Global burden of diabetes, 1995-2025: prevalence, numerical estimates, and projections

Pharmacological management of type 2 diabetes mellitus: rationale for rational use of insulin

Type 2 diabetes mellitus is a chronic metabolic disorder associated with high morbidity and mortality from long-term microvascular and macrovascular complications. Evidence from randomized controlled trials indicates that aggressive treatment directed at improving glycemic control reduces the incidence of diabetes-related microvascular complications. Traditionally, oral monotherapy for type 2 diabetes is initiated when diet and exercise do not control hyperglycemia, followed by the sequential, stepwise addition of oral agents as glycemic control deteriorates. Insulin is the last therapeutic option used, generally reserved for advanced stages of the disease when multiple oral combination treatment fails. Despite a better understanding of the pathophysiologic disease mechanisms in the past decade, the expanded armamentarium of targeted oral antidiabetic drugs, and the conclusive evidence of the benefits of stringent glycemic control, actual treatment outcomes in clinical practice remain suboptimal relative to established treatment goals (glycosylated hemoglobin A1c level <7%). Earlier detection and aggressive treatment are critical to address the natural progression of diabetes because multiple defects (insulin resistance, insulin insufficiency, glucotoxicity, and lipotoxicity) and vascular complications may be present at the time of diagnosis. Acknowledging the inadequacy of traditional strategies and underscoring the importance of insulin as an integral part of the therapeutic armamentarium, clinical trends are moving toward earlier use of insulin combined with 1 or more oral agents. Such strategies can address the multiple abnormalities present early in the disease course and may restore optimal control. A new treatment paradigm for patients with type 2 diabetes to achieve and maintain near-normal glycemic control is warranted.

Lessons learned from young-onset diabetes in China

The prevalence of young-onset diabetes is rapidly rising in China. Young-onset diabetes is etiologically and phenotypically heterogeneous. Thirty percent to 50% of these patients have insulin secretory failure owing to autoimmune or monogenic or other yet to be identified forms of diabetes. Others have a strong family history of diabetes and exhibit features of the metabolic syndrome. Management of these young patients poses major diagnostic and therapeutic challenges, which require a multidisciplinary and holistic approach to ensure that these subjects are identified early and managed appropriately. Understanding the molecular basis of diabetes in these subjects may also eventually lead to improvement in diagnosis, classification, and treatment.

Early and more vigorous detection of diabetes

Currently 17 million Americans have diabetes mellitus (DM); 90% of these have type 2 DM. Of these 17 million, 5.9 million remain undiagnosed. The undiagnosed patient with type 2 DM may be asymptomatic for years, while hyperglycemic injury to target organs occurs long before the development of frank diabetes. The prevalence of diabetes among adults is estimated to increase to almost double the present number by 2025. People with diabetes and at risk for diabetes are also at risk for cardiovascular disease. Several investigators have now demonstrated the benefit of controlling blood glucose levels as well as other risk factors in this population to decrease the incidence of microvascular and macrovascular disease. Prevention or delaying the onset of type 2 DM can be accomplished with a program of diet, weight loss, and exercise.

Type 2 diabetes in Asian-Indian urban children

OBJECTIVE

Due to a background of high prevalence of type 2 diabetes and the increasing rate of obesity occurring in relatively young urban children, we felt the need to look for type 2 diabetes in children.

RESEARCH DESIGN AND METHODS

A study of cases of type 2 diabetes with age at diagnosis of </=15 years seen at a diabetes speciality center in Chennai, India, is reported. A total of 18 children (5 boys and 13 girls) aged 9-15 years with insidious onset of diabetes responding to oral antidiabetic agents (ODAs) for periods from 2 months to 12 years were studied. Clinical details, anthropometry, and details of family history of diabetes were elicited. All of them were tested for the presence of anti-GAD(65) antibodies and for pancreatic beta-cell reserve by measuring serum C-peptide response (radioimmunoassay procedures).

RESULTS

All children showed a response to ODAs, had good beta-cell reserve (>/=0.6 pmol/ml on stimulation), and negligible GAD(65) antibodies indicating the presence of type 2 diabetes. The children were nonketotic; nine were obese, four had acanthosis nigricans, and one had polycystic ovary syndrome. Positive family history of diabetes was present in all cases.

CONCLUSIONS

The clinical, immunological, and biochemical profile showed that the children had type 2 diabetes. The profile of type 2 diabetes was similar to that described in children in many other countries. Although less common than type 1 diabetes, type 2 diabetes in children is a condition that needs to be recognized and looked for in Asian-Indians.

Effect of T. foenumgraecum on glycogen content of tissues and the key enzymes of carbohydrate metabolism

The Indian traditional system of medicine prescribed plant therapies for diseases including diabetes mellitus called madhumeh in Sanskrit. One such plant mentioned in Ayurveda is Trigonella foenumgraecum (FG). In the present study, FG (1g/kg PO) was assessed for its effect on glycogen levels of insulin dependent (skeletal muscle and liver), insulin independent tissues (kidneys and brain) and enzymes such as glucokinase (GK), hexokinase (HK), and phosphofructokinase (PFK). Administration of FG led to decrease in blood glucose levels by 14.4 and 46.64% on 15th and 30th day of the experiment. Liver and 2-kidney weight expressed as percentage of body weight was significantly increased in diabetics (P<0.0005) versus normal controls and this alteration in the renal weight (P<0.0005) but not liver weight was normalized by feeding of FG. Renal glycogen content increased by over 10 folds while hepatic and skeletal muscle glycogen content decreased by 75 and 68% in diabetic controls versus controls and these alteration in glycogen content was partly prevented by FG. Activity of HK, GK and PFK in diabetic controls was 35, 50 and 60% of the controls and FG partially corrected this alteration in PFK, HK and GK.

Nutrition, growth, and body size in relation to insulin resistance and type 2 diabetes

Nutritional and genetic factors interact in the etiology of type 2 diabetes. Undernutrition followed by overnutrition increases adiposity and the risk of diabetes. The thrifty hypotheses suggest that the nutritional challenges could have happened thousands of year ago (thrifty gene selection) or during one's intrauterine life (thrifty phenotype). Current strategies for the prevention of diabetes are related to avoiding overnutrition.

