective: To describe the nursing care, focusing on self-care and empowerment, provided to patients with type 2 diabetes at a private diabetes clinic in India. Method: Eleven diabetes educators with specialist training were interviewed individually. Data was analysed using qualitative contents analysis. Results: One core category called Comprehensive approach was found. Additionally, the data was sorted into four main categories: Nursing care interventions, Counselling, Health education and Health protection. Conclusion: The participants had a comprehensive view of the patients, the disease and the role of health personnel involved in the care. This holistic approach permeated the nursing care performed by the participants, facilitated empowerment and the promotion of self-care to the patients. Clinical relevance: The study provides a widened perspective and understanding of the concepts of self-care and empowerment to patients with type 2 diabetes in different cultural contexts. The results can serve as an inspiration to new ways of promoting self-care and empowerment to patients with other health problems.
Bakgrund: Diabetes typ 2 är en av de snabbast ökande sjukdomarna i världen, särskilt i Indien. Där är prevalensen 9 procent och den befaras stiga betydligt. För att hantera sjukdomen behöver patienten genomföra livsstilsförändringar och behärska egenvård. Därför bör omvårdnaden inriktas på empowerment och att främja patientens förmåga till egenvård. Syfte: Att beskriva den omvårdnad, med fokus på egenvård och empowerment, som ges till patienter med diabetes typ 2 på en specialistklinik i Indien. Metod: Elva diabetesutbildare med specialistutbildning intervjuades individuellt. Materialet analyserades med hjälp av kvalitativ innehållsanalys. Resultat: En kärnkategori, kallad Helhetsperspektiv, hittades. Därutöver sorterades materialet in i fyra huvudkategorier: Omvårdnadsåtgärder, Rådgivning, Hälsoutbildning och Hälsoskyddande åtgärder. Slutsats: Respondenterna hade en helhetssyn på patienterna och sjukdomen, samt på den roll all hälsopersonal som var inblandad i vården hade. Denna helhetssyn genomsyrade omvårdnaden, hur respondenterna arbetade med empowerment till patienterna samt hur de stärkte patienternas kapacitet att utföra egenvård. Klinisk betydelse: Studien bidrar till en vidgad syn på och ökad förståelse för begreppen egenvård och empowerment när det gäller patienter med diabetes typ 2 i olika kulturella kontexter. Resultatet kan även inspirera till nya sätt att arbeta med empowerment och att främja egenvård bland andra patientgrupper.

Introduction - India is beginning to resemble the western worlds’ way of living and that leads to an increased risk of chronic diseases such as diabetes. Due to its very large population India has the world second largest number of people with diabetes; 61, 3 million people. Studies have shown that the awareness of diabetes is poor, especially in rural areas. Aim - To investigate nurses’ experience of applying professional competence in patient education with focus on diabetes type II in an Indian rural hospital. Method – Data was gathered through twelve qualitative interviews. The interviews were tape recorded, transcribed verbatim and then analyzed through content analysis. Result – Three main categories were identified; Acquired competence to meet the patients, Helping the patients manage their disease and Nurses’ ideas for quality improvements regarding diabetes care. Conclusion - This study identified different obstacles that could have a negative effect on the care and treatment of patients with diabetes type II. The nurses had many ideas for quality improvements which could raise the awareness of the disease among patients, improve clinical outcomes and the work environment for the nurses. The nurses are willing to get more education about the disease and implement quality improvements if the resources and equipment are provided by the hospital.

Background: India's growing economy has led to radical lifestyle changes and one of the consequences is an unexpected explosion of non-communicable diseases, such as Type 2 Diabetes. The prevalence of Type 2 Diabetes has more than doubled since 1980 from four to over eight percent in 2016. India has today the second largest adult population affected by Type 2 Diabetes in the world. 72.9 million adults had diabetes in India 2017 and by year 2035 this number is predicted to rise to 109 million. To cope with this epidemic, patients will need to perform adequate self-management. Nurses’ may have a major part in providing the support and knowledge patients require to be able to perform this.  Aim: The aim of the study is to describe nurses’ experience of good self-management among patients diagnosed with T2D. Method: The study has a descriptive and qualitative design. Semi structured interviews with open-ended questions were carried out at a hospital setting in Kerala, India. Results: The analysis from the interviews resulted in three sub-themes and one main theme. The three sub-themes are Support from the family is fundamental for the patient's well-being, The importance of individualized care and The importance of teaching patients how to manage their condition. The three sub-themes resulted in the main theme Three Cornerstones for good self-management. Discussion: The result demonstrates that the nurses’ finds individualized care as an important matter. The participants declare that patients have different knowledge regarding Type 2 Diabetes, and how individualized care is a way to provide what the patient requires in order to perform self-management. The nurses also express how they always involve the patients' family, since their experience is that the absence of the family impairs the patient's condition.

Background. Hypertension and diabetes have become a major public health challenge in India. This research work aims to develop a feasible and scalable intervention for hypertension and diabetes, tailored to primary care settings in India. Objectives. To conduct a healthcare facility assessment to inform the development of a Smartphone-enabled intervention package for hypertension and diabetes at primary healthcare facilities in India. To pilot the Smartphone-enabled hypertension and diabetes intervention package at primary healthcare facilities in India in order to identify the barriers, synergies and health system strengthening requirements for the feasibility and scalability of such an intervention. Methodology. This research work was carried out in five Community Health Centres (CHCs) in Solan, Himachal Pradesh. The implementation and evaluation of the piloting, guided by a conceptual framework1, was carried out using mixed methods, following implementation science principles. Results. In this research work, a six component intervention was developed comprising a Nurse Care Coordinator (NCC), a structured training programme, clinical management guidelines, a Smartphone-based clinical decision-support system, counselling services and follow-up plan for patients. During piloting, NCCs detected that 37% of the out-patient clinic attendees had hypertension/diabetes. At three months of follow-up, systolic blood pressure had a mean reduction of 10.9+/-13.1 mmHg (p<0.001) in 2974 participants while fasting glucose level had a mean reduction of 26.4+/-49.0 mg/dl (p<0.001) in 717 subjects. Discussion. This research work demonstrated that a six component intervention for hypertension and diabetes care is feasible. However, barriers such as inadequate manpower, insufficient drug supply and inadequate lab facilities need to be addressed for optimal intervention delivery. Conclusion. A Smartphone decision-support-enabled, NCC-facilitated intervention for hypertension and diabetes is feasible for primary care settings in India.

Class of 2013 Abstract
Specific Aims: Conduct a comprehensive and systematic review to identify and describe studies from October 2010 to May 2012 that have addressed diabetes interventions in American Indian populations and assess the impact those interventions had on improving humanistic and therapeutic outcomes in preventing or treating diabetes in American Indians. Methods: Studies published between 5 October 2010 and 30 May 2012 that described diabetes interventions or programs in American Indian populations were identified via electronic searches of PubMed, CINAHL, IPA, Cochrane, PsychINFO, Web of Science, and ERIC using key search terms related to (and MeSH terms where applicable) diabetes, interventions, medication adherence, diet, exercise, blood glucose, cholesterol, blood pressure, North American Indians, American Indians, Native Americans, and Alaska Natives. Articles were reviewed and were excluded if the study had no comparison group, was not interventional or programmatic in nature, took place outside the US, study population was < 50% American Indian, or did not report on patient-related outcomes. Data on study characteristics, patient characteristics, and study outcomes were extracted. Main Results: A total of five studies were included. Positive, significant effects were reported on A1c in 40% (n=2), cholesterol in 40% (n=2), blood pressure in 40% (n=2), weight/BMI in 20% (n=1), blood glucose monitoring in 20% (n=1), diet in 20% (n=1), and diabetes knowledge and health literacy in 20% (n=1). Conclusion: The literature review had minimal results. Of those included, the majority of diabetes interventions were educational-related, observational in design, assessed only adults, and study populations were primarily female. Few of the included studies interventions demonstrated significant improvements in diabetic outcomes. Continued research and efforts to further improve diabetes management within the American Indian community is needed.

Type 2 diabetes is epidemic in the American Indian population. One problem health care providers face when working with the American Indian population is communicating about secondary complications, such as periodontal disease. From a public health standpoint, periodontal disease prevention is important not only to prevent unnecessary oral pain and tooth loss, but also to prevent other more serious systemic problems from occurring such as cardiovascular disease, strokes, and bacterial pneumonia. The purpose of this qualitative study was to examine the communication efforts of health care providers and understand if and how they discuss periodontal disease with their American Indian patients with type 2 diabetes. Structured interviews were conducted with health care providers at an American Indian community clinic using questions based on the model of communication competence. Data analysis consisted of an analysis of the interview transcripts looking for concepts, themes, and events to see if discussion of periodontal disease is occurring at diabetic visits. Results of the study showed that although all the providers knew about the link between diabetes and periodontal disease risk, not all the providers were discussing the risk with their patients, and time, perceived health literacy, and other priorities all played a role in the lack of communication. This finding has the potential to influence positive social change by being an impetus for change in current diabetic patient care policies in the areas of communication and education regarding American Indian patients with diabetes about periodontal disease risk.

