Showing papers in "Diabetes Care in 1993"
TL;DR: Findings emphasize the need for rigorous sustained intervention in people with diabetes to control blood pressure, lower serum cholesterol, and abolish cigarette smoking, and the importance of considering nutritional-hygienic approaches on a mass scale to prevent diabetes.
Abstract: OBJECTIVE To assess predictors of CVD mortality among men with and without diabetes and to assess the independent effect of diabetes on the risk of CVD death. RESEARCH DESIGN AND METHODS Participants in this cohort study were screened from 1973 to 1975; vital status has been ascertained over an average of 12 yr of follow-up (range 11–13 yr). Participants were 347,978 men aged 35–57 yr, screened in 20 centers for MRFIT. The outcome measure was CVD mortality. RESULTS Among 5163 men who reported taking medication for diabetes, 1092 deaths (603 CVD deaths) occurred in an average of 12 yr of follow-up. Among 342,815 men not taking medication for diabetes, 20,867 deaths were identified, 8965 ascribed to CVD. Absolute risk of CVD death was much higher for diabetic than nondiabetic men of every age stratum, ethnic background, and risk factor level—overall three times higher, with adjustment for age, race, income, serum cholesterol level, sBP, and reported number of cigarettes/day ( P CONCLUSIONS These findings emphasize the importance of rigorous sustained intervention in people with diabetes to control blood pressure, lower serum cholesterol, and abolish cigarette smoking, and the importance of considering nutritional-hygienic approaches on a mass scale to prevent diabetes.
4,161 citations
TL;DR: Some level of periodontal disease has been found in most populations studied and is responsible for a substantial portion of the tooth loss in adulthood.
Abstract: Periodontal disease is a chronic inflammatory condition characterized by destruction of the periodontal tissues and resulting in loss of connective tissue attachment, loss of alveolar bone, and the formation of pathological pockets around the diseased teeth. Some level of periodontal disease has been found in most populations studied and is responsible for a substantial portion of the tooth loss in adulthood.
1,347 citations
TL;DR: Diabetes in adults is now a global health problem, and populations of developing countries, minority groups, and disadvantaged communities in industrialized countries now face the greatest risk.
Abstract: Objective— To assemble standardized estimates of abnormal glucose tolerance in adults in diverse communities worldwide and provide guidelines for the derivation of comparable estimates in future epidemiological studies. Research Design and Methods— The project was limited to population-based investigations that had used current WHO criteria for diagnosis and classification of abnormal glucose tolerance. Raw data were obtained by WHO from surveys conducted during 1976–1991 of over 150,000 persons from 75 communities in 32 countries. Data within the truncated age range of 30–64 yr were adjusted to the standard world population of Segi. Age-specific prevalences also are reported for selected populations. Results— Within the chosen age range, diabetes was absent or rare ( 50% were previously undiagnosed. In both Chinese and Indian migrant populations, relative prevalence was high when compared with indigenous communities. Conclusions— Diabetes in adults is now a global health problem, and populations of developing countries, minority groups, and disadvantaged communities in industrialized countries now face the greatest risk.
994 citations
TL;DR: An increased prevalence of depression in diabetes relative to the general population is highly suggested by the literature, but biases and methodological problems commonly encountered in prevalence studies may interfere with the strength of this conclusion.
Abstract: OBJECTIVE To determine the prevalence of depression in adult diabetic populations through a comprehensive literature review and to critically evaluate the methods and findings of such studies from an epidemiological perspective. RESEARCH DESIGN AND METHODS A systematic review of the scientific literature revealed a total of 20 studies, 14 of which had been conducted since 1988. Nine of the studies were controlled investigations, whereas the remaining 11 studies did not contain comparison groups. The studies included both treatment and community samples. RESULTS The range of the prevalence of current depression obtained from structured diagnostic interviews in diabetic samples was 8.5–27.3% ( = 14.0%) in controlled studies and 11.0–19.9% ( = 15.4%) in uncontrolled studies. These rates are at least three times the prevalence of major depressive disorder found in the general adult population of the U.S. Investigations using depression symptom scales corroborated these findings, as the range of clinically significant depression symptomatology in diabetic samples was 21.8–60.0% ( = 32.4%) in controlled studies and 10.0–28.0% ( = 19.6%) in uncontrolled studies. CONCLUSIONS An increased prevalence of depression in diabetes relative to the general population is highly suggested by the literature, but biases and methodological problems commonly encountered in prevalence studies may interfere with the strength of this conclusion. An increased prevalence of depression in diabetes relative to other somatic illnesses remains unproven. The pervasive impact of depression on quality of life and its potential negative effect on diabetes management warrant recognition and treatment of the affective disorder in diabetic individuals.
657 citations
TL;DR: No national programs are currently available to address the issue of undiagnosed diabetes, including screening programs to detect the 6.3 million cases in the U.S.
Abstract: U ndiagnosed NIDDM is highly prevalent in the U.S. population, reaching 10-20% in people >50 yr of age, with even higher rates in blacks and Mexican Americans. Recent data show that retinopathy begins developing at least 7 yr before clinical diagnosis of NIDDM, and that onset of NIDDM probably occurs at least 12 yr before its clinical diagnosis. Significant complications are present in patients at diagnosis; for example, 21% of newly diagnosed patients have retinopathy. Thus, during the time that diabetes remains undiagnosed and, consequently, while it remains untreated, retinopathy and other complications of diabetes are developing. Other data confirm that undiagnosed NIDDM is not a benign condition. The prevalence of macrovascular disease in undiagnosed NIDDM is about equal to that found in diagnosed diabetes, and rates of CHD in both diagnosed and undiagnosed diabetes are about twice that for nondiabetic individuals. Mortality in undiagnosed diabetes is also equal to that of diagnosed diabetes, and both are significantly higher than in nondiabetic individuals. Risk factors for microand macrovascular complications in undiagnosed NIDDM are very common and are as frequent as in diagnosed NIDDM. Prevalence of hypertension is 61%, hypercholesterolemia is 49%, LDL cholesterol >130 mg/dl is 62% (>95% of whom have CHD or >2 risk factors for heart disease), hypertriglyceridemia is 28%, obesity is 50% for men and 82% for women, and cigarette smoking is 32%. Effective treatment for hyperglycemia and other risk factors for diabetic complications is available, including dietary and pharmacological therapy and lifestyle and behavioral changes. However, such treatment is either not being offered, in the case of hyperglycemia, or would likely be offered with greater intensity if the clinician were aware that the patient had diabetes. No national programs are currently available to address the issue of undiagnosed diabetes, including screening programs to detect the 6.3 million cases in the U.S. In contrast, major national efforts have been launched by the American Heart Association to fight hypertension and hyper-
463 citations
TL;DR: It is indicated that metformin treatment improves glycemic control, and lowers insulin resistance and risk factors for cardiovascular disease, including PAI-1, and may therefore be useful in the long-term management of NIDDM subjects who have a high risk of cardiovascular disease.
