The Southall Diabetes Survey: prevalence of known diabetes in Asians and Europeans

One-to-one teaching with pictures--flashcard health education for British Asians with diabetes

BACKGROUND

Type 2 diabetes is up to four times more common in British Asians, but they know little about its management and complications.

AIM

To design and evaluate a structured pictorial teaching programme for Pakistani Moslem patients in Manchester with type 2 diabetes.

METHOD

A randomized controlled trial of pictorial flashcard one-to-one education in 201 patients attending a hospital outpatient clinic or diabetic clinics in ten general practices in Manchester. Patients' knowledge, self-caring skills and attitudes to diabetes were measured on four topics before the structured teaching, and compared with results six months later.

RESULTS

All parameters of knowledge were increased in the study group; for example, percentage scores for correctly identifying different food values increased from 57% to 71% (Analysis of Variance (ANOVA) adjusted difference +11.8%) and knowledge of one diabetic complication from 18% to 78%. Self-caring behaviour improved, with 92% of patients doing regular glucose tests at six months compared with 63% at the start. Attitudinal views were more resistant to change, with patients still finding it hard to choose suitable foods at social occasions. Haemoglobin A1c control improved by 0.34% over six months (ANOVA adjusted difference, 95% CI -0.8% to +0.1%).

CONCLUSION

It is concluded that this health education programme can empower Asian diabetics to take control of their diets, learn to monitor and interpret glucose results, and understand the implications of poor glycaemic control for diabetic complications.

Knowledge, uptake and availability of health and social services among Asian Gujarati and white elderly persons

OBJECTIVES

To investigate factors affecting the uptake of health and social services by elderly Asian Gujarati.

METHODS

Four hundred and five Hindu Gujaratis and 381 whites aged 65 years and over residing in Leicester were randomly sampled from the Leicestershire District FHSA list by a computerized method based on linguistic analysis of the patient's name. One hundred and fifty Hindu Gujaratis and 152 whites were interviewed with response rates of 72% for the Asian Gujaratis and 80% for the white groups. The outcome measures were the activities of daily living (ADLs), incontinence, auditory/ visual deficits, cardiovascular disease, cognitive impairment (measured by the Mini-mental State Examination), depression, use of GP and hospital services, knowledge of community health and social services, willingness to use, suitability and cultural accessibility.

RESULTS

The poorer uptake of services by elderly Asian Gujarati could not be explained by better health. They were significantly more likely to be dependent in six of the 14 ADLs and had higher rates of diabetes and impaired vision. Significantly more Asian Gujaratis than whites lived with others (84 versus 52%, p < 0.0001) with a greater availability of alternative sources of help and support. The knowledge and understanding of services were significantly poorer in the Gujarati group; fewer Asian Gujaratis knew how to apply for services and of those applying, fewer had been successful. Where services had been obtained, the levels of dissatisfaction were higher in the Gujarati group. The literacy rates were low in the Gujarati sample with 79% being unable to read or write in English and 27% unable to read or write in their mother tongue.

CONCLUSIONS

The lower uptake of services by elderly Asian Gujarati is not the result of better health but may be explained by greater family support together with a lack of knowledge of and dissatisfaction with what is available. Health services will need to reappraise and revise some of their practices if they are to cater adequately for this growing population with many needs as yet unmet.

Prevalence of retinopathy in non insulin dependent diabetes mellitus at a diabetes centre in southern India

A cohort of 6792 NIDDM patients attending a diabetes centre at Madras in South India was screened using a combination of retinal photography and clinical examination by retinal specialists. A total of 2319 patients (34.1%) had evidence of retinopathy. This included 2090 patients (30.8%) with non-proliferative diabetic retinopathy including 435 patients (6.4%) with maculopathy and 229 patients (3.4%) with proliferative diabetic retinopathy. Multiple logistic regression analyses showed that duration of diabetes, glycosylated haemoglobin, type of treatment (insulin treatment versus non-insulin treatment), systolic and diastolic blood pressures and serum creatinine, showed a positive association with retinopathy while body mass index (BMI) showed an inverse association. The prevalence rates of retinopathy in Southern Indians are comparable to those seen in Europeans. However in view of the high prevalence of diabetes in the Indian sub-continent, diabetic retinopathy could become a formidable challenge in the future.

The admission of Asian patients to intensive therapy units and its implications for kidney donation: a preliminary report from Coventry, UK

OBJECTIVE

To determine the relative admission rates of Asian and non-Asian patients to intensive therapy units (ITUs) in Coventry and to explore the implications of these rates for the transplantation of organs to Asian people.

DESIGN

Examination of 1991 census data and a retrospective review of ITU admissions books. Data were collected on ethnic background, presenting diagnosis, and clinical outcome for each admission.

SETTING

The three ITUs in Coventry.

PATIENTS

All admissions to the ITUs from 1990-93 inclusive.

RESULTS

Asian patients were admitted to ITUs disproportionately to their numbers in the Coventry population. Members of the Asian community were less than half as likely to be admitted to an ITU (p < 0.001) and more likely to die while there (p = 0.007) than members of the non-Asian population in Coventry. The proportions of patients referred to the transplant unit and the rates of subsequent donation do not seem to differ significantly for Asian and non-Asian patients (p = 0.26 in both cases).

CONCLUSIONS

There are clear implications for the availability of cadaveric kidney transplantation to Asian patients, given that few kidneys from non-Asian donors are histocompatible with Asian recipients. Indeed, in Asians, promotion of living related donation may be more effective in countering the organ shortfall than efforts to increase consent to cadaveric transplantation. However, it may be valuable to investigate any patterns of morbidity or social or cultural factors that might explain the initial low admissions rates to ITUs for Asian patients.

Attitudes and beliefs within the Sikh community regarding organ donation: a pilot study

The current shortage of organs for transplantation is a matter of considerable concern in the United Kingdom (U.K.). Whilst issues of histocompatibility create particular problems in this respect for the Asian population in the U.K., it is sometimes suggested that there is also a resistance to the idea of organ transplantation among this community. To explore this issue, a small-scale interview study was conducted in Coventry among members of the Sikh community. A judgemental sample of 22 individuals, from different strata of the local Sikh community, were interviewed either in one-to-one interviews or in a focus group. These interviews had two broad aims: to determine the prevailing attitudes towards organ transplantation, and to gauge the impact and acceptability of the current Department of Health campaign literature. It was found that, whilst there were a number of misgivings to do with notions of mutilation and reincarnation, and anxieties as to technical or clinical aspects of the transplantation process, the prevailing view was supportive of transplantation, and organ donation was seen as a highly appropriate means of exhibiting the altruistic tradition within Sikhism. Such barriers that exist to the idea of transplantation seem to have more to do with knowledge and understanding than with cultural or religious factors. Concerning the campaign literature, informants identified a number of shortcomings, and indicated ways in which the impact of the leaflets and posters might be enhanced. Although the generalizability of these findings is limited, and despite possible threats to the validity of the data collected, this study has produced findings with significant implications for future policy in this area.