Effect of feeding Murraya koeingii and Brassica juncea diet on [correction] kidney functions and glucose levels in streptozotocin diabetic mice

Purpose of the study was to investigate the effects of daily oral feeding 15% of powdered leaves of Murraya koeingii (MK) (commonly called as Curry patta) and 10% powder of seeds of Brassica juncea (BJ) (commonly called as Rai) for 60 days on serum glucose concentrations and kidney functions in streptozotocin (STZ; 100mg/kg) diabetic rats. Serum glucose levels, body weight, urine volume, serum creatinine, and urinary albumin (UAE) levels were monitored on day 0, 10, 25, 40, and 70 of the experiment. After 60 days of STZ administration, urine volume per day and UAE levels were significantly higher (P<0.0005) in diabetic controls (DC) as compared to normal controls (NC). Although feeding of the MK/BJ showed a trend towards improvement in most of the parameters, results were not statistically different from the DC except in serum creatinine values in BJ-fed rats on day 70. Thus, these plants can be best utilized by promoting them as preferable food adjuvants for diabetic patients.

Are spouses of patients with type 2 diabetes at increased risk of developing diabetes?

OBJECTIVE

To determine whether spouses of patients with type 2 diabetes have an increased risk of diabetes compared with spouses of subjects with normal glucose tolerance.

RESEARCH DESIGN AND METHODS

A random sample of spouses of patients with type 2 diabetes (group 1S) attending a general practice diabetes clinic was compared with spouses of nondiabetic subjects (as determined by oral glucose tolerance test [OGTT]) (group 2S). Spouses in both groups underwent OGTT, fasting lipid profile, and blood pressure (BP) measurements.

RESULTS

A total of 245 subjects in group 1S and 234 subjects in group 2S underwent OGTT. Group 1S had a significantly higher incidence of fasting glucose, impaired glucose tolerance, or type 2 diabetes (19.1 vs. 9.4%). Group 1S also had higher fasting glucose and triglyceride levels, higher BMI, and a trend toward higher BP. Multivariate logistic regression analysis, adjusted for BMI and age, showed the risk of diabetes in the spouse of a patient with diabetes was 2.11 (95% CI 1.74-5.1), as compared with the spouse of a subject with normal glucose tolerance. Similarly, the risk of any degree of glucose intolerance in a spouse of a patient with type 2 diabetes was 2.32 (1.87-3.98), as compared with a spouse of a subject with normal glucose tolerance.

CONCLUSIONS

Spouses of patients with type 2 diabetes have a significantly increased risk of glucose intolerance and type 2 diabetes, and they should be classified as high risk for diabetes. This finding has implications for screening programs, which should include spouses of subjects with diabetes.

Dose dependent hypoglycemic effect of aqueous extract of Enicostemma littorale blume in alloxan induced diabetic rats

Previous studies in our lab had confirmed the blood glucose lowering effect of E. littorale Blume in alloxan induced diabetic rats with no change in normoglycemic control rats. Present paper deals with dose dependent (0.5, 1.0, 1.5, 2.5, 3.5 g dry plant equivalent extract/100 g body wt., p.o.) blood glucose lowering effect of aqueous extract of E. littorale Blume in alloxan induced diabetic rats. The effective dose was found to be 1.5 g dry plant equivalent extract/100 g body wt.. The above dose caused significant decrease in glycosylated haemoglobin, liver glucose-6-phosphatase activity and significant increase in serum insulin levels of the diabetic rats. No significant changes were observed in the toxicity parameters of extract treated diabetic rats as compared to diabetic control rats. The above results suggest that E. littorale is a potent antidiabetic agent without any toxic effect at this particular dose (1.5 g dry plant equivalent extract/100 g body wt.).

The prevention of type 2 diabetes--lifestyle change or pharmacotherapy? A challenge for the 21st century

Diabetes mellitus is occurring in epidemic proportions in many countries. In Australia 7.4% of people over 25 years of age have diabetes (mostly type 2) and comparable or higher prevalences have been reported in the United States and a number of Asian countries. The enormous economic and social cost of this disease makes a compelling case for prevention. Epidemiological studies have shown clearly that type 2 diabetes results from an interaction between a genetic predisposition and lifestyle factors including obesity, sedentary behaviour and both calorie excess and various dietary constituents. The natural history of type 2 diabetes includes a preceding period of impaired glucose tolerance (IGT)/impaired fasting glucose (IFG) which provides an opportunity for targeted intervention within large communities. Lifestyle intervention studies have consistently shown that quite modest changes can reduce the progression from IGT to diabetes by 50-60%. It may, however, not be possible to translate these successful findings to larger cohorts or maintain the lifestyle changes longer term. This has lead to consideration of pharmacotherapy. While small studies with sulphonylureas are inconclusive, benefits have been found for metformin, acarbose and troglitazone. Big intervention studies with ramipril, rosiglitazone, valsartan and nateglinide are underway. Pharmacological intervention raises a whole range of ethical, economic and practical issues not the least of which is the problem of long term therapy of the 'otherwise well'.

Insulin sensitisation in the treatment of Type 2 diabetes

Type 2 diabetes is reaching epidemic proportions worldwide, fueled by the increasing prevalence of obesity as many populations adopt a western lifestyle. Secondary complications affecting both the microvascular and macrovascular systems are responsible for premature mortality in Type 2 diabetes, with two thirds or more dying of cardiovascular disease. Two interacting metabolic defects, insulin resistance and beta-cell dysfunction are present in Type 2 diabetes. It is now recognised that insulin resistance is central to a cluster of metabolic abnormalities--called the insulin resistance syndrome--that are responsible for the excess of cardiovascular disease. Older antidiabetic agents such as the sulfonylureas, metformin and insulin are more effective than lifestyle modification in reducing microvascular complications of Type 2 diabetes, but overall do not reduce cardiovascular risk. Metformin, although no more effective as a glucose-lowering agent than sulfonylureas or insulin, does significantly reduce cardiovascular disease, probably as a result of its weak insulin-sensitising action. The newly-marketed thiazolidinedione insulin-sensitising antidiabetic agents also improve multiple biomarkers of cardiovascular risk, suggesting that novel approaches to insulin sensitisation will not only provide effective long-term glycaemic control but improve cardiovascular outcomes in Type 2 diabetes. Multiple therapeutic targets within the insulin signalling cascade are being explored, together with follow-up compounds to the first generation thiazolidinediones. These initiatives, together with developments in beta(3)-adrenoceptor agonists, 11 beta-hydroxysteroid dehydrogenase Type 1 inhibitors and modulators of the glucagon-like peptide 1 axis, all of which also potentially enhance insulin sensitivity, are critically evaluated.