Maturity-onset diabetes has become a growing health problem among Canadian Native Indians. Although there is a growing body of literature examining the etiology and cultural meanings of diabetes in this population, there is little knowledge of the Native perspective of diabetic diet management among groups in Western Canada. Therefore, the purpose of this study was to examine the problems perceived by Native Indians in managing a diabetic diet. Kleinman's conceptual framework guided the formulation of the research question and methodololgy. In order to elicit and understand the experience of diabetic diet management from the perspective of the Native Indian, the qualitative research method of phenomenology was employed. Data were collected through the use of unstructured tape-recorded interviews that allowed the subjects to describe the phenomenon in their own words according to their own reality. The sample consisted of three men and three women all living on reserve from three Coast Salish bands in the Fraser Valley of British Columbia. Four of the subjects were interviewed twice, the other two were seen three times for a total of fourteen in-depth interviews. Data were collected and analyzed simultaneously over a period of seven months. After being transcribed verbatim, interview data were examined for common themes that emerged and the raw data were coded accordingly. As themes surfaced during the analysis, they were clarified, validated, and/or discounted during subsequent meetings with the informants. In this process, the nature of diabetic diet management was elucidated. The problems experienced by the informants were embedded in the larger phenomenon of diabetes management. How the illness was understood and dealt with in the context of daily living shaped the experience of diet management and the nature of the problems that surfaced. Two central interrelated concepts emerged from the data that explained how the subjects lived with their diets on a daily basis. The first concept entailed the evolving personal understanding of diabetes as it was shaped by the subjective experience of symptoms and the anecdotal stories of the numerous relatives with the same illness. The second concept emerged from the interwoven social environment in which the subjects lived out their daily lives. This was discovered to be both a source of difficulty and a source of strength for the individuals of the study. A variety of implications for nursing surfaced from the findings. For nursing practice, diabetic education and program development need to be planned and implemented in collaboration with Native leaders and clients. Educators must examine how nursing curricula can focus on the client's perspective of the illness experience to better enhance communication and health care delivery. There also remain many unanswered questions regarding the diabetic experience in this cultural group and how it is tied to the social network of such communities.
Applied Science, Faculty of
Nursing, School of
Graduate

This thesis explores the impact of type 2 diabetes among Indian and Pakistani migrants. Indians and Pakistanis living in the UK have a high incidence of type 2 diabetes and associated complications. Research is needed in order to understand factors that make it difficult to adhere to lifestyle advice about diet, exercise and medication. Drawing on data collected during a sixteen-month ethnographic investigation, this thesis explores Indians’ and Pakistanis’ perceptions of diabetes. The research revealed that Indians and Pakistanis related the onset of diabetes to processes of migration and settling in the UK as well as to stress and depression. In particular, holding on to negative thoughts and worries, were perceived by respondents as directly affecting the body by causing stress, depression and eventually illness. Struggles over diabetes control were also perceived as to cause distress. Specifically, respondents struggled to adhere to a healthy diet regime, since food, especially taste, played a crucial role in forming, reinforcing and demarcating social relations and in ensuring cultural continuity. In addition, respondents struggled to ‘adhere’ to their prescriptions of diabetes medications due to the uncomfortable side effects that they experienced, particularly in the stomach. Respondents, however, counteracted side effects by turning to alternative medications which were perceived to facilitate flow within the circulatory and digestive system. Thus, in spite of the difficulties that Indians and Pakistanis experienced in following biomedical recommendations for diabetes control, they still actively engaged in searching and using different treatments available to them in order to control the disease.

Objetivo: Comparar el Índice Glicémico (IG) de tres variedades de Chenopodium Quinoa Wildenow (CQW) provenientes de Perú. Materiales y métodos: Se llevó a cabo un estudio cuasi-experimental de acuerdo a la norma ISO 26642:2010(E), en 26 adultos voluntarios aparentemente sanos residentes en Lima, Perú. Las variables de exposición fueron tres variedades de quinua: CQW Blanca Salcedo (CQW–B), CQW Negra Collana (CQW–N) y CQW Roja Pasankalla (CQW–R). Se tomaron muestras de sangre capilar en siete momentos durante un periodo de dos horas y se analizaron mediante el método de glucosa oxidasa. La estimación del IG se basó en las áreas bajo la curva obtenidas mediante el método trapezoidal. La comparación de los valores de IG se realizó mediante el múltiple análisis de varianza para muestras dependientes (MANOVA). Resultados: El IG de CQW - B y CQW – N, fueron clasificadas como de IG medio, con valores de 63,1 ± 22,3 y 62,3 ± 22,5 respectivamente, y la CQW - R fue clasificada como de IG alto, con un valor de 74,8 ± 29,7. No se encontraron diferencias estadísticamente significativas tanto para los valores crudos (p= 0,33), como ajustados por edad y sexo (p= 0,27) entre los IG de las tres variadades de quinua. Conclusiones: El IG de las variedades de quinua estudiadas no es bajo y podría ser incorporado en la dietoterapia de pacientes que requieran del control glicémico, mediante un control adecuado de porciones asesorado por un profesional de la salud capacitado.
Objective: To compare the glycemic index (GI) of three varieties of Chenopodium Quinoa Wildenow (CQW) from Peru. Materials and methods: - 26 participants apparently healthy volunteers living in Lima: a quasi-experimental study according to the ISO 26642 standard was conducted. Exposure variables were three varieties of quinoa: Blanca CQW Salcedo (CQW - B), CQW Black Collana (CQW - N) and CQW Red Pasankalla (CQW - R). Capillary blood samples were taken seven times over a period of two hours and analyzed by the glucose oxidase method. IG estimation was based on the areas under the curve obtained by the trapezoidal method. The comparison of GI values was performed by multiple analysis of variance for dependent samples (MANOVA). Results: The GI of CQW - B and CQW - N were classified as medium-GI, with values of 63.1 ± 22.3 and 62.3 ± 22.5 respectively, and CQW - R was classified as high-GI with a value of 74.8 ± 29.7. No statistically significant both crude level (p = 0.33) differences were found, as adjusted by age and sex (p = 0.27). Conclusion: IG quinoa varieties studied is not low and therefore should be incorporated in the diet therapy of patients requiring glycemic control through proper portion control advice from a dietitian nutritionist.
Tesis

The aim of this study was to determine the predictors of excess weight gain among children participating in the Kahnawake Schools Diabetes Prevention Project (KSDPP). Study objectives were addressed in a secondary analysis of data collected from 1994 to 2004. Mean BMI percentiles and relative weight values increased over time in repeat cross-sectional analyses. Participants followed longitudinally were split into two groups: (1) children gaining weight at ≤ the median value of weight for their age, sex and height (n=86); (2) children gaining > the median value (n=177). Therefore, two-thirds of the participants were gaining weight greater than the norm. Among boys only, those in the higher weight group were heavier for their age, sex and height at the start of their follow-up period. No significant differences were observed in reported dietary intake, physical activity levels or screen time between children in the two weight gain groups.

This study assessed change in the dietary intake and weight, height and body mass index (BMI. kg/ml) measurements of children (grades 4--6) who have participated in the Kahnawake Schools Diabetes Prevention Program (KSDPP). Children from two independent cross sectional samples were assessed at baseline in 1994 (n = 156) and in 1998 (n = 146). Diet was assessed using a single 24-hour recall. Results showed no overall change in energy, fat and sucrose intake. Food groups were created as indicators of diet quality. Results showed a decrease in the frequency of consumption of foods in the high fat food group (p < 0.05) and an increase in the average amount of white sugar consumed (p < 0.05). A decrease in the number of servings of fruit was shown, but also a trend towards their increased frequency of consumption. No significant changes were found in weight, height or BMI. Dietary and anthropometric data were combined but results showed no significant changes in diet by BMI category. Changes in diet are challenging to both measure and implement. These results could be used to identify more specific future interventions.

More than half of all Pima Indians over age 35 have Diabetes Mellitus and prevalence rates continue to rise; this despite billions of dollars spent every year on research and prevention activity by the National Institute of Health, the American Diabetes Association, and the Indian Health Service nationwide. Because of the many health problems which can occur in conjunction with uncontrolled diabetes, including heart disease, kidney disease, neuropathy, retinopathy, and depression, the insidious or symptomless nature of this disease creates an urgent need for early detection, prevention, and effective treatment. Several anthropological studies of Native Americans have been conducted over the last century, but few have focused on Native American understandings of and response to diabetes, particularly its sometimes "latent" quality, as in gestational diabetes which "goes into remission" after childbirth. Biomedical concepts such as risk, prevention, disease latency, and genetic predisposition or heritability are critical to the prevention of many chronic illnesses, but do not translate well or effectively across cultural lines. This dissertation presents a focused ethnography examining this process of integration between Native American and biomedical health models at the Gila River Indian Community, particularly around the issue of diabetes. Because diabetes is a complicating factor in pregnancy and childbirth due to fetal stress, high birth weight, and necessitated cesarean-section deliveries, and due to the relationship between gestational diabetes and the subsequent health of both the mother and infant, pregnant women are the focus of this research.

