Showing papers in "Diabetes Care in 1979"

Diabetes and Glucose Tolerance as Risk Factors for Cardiovascular Disease: The Framingham Study

Abstract: This report examines prospectively, in the Framingham cohort, the relation of diabetes and impaired glucose tolerance to each of the cardiovascular sequelae, taking into account age, sex, and associated cardiovascular risk factors. The incidence of cardiovascular disease, as well as the levels of cardiovascular risk factors, were found to be higher in diabetic than in nondiabetic men and women. The relative impact of diabetes on coronary heart disease, peripheral vascular disease, or stroke incidence was the same in men and women, but for cardiovascular mortality and cardiac failure the impact is greater for women. Present evidence suggests that alleviation of associated cardiovascular risk factors is the most promising course in reducing cardiovascular sequelae in diabetic patients.

Coronary Heart Disease Incidence and Cardiovascular Mortality in Busselton with Reference to Glucose and Insulin Concentrations

Abstract: In the 1966 study of the population of Busselton, Australia, blood sugar and serum insulin levels were measured one hour after an oral glucose load, in addition to the conventional cardiovascular risk factors. The six-year incidence of coronary heart disease (CHD) and the 12-yr mortality from CHD and from all cardiovascular diseases is described in relation to the initial baseline variables measured using the upper 20th percentile values (age-specific and sex-specific) to define the risk ratios. In younger subjects (ages less than 60 yr), elevated blood pressure levels for both sexes (risk ratios from 2.9 to 5.2) and elevated serum cholesterol concentrations for males (risk ratios from 3.0 to 3.3) were strong predictors of cardiovascular risk. In men aged 60 to 69 yr, those with upper range one-hour serum insulin concentrations showed marked associations with the six-year incidence of CHD, the 12-yr mortality from CHD, and the 12-yr mortality from all cardiovascular diseases (risk ratios were 2.0, 2.3, and 2.4, respectively). The relationship of elevated serum insulin and cardiovascular mortality persisted when males of all ages were analyzed, and it appeared to be independent of the other major risk factors. In females, no association between serum insulin and CHD or cardiovascular disease could be found. Although the age and sex specific upper 20th percentile values for one-hour blood sugar concentrations showed a low grade association in patients with subsequent cardiovascular disease end points, more noticeable risk ratios were demonstrated at the higher blood sugar level of 200 mg/100 ml or greater (in the age group 60 yr and over, risk ratios were 2.2 in males and 2.6 in females.

Relationship of Glucose Tolerance and Plasma Insulin to the Incidence of Coronary Heart Disease: Results from Two Population Studies in Finland

Abstract: The relationship of glucose tolerance to the incidence of coronary heart disease (CHD) has been investigated in two cohorts of Finnish men: 3267 men ages 40–59 yr from the Social Insurance Institution9s (SII) Coronary Heart Disease Study and 1059 men ages 30–59 yr from the Helsinki Policemen Study. The relationship of plasma insulin level to the incidence of CHD was also investigated in the Helsinki Policemen Study. An oral glucose lead of 60, 75, or 90 g according to body surface area was used in both studies. In the SII Study, plasma glucose was determined from venous blood samples taken 1 h after glucose load. In the Helsinki Policemen Study, blood glucose was determined from venous blood samples taken at 0, 1, and 2 h, and at a 5-yr reexamination, plasma insulin was measured during OGTT at 0, 1, 2 h. In the SII Study cohort, the 4-yr mortality from CHD and the 4-yr incidence of nonfatal myocardial infarction (MI) did not show a definite relationship to 1-h postload plasma glucose. In the Helsinki Policemen Study cohort, the 5-yr incidence of “hard criteria” CHD (CHD death and nonfatal MI) was significantly related to high 1-h postload blood glucose level but not to fasting or 2-h postload blood glucose levels. 10-yr mortality from CHD was significantly higher in the top quintile of fasting and 1- and 2-h postload blood glucose levels, as was the incidence of “hard criteria” CHD. However, in multivariate analyses including age, systolic blood pressure, plasma cholesterol, and smoking, the blood glucose variables showed no statistically significant independent contribution in predicted risk of CHD. Univariate analyses by quintiles of plasma insulin levels measured at the 5-yr reexamination showed that the incidence of “hard criteria” CHD during the subsequent 5 yr was significantly higher in the top quintiles of fasting and 1-h and 2-h postload plasma insulin than in the combined lower quintiles. Multivariate analyses showed that the value of high 1-h or 2-h postload plasma insulin level for predicting CHD risk was independent of other risk factors, including blood glucose levels during OGTT.

