Metabolic syndrome and coronary heart disease in South Asians, African-Caribbeans and white Europeans: a UK population-based cross-sectional study

AIMS/HYPOTHESIS

The aim of this study was to study differences in the prevalence of the metabolic syndrome and its associations with prevalent CHD according to ethnicity and sex.

METHODS

We performed a combined analysis of two population-based cross-sectional studies conducted between 1988 and 1991 that followed identical protocols. Participants (aged 40-69 years) comprised 2,346 Europeans (76% male), 1,711 South Asians (83% male) and 803 African-Caribbeans (57% male) resident in west London. Fasting blood, overnight urine collection, clinical and anthropometric measurements were performed. Clinical history or major ECG changes defined prevalent CHD. The metabolic syndrome was defined according to the criteria recommended by the World Health Organization (WHO) and the National Cholesterol Education Programme (NCEP).

RESULTS

The prevalence of the metabolic syndrome was highest in South Asians (WHO, men 46%, women 31%; NCEP, men 29%, women 32%) and lowest in European women (WHO, 9%; NCEP, 14%). The prevalence of CHD was 10% in South Asian men, 9% in European men, 5-6% in African-Caribbeans and European women, and 2% in South Asian women. The metabolic syndrome was associated with prevalent CHD in European men [NCEP, odds ratio (OR)=1.6, 95% CI 1.2-2.4; WHO, OR=1.7, 95% CI 1.2-2.5] and South Asian men (NCEP, OR=2.1, 95% CI 1.5-3.1; WHO, OR=1.6, 95% CI 1.1-2.3). Associations with CHD were weaker in African-Caribbeans and were inconsistent among European women.

CONCLUSIONS/INTERPRETATION

The current definitions of the metabolic syndrome give an inconsistent picture of cardiovascular disease risk when applied to different ethnic groups within the UK. Prospective studies are needed to validate workable ethnic-specific definitions.

Markers of inflammation are cross-sectionally associated with microvascular complications and cardiovascular disease in type 1 diabetes--the EURODIAB Prospective Complications Study

AIMS/HYPOTHESIS

The pathogenesis of vascular complications in type 1 diabetes is poorly understood, but may involve chronic, low-grade inflammation. We investigated the association of markers of inflammation with vascular complications in type 1 diabetes.

METHODS

A cross-sectional nested case-control study of the follow-up data of the EURODIAB Prospective Complications Study. This study included 543 individuals (278 men) with type 1 diabetes diagnosed at <36 years of age. Cases (n=348) had complications of diabetes, controls (n=195) had no complications.

RESULTS

C-reactive protein, interleukin-6 and tumour necrosis factor-alpha levels, which were combined in an inflammatory marker Z-score, were associated with albuminuria, retinopathy and cardiovascular disease. Calculated means (95% confidence intervals) of the marker Z-score were -0.15 (-0.22 to -0.07), 0.10 (-0.05 to 0.25), and 0.28 (0.15 to 0.41), p for trend <0.0001, in individuals with normo-, micro- and macroalbuminuria; -0.23 (-0.33 to -0.13), 0.14 (0.02 to 0.25) and 0.20 (0.07 to 0.32), p for trend <0.0001, in individuals with no, non-proliferative and proliferative retinopathy; and -0.28 (-0.39 to -0.18) and 0.06 (-0.08 to 0.20), p<0.001, in individuals without and with cardiovascular disease. Per 1 SD increase of the inflammatory marker Z-score, GFR decreased by -4.6 (-6.6 to -2.6) ml per min per 1.73 m(2) (p<0.001).

CONCLUSIONS/INTERPRETATION

We have shown that markers of inflammation are strongly and independently associated with microvascular complications and cardiovascular disease in type 1 diabetes. These data suggest that strategies to decrease inflammatory activity may help to prevent the development of vascular complications in type 1 diabetes.

Risk factors for cardiac autonomic neuropathy in type 1 diabetes mellitus

AIMS/HYPOTHESIS

Cardiac autonomic neuropathy (CAN) is associated with increased morbidity and mortality in type 1 diabetes. Apart from glycaemic control, risk factors for CAN have not been extensively studied.

METHODS

As part of the EURODIAB Prospective Complications Study, CAN--defined as either a loss of heart rate variability or postural hypotension on standing--was assessed at baseline and follow-up (7.3+/-0.6 years from baseline) in patients with type 1 diabetes.

RESULTS

Follow-up measurements were available for 956 participants without CAN at baseline (age at baseline 31.3+/-8.9 years, duration of diabetes 13.5+/-8.3 years). During follow-up, 163 (17%) subjects developed CAN, yielding an incidence of 23.4 per 1,000 person-years. Blood pressure, weight, the presence of cardiovascular disease, albuminuria, distal symmetrical polyneuropathy (DSP) and retinopathy at baseline were associated with the incidence of CAN after adjustment for sex, duration of diabetes and HbA(1)c. In a multivariate regression model, baseline factors associated with an increased risk of developing CAN were age [odds ratio (OR)=1.3 per decade, 95% CI 1.1-1.7], HbA(1)c (OR=1.2 per percentage point, 95% CI 1.1-1.4), systolic blood pressure (OR=1.1 per 10 mmHg, 95% CI 1.0-1.3), feeling faint on standing (OR=2.0, 95% CI 1.2-3.2), DSP (OR=1.9, 95% CI 1.2-3.0) and retinopathy (OR=1.7, 95% CI 1.1-2.6).

CONCLUSION/INTERPRETATION

This study confirms the importance of exposure to hyperglycaemia as a risk factor for CAN. A small set of variables, including HbA(1)c, hypertension, DSP and retinopathy, predict the risk of CAN. Clinical trials are needed to address the impact of intensive antihypertensive treatment on CAN in type 1 diabetes.

Ethnic differences and determinants of diabetes and central obesity among South Asians of Pakistan

AIMS

To study the within ethnic subgroup variations in diabetes and central obesity among South Asians.

METHODS

Data from 9442 individuals age > or = 15 years from the National Health Survey of Pakistan (NHSP) (1990-1994) were analysed. Diabetes was defined as non-fasting blood glucose > or = 7.8 mmol/l, or known history of diabetes. Central obesity was measured at the waist circumference. Distinct ethnic subgroups Muhajir, Punjabi, Sindhi, Pashtun, and Baluchi were defined by mother tongue.

RESULTS

The age-standardized prevalence of diabetes varied among ethnic subgroups (P = 0.002), being highest among the Muhajirs (men 5.7%, women 7.9%), then Punjabis (men 4.6%, women 7.2%), Sindhis (men 5.1%, women 4.8%), Pashtuns (men 3.0%, women 3.8%), and lowest among the Baluchis (men 2.9%, women 2.6%). While diabetes was more prevalent in urban vs. rural dwellers [odds ratio (OR) 1.50, 95% confidence interval (CI) 1.24, 1.82], this difference was no longer significant after adjusting for central obesity (OR 1.15, 95% CI 0.95, 1.42). However, the ethnic differences persisted after adjusting for major sociodemographic risk factors (unadjusted OR for Pashtun vs. Punjabi 0.59, 95% CI 0.42, 0.84, adjusted OR 0.54, 95% CI 0.37, 0.78). Ethnic variation was also observed in central obesity, which varied with gender, and did not necessarily track with ethnic differences in diabetes.

CONCLUSIONS

Unmeasured environmental or genetic factors account for ethnic variations in diabetes and central obesity, and deserve further study.

Factors associated with progression to macroalbuminuria in microalbuminuric Type 1 diabetic patients: the EURODIAB Prospective Complications Study

AIMS/HYPOTHESIS

Type 1 diabetic patients who develop microalbuminuria are clearly disadvantaged in terms of their risk of morbidity and mortality from renal and cardiovascular diseases. It is therefore important to identify potential factors that can predict progression to macroalbuminuria.

METHODS

This is a 7-year follow-up study of 352 microalbuminuric Type 1 diabetic patients from 31 European centres. Risk factors at baseline were compared in patients who progressed to macroalbuminuria and in patients who remained microalbuminuric or reverted to normoalbuminuria. Risk factors and albumin excretion rate (AER) were measured centrally.