Quality of dietary fatty acids, insulin sensitivity and type 2 diabetes

Epidemiological evidence and intervention studies clearly indicate that the quality of dietary fat influences insulin sensitivity in humans, in particular, saturated fat worsens it, while monounsaturated and omega-6 polyunsaturated fats improve it. Long chain omega-3 fatty acids do not seem to have any effect on insulin sensitivity, at least in humans. Moreover, there is also good epidemiological evidence that the quality of dietary fat may influence the risk of type 2 diabetes, again with saturated fat increasing and unsaturated fat decreasing this risk. No intervention study is available at the moment on this specific point, even if in the Finnish Diabetes Prevention Study the incidence of type 2 diabetes was reduced by a multifactorial intervention, which also included a reduction of saturated fat intake.

Culture and therapy: complementary strategies for the treatment of type-2 diabetes in an urban setting in Kerala, India

There is an epidemic rise in diabetes in the developing world, with ensuing concern about the management and control of the disease. This study investigates the use of complementary therapies to manage Type 2 diabetes in an urban population in Kerala, a state in Southern India. Using ethnographic methods, it shows that the subjects' experiences of the disease and their health management decisions are closely linked to their cultural background and the environmental resources of the region. Participants in the study relied on biomedicine for treating diabetes, but frequently used Ayurvedic medicine and folk herbal remedies as supplements. They named 24 local plants and plant products that were employed to lower blood glucose levels. Knowledge of tried and tested local or regional remedies and their incorporation into individual and community health care practices are evidence of medical knowledge as cultural capital. Greater attention needs to be paid to the broader systems of the environment and culture and their interconnections to understand the use of complementary therapies by persons with chronic illnesses such as diabetes.

Screening for Type 2 diabetes--should it be now?

AIMS

Screening for Type 2 diabetes has been recommended in several countries due to the increasing prevalence of diabetes. This review evaluates whether Type 2 diabetes is a disease that fulfils the criteria for screening set by the World Health Organization.

METHODS

Literature search was performed on the literature bases MedLine, Pub Medical, NIDDK, Cochrane Library and CINAHL using the MeSH terms 'non-insulin-dependent-diabetes-mellitus' and mass screening. Using this strategy we identified studies specifically evaluating screening strategies and diagnostic tests for Type 2 diabetes. The evaluation of psychosocial consequences included studies related to other chronic diseases. This literature was used to evaluate whether the WHO criteria for screening were fulfilled.

RESULTS

The papers were reviewed but a meta-analysis was not possible, as no randomized controlled clinical trials were performed in the area of screening.

CONCLUSION

Type 2 diabetes does not fulfil the criteria for population-based mass screening. No screening and intervention studies have been performed, systematically evaluating the positive and negative effects of screening. Furthermore, intervention studies up until now have been restricted to clinically diagnosed patients with diabetes, and most of these have recruited patients with long diabetes duration and early complications. These groups will have a worse prognosis and thus probably show greater benefits of such intervention. Finally, the psychosocial and health economic consequences of screening and intervention for Type 2 diabetes are largely unknown. Thus, systematic screening and intervention trials should be encouraged, and meanwhile intensified case finding and opportunistic screening in high-risk groups should be performed.

Inhaled insulin--a new therapeutic option in the treatment of diabetes mellitus

The beneficial effects of maintaining an optimal glucose control on chronic complications of diabetes have been firmly established in patients with both Type 1 and 2 diabetes mellitus. Effective glucose control usually requires multiple daily injections of subcutaneous insulin. Limitations of these intensive regimens include inconvenience and poor patient adherence and acceptability. As a consequence, several alternative methods for insulin delivery have been developed with the aim of eliminating the pain, inconvenience and disruption of lifestyle associated with the need for insulin injections. Recent evidence suggests that intrapulmonary insulin delivery may be an effective, non-invasive alternative to subcutaneous regular insulin. In fact, clinical trials in the last few years have shown that intrapulmonary insulin was as good as subcutaneous insulin in controlling glucose levels in patients with both Type 1 and 2 diabetes mellitus. It was well-tolerated and, so far, there is no evidence of an increased risk of hypoglycaemia or adverse bronchopulmonary effects. Although the bio-availability of inhaled insulin is lower than that of subcutaneous insulin, the former has a more physiological pharmacokinetic profile than the latter. Inhaled insulin currently represents the most viable alternative insulin delivery method to preprandial subcutaneous injection.

Sildenafil citrate for treatment of erectile dysfunction in men with type 1 diabetes: results of a randomized controlled trial

OBJECTIVE

In the 5-10% of diabetic men with type 1 diabetes, erectile dysfunction (ED) may be a particularly common and unwanted complication. This is the first study focusing exclusively on the effects of sildenafil in men with type 1 diabetes and ED.

RESEARCH DESIGN AND METHODS

A total of 188 patients were entered into a double-blind, placebo-controlled, parallel-group, flexible-dose study and were randomized to receive sildenafil (25-100 mg; n = 95) or placebo (n = 93) for 12 weeks. Efficacy was evaluated using questions three (Q3; achieving an erection) and four (Q4; maintaining an erection) from the International Index of Erectile Function (IIEF), a global efficacy question (GEQ; "Did treatment improve your erections?"), and a patient event log of sexual activity.

RESULTS

Improvements in mean scores from baseline to end-of-treatment for IIEF Q3 (35.7 vs. 19.9%) and Q4 (68.4 vs. 26.5%) were significant in patients receiving sildenafil compared with those receiving placebo (P = 0.0001). Moreover, the percent of improved erections (GEQ, 66.6 vs. 28.6%) and successful intercourse attempts (63 vs. 33%) was significantly increased with sildenafil compared with placebo. Improvements in sexual function were seen irrespective of the degree of ED severity. Adverse events were generally mild to moderate in severity, with headache (20 vs. 8%), flushing (18 vs. 3%), and dyspepsia (8 vs. 1%) reported more often in the sildenafil than in placebo-treated patients.

