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Showing papers in "Diabetes Care in 1986"


Journal ArticleDOI
TL;DR: Continuous glucose monitoring of five diabetic subjects for 77 ± 22 h revealed that a significant correlation existed between the subcutaneous tissue glucose concentration and the plasma glucose concentration measured simultaneously in each patient.
Abstract: For continuous monitoring of glucose concentration in ambulant diabetic patients, a telemetry glucose monitoring system with a needle-type glucose sensor has been developed. The system consists of a sensor transmitter (4 × 6 × 2 cm, 50 g) that converts current signals generated in a needle-type glucose sensor to high-frequency audio signals and a receiver that continuously calculates glucose concentrations from the received audio signals. The noise range of a monitoring record with the telemetry system (0.3 ± 0.04%, mean ± SEM) was significantly smaller than that with a wire-connected system, the wearable artificial endocrine pancreas (2.5 ± 0.3%). Postprandial tissue glucose concentration responded well to the plasma glucose concentration, with a time lag of 5 min. Continuous glucose monitoring of five diabetic subjects for 77 ± 22 h revealed that a significant correlation existed between the subcutaneous tissue glucose concentration and the plasma glucose concentration measured simultaneously in each patient. These data indicate the usefulness of the telemetry glucose monitoring system in strict glycemic control of diabetic individuals.

397 citations


Journal ArticleDOI
TL;DR: It is concluded that the DFBC is a promising measure of family interaction related specifically to the IDDM regimen and that, for adults, higher levels of nonsupportive family behaviors may be related to reduced regimen adherence and poor control.
Abstract: The Diabetes Family Behavior Checklist (DFBC) was administered to 54 adults and 18 adolescents (less than 19 yr of age) with insulin-dependent diabetes mellitus (IDDM). Subjects and family members completed parallel forms of the DFBC at initial and 6-mo follow-up home interviews. During each of these periods, adherence was assessed via self-report, 1 wk of self-monitoring, and 24-h dietary recalls. The results showed reliable differences between adolescents and adults. More negative interactions with family members were reported by adolescents and their family members, and adolescents were in poorer metabolic control. For adults but not adolescents, negative DFBC scores were prospectively predictive of poorer regimen adherence over the 6-mo interval for measures of glucose testing, insulin injection, and dietary adherence. In addition, higher negative DFBC scores for adults were marginally associated with higher HbA1 levels (P less than 0.10). We conclude that the DFBC is a promising measure of family interaction related specifically to the IDDM regimen and that, for adults, higher levels of nonsupportive family behaviors may be related to reduced regimen adherence and poor control.

317 citations


Journal ArticleDOI
TL;DR: The Diabetes Education Study (DIABEDS) was a randomized, controlled trial of the effects of patient and physician education and its effects on patient knowledge, skills, self-care behaviors, and relevant physiologic outcomes were described.
Abstract: The Diabetes Education Study (DIABEDS) was a randomized, controlled trial of the effects of patient and physician education. This article describes a systematic education program for diabetes patients and its effects on patient knowledge, skills, self-care behaviors, and relevant physiologic outcomes. The original sample consisted of 532 diabetes patients from the general medicine clinic at an urban medical center. Patients were predominantly elderly, black women with non-insulin-dependent diabetes mellitus of long duration. Patients randomly assigned to experimental groups (N = 263) were offered up to seven modules of patient education. Each content area module contained didactic instruction (lecture, discussion, audio-visual presentation), skill exercises (demonstration, practice, feedback), and behavioral modification techniques (goal setting, contracting, regular follow-up). Two hundred seventy-five patients remained in the study throughout baseline, intervention, and postintervention periods (August 1978 to July 1982). Despite the requirement that patients demonstrate mastery of educational objectives for each module, postintervention assessment 11-14 mo after instruction showed only rare differences between experimental and control patients in diabetes knowledge. However, statistically significant group differences in self-care skills and compliance behaviors were relatively more numerous. Experimental group patients experienced significantly greater reductions in fasting blood glucose (-27.5 mg/dl versus -2.8 mg/dl, P less than 0.05) and glycosylated hemoglobin (-0.43% versus + 0.35%, P less than 0.05) as compared with control subjects. Patient education also had similar effects on body weight, blood pressure, and serum creatinine. Continued follow-up is planned for DIABEDS patients to determine the longevity of effects and subsequent impact on emergency room visits and hospitalization.

290 citations


Journal ArticleDOI
TL;DR: The diabetes-specific psychosocial measures of health beliefs and social support were the most consistent and strongest predictors of self-care behavior across the different regimen areas studied.
Abstract: This study assessed potential psychosocial correlates of self-care behaviors (compliance) and of glycemic control in a community sample of 184 people diagnosed as having non-insulin-dependent (type II) diabetes mellitus. Four different diabetes self-care behaviors were studied (medication taking, glucose testing, diet, and exercise), and glycemic control was assessed by glycosylated hemoglobin analyses. Multiple measures were collected within each of several categories of psychosocial variables including knowledge, stress, depression, anxiety, diabetes-specific health beliefs, and social support. Findings indicate that approximately 25% of the variance in self-care behaviors can be explained by psychosocial and demographic variables. In contrast, psychosocial variables were not significant predictors of level of glycemic control. The diabetes-specific psychosocial measures of health beliefs and social support were the most consistent and strongest predictors of self-care behavior across the different regimen areas studied. Possible reasons for these findings, limitations of the study, and directions for future research are discussed.