Diabetes Mellitus and Its Vascular Complications in Japanese Migrants on the Island of Hawaii

Abstract: Japanese migrants and their offspring on the island of Hawaii and Japanese living in Hiroshima were examined for diabetes mellitus and its vascular complications. the same methods and investigators were used in both locations. Death certificates of Japanese and Caucasians dying on the island during the past 26 yr were analyzed. Diabetes, defined as a venous serum glucose concentration of at least 200 mg/dl 2 h after a 50-g oral glucose load, was significantly more common in the Hawaiian Japanese than in the Hiroshima Japanese subjects. This suggests that diabetes is more prevalent in Japanese in Hawaii than in Japan, although lack of knowledge about the total population of Japanese migrants in Hawaii makes this generalization uncertain. The proportion of deaths attributed to diabetes was much higher in Japanese migrants and their offspring in Hawaii than in Japan. During the 1950s, the proportional death rate from diabetes was about half as large in Japanese Hawaiians as in Caucasian Hawaiians, but it increased to become 1.6 times the Caucasian rate during the 1970s. A nutritional study revealed that the total caloric intake was similar in Japanese in Hawaii and Hiroshima, although the estimated level of physical activity was less in the Hawaiian subjects. Consumption of animal fat and simple carbohydrates (sucrose and fructose) were at least twice as high in Hawaiian as in Hiroshima Japanese. Conversely, Hiroshima Japanese consumed about twice the amount of complex carbohydrate as the Hawaiian Japanese. These observations support the hypothesis that a high fat, high simple carbohydrate, low complex carbohydrate diet and/or reduced levels of physical activity increase risk of diabetes. The proportion of deaths attributed to ischemic heart disease was higher in both diabetic and nondiabetic Japanese Hawaiians than in diabetic subjects in Japan. The rates were similar for Japanese and Caucasians in Hawaii. There was no evidence of an environmental influence on the development of microangiopathy (retinopathy) in diabetes, as the prevalence of diabetic retinopathy (stratified for diabetes duration) was similar in Japanese subjects in Hawaii and in Japan, and it was similar to previous reports from England. On the other hand, diabetes alone did not appear to account for the greater prevalence of macroangiopathy in Hawaiian Japanese than in Hiroshima. Thus environmental factors, possibly including diet, appear to be involved in the development of macrovascular complications of diabetes.

Dietary Cyanide and Tropical Malnutrition Diabetes

Abstract: Two categories of diabetes are recognized in the temperate zone—ketosis-prone diabetes requiring insulin and diabetes not requiring insulin. Another unique type of diabetes occurs in the tropics. It has two forms, both different from either form of temperate zone diabetes. Type J and pancreatic diabetes are both characterized by youth onset, antecedent malnutrition, substantial insulin requirement, and resistance to ketosis. In the tropical countries where they are found, both forms are associated with specific dietary practices, including a nutritionally marginal protein intake. The close association with low protein intake distinguishes this form of diabetes from that occurring in North America, Europe, and Oceania. The geographic distribution of malnutrition diabetes, in addition to being limited to the tropics, coincides regularly with the consumption of tapioca (cassava) or other foods that contain cyanide-yielding substances. Ingested cyanide is normally detoxified, principally, by conversion to thiocyanate. This detoxification requires sulfur, derived principally from amino acid sources. Studies in the rat indicate a remarkable ability to detoxify ingested cyanide, a reduction in urinary thiocyanate excretion when protein intake is lowered (especially during growth), production of marked hyperglycemia by either oral or parenteral cyanide, and the development of cyanosis and epidermal changes when there is prolonged exposure to cyanide. Both the association of malnutrition diabetes with food cyanogens and our laboratory observations support a role for cyanide in its pathogenesis.

