Showing papers in "Diabetes Care in 1978"

Diabetes Mellitus and Its Degenerative Complications: A Prospective Study of 4,400 Patients Observed Between 1947 and 1973

Abstract: This article was originally published in French in Diabete et Metabolisme (vol. 3: 97–107, 173–182, 245–256; 1977). The Editors of DIABETES CARE thank the author, and the editors and publisher of Diabete et Metabolisme for granting permission for us to print this English translation. The paper was translated by Marjorie Levin of Miami, Florida. Part 2 of this translation will appear in the July–August issue of DIABETES CARE.

Long-term Effects of High-carbohydrate, High-fiber Diets on Glucose and Lipid Metabolism: A Preliminary Report on Patients with Diabetes

Abstract: High-carbohydrate, high-fiber (HCF) diets have beneficial therapeutic effects for selected patients with diabetes mellitus. We have treated 10 patients with HCF diets on a metabolic ward and followed them for an average of 15 months while they were on maintenance diets at home. The HCF diets containing 70 per cent of calories as carbohydrate were accompanied by significant reductions in requirements for insulin or sulfonylureas. Fasting plasma glucose, serum cholesterol, and triglyceride values were significantly lower on the HCF diet than on a 43 per cent carbohydrate diet. On the HCF diet, insulin therapy was discontinued for five patients and sulfonylurea therapy for three. After an average of 15 months on the maintenance diet containing 55 per cent to 60 per cent carbohydrate, seven patients were still managed without insulin or sulfonylureas. Average fasting plasma glucose values during maintenance diets at home were identical to values on the HCF diets in the hospital. On the maintenance diet, serum cholesterol values were similar to initial values but serum triglyceride values were significantly lower than values on the 43 per cent carbohydrate diet. These studies indicate that moderately high-carbohydrate, high-fiber diets can be successfully followed at home and that improvements in glucose metabolism achieved in the hospital can be sustained outside the hospital.

Cigarette Smoking and Prevalence of Microangiopathy in Juvenile-Onset Insulin-dependent Diabetes Mellitus

Abstract: In order to evaluate a possible relation between cigarette smoking and prevalence of diabetic microangiopathy, a series of 180 consecutive patients suffering from insulin-dependent juvenile-onset diabetes mellitus with different durations of disease (60 patients each with diabetes for 10 to 19 years, 20 to 29 years, and 30 to 39 years, respectively) were examined for clinical signs of retinopathy, nephropathy, and peripheral neuropathy. The results were compared with the patients' previous and actual smoking habits. Cigarette smoking was defined as daily smoking of at least ten cigarettes for one year or more. Smoking habits of the total diabetic sample were not significantly different from those of a nondiabetic control sample. However, a decline in the number of cigarette smokers and a rising number of ex-smokers were noted with increasing duration of diabetes. In comparing smokers and nonsmokers, no difference was found in the prevalence of peripheral neuropathy, background retinopathy, and proliferative retinopathy. However, the prevalence of nephropathy (persistent proteinuria) was significantly higher (p less than 0.05) among these patients who were or had been cigarette smokers. Thus, cigarette smoking might be considered a risk factor for the development of diabetic nephropathy.

Home Blood Glucose Monitoring As an Aid in Diabetes Management

Abstract: Home blood glucose monitoring, using Dextrostix and an Eyetone meter, has been utilized in several subcategories of patients with insulin-dependent diabetes mellitus. These include pregnant patients, anephric patients, patients undergoing weight reduction, patients with altered renal threshold for glucose reabsorption, and patients in whom diabetic regulation is difficult. Patients monitored home blood glucose continually (on a daily basis), intermittently, or only for particular problems or symptoms. Such monitoring can be practically accomplished in a manner acceptable to patients. Motivation, compliance with protocol, and an understanding of the objectives of the program are essential on the part of the patient. Home blood glucose monitoring, however, can provide an insight diabetes regulation that cannot be attained in any other way and can greatly facilitate regulation of diabetes. Such home blood glucose monitoring may increase the likelihood of achievement of a degree of control approximating euglycemia.