237 citations


Journal ArticleDOI
TL;DR: In this paper, the authors assessed levels of regimen adherence and reasons for non-adherence to different aspects of diabetes regimen for persons with type I and type II (non-insulin-dependent, N = 184) diabetes.
Abstract: This study assessed levels of regimen adherence and reasons for nonadherence to different aspects of diabetes regimen for persons with type I (insulin-dependent, N = 24) and type II (non-insulin-dependent, N = 184) diabetes. Standardized questions revealed few differences between type I and type II participants on either levels of reported adherence or reasons for nonadherence. Subjects reported adhering least well to dietary and physical activity components of the regimen. Open-ended questions revealed that the most common reasons for dietary nonadherence were the situational factors of eating out at restaurants and inappropriate food offers from others. In contrast, negative physical reactions were the most frequently reported reasons for exercise nonadherence. The implications of these findings for diabetes education are discussed.

208 citations


Journal ArticleDOI
TL;DR: The pattern of occurrence of this severe eye complication in type I diabetes suggests that the process leading to the development of proliferative retinopathy consists of two or more stages and that progression through each stage may be governed by different factors.
Abstract: The development of proliferative diabetic retinopathy was studied in three cohorts consisting of 292 patients with recent juvenile-onset, type I (insulin-dependent) diabetes who were followed 20–40 yr beginning in 1939, 1949, and 1959. The risk of this severe eye complication was almost nonexistent during the first 10 yr of diabetes, rose abruptly to its maximum level (∼30/1000 person-years), and remained at that level for the next 25 yr. This pattern did not vary with sex, age at onset of diabetes, or level of glycemic control during the first 5 yr of diabetes. However, the risk of proliferative retinopathy was strongly related to the level of glycemic control during the several years preceding onset of this complication. This was a dose-dependent relationship, with patients in the highest quartile of the distribution of the index of frequency of hyperglycemia having a 10-fold higher risk than individuals in the lowest quartile. A virtually identical pattern was observed in patients who developed diabetes in 1959 as was observed in those who developed diabetes in 1949 or 1939. In contrast, diabetic nephropathy as evidenced by persistent proteinuria showed a lower incidence in the 1959 than in the 1939 cohort. In conclusion, these incidence data do not support the notion that the risk of proliferative retinopathy is mainly a function of duration of diabetes. Instead, the pattern of occurrence of this severe eye complication in type I diabetes suggests that the process leading to the development of proliferative retinopathy consists of two or more stages and that progression through each stage may be governed by different factors.

204 citations


Journal ArticleDOI
TL;DR: The contemporary position of diabetic autonomic neuropathy is presented and newer concepts of an enlarged autonomic nervous system, neuroendocrine aspects of autonomic dysfunction are increasingly being explored.
Abstract: Diabetic Autonomic Neuropathy: Present Insights and Future Prospects Autonomic neuropathy is now well recognized as a serious consequence of diabetes mellitus. Although most of the clinical features were described 40 yr ago, the pathophysiological understanding is still far from complete. There are several previous reviews,\" but recent advances make a further consideration of this subject appropriate. The past decade has seen gathering momentum in diabetic autonomic neuropathy research. Simple well-validated and noninvasive tests, particularly tests using cardiovascular reflexes, have now been refined for assessing autonomic nerve damage. Other simple tests involving pupillary, gastrointestinal, genitourinary, and sudomotor function are being developed. The direct recording of impulses conducted by autonomic nerve fibers is now possible with microneurography. With newer concepts of an enlarged autonomic nervous system, neuroendocrine aspects of autonomic dysfunction are increasingly being explored. Although these advances may not seem immediately relevant to the clinician, there have also been parallel developments in the study of the effect on neuropathy of improved glycemic control and newer treatments such as aldose reductase inhibitors and gangliosides. We present the contemporary position of diabetic autonomic neuropathy.