Abstract: OBJECTIVE To investigate the effects of metformin on glycemic control, insulin resistance, and risk factors for cardiovascular disease in NIDDM subjects from two ethnic groups (Caucasian and Asian) with different risks of cardiovascular disease. RESEARCH DESIGN AND METHODS A total of 27 subjects with NIDDM (17 Caucasian, 10 Asian) were given metformin and placebo each for a 12-wk period in a randomized, double-blind, placebo-controlled crossover study, and the dose was increased after 1 and 6 wk, up to a maximum of 850 mg three times a day. Insulin resistance, glycemic control, and cardiovascular risk factors were assessed before and after each treatment phase. The end of 12 wk of metformin treatment was compared with the end of 12 wk of placebo treatment. RESULTS Metformin treatment was associated with significant improvement in FPG at 6 and 12 wk (mean difference at 12 wk, −3.08 mM, 95% CI −4.12 to −2.04 mM, P −1 · min −1 , interquartile range −0.10 to 1.30 ml · kg −1 · min −1 , P = 0.036). β-cell function calculated by HOMA also improved significantly (median difference 14%, interquartile range 7 to 23%, P P = 0.034), total cholesterol (mean difference −0.52 mM, 95% CI −0.83 to −0.22 mM, P = 0.002), and LDL cholesterol (mean difference −0.40 mM, 95% CI −0.64 to −0.16 mM, P = 0.002) fell significantly on metformin treatment, whereas no significant changes were observed in HDL cholesterol. PAI-1 activity fell significantly (mean difference −5.3 AU/ml, 95% CI −8.2 to −2.4 AU/ml, P = 0.001), but plasma fibrinogen concentrations and platelet function, spontaneous or agonist induced, were unaffected. UAE was lower on metformin treatment (median difference −2.4 μg/min, interquartile range −4.4 to −0.2 μg/min, P = 0.004), but metformin had no significant effect on BP. The effects of metformin on glycemic control and cardiovascular risk factors were generally similar in the two ethnic groups. CONCLUSIONS These findings indicate that metformin treatment improves glycemic control, and lowers insulin resistance and risk factors for cardiovascular disease, including PAI-1, and may therefore be useful in the long-term management of NIDDM subjects who have a high risk of cardiovascular disease.
346 citations
TL;DR: The offspring of women who had diabetes during pregnancy, on average, were more obese and had higher glucose concentrations and more diabetes than the offspring ofWomen who developed diabetes after pregnancy or who remained nondiabetic.
Abstract: OBJECTIVE— To review the long-term effects of the diabetic pregnancy on the offspring among the Pima Indians of Arizona.
RESEARCH DESIGN AND METHODS— Studies published by the Phoenix Epidemiology and Clinical Research branch of the National Institute of Diabetes and Digestive and Kidney Diseases, since the inception of the longitudinal diabetes studies in 1965 were reviewed. In addition, pertinent studies from other centers, mentioned as references in these publications, were reviewed. As far as possible, all original articles and abstracts on this aspect of the Pima Indian studies were discussed.
RESULTS— The offspring of women who had diabetes during pregnancy, on average, were more obese and had higher glucose concentrations and more diabetes than the offspring of women who developed diabetes after pregnancy or who remained nondiabetic. Although no new analyses were attempted, several of the older publications were updated by repeating the analyses on later, expanded data sets.
CONCLUSIONS— The diabetic pregnancy, in addition to its effects on the newborn, has effects on the subsequent growth and glucose metabolism of the offspring. These effects are in addition to genetically determined traits.
284 citations
TL;DR: Impaired β-cell function and obesity at diagnosis of GDM were associated with the development of diabetes during a 5-yr, follow-up period and studies designed to prevent diabetes in this high-risk group should examine strategies to maintain both optimal β- cell function and maximum insulin sensitivity.
Abstract: OBJECTIVE To identify phenotypic, genotypic, and metabolic parameters measured at the time of antepartum diagnosis of gestational diabetes mellitus that can indicate the risk of diabetes mellitus at early postpartum (≤6 mo after delivery) and at a 5-yr follow-up. RESEARCH DESIGN AND METHODS The recommendations from the National Diabetes Data Group and International Workshop Conferences on Gestational Diabetes Mellitus were used for screening, diagnosing, and subclassifying gestational diabetes mellitus. National Diabetes Data Group criteria were also used for classification of glucose tolerance postpartum. Plasma glucose, insulin, and free fatty acids were measured after an overnight fast. Plasma glucose and insulin were measured 15, 30, 60, 120, and 180 min after the 100-g oral glucose load. Postpartum glucose tolerance was evaluated at 3–6 mo (early), 1 yr, and annually thereafter. RESULTS The 5-yr cumulative incidence of diabetes during follow-up after gestational diabetes mellitus was nearly 50%. Among those who had diabetes within 5 yr, a history of diabetes in only the mother was nearly threefold more common than a history of diabetes in only the father (30 vs. 11%, P CONCLUSIONS Impaired β-cell function and obesity at diagnosis of GDM were associated with the development of diabetes during a 5-yr, follow-up period. Studies designed to prevent diabetes in this high-risk group should examine strategies to maintain both optimal β-cell function and maximum insulin sensitivity.
