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

RAGE blockade stabilizes established atherosclerosis in diabetic apolipoprotein E-null mice

BACKGROUND

Previous studies suggested that blockade of RAGE in diabetic apolipoprotein (apo) E-null mice suppressed early acceleration of atherosclerosis. A critical test of the potential applicability of RAGE blockade to clinical settings was its ability to impact established vascular disease. In this study, we tested the hypothesis that RAGE contributed to lesion progression in established atherosclerosis in diabetic apoE-null mice.

METHODS AND RESULTS

Male apoE-null mice, age 6 weeks, were rendered diabetic with streptozotocin or treated with citrate buffer. At age 14 weeks, certain mice were killed or treated with once-daily murine soluble RAGE or albumin; all mice were killed at age 20 weeks. Compared with diabetic mice at age 14 weeks, albumin-treated animals displayed increased atherosclerotic lesion area and complexity. In diabetic mice treated with sRAGE from age 14 to 20 weeks, lesion area and complexity were significantly reduced and not statistically different from those observed in diabetic mice at age 14 weeks. In parallel, decreased parameters of inflammation and mononuclear phagocyte and smooth muscle cell activation were observed.

CONCLUSIONS

RAGE contributes not only to accelerated lesion formation in diabetic apoE-null mice but also to lesion progression. Blockade of RAGE may be a novel strategy to stabilize atherosclerosis and vascular inflammation in established diabetes.

Increasing prevalence of diabetes mellitus in Oman

AIMS

To determine the prevalence of diabetes mellitus and impaired fasting glucose by age, gender, and by region and compare results with the 1991 survey; and estimate previously undiagnosed diabetes mellitus in the Omani population.

METHODS

Cross-sectional survey containing a probability random sample of 5838 Omani adults aged >or= 20 years. Diabetes and impaired fasting glucose (IFG) were assessed by fasting venous plasma glucose using 1999 World Health Organization's diagnostic criteria (normoglycaemia < 6.1 mmol/l, IFG >or= 6.1 but < 7 mmol/l,and diabetes >or= 7 mmol/l). The 1991 survey was reanalysed using the same diagnostic criteria, and results were compared.

RESULTS

In 2000, the age-adjusted prevalence of diabetes among Omanis aged 30-64 years reached 16.1% (95% confidence interval (CI) 14.7-17.4) compared with 12.2% (95% CI11.0-13.4) in 1991. IFG was found among 7.1% (95% CI6.2-8.1) of males and 5.1% (95% CI 4.4-6.0) of females. Generally, diabetes was more common in urban then rural regions. Only one-third of diabetic subjects knew that they had diabetes. Nearly half of the study population had a body mass index > 25 kg/m2.

CONCLUSIONS

The prevalence of diabetes is high in Oman and has increased over the past decade. The high rate of abnormal fasting glucose together with high rates of overweight and obesity in the population make it likely that diabetes will continue to be a major health problem in Oman. Primary prevention programmes are urgently needed to counteract major risk factors that promote the development of diabetes.

Prevalence and characteristics of early-onset type 2 diabetes in Mexico

OBJECTIVE

To investigate the prevalence and characteristics of patients with type 2 diabetes diagnosed before the age of 40 years (early-onset disease) in a nationwide, population-based study.

METHODS

Using a multistage sampling procedure, we enrolled a representative sample of Mexican urban adults aged 20 to 69 years. Weight, height, blood pressure, and plasma levels of glucose, insulin, and other metabolic parameters were measured in all subjects.

RESULTS

We identified 993 subjects with type 2 diabetes, including 143 subjects aged 20 to 39 years (14% of those with diabetes). Subjects with early-onset diabetes had a greater prevalence of obesity and higher plasma insulin and lipid levels than did age-matched controls, and a greater prevalence of high-density lipoprotein cholesterol levels <35 mg/dL and severe hypertriglyceridemia than did older subjects with diabetes. Those (n = 32) with a normal body mass index (20 to 25 kg/m(2)) tended to have insulin deficiency as the main abnormality, whereas the "metabolic syndrome" characterized the remaining 111 subjects with early-onset diabetes.

CONCLUSION

Most patients with early-onset type 2 diabetes in Mexico are obese or overweight, suggesting that obesity treatment and prevention programs may be effective in reducing the prevalence of this disease.