complications of Diabetes Mellitus: Relationship to Metabolic Dysfunction

Abstract: T he major morbidity and mortality of diabetes mellitus is a consequence of its vascular complications.' The pathogenesis of these complications remains to be elucidated, but it is clearly multifactorial.\" An issue of fundamental importance is the relationship of the complications to the deranged metabolism (hyperglycemia, insulinopenia, and associated metabolic alterations). If the development of the complications is either a consequence of, or is in part influenced by, the metabolic dysfunction, then the degree of metabolic control achieved by therapy might be expected to influence the development of complications. A definitive answer to this crucial question is not possible at present, because all conventional treatment modalities which attempt to reverse altered metabolism achieve only an approximation of what is true in an individual without diabetes.' In addition, it is clear that the conventional clinical indices for monitoring metabolic control are inadequate and often misleading.\" All the above not withstanding, current available evidence favors the thesis that the complications are secondary to the metabolic disorder'*\" and thus should be prevented or significantly reduced or delayed by achieving a high degree of metabolic control of diabetes mellitus. Four general lines of evidence support this view: (1) clinical and epidemiologic studies; (2) pathological studies; (3) biochemical studies; (4) animal models. This article briefly reviews each of these areas, focusing particularly on articles with clinical relevance.

Immunologic Reactions to Insulin: Insulin Allergy, Insulin Resistance, and the Autoimmune Insulin Syndrome

Abstract: The mainstay of treatment for almost all patients with juvenile-onset diabetes mellitus and many patients with maturity-onset diabetes mellitus is insulin. Since insulin is a polypeptide hormone obtained by acid-ethanol extraction of animal pancreas, it is not surprising that administration of insulin to diabetic patients or to normal persons regularly evokes some immune response. In almost all patients who have taken insulin for longer than 2 months, levels of circulating antibodies to insulin can be measured by assays in vitro. Although in most patients the immune response is clinically insignificant, many insulin-taking diabetic patients will at sometime present a clinical problem related to chronic exposure to this foreign protein; the exact nature of the clinical manifestation will depend on which pathway in the immune system shows the major activation (Figure 1). The various types of immune response noted after insulin administration are listed in Table 1. Our review will concentrate on the relatively more common, cutaneous types of insulin allergy as well as immunologically related insulin resistance. In addition, we will consider some experimental studies of insulin as an antigen in both man and animals and the rare, autoimmune insulin syndrome.

Epidemiology of diabetes and its macrovascular manifestations in Pacific populations: the medical effects of social progress.

Abstract: Worldwide diabetes epidemiology studies have shown quite marked differences in diabetes prevalence rates between ethnic groups. This pattern holds true in the Pacific region and provides unique opportunities for comparative studies. Diabetes is rare in Melanesians, and also in Polynesians, Micronesians, and Australian Aboriginals who retain their traditional life-style. High prevalence rates of insulin-independent diabetes have been demonstrated in Polynesians, Micronesians, and Australian aboriginals who have adopted a Western life-style. Along with the Pima Indians, the Micronesian population of Nauru have the highest diabetes prevalence yet reported--40% of people aged 20 yr and over. As diabetes is rare in traditional living Polynesians and Micronesians, yet high in westernized populations of these ethnic groups, it appears these people may have a "diabetic genotype" that is unmasked by the change in life-style. Obesity, a high caloric Western diet, and reduced physical activity may be the major precipitating factors. Bimodality of glucose tolerance distributions has been demonstrated in both westernized Polynesians and Micronesians. The frequency distributions of both fasting and 2-h postload glucose levels allow separation of these populations into normal and hyperglycemic groups. The optimal cut-off levels between the two groups were a fasting plasma glucose congruent to 140 mg/dl and a 2-h level of congruent 20 mg/dl. These findings provide a valid basis for the diagnosis of diabetes mellitus to be based on the above levels. Only sparse information exists on the prevalence of microvascular and macrovascular complications of diabetes in these populations. However, there is clear evidence that they are occurring and they are similar in nature to the complications seen in Caucasian diabetic patients. Coronary artery disease is not yet a major problem in Pacific Islanders although most of the major risk factors are not present in urbanized communities. However, with increasing westernization, and given more time for the pathologic process of atheroma to develop, it can be expected that coronary artery disease will become a major cause of morbidity and mortality in Polynesians, Micronesians, and the Australian aboriginal.