RESULTS

Over 7.3 years, 13.9% of the microalbuminuric patients progressed to macroalbuminuria, 35.5% remained microalbuminuric and 50.6% reverted to normoalbuminuria. Independent baseline risk factors for progression to macroalbuminuria were HbA(1)c (7.9% vs 6.8%, p=0.004), AER (64.4 vs 44.9 microg/min, p=0.0001) and-after adjusting for diabetes duration, HbA(1)c and AER-body weight (72 vs 67 kg, p=0.05). Independent factors associated with regression to normoalbuminuria were diabetes duration (15 vs 18 years, p=0.004), AER (37.2 vs 44.9 microg/min, p=0.0001) and-after adjusting for diabetes duration, HbA(1)c and AER-waist-to-hip ratio (0.83 vs 0.86, p=0.05) and incidence of peripheral neuropathy at baseline (24% vs 38%, p=0.001). Blood pressure and smoking did not emerge as risk factors at baseline for the outcome of microalbuminuria.

CONCLUSIONS/INTERPRETATION

A significant fraction of microalbuminuric Type 1 diabetic patients will progress to overt proteinuria. Patients with higher AER values, sub-optimal metabolic control, excess body fat and peripheral neuropathy may carry a particularly high risk of clinical nephropathy requiring aggressive therapeutic intervention.

Risk factors for non-fatal myocardial infarction in young South Asian adults

OBJECTIVE

To determine the risk factors for premature myocardial infarction among young South Asians.

DESIGN AND SETTING

Case-control study in a hospital admitting unselected patients with non-fatal acute myocardial infarction.

METHODS AND SUBJECTS

Risk factor assessment was done in 193 subjects aged 15-45 years with a first acute myocardial infarct, and in 193 age, sex, and neighbourhood matched population based controls.

RESULTS

The mean (SD) age of the subjects was 39 (4.9) years and 326 (84.5%) were male. Current smoking (odds ratio (OR) 3.82, 95% confidence interval (CI) 1.47 to 9.94), use of ghee (hydrogenated vegetable oil) in cooking (OR 3.91, 95% CI 1.52 to 10.03), raised fasting blood glucose (OR 3.32, 95% CI 1.21 to 8.62), raised serum cholesterol (OR 1.67, 95% CI 1.14 to 2.45 for each 1.0 mmol/l increase), low income (OR 5.05, 95% CI 1.71 to 14.96), paternal history of cardiovascular disease (OR 4.84, 95% CI 1.42 to 16.53), and parental consanguinity (OR 3.80, 95% CI 1.13 to 1.75) were all independent risk factors for acute myocardial infarction in young adults. Formal education versus no education had an independently protective effect on acute myocardial infarction (OR 0.04, 95% CI 0.01 to 0.35).

CONCLUSIONS

Tobacco use, ghee intake, raised fasting glucose, high cholesterol, paternal history of cardiovascular disease, low income, and low level of education are associated with premature acute myocardial infarction in South Asians. The association of parental consanguinity with acute myocardial infarction is reported for the first time and deserves further study.

The prevalence of hepatitis C virus antibodies among the voluntary blood donors of New Delhi, India

Infection with hepatitis C virus (HCV) is a major cause of transfusion-associated hepatitis, cirrhosis and hepatocellular carcinoma. The present study was conducted with an objective to evaluate the prevalence of anti-HCV antibody in New Delhi, India using a large number of healthy voluntary blood donors. A total of 15,898 healthy voluntary blood donors were subjected to anti-HCV testing (using a commercially available third generation anti-HCV ELISA kit) and 249 were found to be reactive for anti-HCV antibody, yielding an overall prevalence of 1.57%. No significant difference was found between the HCV positivity rate of male (1.57%; 238/15,152) vs. female (1.47%; 11/746) donors, family (1.58%; 213/13,521) vs. altruistic (1.51%; 36/2377) donors and first-time (1.55%; 180/11,605) vs. repeat (1.61%; 69/4293) donors. The age distribution of anti-HCV reactivity showed a maximum prevalence rate of 1.8% in the age group of 20-29 years. In addition, there was a clear trend of decreasing positivity for anti-HCV with increasing age and this trend was statistically significant. The results of the present study show that the prevalence of anti-HCV antibodies in the healthy voluntary blood donors of New Delhi, India is considerably higher than the reported seroprevalence of HCV in majority of the industrialized nations and this represents a large reservoir of infection capable of inflicting significant disease burden on the society. In addition, donors of New Delhi, India showed a trend of decreasing seroprevalence with increasing age, possibly implying a higher exposure rate to HCV in younger subjects.

Differing aspects of insulin resistance in diabetes complications: the shape of things to come. RD Lawrence Lecture 2000

The anticipated global epidemic of diabetes, largely as a consequence of increased rates of obesity, will particularly impact on people of South Asian and African Caribbean descent, two populations at elevated risk of insulin resistance. This article contrasts the consequent heightened risk of heart disease on the one hand in South Asians, and the paradoxical protection from heart disease in African Caribbeans on the other. Protection from the hypertriglyceridaemic effects of insulin resistance is likely to account for much of the African Caribbean paradox, although the mechanisms remain unclear. The growing evidence that insulin resistance is commonly observed in people with Type 1 diabetes, as well as those with Type 2 diabetes, and that features of insulin resistance may play a crucial role in the development of microvascular, as well as macrovascular complications, is also discussed. This indicates novel targets for the prevention and treatment of diabetes complications.

Autonomic neuropathy is associated with increased cardiovascular risk factors: the EURODIAB IDDM Complications Study

AIMS

To assess the prevalence of and risk factors for autonomic neuropathy in the EURODIAB IDDM Complications Study.

METHODS

The study involved the examination of randomly selected Type I (insulin-dependent) diabetic patients from 31 centres in 16 European countries. Neuropathic symptoms and two tests of autonomic function (changes in heart rate and blood pressure from lying to standing) were assessed and data from 3007 patients were available for the present analysis. Autonomic neuropathy was defined as an abnormality of at least one of the tests.

RESULTS

The prevalence of autonomic neuropathy was 36% with no sex differences. The frequency of one and two abnormal reflex tests was 30% and 6%, respectively. The R-R ratio was abnormal in 24% of patients while 18% had orthostatic hypotension defined as a fall in systolic blood pressure > 20 mmHg on standing. Significant correlations were observed between autonomic neuropathy and age (P < 0.01), duration of diabetes (P < 0.0001), HbA1c (P < 0.0001), diastolic blood pressure (P < 0.05), lower HDL-cholesterol (P < 0.01), the presence of retinopathy (P < 0.0001) and albuminuria (P < 0.0001). New associations have been identified from the study: the strong relationship of autonomic neuropathy to cigarette smoking (P < 0.01), total cholesterol/HDL-cholesterol ratio (P < 0.05) and fasting triglyceride (P < 0.0001). As a key finding, autonomic neuropathy was related to the presence of cardiovascular disease (P < 0.0001). All analyses were adjusted for age, duration of diabetes and HbA1c. However, data have been only partly confirmed by logistic regression analyses. Frequency of dizziness on standing up was 18%, while only 4% of patients had nocturnal diarrhoea and 5% had problems with bladder control.

CONCLUSION

Cardiovascular reflex tests, even in the form of the two tests applied, rather than a questionnaire, seem to be appropriate for the diagnosis of autonomic neuropathy. The study has identified previously known and new potential risk factors for the development of autonomic neuropathy, which may be important for the development of risk reduction strategies. Our results may support the role of vascular factors in the pathogenesis of autonomic neuropathy.

The retinal renin-angiotensin system: implications for therapy in diabetic retinopathy

Retinopathy is the most common complication of diabetes, and a leading cause of blindness in people of working age. Optimal blood pressure and metabolic control can reduce the risk of diabetic retinopathy, but are difficult to achieve in clinical practice. In the EUCLID Study, the angiotensin converting enzyme (ACE) inhibitor lisinopril reduced the risk of progression of retinopathy by approximately 50%, and also significantly reduced the risk of progression to proliferative retinopathy. These findings are consistent with extensive evidence that the renin-angiotensin system is expressed in the eye, and that adverse effects of angiotensin II on retinal angiogenesis and function can be inhibited by ACE inhibitors or angiotensin II-receptor blockers. However, in the EUCLID Study retinopathy was not a primary end-point and the study was not sufficiently powered for the eye-related outcomes. Hence, the Diabetic Retinopathy Candesartan Trials (DIRECT) programme has been established to determine whether AT(1)-receptor blockade with candesartan can prevent the incidence and progression of diabetic retinopathy. This programme comprises three studies, involving a total of 4500 patients recruited from about 300 centres worldwide. The patients are normotensive or treated hypertensive individuals, and so the DIRECT programme should assess the potential of an AT(1)-receptor blocker to protect against the pathological changes in the eye following diabetes.