Healthy diet and lifestyle clustering and glucose intolerance

Glucose intolerance represents a spectrum of abnormalities, including impaired fasting glucose, impaired glucose tolerance and type 2 diabetes. It is a major public health challenge worldwide, with rapidly increasing prevalence rates in both developed and developing countries. This global epidemic of diabetes is largely driven by the globalisation of Western culture and lifestyles. Specifically, there is now evidence from large-scale observational studies, and from intervention studies, of powerful synergistic interactions between diet, obesity, exercise, smoking and alcohol in the development of glucose intolerance. It is estimated that >90% of cases of type 2 diabetes in the population could be prevented with the adoption of a prudent diet (high in cereal fibre and polyunsaturated fatty acids and low in trans-fatty acids and glycaemic load), avoidance of overweight and obesity (BMI<25 kg/m2), engagement in moderate to vigorous physical activity for at least 0.5 h/d, non-smoking and moderate alcohol consumption. These findings are biologically plausible and have major public health implications. They form the basis for a clear, simple and coherent message for health promotion and public policy. However, to make progress on these issues health will need to be placed at the centre of public policy and relevant vested interests tackled, notably in the food, entertainment, tobacco and automobile industries.

Projected impact of implementing the results of the diabetes prevention program in the U.S. population

OBJECTIVE

To determine the feasibility of using either fasting plasma glucose or HbA(1c) to identify individuals in the U.S. population who meet the Diabetes Prevention Program (DPP) criteria for intervention, defined as BMI >/=24 kg/m(2), fasting plasma glucose level 96-125 mg/dl, and 2-h glucose level 140-199 mg/dl in an oral glucose tolerance test (OGTT).

RESEARCH DESIGN AND METHODS

Analysis of a representative sample of U.S. adults aged 40-74 years with no medical history of diabetes for whom data on height, weight, fasting plasma glucose, HbA(1c), and 2-h plasma glucose during an OGTT were obtained. Sensitivity, specificity, positive predictive value (PPV), and receiver operator characteristic (ROC) curves for fasting glucose and HbA(1c) were determined.

RESULTS

Using BMI <24 kg/m(2) as an initial criterion eliminated 27.2% of U.S. adults from further testing. Of the remaining group, 41.1% did not have to be considered for an OGTT because their fasting glucose level was below or above 96-125 mg/dl. Overall, 10.6% of adults aged 40-74 years without medical history of diabetes met the DPP eligibility criteria for intervention. Among individuals with BMI >/=24 kg/m(2) and fasting glucose level 96-125 mg/dl, applying a fasting plasma glucose cutoff of >/=105 mg/dl excluded 62.5% of this group and resulted in 56.0% of those with 2-h glucose level 140-199 mg/dl in this group being identified, with a specificity of 72.0% and a PPV of 17.1%. Similar values were obtained for an HbA(1c) cutoff value of >/=5.5%.

CONCLUSIONS

Using data on BMI and setting cutoff values for fasting glucose and HbA(1c) would greatly reduce the number of individuals who would need to undergo an OGTT while achieving adequate sensitivity, specificity, and PPV.

Switch to anaerobic glucose metabolism with NADH accumulation in the beta-cell model of mitochondrial diabetes. Characteristics of betaHC9 cells deficient in mitochondrial DNA transcription

To elucidate the mechanism underlying diabetes caused by mitochondrial gene mutations, we created a model by applying 0.4 microg/ml ethidium bromide (EtBr) to the murine pancreatic beta cell line betaHC9; in this model, transcription of mitochondrial DNA, but not that of nuclear DNA, was suppressed in association with impairment of glucose-stimulated insulin release (Hayakawa, T., Noda, M., Yasuda, K., Yorifuji, H., Taniguchi, S., Miwa, I., Sakura, H., Terauchi, Y., Hayashi, J.-I., Sharp, G. W. G., Kanazawa, Y., Akanuma, Y., Yazaki, Y., and Kadowaki, T. (1998) J. Biol. Chem. 273, 20300-20307). To elucidate fully the metabolism-secretion coupling in these cells, we measured glucose oxidation, utilization, and lactate production. We also evaluated NADH autofluorescence in betaHC9 cells using two-photon excitation laser microscopy. In addition, we recorded the membrane potential and determined the ATP and ADP contents of the cells. The results indicated 22.2 mm glucose oxidation to be severely decreased by EtBr treatment compared with control cells (by 63% on day 4 and by 78% on day 6; both p < 0.01). By contrast, glucose utilization was only marginally decreased. Lactate production under 22.2 mm glucose was increased by 2.9- and 3.5-fold by EtBr treatment on days 4 and 6, respectively (both p < 0.01). Cellular NADH at 2.8 mm glucose was increased by 35 and 43% by EtBr on days 4 and 6 (both p < 0.01). These data suggest that reduced expression of the mitochondrial electron transport system causes NADH accumulation in beta cells, thereby halting the tricarboxylic acid cycle on one hand, and on the other hand facilitating anaerobic glucose metabolism. Glucose-induced insulin secretion was lost rapidly along with the EtBr treatment with concomitant losses of membrane potential depolarization and the [Ca(2+)](i) increase, whereas glibenclamide-induced changes persisted. This is the first report to demonstrate the connection between metabolic alteration of electron transport system and that of tricarboxylic acid cycle and its impact on insulin secretion.