276 citations
TL;DR: The results indicate that the clinical subtype with slowly progressive course (slowly progressive IDDM) has distinct findings including late-age onset, high prevalence of islet cell antibodies, preserved β-cell function, and high family history of NIDDM.
Abstract: OBJECTIVE To examine the clinical and immunogenetic heterogeneity of IDDM. RESEARCH DESIGN AND METHODS We divided 207 IDDM patients into groups based on the interval from clinical onset to initiation of insulin therapy: group A ( n = 134), group B (3–12 mo, intermediate group, n = 31), and group C (>13 mo, slowly progressive group, n = 42). Immunogenetic and clinical markers were compared between group A and group C. RESULTS The mode age of onset was higher in group C (52 yr) than group A (10 yr). Group C had a higher prevalence of islet cell antibodies (42.9%, 18 of 42) than group A (25.4%, 34 of 134, P = 0.05). Serum C-peptide immunoreactivity assayed by radioimmunoassay in response to a 100-g oral glucose tolerance test was significantly higher in group C uhan in group A. Group C patients were also more likely to have a family history of NIDDM (26.1%, 11 of 42) among their first-degree relatives than group A patients (11.2%, 15 of 134, P = 0.039). The prevalences of family history of IDDM and endocrine autoimmune diseases were not different between groups C and A. The frequency of complications of endocrine autoimmune disease was not different between group A (6.7%, 9 of 134) and group C (2.3%, 1 of 42). Significant associations with two class I major histocompatibility complex antigens (HLA-A24 and -Bw54) and one class II antigen (HLA-DR4) were observed in group A. Group A patients were assocciated with three diabetogenic HLA-DQ haplotypes including DQA1*0301-DQB1*0401, DQAl*0301-DQBl*0302, and DQA1 *0301-DQB 1*0303. In contrast, group C lacked the association with class I antigens, although HLA-DR4 and HLA-DQA1* 0301-DQB 1*0401 were more common in this group than in control subjects. CONCLUSIONS These results indicate that the clinical subtype with slowly progressive course (slowly progressive IDDM) has distinct findings including late-age onset, high prevalence of islet cell antibodies, preserved β-cell function, and high family history of NIDDM. An additive effect of class I and class II major histocompatibility complex antigens is suggested as an explanation for the acute clinical manifestations and more severe β-cell destruction in group A patients.
255 citations
TL;DR: Intensive CIT, when combined with CBG measurements, can be used to rapidly improve glycemic control in type II diabetes without development of unacceptable hypoglycemia, however, this degree of metabolic improvement requires large doses of exogenous insulin to overcome peripheral insulin resistance and results in greater hyperinsulinemia with progressive weight gain.
Abstract: Objective— To determine whether tight glycemic control can be obtained using intensive conventional split-dose insulin therapy in the outpatient management of type II diabetes without development of unacceptable side effects. Research Design and Methods— Fourteen type II diabetic subjects were treated with an intensive program of conventional insulin (subcutaneous NPH and regular insulin before breakfast and supper) for 6 mo. Insulin dose adjustments were based on an algorithm built on frequent CPG measurements (4–6 times/day). Patients were monitored biweekly as outpatients and admitted 1 day/mo for metabolic evaluation. Results— Glycemic control was achieved by 1 mo (mean plasma glucose fell from 17.5 ± 0.9 to 7.7 ± 0.7 mM, P −2 ·min −1 ( P −2 ·min −1 ) improved from 1418 ± 156 to 1657 ± 128 μmol·m −2 ·min −1 ( P P P r = −0.75 and −0.78, both P r = −0.53, P r = 0.67, P r = 0.62, P Conclusions— Intensive CIT, when combined with CBG measurements, can be used to rapidly improve glycemic control in type II diabetes without development of unacceptable hypoglycemia. This degree of metabolic improvement, however, requires large doses of exogenous insulin to overcome peripheral insulin resistance and results in greater hyperinsulinemia with progressive weight gain.
253 citations
TL;DR: In this paper, the authors assess prospectively the relationship between microalbuminuria and mortality in a geographically defined population of NIDDM patients and determine the relative importance of micro albuminuria as a risk factor for mortality.
Abstract: Objective— To assess prospectively the relationship between microalbuminuria and mortality in a geographically defined population of NIDDM patients and to determine the relative importance of microalbuminuria as a risk factor for mortality.
Research Design and Methods–A survey of known diabetes undertaken in 1982 identified a cohort of 249 NIDDM patients. Follow-up information was available for 246 patients who contributed 1498 person-yr exposure and were followed up for a mean period of 6.1 yr. The median age of the cohort at entry was 68 yr (range 28–89 yr), and the median duration of diabetes was 7 yr (range 1–41 yr). At baseline, a clinical examination was performed and a random daytime urine specimen was obtained for measurement of urinary albumin concentration.
Results— UAC results were available for 236 patients: 45 (19%) patients had a UAC > 15- 200 mg/L; and 145 (61%) had a normal UAC < or = 15 mg/L. During the follow-up period, 93 patients died. All-causes mortality, expressed as standardized mortality ratio (SMR = 149) and coronary heart disease mortality (CHD SMR = 166) were significantly increased. This excess mortality was significant in women (all-causes SMR = 194, CHD SMR = 234) but not in men (all-causes SMR = 118, CHD SMR = 128). On univariate analysis, systolic blood pressure was the only significant association with albumin concentration ( P = 0.0002). An age-stratified log-rank test was conducted to determine the effect of potential explanatory variables on survival. Survival distributions were significantly different for known duration of diabetes ( P = 0.045), intermittent claudication ( P = 0.012), severity of retinopathy, lens opacity ( P < 0.001) and UAC ( P = 0.013) and diastolic blood pressure approached significance ( P = 0.051). After adjusting for the effects of these potentially confounding variables identified by the log-rank analysis, significant predictors of early mortality on multivariate survival analysis were age, UAC of 40–200 mg/L (relative risk = 2.2, 95% confidence interval 1.3–3.7), more severe retinopathy (relative risk = 3.4, 95% confidence interval 1.9–6.0), and lens opacity (relative risk = 2.4, 95% confidence interval 1.6–3.8).