Amadori-albumin correlates with microvascular complications and precedes nephropathy in type 1 diabetic patients

BACKGROUND

Amadori-albumin, a major glycated protein, is involved in experimental hyperglycaemia-induced microvascular complications, and is associated with advanced nephropathy in Type I diabetic patients in humans. Our aim was to assess the association of Amadori-albumin with early nephropathy and with retinopathy in Type I diabetic patients and the involvement of chronic low-degree inflammation therein.

DESIGN AND METHODS

Amadori-albumin, the Amadori product of haemoglobin (HbA1c), C-reactive protein, and fibrinogen levels were measured in the EUCLID study, a 2-year randomised, double-blind, placebo-controlled trial of lisinopril in 447 Type I diabetic patients. Retinal photographs were taken in 341 patients at baseline and 294 at follow up.

RESULTS

Amadori-albumin was positively associated with albumin the excretion rate and retinopathy status (P = 0.0001 and P = 0.02 for trend, respectively) and with the progression from normoalbuminuria to (micro)albuminuria (38.6 U mL(-1) in nonprogressors, 44.3 U mL-1 in progressors; P = 0.02), but not with the development or progression of retinopathy during a 2-year follow up. Amadori-albumin levels at baseline were associated with C-reactive protein and fibrinogen (P = 0.0007 and P = 0.0001, respectively). C-reactive protein and fibrinogen were also associated with albumin excretion rates (P = 0.03 and P = 0.01, respectively) and retinopathy status (P = 0.02 and P = 0.0006, respectively). Adjustment for these inflammatory markers did not markedly attenuate the association between Amadori-albumin and the albumin excretion rate, while adjustment for fibrinogen, but not C-reactive protein, abolished the association between Amadori-albumin and retinopathy. Lisinopril had no impact on the association between the levels of Amadori-albumin and albumin excretion rates or retinopathy.

CONCLUSIONS

Amadori-albumin was associated with early nephropathy and with retinopathy in Type I diabetic patients and preceded an increase in albumin excretion rate, but not retinopathy. A chronic low-degree inflammation does not appear to be involved in Amadori-albumin-associated microvascular complications in Type I diabetes.

Risk of diabetes-related amputation in South Asians vs. Europeans in the UK

AIMS

To compare the risk of and risk factors for diabetes-related amputation in South Asians and Europeans.

METHODS

This was a population-based case control study based in the health districts of Bolton, Oldham and Central Manchester in the UK. Cases with diabetes-related amputation performed between 1992 and 1997 (n = 172) and controls with diabetes and no amputation (n = 376) were selected from the primary care-based North-west Diabetes Foot Study database. Risk factor data were also collected.

RESULTS

Age at diagnosis adjusted odds ratio (OR) of amputation in South Asians compared with Europeans was 0.26, 95% confidence interval (CI) 0.11-0.65, P = 0.004. In the control population, South Asians were less likely than Europeans to have peripheral vascular disease (PVD) (9% vs. 24%, P = 0.02), neuropathy (30% vs. 54%, P = 0.003), and less likely to have ever been smokers (31% vs. 57%, P = 0.03). When these factors were added to the model, the OR was attenuated to 0.84, 95% CI 0.23-3.08, P = 0.8.

CONCLUSIONS

South Asians with diabetes have about a quarter of the risk of amputation of Europeans. This is mostly explained by low rates of PVD and neuropathy in South Asians, in part associated with low rates of smoking. The reasons for the South Asian protection from both PVD and neuropathy deserve further exploration.

Birth weight, childhood growth and abdominal obesity in adult life

OBJECTIVE

To examine the relationship of adult abdominal obesity to birth weight, childhood growth and lifetime socioeconomic circumstances.

METHODS

A cohort of 3200 men and women with measured waist and hip circumference, height and weight at age 43 who have been followed since their birth in March 1946 in England, Scotland and Wales. Regression models were used to examine mean waist-hip ratio and waist circumference in relation to prospective measures of birth weight, weight relative to height in childhood at ages 4, 7, 11 and 15 and adult body mass index, and to test the independent and interactive nature of the associations and adjust for childhood and adult social class.

RESULTS

There was a small inverse effect of birth weight on waist-hip ratio (P=0.037) but not waist circumference in women, after adjustment for current body size. Relative weight at age 7 was inversely related to waist-hip ratio and waist circumference in men (P<0.001 for both) and waist circumference in women (P=0.007) after adjustment for current body size. These relationships were attenuated in men of large body mass index (P<0.01 for interactions between relative weight at 7 y and body mass index in both cases) but were not modified by birth weight. Relative weights at other ages showed similar patterns to those observed at age 7, the effect being weakest at age 4. These findings were independent of lifetime socioeconomic circumstances.

CONCLUSION

This study found a small prenatal inverse effect of fetal growth on adult waist-hip ratio due to a reduced hip size. There was also an inverse postnatal effect of childhood growth such that for any given adult body size those who had been lighter in childhood were more at risk of abdominal obesity. These relationships were independent of childhood socioeconomic circumstances and support the idea that insulin resistance may be linked to low weight in childhood.

Differing associations of lipid and lipoprotein disturbances with the macrovascular and microvascular complications of type 1 diabetes

OBJECTIVE

Cardiovascular disease (CVD) is increased in patients with type 1 diabetes, but lipid and lipoprotein patterns remain favorable. In contrast, nephropathy is associated with an adverse distribution. We compared the associations and predictive power of lipid and lipoprotein disturbances with these complications.

RESEARCH DESIGN AND METHODS

A nested case-control study from the EURODIAB cohort of 140 case subjects with evidence of at least one complication and 84 control subjects with no complications were analyzed. Conventional and unconventional lipid and lipoprotein fractions, including apolipoprotein (apo)-A1, lipoprotein (Lp)-A1, LpA1/A2, apoB, and LDL particle size were measured centrally.

RESULTS

CVD was only associated with increased LDL cholesterol (3.6 vs. 3.0 mmol/l, P = 0.02). In contrast, albuminuria was associated with elevated cholesterol, triglyceride, LDL, and apoB and with diminished LDL particle size. No disturbances in HDL and related lipoproteins were noted. In normoalbuminuric patients, CVD was not associated with any significant changes in lipids. CVD in macroalbuminuric patients was associated with increased triglyceride level (2.37 vs. 1.07 mmol/l, P = 0.001; P = 0.02 for CVD/albuminuria interaction) and LDL cholesterol (5.4 vs. 3.3 mmol/l, P = 0.005; P = 0.004 for interaction). Independent associations were observed for total cholesterol and for LDL particle size and albuminuria.

CONCLUSIONS

Abnormalities in lipid and lipoprotein disturbances are more closely related to albuminuria than to CVD in patients with type 1 diabetes. Measurement of conventional parameters provide sufficient risk information. ApoB and LDL particle size offer limited extra information. HDL metabolism remains undisturbed in the presence of complications. These changes reflect associations with glycemic control, which is the key to understanding lipid and lipoprotein disturbances.

Risk factors for progression to proliferative diabetic retinopathy in the EURODIAB Prospective Complications Study

AIMS/HYPOTHESIS

Proliferative diabetic retinopathy (PDR), a leading cause of blindness, cannot be totally prevented by optimizing metabolic and blood pressure control and responds to no specific treatment other than partially destructive retinal photocoagulation. Recognizing risk factors using large-scale epidemiological studies could help identify targets for treatment. The EURODIAB Prospective Complications Study (PCS) includes the largest cohort so far of patients with Type I (insulin-dependent) diabetes mellitus.

METHODS

Baseline data were collected between 1989 and 1991 on 3250 patients who were recalled for follow-up. Physical examination, biochemical tests and assessment of complications were done on both occasions. In particular, 1249 patients had retinal photographs taken both basally and after an average of 7.3 years.

RESULTS

Proliferative retinopathy had developed in 157 patients (cumulative incidence 17.3/1000 patient-years; 95%-CI: 13.6-21.1). HbA(1c) (standardized regression estimate--SRE = 3.03, CI 2.49-3.69), diabetes duration (1.71, 1.42-2.06), age at diagnosis < 12 (1.66, 1.11-2.50), diastolic blood pressure less than or equal to 83 (1.50, 1.03-2.20) and waist-to-hip ratio (1.50, 1.03-2.20) were all independent predictors for progression to PDR when entered simultaneously into a logistic regression model. Including retinopathy at baseline maintained the effects of metabolic control and pre-pubertal onset only. Including the albumin excretion rate maintained the effect of control but reduced SRE for pre-pubertal onset to 1.49 (0.94-2.33). There was no evidence for a threshold effect for HbA(1c)concentrations at baseline and progression to proliferative retinopathy.