165 citations


Journal ArticleDOI
TL;DR: Impaired beta cell function is a characteristic feature of many, but not all, NIDD patients who fail on treatment with oral antidiabetic drugs, and the presence of islet cell and thyrogastric antibodies can unmask a distinct group of NIDs patients with a high risk of secondary drug failure and subsequent insulin dependency.
Abstract: To study the etiopathogenesis of secondary drug failure to treatment with oral antidiabetic agents in patients with non-insulin-dependent diabetes (NIDD) we compared 60 "nonresponders" with 60 "responders" to treatment with oral drugs. Secondary drug failure was defined as mean diurnal blood glucose greater than 12 mmol/L after an initial good response of greater than or equal to 2 yr. The nonresponders were characterized by 50% lower C-peptide concentrations than the responders (P less than 0.001). We could not, however, define a critical C-peptide level to discriminate between patients requiring and not requiring insulin therapy. There was a wide overlap of individual C-peptide values between responders and nonresponders that attenuates the clinical value of single C-peptide measurements in predicting therapy. Only by serial measurements over a period of time was it possible to achieve information about changes in beta cell function. The nonresponders showed increased frequency of islet cell (P less than 0.01), thyroid antimicrosomal (P less than 0.01), and gastric parietal cell antibodies (P less than 0.02). In nonresponders, HLA-antigen B8 was increased (P less than 0.05) and HLA-B7 decreased (P less than 0.01) compared with frequencies of responders. In conclusion, impaired beta cell function is a characteristic feature of many, but not all, NIDD patients who fail on treatment with oral antidiabetic drugs. The presence of islet cell and thyrogastric antibodies can unmask a distinct group of NIDD patients with a high risk of secondary drug failure and subsequent insulin dependency. HLA typing may further help to predict secondary failure in NIDD.

153 citations


Journal ArticleDOI
TL;DR: While both BMI and centrality narrow the ethnic difference in NIDDM prevalence, Mexican Americans still have an increased risk of NID DM, suggesting that other factors, possibly genetic, may also be important determinants of the ethnic differences in N IDDM prevalence.
Abstract: Recent data have suggested that central obesity is related positively to the prevalence of non-insulin-dependent diabetes mellitus (NIDDM). We examined whether central obesity (measured by the ratio of subscapular to triceps skinfold) was predictive of NIDDM prevalence independently of overall obesity (measured by body mass index, BMI) in 1231 Mexican Americans and 939 non-Hispanic whites who participated in the San Antonio Heart Study, a population-based survey of diabetes and cardiovascular risk factors. Mexican Americans are characterized by higher rates of NIDDM, greater overall obesity, and more central body fat distribution than age-matched non-Hispanic whites. Using multiple logistic regression with age, ethnicity, BMI, and central obesity as covariates, overall obesity was positively associated with NIDDM prevalence in both sexes (P less than 0.001) but central obesity was related to NIDDM prevalence only in women. Our data suggest that the effect of centrality decreases at higher levels of centrality. While both BMI and centrality narrow the ethnic difference in NIDDM prevalence, Mexican Americans still have an increased risk of NIDDM (odds ratio = 2.33 in men and 1.80 in women), suggesting that other factors, possibly genetic, may also be important determinants of the ethnic differences in NIDDM prevalence.

143 citations


Journal ArticleDOI
TL;DR: A proportional hazards model identified the following risk factors for diabetic retinopathy in patients with non-insulin-dependent diabetes mellitus (NIDDM): elevated initial fasting blood glucose level, marked obesity, and earlier age at onset of diabetes.
Abstract: Retinopathy is an important sequela of diabetes mellitus, but clinical risk factors for this condition have rarely been assessed in a geographically defined population. In this population-based study, the 1135 Rochester, Minnesota, residents with diabetes mellitus initially diagnosed between 1945 and 1969 (incidence cohort) were followed through their complete medical records in the community to January 1, 1982. Because most of the cases of diabetic retinopathy in Rochester residents developed in patients with non-insulin-dependent diabetes mellitus (NIDDM), risk factors for diabetic retinopathy were examined in this group (N = 1031). A proportional hazards model identified the following risk factors for diabetic retinopathy in NIDDM: elevated initial fasting blood glucose level, marked obesity, and earlier age at onset of diabetes. Stratified analyses indicated that duration of diabetes was also significantly associated with an increased risk of retinopathy. Two secular trends, increasing detection of "mild" NIDDM and decreasing risk of diabetic retinopathy, had a major effect on retinopathy risk assessment. These data also suggest that insulin therapy is not an independent risk factor for diabetic retinopathy.

140 citations


Journal ArticleDOI
TL;DR: The results confirm that emotional adjustment in diabetes involves dynamic interactions among feelings that are relatively stable over periods up to 6 mo and that relate meaningfully to other aspects of personality functioning.
Abstract: The ATT39 scale was developed as a norm-referenced measure of emotional adjustment in diabetic patients. Scores on three parallel forms of the parent scale changed in response to educational intervention, and the change in scores was predictive of subsequent improvement in metabolic control. We describe further reliability and validity studies with six factorially derived subscales of the ATT39, which measured perceived levels of stress, adaptation, guilt, alienation, illness conviction, and tolerance for ambiguity. Internal consistency (Cronbach alpha) of the unweighted total score was 0.78, and the Guttman lower bound estimate of reliability was 0.86. The test-retest reliability of the total score varied from 0.70 to 0.87, over intervals of 2 wk, 3 mo, and 6 mo, and reliability coefficients for the six factor scores averaged 0.56. ATT39 factor scores, in 134 insulin-dependent diabetes mellitus (IDDM) and 166 non-insulin-dependent diabetes mellitus (NIDDM) patients, were correlated with scores on the Cattell 16 personality factor questionnaire and the locus of control of behavior scale (LCB). In IDDM, age was related to better adaptation, increased feelings of guilt, and a more cooperative attitude to staff and treatment. In NIDDM, age was associated with increasing resignation to a conviction of chronic illness and less tolerance for the ambiguities involved in diabetes. Intelligence was correlated with less guilt and more tolerance. Anxiety was associated with significant diabetes-related stress, regardless of treatment, and with poorer adaptation and guilt in NIDDM. An external LCB was related to increased stress and guilt. The results confirm that emotional adjustment in diabetes involves dynamic interactions among feelings that are relatively stable over periods up to 6 mo and that relate meaningfully to other aspects of personality functioning.