Known type 2 diabetes mellitus among the Kuwaiti population. A prevalence study

The reported prevalence of type 2 diabetes among the Kuwaiti population varied from one source to another. This study was undertaken to define the magnitude of the problem and to suggest plans for future diabetic care. All type 2 Kuwaiti diabetic subjects registered and continuing to attend regularly in two health areas Mubarak Health Area (MHA) and Farwania Health Area (FHA)] were selected for the study. There were 3222 in MHA and 5114 in FHA among the Kuwaiti population aged 20 years and above, accounting for a total crude prevalence of 7.6% in both health areas and for a prevalence rate of 5.6% in MHA and 10.0% in FHA. The age-specific prevalence of type 2 diabetes in both areas combined rose from 2.639 per 100 population in the age group 20-39 years to 15.350% and 26.252% in the age groups 40-59 and 60 and above, respectively. The female to male ratio was 1.7, 1.6, 1.1, respectively, in MHA and 1.7, 2.0, 0.9 in FHA for the age groups 20-39, 40-59, and 60 and above. This study shows that type 2 diabetes is a major public health problem in Kuwait, with a female preponderance. Obesity is a characteristic feature of the population studied, with a mean body mass index of 31.8 +/- 6.3 and 28.5 +/- 5.1 in women and men, respectively. A positive family history of diabetes mellitus was reported in 63% of the diabetic subjects. There is a need to standardize methods of reporting and to plan a national screening survey.

The need and demand for renal replacement therapy in ethnic minorities in England

STUDY OBJECTIVE

The study aimed to determine the relative risk of being accepted for renal replacement treatment of black and Asian populations compared with whites in relation to age, sex, and underlying cause. The implications for population need for renal replacement therapy in these populations and for the development of renal services were also considered.

DESIGN/SETTING

This was a cross sectional retrospective survey of all patients accepted for renal replacement treatment in renal units in England in 1991 and 1992.

PATIENTS

These comprised all 5901 patients resident in England with end-stage renal failure who had been accepted for renal replacement therapy in renal units in England and whose ethnic category was available from the units. Patients were categorised as white, Asian, black, or other. Population denominators for the ethnic populations were taken from the 1991 census. The census categories Indian, Pakistani, and Bangladeshi were aggregated to form the denominator for Asian patients, and black Caribbeans, black Africans, and black others were aggregated to form the denominator for black patients.

MAIN RESULT

Altogether 7.7% of patients accepted were Asian and 4.7% were black; crude relative acceptance rates compared with whites were 3.5 and 3.2 respectively. Age sex specific relative acceptance ratios increased with age in both ethnic populations and were greater in females. Age standardised acceptance ratios were increased 4.2 and 3.7 times in Asian and black people respectively. The most common underlaying cause in both these populations was diabetes; relative rates of acceptance for diabetic end-stage renal failure were 5.8 and 6.5 respectively. The European Dialysis and Transplant Association coding system was inaccurate for disaggregating non-insulin and insulin dependent forms. "Unknown causes" were an important category in Asians with a relative acceptance of rate 5.7. The relative rates were reduced only slightly when the comparison was confined to the district health authorities with large ethnic minority populations, suggesting that geographical access was not a major factor in the high rates for ethnic minorities.

CONCLUSION

Acceptance rates for renal replacement treatment are increased significantly in Asian and black populations. Although data inaccuracies and access factors may contribute to these findings, the main reason is probably the higher incidence of end-stage renal failure. This in turn is due to the greater prevalence of underlying diseases such as non-insulin dependent diabetes but possibly also increased susceptibility of developing nethropathy. The main implication is that these populations age demand for renal replacement treatment will increase. This will have an impact nationally but will be particularly apparent in areas with large ethnic minority populations. Future planning must take these factors into account and should include strategies for preventing chronic renal failure, especially that due to non-insulin dependent diabetes and hypertension. The data could not determine the extent to which population need was being met; further studies are required to estimate the incidence of end-stage renal failure in ethnic minority populations.

Vascular complications in long-term south Indian NIDDM of over 25 years' duration

The prevalence of vascular complications was assessed in 726 South Indian non-insulin dependent diabetes mellitus (NIDDM) patients with over 25 years' duration of diabetes. Retinopathy was detected in 52.0% of patients which included 41.7% with non-proliferative and 10.3% with proliferative diabetic retinopathy. Nephropathy was present in 12.7% and neuropathy in 69.8% of patients. While 32.8% of patients had ischaemic heart disease, the prevalence of peripheral vascular disease was only 15.4%. Multivariate logistic regression analyses showed that serum creatinine was associated with retinopathy, creatinine and post-prandial plasma glucose with nephropathy and post-prandial plasma glucose and age with neuropathy. This is one of the first reports on vascular complications in long-term diabetes from the Indian sub-continent.

Ethnic influence on health and dependency of elderly inner city residents

The objectives of the study were to assess and compare the social characteristics, prevalence of disease, health needs, dependency and use of health services by elderly people in the different ethnic groups living in an inner city. A prevalence study was conducted using a questionnaire administered to people aged 65 years and over living at home, selected from the registers of inner city general practices in West Birmingham. Contact was made with 736 individuals from the original sample of 1,450 names, and completed questionnaires were obtained from 669 individuals (297 men, 372 women). Respondents were divided by place of birth into four groups: UK, Asia, West Indies, and 'Other'. Outcome measures were demographic data, language, household composition, prevalence of disease and health problems, help with activities of daily living, and contact with and knowledge of community health services. We found that those born in the UK were likely to be older, female, unmarried and living alone. In the Asian group, only 15% spoke English and 59% lived in a household with more than three other people compared with 4% in both the UK and West Indian groups. Hypertension was more common in West Indians, arthritis in Asians and diabetes mellitus more common in both groups than in the UK group. Asians were more likely to complain of poor vision. The level of dependency was similar in all groups despite age differences. Contact with community health services was low among Asians who also had a low awareness of the availability of these services. The conclusions from the study were that the average age of elderly individuals in ethnic minority groups is less than that of the indigenous population, making direct comparison difficult. Nevertheless, they have a higher prevalence of age-related disease and a similar level of dependency. They are less well served by, and have little knowledge of the existence of, community health services. For older Asians, difficulty in communicating with English-speaking health personnel is a major barrier to effective health care. Access to health care by older people from ethnic minorities needs to be improved, and services developed in a more culturally sensitive manner.