CONCLUSION/HYPOTHESIS

Metabolic control and duration of diabetes are strong indicators of progression to proliferative retinopathy. Onset of diabetes before puberty could be an additional independent risk factor.

Risk factors, ethnic differences and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO Multinational Study of Vascular Disease in Diabetes

AIMS/HYPOTHESIS

We aimed to examine geographic differences, risk factors and mortality associated with amputation.

METHODS

Data from 10 of the original 14 centres of the WHO Multinational Study of Vascular Disease in Diabetes were used. This included 3443 men and women aged 35 to 55 years at baseline.

RESULTS

Incidences of amputation, adjusted for sex and duration in Type I (insulin-dependent) diabetes mellitus, were 31.0, 8.2, 3.5 and 1.0 per 1,000 person years in the American Indian, Cuban, European and East Asian centres respectively. In Type II (non-insulin-dependent) diabetes mellitus, incidences of amputation were 9.7, 2.0, 2.5 and 0.7 per 1000 person years in the American Indian, Cuban, European and East Asian centres respectively. Key risk factors for amputation included glucose, triglyceride, and retinopathy, and were similar for American Indians and Europeans. The age, duration and sex adjusted relative risk for amputation in American Indians compared with Europeans was 11.48 (95% CI 3.56, 36.98) in Type I diabetes and 3.86 (95 % CI 2.36, 6.32) in Type II diabetes. Adjusting for heart disease, retinopathy, proteinuria, glucose, blood pressure and triglyceride attenuated these relative risks to 10.83 (95 % CI 3.20, 36.65) and 3.15 (1.91, 5.20) in Type I and Type II diabetes respectively. Amputation doubled mortality rates in all groups.

CONCLUSION/INTERPRETATION

Vascular complications and their risk factors are themselves risk factors for amputation in both Type I and Type II diabetes and are common to several geographical regions worldwide. However, reasons for differences between geographical regions and the degree to which different health care systems could be responsible is not clear.

Blood pressure response to standing in the diagnosis of autonomic neuropathy: the EURODIAB IDDM Complications Study

Autonomic neuropathy is associated with poor prognosis. Cardiovascular reflexes are essential for the diagnosis of autonomic nerve dysfunction. Blood pressure response to standing is the most simple test for the evaluation of sympathetic integrity, however it is still discussed which diagnostic criteria of abnormal response should be considered as optimal. The EURODIAB IDDM Complications Study involved the examination of randomly selected Type 1 diabetic patients from 31 centres in 16 European counties. Data from 3007 patients were available for the present evaluation. Two tests of autonomic function (response of heart rate /R-R ratio/ and blood pressure from lying to standing) just as the frequency of feeling faint on standing up were assessed. R-R ratio was abnormal in 24% of patients. According to different diagnostic criteria of abnormal BP response to standing (>30 mmHg, >20 mmHg, and >10 mmHg fall in systolic BP), the frequency of abnormal results was 5.9%, 18% and 32%, respectively (p < 0.001). The frequency of feeling faint on standing was 18%, thus, it was identical with the prevalence of abnormal blood pressure response to standing when >20 mmHg fall in systolic blood pressure was considered as abnormal. Feeling faint on standing correlated significantly with both autonomic test results (p < 0.001). A fall >20 mmHg in systolic blood pressure after standing up seems to be the most reliable criterion for the assessment of orthostatic hypotension in the diagnosis of autonomic neuropathy in patients with Type 1 diabetes mellitus.

Microalbuminuria in type 1 diabetes: rates, risk factors and glycemic threshold

BACKGROUND

The occurrence of microalbuminuria in type 1 diabetes is strongly predictive of renal and cardiovascular disease and is still likely to occur despite improvements in glycemic control. A better understanding of microalbuminuria is required to inform new interventions. We determined the incidence and risk factors for microalbuminuria [albumin excretion rate (AER) 20 to 200 microg/min] in the EURODIAB Prospective Complications Study.

METHODS

This is a seven-year follow-up (between 1988 and 1991) of 1134 normoalbuminuric men and women (aged 15 to 60) with type 1 diabetes from 31 European centers. Risk factors and AER were measured centrally.

RESULTS

The incidence of microalbuminuria was 12.6% over 7.3 years. Independent baseline risk factors were HbA1c (7.1 vs. 6.2%, P = 0.0001) and AER (9.6 vs. 7.8 microg/min, P = 0.0001) and, independent of these, fasting triglyceride (0.99 vs. 0.88 mmol/L, P = 0.01), low-density lipoprotein cholesterol (3.5 vs. 3.2 mmol/L, P = 0.02), body mass index (24.0 vs. 23.4 kg/m2, P = 0.01), and waist to hip ratio (WHR; 0.85 vs. 0.83, P = 0.009). Triglyceride and WHR risk factors were nearly as strong as AER in predicting microalbuminuria (standardized regression effects of 1.3 for triglyceride and WHR and 1.5 for AER). Blood pressure at follow-up, but not at baseline, was also raised in those who progressed. There was no evidence of a threshold of HbA1c on microalbuminuria risk.

CONCLUSIONS

The incidence of microalbuminuria in patients with type 1 diabetes remains high, and there is no apparent glycemic threshold for it. Markers of insulin resistance, such as triglyceride and WHR, are strong risk factors. Systemic blood pressure is not raised prior to the onset of microalbuminuria.

A comparison of left ventricular abnormalities associated with glucose intolerance in African Caribbeans and Europeans in the UK

OBJECTIVE

To determine whether abnormalities of the left ventricle differ by glucose tolerance status, to explore reasons for differences, and to assess ethnic differences in these relations.

DESIGN

Population based prevalence study.

SETTING

London, UK.

PATIENTS

1152 African Caribbeans and Europeans.

METHODS

Echocardiograms, blood pressure, obesity, fasting and two hour blood glucose, insulin and lipids, and urinary albumin excretion rate were measured.

MAIN OUTCOME MEASURES

Left ventricular mass index, wall thickness, and early (E) to atrial (A) wave ratio.

RESULTS

Left ventricular mass index was greater in diabetic Europeans than in normoglycaemic Europeans (mean (SE), 95.6 (5.0) v 79.7 (0.8) g/m(2), p = 0.001) and in diabetic African Caribbeans than in normoglycaemic African Caribbeans (88.6 (2.5) v 82.4 (0.9) g/m(2), p = 0.02). Similar, but weaker associations were observed for the E:A ratio. beta Coefficients between left ventricular mass index and fasting glucose in the normoglycaemic range, adjusted for age and sex, were 2.43 in Europeans (p = 0.05) and 3.74 in African Caribbeans (p = 0.02). These were attenuated to 1.19 (p = 0.4) and 3.03 (p = 0.08) in Europeans and African Caribbeans, respectively, when adjusted further for blood pressure and obesity. Adjustments for other risk factors made little difference to the coefficients. There were no ethnic differences in risk factor relations.

CONCLUSIONS

Abnormalities of the left ventricle occur in response to glucose intolerance and are observable into the normoglycaemic range. These disturbances are largely accounted for by associated obesity and hypertension. African Caribbeans have a greater degree of left ventricular structural impairment, emphasising the importance of tight blood pressure control.

Circulating plasma vascular endothelial growth factor and microvascular complications of type 1 diabetes mellitus: the influence of ACE inhibition

AIMS

To determine whether circulating plasma vascular endothelial growth factor (VEGF) is elevated in the presence of diabetic microvascular complications, and whether the impact of angiotensin-converting enzyme (ACE) inhibitors on these complications can be accounted for by changes in circulating VEGF.

METHODS

Samples (299/354 of those with retinal photographs) from the EUCLID placebo-controlled clinical trial of the ACE inhibitor lisinopril in mainly normoalbuminuric non-hypertensive Type 1 diabetic patients were used. Albumin excretion rate (AER) was measured 6 monthly. Geometric mean VEGF levels by baseline retinopathy status, change in retinopathy over 2 years, and by treatment with lisinopril were calculated.