Journal ArticleDOI
TL;DR: The characteristic clinical and pathologic findings and the course of the illness are delineated with emphasis on the importance of recognition of the syndrome so that biopsy and overzealous therapy are avoided.
Abstract: Diabetic patients may develop a painful mass in the leg as a manifestation of spontaneous infarction of muscle. Experience with six patients with focal infarction of muscle without peripheral gangrene has demonstrated a stereotyped clinical presentation. The use of an open muscle biopsy to confirm the diagnosis has been associated with increased signs and symptoms. Clinical exacerbations occur during vigorous physical therapy. We delineate the characteristic clinical and pathologic findings and the course of the illness with emphasis on the importance of recognition of the syndrome so that biopsy and overzealous therapy are avoided.

Journal ArticleDOI
TL;DR: Cardiac autonomic neuropathy is associated with an impairment of the hemodynamic responses to exercise in diabetic subjects without ischemic heart disease, and age, duration of diabetes, and the presence and severity of microvascular disease did not correlate with any of the Hemodynamic parameters.
Abstract: Abnormal hemodynamic responses to exercise have been observed in diabetic subjects, but the pathogenesis and significance remain uncertain We used maximal treadmill exercise to study 32 subjects with long-term insulin-dependent diabetes without clinical evidence of cardiac disease Two of the 32 had occult ischemic heart disease revealed by stress electrocardiography and myocardial-perfusion scintigraphy and were excluded from subsequent analysis In the remaining 30 subjects, we compared the responses to exercise of the 17 subjects with cardiac autonomic neuropathy diagnosed by noninvasive maneuvers (group 1) with the 13 without (group 2) At rest, the pressure-rate product (PRP) was higher in group 1 (1140 ± 57 vs 959 ± 53, P P P = 02), and the PRP (1020 ± 73 vs 1820 ± 82, P P > 1) At each stage of exercise, the increase in heart rate and systolic blood pressure was lower in group 1 patients The severity of cardiac autonomic neuropathy correlated inversely with the maximal increase in heart rate(γ = – 68, P P

Journal ArticleDOI
TL;DR: Among diabetic subjects, self-reported bulimic behaviors were related to poorer glycemic control and modification of these eating behaviors would improve gly glucose control.
Abstract: Several recent case reports have shown that anorexia nervosa and bulimia negatively affect glycemic control in diabetic patients. However, there have been no systematic studies to assess the prevalence of clinical or subclinical eating disorders among diabetic patients or to determine the impact of such disturbances on glycemic control. This study reports a survey of 202 adolescents, aged 12–18 yr, seen in the Diabetes Clinic, Children9s Hospital of Pittsburgh, who were asked to complete the Binge Eating Scale (BES) and the EAT-26 questionnaire. Responses of diabetic patients to the EAT-26 questionnaire were compared with those of a nondiabetic control group and were related to measures of glycemic control. Diabetic subjects scored higher on the total EAT-26 than nondiabetic control subjects, ordinarily indicative of more eating pathology. However, diabetic subjects scored higher only on the dieting subscale of this questionnaire, probably reflecting adherence to the diabetes dietary regimen. Subjects with diabetes scored lower, or did not differ significantly, from nondiabetic control subjects on measures of oral control and bulimia. Among diabetic subjects, self-reported bulimic behaviors were related to poorer glycemic control. Patients with the highest scores on the BES had an average HbA 1 of 13.1% compared with 11.8% for age- and sex-matched patients at the 50th percentile, and 10.8% for patients in the lowest 10th percentile. Further studies are needed to determine whether modification of these eating behaviors would improve glycemic control.

Journal ArticleDOI
TL;DR: The results suggest that, in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care, education alone is ineffective.
Abstract: Home health nurses provided individualized instruction in diabetes self-care within the home environment of 393 diabetic individuals. Each subject was randomly assigned to either the intervention (those receiving home teaching) or control (those not receiving home teaching) group. At 6 mo postenrollment, intervention subjects showed significantly greater self-care knowledge and skills than control subjects, although the actual differences between the two groups in terms of self-care skills were probably too small to have any practical meaning. The primary objective of the study, which was the reduction of the number of preventable diabetes-related hospitalizations (ketoacidosis, ketotic coma, nonketotic coma, insulin reaction, and diabetes out of control), was not achieved; no differences between the groups were noted after 12 mo of follow-up. Similarly, length of hospital stay, foot problems, emergency room and physician visits, and sick days were roughly equivalent in both groups during the follow-up year. These results suggest that, in the absence of concurrent changes in the health-care delivery system and strategies for influencing attitudes toward self-care, education alone is ineffective.