The relationship between insulin resistance and cardiovascular risk factors in overweight/obese non-diabetic Asian adults: the 1992 Singapore National Health Survey

OBJECTIVE

Insulin resistance (IR) is associated with cardiovascular risk factors including hypertension, dyslipidemia, glucose intolerance and hyperuricemia. The relationship between IR and these cardiovascular risk factors in obese non-diabetic individuals is not well studied. We explore this relationship by comparing the cardiovascular risk factors among insulin-sensitive and insulin-resistant overweight/obese non-diabetic Asian adults in the 1992 National Health Survey of Singapore.

DESIGN AND MEASUREMENTS

A total of 3568 subjects were examined in the survey, which involved a combination of disproportionate stratified sampling and systematic sampling. Anthropometric measurements, level of physical activity, blood pressure, insulin, lipid profile, uric acid and standard 75 g oral glucose tolerance test were performed after a 10 h overnight fast. Subjects with diabetes were excluded from the analysis. Homeostasis model assessment (HOMA) was used to assess insulin sensitivity. Relative LDL size was derived from the formula LDL/ApoB. We defined insulin-sensitive individuals as having a HOMA value <1.479 (below median in individuals without diabetes; n=3226) and overweight/obesity as body mass index (BMI) >or=25.0 kg/m(2).

RESULTS

There were 156 insulin-sensitive (S) and 679 insulin-resistant (R) overweight/obese individuals, respectively. The groups did not differ in terms of gender and ethnic distribution and level of physical activity. However, subjects in group S were younger than those in group R (mean+/-s.d.; 40.1+/-12.1 vs 42.4+/-12.7 y; P<0.05). Group R individuals were also slightly more obese globally and centrally than group S (BMI=28.2+/-3.2 vs 27.1+/-2.8 kg/m(2); waist circumference (WC)=86.7+/-9.3 vs 82.5+/-8.3 cm; P<0.01). There were more subjects with impaired glucose tolerance (IGT) in group R than in group S (29.7 vs 16.0%; P<0.01). After adjustment for age and indices of global and regional obesity (ie BMI and WC), insulin-resistant individuals showed higher apolipoprotein B, triglyceride, fasting (FPG) and 2 h post-load plasma glucose (2hPG) but lower HDL and LDL size. Further adjustment for FPG, 2hPG and level of physical activity had minimal impact on the results.

CONCLUSIONS

Insulin-resistant overweight/obese non-diabetic Asian adults had greater burden of the cardiovascular dysmetabolic syndrome than insulin-sensitive overweight/obese individuals. This could not be fully explained by differences in global and regional obesity, glucose tolerance and level of physical activity.

A screening procedure detecting high-yield candidates for OGTT. The Women's Health in the Lund Area (WHILA) study: a population based study of middle-aged Swedish women