Conclusions— The findings from this population-based cohort confirm the predictive power of microalbuminuria as a risk factor for mortality in NIDDM. In contrast to prospective studies of conventional cardiovascular risk factors in NIDDM, consistent evidence indicates that microalbuminuria is an independent predictor of excess mortality regardless of the collection procedure used.
TL;DR: In summary, immunological complications of insulin therapy have decreased significantly during the last two decades and are now predominantly observed in patients with interrupted insulin therapy.
Abstract: Immunological complications of insulin therapy have been evident since animal insulins became available for the treatment of diabetes mellitus in 1922. Insulin allergy has been particularly common, with local symptoms still occurring in approximately 5% of all patients. Insulin antibodies of high titers were observed in many patients treated with early insulin preparations containing proinsulin, C-peptide, and other peptide contaminants. Immunoglobulin G-insulin antibodies of very high levels can lead to immune-mediated insulin resistance, which is now extremely rare because of the widespread use of highly purified porcine insulin and human insulin preparations. Lipoatrophy, which was reported in 10-55% of patients treated with nonpurified bovine/porcine insulin preparations, has almost disappeared in patients since the advent of exclusive human insulin treatment. In view of the wide spectrum of immune-mediated complications of insulin therapy, much attention has been directed to the reduced immunogenicity and allergenicity of highly purified porcine insulins and the more recently available recombinant and semisynthetic human insulin preparations. Insulin antibodies of the immunoglobulin G and immunoglobulin E type can develop, however, in very low titers in patients treated exclusively with human insulin. Frequency and levels of immunoglobulin G insulin antibodies are identical in patients treated either with biosynthetic or semisynthetic human insulin preparations. Allergic symptoms to human insulin are now found in < 1% of de novo-treated patients, but still may occur when human insulin is used in the insulin-allergic patient. In summary, immunological complications of insulin therapy have decreased significantly during the last two decades and are now predominantly observed in patients with interrupted insulin therapy.
TL;DR: The average HbA1c among intensively managed patients who reported that they followed specific diet-related behaviors was 0.25 to 1.0 lower than among subjects who did not follow these behaviors, and health-care providers may wish to use these results to focus clinical care for intensively treated IDDM patients by emphasizing counseling on meal plans.
Abstract: OBJECTIVE To determine whether specific diet-related behaviors practiced by IDDM patients in the intensive treatment group of the Diabetes Control and Complications Trial were associated with lower HbAlc values. RESEARCH DESIGN AND METHODS A questionnaire addressing various aspects of their dietary behavior during the previous year in the DCCT was completed by 623 DCCT intensive treatment group subjects. The association between selfreported diet behaviors and the subject9s mean HbA 1c during the previous year was evaluated using a linear rank test for trend. The goal of intensive treatment was to achieve blood glucose and HbA 1c levels as close to the nondiabetic range as possible without hypoglycemia. RESULTS Adherence to the prescribed meal plan and adjusting food and/or insulin in response to hyperglycemia were significantly associated with lower HbA 1c levels. Over-treating hypoglycemia and consuming extra snacks beyond the meal plan were associated with higher HbA 1c levels. Adjusting insulin dose for meal size and content and consistent consumption of an evening snack were associated, albeit to a lesser degree, with lower HbA 1c . CONCLUSIONS The average HbA 1c among intensively managed patients who reported that they followed specific diet-related behaviors was 0.25 to 1.0 lower than among subjects who did not follow these behaviors. Health-care providers may wish to use these results to focus clinical care for intensively treated IDDM patients by emphasizing counseling on meal plans, prompt response to high blood glucose levels, appropriate treatment of hypoglycemia, and consistent snacking behaviors.
TL;DR: The proportion of peripheral (toe, leg) amputations was markedly higher in diabetic patients who also tended to have more reamputations during the follow-up than did nondiabetic subjects, and the diabetic status per se was a statistically significant risk factor for mortality in women, but not in men.
Abstract: Objective— To study the incidence of LEAs attributable to PVD in diabetic and nondiabetic patients. The age at first amputation, the level of amputation, the number of reamputations, and survival after amputation also were examined in the study populations. Research Design and Methods— This retrospective study was based on a population of 253,000 inhabitants in eastern Finland. All patients with their first LEA performed during the period from 1 January 1978 to 31 December 1984 were identified from the registers of operation theaters in the study area. Furthermore, patient records and death certificates were reviewed. Amputations attributable to causes other than evident atherosclerotic vascular disease were excluded. Results— Altogether, 477 patients (85 diabetic men, 127 nondiabetic men, 169 diabetic women, and 96 nondiabetic women) were identified. The overall LEA rate was 26.9/100,000 per yr, and the incidence increased strongly with age in both diabetic and nondiabetic patients. The age-adjusted amputation incidence per yr was 349.1/100,000 for diabetic men, 33.9/100,000 for nondiabetic men, 239.4/100,000 for diabetic women, and 17.2/100,000 for nondiabetic women. The proportion of peripheral (toe, leg) amputations was markedly higher in diabetic patients who also tended to have more reamputations during the follow-up than did nondiabetic subjects. The diabetic status per se was a statistically significant risk factor for mortality in women, but not in men. Conclusions— Diabetic men and women had a 10.3- and 13.8-fold higher risk, respectively, for LEA.