In Australia, type 2 diabetes mellitus (T2DM) is a leading cause of morbidity and mortality with approximately 1.2 million people affected. Australia has a large number of migrants: as of June 2019, 7.5 million (29.7%) Australians were born overseas, and the Indian migrant population is 660,000 (2.6% of the total population). Evidence suggests that there is a very high prevalence of diabetes among Indian migrants (14.8%) compared to the Australian-born population (7.1%) along with a high rate of diabetes-related hospitalisation and complications. Indians are traditionally known for high use of ayurvedic medicines (AM), a component of complementary and alternative medicines (CAMs). Diabetes management's primary goal is to reduce symptoms, avoid the associated harms and improve quality of life. The patient can achieve these goals by adhering to treatment and lifestyle modifications. However, maintaining a normal blood sugar level can be challenging for Indian migrants because of several factors, such as an unhealthy diet, inadequate physical activity, poor adherence to medicines, religious factors, poor understanding of the health system, treatment costs, migration-related stress, seeking a job and other family-related issues. Ethno-racial and socio-cultural characteristics affect not only the susceptibility of individuals to diabetes, but also the day-to-day management of diabetes. While it is understood that Indian migrants are generally more at risk of developing diabetes than local Australians, the impact of Indian ethno-cultural traditions and religious and social norms on diabetes management is not well understood. The socio-cultural structure, traditions and ideologies of Indian migrants are complex and unique, and their impact on diabetes needs to be explored for a comprehensive understanding of, and interventions to improve, diabetes management for Indian migrants. Overall, this research aimed to gain an understanding of the factors that influence decision-making about medications and medication adherence in Indian migrants with type 2 diabetes (T2D), living in Australia. The research consisted of two stages: in-depth qualitative interviews and on-line survey using discreet choice experiments. The specific qualitative study objectives were: • To investigate Indian migrants’ awareness and understanding of, and access to, the healthcare system; how they feel it compares with their experience in India; and how they perceive this access influences their diabetes care. • To investigate Indian migrants’ medication-taking behaviour (with conventional medicines for diabetes) and factors that influence adherence at its three phases. • To explore the beliefs, decision-making process and experiences of patients with type 2 diabetes mellitus (T2DM) using AM, with a specific focus on the AM use pattern and disclosure to doctors, sources of information about AM and where AM is purchased. • To explore how Indian migrants cope with T2DM through religion and spirituality, and the impact of religion and fasting on insulin use. The specific discrete choice experiment (DCE) study objectives were: • To determine the preferences for conventional vs AM in Indian migrants with T2DM. • To identify the factors that may influence the preferences. Methods Qualitative study A qualitative study was designed consisting of face-to-face interviews. The study included Indian-born migrants (Australian citizen/permanent resident) aged 18 years or over; with T2DM; using at least one anti-diabetic medication; living in Greater Sydney or its surrounding suburbs, responsible for their own medications and fluent in English and/or Hindi. Twenty-three participants were interviewed; data saturation was reached after the 18th interview. The interview protocol was prepared after an extensive literature review, and comprised open-ended questions to enable participants to speak freely. The 40–45-minute interviews were audio recorded, transcribed verbatim and thematically analysed using a framework and an inductive approach to thematic analysis. Data analysis was performed manually using Microsoft Word. The consolidated criteria for reporting qualitative research (COREQ) was used to provide transparency in data reporting to improve the rigor, comprehensiveness and trustworthiness of the study. DCE research methods Participants completed an online survey with eight choice tasks and answered demographics questions. In the choice tasks, they chose their preferred medicine (conventional vs AM) or a 'no medicine' option. Paid and unpaid strategies were employed to recruit the participants, using Facebook and email. A D-efficient design was used to balance the attribute levels and to select a subset of the medication profiles. A total of 32 choice tasks were generated; however, to improve feasibility, the survey was blocked in 4 iterations, with each respondent completing 8 chosen tasks. Attributes and attribute-levels for the DCE were chosen systematically following a literature review and the qualitative research findings. Eight attributes (glycated haemoglobin, side effects, number of times medicine is taken (frequency), formulation, instructions to take with food, hypoglycemic events, weight change and cost of the medications) were selected. The levels chosen were widely spaced to encourage participants to maximise trade-off and increase the reliability of parameter estimates. Descriptive statistics (standard deviation, mean and frequency) for the socio-demographic characteristics of the sample and other parameters were reported. The DCE responses were analysed; a mixed multinomial logit (MMNL) model was used as it relaxes the assumption of identical distribution and accounts for heterogeneity in preferences between individuals. In DCE, parameter (β) estimates refer to the importance given by patients to an individual attribute-level, where a higher value indicates higher utility. The computer programme NLogit 6 was used for data analysis. Results Qualitative study Twenty-three participants were interviewed. The majority of participants were male (n=18) and followed Hinduism (n=17). Twelve participants had used AM at least once since they had been diagnosed with diabetes, and the remaining 11 had never used AM for diabetes (5 used AM for other conditions). Once diagnosed with T2DM, Indian migrants reported mixed emotions. Participants contemplated the need to restrict their diet, change their lifestyle and use lifelong medicines, and raised several issues related to their physical and mental health, which they felt were deteriorating. Consequently, they felt that they had to take further action to manage their diabetes: to maintain a normal blood sugar level, and to maintain well-being and inner or spiritual comfort. Controlling diabetes and associated health problems, such as co-morbid conditions and diabetes-related health issues, through the use of medications (either conventional or ayurvedic) was regarded as an important strategy. The findings show a limited knowledge of the healthcare system, and the use of informal sources (e.g., family, friends, social media) to learn about the healthcare system and the available services. Several barriers to decision-making in accessing health services were identified, such as socio-cultural beliefs, social impacts, preference for Indian healthcare professionals and the high cost of medications; these ultimately influenced diabetes management, which could lead to poor diabetes control. The study also identified some enablers encouraging people to improve their diabetes care, such as Health Cards (Medicare and NDDS card), which enable access to free GP consultations and laboratory tests and other diabetes products at a subsidised price. The findings suggest that religious beliefs influence diabetes management in this group. Participants believed that prayers gave them inner strength to manage their diabetes, and that prayers/blessings from religious leaders could help them manage their health conditions, including diabetes. Participants who held stronger religious beliefs were not in favour of using insulin or other medication derived from animal sources, and believed that fasting was an important religious obligation which could not be skipped due to diabetes. In contrast, some participants believed that animal-based medicines were permissible to consume and fasting could be skipped as it was detrimental to the health and well-being of people with diabetes. For the 12 participants that used AM, the decision-making process included evaluating AM benefits vs harms, and the positive opinions of others who used AM. Most participants expressed positive beliefs about AM (no side effects, can cure the condition and are effective), which influenced their decision to initiate AM. The decision to initiate AM was also influenced by other factors such as personals beliefs, social influence, and others’ experiences of using AM. They sought information from various sources such as family members, friends, multimedia, and from healthcare professionals in India. Participants believed that AM does not have side effects because it is obtained from a natural source (herbals), is effective and can cure diabetes. The use of AM was discontinued within months of initiation if there were no benefits. Participants used both ayurvedic and conventional medicines together as they believed that the combination of both medicines could better control blood sugar with no harmful effects. Most participants discontinued taking AM if they felt it was ineffective. Negative beliefs about AM centered on lack of scientific evidence to show effectiveness, and formulations. The majority of participants were initially prescribed oral antidiabetic medication and only two were started on insulin. From the time of diagnosis, patients made daily decisions about their diabetes disease control. The medication-taking behaviour among the participants changed at the three different phases of medication-taking (initiation, implementation, and discontinuation). Several factors influenced adherence at these three phases of adherence. At the initiation phase, most of the patients started conventional medication as soon as prescribed by GPs, while some postponed treatment initiation. The decision to initiate and continue the use of medications (adherence) was based on a balance between patient concerns and needs. The key motive was the desire to improve the diabetes outcome (control blood glucose level), and some participants were motivated to initiate treatment by advice/recommendations from GPs and the information they received about the medication. Fear of side effects delayed treatment initiation with conventional medications. Most participants reported taking their medication as prescribed. However, some reported forgetting their medication, especially when they were in a hurry for work or were out for family dinners or a party. In the implementation phase, patient benefits in (blood glucose levels) influenced people to adhere to conventional medications. Negative factors such as stigma and fear of side effects and drug dependence were identified barriers to adherence during the implementation phase. A few participants discontinued taking conventional medications once they started getting benefits and moved to AM; however, they restarted conventional medications if the desired results were not achieved with the ayurvedic medication. A few participants discontinued taking their medication due to fear of side effects. Overall, findings showed that negative beliefs and concerns about medications, such as fear of side effects, the stigma of diabetes and medications and fear of drug dependence, are common factors that influenced the initiation of medication. Decision to initiate the process was influenced by the balance between the desire to improve blood sugar levels and Hba1c outcomes (necessity beliefs) and negative medication beliefs (concerns). If the benefits were greater than the concerns, participants were more likely to initiate medications (either conventional or ayurvedic). DCE research The survey was completed by 141 participants. The average age was 49.7 years; most were male (n=92, 65.2%). The majority followed Hinduism (n=75, 53.2%). Many (n=80, 56.7%) respondents had co-morbid conditions, mainly cardiovascular disease. The majority (n=114, 80%) of participants used prescribed oral conventional medicine and 31.2% (n=44) used AM alone or with conventional medicines for their diabetes. Overall, the preference of respondents to initiate a medicine was negative for both medicines (conventional (β=−2.33164, p<0.001) and AM (β=−3.12181, p<0.001)); however, significant heterogenicity was noted in participants’ preferences (SD: 2.33122, p<0.001). Six attributes were identified to be a significant influence on medicine preferences: occurrence of hypoglycaemic events (relative importance, RI= 24.33%) was the most important, followed by weight change (RI=20.00%), effectiveness of the medicine (RI= 17.91%), instructions to take with food (RI= 17.05%), medicine side effects (RI=13.20%) and medicine formulation (RI= 7.49%). Another important finding was that participants expressed a desire to initiate a medicine despite the medicine having side effects, with the preference for initiation being higher with mild side effects compared with moderate to severe side effects. Conclusions This is the first qualitative study of Indian migrants with T2DM to explore their understanding of the Australian healthcare system; their medication-taking behaviour; and the impact of religious, cultural and other factors on diabetes management. The qualitative study revealed that Indian migrants had limited knowledge about the Australian healthcare system and relied on informal sources for information. Sociocultural beliefs, social influences, preferences for healthcare professionals, and high cost of medicine were barriers to accessing healthcare, while healthcare cards (Medicare and NDSS) were the main enablers. Religious beliefs play an important role in the self-management of diabetes among Indian migrants living in Australia. However, both positive and negative beliefs were identified regarding praying, using animal-based medicines, and the impact of fasting on the management of diabetes. Participants had a limited understanding of the rulings and teachings of their religion within the context of diabetes. Overall, Indian migrants usually use AM alone or with conventional medicine for diabetes self-management. Most took conventional medicines, though there were delays in initiation of the prescribed medicines. Side effects was a significant factor influencing medication adherence at all phases, whilst motivation to manage diabetes effectively was the key facilitator of medication taking. The quantitative findings demonstrated negative preferences for both conventional and ayurvedic medications; that is, Indian migrants were more likely to not start either conventional or ayurvedic medication to manage diabetes. Overall, if choosing between medications, they were more likely not to take ayurvedic medication compared to conventional medication. Preferences for conventional and ayurvedic medication were heterogenous and influenced by several factors. Experiencing hypoglycemic events was the most influential factor, followed by weight change, glycated haemoglobin, instructions for taking with food, side effects and formulation of medications. However, Indian migrants with T2DM indicated willingness to initiate medication to gain benefits despite mild and moderate side effects. This research has highlighted the importance of AM as a treatment option for T2D in Indian migrants living in Australia, and the range of factors influencing medication taking. The study findings point to the importance of healthcare professionals, particularly prescribers, to consider the range of factors that can impact medication taking when monitoring adherence, from initiation to persistence and discontinuation of therapy