Journal ArticleDOI
TL;DR: In juvenile cohorts, the presumed association between psychologic status and coping behaviors requires further examination, because selfrated psychologic adjustment, psychiatric diagnosis, and illness-related coping behaviors were unrelated to one another; psychologic variables were similarly unrelated to the use of socially oriented coping strategies.
Abstract: Psychologic adjustment, assessed by self-ratings of anxiety, self-esteem, and depression, and cognitive as well as behavioral coping strategies, elicited by interview, were monitored longitudinally among school-age children with recent-onset insulin-dependent diabetes mellitus (IDDM). Our article documents the findings over the 1st yr of the illness. From the start, the children viewed themselves as self-confident and emotionally comfortable. The diagnosis of IDDM created minimal emotional upheaval (which faded within 6 mo), despite this cohort9s consistent report that the diet, insulin injections, and urine tests were difficult. The most prevalent cognitive strategies for coping with IDDM included wishful thinking, thoughts of forbidden foods, and resentful thoughts. Behavioral coping strategies, including information seeking, were evident from the beginning. The frequency of socially oriented coping behaviors (e.g., showing IDDM management to peers) indicated that the young patients actively tried to adapt to the illness and were more comfortable with aspects of home care than previously thought. Selfrated psychologic adjustment, psychiatric diagnosis, and illness-related coping behaviors were unrelated to one another; psychologic variables were similarly unrelated to the use of socially oriented coping strategies. Therefore, in juvenile cohorts, the presumed association between psychologic status and coping behaviors requires further examination.

Journal ArticleDOI
TL;DR: This study suggests that onset of diabetes does not necessarily lead to major disruptions of psychological adaptation and affirms the view that early adjustment to diabetes is embedded in a context of overall personality development and adaptation.
Abstract: Children with recent onset of insulin-dependent diabetes mellitus (IDDM) were compared with a sample of children with a recent acute medical problem. No differences were found in terms of self-esteem, locus of control, behavioral symptoms, or social functioning. A separate assessment of adjustment to diabetes was strongly correlated with each of these general personality, behavioral symptom, and social functioning measures. Sociodemographic factors such as age, gender, and social class did not predict the level of adjustment to diabetes. This study suggests that onset of diabetes does not necessarily lead to major disruptions of psychological adaptation. It also affirms the view that early adjustment to diabetes is embedded in a context of overall personality development and adaptation.

Journal ArticleDOI
TL;DR: There was no change in the markedly blunted glucose response to a fructose challenge but a significantly lower insulin response (area under the 3-h curve) was observed after 14 days of fructose feeding.
Abstract: We studied the metabolic effects of 2-wk fructose feeding as the sweetener in the diet of seven non-insulin-dependent diabetic individuals The data demonstrated reduced postprandial hyperglycemia to an oral glucose challenge after 14 days without a significant difference in insulin response There was no change in the markedly blunted glucose response to a fructose challenge but a significantly lower insulin response (area under the 3-h curve) was observed after 14 days of fructose feeding There was reduced postprandial hyperglycemia after 14 days of fructose feeding with test meals as compared with baseline, without significant differences in insulin response We also found no significant difference in free fatty acids, cholesterol, high-density lipoprotein (HDL) cholesterol, pyruvate, lactate, or uric acid after fructose feedings There was a 13% increase in triglyceride levels after 14 days in 5 subjects with initial fasting hypertriglyceridemia (greater than 150 mg/dl) Insulin receptor binding to isolated adipocytes did not change after 14 days of fructose feeding