TL;DR: Fasting glucose, HbA1c, fasting and glucose-stimulated insulin, blood pressure and left ventricular mass, cholesterol, triglycerides, and fibrinogen decreased significantly after metformin treatment, whereas high-density lipoprotein cholesterol increased.
Abstract: OBJECTIVE To determine the effects of metformin on blood pressure, left ventricular mass, and some metabolic and endocrine parameters in nondiabetic, obese, hypertensive women. RESEARCH DESIGN AND METHODS Twelve obese, nondiabetic, hypertensive women received 850 mg metformin 2 times/day for 12 wk and placebo for another 12 wk, according to a double-blind, cross-over, randomized design. All patients were hospitalized 4 times, i.e., before randomization and after each treatment (metformin or placebo), to conduct metabolic and cardiovascular investigations (oral glucose tolerance test, euglycemic clamp associated with indirect calorimetry, and echocardiography). RESULTS Fasting glucose, HbA 1c , fasting and glucose-stimulated insulin, blood pressure and left ventricular mass, cholesterol, triglycerides, and fibrinogen decreased significantly after metformin treatment, whereas high-density lipoprotein cholesterol increased. The improvement in glucose metabolism resulted from increased sensitivity to insulin. CONCLUSIONS These findings suggest that metformin treatment in obese, nondiabetic, hypertensive women produces a more favorable cardiovascular risk profile.
TL;DR: Symptoms of sensory neuropathy affect 30–40% of diabetic patients in the U.S. population and increases with longer duration of diabetes; hypertension and hyperglycemia predispose to symptoms of sensory Neuropathy.
Abstract: OBJECTIVE To ascertain the prevalence and determinants of sensory neuropathy symptoms through structured interview of a representative sample of people with diabetes in the U.S. population. RESEARCH DESIGN AND METHODS The 1989 National Health Interview Survey consisted of a representative sample of 84,572 persons in the U.S. ≥ 18 yr of age. A household respondent identified all people in the household believed to have diabetes ( n = 2829). Subjects who could not be personally interviewed ( n = 129) and individuals who stated they did not have diabetes ( n = 295) were excluded. A detailed questionnaire was administered to 99.3% of the remaining 2405 subjects. Questions on symptoms of sensory neuropathy included whether during the past 3 mo the subjects had experienced numbness or loss of feeling, pain or tingling, or decreased ability to feel hot or cold. The neuropathy questions were also administered to a representative sample of 20,037 subjects who were not known to have diabetes. RESULTS Prevalence of symptoms of sensory neuropathy was 30.2% among people with IDDM. This prevalence was 36.0% for men with NIDDM and 39.8% for women with NIDDM, compared with 9.8 and 11.8% for nondiabetic men and women, respectively. In logistic regression, factors independently related to symptoms of sensory neuropathy in people with NIDDM included duration of diabetes, hypertension, hyperglycemia, and glycosuria. Long duration of NIDDM (>20 yr) was associated with a twofold increased risk of symptoms of sensory neuropathy compared with those with 0-4 yr of diabetes. Hypertension was associated with a 60% higher likelihood of symptoms. Diabetic individuals whose blood glucose was high all or most of the time or whose urine tests showed glucose all of the time were > 2 times as likely to have symptoms of sensory neuropathy than those who did not report hyperglycemia or glycosuria. Age, sex, ethnicity, cigarette smoking, and height were not determinants of sensory neuropathy. CONCLUSIONS Symptoms of sensory neuropathy affect 30–40% of diabetic patients in the U.S. Men and women are affected equally. Prevalence of these symptoms increases with longer duration of diabetes; hypertension and hyperglycemia predispose to symptoms of sensory neuropathy.
TL;DR: The prevalence of NIDDM in urban Africans in Cape Town, South Africa is moderately high, and considerably higher than previous reports from Africa, and has important implications in view of the large-scale urbanization occurring in southern Africa.
Abstract: OBJECTIVE To determine the prevalence of NIDDM and associated risk factors in urban Africans in Cape Town, South Africa.
RESEARCH DESIGN AND METHODS With a three-stage, proportional, stratified, random cluster method, we sampled 1000 Africans, > 30 yr of age, living in African residential areas in Cape Town. We assessed glucose tolerance with a 75-g oral glucose tolerance test, according to World Health Organization criteria, and obtained anthropometric and demographic data.
RESULTS The response rate was 79%. The prevalence of NIDDM was 8.0% (confidence interval 5.8–10.3%), age-adjusted to world population figures and that of impaired glucose tolerance, 7.0% (confidence interval 4.9–9.1%). Multivariate analysis indicated that increased age (odds ratio 4.18), upper-segment fat distribution (odds ratio 2.94), proportion of life spent in an urban area (odds ratio 2.32), and obesity (odds ratio 2.31) were significant independent risk factors for NIDDM. In contrast, sex, family history, alcohol intake, and physical activity were not independent risk factors. Only increased age (odds ratio 4.06) was a significant risk factor for impaired glucose tolerance.
CONCLUSIONS The prevalence of NIDDM in urban Africans in Cape Town, South Africa, is moderately high, and considerably higher than previous reports from Africa. The association of NIDDM with urbanization has important implications in view of the large-scale urbanization occurring in southern Africa.
TL;DR: GLA had a beneficial effect on the course of diabetic neuropathy, and treatment was more effective in relatively well-controlled than in poorly-controlled diabetic patients.
Abstract: Objective— To compare the effects of placebo and GLA on the course of mild diabetic neuropathy over 1 yr. Research Design and Methods— We entered 111 patients with mild diabetic neuropathy from seven centers into a randomized, double-blind, placebo-controlled parallel study of GLA at a dose of 480 mg/day. MNCV, SNAP, CMAP, hot and cold thresholds, sensation, tendon reflexes, and muscle strength were assessed by standard tests in upper and lower limbs. Results— For all 16 parameters, the change over 1 yr in response to GLA was more favorable than the change with placebo, and for 13 parameters, the difference was statistically significant. Sex, age, and type of diabetes did not influence the result, but treatment was more effective in relatively well-controlled than in poorly-controlled diabetic patients. Conclusions— GLA had a beneficial effect on the course of diabetic neuropathy.