This study assessed the diets of participants in the Kahnawake Schools Diabetes Prevention Project (KSDPP). Data were gathered from three cross-sectional surveys of students in grades four to six in the Mohawk community of Kahnawake. Single 24-hour recall interviews were conducted in 2002 (n = 151), 1998 (n = 153) and 1994 (n = 164). Mean number of servings of Vegetables and Fruits (3.6 per day), Milk Products (1.6 per day), and Meat and Alternatives (1.5 per day) were found to be below ranges recommended by Canada's Food Guide to Healthy Eating. Correspondingly, mean intakes of fibre, calcium and vitamin D were found to be below Adequate Intake references. Positive changes detected include a decrease in soda consumption and a shift toward whole grains. Results indicate that improved nutrient intakes will require closer adherence to the principles of Canada's Food Guide to Healthy Eating. KSDPP intervention staff are using results as a basis for intervention.

El objetivo de esta tesis fue determinar las propiedades antihiperglicemiantes del liofilizado del extracto acuoso de alta temperatura de la corteza del tronco de Mangifera indica (EMI), en ratas hiperglicémicas agudas. Determinamos el efecto antihiperglicemiante utilizando tres concentraciones (50, 250 y 750 mg/Kg/ml.) de EMI en un modelo de hiperglicemia aguda in vivo en ratas normoglicémicas. Se midió la evolución temporal de la glicemia tras la administración de EMI (30 minutos antes de la glucosa) por vo, utilizando un sistema de bioamperometría.
The objective of this thesis was to determine the antihyperglycemic properties of the lyophilization of the aqueous extract of high temperature of the crust of the trunk of Mangifera indica (EMI) in acute hyperglycemic rats. We determined the antihyperglycemic effect using three concentrations (50, 250 and 750 mg/Kg/ml.) of EMI in an acute model of hyperglycemia in live normoglycemic rats. The temporary evolution of glycemia mediated after the administration of EMI (30 minutes before the glucose) orally, using a bioamperometry system.

Background: Indian Asians are at increased risk of type-2 diabetes (T2D), insulin resistance and related metabolic disturbances compared to Europeans. The contribution of known lifestyle and genetic risk factors to the excess risk of T2D in Indian Asians is not well understood. Methods and materials: I investigated 16,774 Indian Asian and 7,301 European men and women participating in the in the London Life Sciences Population Study to determine the prevalence of T2D and related glycaemic disorders. I examined the contribution of adiposity, leisure time physical activity, major dietary macronutrients and known genetic susceptibility factors to the increased risk of T2D and related metabolic disturbances amongst Indian Asians compared to Europeans. Lastly I carried out a genome-wide association and replication study amongst 58,687 Indian Asian participants to identify novel genetic factors in this ethnic group. Results: The prevalence of T2D is ~4-fold higher amongst Indian Asians than Europeans, and is not accounted for by differences in adiposity and leisure time physical activity. In dietary studies, intake of fibre is inversely related to risk of insulin resistance among Indian Asians. However, major dietary macronutrients do not account for differences in insulin resistance between Indian Asians and Europeans. In genetic studies I demonstrate association of 25 previously reported T2D genetic variants with T2D amongst Indian Asians. Of the 48 T2D genetic variants examined, risk allele frequencies were similar and effect sizes lower amongst Indian Asians compared to Europeans; therefore known T2D genetic variants do not account for the increased risk of T2D in this racial group. In the GWAS I discover 6 novel T2D genetic variants among Indian Asians (GRB14, ST6GAL1, VPS26A, HMG20A, AP3S2 and HNF4A). Conclusions: T2D has emerged as a major healthcare problem worldwide, with rates highest among individuals of Indian Asian descent. For the first time I discover six novel genetic susceptibility factors for T2D amongst Indian Asians. However, there is a ~4-fold higher risk of T2D among Indian Asians compared to Europeans, which remains largely unexplained.

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Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES)
Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)
Diabetes mellitus (DM) é uma síndrome de etiologia múltipla caracterizada por hiperglicemia crônica. Esta hiperglicemia induz o aumento na produção de espécies reativas de oxigênio (ERO) e diminuição das defesas antioxidantes. Devido às complicações causadas pelo diabete, muitos indivíduos optam por terapias alternativas à base de plantas medicinais para amenizar seus efeitos. Sendo assim, nesta revisão de literatura, foram analisados e descritos diversos trabalhos experimentais com a utilização de animais diabéticos para comprovar os efeitos antioxidantes de algumas dessas plantas e verificar se os títulos e resumos disponibilizados nos artigos são compatíveis aos objetivos de nossa busca
Diabetes mellitus (DM) is a syndrome of multiple etiologies characterized by chronic hyperglycemia. This hyperglycemia induces increased production of reactive oxygen species (ROS) and decreased antioxidant defenses. Due to complications caused by diabetes, many people choose for alternative therapies and herbal medicine to alleviate its effects. Thus, in this literature review, several experimental studies with the use of diabetic animals were analyzed to demonstrate the antioxidant effects of some plants and to verify if the titles and abstracts provided in the articles are compatible to the aims of our search

El objetivo del trabajo fue realizar una comparación de las propiedades clasificatorias entre una regresión logística y un perceptrón multicapa aplicado a un problema dicotómico como es el diagnóstico positivo o negativo de diabetes. Los datos utilizados son del Pima Indian Diabetes Database que son propiedad del National Institute of Diabetes and Digestive and Kidney Diseases de los Estados Unidos de América. La metodología fue en el desarrollo de los algoritmos de la regresión logística y la construcción de un perceptrón multicapa en el lenguaje Python. LOs resultados muestran la superioridad clasificatoria del perceptrón multicapa por lo cual se sugiere su uso en problemas de clasificación.

The American Indian/Alaska Natives people are plagued by Type II Diabetes. The poor management of this disease process has dire effects on the morbidity and mortality of this population. It is imperative to identify the challenges that this group of people face with the self-management of Type II Diabetes. The conceptual framework for this study was based on Dorothea Orem's health deviation of self-care requisites. These health deviations result from the disease state and are used for diagnosis and treatment (Orem, 1985). The literature review and the discussion of results with the relevant literature were organized according to Orem's six themes of health deviations in the self-management. A qualitative research method, involving open-ended interviews with five Native American participants, was used. The participants were asked questions regarding their diagnosis, challenges in self-management, knowledge of long term effects, and additional needed resources. The data were analyzed using Luborsky's (1994), method of thematic analysis to identify the challenges Native American adults encounter in the self-management of Type II Diabetes, resulting in 8 topics. These included: a) feelings about Type II Diabetes diagnosis and the implications for lifestyle changes, b) prior experiences with family who have Type II Diabetes, c) challenges and lifestyle changes in managing Type II Diabetes, d) personal contributing factors to poor management, e) support systems for managing Type II Diabetes, f) identification of good management of Type II Diabetes, g) knowledge of long term effects of Type II Diabetes, h) additional support and resources needed to manage Type II Diabetes. Diabetes is a complex disease process that requires ongoing education and consistent medical care. It is essential that health care providers evaluate and tailor their care to the challenges of their patient population to improve the health status of those with Type II Diabetes.

Treatment of prediabetes includes education which provides the prediabetic person with information to help them make lifestyle modification choices regarding their nutrition, exercise and weight control; in order that they control their illness and delay or prevent the development of diabetes. American Indians have a high incidence of both prediabetes and diabetes as a group compared to other ethnic groups in the U.S. There is a lack of data in the literature about what American Indians from the Crow Tribe in Montana consider to be cultural information that they feel should be included in education for pre-diabetics. This qualitative ethno-nursing study was conducted through one-on-one interviews with six American Indian women of the Crow Tribe over a period of months to determine what they defined as culturally important for the health care provider to know when teaching about prediabetes. The data from these interviews were then analyzed using qualitative software by Ethnograph ®, and four primary themes were found. These themes were: extended family and elders, spirituality and traditions, culturally specific foods and activities and a feeling of inevitability of developing diabetes. As cultural competency is an area that is included in all schools of nursing and some schools of medicine, it is important that health care providers have an awareness of cultural specific health information. All the informants in this study reported that they felt more respected when their health care provider brought up the topic of how their culture affects their health habits, as well as how important to them it is that the health care provider be open to learning about the specifics of their culture.