Influence of Indigestible Fibers on Glucose Tolerance

Abstract: In eight patients exhibiting chemical diabetes mellitus with a poststimulative hypoglycemia, we observed that the pattern of the oral glucose tolerance test (OGTT) was improved when indigestible fiber was added to the oral glucose load. As compared with a standard OGTT, the peak blood glucose, expressed as per cent change from baseline, was particularly blunted by pectin or by cellulose phosphate but remained unchanged with cellulose supplementation. The time interval required to reach the blood glucose peak was significantly prolonged with pectin. The rate of blood glucose rise was reduced to a greater extent by pectin than by cellulose phosphate, which in turn was more efficient than cellulose. The blood glucose nadir expressed as per cent change from baseline was blunted by pectin, while the results were not significantly different after addition of either cellulose phosphate or cellulose. On the other hand, the plasma immunoreactive insulin did not show any significant change whether the glucose was given with or without one of the aforementioned types of fiber. From these results, it is concluded that an additional fiber intake may be of interest in the management of chemical diabetes. The use of pectin may diminish the poststimulative hypoglycemia.

Sulfonylurea drugs: mechanism of antidiabetic action and therapeutic usefulness.

Abstract: The usefulness of oral sulfonylurea drugs in the treatment of patients with insulin-independent (\"adult-onset,\" \"nonketotic\") diabetes mellitus continues to be debated. Important questions have been raised regarding both the potential toxicity and the therapeutic effectiveness of these agents. Some clinicians have abandoned their use entirely, while others continue to prescribe them with varying frequency and await further information. This review will attempt to provide a rational approach to the administration of oral sulfonylureas, based on our current understanding of their mechanism of action and clinical effect. The hypoglycemic effect of the sulfonylureas was first discovered in France, during World War II, as a chance finding in the course of investigations concerning the antibiotic properties of modified sulfonamides. Much of the early work was undertaken by Auguste Loubatieres. Widespread clinical application of these drugs did not occur, however, until the synthesis of carbutamide after the war, in Germany, followed by the development of the agents most commonly used in the United States, tolbutamide and chlorpropamide. In recent years the first generation of sulfonylureas has been followed by a second generation of compounds, which are far more potent than the original compounds. Sulfonylureas of both generations are shown in figure 1. Since the early 1950s, sulfonylureas, mainly tolbutamide and chlorpropamide, have been used extensively in the treatment of diabetes. The incidence of adverse reactions is low, with a total rate for all side effects estimated at 3.2 per cent for tolbutamide and 6 per cent for chlorpropamide.' The most frequently described significant side effects are hematologic (agranulocytosis, bone marrow aplasia, red cell aplasia) and gastrointestinal (nausea, vomiting, heartburn, abnormal liver function tests, jaundice). Other described effects include cutaneous reactions (rashes, pruritis), vasomotor effects (disulfiramlike reaction to alcohol—most commonly seen with chlorpropamide), possibly hypothyroidism, and dilutional hyponatremia with water intoxication (due to the antidiuretic action of chlorpropamide and perhaps tolbutamide). In contrast to these two, some other sulfonylureas (e.g. tolazamide and acetohexamide) may have a diuretic action. Severe hypoglycemia may rarely occur, most often in patients with renal or hepatic impairment. The subject of drug interactions with sulfonylureas, which may significantly alter their activity, has recently been extensively reviewed. For the large majority of patients, administration of a sulfonylurea induces no obvious ill effects. However, in 1970, the report of the University Group Diabetes Program (U.G.D.P.) suggested that tolbutamide therapy is no more effective than diet alone in the treatment of diabetes and may be associated with an increased cardiovascular mortality. While a number of important critical analyses of the methodology and results of the U.G.D.P. have been published,'' the controversies initiated by the U.G.D.P. report concerning the safety and efficacy of tolbutamide treatment for patients with nonketotic diabetes mellitus have yet to be resolved. A serious consequence of this study has been the condemnation of the therapeutic use of the entire class of sulfonylurea drugs. However, a complete evaluation of the usefulness of the sulfonylureas requires examination of the following questions:

Evaluation of Patients' Knowledge of Diabetes Self-Care

Abstract: A survey conducted at a Veterans Administration Hospital to evaluate patient capability for self-management found that over 35 per cent of the patients interviewed lacked any formal training. Seventeen patients had been placed on insulin without formal instruction. Almost one half the patients who claimed to have attended training programs could not demonstrate adequate knowledge or skills in any of the major areas of self-care: insulin administration, urine testing, diet, foot care, and management of hypoglycemia and hyperglycemia. While patients with training were more knowledgeable than patients without training, the difference was slight. The results indicate the need for systematic analysis of patient knowledge and the evaluation of training programs on a continuing basis.