CONCLUSIONS

Treatment with sildenafil for ED was effective, resulting in an increased percentage of successful attempts at intercourse, and was well tolerated among men with type 1 diabetes.

Neonatal anthropometry: the thin-fat Indian baby. The Pune Maternal Nutrition Study

OBJECTIVE

To examine body size and fat measurements of babies born in rural India and compare them with white Caucasian babies born in an industrialised country.

DESIGN

Community-based observational study in rural India, and comparison with data from an earlier study in the UK, measured using similar methods.

SUBJECTS

A total of 631 term babies born in six rural villages, near the city of Pune, Maharashtra, India, and 338 term babies born in the Princess Anne Hospital, Southampton, UK.

MEASUREMENTS

Maternal weight and height, and neonatal weight, length, head, mid-upper-arm and abdominal circumferences, subscapular and triceps skinfold thicknesses, and placental weight.

RESULTS

The Indian mothers were younger, lighter, shorter and had a lower mean body mass index (BMI) (mean age, weight, height and BMI: 21.4 y, 44.6 kg, 1.52 m, and 18.2 kg/m(2)) than Southampton mothers (26.8 y, 63.6 kg, 1.63 m and 23.4 kg/m(2)). They gave birth to lighter babies (mean birthweight: 2.7 kg compared with 3.5 kg). Compared to Southampton babies, the Indian babies were small in all body measurements, the smallest being abdominal circumference (s.d. score: -2.38; 95% CI: -2.48 to -2.29) and mid-arm circumference (s.d. score: -1.82; 95% CI: -1.89 to -1.75), while the most preserved measurement was the subscapular skinfold thickness (s.d. score: -0.53; 95% CI: -0.61 to -0.46). Skinfolds were relatively preserved in the lightest babies (below the 10th percentile of birthweight) in both populations.

CONCLUSIONS

Small Indian babies have small abdominal viscera and low muscle mass, but preserve body fat during their intrauterine development. This body composition may persist postnatally and predispose to an insulin-resistant state.

High prevalence of undiagnosed diabetes mellitus in Southern Germany: target populations for efficient screening. The KORA survey 2000

AIMS/HYPOTHESIS

To estimate the prevalence of undiagnosed diabetes mellitus, impaired glucose tolerance (IGT) and impaired fasting glucose (IFG), and their relations with cardiovascular risk factors in the general population aged 55 to 74 years in Southern Germany.

METHODS

Oral glucose tolerance tests were carried out in a random sample of 1353 subjects aged 55 to 74 years participating in the KORA (Cooperative Health Research in the Region of Augsburg) Survey 2000. Prevalences of glucose tolerance categories (1999 WHO criteria) were adjusted for sample probabilities. The numbers needed to screen (NNTS) to identify one person with undiagnosed diabetes were estimated from age-adjusted logistic regression models.

RESULTS

Sample design-based prevalences of known and unknown diabetes, IGT, and IFG were 9.0%, 9.7%, 16.8%, 9.8% in men, and 7.9%, 6.9%, 16.0%, 4.5% in women, respectively. In both sexes, participants with undiagnosed diabetes had higher BMI, waist circumference, systolic blood pressure, triglycerides, uric acid, and lower HDL-cholesterol than normoglycaemic subjects. A combination of abdominal adiposity, hypertension, and parental diabetes in men resulted in a NNTS of 2.9 (95%CI: 2.0-4.6). In women, the combination of increased triglycerides, hypertension and parental diabetes history yielded a NNTS of 3.2 (95%CI: 2.2-5.1).

CONCLUSION/INTERPRETATION

About 40% of the population aged 55 to 74 years in the Augsburg region have disturbed glucose tolerance or diabetes. Half of the total cases with diabetes are undiagnosed. Cardiovascular risk factors worsen among glucose tolerance categories, indicating the need for screening and prevention. Screening for undiagnosed diabetes could be most efficient in individuals with abdominal adiposity (men), hypertriglyceridaemia (women), hypertension, and parental diabetes history.

Insulin resistance and risk of chronic kidney disease in nondiabetic US adults

This study examined the relationship of fasting serum glucose, insulin, C-peptide, glycosylated hemoglobin A (HbA1c), and Homeostasis Model Assessment (HOMA)-insulin resistance to risk of chronic kidney disease (CKD) among 6453 persons without diabetes (fasting glucose <126 mg/dl and not taking diabetes medication) who participated in the Third National Health and Nutrition Examination Survey and were aged 20 yr or older. CKD was defined as an estimated GFR <60 ml/min per 1.73 m(2). The prevalence of CKD was significantly and progressively higher with increasing levels of serum insulin, C-peptide, HbA1c, and HOMA-insulin resistance. After adjustment for potential confounding variables, the odds ratio of CKD for the highest compared with the lowest quartile was 4.03 (95% confidence interval [CI], 1.81 to 8.95; P = 0.001), 11.4 (95% CI, 4.07 to 32.1; P < 0.001), 2.67 (95% CI, 1.31 to 5.46; P = 0.002), and 2.65 (95% CI, 1.25 to 5.62; P = 0.008) for serum insulin, C-peptide, HbA1c levels, and HOMA-insulin resistance, respectively. For a one SD higher level of serum insulin (7.14 micro U/ml), C-peptide (0.45 Deltamol/ml), HbA1c (0.52%), and HOMA-insulin resistance (1.93), the odds ratio (95% CI) of CKD was 1.35 (1.16 to 1.57), 2.78 (2.25 to 3.42), 1.69 (1.28 to 2.23), and 1.30 (1.13 to 1.50), respectively. These findings combined with knowledge from previous studies suggest that the insulin resistance and concomitant hyperinsulinemia are presented in CKD patients without clinical diabetes. Further studies into the causality between insulin resistance and CKD are warranted.

The effects of diabetes on the risks of major cardiovascular diseases and death in the Asia-Pacific region

OBJECTIVE

To provide reliable age- and region-specific estimates of the associations between diabetes and major cardiovascular diseases and death in populations from the Asia-Pacific region.

RESEARCH DESIGN AND METHODS

Twenty-four cohort studies from Asia, Australia, and New Zealand (median follow-up, 5.4 years) provided individual participant data from 161,214 people (58% from Asia) of whom 4,873 had a history of diabetes at baseline. The associations of diabetes with the risks of coronary heart disease, stroke, and cause-specific mortality during follow-up were estimated using time-dependent Cox models, stratified by study cohort and sex and adjusted for age at risk.