Journal ArticleDOI
TL;DR: A considerable difference of opinion exists between their group and the Council on Nutrition, and the authors are very concerned that attempts by the health profession to follow these recent recommendations will, at best, complicate the lives of patients with diabetes and, at the worst, increase their likelihood of developing the vascular complications of diabetes.
Abstract: The Council on Nutrition of the American Diabetes Association (ADA) recently published a statement that contains five recommendations concerning the nutritional management of diabetes mellitus.' Three of these recommendations are general statements outlining the Council's belief that i) we should strive to achieve control of blood glucose and lipid levels in patients with diabetes without compromising overall nutrition or health, 2) current evidence does not permit a precise appraisal of the clinical utility of the glycemic index of different carbohydrate-rich foods in reaching this primary goal, and 3) further research in nutrition and diabetes is necessary to develop optimal nutrition management. It seems unlikely that anybody will disagree with these principles. On the other hand, the Council on Nutrition also stated that diet planning could now include the incorporation of sucrose without the expectation of adverse effects. In addition, the Council supported the use of the "glycemic index" in the selection of carbohydrate-containing foods, implying that this would result in lower glycemic responses to meals. We were both surprised and somewhat concerned about the last two items for several reasons. At the simplest, we were not even sure what was meant. For example, what is a "moderate" amount of sucrose? Does the statement refer to foods that naturally contain sucrose, like fruit, or does it apply to foods containing refined sugar, like Danish pastry? How should we place "more emphasis on those carbohydrate-containing foods that produce the smallest rise in blood glucose" or "less emphasis on those (foods) that are associated with higher glycemic responses?" More important, we could not fathom what scientific evidence led to the promulgation of these two principles by the Council on Nutrition. Indeed, our research group has been actively involved in studying both the relevance of the glycemic index to the treatment of patients with non-insulin-dependent diabetes mellitus (NIDDM) as well as the effects of increased sucrose consumption on various facets of carbohydrate and lipid metabolism in several patient populations. In the case of the glycemic index, we have published data that raise questions concerning its clinical utility in the treatment of NIDDM and are unaware of evidence that has shown it to be clinically effective when incorporated into the planning of meals for diabetic patients. As far as sucrose is concerned, we believe that there is substantial published information that suggests the "consumption of a moderate amount of sucrose" can lead to deleterious effects on both carbohydrate and lipid metabolism." Obviously, a considerable difference of opinion exists between our group and the Council on Nutrition, and we are very concerned that attempts by the health profession to follow these recent recommendations will, at best, complicate the lives of patients with diabetes and, at the worst, increase their likelihood of developing the vascular complications of diabetes. Consequently, we feel compelled to offer a different perspective on the glycemic effects of carbohydrates.

Journal ArticleDOI
TL;DR: It is concluded that different types of pasta may produce different glycemic responses but that these are not necessarily related to differences in cooking or surface area.
Abstract: To see whether food form, the degree of cooking, or protein enrichment affected the glycemic response to pasta, we gave test-meal breakfasts to 13 diabetic patients. Macaroni had a significantly greater glycemic index (GI) (68 +/- 8) than spaghetti (45 +/- 6, P less than .01); the GI of star pastina was intermediate (54 +/- 6). The GI of spaghetti was not significantly affected by cooking for 5 or 15 min (45 +/- 6 and 46 +/- 5, respectively), or by protein enrichment (38 +/- 4). The GI of spaghetti was similar in 11 non-insulin-dependent and 6 insulin-dependent diabetic patients (49 +/- 7 compared with 57 +/- 8). We conclude that different types of pasta may produce different glycemic responses but that these are not necessarily related to differences in cooking or surface area.

Journal ArticleDOI
TL;DR: Non-insulin-dependent diabetes mellitus is a major health problem in American Indian communities and hospitalizations and analyzes mortality in American Indians and native Alaskans are analyzed.
Abstract: Non-insulin-dependent diabetes mellitus is a major health problem in American Indian communities. Indian Health Service (IHS) collects information about outpatient visits and hospitalizations and analyzes mortality in American Indians and native Alaskans. Between October 1, 1982, and September 30, 1983 (fiscal year 1983), diabetes was the second leading clinical impression for all outpatient visits of patients 15 yr and older. Discharge diagnoses confirm both microvascular and macrovascular complications. Seventy-six percent of all IHS hospitalizations during fiscal year 1983 for lower-extremity amputation also coded diabetes. In 1982, the age-adjusted diabetes death rate per 100,000 was 19.9 for American Indians and native Alaskans, compared with 9.6 for all races in the United States.

Journal ArticleDOI
TL;DR: It appears that some of the programs actually increased, rather than decreased, health care expenditures, and it is suggested that the rationale for education and nutritional services be based on improved health status.
Abstract: The Board of Directors of the American Diabetes Association (ADA) recently endorsed a resolution recommending third-party payment for outpatient education and nutritional counseling. One of the major rationales for the statement was that education and nutritional counseling will lead to reductions in health care costs. This article critically reviews the 13 studies cited in support of the ADA Policy Statement. Among these studies, only 2 compared a treated group with a control group. Both of the studies with control groups failed to randomly assign patients to treatment condition. Only 4 of the studies showed an accounting of program costs. Upon close inspection, it appears that some of the programs actually increased, rather than decreased, health care expenditures. Attrition from programs was reported in only a minority of cases, and was large when reported. The effect of the programs upon diabetes control was inconsistent across studies. It is suggested that the rationale for education and nutritional services be based on improved health status. In addition, the execution of a systematic experimental study to evaluate these services is urged.

Journal ArticleDOI
TL;DR: This work focuses on the early structural and functional changes that occur as a consequence of diabetic renal disease and examines the evidence for microalbuminuria as an early marker and predictor for future overt diabetic nephropathy.
Abstract: End-stage renal failure secondary to diabetes has increasingly become a health and socioeconomic issue. Diabetic nephropathy is the major cause of death in type I insulin-dependent diabetic patients and accounts for ∼25% of all patients beginning hemodialysis in the United States. Once diabetic nephropathy is well established, attempts to modify the relentless downward progression of the disease have been essentially unsuccessful. We focus on the early structural and functional changes that occur as a consequence of diabetic renal disease and examine the evidence for microalbuminuria as an early marker and predictor for future overt diabetic nephropathy. The rationale for different therapeutic interventions to alter the course of early diabetic nephropathy are discussed.