Fatal diabetic ketoacidosis: major causes and approaches to their prevention.

Abstract: While the actual incidence of diabetic ketoacidosis is not known, at the present time this condition accounts for roughly 14 per cent of the admissions of diabetic patients to hospitals in the United States and is responsible for 4-5 per cent of the deaths in the Japanese diabetic population. Mortality figures collected from various medical centers during the last decade have varied from as low as 0.5 per cent to as high as 15.4 per cent with a mean mortality of 6.8 per cent in the 2,348 patients for whom adequate information is available. Thus, although the mortality due to ketoacidosis has decreased from the range of 27 to 44 per cent observed between 1930 and 1950,~ the survival of patient has not appeared to improve strikingly during the past 25 years. It has long been assumed that many of the deaths associated with ketoacidosis are due to coexisting medical disease such as myocardial infarction, cerebrovascular accident, mesenteric arterial occlusion, pancreatitis, and infection. If this were the case, the physician would have to be satisfied with attempting to prevent those deaths due to \"uncomplicated\" diabetic ketoacidosis and would resign himself to the loss of patients with severe complicating medical disease. If, on the other hand, certain of the coexisting diseases could be shown to be the consequence of diabetic ketoacidosis rather than its cause, then it would be possible to take appropriate measures to decrease the frequency of their development during the treatment of this disorder. The fact that, in certain series, the mortality associated with ketoacidosis has been zero would support the possibility that many of the so-called \"unavoidable\" deaths might have been prevented. It is the purpose of this discussion to examine the causes of death in patients treated for diabetic ketoacidosis and to propose therapeutic measures which might decrease the associated mortality. Since McGarry and Foster have recently reviewed the biochemical physiology of ketoacidosis, only those aspects which are pertinent to the treatment of diabetic ketoacidosis will be considered here. PATHOGENESIS OF KETOACIDOSIS

Self-esteem and Depression in Adolescent Diabetic Girls

Abstract: This investigation was designed to examine self-esteem and depression in diabetic adolescent girls. One hundred nondiabetic girls age 12-16 and 105 diabetic girls age 12-16 were administered the Rosenberg Self-Esteem Scale and the Beck Depression Inventory. Results indicated no significant difference between diabetic and nondiabetic girls in self-esteem scores. Diabetic girls showed significantly more depression than nondiabetic girls. Close examination of results revealed that, in fact, diabetic and nondiabetic adolescent girls were very similar. A major finding was that depression in the diabetic group was expressed primarily through physiologic symptoms of depression as seen in the vital depression scores, rather than through the pessimism, indecision-inhibition, or self-debasement measures of depression. Results were interpreted to mean that diabetic girls did not manifest deeper depression than nondiabetic girls but, rather, a greater awareness of their physiologic status. Diabetes emerged as a focus for the expression of normal adolescent conflicts. The importance of integrating developmental issues into the treatment plans for diabetic patients is emphasized.

Long-term effects of pancreatic transplant function in patients with advanced juvenile-onset diabetes.

Abstract: Present methods of management of juvenile-onset diabetes mellitus do not prevent serious and debilitating complications affecting multiple organ systems. In an effort to reverse advanced forms of these complications, segmental transplantation of the pancreas has been performed on 10 patients, seven of whom simultaneously or subsequently received renal transplants. Long periods of normoglycemia (two to four and one-half years) were achieved in two patients who also maintained transplant kidney function. The course of these two patients is described to illustrate the possible value and limitations of the procedure. These patients had normal blood glucose levels, exhibited repeated normal intravenous glucose tolerance curves, and had repeated normal endogenous insulin levels. Their courses were characterized by (1) absence of problems related to pancreatic exocrine secretions into the bladder; (2) stable eye changes despite some episodes of hemorrhage from preexisting retinopathy; (3) vascular complications, including stroke and gangrene of extremities necessitating amputation despite successful femoropopliteal bypass grafting; (4) peripheral neuropathy; and (5) repeated infections. Both patients succumbed to vascular complications. Thus, pancreatic transplantation can maintain blood glucose and insulin at normal levels for extended periods of time. However, it does not reverse such complications as advanced retinopathy or atherosclerosis. Since the procedure may have value in preventing progression of these complications, it should be evaluated in patients with less advanced complications of diabetes.