TL;DR: It is suggested that glycemic control, age or duration of IDDM, disturbed lipids, and possibly elevated blood pressure all may contribute to the development of microalbuminuria; and, further, that the adverse cardiovascular risk profile seen in individuals with overt nephropathy may begin to develop even before the detection of micro Albuminuria.
Abstract: OBJECTIVE To examine the relationships between microalbuminuria and the development of overt diabetic nephrology, elevated blood pressure, and a more atherogenic lipid profile; and to identify risk factors for the development of microalbuminuria in individuals with IDDM. Microalbuminuria has been associated with the subsequent development of overt diabetic nephropathy in individuals with IDDM. It is associated with elevated blood pressure and a more atherogenic lipid profile, but the temporal relationship between the development of microalbuminuria and the changes in these factors is unclear. RESEARCH DESIGN AND METHODS Baseline characteristics were examined in 256 individuals with IDDM who had normal albumin excretion (urinary AER ≤20 μg/min in ≥2 timed urine collections) and were re-examined 2 yr later. RESULTS At follow-up, 24 had developed microalbuminuria (AER 20–200 (Ag/min in ≥2 timed urine collections) and 1 had developed overt nephropathy (AER ≥200 μg/min). Overall, the significant independent predictors of microalbuminuria were HbA 1 ( P P P P = 0.05). Sex-specific analyses showed HbA 1 age, and baseline AER were particularly important for men; whereas, for women, the main predictors were duration of IDDM and triglycerides. Duration-specific analyses showed that HbA 1 was an important predictor both for individuals with 20-yr duration. Low-density lipoprotein cholesterol was more important for subjects with shorter durations; whereas triglycerides were important for those with longer durations. CONCLUSIONS These results suggest that glycemic control, age or duration of IDDM, disturbed lipids, and possibly elevated blood pressure all may contribute to the development of microalbuminuria; and, further, that the adverse cardiovascular risk profile seen in individuals with overt nephropathy may begin to develop even before the detection of microalbuminuria.
TL;DR: It is suggested that, after treatment for obesity, multifaceted programs comprised of continued professional contact, skills training, social support, and exercise, can enhance the long-term maintenance of weight loss.
Abstract: The management of obesity represents an important objective in the care of many NIDDM patients. In recent years, progress has been made in increasing initial weight reductions, but poor long-term maintenance of weight loss remains a vital clinical concern. This article reviews the challenge of weight-loss maintenance and recommends the adoption of a continuous care model of obesity management. Strategies to improve the long-term maintenance of weight loss are described, and empirical tests of their effectiveness are reviewed. Collectively, the findings suggest that, after treatment for obesity, multifaceted programs comprised of continued professional contact, skills training, social support, and exercise, can enhance the long-term maintenance of weight loss.
TL;DR: The results support the notion that IDDM adolescents should be seen as a high-risk group for psychiatric disorders.
Abstract: OBJECTIVE To determine whether the rate of psychiatric disorders increases in children and adolescents with IDDM. RESEARCH DESIGN AND METHODS The rate of psychiatric disorders was assessed by highly structured interviews in a group of 93 IDDM adolescents 17–19 yr of age and compared with a healthy (nondiabetic) age-, sex-, and socioeconomic status-matched control group. RESULTS The rate of psychiatric disorders was 33.3% in the diabetic group, more than threefold higher than in the control group (9.7%). With regard to the ratepsychiatric disorders, no sex-specific differences between the two groups were found. The diabetic adolescents suffered from significantly more introversive symptoms than their healthy counterparts, especially somatic symptoms, sleeping disturbances, compulsions, and depressive moods. In spite of the elevated rate of psychiatric disorders, the rates of life events and familial adversities did not increase in the diabetic group. CONCLUSIONS The results support the notion that IDDM adolescents should be seen as a high-risk group for psychiatric disorders.
TL;DR: Daily vitamin E supplements seem to produce a minimal but significant improvement in the metabolic control in type II diabetic patients, and more studies are necessary before conclusions can be drawn about the safety of vitamin E during long-term administration.
Abstract: OBJECTIVE To investigate the potential metabolic benefits deriving from daily vitamin E administration in type II diabetic patients. RESEARCH DESIGN AND METHODS Twenty-five type II diabetic patients were invited to randomly take placebo or vitamin E (d-α-tocopherol; 900 mg/day) along a similar 3-mo period in a double-blind, crossover procedure. A wash-out period of 30 days separated the two treatment periods. At the end of each treatment period blood samples were drawn for plasma metabolites determination, and an intravenous glucose tolerance test (25 g of glucose as bolus in 3 min) was performed. During this study oral hypoglycemic agents were not discontinued or changed in their dosage. RESULTS Chronic vitamin E administration reduced plasma glucose (8.3 ± 0.3 vs. 7.5 ± 0.2 mM, P > 0.05), triglycerides (2.27 ± 0.08 vs. 1.67 ± 0.09 mM, P P P 1 levels (7.8 ± 0.3 vs. 7.1 ± 0.5%, P CONCLUSIONS Daily vitamin E supplements seem to produce a minimal but significant improvement in the metabolic control in type II diabetic patients. More studies are necessary before conclusions can be drawn about the safety of vitamin E during long-term administration.
TL;DR: Fundus photographs taken by the 45° camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy.