Feasibility of Improved Blood Glucose Control in Patients With Insulin-Dependent Diabetes Mellitus

Abstract: An attempt was made to improve the control of blood glucose in patients with insulin-dependent diabetes mellitus. Ten patients were studied over a period exceeding 8 mo in the outpatient department. Each patient was taught to monitor his or her own blood glucose concentration and was enrolled in an exercise program. In addition, they were taught to calibrate insulin, food, and exercise in terms of the response of the blood glucose. After 3 mo of study, there was a significant decrease in hemoglobin A1c (Hb A1c) values from a mean concentration of 10.3 to 7.6%. Hb A1c values correlated well with mean blood glucose levels (r = 0.86). Dietary analysis revealed that the patients selected a diet consisting of 25% protein, 44% fat, and 31% carbohydrate, but there was a wide range in caloric distribution. There was no correlation between blood glucose control as measured by Hb A1c and caloric distribution. Systolic blood pressures decreased greater than 10 mm Hg. Serum alkaline phosphatase also decreased in each patient as control of blood glucose improved. Three of the patients with abnormalities of nerve conduction measurement at the beginning of the study had a complete return to normal at 8 mo. An outpatient program such as this may be cost effective through the avoidance of diabetes-related hospitalizations and may provide a mechanism whereby larger studies can be designed to define further the relationship of glycemia to the sequelae of diabetes.

Psychological aspects of diabetes mellitus: a critical review.

Abstract: In recent years, there have been an increasing number of studies concerning psychological aspects of diabetes mellitus. Four important topics are raised in these varied studies: (1) the role of psychological factors in the onset of diabetes; (2) the influence of the immediate environment upon the course of the disease; (3) the immediate response and long-term psychological adjustment of the diabetic individual after the onset; and (4) the family: the reaction of the family to the illness and the impact of diabetes upon the family structure. Since this is so complex and broad an area, we will review each of these topics by looking at the specific studies. In this review, we will focus on specific issues that concern research designs and conflicting findings. Our own interests have been in the impact of diabetes upon both individual development and the family. We have uncovered some interesting developmental patterns from our pilot studies. We will also indicate our own approach, and some of these initial findings.

Studies of the HLA System and Insulin-dependent Diabetes Mellitus

Abstract: The relationship between the HLA system and insulin-dependent diabetes mellitus (IDDM) is reviewed. Data compiled by the HLA and Disease Registry reveal that HLA-B8 and/or Dw3 are associated with IDDM in all populations studied so far, but further population studies in non-Caucasian populations should be performed. In Caucasians, HLA-Dw2 renders protection against IDDM while HLA-Dw3 and Dw4 are associated with susceptibility to IDDM. The exact mode of inheritance of susceptibility to IDDM remains to be established. Involvement of at least two genes is likely. Heterogeneity of IDDM is highly possible and should be a matter of major interest in diabetes research.