RESULTS

No significant correlation was observed between VEGF at baseline and age, diabetes duration, glycaemic control, blood pressure, smoking, fibrinogen and von Willebrand factor. Mean VEGF concentration at baseline was 11.5 (95% confidence interval 6.0--27.9) pg/ml in those without retinopathy, 12.9 (6.0--38.9) pg/ml in those with non-proliferative retinopathy, and 16.1 (8.1--33.5) pg/ml in those with proliferative retinopathy (P = 0.06 for trend). Baseline VEGF was 15.2 pg/ml in those who progressed by at least one level of retinopathy by 2 years compared to 11.8 pg/ml in those who did not (P = 0.3). VEGF levels were not altered by lisinopril treatment. Results were similar for AER.

CONCLUSIONS

Circulating plasma VEGF concentration is not strongly correlated with risk factor status or microvascular disease in Type 1 diabetes, nor is it affected by ACE inhibition. Changes in circulating VEGF cannot account for the beneficial effect of ACE inhibition on retinopathy.

Markers of insulin resistance are strong risk factors for retinopathy incidence in type 1 diabetes

OBJECTIVE

To determine the incidence of retinopathy and the relative importance of its risk factors in type 1 diabetes.

RESEARCH DESIGN AND METHODS

This is a 7.3-year follow-up of 764 of 1,215 (63%) people with type 1 diabetes across Europe, aged 15-60 years at baseline with no retinopathy (the EURODIAB Prospective Complications Study). Retinal photographs were taken at baseline and follow-up and risk factors were assessed to a standard protocol.

RESULTS

Retinopathy incidence was 56% (429/764, 95% CI 52-59%). Key risk factors included diabetes duration and glycemic control. We found no evidence of a threshold effect for HbA1c on retinopathy incidence. Univariate associations were observed between incidence and albumin excretion rate, cholesterol, triglyceride, fibrinogen, von Willebrand factor, gamma-glutamyltransferase, waist-to-hip ratio, and insulin dose. No associations were observed for blood pressure, cardiovascular disease, or smoking. Independent risk factors, as assessed by standardized regression effects, were HbA1C (1.93, P = 0.0001), duration (1.32, P = 0.008), waist-to-hip ratio (1.32, P = 0.01), and fasting triglyceride (1.24, P = 0.04).

CONCLUSIONS

Retinopathy incidence in type 1 diabetes remains high. Key risk factors include diabetes duration and glycemic control, with no evidence of a threshold for the latter. Other independent risk factors, such as waist-to-hip ratio and triglyceride levels, both markers of insulin resistance, were strongly related to incidence.

Repeated measures in clinical trials: simple strategies for analysis using summary measures

The summary measures approach to analysing repeated measures is described. The circumstances under which it can be advantageous to use such measures are considered. Strategies for baseline adjustment where there are multiple baselines are examined, as is the choice of appropriate summary statistic. A compromise trend/mean measure, regression through the origin, is proposed as being useful under some circumstances. An analysis using this measure is illustrated with a suitable example.

Relation of plasma lipids to insulin resistance, nonesterified fatty acid levels, and body fat in men from three ethnic groups: relevance to variation in risk of diabetes and coronary disease

Afro-Caribbean men in the United Kingdom have a favorable lipoprotein profile and are at low risk of coronary heart disease (CHD) compared with Europeans and South Asians, but are at high risk of non-insulin-dependent diabetes mellitus (NIDDM) compared with Europeans. To investigate these differences, a cross-sectional comparison was undertaken for measures of lipoprotein metabolism, body composition, and insulin's glucoregulatory and antilipolytic actions in 92 healthy men (42 to 61 years) of Afro-Caribbean, South Asian, or European origin. Afro-Caribbean men were more insulin-resistant than Europeans (insulin sensitivity [Si], 1.96 v3.01 min(-1) x microU(-1) x mL, P < .01). They nevertheless had a more favorable lipoprotein profile, with lower levels of very-low-density lipoprotein (VLDL) cholesterol (0.21 v 0.40 mmol/L, P < .01) and triglycerides (0.34 v 0.74 mmol/L, P < .01), lower serum total triglycerides, higher high-density lipoprotein 2 (HDL2) cholesterol, and larger low-density lipoprotein (LDL) particle size. These differences were not accounted for by differences in nonesterified fatty acid (NEFA) levels, the sensitivity of suppression of NEFA levels to insulin, or body composition. South Asians were also more insulin-resistant than Europeans but had a less favorable lipoprotein profile. Afro-Caribbean men in the United Kingdom are as insulin-resistant as South Asian men but less susceptible to the lipid disturbances that characteristically accompany insulin resistance. This favorable lipid pattern may relate to more effective VLDL metabolism rather than a reduced supply of NEFA as substrate for triglyceride synthesis.

Window rectostomy: an alternative method of fecal diversion for high anorectal malformations in males without a urinary fistula

This report analyzes our initial experience with window rectostomy (WR) as a new method of fecal diversion for high anorectal malformations (ARM) in 27 males without a urinary fistula between May 1994 and May 1998; total correction was achieved in two stages. In the first stage, during the neonatal period, the dilated rectum was exteriorized as a WR through the left lower abdomen. In the second, after 3-5 months an abdominoperineal pull-through (APPT) procedure was performed in which the window rectostomy was mobilized and taken down to form a new anus. The results were compared with cases of high ARM with urinary fistula that were managed in three stages, i.e., proximal sigmoid colostomy, APPT, and colostomy closure. All 27 cases showed satisfactory results without any mortality or major pelvic infection. The main advantages of WR are that it provides more functioning bowel length after diversion and avoids a colostomy-closure operation and repeated hospitalizations, thus reducing the total cost of treatment.

Antihypertensive therapy for preventing cardiovascular complications in people with diabetes mellitus

OBJECTIVES

To assess the effect of intervention, both pharmacological and non-parmacological, to reduce blood pressure in people with diabetes mellitus on all cause mortality, specific causes of death, including cardiovascular disease, stroke, ischaemic heart disease and renal disease, morbidity associated with macro- and microvascular complications of diabetes mellitus and also side effects of the interventions and their influence on quality of life and well being.

SEARCH STRATEGY

The search strategy employed was to searching electronic databases such as EMBASE and MEDLINE for all trials of anti-hypertensive treatment in diabetes mellitus. As well as searching specialist journals in the fields of cardiovascular disease, stroke, hypertension and renal diease.

SELECTION CRITERIA

All trials were considered independently and then discussed by 2 reviewers to determine there eligibility for inclusion in the review. Their methodological quality was also assessed from details of the randomisation methods, blinding and whether the intention-to-treat method of analysis was used. Trials included in the review were all randomised contolled trials of the treatment for anti-hypertensive therapy for the specified endpoints which included subjects with diabetes mellitus.

DATA COLLECTION AND ANALYSIS

Data was sought on the number of patients with diabetes with each outcome measure by allocated treatment group, either from previous publications or, if this was not possible, the raw data was obtained and analysed using the intention-to-treat method. If these data were not available the results from the 'Per Protocol' analysis were used. To compare the treatment effect of the intervention with that of placebo on all cause mortality and cardiaovascular mortality and morbidity, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for each trial and a meta analysis performed using Peto's ORs as the summary measure.

MAIN RESULTS

The initial search yielded 760 references, from which 23 appropriate trials were identified (3 for primary prevention and 20 for secondary prevention), and 15 of these trials had data available for analysis. For the primary prevention trials the summary ORs (95% CIs) for all cause mortality and CVD were 0.85 (0.62,1.17) and 0.64 (0.50,0.82) respectively. Of the seven trials for long-term secondary prevention (i.e. follow-up greater than one year), the summary OR (95% CI) for all cause mortality was 0.82 (0.69,0.99). Data on CVD mortality and morbidity was only available for 2 of these trials and the summary OR (95% CI) was 0.82 (0.60,1.13). There were five trials for short term secondary prevention trials (i.e. follow-up of less than 1 year) with data available for analysis. The summary ORs (95% CIs) for all cause mortality and CVD were 0.64 (0.50,0.83) and 0.68 (0.43,1.05) respectively.

REVIEWER'S CONCLUSIONS

Primary intervention trials indicated a treatment benefit for CVD, but not for total mortality in people with diabetes. For both short- and long-term secondary prevention, the present meta-analysis indicated a benefit for total mortality in diabetic subjects. However lack of information on CVD outcomes probably reduced the power of the meta-analysis to detect any corresponding benefit for this end-point. This, along with the fact that all published data of randomised control trials of anti-hypertensive therapy in diabetes for all cause mortailty and CVD outcomes are taken from the hypertension trials not specific to diabetes, underlines the need for further high quality trials examining the effects of blood pressure lowering interventions in people with diabetes.