Journal ArticleDOI
TL;DR: Positive educational benefit of both interactive computer-based programs is confirmed, probably acting through enhancement of both knowledge and motivation, suggesting a motivational effect resulting from program participation.
Abstract: Two interactive computer-based systems have been evaluated: a teaching program with text and animated graphics and a multiple-choice knowledge-assessment program (KAP) with optional prescriptive feedback. One hundred seventy-four routine-attending insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) patients were allocated to active and control groups to determine the effect of these programs on knowledge and control after a 4- to 6-mo follow-up period. Interactive computer teaching (ICT) resulted in a significant knowledge increment in both IDDM and NIDDM patients (P less than .05), together with a mean fall of 0.8 and 0.7%, respectively, in HbA1c (P less than .05 and P greater than .1), but no changes were observed in respective control groups. The KAP with feedback also produced a significant knowledge increment in both IDDM and NIDDM patients (P less than .05), of similar magnitude to the ICT program, and a mean fall in HbA1c of 1.2 and 1.3%, respectively (P less than .05), with no changes in the corresponding control groups. Even when KAP was used without prescriptive feedback, smaller but significant mean falls in HbA1c of 0.7 and 0.8% (P less than .05) were seen in IDDM and NIDDM patients, respectively, suggesting a motivational effect resulting from program participation.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal ArticleDOI
TL;DR: Computer programs in compiled BASIC for the IBM-PC and compatible microcomputers for use by physicians, paramedical personnel, and/or patients to assist with self-monitoring of blood glucose (SMBG) and self-adjustment of insulin dosage are developed.
Abstract: We have developed computer programs in compiled BASIC for the IBM-PC and compatible microcomputers for use by physicians, paramedical personnel, and/or patients to assist with self-monitoring of blood glucose (SMBG) and self-adjustment of insulin dosage. The programs can potentially assist with patient education and motivation, and provide: a customized "electronic notebook" for storage and retrieval of information on blood glucose, insulin dosage, hypoglycemic reactions, urinary ketones, diet, activity, weight, illness, apparent explanations for hypoglycemic reactions or glucose values outside target ranges, and comments; graphic displays of glucose and insulin versus date, and of a "glucose profile" versus time of day or versus day of the week; simple and detailed statistical analyses; a legible summary of data; a facility to permit the physician to prepare a "customized treatment plan" for each patient, involving a choice of six regimens, target levels for each of eight time periods, four supplement tables (when well or sick, before meals, or at bedtime), rules to reduce insulin in response to hypoglycemic reactions or documented hypoglycemia, rules to increase routine insulin doses in response to persistent unexplained hyperglycemia, and rules when the patient should call the physician; suggestions regarding compensatory supplements and adjustments of routine insulin dosage; explanations why various insulin dosages should or should not be altered, and why various glucose values should be tested; comparisons of the insulin dosage administered by the patient and the recommendations of the program, together with explanations for discrepancies offered by the patient, to help evaluate compliance. The program is "user-friendly," easy to learn, and easy to use.(ABSTRACT TRUNCATED AT 250 WORDS)

Journal ArticleDOI
TL;DR: The results demonstrate a generalized increase in plantar foot temperature in group III compared with groups I and II and suggest the need for prospective studies to evaluate LCT as a diagnostic modality in the prediction of foot ulceration in the diabetic population.
Abstract: Liquid crystal thermography (LCT) was used to determine temperature variations on the plantar surface of feet. The purpose was to identify thermal emission patterns associated with diabetic foot ulcers. Three population groups were screened: group I, 16 nondiabetic controls; group II, 21 diabetic patients with no history of pedal ulcers; and group III, 28 diabetic patients with active pedal ulceration or history of foot ulcerations. The results demonstrate a generalized increase in plantar foot temperature in group III compared with groups I and II. Temperature readings under metatarsal heads 1-5, great toe, heel, and lateral band were significantly increased (P less than .01) in group III. Additionally, the warm lateral surface displayed by group III patients was not significantly different in temperature from the medial arch of the foot. In groups I and II, the lateral band was significantly cooler (P less than .01) than the medial arch. In group III patients with active ulceration on only one foot, no significant difference in temperature was found between the foot with active ulceration compared with the contralateral nonulcerated foot. When patients with active pedal ulceration were compared with patients with a history of foot ulcers, no significant difference in temperature was seen at five of seven sites tested. A warm concentric color band surrounding active plantar ulcers was identified in group III. This pattern extended from the center of the ulcer to a distance of 8 mm. A significant change in temperature (P less than .01) was noted at 6- and 8-mm distances from the center of the ulcer. In addition, a mottled thermographic pattern was observed more frequently in group III patients than in groups I and II.(ABSTRACT TRUNCATED AT 250 WORDS)