Jet Injection of Insulin During Self-Monitoring of Blood Glucose

Abstract: Insulin-dependent diabetes mellitus has been treated with four jet injections of insulin (regular insulin before each meal and intermediate insulin at bedtime) during self-monitoring of blood glucose levels. The blood glucose levels generally remain within 60 and 150 mg/dl.

Prolonged sulfonylurea administration decreases insulin resistance and increases insulin secretion in non-insulin-dependent diabetes mellitus: evidence for improved insulin action at a postreceptor site in hepatic as well as extrahepatic tissues

Abstract: To determine whether long-term sulfonylurea therapy ameliorates glucose homeostasis in patients with NIDDM predominantly by improving insulin secretion or by improving insulin action, we evaluated changes in fasting plasma glucose concentrations, intravenous glucose tolerance, glucose-stimulated insulin secretion, facilitation of glucose disposal by exogenous insulin, and erythrocyte insulin receptor binding before and after prolonged (congruent to 4 mo) administration of tolazamide to 18 patients with NIDDM. Before tolazamide administration, 15 patients had decreased insulin secretion (50 +/- 31 vs 577 +/- 176 microU/ml X 10 min in nondiabetic subjects, P less than 0.05) and insulin resistance (Km 166 +/- 31 vs 58 +/- 3 microU/ml in nondiabetic subjects, P less than 0.05; Vmax 7.3 +/- 0.6 vs 9.8 +/- 0.2 mg/kg/min in nondiabetic subjects, P less than 0.05), whereas the other three patients had comparably impaired insulin secretion (56 +/- 52 microU/ml X min) but were not insulin resistant (Km 70 +/- 6 microU/ml; Vmax 10.8 +/- 0.6 mg/kg/min). The insulin-resistant patients had fasting hyperinsulinemia (19 +/- 4 vs 11 +/- 1 microU/ml in nondiabetic subjects, P less than 0.05), decreased erythrocyte insulin receptor binding (4.8 +/- 0.4 vs 5.8 +/- 0.3%/1.6 X 10(9) cells in nondiabetic subjects, P less than 0.05), and impairment in both insulin-induced suppression of glucose production (Km 97 +/- 31 vs 21 +/- 7 microU/ml in nondiabetic subjects, P less than 0.05), and insulin-induced stimulation of glucose utilization (Km and Vmax 176 +/- 29 microU/ml and 5.8 +/- 0.7 mg/kg/min vs 50 +/- 2 microU/ml and 9.1 +/- 0.6 mg/kg/min in nondiabetic subjects, both P less than 0.05). The nonresistant patients were not hyperinsulinemic (12 +/- micU/ml), had normal insulin receptor binding (5.9 +/- 0.5%/1.6 X 10(9) cells), and were less hyperglycemic than the insulin-resistant patients (128 +/- 11 vs 181 +/- 12 mg/dl, P less than 0.05). After tolazamide administration, both the early phase of glucose-induced insulin secretion (56 +/- 52 vs 141 +/- 68 microU/ml . 10 min) and insulin binding (5.9 +/- 0.5 vs 7.0 +/- 0.5%/1.6 X 10(9) cells) increased in all three nonresistant patients, but there was no consistent improvement in fasting hyperglycemia (128 +/- 11 vs 130 +/- 24 mg/dl), intravenous glucose tolerance (Kivgtt 0.77 +/- 0.18 vs 0.89 +/- 0.29%/min), or facilitation of glucose disposal by insulin (Km 70 +/- 5 vs 64 +/- 5 microU/ml; Vmax 10.8 +/- 0.6 vs 10.1 +/- 0.2 mg/kg/min).(ABSTRACT TRUNCATED AT 400 WORDS)