RESULTS

In all, 9,277 deaths occurred (3,635 from cardiovascular disease). The hazard ratio (95% CI) associated with diabetes was 1.97 (1.72-2.25) for fatal cardiovascular disease; there were similar hazard ratios for fatal coronary heart disease, fatal stroke, and composites of fatal and nonfatal outcomes. For all cardiovascular outcomes, hazard ratios were similar in Asian and non-Asian populations and in men and women, but were greater in younger than older individuals. For noncardiovascular death, the hazard ratio was 1.56 (1.38-1.77), with separately significant increases in the risks of death from renal disease, cancer, respiratory infections, and other infective causes. The hazard ratio for all-causes mortality was 1.68 (1.55-1.84), with similar ratios in Asian and non-Asian populations, but with significantly higher ratios in younger than older individuals.

CONCLUSIONS

The relative effect of diabetes on the risks of cardiovascular disease and death in Asian populations is much the same as that in the largely Caucasian populations of Australia and New Zealand. Hazard ratios were severalfold greater in younger people than older people. The rapidly growing prevalence of diabetes in Asia heralds a large increase in the incidence of diabetes-related death in the coming decades.

Dietary fat intake as risk factor for the development of diabetes: multinational, multicenter study of the Mediterranean Group for the Study of Diabetes (MGSD)

OBJECTIVE

To investigate the role of dietary factors in the development of type 2 diabetes.

RESEARCH DESIGN AND METHODS

In the context of the Multinational MGSD Nutrition Study, three groups of subjects were studied: 204 subjects with recently diagnosed diabetes (RDM), 42 subjects with undiagnosed diabetes (UDM) (American Diabetes Association criteria-fasting plasma glucose [FPG] > or =126 mg/dl), and 55 subjects with impaired fasting glucose (IFG) (FPG > or =110 and <126 mg/dl). Each group was compared with a control group of nondiabetic subjects, matched one by one for center, sex, age, and BMI. Nutritional habits were evaluated by a dietary history method, validated against the 3-day diet diary. In RDM, the questionnaire referred to the nutritional habits before the diagnosis of diabetes. Demographic data were collected, and anthropometrical and biochemical measurements were taken.

RESULTS

Compared with control subjects, RDM more frequently had a family history of diabetes (49.0 vs. 14.2%; P < 0.001), exercised less (exercise index 53.5 vs. 64.4; P < 0.01), and more frequently had sedentary professions (47.5 vs. 27.4%; P < 0.001). Carbohydrates contributed less to their energy intake (53.5 vs. 55.1%; P < 0.05), whereas total fat (30.2 +/- 0.5 vs. 27.8 +/- 0.5%; P < 0.001) and animal fat (12.2 +/- 0.3 vs. 10.8 +/- 0.3%; P < 0.01) contributed more and the plant-to-animal fat ratio was lower (1.5 +/- 0.1 vs. 1.8 +/- 0.1; P < 0.01). UDM more frequently had a family history of diabetes (38.1 vs. 19.0%; P < 0.05) and sedentary professions (58.5 vs. 34.1%; P < 0.05), carbohydrates contributed less to their energy intake (47.6 +/- 1.7 vs. 52.8 +/- 1.4%; P < 0.05), total fat (34.7 +/- 1.5 vs. 30.4 +/- 1.2%; P < 0.05) and animal fat (14.2 +/- 0.9 vs. 10.6 +/- 0.7%; P < 0.05) contributed more, and the plant-to-animal fat ratio was lower (1.6 +/- 0.2 vs. 2.3 +/- 0.4; P < 0.05). IFG differed only in the prevalence of family history of diabetes (32.7 vs. 16.4%; P < 0.05).

CONCLUSIONS

Our data support the view that increased animal fat intake is associated with the presence of diabetes.

Intrauterine determinants of diabetic kidney disease in disadvantaged populations

Disadvantaged populations worldwide are experiencing an increasing incidence of kidney disease, much of which is attributable to diabetes. This report reviews the evidence that intrauterine exposure to growth retardation, diabetes, and vitamin A deficiency contribute disproportionately to the rising incidence of kidney disease in disadvantaged people, because they encounter these exposures more frequently than people from developed countries. These abnormal intrauterine exposures reduce nephron mass by impairing nephrogenesis, thereby increasing the susceptibility to kidney damage from diseases such as hypertension and diabetes that commonly affect disadvantaged people.

Clinical Impact of the New Criteria for the Diagnosis of Diabetes Mellitus

In 1997 the American Diabetes Association lowered the threshold for diagnosis of diabetes from a fasting plasma glucose concentration of 7.8 mmol/l to 7.0 mmol/l and advised that the oral glucose tolerance test no longer be used in routine clinical practice. In 1999 the World Health Organization endorsed the reduction in fasting plasma glucose threshold but recommended retaining the oral glucose tolerance test for anyone with impaired fasting glucose (6.1 mmol/l-6.9 mmol/l). This Review discusses the impact of these changes on the prevalence of diabetes and examines the implications for individuals and specific high-risk groups. The phenotype of those diagnosed with diabetes and the predictive value for the development of complications according to the different criteria are compared. It is clear that these changes in diagnostic criteria have major importance both for individuals and for resource planning at a national level.

Influence of diabetes mellitus on heart failure risk and outcome

Our aim is to summarize and discuss the recent literature linking diabetes mellitus with heart failure, and to address the issue of the optimal treatment for diabetic patients with heart failure. THE STUDIES LINKING DIABETES MELLITUS (DM) WITH HEART FAILURE (HF) : The prevalence of diabetes mellitus in heart failure populations is close to 20% compared with 4 to 6% in control populations. Epidemiological studies have demonstrated an increased risk of heart failure in diabetics; moreover, in diabetic populations, poor glycemic control has been associated with an increased risk of heart failure. Various mechanisms may link diabetes mellitus to heart failure: firstly, associated comorbidities such as hypertension may play a role; secondly, diabetes accelerates the development of coronary atherosclerosis; thirdly, experimental and clinical studies support the existence of a specific diabetic cardiomyopathy related to microangiopathy, metabolic factors or myocardial fibrosis. Subgroup analyses of randomized trials demonstrate that diabetes is also an important prognostic factor in heart failure. In addition, it has been suggested that the deleterious impact of diabetes may be especially marked in patients with ischemic cardiomyopathy. TREATMENT OF HEART FAILURE IN DIABETIC PATIENTS : The knowledge of the diabetic status may help to define the optimal therapeutic strategy for heart failure patients. Cornerstone treatments such as ACE inhibitors or beta-blockers appear to be uniformly beneficial in diabetic and non diabetic populations. However, in ischemic cardiomyopathy, the choice of the revascularization technique may differ according to diabetic status. Finally, clinical studies are needed to determine whether improved metabolic control might favorably influence the outcome of diabetic heart failure patients.