Orientador: Débora Cristina Damasceno
Coorientador: Tiago Rodrigues
Banca: Kleber Eduardo de Campos
Banca: Emilio Herrera
Resumo: Diabetes mellitus (DM) é uma síndrome de etiologia múltipla caracterizada por hiperglicemia crônica. Esta hiperglicemia induz o aumento na produção de espécies reativas de oxigênio (ERO) e diminuição das defesas antioxidantes. Devido às complicações causadas pelo diabete, muitos indivíduos optam por terapias alternativas à base de plantas medicinais para amenizar seus efeitos. Sendo assim, nesta revisão de literatura, foram analisados e descritos diversos trabalhos experimentais com a utilização de animais diabéticos para comprovar os efeitos antioxidantes de algumas dessas plantas e verificar se os títulos e resumos disponibilizados nos artigos são compatíveis aos objetivos de nossa busca
Abstract: Diabetes mellitus (DM) is a syndrome of multiple etiologies characterized by chronic hyperglycemia. This hyperglycemia induces increased production of reactive oxygen species (ROS) and decreased antioxidant defenses. Due to complications caused by diabetes, many people choose for alternative therapies and herbal medicine to alleviate its effects. Thus, in this literature review, several experimental studies with the use of diabetic animals were analyzed to demonstrate the antioxidant effects of some plants and to verify if the titles and abstracts provided in the articles are compatible to the aims of our search
Mestre

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Pontif?cia Universidade Cat?lica de Campinas
Diabetes Mellitus is a chronic disease, characterized by a complex treatment. The present study was aimed at analyzing the contingencies to which type 2 diabetic patients would be submitted to concerning disease-related treatment conditions. Participants were 8 chronically ill adults under follow-up treatment at a health center in the city of Campinas Sao Paulo. A semi-structured interview questionnaire, and both the identification and the clinic evaluation forms were used for evaluation. Participants were divided into 2 groups by the test results of glicosilated hemoglobin (criterion that determines diabetes control): Group A (control) and Group B (non control). The results showed that Group A presented high compliance regarding instruction following on glucemia measurement, increased self control behaviors and positive reinforcement contingencies, compared to group B. Regarding insulin administration Group A presented greater discrimination of private events than group B. As to diet control there was a prevalence of self-ruled behaviors and self-controlled behaviors by Group A compared to Group B. On physical activity practice Group A demonstrated discrimination of private events and positive reinforcement. These results may be beneficial in directing future intervention programs that focus on promoting treatment enrollment behaviors.
O diabetes mellitus ? uma doen?a cr?nica, caracterizada por um tratamento complexo. O presente estudo teve como objetivo analisar as conting?ncias a que portadores de diabetes tipo 2 estariam submetidos frente as condi??es impostas pelo tratamento da doen?a. Participaram da pesquisa 8 adultos com o diagn?stico da doen?a e que realizavam acompanhamento m?dico em um centro de sa?de da cidade de Campinas. Para a avalia??o foi utilizada ficha de identifica??o, ficha de avalia??o cl?nica e o roteiro de entrevista semi-estruturada. A partir do resultado do exame de hemoglobina glicada (crit?rio que determina o controle do diabetes), os participantes foram divididos em 2 grupos: Grupo A (com controle) e o Grupo B (sem controle). Os resultados obtidos, com rela??o ? mensura??o da glicemia, mostraram que houve um melhor seguimento das orienta??es passadas pela equipe, comportamentos de autocontrole e conting?ncias de refor?amento positivo, do Grupo A em rela??o ao Grupo B. Na administra??o da insulina, o Grupo A apresentou uma melhor discrimina??o de eventos privados do que o Grupo B. No controle da dieta houve a preval?ncia de comportamentos governados por regras e de comportamentos autocontrolados no Grupo A do que no B. A pr?tica de exerc?cio f?sico revelou a presen?a de refor?o positivo e discrimina??o de eventos privados no Grupo A. Os resultados apresentados podem favorecer o direcionamento de poss?veis programas de interven??o que tenham como foco a promo??o de comportamentos de ades?o ao tratamento.

Minority populations such as American Indians (AIs) in the United States experience large-scale healthcare related disparities when compared with non-minority citizens. Diabetes can affect all races and ethnicities across the globe, regardless of age, sex, or location on the map, and affects AIs at disproportionately high rates. While type 1 diabetes mellitus (T1DM) is not preventable, type 2 diabetes mellitus (T2DM) can be prevented and avoided in some instances. The implementation of an evidence-based diabetes program in a school-based setting has the potential to positively improve the health of school-aged children. Based on the need for high-quality diabetes prevention education, an evidence-based educational curriculum was piloted in order to ascertain the feasibility of using such a program to increase diabetes and obesity prevention knowledge in the school setting. The implementation of the Diabetes Education in Tribal Schools (DETS) curriculum in community and school-based settings has been reported in literature. The program is intended to lower the prevalence of T2DM by incorporating lifestyle management options that specifically targets American Indian/Alaska Native (AI/AN) minority communities. Three lessons from the DETS curriculum were presented to the Boys and Girls Club of Three Affiliated Tribes (TAT) in Mandaree, North Dakota. Throughout the curriculum, students were educated regarding T2DM and obesity prevention by engaging in interactive learning activities. The results of the project revealed that community-based interventions for preventing T2DM and obesity can be a helpful way to reach children in the community setting. Overall, this curriculum was effective and successfully taught to voluntary participants. The measures used included qualitative interviewing and learning activities with answers/responses from the participants. Active community involvement by healthcare providers can promote primary prevention through educational activities.

Since European settlers arrived to the United States (U.S.), American Indians (AI) have been separate and unequal members of society. After a long history of discrimination, ethnocide, genocide, and distrust, the AI have become a population with severe disparities, having the highest rates of diabetes, depression, suicide, tuberculosis, and alcoholism than any other minority or majority population in the U.S. The author's purpose for conducting this study was to explore a possible relationship between depression or psychological distress and diabetes in AI women. AI women are the most under studied group in the country; therefore, a secondary analysis of the large established California Health Interview Survey (CHIS) was done. The sample used 1,110 self-identified AI women's data. Even though the literature shows that the AI have the highest rates of diabetes and depression of any population, this analysis revealed no statistically significant relationship between the two diseases. It did reveal many limitations and implications associated with the use of such large databases for the AI woman. Among the limitations were the survey itself, its administration to the AI population, guidelines for self-identifying as AI, and the researcher's limited access to the data. The implications of this study are significant. Large databases provide the basis for social and political decisions such as allocation of federal dollars for health care. Healthcare and health care services are designed according to the health burden of specific populations. If these databases are in error, or not representative of the true population, healthcare decisions will not reflect the true health care needs of the population. The inadequacies of large databases results in less funding, leading to less quality health care, and an increase in AI health disparities. Further research is needed to determine the actual health burden depression and diabetes place on the AI woman.

The United States (US) is plagued by a high-cost health care system producing lower than desired patient quality outcomes. In 2012, the Patient Protection and Affordable Care Act was enacted to financially incentivize cost-effective models of care that improve the health of US citizens. One emerging solution is engaging patients with chronic conditions in self-management practices.

Guided by Krieger's Eco-Social Theory, this study used semi-structured interviews, scales and a questionnaire to detect factors that facilitate patient activation of self-management in patients with type 2 diabetes. Managed and unmanaged participants were equally represented in the study sample. White participants and participants from two American Indian tribes located in Northeast Wisconsin were included in this study. Findings indicated the establishment of routine behavior and the ability to identify healthy alternatives when routines were disrupted support patient activation of self-management. Experiencing success such as weight loss was also identified as a factor in facilitating patient activation. Social roles and responsibilities challenged unmanaged patients.

The study concluded that community, culture and environment have both a negative and positive influence on patient activation of self-management of type 2 diabetes. The current epidemics of obesity and diabetes create an apathetic response to the type 2-diabetes diagnosis that affects subsequent treatment and self-management in the communities studied. Aspects of local cultures such as unhealthy regional and tribal foods, lack of options for menu items low in carbohydrates and sugar in restaurants, high consumption of soda and alcohol and holidays/tribal events provide significant challenges for unmanaged patients. Workplace policies surrounding health insurance premiums had an impact on attendance at educational events but not on sustaining self-management behaviors. Positive aspects of the workplace include the imposition of structure and routine and the emotional support of colleagues. Warm seasons were also found to activate self-management by providing an opportunity for outdoor exercise and healthier modes of food preparation.

Consistent with a previous study, high rates of childhood trauma were found among the study groups. However, findings did not support the hypothesis that levels of childhood trauma were linked to self-management. While some evidence of historical grief and loss along with associated symptoms was found among the American Indian populations, there was no correlation between managed condition and level of grief and loss. Further examination of the connection between childhood and historical trauma to the current obesity and diabetic epidemics in these communities is recommended. Recommendations for changes to public health and health care policy are included.

Type 2 Diabetes (T2D) affects over 246 million people worldwide. South Asians are the largest group affected and have the fastest growing prevalence. South Asians have been identified as at risk due to biomedical dispositions including central adiposity and insulin resistance. Lifestyle factors are also associated with T2D. However, the majority of research area tends to homogenise south Asians, consequently overlooking some of the subtle cultural differences between sub groups. As a result, British Indian Punjabi men have been neglected from research, despite being one of the largest groups at risk. This qualitative study examined the social and cultural factors which influence Indian Punjabi men’s health beliefs and risk perceptions of T2D. Twenty-four interviews were carried out with Indian Punjabi men from first and second generations. The data was analysed using a thematic analysis approach. The findings revealed the cultural significance associated with hospitality and drinking, which emerged as important socio-cultural practices. The findings also demonstrated generational differences in how the men perceived their risk of T2D in either individual or collective terms. The findings of this research study have the potential to make an important contribution to T2D care by highlighting changes to future care strategies.

The American Indians population in Minneapolis, Minnesota has experienced limited health care access and threefold diabetes health disparity. The purpose of this study was to measure the extent to which collaborating marketplace clinics and community-based support groups expanded diabetes care and provided self-management education for this largely urban Indian neighborhood. The marketplace clinics located in nearby CVS, Walmart, Target, and Supervalu stores committed financial support, certified educators, and pharmacy staff for the community-based support group. The study was conducted within the patient activation measure (PAM) analytical framework to assess the participants' acquired knowledge, skills, and confidence for diabetes self-management. A case-control study and 3 years retrospective analysis of secondary data were used to test whether the Minneapolis marketplace clinics and the Phillips community diabetes support group participants (n = 48) had improved diabetes health outcomes relative to the control group (n = 87). The intervention group employed motivational interviewing and PAM in coaching diabetes self-care and behavioral modification. The control group received only basic self-management education. T test and Cohen's d effect size measurements were used to quantify the size of the health outcome variables' difference between the study intervention and comparison groups. The positive effects of marketplace clinics and community-based complementation were shown through improved blood sugar control (A1C), weight loss (BMI), and healthful lifestyle changes. Social change progress could be realized by incorporating PAM with diabetes prevention programs for 33 Urban Indian Health Organizations that are located in large cities throughout the United States.