Skeletal muscle membrane lipid composition is related to adiposity and insulin action

The cellular basis of insulin resistance is still unknown; however, relationships have been demonstrated between insulin action in muscle and the fatty acid profile of the major membrane structural lipid (phospholipid). The present study aimed to further investigate the hypothesis that insulin action and adiposity are associated with changes in the structural lipid composition of the cell. In 52 adult male Pima Indians, insulin action (euglycemic clamp), percentage body fat (pFAT; underwater weighing), and muscle phospholipid fatty acid composition (percutaneous biopsy of vastus lateralis) were determined. Insulin action (high-dose clamp; MZ) correlated with composite measures of membrane unsaturation (% C20-22 polyunsaturated fatty acids [r= 0.463, P < 0.001], unsaturation index [r= -0.369, P < 0.01]), a number of individual fatty acids and with delta5 desaturase activity (r= 0.451, P < 0.001). pFAT (range 14-53%) correlated with a number of individual fatty acids and delta5 desaturase activity (r= -0.610, P < 0.0001). Indices of elongase activity (r= -0.467, P < 0.001), and delta9 desaturase activity (r= 0.332, P < 0.05) were also related to pFAT but not insulin action. The results demonstrate that delta5 desaturase activity is independently related to both insulin resistance and obesity. While determining the mechanisms underlying this relationship is important for future investigations, strategies aimed at restoring "normal" enzyme activities, and membrane unsaturation, may have therapeutic importance in the "syndromes of insulin resistance."

Pakistan national diabetes survey: prevalence of glucose intolerance and associated factors in Shikarpur, Sindh Province

The prevalence of diabetes mellitus and impaired glucose tolerance (IGT) and their relationship to age and obesity was estimated in the rural town of Shikarpur in Sindh Province, Pakistan by a population-based survey in 1994. Oral glucose tolerance tests were performed in a stratified random sample of 967 adults (387 men, 580 women) aged 25 years and above. The diagnoses of diabetes and IGT were made on the basis of WHO criteria. The response rate was 71% for men and 80% for women. The prevalence of diabetes was 16.2% (9.0% known, 7.2% newly diagnosed) in men, and 11.7% (6.3% known, 5.3% newly diagnosed) in women. The prevalence rose with age to a peak of 30% and 21% in 65-74 year-old men and women respectively. IGT was detected in 8.2% of men and 14.3% of women. Thus, total glucose intolerance (diabetes and IGT combined) was present in 25% of subjects examined. These results indicate that glucose intolerance in South Asians can no longer be regarded as a problem confined to migrant communities. Of the 72 subjects previously known to have diabetes, none was using insulin treatment, but 57 (79%) took oral hypoglycaemic agents. Central obesity and positive family history were strongly associated with diabetes, as was prevalence of hypertension. The association with central obesity was greater for women than for men, and suggests important, modifiable risk factor(s) related to lifestyle.

Glucose intolerance and impairment of insulin secretion in relation to vitamin D deficiency in east London Asians

Vitamin D deficiency reduces insulin secretion and still occurs in East London Asians in whom the prevalence of diabetes mellitus is at least four times that of Caucasians. Vitamin D status was assessed in 44 of 65 non-diabetic subjects 'at risk' of diabetes (spot blood glucose level >6.0 mmol/l <2 h post cibum, or>4.6 mmol/l >2 h post cibum on two separate occasions) and in 15 of 60 age and sex-matched 'low-risk' control subjects who attended for oral glucose tolerance test (OGTT) after screening of 877 omnivorous subjects not known to have diabetes. It was found that 95% of at-risk and 80% of low-risk subjects were vitamin D deficient (serum 25-hydroxy-vitamin D <11 ng/ml). Diabetes was present in 16, impaired glucose tolerance in 12 and normoglycaemia in 19 at-risk subjects, imparied glucose tolerance in 2, and normoglycaemia in 13 low-risk subjects. Correlation of 30-min OGTT blood glucose, specific insulin and C-peptide levels with 25-hydroxy-vitamin D concentrations in 44 at-risk subjects were -0.31 (p=0.04), 0.59 (p=0.0001) and 0.44 (p=0.006). In 15 'not-at-risk' subjects 30-min OGTT specific insulin and C-peptide levels correlated with 25-hydroxy-vitamin D, r=0.39 (p=0.04) and 0.16 (p=0.43), respectively. Serum alkaline phosphatase concentration was higher in at-risk than not-at-risk subjects (59.6 vs 46.5 IU/l, p=0.012); corrected calcium concentrations were comparable (2.38 vs 2.39 mmol/l, p=0.7). Following treatment with 100,000 IU vitamin D by i.m. injection, specific insulin, C-peptide [30 min on OGTT] and 25-hydroxy-vitamin D concentrations had risen 8-12 weeks later [mean +/- DS] from 57 +/- 62 to 96.2 +/- 82.4 mU/l [p=0.0017], 1.0 +/- 0.4 to 1.7 +/- 0.8 pmol/ml [p=0.001] and 3.6 +/- 1.8 to 13.5 +/- 7.4 ng/ml [p=0.0001], (but not to low-risk group values of 179 +/- mU/l, 2.7 +/- 1.14 pmol/ml and 8.16 +/- 6.4 ng/ml), respectively. Both total serum alkaline phosphatase and corrected calcium concentrations rose following vitamin D treatment in the at-risk subjects by 11.1 +/- 8.22 (from 44 to 55 IU/l) and 0.15 +/- 0.18, (2.43 to 2.57 mmol/l), respectively (p=0.004). Abnormal glucose tolerance was unchanged by vitamin D treatment. The value of early and sustained repletion with vitamin D in diabetes prophylaxis should be examined in communities where vitamin D depletion is common.