Developing risk stratification charts for diabetic and nondiabetic subjects

AIMS

To provide estimates of the 10-year risk of coronary heart disease events for diabetic and nondiabetic men and women with different levels of risk factors and, for diabetic subjects, with and without microalbuminuria.

METHODS

Use of risk coefficients derived from the Framingham Study and a meta-analysis of the influence of microalbuminuria on cardiovascular disease. The risk of a coronary heart disease event has been calculated for men and women with and without diabetes mellitus, and among diabetic subjects, with and without microalbuminuria, according to age, systolic blood pressure and the ratio of total to high density lipoprotein cholesterol.

RESULTS

These risk estimates have been developed as a series of colour charts. The use of Framingham estimates of risk have been validated by comparing them with estimates derived from the Dundee Risk Disk and from the PROCAM Study, these estimates providing reasonable agreement despite the geographical and temporal differences in their development.

CONCLUSIONS

These charts permit the overall level of risk to be derived, which can inform decision making about thresholds for therapeutic interventions, as well as assisting in patient education.

Relationships of fasting and postload glucose levels to sex and alcohol consumption. Are American Diabetes Association criteria biased against detection of diabetes in women?

OBJECTIVE

To compare, in men and women, the prevalence of undiagnosed type 2 diabetes assessed using criteria from the American Diabetes Association (ADA) and the World Health Organization (WHO) and to investigate risk factors associated with fasting and 2-h postload plasma glucose.

RESEARCH DESIGN AND METHODS

Data from two companion surveys of Europeans, South Asians, and Afro-Caribbeans in west London were used. A total of 4,367 men and women aged 40-64 years who were not known to have diabetes underwent an oral glucose tolerance test after an overnight fast. The prevalence of undiagnosed diabetes was estimated using the ADA (fasting plasma glucose > or = 7.0 mmol/l) and WHO (2-h postload glucose > or = 11.1 mmol/l) criteria for epidemiologic studies. The association of body fat and usual alcohol intake with plasma glucose and diabetes prevalence was assessed.

RESULTS

Compared with the WHO criterion, the ADA criterion gave a higher prevalence of diabetes in men (6.4 vs. 4.7%) but a lower prevalence in women (3.3 vs. 4.2%). In Afro-Caribbeans, the sex difference in diabetes prevalence was reversed. Women had significantly lower fasting glucose than men despite higher 2-h glucose levels. Alcohol intake was positively associated with fasting glucose in men and women but not with 2-h glucose levels.

CONCLUSIONS

The new ADA criterion, based on fasting glucose alone, does not take account of sex differences in metabolic response to fasting or possible artifactual effects on fasting glucose. With the ADA criterion, alcohol intake was a significant risk factor for diabetes in our study population; this was not the case with the WHO criterion.

[Effect of lisinopril on progression of retinopathy and microalbuminuria in normotensive subjects with insulin-dependent diabetes mellitus]

Effect of lisinopril on progression of retinopathy and microalbuminuria in normotensive subjects with insulin-dependent diabetes mellitus. Retinopathy and nephropathy are the most important microvascular complications in diabetes with hyperglycaemia and hypertension as important risk factors. Antihypertensive treatment with angiotensin-converting enzyme inhibitors has been shown to delay progression of nephropathy, but the effect on retinopathy has not been established. We, therefore, performed a trial of the effect of the ACE-inhibitor lisinopril on retinopathy and nephropathy in normotensive patients with IDDM. We performed a two year randomized double-blind placebo-controlled trial of the ACE-inhibitor lisinopril on 530 normotensive IDDM patients within the age group 20-59 years from 18 European centres. Patients were either normo- or microalbuminuric. Retinopathy was classified from retinal photographs into five levels (none to proliferative). The primary endpoint of the trial was progression of albuminuria. Mean albumin excretion rate (AER) was 8.0 micrograms/min at baseline in both treatment groups. After two years AER was 2.2. micrograms/min lower in the lisinopril than in the placebo group, a difference of 18.8% (p = 0.03). The difference in AER was 38.5 micrograms/min between treatment groups in patients with microalbuminuria at baseline (p = 0.001), and 0.23 microgram/min in patients with normoalbuminuria at baseline (p = 0.6). Retinopathy was a secondary endpoint. Patients treated with lisinopril had significantly lower Hb-A1c at baseline than the placebo group (6.9%-7.3%). Retinopathy progressed with at least one level in 13.2% of lisinopril treated and 23.4% of placebo treated patients (odds ratio 0.50, p = 0.02). Progression by two levels or progression to proliferative retinopathy were also significantly reduced in the lisinopril group compared to the placebo group (odds ratio 0.27 and 0.18, respectively). In conclusion, lisinopril delays progression of retinopathy and nephropathy in normotensive IDDM patients with micro- or normoalbuminuria.

Factors associated with obesity in South Asian, Afro-Caribbean and European women

OBJECTIVE

To investigate correlates of body mass index (BMI) and other anthropometric measurements in South Asian, Afro-Caribbean and European women in the UK.

SUBJECTS

291 South Asian, 303 Afro-Caribbean, and 559 European women aged 40-69y in West London, UK.

DESIGN

Cross-sectional survey.

MAIN OUTCOME MEASURES

BMI, waist-to-height ratio (WHt), and skinfold thicknesses.

RESULTS

Compared with European women, South Asian and Afro-Caribbean women were more like to be obese (odds ratios (OR) 1.83 and 3.01, respectively), but less likely to rate themselves as overweight (BMI-adjusted OR 0.19 and 0.34, respectively). The proportion of women who walked at least 2.5 km/d, excluding activity at work, was lower in South Asians (22%) than in Europeans (44%) or Afro-Caribbeans (40%). Among employed women, the proportion who were active at work was higher in South Asians (63%) and Afro-Caribbeans (70%) than in Europeans (49%). In Europeans, obesity was inversely associated with social class, education, smoking, alcohol intake, and distance walked, and positively associated with time spent watching television. Adjustment for alcohol intake, smoking, education and transport, physical activity explained over 80% of the difference in BMI between South Asians and Europeans, but not the difference between Afro-Caribbeans and Europeans.

CONCLUSION

The factor that may be most amenable to intervention in South Asian women is low physical activity outside the workplace. The high prevalence of obesity in Afro-Caribbean women, however, is not accounted for by any behavioural factors measured in this study, and the reasons for high rates of obesity in this group remain to be established.

Gender differences in accessing cardiac surgery across England: a cross-sectional analysis of the health survey for England

OBJECTIVE

To examine gender differences in access to cardiac surgery in a nationally representative sample.

DESIGN

Nationwide cross sectional household based survey (Health Survey for England).

SETTING

Private households in England around 1993 and 1994.

SUBJECTS

1708 subjects reporting a history of either doctor diagnosed angina or heart attack from a stratified random sample of 32 378 people aged 16 and above.

OUTCOME MEASURE

The proportion reporting having had cardiac surgery or on a waiting list.

RESULTS

13.5% reported previous (n = 206) or pending (n = 25) cardiac surgery. Men were more likely than women to have had or to be waiting for cardiac surgery (19.1% of men versus 6.8% of women, chi2 54.7, P<0.001). This finding was consistent regardless of age group and across three regional areas. The unadjusted odds ratio for cardiac surgery for men versus women was 3.3 (95% Cl 2.3, 4.5, P<0.001) and was only slightly attenuated to 2.8 (95% CI 1.9, 4.0. P<0.001), after adjustment for other factors. The gender difference remained even when analysis was restricted to subjects reporting a previous heart attack, and after statistical adjustment for disease severity.

CONCLUSION

Women are less likely than men to receive cardiac surgery across all age groups and regional areas. These results include private operations and adjust for individual behavioural data. Neither disease severity or co-morbidity explains these discrepancies. Further studies are required to determine why this inequality occurs and how it can be addressed.

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study

Diabetic retinopathy remains the most common cause of blindness in people of working age but the provision of high quality eye screening for diabetic patients is still erratic in many health districts in the UK. National consensus guidelines recommend comprehensive population coverage, high sensitivity (>80%), high specificity (>95%), agreed clinical criteria, referral procedures and centralized data collection to facilitate audit. This study looks at the effectiveness of implementing a prompted recall programme for retinal screening in an inner-city district of North London. The scheme uses trained, accredited optometrists to screen patients with diabetes who are looked after in the community by their general practitioner. During the first 17 months of the scheme, 63 optometrists attended training and gained accreditation. Of the 666 patients recruited, 645 were scheduled for screening and 536 (83%) attended. Fourteen per cent of patients screened were found to have background retinopathy and 2.3% sight-threatening eye disease. In two audits, carried out 15 months apart in a random sample of GP practices, the incidence of recorded dilated fundoscopy increased from 48% at baseline to 56%, an increase of 8% (95% CIs 2%-14%). For referable eye disease, the sensitivity of this screening technique was 100%, the specificity 94% (95% CIs 90%-98%), the positive predictive value 79% (95% CIs 72%-86%) and the negative predictive value 100%. The administrative cost per case screened was Pound Sterling 12.60 (excluding clinical costs and any additional optometry payment).