Type 2 diabetes (T2DM) is a growing health concern among American Indian populations. Many behavioral risk factors for T2DM are influenced by the family unit. Purpose: The purpose of this study was to assess the influence of certain parent/guardian variables on youth type 2 diabetes risk factors. Methods: The parents/guardians of 10-14 year old Northern Plains American Indian youth (n=37) were surveyed regarding their knowledge for physical activity and nutrition, support behaviors for physical activity and nutrition in their youth, and their individual physical activity and nutrition behaviors. Youth variables including physical activity behavior, dietary behavior, and body mass index percentile-for-age (BMI %ile) were also collected. Results: Higher levels of parent/guardian physical activity support were correlated with higher youth BMI %ile (r= 0.433, p=0.013). Parent/guardian nutrition support was also significantly correlated with higher youth BMI %ile as well (r=0.406, p=0.021). Parent/guardian physical activity support and nutrition support were not significantly correlated (p>0.05) with youth physical activity behavior or dietary behavior. Parent/guardian knowledge about physical activity and nutrition was not associated with youth physical activity, youth dietary intake, or youth BMI %ile. Parent/guardian nutrition behaviors and physical activity behaviors were also not significantly correlated with youth physical activity, dietary intake, or BMI %ile. Discussion: The results for parent/guardian support to be associated with higher youth BMI %ile were unexpected and deserve attention in future research to evaluate the motivating forces behind parent/guardian support of youth physical activity and nutrition. Although parents/guardians have an influential role in the lives of adolescents, this role did not translate broadly to measurable outcomes concerning T2DM risk factors for the 10-14 year old Northern Plains American Indian youth in the study. While this study was not conclusive regarding the influence of parent/guardian factors on youth disease risk factors, this topic merits further research in light of the increasing incidence of T2DM among American Indian youth.

Coronary artery disease (CAD), Hypertension (Ht) and Type 2 Diabetes Mellitus (T2DM) are all global health problems. This is particularly evident amongst South Asian population groups. The conventional risk factors do not fully explain the higher prevalence of these diseases among South Asians. The endothelial Nitric Oxide Synthase (eNOS) gene is responsible for the production of Nitric Oxide (NO), which may contribute to the physiology of all three disease states. Endothelial dysfunction (which is characterised by a reduction in basal NO) has been shown to be present in, or prior to all three diseases. Numerous variations exist within the eNOS gene, of these variations three have been shown to have a possible functional effect. The first is the Glu298Asp polymorphism within the exon region of the gene, resulting in an amino acid substitution of Glutamate (Glu) to Aspartate (Asp). The second, known as the T-786C polymorphism, is a thymine to cytosine mutation at position -786 in the promoter region. Finally a VNTR polymorphism in Intron 4 causes either a 4 27bp repeat or a 5 27bp repeat. It is hypothesised that these variations could have an effect on the ability of eNOS to produce NO and thus may increase the risk or contribute to the development of the diseases. Previous studies on these variants have shown conflicting results and further studies are warranted to understand and confirm the role of eNOS gene polymorphisms in cardio-metabolic diseases. There is very limited research into the distributions of these genetic variants and their interaction in diseases processes in North Indian populations. Objectives: 1. To analyse through a case control study three different polymorphisms of the eNOS gene for possible association with Coronary Artery Disease (CAD), Hypertension (Ht) and Type 2 Diabetes Mellitus (T2DM) in North Indian population groups. 2. To statistically evaluate descriptive statistics including; age, gender, smoking, dietary behaviours and lipid parameters for possible influence on disease and potential interaction with genetic polymorphisms. 3. To evaluate linkage disequilibrium between the three eNOS variants and carryout haplotype analysis to work out haplotype risk in different diseases. 4. To analyse through a case control study the deletion variant of the Angiotensin-converting enzyme (ACE) gene for possible association with Coronary Artery Disease (CAD), Hypertension (Ht) and Type 2 Diabetes Mellitus (T2DM) in North Indian population groups. 5. To determine a possible interactive effect of the eNOS polymorphisms with the ACE polymorphism. Subjects and Methods: The Glu298Asp and Intron 4 variants were genotyped using a PCR-RFLP technique, the T-786C variant was genotyped using a real time-PCR technique. The ACE deletion variant was also genotyped using a standard PCR technique. The genotyping was undertaken in a total of 457 CAD patients and 220 matched controls from Lucknow, Uttar Pradesh in North India, 319 T2DM patients and 307 matched controls from Punjab, North India and 210 Ht and 162 matched controls, also from Punjab, North India. Results: CAD: The Glu298Asp was significantly associated with CAD among smokers (TT+GT vs. GG OR=2.84 (CI: 1.61-5.0), p<0.001). The Intron 4 variant was also significantly associated with CAD in a smoking dependent manner (4aa+4ab vs. 4bb OR=0.56 (CI: 0.33-0.96). The T-786C variant showed no overall influence on CAD risk. There was also evidence for both synergistic and haplotypic effects of the eNOS gene on CAD status (haplotype G-C-4b OR=4.76 (CI: 1.43-15.78), p<0.001). The ACE genetic variant was confirmed to be a strong independent risk factor for CAD under a dominant model (OR=2.18 (CI: 1.46-3.25), p<0.001). There was no evidence for an interactive effect between the ACE deletion and any of the three eNOS variants incorporated in the current study. Ht: The Glu298Asp variant was not shown to increase Ht risk, with a reduced risk association found under a recessive model (OR=0.316 (CI:0.089-1.116)), p=0.061). The T-786C variant s role in disease remained unclear with the findings showing a non significant increased risk. The Intron 4 variant was also shown to increase Ht risk, in a non significant manner. Sufficiently powered studies would be required to clarify these possible associations. The combined analysis, using logistic regression and haplotype analysis revealed no significant associations, but there was a possible protective effect of the T-C-4b haplotype (OR=0.46 (CI: 0.21-1.01), p=0.054). The ACE gene variant was confirmed to be a strong independent risk factor for Ht under a recessive model (OR=1.81 (CI: 1.20-2.74), p=0.01). Again there was no evidence for an interactive effect between the ACE deletion and any of the three eNOS variants in hypertension. T2DM: The Glu298Asp variant was found to be associated with T2DM under a dominant model, the protective effect remained significant following adjustment for conventional risk factors and other gene variants (OR=0.407 (CI: 0.231-0.717), p=0.002). The T-786C variant showed no overall influence on T2DM risk. The Intron 4 variant also found no overall influence. Haplotype analysis found the T-T-4b was found to be significantly protective for T2DM (OR=0.41 (CI: 0.26-0.65), p=0.0002). Finally the ACE gene variant was confirmed to be a risk factor for T2DM under a dominant model (OR=2.62 (CI: 1.51-4.54), p=0.001). Overall Conclusions: To conclude, this study successfully identified the frequency of three eNOS gene variants and the ACE deletion variant in three complex diseases within north Indian populations. There is a clear role of the eNOS gene in all three diseases and consequently the genetic variants have susceptible/protective associations. The association with disease was found to be present at an individual level, in association with risk factors and at a haplotypic level. These findings warrant further studies to confirm and untangle the genetics of complex diseases and genetic risk profiles calculations which will contribute to the field of medical genomics/personalised medicare and interventions among North Indian populations.

The purpose of this research was to evaluate the impact of glycemic measures, and changes in identified risk factors (BMI, waist circumference, lipids, blood pressure) on follow-up glycemia, in Pima children at high risk for type two diabetes (type 2 DM).I computed incidence and cumulative incidence of type 2 DM in Pima children 5-19 years of age between 1983 and 2004. Cox proportional hazards rates for development of type 2 DM were calculated by glycemic measure (HbA1C, 20PG, FPG) controlling for confounding factors (age, sex, BMI, blood pressure, and cholesterol). Diabetes was defined by the presence of at least one of four criteria: 1) 20PG of >200 mg/dl, 2) FPG of >126 mg/dl, 3) HbA1C > 8.0%, or 4) hypoglycemic treatment. Linear regression models were computed to identify the impact of changes in risk factors on changes in HbA1C. Only exams performed in non-diabetic children during childhood were included in the regression models.Among 2658 non-diabetic children, 258 cases of diabetes occurred during mean 9.1 years of follow-up (1.5 - 21.7). The age-sex adjusted incident rate of diabetes was 19.0 cases per 1000 person-years, and cumulative incidence was 54% by age 40. Incidence rates increased with increasing baseline values of 20PG, and FPG, but not for HbA1C. For HbA1C the relationship was u-shaped with the lowest and highest quartiles having the highest DM rates. After adjustment for confounding risk factors using Cox proportional hazards analysis, the risk for diabetes increased 2-fold for every 10 mg/dl increase in FPG. Changes in waist circumference best predicted changes in HbA1C (R2 = 0.48, Ï <0.001). However, the ability of waist circumference to predict change is limited due to the powerful effect of regression to the mean, suggesting that these risk factors contribute very little to changes in HbA1C, at least in childhood.Childhood levels of glycemia predict development of type 2 DM later in life. While changes in waist circumference are associated with only moderate changes in HbA1C, this does not refute the significant contribution of adiposity in childhood to the development of type 2 DM.