The WHO Multinational Study of Vascular Disease in Diabetes: 2. Macrovascular Disease Prevalence

Abstract: 14 national groups have collaborated under WHO auspices to select, from local defined populations of individuals with clinical diabetes, groups of approximately 500 within the age range 35--55 yr stratified by age, sex, and known duration of diabetes. In each center, the selected patients were submitted to a standardized study protocol, which included systematic inquiry (WHO questionnaire) for the presence of symptoms of angina pectoris, history of myocardial infarction, presence of intermittent claudication, and cigarette smoking history. Examination included standard biometry, blood pressure measurement, 12-lead (centrally Minnesota coded) electrocardiography, and central laboratory measurement of serum cholesterol and creatine. Ophthalmoscopic and urinary examinations were also included. The prevalence of arterial disease symptoms and electrocardiographic abnormalities show very large variation between countries, the lowest rates generally being found in the Oriental samples and the highest in the European. "Risk factors" for arterial disease (blood pressure, serum cholesterol, and cigarette smoking) also vary widely between diabetic groups. Although data are not yet complete, these differences appear unlikely to explain the variation in the atherosclerotic morbidity observed. Diabetic women were at least as vulnerable to arterial disease as diabetic men. A high prevalence of nonspecific abnormalities of the repolarization phase of the ECG was found, even in groups where ischemic abnormalities were rare. The origin of these is uncertain; they may represent variable local changes or possibly diabetic cardiomyopathy. This preliminary report confirms and quantifies previous indications that the impact of atherosclerotic disease on persons with diabetes varies considerably between national groups, in broad terms, running parallel with the variations in prevalence in the populations in general and suggesting that cultural and/or ethnic factors are more important determinants of atherosclerosis in diabetic individuals than is the diabetic state per se.

A Multidisciplinary, Comprehensive, Ambulatory Treatment Scheme for Diabetes Mellitus in Children

Abstract: A study has been carried out on 262 children with juvenile diabetes and their parents, treated up to 10 yr on an ambulatory basis by a multidisciplinary team composed of pediatric endocrinologist, nurse, dietitian, psychologist, and social worker. Comparison of the findings with those of a study performed before inception of the Counselling Center for Juvenile Diabetics revealed the following positive influences: the degree of control attained was both higher and sustained with greater regularity; there were fewer complications with no episodes of coma, brittle diabetes, or severe ketoacidosis and almost no need for hospitalization; the attitude of the affected child, his parents, and his teachers was found to be considerably improved; there was better understanding of the nature of the disease and its requirements; the child's motivation to maintain the diabetic regimen was greater and conflicts within the family circle were markedly reduced; the child's self-concept was much higher; and both scholastic achievements and social adjustment were greater. We concluded that psychological stability is a basic factor in the control of diabetes, and the value of the multidisciplinary approach in the treatment of this chronic disease is indicated.

The WHO multinational study of vascular disease in diabetes: 1. General description.

Abstract: A general description of the multinational study under the auspices of the World Health Organization is presented The purpose was to compare the prevalence of vascular disease in representative samples of diabetic subjects of different ethnic and cultural habitus Standardized methods of investigation were devised Fourteen centers participated, and the data collected so far indicate that the characteristics of the populations studied varied as to age composition, adiposity, cigarette smoking, treatment, age at diagnosis, and duration of diabetes Thus, taking these factors into consideration and while awaiting completion of the data, conclusions must be drawn with reserve

Hemoglobin a1c values in children with overt diabetes maintained in varying degrees of control.

Abstract: The concentration of hemoglobin A 1c has been found to be elevated in patients with uncontrolled diabetes. HbA 1c levels change at a slow rate so that a single measurement is believed to reflect the overall degree of control achieved by a patient for about the previous 2 mo. Using the Trivelli method, we determined HbA 1c levels in 81 children with overt insulin-dependent diabetes and in 14 healthy children and young adults who served as controls. Five of the diabetic children with recent onset had sequential HbA 1c determinations at 3–6-wk intervals. Each had a rapid decline in HbA 1c level to near normal values after the patient was kept essentially euglycemic for about 60 days. Before the HbA 1c determination, each diabetic child was given an overall control rating for the previous 2 mo or more based on criteria defined in our clinic. HbA 1c values increased progressively as diabetic control declined. There was a statistically significant correlation between the clinical control ratings and HbA 1c levels (P