Pattern of non-insulin dependent diabetes mellitus in Kuwait

The aim of this study was to examine distinctive clinical characteristics of non-insulin dependent diabetes mellitus (NIDDM) patients in Kuwait including mode of presentation at diagnosis, family history of diabetes, therapeutic management and response to treatment. We studied 3299 Kuwaiti patients (1454 male (M) and 1845 female (F) subjects) registered in Salmiya diabetic clinic, a part of the national network of diabetes control and care programme, and located in the urban Hawally Governorate, Kuwait. The mean age of the patients was 53 years (+/- 13.9 years), and 73.8% were in the age group 45-64 years. The majority of patients (53.6%) were diagnosed as they were clinically symptomatic; in contrast a significant minority (37.8%) were diagnosed by chance mainly during investigation for unrelated events. The 8.6% of the women diagnosed during pregnancy had a high parity index 6.5 +/- 2.9. A high percentage of the diabetic patients (63%) reported a positive family history in first degree relatives. The mean duration of diabetes mellitus was 7.8 years (range 2-28 years) and 70% of the patients had diabetes mellitus for 9 years or less. The mean body mass index (BMI) was 31.8 +/- 6.3 kg/m2 and 28.5 +/- 6.3 kg/m2 in women and men, respectively. Among the diabetic women 57.7% were obese (BM > 30 kg/m2) and 30.2% were overweight (BMI 25-30 kg/m2) as compared to 33.6% and 44.3% among diabetic men, respectively. High blood pressure (> or = 160/95 mmHg) was reported in 14.9%. The main therapeutic modality in the majority of patients, (63.2%), was the administration of oral hypoglycaemic agents (OHA), while 23.7% were on a diet regimen and only 13.1% were on insulin therapy. The study throws light on the pattern of NIDDM among Kuwaiti patients. Frequent association with obesity suggests that it may be a major risk factor. The strong familial aggregation reported paves the way for future research among these families for cosegregation of a defined genetic trait with NIDDM in the Arab population subset.

Variation of diabetes mellitus prevalence in general practice and its relation to deprivation

This is an observational study to compare age standardized diabetes prevalences and relate these to socio-economic measures of deprivation. It includes data from eight general (family) practices in the Bristol, UK, area with no ethnic minorities affecting diabetes prevalence. A total population of 71 599 was covered, including 181 Type 1 and 901 Type 2 diabetic patients, 91 of whom were controlled with insulin, 499 with oral hypoglycaemics, and 311 with diet alone. Actual Type 1 and Type 2 diabetes prevalences were standardized to what they would be if each practice had the UK national age profile. Total standardized diabetes prevalence varied from 1.31% to 2.51% (p < 0.001) and Type 2 diabetes prevalence from 0.97% to 2.29% (p < 0.001). There was no significant variation in the prevalence of Type 1 diabetes. The Spearman rank correlation coefficient indicated a significant association between standardized diabetes prevalence and two measures, the Jarman and Townsend indices, of deprivation in the electoral ward where each practice was situated. Total standardized diabetes prevalence was significantly correlated with each of the Jarman and Townsend indices (r = 0.76, p < 0.05). Standardized Type 2 diabetes prevalence was similarly significantly correlated to each deprivation index (rs = 0.74, p < 0.05). Type 2 diabetes prevalence is affected by socio-economic factors with implications for health targets and capitation based budgets.

Diabetes care in South Asian and white European patients with type 2 diabetes

Aspects of diabetes care in South Asian and white European patients with Type 2 diabetes attending a hospital review clinic were explored. Among the clinic population of 1710 patients, 258 (15%) were of South Asian origin. A significantly greater proportion (95% CI for difference in proportions 8-22%) of these patients was treated with oral hypoglycaemic drugs than in white Europeans, in whom there was a correspondingly greater proportion receiving insulin treatment. In a case-control study, where 154 patients in each racial group were stratified according to treatment regimen, significantly more South Asian patients (13/30 vs 6/30, p < 0.05) on insulin were treated with a once-daily regimen. Despite these observed differences in treatment of diabetes, glycaemic control was no worse in South Asian patients when compared to their white European counterparts. South Asian diabetic patients attending hospital diabetes clinics in the UK can experience similar levels of glycaemic control to white Europeans.

Diabetes in pregnancy

OBJECTIVE

To determine whether there is an association between the level of glycemic control and perinatal complications in pregnant diabetic patients.

METHODS

Two hundred sixty confirmed cases of pre-existing diabetes, gestational diabetes and impaired glucose tolerance were analyzed to assess risk factors, modality of treatment, level of blood sugar control and effect on perinatal morbidity and mortality.

RESULTS

Risk factors for the development of diabetes included age ( > 25 years), East Indian ethnic origin, glycosuria, and a history of diabetes in a first-degree relative. Treatment consisted of diet alone or in combination with soluble insulin. There is a marked increase in perinatal mortality and maternal morbidity if normoglycemia is not maintained.

CONCLUSIONS

A greater emphasis must be placed on the detection of diabetes in pregnancy and effective treatment should be instituted as early as possible to achieve normoglycemia if associated complications are to be reduced.

The frequency of known diabetes, hypertension and ischaemic heart disease in affluent and poor urban populations of Karachi, Pakistan

The high frequency of diabetes mellitus and coronary artery disease among people of South Asian extraction living in the West is well established. The prevalence of these disorders in Southern Asia is less certain. No previous attempt has been made to estimate their occurrence in Pakistan. In order to compare the prevalence of known diabetes mellitus, hypertension and ischaemic heart disease between affluent and poor urban communities in Pakistan, a survey of consecutive households was undertaken in a relatively prosperous and a poor area in Karachi. Information was obtained on 4232 adults evenly distributed between the two areas. Body weight and height were measured in 199 healthy subjects at the two sites. The prevalence of known diabetes in the affluent population was 4.5%, significantly higher than 1.8% in the poor area (p < 0.001). A maximal prevalence of 25% was seen in the affluent community aged 55-64. Diabetes was more common in females in both populations. The overall prevalence of hypertension was similar in the two areas although significantly more frequent in the middle aged and affluent. A history of ischaemic heart disease occurred in 1.9% of the affluent and 0.6% of the poor (p = 0.003). Healthy subjects were heavier and more obese in the richer community. Thus the susceptibility of South Asian populations to diabetes and ischaemic heart disease is also apparent in an affluent segment of Pakistani society. The phenomenon is not attributable simply to urbanization. Obesity is probably an important contributory factor. The economic implications for developing South Asian countries are serious.