The objective was to evaluate a screening procedure for detecting high-yield candidates for an OGTT, in a population of middle-aged Swedish women. A two-step screening procedure was performed in 6917 subjects. Women with a positive screening outcome, i.e. increased non-fasting capillary blood glucose, serum triglycerides, BMI, WHR, blood pressure or a family history of diabetes, pharmacological treatment of hypertension or hyperlipidaemia at the primary screening underwent a 75-g OGTT. A control group of women with negative screening outcome (n = 221) also underwent an OGTT. In 2923 women with positive screening outcome, 517 (17.7%) had NFG/IGT (normal fasting venous blood glucose <5.6 mmol/l and 2h-glucose 6.7-9.9 mmol/l), 109 (3.7%) IFG/IGT (fasting 5.6-6.0 and 2h 6.7-9.9 mmol/l) and 223 (7.6%) diabetes (fasting > or = 6.1 or 2h > or = 10.0 mmol/l). These figures were three, five and four times higher, respectively, than in the control group with negative screening outcome (p < 0.001 for all); no differences were found for IFG/NGT (fasting 5.6-6.0 and normal 2h < 6.7 mmol/l) (4.6% vs. 7.2%). For predicting impaired glucose metabolism (IFG/NGT, NFG/IGT, IFG/IGT, diabetes), the screening instrument showed an estimated sensitivity of 70%, specificity of 55%, positive predictive value of 34% and negative predictive value of 85%, based on findings in the control sample. The odds ratio for NFG/IGT increased with the numbers of risk factors from 2.8 to 7.7, for IFG/ IGT from 5.7 to 55.0 and for diabetes from 2.5 to 18.1. High B-glucose, WHR and BMI were the three most important factors associated with an increased risk for NFG/IGT, IFG/IGT and diabetes. In subjects with IFG/NGT, none of the screening variables was associated with an increased risk. In summary, the results show a population screening method focused on features of the metabolic syndrome that discloses high-yield candidates for OGTT. A high prevalence of unknown impaired glucose metabolism was found in middle-aged women with a positive screening profile.

Comparison of carotid intima-media thickness, arterial stiffness, and brachial artery flow mediated dilatation in diabetic and nondiabetic subjects (The Chennai Urban Population Study [CUPS-9])

This study compares flow-mediated dilation (FMD) and the augmentation index (AI) in diabetic and nondiabetic subjects and correlates these measurements with carotid intima-media thickness (IMT). Fifty diabetic subjects and 50 age- and sex-matched nondiabetic control subjects were recruited from the Chennai Urban Population Study. IMT of the common carotid artery and FMD of the brachial artery were determined using high-resolution B-mode ultrasonography. AI was measured using the Sphygmocor apparatus. The mean AI of diabetic subjects was significantly higher than the nondiabetic subjects (27.48 +/- 7.41% vs 19.10 +/- 8.19%, p <0.0001). The FMD values were significantly lower among diabetic subjects compared with the nondiabetic subjects (2.1 +/- 2.95% vs 6.64 +/- 4.38%, p <0.0001). At any given age point, diabetic subjects had significantly higher AI and lower FMD values compared with nondiabetic subjects (p <0.05). In the total population, AI and FMD showed a correlation with age (p <0.001), fasting plasma glucose (p <0.01), glycosylated hemoglobin (p = 0.001), and IMT (p = 0.001). Among the nondiabetic subjects, FMD and AI showed a strong correlation with IMT. FMD also showed a strong correlation with age and systolic blood pressure, whereas AI showed a correlation with fasting plasma glucose in diabetic subjects. AI and FMD values showed a strong correlation with age. AI values increased and FMD values decreased with an increase in quartiles of IMT both in diabetic and nondiabetic subjects. Multivariate linear regression analyses in the total study population showed that age and glycosylated hemoglobin were the risk factors associated with AI and FMD, in addition to diastolic blood pressure with AI. Diabetic patients have decreased FMD and increased arterial stiffness compared with age- and sex-matched nondiabetic subjects. These functional changes correlate well with the structural changes of the arteries measured by IMT.

Epidemiologic evidence for the relation between socioeconomic status and depression, obesity, and diabetes

Many of the leading causes of death and disability in the United States and other countries are associated with socioeconomic position. The least well-off suffer a disproportionate share of the burden of disease, including depression, obesity, and diabetes. Research suggests that the adverse effects of economic hardship on both mental and physical health and functioning are evident at young ages and persist across the lifecourse. Moreover, these associations are seen across cultures. Data from four large epidemiologic studies on the role of psychological characteristics, social factors, and behaviors in health and disease risk are presented that highlight the striking associations between socioeconomic factors and chronic diseases. Data from these studies demonstrate that the effects of economic disadvantage are cumulative, with the greatest risk of poor mental and physical health seen among those who experienced sustained hardship over time.

A diabetes outcome progression trial (ADOPT): an international multicenter study of the comparative efficacy of rosiglitazone, glyburide, and metformin in recently diagnosed type 2 diabetes

OBJECTIVE

Therapies with metformin, sulfonylureas, or insulin improve glycemic control in the short term but do not prevent progressive islet beta-cell failure or long-term deterioration in glycemia. Our goal was to evaluate, in patients recently diagnosed with type 2 diabetes (<3 years), the long-term efficacy of monotherapy with rosiglitazone on glycemic control and on the progression of pathophysiological abnormalities associated with type 2 diabetes as compared with metformin or glyburide monotherapy.