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Diabetes is associated with endothelial dysfunction and several cardiovascular disorders, such as systemic arterial hypertension. Moreover, hypertension and diabetes coexist very frequently, as 60-65% of diabetics are hypertensive. The coexistence of hypertension and diabetes can reduce endothelium-mediated vasodilatation, which can be partially explained by a reduced production of nitric oxide (NO) or a decreased response to NO in the vascular smooth muscle. On the other hand, it has been shown that a single session of exercise can promote significant reductions in blood pressure (BP). This occurrence is known as post-exercise hypotension (PEH) and appears to be associated with the activity of the kallikrein-kinin system and release of NO. Although studies have observed PEH in individuais with T2D the molecular mechanisms have not been fully elucidated. ln addition, the prescription of exercise intensities based on lactate threshold (L T) has been suggested for individuais with T2D.Moreover, in spite of previous studies showing that individuais with T2D exhibit PEH when exercising at intensities around LT , There is evidence that subjects with T2D exhibit lower plasma kallikrein activity (PKA) compared to healthy individuais, suggesting that lower NO release and reduced endothelium-dependent vasodilation would be occurring in response to exercise for this population. However, no investigations were made on the integrated responses of PKA, BK, dessArg9-BK and NO and its association to the occurrence of PEH in individuais with or without T2D.Furthermore, to the best of our Knowledge, there is only one study that has investigated the effects of exercise (aerobic and / or resistance) on the 24-hour BP response in individuais with T2D. Not to mention that it is not of our knowledge, studies that have investigated the effects of different aerobic exercise intesities on BP 24 hours in subjects with T2D.Additionally, Several studies have investigated the effects of different exercise modes ( e.g., aerobic vs. resistance ), intensities, and durations on BP responses during the post-exercise recovery period. Studies regarding the effects of different sports modalities, especially martial arts, have also been performed, such as: Tai Chi Chuan, Jiu Jitsu, and Judo. However, until now, no study has explored the BP responses after a single Contact Karate (CK) session. It is worth mentioning that the scientific literature related to combat sports has hardly been explored, especially regarding health-related variables (i.e., post-exercise BP reduction). Most studies have investigated performance-related parameters in athletes, making the evaluation of health-related variables (such as PEH) a scientific gap. Therefore, investigations related to this issue have been strongly encouraged. It should be noted that given the known complications of type 2 diabetes and characteristics of sport (high physical contact of high impact), it is wise to initially investigate the effects of a contact karate session on the blood pressure response after exercise in apparently healthy subjects and then, if possible, in special populations as diabetes and hypertension. With regard to chronic exercise, in particular the resistance exercise, the available literature concerning their effects on the response of NO and, in tum, on BP in individuais with T2D, it is still incipient. To the best of our knowledge, there have been only two randomized clinical trials ofRT's effects on NO concentration and BP levels in T2D patients, only one of which, verified the NO response (along with BP) due to R T. Therefore, there is an apparent lack of evidence on R T' s effects on the responses of NO and BP in T2D patients. Objectives: Study 1) to investigate and compare the responses of PKA, BK, desArg9-BK, NO and BP after a single session of moderate-intensity aerobic exercise in T2D and non-diabetic (ND) individuais; study 2) To verify the effects of different intensities of aerobic exercise on 24-hour ambulatory BP responses in individuais with T2D and prehypertension; study 3) to verify the effects of a Contact Karate (CK) session on BP responses during a post-exercise recovery period in young adults; study 4) to determine the effects of eight weeks RT on the responses of NO and BP in T2D patients and their controls peers. Methods: study l)Ten subjects with T2D and 10 Non-diabetics (ND) underwent three sessions: 1) maximal incremental test on cycle ergometer to determine lactate threshold (L T); 2) 20- min of constant-load exercise on cycle ergometer, at 90% LT and; 3) control session. BP and oxygen uptake were measured at rest and at 15, 30 and 45 min post-exercise. Venous blood samples were collected at 15 and 45 minutes of the recovery period for further analysis of PKA, BK and desArg9-BK. NO was analyzed at 15 minutes post exercise. Study 2) ten individuals with T2D and prehypertension completed three sessions applied in random order: non-exercise control (CON) and exercise at moderate (MOD) and maximal (MAX) intensities. Heart rate (HR), BP, blood lactate concentrations ([Lac ]), oxygen uptake (VO2), and rate of perceived exertion (RPE) were measured at rest, during the experimental sessions, and during the 60 min recovery period. After this period, ambulatory blood pressure was monitored for 24 h. Study 2) ten individuals with T2D and prehypertension completed three sessions applied in random order: non-exercise control (CON) and exercise at moderate (MOD) and maximal (MAX) intensities. Heart rate (HR), BP, blood lactate concentrations ([Lac ]), oxygen uptake (VO2), and rate of perceived exertion (RPE) were measured at rest, during the experimental sessions, and during the 60 min recovery period. After this period, ambulatory blood pressure was monitored for 24 h. Study 3) Thirty-two male CK athletes volunteered and underwent one CK session (50 min) anda control session. BP was measured during rest (before sessions), as well as on the 15th, 30th, 45th, and 60th min of the post-exercise recovery. Study 4) We performed eight-weeks of randomized controlled trial in T2D patients and ND individuals. After initial screening, were randomly allocated into four groups: (1) trained T2D (T2DTRAINED; n = 9), (2) trained ND (NDTRAINED; n = 10), (3) control T2D (T2DCON; n = 8) and (4) control ND (NDCON; n = 7). NO and BP were determined before and after the intervention. Results: study 1) The ND group presented PEH of systolic blood pressure (SBP) and mean arterial pressure (MAP) on the 90% L T session but T2D group did not. Plasma NO increased ~24.4% for ND and ~13.8% for T2D group 15min after the exercise session. Additionally, only ND individuais showed increases in PKA and BK in response to exercise and only T2D group showed increased desArg9-BK production. Study 2) Compared with CON, only MAX elicited post-exercise BP reduction that lasted for 8 h after exercise and during sleep. Study 3) The SBP, diastolic blood pressure, and MAP were significantly lower at the post-exercise period compared to pre-exercise rest (p<.05), with the largest reductions being observed at the 60th min of recovery and at the sarne periods of post-exercise recovery of the control session. Study 4) After eight weeks of RT (three times per week), the T2D and ND experimental groups decreased systolic blood pressure (SBP) by 7.0 and 3.4 mmHg, respectively. However, the control groups showed maintenance (0.24 mmHg for T2D) or elevation (2.2 mmHg for ND) of systolic blood pressure. Although none of these changes were significant (p > .05). As regards the absolute values of BP, T2D subjects who did not undergo the training (T2DCON) tended (p = .057) to have increase SBP and significantly (p = .05) increased MAP. Conclusions: studyl) it was concluded that T2D individuals presented lower PKA, BK and NOx release as well as higher desArg9-BK production and reduced PEH in relation to ND participants after a single exercise session. Study 2) A single session of aerobic exercise resulted in 24 h BP reductions in individuals with T2D, especially while sleeping, and this reduction seems to be dependent on the intensity of the exercise performed. Study 3) a single CK session can promote a decrease in BP for at least 60 min after performing this type of exercise in young adults. Study 4) eight weeks of RT does not increase NO concentrations and, in tum, does not reduce BP in T2D patients-though it prevented its increase.
Introdu????o: o diabetes est?? associado com disfun????o endotelial, bem como com diversas desordens cardiovasculares, como hipertens??o arterial sist??mica (HAS). A HAS e o diabetes coexistem muito frequentemente. Aproximadamente, 60-65% dos diab??ticos s??o hipertensos. A coexist??ncia do diabetes e HAS pode reduzir a vasodilata????o endot??lio-dependente, que pode ser parcialmente explicada por uma reduzida produ????o ou resposta ao ??xido n??trico (ON) na nusculatura vascular lisa. Por outro lado, estudos t??m demonstrado que uma ??nica sess??o de exerc??cio pode promover redu????es significativas na press??o arterial (PA). Esta ocorr??ncia ?? conhecida como hipotens??o p??s-exerc??cio (HPE) e parece estar associada com a atividade do sistema calicre??na-cinina e libera????o do ON. Embora estudos tenham observado HPE em indiv??duos com diabetes tipo 2 (DT2), os mecanismos moleculares relacionados ?? sua ocorr??ncia n??o foram completamente elucidados. Adicionalmente, a prescri????o de intensidades de exerc??cio baseada em cargas relativas ao limiar de lactato (LL) t??m sido sugerida para indiv??duos com DT2. No entanto, apesar de estudos anteriores demonstrarem que os indiv??duos com DT2 apresentam HPE quando submetidos a exerc??cios em intensidades em torno LL . Existe evid??ncia que indiv??duos com DT2 apresentam menor atividade da calicre??na plasm??tica (ACP) em compara????o aos indiv??duos n??o diab??ticos, sugerindo uma menor libera????o de ON e redu????o da vasodilata????o endot??lio-dependente em resposta ao exerc??cio para essa popula????o. Contudo, para o nosso melhor conhecimento, ainda n??o foram realizadas investiga????es sobre as respostas integradas de ACP, bradicinina (BK), des-Arg9-bradicinina, ON e sua associa????o com a ocorr??ncia de HPE em indiv??duos com ou sem DT2. Ademais, salvo melhor ju??zo, existe apenas um estudo que tenha investigado os efeitos do exerc??cio f??sico (aer??bio e/ou resistido) sobre a resposta da PA de 24 horas em indiv??duos com DT2. Sem mencionar que tamb??m n??o ?? do nosso conhecimento, estudos que tenham investigado os efeitos de diferentes intensidades de exerc??cio aer??bio sobre a PA de 24 horas em indiv??duos com DT2. Somando a isso, diversos estudos t??m investigado os efeitos de diferentes modos de exerc??cio (aer??bio vs. resistido), intensidades, e dura????es, sobre as respostas da P A p??s-exerc??cio. Estudos sobre os efeitos de diferentes modalidades esportivas, especialmente artes marciais, tamb??m foram realizados, tais como: Tai Chi Chuan, Jiu Jitsu e Jud??. Contudo, at?? o presente momento, nenhum estudo investigou a resposta da P A ap??s uma ??nica sess??o de Carat?? de contato (CC). Vale ressaltar que a literatura cient??fica relacionada a esportes de combate t??m sido pouco explorada, especialmente em rela????o ??s vari??veis relacionadas com a sa??de ( ou seja, a redu????o da PA p??s-exerc??cio). A maioria dos estudos investigaram os par??metros relacionados com o desempenho em atletas, tornando a avalia????o de vari??veis relacionadas com a sa??de, uma evidente lacuna cient??fica. Portanto, investiga????es relacionadas a este assunto t??m sido fortemente encorajada. Cabe salientar que, dado as conhecidas complica????es do DT2 e as caracter??sticas da modalidade em quest??o ( elevado contato f??sico de alto impacto), torna-se prudente inicialmente investigar os efeitos de uma sess??o de CC sobre a resposta da P A p??s-exerc??cio em indiv??duos aparentemente saud??veis e posteriormente, se poss??vel, em popula????es especiais como diab??ticos e hipertensos. No que se refere ao exerc??cio cr??nico, em particular sobre o exerc??cio de for??a, a literatura dispon??vel a respeito dos seus efeitos sobre a resposta do ON e, por sua vez, sobre a PA em indiv??duos com DT2, ainda ?? muito incipiente. Para o melhor do nosso conhecimento, existem apenas dois ensaios cl??nicos randomizados sobre os efeitos do treinamento resistido (TR) sobre a resposta do ON e P A em pacientes com DT2, dos quais apenas um, verificou a resposta do ON juntamente com a P A frente ao TR. Portanto, h?? uma aparente falta de evid??ncias a respeito dos efeitos do TR sobre as respostas do NO e PA em pacientes com DT2. Objetivos: estudo 1) investigar e comparas as respostas de ACP, BK, desArg9-bradicinina, ON e PA ap??s uma ??nica sess??o de exerc??cio aer??bio realizada em intensidade moderada (90% da carga de LL) em indiv??duos com e sem DT2; estudo 2) verificar e comparar os efeitos de uma ??nica sess??o de exerc??cio aer??bio sobre a resposta da PA de 24 horas e verificar os efeitos da intensidade do exerc??cio aer??bio sobre a resposta da PA 24 h em indiv??duos com DT2 e pr??-hipertensos; estudo 3) avaliar os efeitos de uma ??nica sess??o de CC sobre a resposta da PA p??s-exerc??cio em adultos jovens; estudo 4) investigar os efeitos de oito semanas de TR sobre as respostas de ON e P A em pacientes com DT2 e seus pares controles. M??todos: estudo 1) Dez indiv??duos com e DT2 e 10 n??o diab??ticos (ND) foram submetidos a tr??s sess??es: 1) teste incremental m??ximo em bicicleta ergom??trica para determinar o limiar de lactato (LL); 2) 20 min de exerc??cio de carga constante em cicloerg??metro, em 90% L T e; 3) sess??o controle. PA e consumo de oxig??nio foram mensurados em repouso e aos 15, 30 e 45 min p??s-exerc??cio. Amostras de sangue venoso foram coletadas em 15 e 45 minutos do per??odo de recupera????o para posterior an??lise de ACP, BK e desArg9- bradicinina. ON foi analisado aos 15 minutos ap??s o exerc??cio. Estudo 2) Dez indiv??duos com diabetes tipo 2 e pr??-hipertens??o foram submetidos a tr??s sess??es aplicadas em ordem rand??mica: 1) controle ( CON), sem exerc??cio e exerc??cio em intensidades moderadas (MOD) e m??xima (MAX). A frequ??ncia card??aca (FC), P A, as concentra????es de lactato sangu??neo ([Lac ]), consumo de oxig??nio (V02) e taxa de percep????o de esfor??o (TPE) foram coletados em repouso, durante as sess??es experimentais e durante o per??odo de recupera????o de 60 min. Ap??s esse per??odo, a P A de 24 h foi monitorada. Estudo 3) Trinta e dois atletas CC foram submetidos a uma sess??o de CC (50 min) e uma sess??o CON. A PA foi medida durante o repouso, bem como aos 15, 30, 45 e 60 min da recupera????o p??s-exerc??cio. Estudo 4) Foi realizada oito semanas de estudo randomizado controlado em pacientes DT2 e ND). Ap??s a triagem inicial, foram distribu??dos aleatoriamente em quatro grupos: (1) treinados com DT2 (TREINADODT2; n = 9), (2) treinados ND (TREINADOND; = n 1 O), ( 3) controle DT2 (CON DT2; n = 8) e (4) controle ND (CONND; n = 7). NO e BP foram determinadas antes e ap??s a interven????o. Resultados: estudo 1) somente o grupo n??o diab??tico (ND) apresentou HPE para press??o arterial sist??lica e press??o arterial m??dia na sess??o LT 90%. O ON plasm??tico aumentou ~ 24,4% no grupo ND e ~ 13,8% para o DT2 15 min ap??s a sess??o de exerc??cios. Al??m disso, apenas os indiv??duos ND mostraram aumentos de ACP e BK em resposta ao exerc??cio e somente os DT2 mostraram um aumento da produ????o desArg9-bradicinina. estudo 2) Ademais, comparado com a sess??o CON, somente a sess??o de exerc??cio MAX apresentou HPE, que durou at?? 8 h ap??s o exerc??cio e durante o sono. estudo 3) Em rela????o ao CC, a press??o arterial sist??lica (PAS), diast??lica (PAD) e press??o arterial m??dia (MAP) foi significativamente menor no per??odo p??s-exerc??cio em rela????o ao pr??-exerc??cio repouso, bem como em rela????o a sess??o CON, com as maiores redu????es sendo observadas aos 60 min de recupera????o. estudo 4) Ap??s oito semanas de RT, ambos os grupos experimentais (DT2 e ND), apresentaram diminui????o da PAS em 7,0 e 3,4 mmHg, respectivamente. No entanto, os grupos controle (DT2 e ND) demonstrou manuten????o (0,24 mmHg para DT2) ou eleva????o (2,2 mmHg para ND) da PAS. Embora nenhuma das mudan??as foram significativas (p> 0,05). Conclus??es: estudol) concluiu-se que os indiv??duos comDT2 apresentaram menor libera????o ACP, bradicinina e ON, bem como maior produ????o desArg9-bradicinina e reduzida HPE em rela????o aos participantes do grupo ND ap??s uma ??nica sess??o de exerc??cio. Estudo 2) uma ??nica sess??o de exerc??cio aer??bio resultou em redu????o da PA de 24 h em indiv??duos com DT2, especialmente durante o sono, e esta redu????o parece ser dependente da intensidade do exerc??cio realizado. Estudo 3) uma ??nica sess??o CC pode promover uma diminui????o da PA durante pelo menos 60 minutos depois de realizar este tipo de exerc??cio em adultos jovens. Estudo 4) oito semanas de TR n??o aumenta as concentra????es de ON e, por sua vez, n??o reduz a P A em indiv??duos com DT2, por??m parece impedir o seu aumento.