Effect of angiotensin-converting enzyme (ACE) gene polymorphism on progression of renal disease and the influence of ACE inhibition in IDDM patients: findings from the EUCLID Randomized Controlled Trial. EURODIAB Controlled Trial of Lisinopril in IDDM

We examined whether the ACE gene insertion/deletion (I/D) polymorphism modulates renal disease progression in IDDM and how ACE inhibitors influence this relationship. The EURODIAB Controlled Trial of Lisinopril in IDDM is a multicenter randomized placebo-controlled trial in 530 nonhypertensive, mainly normoalbuminuric IDDM patients aged 20-59 years. Albumin excretion rate (AER) was measured every 6 months for 2 years. Genotype distribution was 15% II, 58% ID, and 27% DD. Between genotypes, there were no differences in baseline characteristics or in changes in blood pressure and glycemic control throughout the trial. There was a significant interaction between the II and DD genotype groups and treatment on change in AER (P = 0.05). Patients with the II genotype showed the fastest rate of AER progression on placebo but had an enhanced response to lisinopril. AER at 2 years (adjusted for baseline AER) was 51.3% lower on lisinopril than placebo in the II genotype patients (95% CI, 15.7 to 71.8; P = 0.01), 14.8% in the ID group (-7.8 to 32.7; P = 0.2), and 7.7% in the DD group (-36.6 to 37.6; P = 0.7). Absolute differences in AER between placebo and lisinopril at 2 years were 8.1, 1.7, and 0.8 microg/min in the II, ID, and DD groups, respectively. The significant beneficial effect of lisinopril on AER in the II group persisted when adjusted for center, blood pressure, and glycemic control, and also for diastolic blood pressure at 1 month into the study. Progression from normoalbuminuria to microalbuminuria (lisinopril versus placebo) was 0.27 (0.03-2.26; P = 0.2) in the II group, and 1.30 (0.33-5.17; P = 0.7) in the DD group (P = 0.6 for interaction). Knowledge of ACE genotype may be of value in determining the likely impact of ACE inhibitor treatment.

Comparison of prevalence and risk factors for microalbuminuria in South Asians and Europeans with type 2 diabetes mellitus

Although Type 2 (non-insulin-dependent) diabetes mellitus (Type 2 DM) is more common in South Asians than in Europeans in the UK, very little is known about complications and their risk factors in South Asians. We sought microalbuminuria in a cross-sectional study of 583 European and 889 South Asian Type 2 DM clinic attenders to Ealing Hospital, London, over 1 year. Albumin/creatinine ratios were measured in early morning urines. Prevalence of microalbuminuria was greater in South Asians compared to Europeans (40% versus 33% in men, p = 0.003, and 33% versus 19% in women, p < 0.0001). Glycaemic control was worse and prevalence of hypertension, retinopathy and heart disease was higher in South Asians. Key risk factors for microalbuminuria in both ethnic groups were glycaemic control, diabetes duration, blood pressure, triglyceride and retinopathy, but none accounted for the higher microalbuminuria prevalence in South Asians. Age and sex adjusted odds ratio for microalbuminuria was 1.78 (95% CI 1.02, 2.82, p = 0.02) in South Asians versus Europeans. After adjustment for confounders, this became 2.07, 95% CI 1.13, 3.79, p = 0.02. We conclude that microalbuminuria is more common in South Asians with Type 2 DM than in Europeans and, although risk factor relationships appeared similar in both groups, and some risk factors were more prominent in South Asians, this cannot account for the high prevalence of microalbuminuria observed in South Asians.

Nitrate therapy may retard glaucomatous optic neuropathy, perhaps through modulation of glutamate receptors

Nitrates have been a major part of the internist's pharmacopoeia for more than 100 years, predominantly for the relief of anginal symptoms. The effects of nitroglycerin on the eye and specifically on intraocular pressure has been investigated with diverse results. However, nitroglycerin may also serve to protect retinal ganglion cells against glutamate mediated toxicity--a form of cell death that may be critical in glaucomatous blindness. Consequently, we therefore sought to evaluate whether nitroglycerin preparations, taken for non-ophthalmic reasons, had an effect on glaucomatous damage.

Socioeconomic gradient in morbidity and mortality in people with diabetes: cohort study findings from the Whitehall Study and the WHO Multinational Study of Vascular Disease in Diabetes

OBJECTIVE

To assess whether the inverse socioeconomic mortality gradient observed in the general population persists in diabetic people.

DESIGN

The Whitehall cohort study and the London cohort of the WHO multinational study of vascular disease in diabetes.

SETTING

London.

SUBJECTS

17,264 male civil servants (17,046 without diabetes, 218 with diabetes) aged 40-64 examined in 1967-9, and 300 people with diabetes aged 35-55 from London clinics examined in 1975-7. Both cohorts were followed up until January 1995.

MAIN OUTCOME MEASURES

Mortality from all causes, cardiovascular disease, and ischaemic heart disease.

RESULTS

In both cohorts people in the lower social groups were older, had higher blood pressure, and were more likely to smoke. In the Whitehall study, the prevalence of heart disease was higher in the lowest social group compared with the highest group, by 6% among non-diabetic people (P = 0.0001) and by 14% among diabetic subjects (P = 0.02). In the WHO study proteinuria was more common in the lowest social group compared with the highest (27% v 15%, P = 0.01), as was retinopathy (54% v 48%, P = 0.5). There was a clear socioeconomic gradient in all cause mortality in both cohorts, with death rates being about twice as high in the lowest compared with the highest social groups. In the Whitehall study this gradient was similar in both diabetic and non-diabetic subjects, and it persisted for mortality from cardiovascular disease and from ischaemic heart disease. About half of the increased risk of death in the lowest social group was accounted for by blood pressure and smoking.

CONCLUSIONS

We confirm the existence of an inverse socioeconomic mortality gradient in diabetic people and suggest that this is largely due to conventional cardiovascular risk factors.

Effect of lisinopril on progression of retinopathy in normotensive people with type 1 diabetes. The EUCLID Study Group. EURODIAB Controlled Trial of Lisinopril in Insulin-Dependent Diabetes Mellitus

BACKGROUND

Retinopathy commonly occurs in people with type 1 diabetes. Strict glycaemic control can decrease development and progression of retinopathy only partially. Blood pressure is also a risk factor for microvascular complications. Antihypertensive therapy, especially with inhibitors of angiotensin-converting enzyme (ACE), can slow progression of nephropathy, but the effects on retinopathy have not been established. We investigated the effect of lisinopril on retinopathy in type 1 diabetes.

METHODS

As part of a 2-year randomised double-blind placebo-controlled trial, we took retinal photographs at baseline and follow-up (24 months) in patients aged 20-59 in 15 European centres. Patients were not hypertensive, and were normoalbuminuric (85%) or microalbuminuric. Retinopathy was classified from photographs on a five-level scale (none to proliferative).

FINDINGS

The proportion of patients with retinopathy at baseline was 65% (117) in the placebo group and 59% (103) in the lisinopril group (p = 0.2). Patients on lisinopril had significantly lower HbA1c at baseline than those on placebo (6.9% vs 7.3 p = 0.05). Retinopathy progressed by at least one level in 21 (13.2%) of 159 patients on lisinopril and 39 (23.4%) of 166 patients on placebo (odds ratio 0.50 [95% CI 0.28-0.89], p = 0.02). This 50% reduction was the same when adjusted for centre and glycaemic control (0.55 [0.30-1.03], p = 0.06). Lisinopril also decreased progression by two or more grades (0.27 [0.07-1.00], p = 0.05), and progression to proliferative retinopathy (0.18 [0.04-0.82], p = 0.03). Progression was not associated with albuminuric status at baseline. Treatment reduced retinopathy incidence (0.69 [0.30-1.59], p = 0.4).

INTERPRETATION

Lisinopril may decrease retinopathy progression in non-hypertensive patients who have type 1 diabetes with little or no nephropathy. These findings need to be confirmed before changes to clinical practice can be advocated.