The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of Type 2 diabetes

The relative contributions of insulin resistance and beta-cell dysfunction to the pathophysiology of Type 2 diabetes have been debated extensively. The concept that a feedback loop governs the interaction of the insulin-sensitive tissues and the beta cell as well as the elucidation of the hyperbolic relationship between insulin sensitivity and insulin secretion explains why insulin-resistant subjects exhibit markedly increased insulin responses while those who are insulin-sensitive have low responses. Consideration of this hyperbolic relationship has helped identify the critical role of beta-cell dysfunction in the development of Type 2 diabetes and the demonstration of reduced beta-cell function in high risk subjects. Furthermore, assessments in a number of ethnic groups emphasise that beta-cell function is a major determinant of oral glucose tolerance in subjects with normal and reduced glucose tolerance and that in all populations the progression from normal to impaired glucose tolerance and subsequently to Type 2 diabetes is associated with declining insulin sensitivity and beta-cell function. The genetic and molecular basis for these reductions in insulin sensitivity and beta-cell function are not fully understood but it does seem that body-fat distribution and especially intra-abdominal fat are major determinants of insulin resistance while reductions in beta-cell mass contribute to beta-cell dysfunction. Based on our greater understanding of the relative roles of insulin resistance and beta-cell dysfunction in Type 2 diabetes, we can anticipate advances in the identification of genes contributing to the development of the disease as well as approaches to the treatment and prevention of Type 2 diabetes.

Oral treatments for type II diabetes in patients with cardiovascular disease

The incidence of type II diabetes mellitus is rising rapidly, both in the United States and worldwide. Often, the disease is first diagnosed by cardiologists during an evaluation for coronary or peripheral vascular disease. It is therefore important to understand the basic pathophysiology of insulin resistance, its role in the development of type II diabetes, and its association with accelerated atherosclerosis. An appreciation of when to begin testing for diabetes, how to make the diagnosis, and what treatment strategy to choose is imperative. While there are as yet little randomized data to guide hypoglycemic therapy as it pertains to reducing cardiovascular risk, evidence is accumulating that treatment of diabetes will have an impact on cardiovascular outcomes.

Implementing program evaluation and accountability for population health: progress of a national diabetes control effort

Diabetes affects some 16 million Americans at a cost estimated at $100 billion. The Centers for Disease Control and Prevention funds a diabetes control program (DCP) in every state as part of the National Diabetes Control Program (NDCP). In 1999, a new policy added emphasis on evaluation and made NDCP and its DCPs accountable for achieving impacts related to the health of populations with diabetes. The article reports on the experiences of the NDCP in implementing a performance-based program evaluation paradigm. It also discusses potential future directions for national diabetes-control efforts.

The impact of ethnicity on type 2 diabetes

The rapid increase of diabetes prevalence in the US population and across all westernized world has been associated with environmental changes that promote obesity. Although dietary factors, such as total caloric intake, relative excess of dietary saturated fats content and lack of fibers, together with reduced level of physical activity clearly determine the main features of the "obesogenic" environment typical of "western" societies, the impact of lifestyle factors on obesity and diabetes appears to differ in various ethnic groups. Although ethnic-related differences in lifestyle factors may account for some of the predisposition to obesity and diabetes of various ethnic groups, genetic factors may play a more determinant role. These observations pose important public health questions in regard to strategies for treatment and prevention of diabetes both within the multiethnic US population and in the population of origin of various ethnicities. The elucidation of the pathophysiologic mechanisms responsible for the heterogeneous relationship between obesity and type 2 diabetes in various ethnicities may give important contributions to better understand the complex mechanisms involved in the development of this disease. This review examines epidemiological and pathophysiological aspects of the interaction between environment and ethnic predisposition to type 2 diabetes.

The changing world demography of type 2 diabetes

In recent years it has been estimated that the current global prevalence of type 2 diabetes amounts to about 150 million patients. Projections suggest that by the year 2025 the number of prevalent patients in the world will reach approximately 300 million. It is assumed that the increase in the number of patients will be most pronounced in nations currently undergoing socio-economic development including increasing urbanization. The technique used to provide these estimates is based on results from available, contemporary survey results, combined with expected future trends in demographic indicators. We suggest that the currently available methods for the estimation of the future global burden of type 2 diabetes mellitus yield underestimates. Further modifications and validity tests of the modelling techniques are necessary in order to develop a reliable instrument to globally monitor the effects of the struggle against the diabetes problem.

Randomized controlled community-based nutrition and exercise intervention improves glycemia and cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica

OBJECTIVE

The prevalence of type 2 diabetes, especially in developing countries, has grown over the past decades. We performed a controlled clinical study to determine whether a community-based, group-centered public health intervention addressing nutrition and exercise can ameliorate glycemic control and associated cardiovascular risk factors in type 2 diabetic patients in rural Costa Rica.

RESEARCH DESIGN AND METHODS

A total of 75 adults with type 2 diabetes, mean age 59 years, were randomly assigned to the intervention group or the control group. All participants received basic diabetes education. The subjects in the intervention group participated in 11 weekly nutrition classes (90 min each session). Subjects for whom exercise was deemed safe also participated in triweekly walking groups (60 min each session). Glycosylated hemoglobin, fasting plasma glucose, total cholesterol, triglycerides, HDL and LDL cholesterol, height, weight, BMI, and blood pressure were measured at baseline and the end of the study (after 12 weeks).