Growth and Maturation of Children with Insulin-dependent Diabetes Mellitus

Abstract: The purpose of this paper is to define criteria used for classifying patients into varying degrees of diabetic control and to verify that children with diabetes maintained in higher degrees of metabolic control do not have delayed growth and maturation. Growth records of 252 children with insulin-dependent diabetes who have been under continuous observation in our clinic at three- to five-month intervals for at least three years and up to 16 years have been individually reviewed and analyzed. All children received two daily injections of a mixture of two parts of an intermediate to one part of regular insulin and were instructed to eat structured meals of high-quality selected foods. An over-all rating for diabetic control based primarily on the frequency and degree of glycosuria was made for the time period between clinic visits. The over-all diabetic control rating and the size of the subgroups were “good” — 20 per cent, “fair to good” — 64 per cent, and “fair”—16 per cent. All children maintained in “good” and “air to good” control (84 per cent), grew and matured at a normal rate regardless of the age at onset or duration of diabetes. All children in lower degrees of control coming under care for greater than 24 months after diagnosis had accelerated growth during the early months after attaining a higher degree of control.

Diabetic truncal mononeuropathy--a new clinical syndrome

Abstract: Although diabetic mononeuropathy affecting the cranial and peripheral nerves is well recognized, there is little known or documented about diabetic mononeuropathy affecting the thoracic nerves, i.e., the truncal nerves. This series of 40 cases attests to its frequency; equal sex distribution; significance in differential diagnosis including coronary artery disease, intra-abdominal surgical diseases such as gallbladder pathology and appendicitis, pleurisy, and neoplasms. Truncal mononeuropathy has characteristics that differ from those of other diabetic mononeuropathies in that it is primarily sensory and typically not a first manifestation of clinical diabetes, whereas the other forms of diabetic mononeuropathy are primarily motor in effect and not infrequently may be the initial clinical presenting manifestation of diabetes. Finally, diabetic truncal mononeuropathy has a good prognosis.

Joint Contractures in Patients with Juvenile Diabetes and Their Siblings

Abstract: Six hundred fifteen children (310 with diabetes, 106 nondiabetic siblings, and 199 nonsibling controls) were examined for the presence of joint contractures. Forty children had contractures: 8.4 per cent of those with diabetes and 4.6 per cent of those without diabetes. Contractures were present, however, in 9.4 per cent of nondiabetic siblings, and only 2 per cent of nonsibling controls, suggesting a familial tendency to joint contractures. The older the patient, the more likely he was to have contractures. There was no correlation with sex, race, or age at onset of the disease.

Neonatal Morbidity Among Infants of Diabetic Mothers

Abstract: While the modern approach to management of diabetic pregnancy has reduced the perinatal mortality significantly, the neonatal morbidity remains high. This study has investigated factors which may account for the persisting high neonatal morbidity when birth trauma has been virtually eliminated and the incidence of respiratory distress syndrome (RDS) considerably reduced. Major congenital malformations emerge not only as the leading cause of perinatal losses but also as an important cause of morbidity. Delivery before 37 weeks increased the incidence of RDS and hypocalcemia, and it is suggested that, when strict metabolic control is used and with the help of facilities to monitor the fetus closely in the last weeks of pregnancy, the number of infants delivered at this early date can be further reduced. The present study also indicates that normoglycemia should also be encouraged on the day of delivery as maternal hyperglycemia at this stage increases the incidence of neonatal hypoglycemia. Jaundice, which very commonly affects newborn infants of diabetic mothers, is influenced by the use of oxytocin for vaginal delivery and by infant overweight (greater than 90th percentile) at birth, factors which are not beyond control. Finally, route of delivery per se may not be important in relation to neonatal morbidity.

Use of Fructose, Xylitol, or Sorbitol as a Sweetener in Diabetes Mellitus

Abstract: Nonnutritive sweeteners have been utilized in the diet of diabetic patients an an agent to replace glucose and sucrose. Since saccharin might be removed from the marketplace, the nutritive sweeteners fructose, xylitol, and sorbitol are being considered as possible alternatives for glucose and sucrose. This review considers the effects of these nutritive sweeteners on the main dietary concerns in the diabetic diet--control of blood glucose levels, obesity, and hyperlipidemia. The potential side effects of these agents are also reviewed.