Abstract: OBJECTIVE— To define the test characteristics of four methods of screening for diabetic retinopathy. RESEARCH DESIGN AND METHODS— Four screening methods (an exam by an ophthalmologist through dilated pupils using direct and indirect ophthalmoscopy, an exam by a physician9s assistant through dilated pupils using direct ophthalmoscopy, a single 45° retinal photograph without pharmacological dilation, and a set of three dilated 45° retinal photographs) were compared with a reference standard of stereoscopic 30° retinal photographs of seven standard fields read by a central reading center. Sensitivity, specificity, and positive and negative likelihood ratios were calculated after dichotomizing the retinopathy levels into none and mild nonproliferative versus moderate to severe nonproliferative and proliferative. Two sites were used. All patients with diabetes in a VA hospital outpatient clinic between June 1988 and May 1989 were asked to participate. Patients with diabetes identified from a laboratory list of elevated serum glucose values were recruited from a DOD medical center. RESULTS— The subjects (352) had complete exams excluding the exam by the physician9s assistant that was added later. The sensitivities, specificities, and positive and negative likelihood ratios are as follows: ophthalmologist 0.33, 0.99, 72, 0.67; photographs without pharmacological dilation 0.61, 0.85, 4.1, 0.46; dilated photographs 0.81, 0.97, 24, 0.19; and physician9s assistant 0.14, 0.99, 12, 0.87. CONCLUSIONS— Fundus photographs taken by the 45° camera through pharmacologically dilated pupils and read by trained readers perform as well as ophthalmologists for detecting diabetic retinopathy. Physician extenders can effectively perform the photography with minimal training but would require more training to perform adequate eye exams. In this older population, many patients did not obtain adequate nonpharmacological dilation for use of the 45° camera.
TL;DR: A program promoting preconception counseling can be implemented on a statewide basis by using various health-care providers to deliver the program.
Abstract: OBJECTIVE To determine if a noncentralized, statewide program could be established to educate health-care providers and women with pregestational diabetes on available strategies to prevent adverse outcomes in pregnancies complicated by diabetes. Characteristics of women who participated in the program and the outcomes of their pregnancies are evaluated. RESEARCH DESIGN AND METHODS A network of regional providers caring for pregnant women with diabetes was developed. Continuing education sessions were delivered to both providers and women with existing diabetes on the importance of preconception counseling. RESULTS Maine health-care providers collaborated on the development and adoption of three patient-care guidelines that address preconception counseling, prenatal care, and contraception for women with established diabetes. A total of 185 pregnancies among 160 women with pregestational diabetes reporting estimated delivery dates between 1 January 1987 and 31 December 1990 were identified. Of the total pregnancies, 62 (34%) occurred in women who received preconception counseling: among these 62 pregnancies were one major congenital defect (1.6%) and four fetal or neonatal deaths (6.4%). Among the 123 (66%) pregnancies occurring in women that had not received preconception counseling, 8 (6.5%) infants were born with congenital abnormalities, and 26 (21.1%) fetal or neonatal deaths were documented. CONCLUSIONS A program promoting preconception counseling can be implemented on a statewide basis by using various health-care providers to deliver the program. Participation in such a program appears to be related to improved pregnancy outcomes among women with pregestational diabetes.
TL;DR: High intake of total dietary fat is positively related to relative fasting hyperinsulinemia in nondiabetic women, particularly those who are sedentary, and this effect appears to be partly mediated by the relation of dietary fat with obesity.
Abstract: OBJECTIVE To evaluate the associations between the usual intake of dietary fats and insulin concentrations. Insulin concentrations and insulin resistance have been positively related to risk for NIDDM, obesity, hypertension, dyslipidemia, and coronary heart disease, yet little is known of the environmental risk factors for relative hyperinsulinemia. Insulin resistance can be induced by high-fat feeding in laboratory animals; therefore, high-fat diets may increase risks for developing NIDDM. RESEARCH DESIGN AND METHODS Subjects included 544 nondiabetic women who participated in the second examination of the Kaiser Permanente Women Twins Study (1989-1990). Fasting and 2-h post 75-g glucose load insulin levels were determined. Dietary fat intake was assessed by a food frequency questionnaire. Generalized least-squares regression analyses for unpaired twin data were used to determine the relationship between dietary fat intake and insulin levels after adjustment for total calories, age, several behavioral variables, and in some models, percentage of body fat and waist-to-hip ratio. Associations of dietary fat intake with insulin levels were also evaluated within the subset of monozygotic twin pairs ( n = 164 pairs) after removal of genetic influences by regression analysis of intrapair differences. RESULTS Among the 544 individual women, a 20 g/day increase in total dietary fat was associated with a higher fasting insulin level (9% [ P P P = 0.04), even after adjustment for obesity. Only saturated fat intake was significantly associated with 2-h postglucose load insulin level before ( P = 0.04) but not after adjustment for obesity. Within identical twin pairs, total dietary fat was positively related to fasting insulin before ( P = 0.03) but not after adjustment for obesity ( P = 0.11). CONCLUSIONS High intake of total dietary fat is positively related to relative fasting hyperinsulinemia in nondiabetic women, particularly those who are sedentary. This effect appears to be partly mediated by the relation of dietary fat with obesity.
TL;DR: It may be prudent for physicians and their patients to make greater use of the role of self-monitoring in achieving blood glucose control, and special attention should be directed to the subgroups of patients (blacks, patients not treated with insulin, those with less education, and those with no education in diabetes) in which the frequency of Self-Monitoring is particularly low.