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TL;DR: It is doubtful if diabetes mellitus per se should be regarded as a cause of generalized or localized pruritus, other thanPruritus vulvae, which was significantly more common in diabetic women and was significantly associated with poor diabetes control.
Abstract: Three hundred diabetic and 100 nondiabetic hospital outpatients (both groups of comparable age and sex distribution) were assessed for the presence of generalized and localized pruritus. Pruritus vulvae was significantly more common in diabetic women (18.4%) than in controls (5.6%) and was significantly associated with poor diabetes control (mean glycosylated hemoglobin level less than 12%). Other forms of localized pruritus were equally common in diabetic and nondiabetic patients, regardless of glycosylated hemoglobin levels. Generalized pruritus was present in 14 diabetic patients, but in 5 cases the symptom was ascribed to intercurrent illness or drug administration. Thus, generalized pruritus without apparent cause was present in only 8 diabetic patients (2.7%) and was not significantly more common than in nondiabetic patients. It is doubtful if diabetes mellitus per se should be regarded as a cause of generalized or localized pruritus, other than pruritus vulvae.

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TL;DR: It is concluded that casting is a useful therapy for neuropathic ulcers, although several clinic visits, including cast removal and foot inspection, are necessary to avoid potential side effects caused by the casting of insensitive feet.
Abstract: Neuropathic foot ulceration is a major medical and economic problem among diabetic patients, and the traditional treatment involves bed rest with complete freedom from weight-bearing. We have investigated the use of walking plaster casts in the management of seven diabetic patients with long-standing, chronic plantar ulcers. Although all ulcers healed in a median time of 6 wk, this therapy was not without side effects, which are described in detail. We conclude that casting is a useful therapy for neuropathic ulcers, although several clinic visits, including cast removal and foot inspection, are necessary to avoid potential side effects caused by the casting of insensitive feet.

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TL;DR: Serum and lipoprotein lipids were examined in 133 newly diagnosed (type II) diabetic patients, aged 45–64 yr, and in 144 randomly selected nondiabetic control subjects of similar age.
Abstract: Serum and lipoprotein lipids were examined in 133 newly diagnosed (type II) diabetic patients (70 men, 63 women), aged 45–64 yr, and in 144 randomly selected nondiabetic control subjects of similar age (62 men, 82 women). The serum total cholesterol levels in diabetic and nondiabetic subjects were similar, but the HDL-cholesterol levels were lower and the serum total triglyceride levels higher in the diabetic than in nondiabetic subjects. No significant differences were found in apoprotein A-I and A-II levels between the diabetic and nondiabetic subjects. After adjustment for age, alcohol intake, obesity, 2-h postglucose serum insulin, and serum triglycerides, male diabetic subjects still had lower HDL-cholesterol levels than corresponding nondiabetic subjects. On the other hand, female diabetic subjects had higher serum triglycerides than their nondiabetic counterparts, even after adjustment for age, alcohol intake, 2-h postglucose serum insulin, and obesity.

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TL;DR: It is demonstrated that consumption of white beans prepared in a manner that maintains the integrity of the cells profoundly modified the ensuing plasma glucose and insulin response in patients with NIDDM as compared with white beans milled in a more conventional fashion.
Abstract: In the present study eight control subjects and eight patients with non-insulin-dependent diabetes mellitus (NIDDM) consumed single portions of processed beans equivalent to 50 g of carbohydrate. The beans were processed by different methods into two physical forms; one maintained the integrity of the bean cells (undamaged bean cells, UC) and the other ruptured the bean cells (damaged bean cells, DC). Incremental glucose response areas after ingestion of either UC or DC were not significantly different in control subjects, while incremental insulin response areas (49 +/- 7 vs. 26 +/- 4 microU X ml-1 X h-1, P less than .05) were significantly lower after eating UC-processed beans. In patients with NIDDM both incremental glucose (150 +/- 14 vs. 73 +/- 25 mg X dl-1 X h-1, P less than .001) and insulin (67 +/- 16 vs. 46 +/- 11 microU X ml-1 X h-1, P less than .05) response areas were significantly lower after UC administration. To test the effectiveness of the UC-processed bean when incorporated into mixed meals, nine patients with NIDDM consumed mixed meals containing either DC or UC on two separate mornings. The test meals represented a typical Mexican American use of pureed beans wrapped in a flour tortilla topped with melted cheese. Incremental glucose responses were significantly lower after the UC meal (171 +/- 42 mg X dl-1 X h-1, P less than .05) when compared with the DC meal (212 +/- 34 mg X dl-1 X h-1). Incremental insulin areas were also lower after the UC (91 +/- 19 microU X ml-1 X h-1) when compared with the DC meal (120 +/- 22 microU X ml-1 X h-1).(ABSTRACT TRUNCATED AT 250 WORDS)