Fiber and Diabetes

Abstract: Plant fibers have important influences on gastrointestinal physiology and the absorption of many nutrients. Certain fibers delay the absorption of carbohydrates and result in less postprandial hyperglycemia. Because the intake of plant fibers lowers plasma glucose concentrations and decreases glycosuria, high-fiber foods may be useful in the management of diabetes mellitus. Consumption of selected fibers and fiber-rich foods lowers serum cholesterol values and may lower triglyceride concentrations. Plant fiber intake may lead to mineral depletion or vitamin deficiency, but this has not been observed in several long-term studies. Further work is required to delineate the therapeutic utility of plant fibers in the diet of persons with diabetes and to assess the undesirable effects of fiber intake. In our opinion, persons with diabetes who are eating very low-fiber diets would benefit from an increase in plant fiber intake from whole grains, legumes, and vegetables.

Hypocalcemia, Hypomagnesemia, and Transient Hypoparathyroidism During Therapy with Potassium Phosphate in Diabetic Ketoacidosis

Abstract: The effects of intravenous administration of potassium phosphate in the treatment of diabetic ketoacidosis were studied in nine children, ages 9 9/12 to 17 10/12 yr. During phosphate infusion (20--40 meq/L of fluid), all children maintained normal serum concentrations of phosphorus. Transient hypocalcemia occurred in six and transient hypomagnesemia in five patients. One child developed carpopedal spasms refractory to intravenous infusion of calcium gluconate but responsive to intramuscular injection of magnesium sulfate. In three patients, serum levels of intact parathyroid hormone were low at the time of hypocalcemia, an observation that suggests transient hypoparathyroidism. This study indicates that the use of potassium phosphate as the sole source of potassium replacement might potentiate ketoacidosis-induced hypocalcemia through multiple mechanisms.

Fasting Hyperglycemia and Associated Free Insulin and Cortisol Changes in “Somogyi-Like” Patients

Abstract: Blood glucose levels were measured over a 24-h period in eight insulin-dependent diabetic subjects who were difficult to control and who presented with morning fasting hyperglycemia. At least seven exhibited clinical characteristics suggestive of the Somogyi phenomenon. A continuous glucose monitoring apparatus was used to relate the concentrations of glucose during the day to concomitant levels of free insulin and cortisol. In all patients a significant (P < 0.01) rise in fasting morning glucose started at about 0600 h, while they were still asleep. In six patients the morning elevation of blood glucose was preceded by stable, almost normal glucose levels during the night (117 ± 2.5 mg/dl); one of the two remaining patients (no. 7) exhibited high overnight glucose levels (268 ± 7 . 2 mg/dl), whereas the other (no. 8) had a mild hypoglycemic episode (45 mg/dl) 6 h before the hyperglycemic period.In all patients the fasting glucose rise was associated with the usual morning cortisol surge (P < 0.05)and with a significant decrease in the concentration of serum free insulin (P < 0.01). The free insulin levels in patient no. 8 were higher, while those of patient no. 7 were lower, than in the other six patients. We conclude that the diurnal morning rise in cortisol may cause hyperglycemia in insulin dependent diabetic patients if insufficient exogenous insulin remains and/or endogenous insulin is not secreted. In such patients the high levels of fasting glucose in the morning may misrepresent their overnight control of blood glucose and lead to an erroneous impression of the Somogyi phenomenon.

Recommendations on the standardization of methods and reporting of tests for diabetes and its microvascular complications in epidemiologic studies.

Abstract: This paper emphasizes the need and importance of standardization of methods and reporting in the epidemiology of diabetes and suggests methods for determination of glucose tolerance and for reporting data on such characteristics as history, obesity, and presence of microangiopathy

Gastrointestinal Manifestations of Diabetes Mellitus

Abstract: This review briefly outlines the gastrointestinal manifestations of diabetes mellitus. Usually, gastrointestinal abnormalities are asymptomatic. Severe gastrointestinal dysfunction may be quite debilitating, however. Gastrointestinal symptoms that are a consequence of diabetes may be confused with other primary gastrointestinal disorders. We attempt to provide a clinical approach to differentiating the basis of symptoms and outline the therapeutic plan that we generally employ. Much additional research is necessary to clarify our understanding of the pathophysiology of the gastrointestinal complications of diabetes and to develop improved therapeutic strategies.