Abstract: OBJECTIVE To evaluate self-monitoring of blood glucose, which is considered an important practice for patients with diabetes. However, little is known about the frequency or determinants of this technique. RESEARCH DESIGN AND METHODS A detailed questionnaire on diabetes was administered to a representative sample of 2405 diabetic subjects ≥ 18 yr of age in the U.S. population in the 1989 National Health Interview Survey. RESULTS Among subjects with IDDM, 40% monitored their blood glucose at least 1 time/day. Among subjects with NIDDM treated with insulin, 26% monitored at least 1 time/day and among NIDDM subjects not treated with insulin, the percentage was 5%. When stratified by age, little difference was observed between IDDM subjects and insulin-treated NIDDM subjects in the percentage testing at least 1 time/day. By multivariate analysis, age and insulin use were the major determinants of whether diabetic subjects tested their blood glucose. Race and education were also independently related to self-monitoring of blood glucose. Blacks were 60% less likely to test their blood glucose at least 1 time/day compared with non-Hispanic whites and Mexican Americans. Those with college education were 80% more likely to test their blood glucose compared with those with lower education levels. Having had a patient education class in diabetes management and frequent physician visits for diabetes care were positively related to self-testing. Self-monitoring was not related to higher income or having health insurance. CONCLUSIONS A large proportion of patients with diabetes do not test their blood glucose. Financial barriers associated with income and health insurance do not appear to impede the practice of self-monitoring. Because of the importance of blood glucose control in the prevention of diabetes complications and the role of self-monitoring in achieving blood glucose control, it may be prudent for physicians and their patients to make greater use of this technique. Special attention should be directed to the subgroups of patients (blacks, patients not treated with insulin, those with less education, and those with no education in diabetes) in which the frequency of self-monitoring is particularly low.
TL;DR: A diet rich in monounsaturated fat has beneficial effects on blood pressure and glucose metabolism, whereas no adverse effects on lipid composition in NIDDM subjects is detected.
Abstract: OBJECTIVE To compare the influence on blood pressure, glucose, and lipid levels of a diet rich in monounsaturated fatty acids with an isocaloric, highcarbohydrate diet in 15 NIDDM subjects. RESEARCH DESIGN AND METHODS A crossover design with diet interventions and wash-out periods of 3 wk was applied. The patients were randomly assigned to a 3-wk treatment with a high-carbohydrate diet containing 50% of energy as carbohydrate and 30% of energy as fat (10% of energy as monounsaturated fatty acids) or an isocaloric diet with 30% of energy as carbohydrate and 50% of energy as fat (30% of energy as monounsaturated fatty acids). On the last day of the two diets, 24-h ambulatory blood pressure was measured and day profiles of glucose, hormones, and lipids were performed to a test menu rich in carbohydrates. RESULTS The diet rich in monounsaturated fat reduced daytime systolic (131 ± 3 vs. 137 ± 3 mmHg, P P P P P P P CONCLUSIONS A diet rich in monounsaturated fat has beneficial effects on blood pressure and glucose metabolism, whereas no adverse effects on lipid composition in NIDDM subjects is detected.
TL;DR: The results suggest that any association of Lp(a) concentration with IDDM complications is likely to be weak or nonexistent, however, prospective studies are needed before its full role can be determined.
Abstract: OBJECTIVE To examine the potential associations of lipoprotein(a) and the complications of IDDM and their risk factors. RESEARCH DESIGN AND METHODS This report focuses on 186 individuals with IDDM (mean age = 34 yr) participating in a 10-yr prospective study examining various complications. Lp(a) concentrations were evaluated for those with and without complications. RESULTS A weak correlation was seen between Lp(a) and HbAj ( r = 0.16, P P 30 mg/dl). CONCLUSIONS These results suggest that any association of Lp(a) concentration with IDDM complications is likely to be weak or nonexistent. However, prospective studies are needed before its full role can be determined.
TL;DR: Total serum sialic acid levels were significantly elevated in a relatively small group of NIDDM patients and were correlated with hypertension and retinopathy, and a larger study of circulating sIALic acid concentrations as a risk factor for the development of diabetic angiopathy is justified.
Abstract: Objective— In view of the possible link between serum sialic acid and cardiovascular disease in the general population, we investigated whether serum total and lipid-associated sialic concentrations are elevated in NIDDM patients compared with normal subjects. We also investigated how sialic acid levels relate to glycemic control, blood pressure, microalbuminuria, retinopathy, and serum lipid levels. Research Design and Methods— We selected 20 NIDDM patients at random and matched them for age and sex with 20 normal subjects. The patients also had a similar BMI as the control subjects. A first morning blood sample was taken for sialic acid, glucose, fructosamine, and lipid analysis, as was a first morning urine sample for assessment of microalbuminuria. Retinopathy was assessed by fundoscopy. Results— Both total and lipid-associated sialic acid levels were elevated in the NIDDM patients compared with control subjects (mean ± SD, total: 0.74 ± 0.11 vs. 0.60 ± 0.22 g/L, P P r = 0.58, P r = 0.58, P P = 0.09). In 9 patients with background retinopathy with or without maculopathy, the total serum sialic acid concentration was higher than in those without retinopathy (0.81 ± 0.09 vs. 0.69 ± 0.10 g/L, P Conclusions— Total serum sialic acid levels were significantly elevated in a relatively small group of NIDDM patients and were correlated with hypertension and retinopathy. A larger study of circulating sialic acid concentrations as a risk factor for the development or marker of diabetic angiopathy is therefore justified.
TL;DR: Findings suggest a relationship between controllable risk factors, blood pressure and GHb, and microalbuminuria in older-onset diabetic individuals.
Abstract: OBJECTIVE To examine the prevalence of microalbuminuria and the relationships of microalbuminuria to blood pressure and other risk factors. RESEARCH DESIGN AND METHODS Individuals diagnosed with diabetes at ≥30 yr of age either taking insulin ( n = 435) or not taking insulin ( n = 363), who were participants in the population-based Wisconsin Epidemiologic Study of Diabetic Retinopathy, were examined during 1984-1986. Random urine samples were collected and an agglutination inhibition test was used to determine the presence of microalbuminuria, which is defined as ≥0.03 g/L but RESULTS The frequency of microalbuminuria was 29.2% in those individuals taking insulin and 22.0% in those not taking insulin. Microalbuminuria was significantly associated with the male sex, older age, higher systolic blood pressure, higher GHb, use of insulin, higher recent alcohol consumption, and a history of cardiovascular disease. CONCLUSIONS These findings suggest a relationship between controllable risk factors, blood pressure and GHb, and microalbuminuria in older-onset diabetic individuals.