Mortality and morbidity from diabetes in South Asians and Europeans: 11-year follow-up of the Southall Diabetes Survey, London, UK

Over 20% of middle aged and elderly South Asian people throughout the world have diabetes. The associated mortality and morbidity risks are unclear. We compared mortality and morbidity in a cohort of South Asian and European people with diabetes in London, UK, in an 11-year follow-up of a population-based sample of 730 South Asians (mean age 55 in 1984) and 304 Europeans (mean age 67 in 1984) with diabetes aged 30 years and above in 1984. By 1995, 242 (33%) of South Asians, and 172 (57%) of Europeans had died. The all-cause mortality rate ratio (South Asian versus European) was 1.50 (95% CI 0.72-3.12) for those aged 30-54 years at baseline. Ethnic differences in mortality rates were abolished or reversed in people aged 65 years and above at baseline. The mortality rate ratio for circulatory deaths was 1.80 (95% CI 1.03-3.16, p < 0.05) and for heart disease was 2.02 (95% CI 1.04-3.92, p < 0.05) in those aged 30-64 years at baseline. Seventy-seven per cent of South Asian deaths were caused by circulatory disease, compared with 46% of European deaths. South Asian survivors were 3.8 times (95% CI 1.8-8.0, p = 0.001) more likely to report a history of myocardial infarction than Europeans. South Asian adults with diabetes show a markedly increased predisposition to cardiovascular disease compared with Europeans, especially in younger people. This emphasizes the urgent need to reduce cardiovascular risk in this vulnerable group.

Angiotensin converting enzyme inhibitors in diabetic patients with microalbuminuria or normoalbuminuria

In adult diabetic patients microalbuminuria is a marker of early vascular damage in the micro- and macrocirculation. Microalbuminuria is a powerful predictor of renal and cardiovascular disease outcome and is associated with other, potentially modifiable, risk factors of vascular damage. Studies of secondary prevention have shown that blood pressure lowering drugs effectively reduce albumin excretion rate. Angiotensin converting enzyme (ACE) inhibitors seem particularly effective in reducing the risk of progression to clinical albuminuria in both insulin dependent and non-insulin dependent diabetic patients and this beneficial effect appears to be long-lasting. Whether this postpones the onset of end-stage renal failure and/or reduces early mortality in these patients remains to be established. Recent studies of primary prevention in insulin-dependent diabetic patients predominantly with normoalbuminuria demonstrate that ACE inhibition reduces significantly the rate of progression of albumin excretion rate and, of great interest, seems to affect beneficially the progression of retinopathy. These results compare favorably with the beneficial effect of intensified insulin therapy and strict blood glucose control in this same group of patients. Thus, ACE inhibitors are a powerful tool to prevent progression of microalbuminuria in diabetes and may prove useful as an adjunct therapy to intensified insulin therapy in the prevention of development of microalbuminuria and of retinopathy progression in insulin dependent diabetes.

Lay diagnosis and health-care-seeking behaviour for chest pain in south Asians and Europeans

BACKGROUND

South Asian people in the UK experience greater delays than Europeans in obtaining appropriate specialist management for heart disease, but the causes are not known. We investigated whether south Asians and Europeans interpret and act upon anginal symptoms differently.

METHODS

We randomly selected 2000 people from general practitioners' (family physicians) lists in London, UK, to receive a questionnaire that included a short fictional case history of an individual with possible anginal pain and asked how respondents would react to experiencing it. A second questionnaire seeking information on medical history, attitudes to health, and demography was sent later. The main outcome measure was the proportion who said they would seek immediate care (hospital emergency department or general practitioner) for the pain described in the case scenario.

FINDINGS

The rate of response to both questionnaires was 60.2% (903 of 1500 who received both), 553 responders were of European origin, 124 were Hindu, and 235 were Sikh. There were no differences between the ethnic groups in the proportion identifying the pain as cardiac, but south Asians would be more anxious about the pain than would Europeans. Of the men, 55 (23%) Europeans, 20 (38%) Hindus, and 52 (47%) Sikhs said they would seek immediate care (p < 0.0001 for heterogeneity); of women, 77 (24%), 25 (35%), and 58 (46%), respectively, would seek immediate care (p < 0.0001). After adjustment for confounding variables the odds ratio for seeking immediate care in Hindus compared with Europeans was 2.67 (95% CI 1.49-4.73) and that for Sikhs compared with Europeans was 3.18 (1.98-5.12).

INTERPRETATION

Hindus and Sikhs reported a greater likelihood of seeking immediate care for anginal symptoms than Europeans; this finding indicates that barriers to cardiology services for south Asians are unrelated to difficulties in interpretations of symptoms or willingness to seek care. Improvement of awareness of heart disease may not decrease delays in obtaining care. Service-related explanations must be explored, such as general practitioners' difficulties in arriving at a diagnosis or differences in management because of ethnic origin.

Which features of smoking determine mortality risk in former cigarette smokers with diabetes? The World Health Organization Multinational Study Group

OBJECTIVE

The effects of quitting smoking on mortality risk in individuals with diabetes is unknown and may differ from the benefits observed in the general population. We therefore determined the mortality risks in ex-smokers with diabetes, compared with subjects who have never smoked, by the number of years since quitting, the number of cigarettes smoked, and the number of years of smoking.

RESEARCH DESIGN AND METHODS

An international cohort study of 4,427 individuals with diabetes was studied. Baseline examinations were performed in 1975-1977 when smoking habits were determined by questionnaire. Mortality follow-up continued until 1988.

RESULTS

All-cause mortality risks were higher for recent quitters (1-9 years; relative risk [RR], 1.53 [95% CI 1.19-1.97]; P = 0.001) than for those who quit earlier (> or = 10 years; RR, 1.25 [95% CI 1.03-1.52]; P = 0.02), compared with subjects who have never smoked. These risks were highest in those who had smoked the longest (> or = 30 years: RR, 1.66 [95% CI 1.22-2.26]; P = 0.001; vs. 1-9 years: RR, 1.17 [95% CI 0.85-1.60]; P = 0.3). Risks were also highest in those who had smoked the most and least number of cigarettes. Adjustment for key confounders, which included a previous history of heart disease, proteinuria, and blood pressure, did not materially affect these relationships.

CONCLUSIONS

Quitting smoking does reduce mortality risk in ex-smokers with diabetes, but risks remain high several years after quitting and are highly dependent on the duration of smoking. Thus, individuals with diabetes who smoke should be encouraged to quit as soon as possible in the course of disease.

Differences in mortality and morbidity in African Caribbean and European people with non-insulin dependent diabetes mellitus: results of 20 year follow up of a London cohort of a multinational study

OBJECTIVE

To examine differences in morbidity and mortality due to non-insulin dependent diabetes in African Caribbeans and Europeans.

DESIGN

Cohort study of patients with non-insulin dependent diabetes drawn from diabetes clinics in London. Baseline investigations were performed in 1975-7; follow up continued until 1995.

PATIENTS

150 Europeans and 77 African Caribbeans with non-insulin dependent diabetes.

MAIN OUTCOME MEASURES

All cause and cardiovascular mortality; prevalence of microvascular and macrovascular complications.

RESULTS

Duration of diabetes was shorter in African Caribbeans, particularly women. African Caribbeans were more likely than the Europeans to have been given a diagnosis after the onset of symptoms and less likely to be taking insulin. Mean cholesterol concentration was lower in African Caribbeans, but blood pressure and body mass index were not different in the two ethnic groups. Prevalence of microvascular and macrovascular complications was insignificantly lower in African Caribbens than in Europeans. 59 Europeans and 16 African Caribbeans had died by the end of follow up. The risk ratio for all cause mortality was 0.41 (95% confidence interval 0.23 to 0.73) (P = 0.002) for African Caribbeans v Europeans. This was attenuated to 0.59 (0.32 to 1.10) (P = 0.1) after adjustment for sex, smoking, proteinuria, and body mass index. Further adjustment for systolic blood pressure, cholesterol concentration, age, duration of diabetes, and treatment made little difference to the risk ratio. Unadjusted risk ratio for cardiovascular and ischaemic heart disease were 0.33 (0.15 to 0.70) (P = 0.004) and 0.37 (0.16 to 0.85) (P = 0.02) respectively.

CONCLUSIONS

African Caribbeans with non-insulin dependent diabetes maintain a low risk of heart disease. Management priorities for diabetes developed in one ethnic group may not necessarily be applicable to other groups.