RESEARCH DESIGN AND METHODS

A Diabetes Outcome Progression Trial (ADOPT) is a randomized, double-blind, parallel-group study consisting of a screening visit, a 4-week placebo run-in, a 4-year treatment period, and an observational follow-up of approximately 3,600 drug-naïve patients with type 2 diabetes diagnosed within the previous 3 years. After run-in, patients will be randomized to rosiglitazone, glyburide, or metformin titrated to the maximum effective daily doses (8 mg rosiglitazone, 15 mg glyburide, or 2 g metformin). The primary outcome is time to monotherapy failure, defined as the time following titration to the maximal effective or tolerated dose when fasting plasma glucose exceeds 180 mg/dl (10 mmol/l). Secondary outcomes include measures of islet beta-cell function, insulin sensitivity, dyslipidemia, changes in urinary albumin excretion, plasminogen activator inhibitor-1 antigen, fibrinogen, and C-reactive protein. Safety and tolerability will also be evaluated. Patient-reported outcomes and resource utilization data will be collected and analyzed.

CONCLUSIONS

ADOPT will provide data on the effect of mechanistically differing treatment options on metabolic control, beta-cell function, and markers of macrovascular disease risk in type 2 diabetes.

Steatohepatitis in obese individuals

Nonalcoholic steatohepatitis (NASH), which is the most severe histological form of nonalcoholic fatty liver disease (NAFLD), is emerging as the most common clinically important form of liver disease in developed countries. Although its prevalence is 3% in the general population, this increases to 20-40% in obese patients. Since NASH is associated with obesity, prevalence has been predicted to increase along with the arsent epidemic of obesity and type II diabetes mellitus. The importance of this observation comes from the fact that NASH is a progressive fibrotic disease, in which cirrhosis and liver-related death occur in 25% and 10% in these patients respectively over a 10-year period. This is of particular concern given the increasing recognition of NASH in children. Treatment consists of treating obesity and its co-morbidities; diabetes and hyperlipidemia. Nascent studies suggest that a number of pharmacological therapies may be effective, but all remain unproven at present. Histological and laboratory improvement occurs with a 10% decrease in body weight. Bariatric surgery is indicated in selected patients.A greater understanding of the pathophysiological progression of NASH in obese patients must be obtained in order to develop more focused and improved therapy.

Diabetes self-care and educational needs in Tanzanian and Swedish diabetic patients: a cross-cultural study

The aim was to compare self-care and perceived educational needs in adult Tanzanian and Swedish diabetic patients. One hundred and fifty Tanzanians were matched with Swedes (n=150). All 300 patients filled in questionnaires about their self-care and educational needs. The comparison indicated the Tanzanians were almost as satisfied with their self-care as the Swedes, but Tanzanians were dissatisfied with the lack of drugs and wanted more diabetes education while the Swedes were more dissatisfied with their own self-care behaviour. None of theTanzanians monitored their own blood glucose, whereas half the patients in the Swedish group did so weekly or monthly. The findings suggest that diabetes education in Tanzania should concentrate more on basic diabetes knowledge. In Sweden, however, the main points to be stressed should be life style and psychology.

Epidemiology of onychomycosis in patients with diabetes mellitus in India

BACKGROUND

The number of individuals diagnosed with diabetes mellitus is increasing worldwide. Although onychomycosis is often observed in diabetics, there have been no large studies of its epidemiology in this patient group in India.

METHODS

We studied the prevalence of onychomycosis in diabetics attending the Diabetes Clinic at the Postgraduate Institute of Medical Education and Research, Chandigarh, India, and compared it with that in a nondiabetic control group. A total of 400 diabetic subjects (237 males, 163 females), aged 48.8 +/- 0.5 years (mean +/- SD), were evaluated.

RESULTS

The prevalence of onychomycosis in the diabetic and control groups was 17% and 6.8%, respectively, the difference being statistically significant (P < 0.001). The presence of onychomycosis was found to correlate significantly with increasing age (P < 0.01) and male gender (P < 0.05) in both diabetic and control groups. From diabetics, yeasts were the most common isolate (48.1%), followed by dermatophytes and nondermatophyte molds in 37% and 14.8%, respectively. In the control group, the distribution of yeasts, dermatophytes, and nondermatophyte molds was 25%, 62.5%, and 12.5%, respectively. After controlling for age and sex, a stepwise logistic regression demonstrated that significant predictors for onychomycosis included the duration of diabetes (P < 0.01), absent or feeble peripheral pulses (P < 0.15), peripheral neuropathy (P < 0.05), and retinopathy (P < 0.001).