RESULTS

The intervention group lost 1.0 +/- 2.2 kg compared with a weight gain in the control group of 0.4 +/- 2.3 kg (P = 0.028). Fasting plasma glucose decreased 19 +/- 55 mg/dl in the intervention group and increased 16 +/- 78 mg/dl in the control group (P = 0.048). Glycosylated hemoglobin decreased 1.8 +/- 2.3% in the intervention group and 0.4 +/- 2.3% in the control group (P = 0.028).

CONCLUSIONS

Glycemic control of type 2 diabetic patients can be improved through community-based, group-centered public health interventions addressing nutrition and exercise. This pilot study provides an economically feasible model for programs that aim to improve the health status of people with type 2 diabetes.

Behavior and biology: the prevention of type 2 diabetes

Type 2 diabetes mellitus (DM), characterized by insulin resistance and a beta-cell secretory defect, appears to result from a number of gene and environmental interactions. There are marked differences in the phenotypic expression of type 2 DM with individuals exhibiting varying levels of insulin resistance and impairments in insulin secretion. Study results indicate that a number of healthy lifestyle behaviors, such as increased physical activity and reduced intake of dietary fat, are associated with decreased development of type 2 DM. This article explores the genetic and environmental factors associated with the development of type 2 DM along with the role of lifestyle modifications in the prevention of this disease.

Age- and sex-specific prevalences of diabetes and impaired glucose regulation in 13 European cohorts

OBJECTIVE

To report the age- and sex-specific prevalences of diabetes and impaired glucose regulation (IGR) according to the revised 1999 World Health Organization criteria for diabetes in Europe.

RESEARCH DESIGN AND METHODS

A total of 13 studies from nine European countries with 7,680 men and 9,251 women aged 30-89 years were included in the data analysis.

RESULTS

In most of the study populations, the age-specific prevalences of diabetes were <10% in subjects younger than 60 years and between 10 and 20% at 60-79 years of age. Mean 2-h plasma glucose (2hPG) concentration increased linearly with age, but fasting plasma glucose (FPG) concentration did not. The increase in the prevalence of undiagnosed diabetes and IGR in the elderly was mainly a result of the large increase in 2hPG rather than FPG. Diabetes and impaired fasting glycemia defined by isolated fasting hyperglycemia was more common in men than in women 30-69 years of age, whereas the prevalence of isolated postload hyperglycemia, particularly impaired glucose tolerance, was higher in women than in men, especially in the elderly (individuals >70 years of age). More than half of the diabetes was undiagnosed in subjects younger than 50 years of age.

CONCLUSIONS

Most European populations have a moderate to low prevalence of diabetes and IGR. Diabetes and IGR will be underestimated in Europe, particularly in women and in elderly men, if diagnoses are based on fasting glucose determination alone.

Pancreatic beta-cell loss and preservation in type 2 diabetes

BACKGROUND

In most individuals, the need to respond to progressive states of insulin resistance is met by increasing insulin production. For insulin-resistant patients, however, the balance between insulin supply and demand may fail from the progressive loss of pancreatic beta-cell function, eventually leading to type 2 diabetes mellitus.

OBJECTIVE

The aim of this review was to discuss the current concepts underlying potential pancreatic beta-cell failure in the progression toward type 2 diabetes and therapies that may alter the process.

METHODS

Data included in this review were identified through a MEDLINE search for articles published from 1966 to April 2003. Search terms used were beta cell, diabetes, insulin resistance, obesity, cardiovascular disease, thiazolidinediones, and metformin.

RESULTS

Evidence of the progressive loss of beta-cell function may include altered conversion of proinsulin to insulin, changes in pulsed and oscillatory insulin secretion, and quantitative reductions in insulin release. Potential underlying mechanisms are glucose toxicity, lipotoxicity, poor tolerance of increased secretory demand, and a reduction in beta-cell mass.

CONCLUSION

Current clinical management of type 2 diabetes is focused on treatment of the signs and symptoms of late-stage disease rather than addressing potential underlying causes, which may be amenable to currently available therapies, based on a broad understanding of existing data, practice experience, and rational speculation.

Diagnosis and treatment of type 2 diabetes in three Belgian regions. Registration via a network of sentinel general practices

BACKGROUND

The objective of this descriptive study is to investigate the incidence of type 2 diabetes in sentinel general practices in three regions in Belgium and to describe the patient characteristics and the start of the medical management after diagnosis.

METHODS

For two successive years all patients who were newly diagnosed with type 2 diabetes were registered. Two weeks after inclusion, the registering physician completed an extensive questionnaire. This questionnaire dealt with risk factors, biochemical parameters, existing complications and treatment.

RESULTS

According to this study, the yearly incidence of type 2 diabetes in Belgium is 231 per 100,000 inhabitants. Though the biochemical parameters (BMI, HbA1c, serum cholesterol and triglycerides) do not differ in the three regions of the country being investigated, there are considerable differences in the treatment prescribed for diabetes and its co-morbidity. In Flanders, treatment is usually started with sulphonylurea, in the Walloon provinces with biguanides. Hypolipaemic treatment is also started more frequently in the latter region. In Flanders, hypertension is registered in 51.4% of the newly diagnosed patients with diabetes, which is higher than in the other regions. However, no difference is noted between the different regions in the number of patients with diabetes who are treated for hypertension.

CONCLUSION

A network of sentinel physicians, taking part in voluntary registration, can be helpful in calculating the incidence of a health problem, in particular type 2 diabetes in general practice. The sentinel net can also serve as an instrument for describing patient characteristics and showing how physicians deal with health problems. The regional differences in medical approach that are described require further investigation, mainly with respect to their impact on the patients' outcome.

Reducing the global burden of cardiovascular disease: the role of risk factors

During the last century, cardiovascular disease (CVD) has burgeoned from a relatively minor disease worldwide to a leading cause of morbidity and mortality. By 2020 it is projected that CVD will surpass infectious disease as the worlds leading cause of death and disability. Some of this increase in the relative importance of CVD is due to improved public health measures and medical care leading to longer life spans and reduced mortality from other causes. However, a substantial portion of the increasing global impact of CVD is attributable to economic, social, and cultural changes that have led to increases in risk factors for CVD. These changes are most pronounced in the countries comprising the developing world. Because the majority of the worlds population lives in the developing world, the increasing rate of CVD in these countries is the driving force behind the continuing dramatic worldwide increase in CVD. In order to blunt the impact of the global explosion in CVD, it will be crucial to attempt to understand and reduce the global increase in CVD risk factors. In this review, the authors describe the changes responsible for the global epidemic of CVD, with particular attention to the contributions of established risk factors and their impact on the growth of CVD among the worlds various economic sectors. The authors outline the major challenges facing countries in different economic sectors, and discuss ways to address these challenges with the goal of reducing the global burden of CVD.

