LETTERS 1 liferative or proliferative diabetic retinop- ATSUSHI MINAMOTO, PHD 3 OBSERVATIONS athy. Data are presented as means Ϯ SD. HIDEHARU FUNATSU, PHD 4 The Mann-Whitney U test was used to HIDETOSHI YAMASHITA, PHD ␣ 5 compare IL-6 and TNF- levels. To deter- SHIGEO NAKAMURA, PHD 4 mine the relationship between the sever- KEN KIRIYAMA, PHD 5 Relationship ity of periodontal disease and ETDRS, HIDEMI KURIHARA, PHD 1 retinopathy severity, or angiogenic fac- HIROMU K. MISHIMA, PHD Between Periodontal tors, as well as between X and Y parame- Disease and Diabetic ters, Spearman’s rank-order correlation Retinopathy coefficient and logistic regression model From the 1Department of Ophthalmology and Vi- were applied. sual Science, Hiroshima University Graduate School The severity of periodontal disease of Biomedical Sciences, Hiroshima, Japan; the 2De- was significantly correlated with the se- partment of Ophthalmology, Hiroshima Prefectural ecently, various studies have re- verity of diabetic retinopathy (P ϭ Hospital, Hiroshima, Japan; the 3Department of ported that periodontal disease ad- 0.0012), and the risk of proliferative dia- Ophthalmology, Diabetes Center, Tokyo Women’s Medical University, Tokyo, Japan; the 4Department versely affects diabetes (1). The betic retinopathy was significantly higher R of Ophthalmology and Visual Science, Yamagata control of periodontal disease in elderly in the presence of periodontal disease ϭ ϭ University School of Medicine, Yamagata, Japan; individuals has been reported to improve (odds ratio 2.80, P 0.036). There and the 5Department of Periodontal Medicine, Hi- the control of blood glucose (2). Severe was no significant relationship between roshima University Graduate School of Biomedical periodontal disease is associated with el- the severity of periodontal disease and Sciences, Hiroshima, Japan. ϭ Address correspondence to Hiromu K. Mishima, evated blood lipopolysaccharide levels as HbA1c or duration of diabetes (P 0.098 and 0.295, respectively). There was a sig- PhD, Hiroshima University Graduate School of Bio- a result of periodontogenic bacteria, medical Sciences, Department of Ophthalmology which induce higher levels of interleu- nificant relationship between the severity and Visual Science, 1-2-3 Kasumi, Minami-ku, Hi- kin-6 (IL-6) and tumor necrosis factor-␣ of diabetic retinopathy and duration of roshima 734-8551, Japan. E-mail: hkmishi@ (TNF-␣) (3,4). Control of periodontal diabetes (P ϭ 0.002). The vitreous fluid hiroshima-u.ac.jp. disease is now considered not only a den- level of IL-6 (mean 154.2 Ϯ 164.6 pg/ml © 2004 by the American Diabetes Association. tal problem but also an issue affecting the [range 0.993–597.0]) was significantly el- patient’s overall quality of life. Proinflam- evated in patients with diabetic retinopa- matory cytokines such as IL-6 have been thy compared with that in nondiabetic shown to be involved in the pathogenesis patients (mean 1.34 Ϯ 0.91 pg/ml [0.6– of diabetic retinopathy (DR) (5), while the 3.68]) (P Ͻ 0.0001). Furthermore, the ●●●●●●●●●●●●●●●●●●●●●●● relationship between diabetic retinopathy vitreous fluid level of IL-6 was signifi- References and periodontal disease remains unclear. cantly correlated with the severity of peri- ϭ 1. Loe H: Periodontal disease: the sixth com- We investigated whether periodontal dis- odontal disease (P 0.012). There was plication of diabetes mellitus. Diabetes ease is correlated with diabetic retinopathy. no significant relationship between the Care 16:329–334, 1993 The study was based on a prospective vitreous fluid level of IL-6 and HbA1c or 2. Grossi SG, Skrepcinski FB, DeCaro T, review of 73 eyes in 73 consecutive dia- duration of diabetes (P ϭ 0.293 and Robertson DC, Ho AW, Dunford RG, betic patients. The mean duration of dia- 0.705, respectively). In contrast, the vit- Genco RJ: Treatment of periodontal dis- betes was 14.3 Ϯ 7.1 years (range 2–33), reous fluid level of TNF-␣ was not signif- ease in diabetics reduces glycated hemo- Ϯ and the mean HbA1c was 7.5 1.6% icantly correlated with the severity of globin. J Periodontol 68:713–719, 1997 (5.2–13.7). IL-6 and TNF-␣ levels in the periodontal disease. The IL-6 concentra- 3. Grossi SG, Genco RJ: Periodontal disease vitreous fluid samples from 32 eyes ob- tion in vitreous fluid (mean 154.2 Ϯ and diabetes mellitus: a two-way relation- tained during vitrectomy and in paired 164.6 pg/ml [0.993–597.0]) was signifi- ship. Ann Periodontol 3:51–61, 1998 plasma samples were measured by en- cantly higher than that in plasma (mean 4. Soolari AS, Champagne C, Punzi JS, Amar zyme-linked immunosorbent assay. Non- 1.89 Ϯ 3.47 pg/ml [0.156–18.8]) (P Ͻ S, Van Dyke TE: Serum modulation of diabetic patients included 10 with 0.0001). neutrophil response to Porphyromonas macular hole and 2 with epiretinal mem- There was a significant relationship gingivalis LPS in periodontal disease. J Int brane. Institutional ethics committee ap- between periodontal disease and severity Acad Periodontol 1:101–109, 