Excess maternal history of diabetes in Caucasian and Afro-origin non-insulin-dependent diabetic patients suggests dominant maternal factors in disease transmission

We examined the records of 2576 patients with non-insulin-dependent diabetes mellitus (NIDDM) and categorised them according to race and family history of diabetes. Family history of diabetes is known to play an important role in the development of NIDDM, and a maternal history is thought to be most influential. We found that a maternal history of diabetes was present in 60% of Caucasian and West Indian patients with a parental history of diabetes, whereas in Asian patients the figure was only 34%. Asian men were also more likely to have a father with diabetes. This anomaly may be due to cultural differences in the reporting of the disease. Our data support the dominant maternal role in the development of NIDDM in their offspring and suggest an under-reporting of NIDDM in Asian females.

The Verona diabetes study: a population-based survey on known diabetes mellitus prevalence and 5-year all-cause mortality

This population-based survey aimed to determine the prevalence of known diabetes mellitus on 31 December 1986, and to assess all-cause mortality in the subsequent 5 years (1987-1991) in Verona, Italy. In the study of prevalence, 5996 patients were identified by three independent sources: family physicians, diabetes clinics, and drug prescriptions for diabetes. Mortality was assessed by matching all death certificates of Verona in 1987-1991 with the diabetic cohort. Overall diabetes prevalence was 2.61% (95% confidence interval 2.56-2.67). Prevalence of insulin-dependent and non-insulin-dependent diabetes mellitus was 0.069% (0.059-0.078) and 2.49% (2.43-2.54), respectively. Diabetes prevalence sharply increased after age 35 years up to age 75-79, and finally declined. Prevalence was higher in men up to age 69 years, in women after age 75 years. Of the diabetic cohort 1260 patients (592 men, 668 women) died by 31 December 1991, yielding an overall standardized mortality ratio of 1.46 (CI 1.38-1.54). Even though the differences narrowed with age, mortality rates in the diabetic cohort were higher than in the non-diabetic population at all ages. Women aged 65-74 years showed observed/expected ratio higher than men (2.27, CI 1.92-2.66, vs 1.50, CI 1.30-1.72), while in other age groups the sex-related differences were not significant. Pharmacological treatment of diabetes was associated with an excess mortality, while treatment with diet alone showed an apparent protective effect on mortality (observed/expected ratio 0.73, CI 0.58-0.92).(ABSTRACT TRUNCATED AT 250 WORDS)

DIAMOND: a computerized system for the management and evaluation of district-wide diabetes care

A computerized diabetic clinic management system, DIAMOND, has been developed with the collaboration of local general practitioners (GPs) to assist communication about diabetic patients across the district. DIAMOND is written in a Windows format using Microsoft Access and its dataset is in line with BDA and Diabcare recommendations. DIAMOND is user-friendly and includes displays and help messages throughout and does not require advanced computer knowledge. The main index contains two primary tables: a patient registration table with demographic data and an episode table with clinically important physical and biochemical measures. All entered data are coded to facilitate audit and an audit function, which automatically presents data, either numerically or graphically, is included in the report facility. DIAMOND also incorporates a system for patient education and training (PEATS) which may be operated by a health professional or the patient. Over 4500 patients in Newham are presently registered on DIAMOND with in excess of 15,000 episodes. Evaluation of this information is providing important clinical information both within individual GP practices and district-wide to assist future plans for health care provision.

Insulin resistance with respect to lipolysis in non-diabetic relatives of European patients with type 2 diabetes

Type 2 diabetes is characterized by resistance to insulin action of glucose metabolism and lipolysis. First-degree relatives of diabetic patients are at increased risk of developing diabetes themselves and early metabolic abnormalities in these relatives may represent primary defects in the pathogenesis of diabetes. Our previous work has demonstrated impaired suppression of lipolysis after an oral glucose load in glucose-tolerant relatives of Asian origin, but not in European relatives. To investigate whether a more subtle defect exists in the European population we studied 8 first-degree relatives of European patients and 9 matched control subjects. All had normal glucose tolerance. Glycerol and glucose turnovers were measured using a primed constant infusion of the stable isotopic tracers [1,1,1,2,3(2)H5] glycerol and [6,6(2)H] glucose, basally and in response to a very low dose insulin infusion (0.005 units kg-1 h-1). The relatives had higher basal insulin concentrations (median (range): 49 (30 to 113) vs 28 (18 to 66) pmol 1(-1), p < 0.05) compared to controls, but basal glycerol and glucose turnovers and plasma concentrations of glycerol, glucose, and non-esterifed fatty acids (NEFA) were similar. Following insulin, the suppression of glycerol appearance in the circulation measured isotopically was significantly less complete in the relatives compared with controls (mean change +/- SEM: + 0.06 +/- 0.21 vs - 0.51 +/- 0.16 mumol kg-1 min-1, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Hospital admissions and social deprivation of patients with diabetes mellitus

This study examined the relationship between hospital admissions for patients with diabetes mellitus and residence in an area of social deprivation. Admissions of patients with diabetes mellitus were identified during a 5-year period between 1987 and 1992 using the district patient information service. All persons admitted were assigned to an electoral ward on the basis of their postcode. Age standardized admission rates were compared to the Townsend Deprivation Score for each electoral ward. A positive correlation was found between age standardized admission rate and Townsend Score (r = 0.76, p < 0.001). We believe this has significance for planning health care resources.

Population need for renal replacement therapy in Thames regions: ethnic dimension

OBJECTIVES

To determine the use of renal replacement therapy by ethnic origin and to ascertain the variation in provision of such therapy and to relate this to the distribution of ethnic minority populations.

DESIGN

Analysis of retrospective and cross sectional data from 19 renal units.

SETTING

All four Thames regional health authorities.

SUBJECTS

Patients resident in the Thames regions who were accepted as new patients for renal replacement therapy during 1991 and 1992 and the patients who were already undergoing such treatment between December 1992 and April 1993.

MAIN OUTCOME MEASURES

Rates of acceptance for and prevalence of renal replacement therapy among white, black, and Asian people.

RESULTS

The average annual acceptance rates per million in 1991-2 were 61 for white people, 175 for black people, and 178 for Asians, and the prevalences per million were 351, 918, and 957 respectively. The relative risks increased with age. A threefold increase in the acceptance rate occurred in people aged under 55 in both the black and Asian populations, suggesting that the higher rates are probably not due to factors related to access alone. Treatment rates varied considerably among districts, reflecting both the distribution of ethnic minority populations and access to services.

CONCLUSION

Black and Asian people receive and have a greater need for renal replacement therapy, and the need will increase as these populations age. These findings have important implications for the provision of renal services in districts with a high proportion of ethnic minorities and for the management of diabetes mellitus and hypertension, two important causes of end stage renal failure in these populations.