In this research I examine the adaptive strategies and practices that an indigenous community uses to cope with stresses and threats of their local environment. I consider the premise that the continuous interactions with nature by a people who have lived in the same geographic region for great periods of time can lead to traditional ecological knowledge that benefits human well being, and can also result in practices that result in the protection and sustainable use of the natural resources of their environment. Case studies with the Seri Indians in Sonora, Mexico are provided to demonstrate how adaptive behaviors evolved in coastal-desert environment can affect health and also contribute to conservation. In each study, I examine practices that the Seri Indians use to cope with the constraints and opportunities inherent in their desert and sea environment. The case studies take place in 3 landscapes of different geographic scale and cultural contexts. The first study is of a seascape where ritual sea songs are sung to navigate through dangerous channel between two islands. The second study examines medicinal plant associations with the ironwood tree (Olneya tesota Gray) in a series of landscapes of the Central Gulf Coast of Sonora. The third study considers a group of five desert plants adapted by the Seri to treat diabetes in light of the biological and cultural factors that influenced the Seri selection of these plants. The studies demonstrate in different environments, spatial scales and cultural contexts, how dynamic human-environment interactions take place at the interface between biological and cultural adaptation; interactions that are mutually reinforced in the human experience.

Prevalence of type 2 diabetes is rising globally18, 19 and the impact is most marked in developing countries like India19 as Asian Indians have an increased predisposition to develop diabetes20. Many studies have reported that Asian Indians have an unusually high prevalence of diabetes mellitus21, 22. The risk variables associated with diabetes are similar in all countries, but their expression and intensity vary widely between races and between countries. Though earlier studies have documented a rising prevalence of diabetes in India, they have compared data from different regions of India or different parts within a state. To compare secular trends, it would be more accurate to document the prevalence of diabetes within the same region. Hence the data obtained in the present study were compared with three earlier epidemiological studies using similar methods carried out in the same city (Chennai).

We have mapped and evaluated diabetes research in India and China, based on papers published during 1990â 1999 and indexed in PubMed, Science Citation Index (SCI) and Biochemistry and Biophysics Citation Index (BBCI) and citations to each one of these papers up to 2000. We have identified institutions carrying out diabetes research, journals used to publish the results, subfields in which the two countries have published often, and the impact of the work as seen from actual citations to the papers. We have also assessed the extent of international collaboration in diabetes research in these two countries, based on papers indexed in SCI and BBCI. There is an enormous mismatch between the disease burden and the share of research performed in both countries. Although together these two countries account for 26% of the prevalence of diabetes, they contribute less than 2% of the worldâ s research. We argue that both India and China need to (i) strengthen their research capabilities in this area, (ii) increase investment in health-care research considerably, (iii) facilitate substantive international collaboration in research, and (iv) support cross-disciplinary research between basic life sciences researchers and medical researchers. As data such as those presented here should form the basis of health policy, India and China should encourage evaluation of research.