1999 proval was obtained, and all participants of diabetic retinopathy, but it was unclear 5. Funatsu H, Yamashita H, Shimizu E, Kojima R, Hori S: Relationship between gave informed consent. The severity of di- whether periodontal disease directly af- fects the progression of diabetic retinopa- vascular endothelial growth factor and in- abetic retinopathy was quantified accord- terleukin-6 in diabetic retinopathy. Retina thy because this was a cross-sectional ing to the modified Early Treatment 21:469–477, 2001 Diabetic Retinopathy Study (ETDRS) ret- study. Further prospective studies, in- 6. The Early Treatment Diabetic Retinopa- inopathy severity scale (6). The severity of cluding evaluation of systemic factors, are thy Study Research Group: Fundus pho- periodontal disease was quantified ac- necessary. tographic risk factors for progression of cording to bone loss and then graded and diabetic retinopathy: ETDRS report num- 1 evaluated (7). Patients with periodontal HIDETAKA NOMA, MD ber 12. Ophthalmology 98:823–833, 1991 1 disease were classified as positive or neg- IKUO SAKAMOTO, PHD 7. Jeffcoat MK, Wang IC, Reddy MS: Radio- 1 ative based on median values. Diabetic HIDEKI MOCHIZUKI, MD graphic diagnosis in periodontics. Peri- 2 patients were classified as having nonpro- HIDETOSHI TSUKAMOTO, PHD odontol 2000 7:54–68, 1995 DIABETES CARE, VOLUME 27, NUMBER 2, FEBRUARY 2004 615 Letters Effect of Diabetes a car (1.5 h/week), and sitting at home OW: A culturally sensitive tool for Mexi- (1.38 h/week). can people with diabetes: “La Manzana de Intervention This study shows that the majority of la Salud”. Rev Biomed 14:51–59, 2003 Programs on Mexicans with diabetes who are willing to 4. Clark DO: Physical activity efficacy and participate in diabetes education groups effectiveness among older adults and mi- Physical Activity norities. Diabetes Care 20:1176–1182 at the primary health care clinics engage Among Migrant Ͼ 5. Aguilar-Salinas CA, Velazquez-Monroy in 20 min of daily physical activity, O, Gomez-Perez FJ, Gonzalez-Chavez A, Mexican Women which therefore reinforces the need for Esqueda AL, Molina-Cuevas V, Rull- With Type 2 promoting culturally based interventions Rodrigo JA, Tapia Conyer R, the Encuesta (3,4). These results are better than the na- Nacional de Salud 2000 Group: Charac- Diabetes tional data for adults with type 2 diabetes teristics of patients with type 2 diabetes in in Mexico and the U.S. (5,6); however, Mexico: results from a large population- the groups we studied were especially based nationwide survey. Diabetes Care he 2000 Dietary Guidelines for motivated subjects interested in obtaining 26:2021–2026, 2003 Americans and the dietary guide- better metabolic control through diabetes 6. Nelson KM, Reiber G, Boyko EJ: Diet and T lines for the control of diabetes in education groups. On the other hand, the exercise among adults with type 2 diabe- tes. Diabetes Care 25:1722–1728, 2002 Mexico include recommendations that population from this study, which has a adults participate in at least 30 min of low socioeconomic status, usually con- moderate physical activity, preferably fronts major environmental or economic daily (1,2). However, to our knowledge, barriers that prevent access to safe recre- there have been no studies that explore ational areas or fitness facilities. Thus, the effect of diabetes intervention pro- even with economic constraints and inad- Alternative Site grams on physical activity among migrant equate environmental access to physical Testing at the Mexican women with type 2 diabetes. activity, promoting physical activity in a Earlobe Tip All women from seven diabetes edu- culturally based intervention is a worth- cation groups from three different Mexi- while strategy that should be supported. can institutions located in Tijuana were Although further studies in large popula- Reliability of glucose measurements invited to answer a previously validated tions are still required to evaluate the ef- and pain perception questionnaire on physical activity. Of 111 fectiveness at a larger scale, at the primary questionnaires, 100 were adequately an- care level of Mexican institutions, stron- Ϯ swered. The mean age was 53 12 years. ger emphasis should be placed on pro- here is growing interest in alterna- The majority of the sample was migrants moting physical activity. tive less painful sites for capillary from other Mexican states, and 40% were T blood glucose (CBG) monitoring. classified as overweight and 31% as MONTSERRAT BACARDı´-GASCO´ N, MD The earlobe tip is a potential site (1) that obese. Of the women, 62, 45, and 15% PERLA ROSALES-GARAY, MD has been occasionally used by nurses Ͼ Ͼ Ͼ reported 20, 30, and 60 min of ARTURO JIME´ NEZ-CRUZ, MD, PHD when fingertip testing is refused or diffi- physical activity per day, respectively. cult. We investigated the clinical value Seventy-three percent reported Ͼ80 min From the Nutrition Program, Medical School, Uni- and accuracy of earlobe CBG measure- of weekly physical activity.