Prevalence of coronary heart disease and cardiovascular risk factors in middle aged males in a defined population in central Sri Lanka

In a cross-sectional survey, we estimated the prevalence of coronary heart disease in a sample of 975 middle-aged males (35-59 years), from a defined population in the Central province of Sri Lanka using the London School of Hygiene cardiovascular questionnaire and a 12-lead electrocardiogram. The estimated prevalence rates were: (a) Definitive evidence of ischemic heart disease (positive symptoms and ECG changes of ischemia), 16/1000 (95% C.L., 9-27). (b) Evidence of coronary heart disease based on history alone 54/1000 (95% C.L., 40-71). (c) Estimate based on ECG changes of ischemia without symptoms 32/1000 (95% C.L., 21-46). Median values for major risk factors were: systolic blood pressure 120 mmHg, diastolic blood pressure 88 mmHg, serum cholesterol 4.99 mmol/l, high density lipoproteins 0.99 mmol/l and body-mass index 20.4 kg/m2. About half (57.9%) the subjects were current smokers, 17% had actual hypertension (systolic blood pressure > 159 mmHg and/or diastolic blood pressure > 94 mmHg and/or been treated for hypertension), 12.6% had hypercholesterolemia (serum cholesterol levels > 6.5 mmol/l), 18.4% had a body-mass index > 24 kg/m2 and 5.8% were diabetic. Hypercholesterolemia (> 6.5 mmol/l), a higher body-mass index (> 24 kg/m2) and diabetes were more prevalent among subjects living in an urban rather than a rural environment.

Sex and ethnic group differences in fat distribution in young United Kingdom South Asians and Europids

South Asians (Asians) have a high prevalence of non-insulin-dependent diabetes (NIDDM) and a high incidence of ischaemic heart disease (IHD). To investigate whether this predisposition can be detected in young adult life, metabolic risk factors for these diseases were compared in U.K. Europid and Asian students. Among the 80 Europid and 80 Asian students aged between 20 and 23 years and well matched for body mass index (BMI), Asians were found to be relatively hyperglycaemic [5.1 (5.0-5.2) vs 4.6 (95% CI: 4.5-4.7) mmol/l] and hypercholesterolaemic [5.3(5.2-5.4) vs 4.9 (4.8-5.0) mmol/l] and to have a higher waist/hip and subscapular/triceps ratio. The waist/hip ratio was found to be a better predictor of glucose and cholesterol than calliper measurements in both ethnic groups although the subscapular/triceps ratio was independently related to both glucose and cholesterol. Predictors of both IHD and NIDDM are present at an early age in U.K. Asians.

Childhood-onset diabetes in the white and South Asian population in Leicestershire, UK

The prevalence of childhood-onset Type 1 diabetes mellitus is important for determining health care provisions. In Leicestershire 13.5% of the childhood population (0-14 years) is of South Asian origin (census 1991). This study determined the prevalence of Type 1 diabetes in Whites and South Asians in Leicestershire, using a capture/recapture method to coincide with the 1991 Census day. Children (0-14 years) with Type 1 diabetes were captured from the central diabetic register. The health visitor and consultant records were used to recapture the cases. Total ascertainment of cases was 95-100%. The prevalence of Type 1 diabetes in White children (107 cases) was 0.75/1000 children (95% CI 0.61-0.89) compared with the South Asian prevalence (18 cases) of 0.77/1000 (95% CI 0.41-1.13). The overall prevalence in White males was 0.82/1000 (0.61-1.03) compared with 0.68/1000 (0.48-0.87) in females. In South Asian males it was 0.59/1000 (0.15-1.03) compared with 0.96/1000 (0.39-1.53) in females. The prevalence of Type 1 diabetes in children of South Asian migrants to the United Kingdom cannot be said to be different from White children.

Reduced postprandial energy expenditure in women predisposed to type 2 diabetes

Type 2 (non-insulin dependent) diabetes is so common that it has been hypothesized that in the course of evolution the predisposition to it may have conferred some advantage, before or during the reproductive years. It is frequently preceded by gestational diabetes. In order to test the basis for the hypothetical advantage, energy expenditure was investigated in 10 women with documented transient diabetes in a previous pregnancy. They were studied early in a subsequent pregnancy while glucose tolerance wa still normal and 9 were re-studied after pregnancy. Their results were compared with normal matched controls. During pregnancy, resting energy expenditure was similar in the study group and controls (6.58 (5.77-7.55) median (range) vs 6.91 (6.56-7.36) MJ day-1, respectively). However, the energy response to a mixed meal (42 kJ, kg-1 lean body mass) was decreased in the study group (45 (33-68) vs 76 (50-89) kJ, p < 0.05). After pregnancy resting energy expenditure was again similar in the two groups, but the decrease in postprandial thermogenesis persisted (78 (59-84) vs 92 (79-105) kJ, p < 0.05). The patients were resistant to exogenous insulin, 0.05 U kg-1 intravenously (slope of the plasma glucose decline in the 15 min after insulin; during pregnancy patients 52 (37-92) vs controls 111 (104-121) mumol l-1 min-1, p < 0.01; after pregnancy 130 (88-156) vs controls 186 (152-221) mumol l-1 min-1, p < 0.01). The postprandial energy saving in these women could constitute an evolutionary advantage. Insulin resistance may be the mechanism for limiting postprandial thermogenesis.

The Problem of Integration: Asian People and Diabetes

There is a high prevalence of non-insulin dependent diabetes (NIDD) in some Asian populations in the UK. The study by Mckeigue showed that the prevalence was high amongst the Bangladeshi population. Most doctors were aware of this and concerned that they did not know sufficient about the everyday lives and eating patterns of their patients to advise them about how to adjust their lifestyle to control their diabetes. As non-insulin dependent diabetes is managed by controlling eating, and by tablets which stimulate the production or use of the naturally produced insulin, it is important that the medically prescribed treatment is integrated into the lifestyle because the day to day treatment is in the hands of the patients themselves. The patient has to control his or her eating; decide what to eat, how much to eat, and what not to eat. All diabetic people have to make these decisions in the context of their everyday lives surrounded by other people who are enjoying eating without such restraints. The evidence from this study suggests that the problem is particularly difficult for diabetic. Bangladeshi people. The reason for this appears to be that food plays a very important part in Bangladeshi culture which has many rules restricting what can be eaten and also placing importance on eating certain foods. The problem for them, is to integrate this traditional and religious rule governed system of eating with the system of modern medicine. The aim of this study was to understand and describe the ways in which diabetic Bangladeshi people are attempting this integration.