Effect of Added Fiber on the Glucose and Metabolic Response to a Mixed Meal in Normal and Diabetic Subjects

Abstract: 10 g of guar was added to a test meal given to 11 subjects, six of whom had insulin-dependent diabetes, after an overnight fast. The addition of guar to the meal produced an overall decrease in the blood glucose concentrations after the meal in both normal and diabetic subjects. The insulin secretory response in the normal subjects was less when guar was included in the meal than when it was not. In normal subjects, but not in diabetic subjects, the addition of guar also resulted in a diminished response of lactate, pyruvate, and alanine to the test meal and a blunting of the fall in serum ketones. This is likely related to the fact that the same dose of insulin was given in the diabetic subjects with both test meals. Thus, in the normal circumstances, the diminished glycemic response to the guar-containing meal resulted in diminished insulin secretion, which was not the case with the diabetic subjects.

Metoclopramide for gastroparesis diabeticorum.

Abstract: Three patients with uncontrolled diabetes mellitus and with symptoms due to gastric retention proved to have gastroparesis diabeticorum. The diagnosis was established by the beefsteak-barium meal. After the administration of metoclopramide, gastric emptying improved and the diabetes was easily controlled. Gastroparesis diabeticorum is one cause of uncontrolled diabetes mellitus and may be helped by the administration of metoclopramide.

Current Patterns of Neonatal Morbidity and Mortality in Infants of Diabetic Mothers

Abstract: Recent advances in antepartum fetal evaluation have contributed to a marked reduction in fetal deaths in pregnancies complicated by overt diabetes mellitus. To determine the effect of these changes on neonatal morbidity and mortality, a retrospective analysis of complications in 322 infants of diabetic mothers (IDM) in White classes B--R was undertaken. The majority (89 per cent) of the IDM were delivered at term with a mean gestational age of 38 weeks. Neonatal morbidity correlated significantly with gestational age, occurring in 80 per cent of the preterm and 40 per cent of the term infants. The overall incidence of complications was: hyperbilirubinemia 37 per cent, hypoglycemia 31 per cent, hypocalcemia 13 per cent, polycythemia 8 per cent, and necrotizing enterocolitis 2 per cent. Respiratory distress syndrome (RDS) occurred in 9 per cent and congenital malformations in 6 per cent of the infants. Nine infants died, and four of these deaths were due to anomalies. These data indicate that (1) a reduction in fetal mortality has been accompanied by a reduction in neonatal mortality; (2) neonatal morbidity has been decreased but remains significant in the IDM; and (3) congenital anomalies have replaced RDS as a major cause of neonatal death for the IDM.

Diabetes Mellitus and Pregnancy

Abstract: Proper therapy in pregnancy complicated by diabetes mellitus affords the physician an opportunity that is unparalleled in immediate impact and over-all therapeutic dimension for his or her patient. The immediate survival of the mother can be virtually assured and that of the unborn child brought close to that of the child of the nondiabetic gravida. Further, the benefit of this care extends considerably beyond these traditional clinical targets. Such relatively remote events as intellectual and psychologic performance in offspring from these pregnancies may be jeopardized by inadequate attention to details of medical management during pregnancy. Lastly, an opportunity is presented to both physician and patient to beneficially influence future diabetes therapy. The intense motivation of the mother, together with her positive experiences, can be channeled to promote an enduring attitudinal and behavioral approach to future

Microbiology of Deep Tissue in Diabetic Gangrene

Abstract: Information on the incidence and nature of the causative organisms in the infected tissues of patients with diabetic gangrene is scanty. Studies in which material for culture was obtained from the presenting lesion reveal multiple organisms in host isolates. No data are available regarding the bacterial flora of the deep infected tissue itself, uncontaminated by surface organisms. In this investigation 58 specimens from 52 patients were obtained utilizing aerobic and anaerobic culture techniques. In the surgical theater, material was obtained from the infected deep tissues using careful aseptic dissection techniques. All patients had been on antibiotic therapy from 2 to 10 days before the study. An average of 2.3 organisms per specimen was found. The predominant organisms were Proteus sp. Enterococcus, Staphylococcus aureus , and other enterobacteriacae in that order. Anaerobes were isolated in 27 per cent of cases, but never as the only organism. Prior antibiotic therapy did not eradicate infection in infected diabetic gangrene.