Accelerated Insulin Degradation: An Alternate Mechanism for Insulin Resistance

Abstract: We have examined insulin and glucagon degrading activities of muscle and fat tissues in 11 subjects (4 lean controls, 3 insulin-resistant obese subjects, 2 non-insulin-dependent diabetic subjects, and 2 insulin-treated diabetic subjects) and correlated degrading activity with (1) basal insulin level and (2) state of insulin resistance. We found hyperinsulinemia and insulin resistance to be significantly correlated with accelerated insulin and glucagon degrading activity. Weight reduction in an insulin-resistant obese patients results in parallel reduction in both basal insulin level and insulin–glucagon degrading activity. These data are consistent with the hypothesis that an alternative mechanism for insulin resistance may be an accelerated insulin degradation at the level of target tissues.

Diabetes mellitus: the search for genetic markers.

Abstract: The search for genetic markers has established that idiopathic diabetes mellitus is a genetically heterogeneous group of disorders that have glucose intolerance in common. The types of genetic markers--subclinical linkage, and association--and how they are utilized to delineate the genetic basis of the diabetic syndrome are discussed. The use of such markers as insulin levels, pancreatic islet cell antibodies, and HLA antigens has permitted the separation of insulin-dependent (juvenile) and not insulin-dependent (maturity) diabetes. Such studies have also started to reveal heterogeneity within these broad groups of insulin-dependent and not insulin-dependent types. This extensive heterogeneity has major implications for understanding the pathogenesis and genetics of diabetic mellitus and is of potentially great clinical significance, since the natural history and complications may well differ between these different disorders.

Sexual problems in diabetes mellitus: psychological aspects.

Abstract: The evolving changes in societal attitudes toward human sexuality have been accompanied by the recognition that a wide variety of medical disorders can affect sexual functioning. It is no longer unusual for diabetic patients among the medically ill to express their sexual concerns to the health practitioner. In addition, the availability of psychological, behavioral, and surgical approaches for the treatment of sexual disorders has resulted in an increased number of diabetic patients who seek help specifically for their sexual problems. It is the responsibility of the health practitioner to encourage expression of the patients' concerns, provide information, advice, and reassurance when appropriate and to seek consultation when indicated. Unfortunately, the medical professional is handicapped by the limited amount of systematic information available on the relationship between diabetes mellitus and sexual activity. In this article, we will review data on the prevalence and nature of sexual disorders in men and women with diabetes. Information will be presented on physiopathologic mechanisms and psychological determinants of sexual dysfunction in diabetic individuals and on the development of a methodology for the accurate assessment of organic deficit in erectile capacity. The article will then review psychological approaches to the treatment of sexual disorders associated with diabetes and, finally, will briefly discuss some of the psychological factors to be considered in the screening of patients when prosthetic implantation is indicated.