Emerging standards for diabetes care from a city-wide primary care audit

Aggregated data from Manchester practices participating in the Diabetes 2000 project were used to develop peer group standards of mean performance and of excellence. The crude prevalence of known diabetes mellitus was 1.21% of which 20.2% had Type 1 diabetes. The aggregated mean of patients who had the following examinations performed in the preceding year were: glycated haemoglobin 56.8%; weight or body mass index 67.8%; foot pulses 37.3%; ankle reflexes 31.3%; proteinuria 60%; fundoscopy 48.2%; blood pressure 81.1%; serum cholesterol or lipids 34%. The percentage of patients referred to or seen by health care professionals in the preceding year were 14.4% to diabetes specialist nurses; 22.1% to opticians or ophthalmologists; 25% to chiropodists; and 21.5% to dietitians. The best performing practices examined 79% of patients fundi in the preceding year, 84% of their foot pulses, 74% of their ankle reflexes, and gave appropriate smoking advice in 65% of cases. These standards were fed back to the participating practices so that they could compare their own performance with that of the city-wide mean, and with the best performing practices. From these data practices have then been able to set themselves realistic targets for improved performance in the following year.

Impaired glucose tolerance and diabetes mellitus in a rural population in south India

In the present study the prevalence of impaired glucose tolerance and non-insulin dependent diabetes mellitus in a rural population in South India was assessed and its associations with body mass index and a family history of diabetes mellitus. Data were obtained from inhabitants of two villages located in the North Arcot District of Tamil Nadu. After an overnight fast, 467 randomly selected subjects, aged 40 years or over, were given 75 g glucose orally. After two hours the capillary glucose level was determined. The prevalence of impaired glucose tolerance (2 h value > or = 7.8 mmol/l and < 11.1 mmol/l) was 6.6% (31 subjects). Non-insulin dependent diabetes mellitus (2 h value > or = 11.1 mmol/l) was found in 23 subjects (4.9%). Of these, 53% were previously unknown. Age and sex adjusted mean body mass index was significantly higher among subjects with impaired glucose tolerance compared to subjects without glucose intolerance, with a mean difference of 1.4 kg/m2 (95% confidence interval (CI) 0.2, 2.6). A positive family history of diabetes was non-significantly higher in subjects with impaired glucose tolerance. Subjects with non-insulin-dependent diabetes mellitus had a higher mean body mass index compared to subjects with normal glucose levels with a mean difference of 1.9 kg/m2 (95% CI 0.5, 3.3). A positive family history of diabetes was more common among diabetics with a difference of 20% (95% CI 10, 30). Our findings suggest that in a considerable proportion (11.5%) of the rural South Indian population aged 40 years or over glucose intolerance is present.(ABSTRACT TRUNCATED AT 250 WORDS)

Geographical mapping of diabetic patients from the deprived inner city shows less insulin therapy and more hyperglycaemia

To determine whether or not economic and social deprivation were associated with different diabetic treatment and metabolic control, data of patients from deprived inner city wards and prosperous wards were compared. A database was obtained for 1528 patients attending our hospital Diabetes Care Centre. Demographic data and postcodes were used to construct geographical maps of disease and deprivation. Blood glucose and glycated haemoglobin were measured. Inner city patients were less likely to be taking insulin, but if they were, they were more likely to have higher blood glucose values (p = 0.02) and higher glycated haemoglobin values (p = 0.02), compared to patients from prosperous wards. Insulin-treated patients from socially and economically deprived wards had worse diabetic control than patients from more prosperous wards. The study emphasizes the needs to target deprived patients for education and motivation to understand diabetes, and to optimize metabolic control.

The prevalence of eye disease in Leicester: a comparison of adults of Asian and European descent

Random samples of people aged 40 years and over were drawn from lists of patients registered with two neighbouring inner-city general practices: one predominantly with Asian patients and the other predominantly with European patients. The people selected were invited to attend specially arranged eye clinics for examination by an ophthalmologist and an optician. We examined 377 people and found that, compared to people of European descent, Asians had a significantly higher prevalence of age-related cataract: 30% compared to 3% in people aged under 60 years and 78% compared to 54% in those aged 60 years and over. The age of onset of cataract seems to be earlier in Asians. After adjustment for age, there were no statistically significant ethnic differences in the prevalences of open-angle glaucoma, macular degeneration or diabetic retinopathy.

Myocardial infarction and thrombolysis: a comparison of the Indian and European populations on a coronary care unit

We reviewed the ward admission notes of 211 Indian and 192 European patients admitted over a period of 12 months to a coronary care unit. More Indian patients had myocardial infarctions (34% vs 27%, p < 0.05); they were more likely to have diabetes mellitus (47% vs 14%, p < 0.001), but less likely to smoke (19% vs 67%, p < 0.001). Fewer Indian patients were treated with thrombolysis (49% vs 80%, p < 0.001), late presentation being the principal reason (62% vs 40%, p < 0.05). The referral rates for exercise stress testing and cardiac catheterisation were not significantly lower for Indian patients. The Indian patient admitted into a coronary care unit is more likely to have had a myocardial infarction and yet less likely to receive care comparable to that of his European counterpart.

Betel nut (Areca catechu) consumption and the induction of glucose intolerance in adult CD1 mice and in their F1 and F2 offspring

Many mutagenic nitroso compounds are also diabetogenic. Betel-nut (Areca catechu) chewing populations have an increased incidence of foregut cancers related to betel-nut nitrosamines which suggests that betel consumption could be diabetogenic. Young adult CD1 mice with a low spontaneous incidence of diabetes were fed betel nut in standard feed for 2-6 days. Single point (90 min) intra-peritoneal glucose tolerance tests were used to follow glucose tolerance up to 6 months of age. Glucose intolerance was defined as over 3 SD above mean control values. Glucose intolerance was found in 3 of 51 male and 4 of 33 female adult mice which were fed the betel diet (p < 0.01). Studies on the progeny of these mice are presented separately for animals studied in Aberdeen (Group 1) and London (Group 2). In matings of Group 1 betel-fed parents glucose intolerance was found in 4 of 25 male and 1 of 22 female F1 offspring, with significant hyperglycaemia in F1 males born to hyperglycaemic but not to normoglycaemic mothers (p < 0.01). In the F2 generation 4 of 23 males and 1 of 16 females and in the F3 generation 1 of 16 males and 0 of 20 females were glucose intolerant. In the Group 2 studies where betel-fed parents were mated to normal controls glucose intolerance was found in 10 of 35 male and 10 of 33 female F1 progeny (p < 0.005), and mean islet areas were increased in offspring of betel-fed parents (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Insulin sensitivity in non-diabetic relatives of patients with non-insulin-dependent diabetes from two ethnic groups

OBJECTIVE

Non-insulin-dependent diabetes is a heterogeneous disorder, the basis of which may differ in different ethnic groups. In order to investigate early metabolic abnormalities occurring during the development of the condition we assessed insulin secretion and insulin action in subjects predisposed to the later development of non-insulin-dependent diabetes from two different ethnic groups.