Service and Education for the Insulin-dependent Child

Abstract: A pilot program of service and education was designed to actively involve the inner-city, insulin-dependent child in his own diabetes management. A telephone service for questions and advice, managed by a pediatric nurse specialist, was responsible for a significant reduction in hospital admissions. The project was enthausiastically received and utilized by inner-city residents and resulted in an increased referral rate from the entire metropolitan area.

Diabetes Mellitus and Autonomic Dysfunction After Vacor Rodenticide Ingestion

Abstract: A case of N-3 pyridylmethyl-N' 4 nitrophenyl urea (Vacor) rodenticide poisoning in a 52-year-old man is presented. Vacor is structurally related to alloxan and streptozotocin, agents that have been used extensively to produce diabetes mellitus in laboratory animals. Seven days after ingestion of Vacor, the patient presented in diabetic ketoacidosis complicated by postural hypotension and adynamic ileus. The patient recovered from ketoacidosis but has continued to require insulin. With infusion of arginine, glucagon rose from 185 to 650 pg./ml. and C-peptide from 0.5 to 3.4 ng./ml. Six weeks after onset of diabetes, no anti-islet-cell antibodies were detected. Muscle capillary basement membrane thickness on electron microscopy was found to be 1,918 +/- 194 A. The absence of hyperglycemia after Vacor ingestion should not lead to complacency on the part of the attending physician. The patient must be observed closely for development of ketoacidosis and treated prophylactically with nicotinamide, the suggested antidote.

Diabetic glucose control: matching plasma insulin concentration to dietary and stress hyperglycemia.

Abstract: Optimal management of the diabetic patient includes normalization of plasma glucose concentration. Attainment of this goal is difficult because both food and stress result in acute elevations of blood glucose that cannot be matched with a single subcutaneous injection of NPH insulin. This paper examines the currently available methods for delivery of insulin to the diabetic subject and the degree of metabolic control attained. It suggests that optimal diabetic control will be achieved only when newer methods of insulin delivery are available to the clinician that match plasma insulin requirements to the simultaneous plasma glucose concentration.

Composition of Foods Commonly Used in Diets for Persons with Diabetes

Abstract: Information on the carbohydrate, protein, fat, kilocalorie, and plant fiber content of 152 common foods has been collated. These data are based on information currently available and will need to be modified and updated as more information emerges. These data are presented in six tables that follow the format of the commonly used Exchange Lists for Meal Planning for patients with diabetes mellitus.

Diabetic retinopathy: a general survey.

Abstract: Diabetic retinopathy has become one of the major causes of legal blindness and can cause a degree of visual loss that prevents independent ambulation and even total blindness. It-is now the second leading cause of new blindness in the United States and the leading cause in adults under age sixty-five.1–2 The tragedy of this is even more greatly magnified when one considers that those blinded by diabetes are often quite young, in their twenties or thirties. Fortunately, most patients with diabetic retinopathy do not have visual impairment. The prevalence of diabetic retinopathy is strongly and positively associated with duration of diabetes.3–5 Retinopathy is seen after a shorter duration of diabetes in older patients than in younger patients, but prevalence figures for all ages seem to merge after ten years duration of diabetes.3 Thus, the overall prevalence of clinically detectable retinopathy in patients under age thirty at diagnosis is less than 10% if the duration of the disease is less than ten years, while the prevalence for patients over age 60 at diagnosis is 35–40% with the same duration.4 After fifteen years duration of diabetes, 60–70% of patients will have retinopathy.3–5 The true prevalence of diabetic retinopathy remains unknown, however, and statistical data are complicated by a variety of factors. Most studies focus on juvenile-onset diabetes, or of diabetes of long duration, and do not include the large numbers of elderly patients with mild diabetes without retinopathy. Studies have usually been done in referral centers for either diabetes or eye disease. Thus, the prevalence of the disease is probably more common than appreciated by most physicians, but not as common as thought by most ophthalmologists who are biased by the type of diabetic patients referred for ophthalmic care.

The need for special foods and sugar substitutes by individuals with diabetes mellitus.