The status of diabetes control in Asia--a cross-sectional survey of 24 317 patients with diabetes mellitus in 1998

AIMS

To establish the status of diabetes control in Asia, the Diabcare-Asia 198 study collected data from 230 diabetes centres in Bangladesh, People's Republic of China, India, Indonesia, Malaysia, Philippines, Singapore, South Korea, Sri Lanka, Taiwan, Thailand and Vietnam from March to December 1998.

METHODS

Data were obtained either by patient interview during the enrolment visit or by reviewing medical records for the most recent laboratory assessment and clinical examinations. Blood samples were also collected during patients'. visits for central assessments of HbA1c (normal range 4.7-6.4%).

RESULTS

The mean of centrally measured HbA1c was 8.6 +/- 2.0% for 18 211 patients (82% of the analysis population). Of the patients with central HbA1c measurements, the majority (55%) had values exceeding 8%, indicative of poor glycaemic control. The prevalence of retinopathy, microalbuminuria and neuropathy was also higher in the group of patients with higher HbA1c. Based on the findings from central HbA1c measurements and reported local HbA1c assessments, it also appears that more patients with poor glycaemic control did not have access to glycated haemoglobin measurements. Mean HbA1c of thediabetic populations in Bangladesh, Indonesia, Korea, Malaysia and Taiwan were significantly lower (all P = 0.0001, except P = 0.0007 for Malaysia), while that of China, India, Philippines and Vietnam was significantly higher (all P = 0.0001) than the grand mean.

CONCLUSIONS

In our study population of the Asian diabetes patients treated at diabetes centres, more than half were not well controlled. The prevalence of diabetic microvascular complications was higher in the group of patients with higher HbA1c. Further therapeutic actions to improve glycaemic control are required to prevent chronic diabetic complications.

Hypoglycemic and antihyperglycemic effect of Brassicajuncea diet and their effect on hepatic glycogen content and the key enzymes of carbohydrate metabolism

Plants in the form of food or other remedial forms have been used for the treatment of various human ailments. Diabetes is one such disorder in which various form of plants and herbal remedies have been tried. Brassicajuncea (BJ) seeds (Rai) are consumed in India as a spice in various food items. Previous studies have shown the hypoglycemic effect of this plant in rats. The present study was undertaken to study the hypoglycemic and antihyperglycemic of various strengths (5, 10 and 15%) of BJ seed diet in alloxan and streptozotocin induced diabetes in albino rats. In addition, key enzymes of carbohydrate metabolism (glucokinase--EC 2.7.1.1, hexokinase--EC 2.7.1.1, and phosphofructokinase--EC 2.7.1.11) and hepatic glycogen content was also assessed to understand the mechanism of action. BJ diet (10 and 15%) showed significant antihyperglycemic effect in alloxan (35 mg/kg) but not in STZ (60 mg/kg) rats. It also failed to modulate the hepatic glycogen content and enzyme activities.

The relationship between glucose control and the development and progression of diabetic nephropathy

Diabetic nephropathy is a major cause of morbidity and mortality in patients with diabetes; it occurs in about one third of such patients. The course of nephropathy is better defined and similar for both type 1 and type 2 diabetes. Patients initially develop microalbuminuria (albumin excretion rates [AERs] between 20 and 200 micrograms/min), then overt nephropathy (AER > or = 200 micrograms/min), and finally a decline in glomerular filtration rate (GFR) eventuating in end-stage renal disease. Although metabolic control has long been hypothesized as a contributor to the development of nephropathy, it is only in recent years that this hypothesis has been proven. A number of observational studies have shown correlations between glycemic control and the development of various levels of albuminuria and also declines in GFR. However, large long-term prospective, randomized, interventional studies have now definitely proven that improved metabolic control that achieves near-normoglycemia can significantly decrease the development and progression of diabetic nephropathy as well as other long-term complications of diabetes, including retinopathy and neuropathy. It is now conceivable that the achievement of near-normoglycemia, plus medications that inhibit the renin-angiotensin system if microalbuminuria develops, may greatly decrease the numbers of patients eventually requiring renal replacement therapy.

Losartan reduces the burden and cost of ESRD: public health implications from the RENAAL study for the European Union

Type 2 diabetes is the leading cause of end-stage renal disease (ESRD) in most industrialized countries in Europe. The RENAAL (Reduction of Endpoints in NIDDM with the Angiotensin II Antagonist Losartan) Study evaluated the renal protective effects of losartan versus placebo on a background of non-ACE-I/non-AIIA conventional antihypertensive therapy in 1513 patients with type 2 diabetes and nephropathy. Losartan reduced the incidence of doubling of serum creatinine, end-stage renal disease (ESRD), or death by 16% (P=0.022) and reduced the risk of progression to ESRD, defined as the initiation of dialysis or transplantation, by 29% (P=0.002). We set out to estimate the potential effect of losartan on the burden and costs associated with ESRD over 3.5 years in the European Union (EU). The risk reduction in new cases of ESRD was calculated by combining type 2 diabetes population estimates for the EU with the percent absolute risk reduction of ESRD in patients treated with losartan as observed in RENAAL. The number of days each patient experienced ESRD was defined as the length of time from onset of ESRD until the minimum of death or 3.5 years. ESRD-free person-years avoided with losartan treatment were calculated by combining the population estimate with the ESRD days avoided divided by number of days in a year. ESRD costs from Germany were used to approximate the potential cost savings from reduced time with ESRD and fewer ESRD cases on a EU wide basis. There are approximately 700,000 diagnosed type 2 diabetes patients with proteinuria (urine albumin/creatinine >or=300 mg/g) in the EU. The addition of losartan to the treatment regimen of these patients is expected to lead to a reduction of 44,100 cases of ESRD, 64,400 fewer person-years with ESRD, and reduce ESRD-related costs by euro 2.6 billion over 3.5 years based on RENAAL data. Treatment with losartan not only reduced the incidence of ESRD, but also can result in substantial cost savings in the European Union.