Pathogenesis of Diabetic Ketoacidosis: A Reappraisal

Abstract: This study reviews the pathogenic hormonal abnormalities (insulin deficiency and stress hormone excess) in diabetic ketoacidosis. The data both supporting and negating a primary role for insulin deficiency in the pathogenesis of diabetic ketoacidosis are examined. Evidence implicating excess stress hormone secretion as a necessary event in the development of severe metabolic decompensation is discussed. The data suggest that diabetic ketoacidosis may be prevented by correcting either the relative deficiency of insulin or the excess secreation of one or a combination of the stress hormones. Studies supporting a primary role for insulin deficiency in the pathogenesis of diabetic ketoacidosis include the beneficial therapeutic response to insulin administration in ketoacidosis, development of ketoacidosis; and (3) stress hormone excess is necessary for fulminant ketoacidosis to be manifested.s following insulin withdrawal from diabetic man and animals, and hypoglycemic and hypoketonemic effects of insulin. Studies negating a primary role for insulin deficiency in ketoacidosis include the "normal" plasma insulin concentration in the majority of ketoacidotic cases, delayed onset of ketoacidosis after insulin withdrawal from diabetic man, and lack of hypolipolytic and hypoketonemic effect of insulin without prior stress hormone adipocyte and hepatocyte stimulation. Evidence that stress hormones (glucagon, catecholamines, cortisol, and growth hormone) contribute to the metabolic decompensation of ketoacidosis includes: (1) in all cases of ketoacidosis, at least one stress hormone is always elevated; (2) pharmacologic blockade of each of the stress hormones reduces the rate and/or frequency of metabolic decompensation in diabetic man; (3) removal of the pituitary and/or the adrenal gland in diabetic animals completely prevents the development of ketoacidosis after insulin withdrawal; and (4) administration of each of the four stress hormones under appropriate conditions induces metabolic decompensation in diabetic man with "normal" circulating levels of plasma insulin concentration. From these studies, the following conclusions are supported: (1) absolute insulin deficiency is an unusual cause of ketoacidosis; (2) the presence of relative insulin deficiency is necessary for the development of ketoacidosis; and (3) stress hormone excess is necessary for fulminant ketoacidosis to be manifested.

The WHO Multinational Study of Vascular Disease in Diabetes: 3. Microvascular Disease

Abstract: A preliminary comparison and analysis of microvascular disease was performed in 14 stratified samples of diabetic subjects. Microvascular disease was assessed by estimating visual disabilities, by standardized examination of the optic fundus by direct ophthalmoscopy, by estimating proteinuria, and by measuring the serum creatinine concentration. Visual impairment by questionnaire positive varied considerably between centers, probably due to cultural differences in interpretation of the questions. Physician-assessed visual disability also yielded considerable differences in frequency; however, the frequency differences were unrelated to those observed for macrovascular disease. Retinopathy—the sum of all components—was related to duration of diabetes in each participating center. The apparent frequency of proteinuria varied considerably between centers. In general, the frequency of retinopathy was related to the level of systolic blood pressure, but there was no systematic association with cigarette smoking.

Teaching the person with diabetes: experience with a follow-up session.

Abstract: We studied 371 diabetic patients who attended an outpatient follow-up session after completing an in-patient diabetes education program. Identified gaps in information on diabetes care included problems with understanding the prescribed diet (155 patients), incorrect urine testing (30 patients), and unacceptable technics of insulin administration (26 patients). We also reviewed 178 consecutive patients who had been invited to this follow-up session to ascertain how often readmission to the hospital occurred. 88 of these patients attended a follow-up session while 90 patients did not attend. Over the ensuing 5 yr, the latter group had a significantly higher readmission rate (P

Ego Development and Self-Esteem in Diabetic Adolescents

Abstract: This study explores the impact of diabetes mellitus upon aspects of adolescent development. Using specific assessment techniques and interviews, we followed ego development and self-esteem variables. Clinical considerations suggest that both personality dimensions are important for the understanding of diabetic adolescents. The significance of ego development is implied in many case reports, which note the disruption in individual coping that frequently follows the onset of diabetes. Clinical observations and empirical studies have also commented upon diminished self-esteem in diabetic patients. Our sample consisted of male and female diabetic adolescents, whose average age was 13. All patients completed Loevinger9s sentence completion test of ego development and the Coopersmith self-esteem inventory. Previous studies have indicated favorable reliability and validity for both instruments. A subgroup of the sample was also interviewed. The ego development and self-esteem scores were contrasted with two groups of similar age adolescents who had previously completed these same tests, and a control group. The diabetic adolescents were clearly at lower levels of ego development than the nondiabetic groups. These lower stages were not correlated with duration of illness. A second finding was that the boys were at lower levels of ego development than the girls, regardless of age or illness duration. Self-esteem scores were associated with both illness duration and ego development. Subjects at the lowest levels of ego development also had the lowest self-esteem. Study of the interviews revealed that the patients at these lower ego development levels manifested concrete, more stereotyped, and resigned responses than those patients at the higher ego development stages.