Abstract: The need for special dietary products marketed for use by individuals with diabetes mellitus and the safety and efficacy of certain nutritive sweetener substitutes for sucrose are reviewed. Special foods for individuals with diabetes mellitus are not necessary to achieve the dietary objectives recommended by leading United States and European authorities. They can be achieved conveniently and at minimum expense through enlightened choices of commonly available food items. At present, specific and unique characteristics of food products with special therapeutic properties for diets of diabetic individuals cannot be delineated or defined on rational nutritional grounds. Such terms as “diet”, “dietetic”, and “diabetic” on food labels have no uniform meaning for consumers, and diabetologists have observed that patients tend to consume such foods without regard to their energy content. Some consumers regard the reduced-calorie and low-calorie prepared food products as convenient in diets for weight reduction and diabetes although their use in dietary management of diabetes has no therapeutic basis other than weight reduction and maintenance. When fed as pure substances to fasted subjects, the nonglucose carbohydrate nutritive sweeteners, fructose, xylitol, and sorbitol, are absorbed relatively slowly and produce less postprandial hyperglycemia and insulin response than sucrose or glucose. Adequate studies of their long-term effectiveness when ingested as part of mixed meals have not been conducted. Although these sucrose substitutes are generally considered safe, the significance of recent information on possible carcinogenicity of oral xylitol in long-term feeding studies has not been fully evaluated. In view of the lack of certain essential information on the long-term effectiveness of various diets in preventing or mitigating the chronic debilitating complication of diabetes, suggestions for future research are included.

Why don't we teach and treat diabetic patients better?

Abstract: of yesterday's experts may have resulted in the enhanced risk of atherogenesis run by our diabetic patients? This issue of DIABETES CARE includes two articles that are germaine to these questions. Anderson and Ward outline their experience with a high-fiber diet in the treatment of diabetes. 10 They and others 11 \" 15 have been finding that such diets may be beneficial for diabetic patients, both in terms of blood glucose control, and control of blood lipids. Yet, if the lipid hypothesis is unproven, the fiber hypothesis is even less well established. And Monnier et al., 16 also in this issue of DIABETES CARE, provide evidence that not all fibers have the same effects, at least in terms of glucose metabolism. The conclusion I must draw from this is that we have much yet to learn about the complex interrelationships between lipids, diet, fiber, diabetes, and atherogenesis. Personally, I happen to believe both that the lipid hypothesis is correct and that high fiber intake is beneficial. Yet, before we adopt either or both as dogma, I think we should recall again that standard practice for many years called for disproportionate carbohydrate limitation (and hence high fat intake), and, although an attractive approach at the time, it is now viewed as having been a wrong, and even harmful, approach. And at the time, the authorities supported that position. I should also point out that those who advocated liberalizing carbohydrate intake were often severely criticized at that time. Several years ago, those advocating high fiber intake were also often criticized. And, today, we hear criticism of those who advocate megavitamin programs, vegetarian or natural foods, and other unconventional nutritional positions. Let us not cast stones. lipoprotein concentration and development of ischaemic heart disease. Special report: principles of nutrition and dietary recommendations for patients with diabetes mellitus.term effects of high carbohydrate, high fiber diets on glucose and lipid metabolism. A preliminary report on patients with diabetes. effects of a high carbohydrate, high fiber diet on hyperglycemic diabetic men. Am. Why Don't We Teach and Treat Diabetic Patients Better? I would like to start with outlining an ideal situation concerning the relationship between the patient, the primary care physician, and the diabetes specialist. First, all three are highly motivated, very intelligent, and well aware of the needs and the extent of the knowledge and of the ignorance of each other. All three are cooperative. …

Fructose as a Dietary Sweetener in Diabetes Mellitus

Abstract: Human beings, including those with diabetes, have a desire for sweetness in the diet that cannot be ignored. The Food and Drug Administration ban of cyclamates and possible ban of saccharin have raised the question of alternative sweeteners for diabetic persons. Considerable interest has been focused on fructose, and both basic and clinical research has delineated its metabolic effects. This paper reviews the characteristics of fructose, as well as its physiology and metabolism in both normal and diabetic man. Findings seems to indicate that, in controlled diabetes, chronic or limited consumption of fructose at moderate doses has no adverse effects on the levels of blood glucose, cholesterol, or tryglycerides.