DESIGN

Subjects were studied on two separate occasions by an oral glucose tolerance test and a short insulin tolerance test.

PATIENTS

Twenty-four glucose-tolerant first-degree relatives of patients with non-insulin-dependent diabetes (12 of European and 12 of Asian origin) were compared with 24 ethnically matched control subjects with no family history of diabetes.

MEASUREMENTS

Insulin, proinsulin, glucose and intermediary metabolites were measured during a 75-g oral glucose tolerance test. Insulin sensitivity was assessed using a 15-minute insulin tolerance test (0.05 units/kg).

RESULTS

Asian relatives compared to Asian controls had significantly higher fasting levels of immunoreactive insulin (83 +/- 17 vs 40 +/- 6 pmol/l, P < 0.05), which were not due to increased proinsulin. Blood glycerol concentrations were elevated (83 +/- 9 vs 51 +/- 4 mumol/l, P < 0.005), but fasting glucose and non-esterified fatty acid (NEFA) concentrations were similar. Relatives of European origin did not differ from their European controls in any of these measurements. The glucose response to oral glucose was similar in relatives and controls, irrespective of ethnic group. The insulin responses were non-significantly greater in relatives from both ethnic groups. Proinsulin levels were not significantly different. Asian relatives had higher circulating glycerol and NEFA levels after oral glucose than Asian controls, but these differences were not observed in the European group. Insulin sensitivity was reduced in the Asian relatives compared to their controls (183 +/- 7 vs 139 +/- 12 mumol/l/min, P < 0.01) but there was no difference in insulin sensitivity between the European relatives and European controls (167 +/- 11 vs 160 +/- 11 mumol/l/min).

CONCLUSIONS

First-degree relatives of non-insulin-dependent diabetic patients of Asian, but not of European, origin are insulin insensitive in terms of both glucose metabolism and lipolysis, and have true hyperinsulinaemia. This suggests that insulin insensitivity may be an early abnormality in the development of non-insulin-dependent diabetes in the Asian population.

Gestational diabetes: a challenge for the future

It is well established that pregnancy is associated with temporary changes in maternal metabolism which include a decrease in maternal insulin sensitivity to values similar to those associated with Type 2 diabetes. Fasting glucose concentrations fall throughout pregnancy, postprandial values rise. The maintenance of glucose tolerance in pregnancy requires a two- to three-fold increase in postprandial maternal insulin secretion. Glucose intolerance develops in women unable to compensate for the metabolic changes incurred by pregnancy. Increasing maternal hyperglycaemia is associated with increasing pregnancy morbidity and an increased likelihood of subsequent diabetes in the mother. In addition, maternal hyperglycaemia has a direct effect on the development of the fetal pancreas and is associated with an increased susceptibility to future diabetes in the infant, an effect which is independent of genetic factors. Gestational diabetes mellitus (GDM) is defined as glucose intolerance first recognized in pregnancy, and by definition includes a small number of women with previously unrecognized diabetes or impaired glucose tolerance (IGT). Figures on the prevalence of GDM vary between maternity units, depending on screening methods and the ethnic distribution of the populations. However, in a comprehensive study of a multi-ethnic antenatal population in inner London, UK it was found that only 2% of pregnant women develop significant glucose intolerance. Obstetricians and physicians debate the importance of identifying this 2% of women. The lack of agreed criteria for diagnosing gestational diabetes and the questionable obstetric benefits of treating all women with mild disturbances of glucose tolerance in pregnancy has resulted in few UK centres undertaking universal screening for GDM.(ABSTRACT TRUNCATED AT 250 WORDS)

Dietary recommendations for children and adolescents with diabetes: an implementation paper. British Diabetic Association's Professional Advisory Committee

General Recommendations: 1. Children with diabetes mellitus have the same basic nutritional requirements as other children. 2. Dietary recommendations should be based on good eating habits for the whole family. Radical changes in diet involving unusual foods or eating patterns for the child with diabetes alone are not appropriate. 3. Energy requirements of children vary widely and the energy content of the diet should be based on what the child usually eats. The diet should be reviewed regularly to meet the changing needs of growth and physical exercise without obesity. 4. The insulin regimen should, as far as is possible, be chosen to fit the child's daily lifestyle and preferred eating habits. Insulin type, dose, and frequency should be reviewed with the diet as the child develops. 5. Regular distribution of meals and snacks throughout the day remains the most important way to avoid extremes of hyperglycaemia and hypoglycaemia. This distribution should be based on an exchange system, using handy measures and taking into account food and meal type, the particular insulin regimen and the child's exercise patterns and usual eating habits. Currently this exchange system is based on carbohydrate foods but in the future the energy and fat contents will need further consideration. 6. Most special 'diabetic foods' are unnecessary. Low calorie sweeteners, as used in low calorie fruit squashes and fizzy drinks, are useful. 7. Children with diabetes from specific ethnic minority groups, or on vegan diets or living in deprived circumstances require special dietary attention for their diabetes. Those with coexisting chronic disorders such as cystic fibrosis or coeliac disease, should receive dietary advice from professionals with specialist knowledge. 8. Translating the principles of diabetic dietary management into a varied diet, arranged readily by the parents and eaten by the child, is demanding. It can best be met by a skilled dietitian working in close co-operation with child, parents, diabetes specialist nurse and doctor. Infancy 9. The diet should not differ from that of infants without diabetes. Breast feeding should be encouraged or a standard infant formula-feed used. Solids may be introduced from 3-6 months, but breast milk or a modified infant formula is encouraged as part of the increasingly mixed diet to at least the end of the first year. 10. Diabetes is rare in infancy so expert advice should be sought from dietitians experienced in paediatric diabetes. Under fives: 11.(ABSTRACT TRUNCATED AT 400 WORDS)