CONCLUSIONS

Diabetics were found to be 2.5 times more likely to have onychomycosis than the controls. Predisposing factors included increasing age, male gender, duration of diabetes, impaired peripheral circulation, peripheral neuropathy and retinopathy.

Hypoglycemic and antihyperglycemic activity of Murraya koenigii leaves in diabetic rats

The commonly used spice curry patta (Murraya koenigii) is traditionally consumed by diabetics in southern part of India. Feeding of diet containing various doses of curry leaves (5, 10 and 15%) to normal rats for 7 days as well as mild diabetic (blood glucose levels >175 mg/dl induced by alloxan 35 mg/kg IP) and moderate diabetic rats (blood glucose levels >250 mg/dl induced by STZ 60 mg/kg IP) for 5 weeks showed varying hypoglycemic and anti-hyperglycemic effect. In normal rats, reduction in blood glucose was almost negligible (approximately 4% with 10 and 15% diet). In mild and moderate diabetic rats, feeding of 5, 10 and 15% diet caused a maximal reduction in blood sugar by 13.1, 16.3 and 21.4% (NS, P<0.05 and 0.005) and 3.2, 5.58, 8.21% (NS), respectively. The mechanism of action is further discussed in light of results of previous and the present study.

Temporal changes in prevalence of type 2 diabetes and impaired glucose tolerance in urban southern India

The prevalence of type 2 diabetes and impaired glucose tolerance (IGT) is increasing in urban areas of developing countries, especially in India. This is a report of the temporal changes in the prevalence of diabetes and IGT in urban areas of Chennai (Madras), India, in adults aged > or =20 years, with an emphasis on identifying the risk factors responsible for the changes. Three urban diabetic surveys conducted in 1989, 1995 and 2000 were compared for the age-standardized prevalence, anthropometric, demographic and lifestyle characteristics of the glucose-intolerant groups. Multiple logistic regression analyses were used for the identification of risk variables associated with diabetes and IGT. The trend was statistically significant for diabetes (chi(2)=18.0, P<0.001) and for IGT (chi(2)=48.2, P<0.001). The period between 1989 and 1995 showed a 40% rise in the prevalence of diabetes and a further increase of 16.4% in the next 5 years. Age increased in each survey for both genders. Waist girth and waist:hip ratio were significantly higher in women, in the 2000 survey. There was no change in the mean body mass index with time in both genders. An increase in IGT was seen in year 2000, especially so in subjects aged <40 years. The prevalence of diabetes and IGT is increasing in India. Increasing age and positive family history showed associations with diabetes.

Diet and risk of coronary heart disease and type 2 diabetes

A high intake of saturated fat is an important risk factor for coronary heart disease (CHD) and type 2 diabetes. However the declining rates of CHD in many affluent societies and the steady increase in type 2 diabetes worldwide suggest that these important causes of serious morbidity and premature mortality have differing risk or protective factors worldwide. Changed macronutrient composition, reduced cigarette smoking, and improved treatment of risk factors and acute cardiac events might explain the reduction in risk of CHD, whereas the increasing rates of obesity are probably the most important explanation for the increase in diabetes. Coronary risk factors associated with diabetes could outweigh improvements in conventional cardiovascular risk factors such that the decline in CHD could be stopped or reversed unless rates of obesity can be reduced. Reduced intake of saturated fatty acids and other lifestyle interventions aimed at lowering rates of obesity are the changes most likely to reduce the epidemic numbers of people with type 2 diabetes and CHD.

The impact of diabetes mellitus and prior myocardial infarction on mortality from all causes and from coronary heart disease in men

OBJECTIVES

The goal of this study was to examine the impact of diabetes and prior myocardial infarction (MI) on mortality in men.

BACKGROUND

Previous studies have suggested that a history of diabetes and a prior MI confer similar risk for subsequent fatal coronary heart disease (CHD). Few studies have examined duration of diabetes in relation to mortality.

METHODS

We examined type 2 diabetes and prior MI in relation to mortality among 51,316 men aged 40 to 75 years in the Health Professionals Follow-up Study.

RESULTS

During 10 years of follow-up, we documented 4,150 deaths from all causes, including 1,124 deaths from CHD. Compared with men without diabetes or prior MI at baseline, the multivariate relative risks (RRs) for fatal CHD were 3.84 (95% confidence interval [CI], 3.12 to 4.71) for those with diabetes only, 7.88 (95% CI, 6.86 to 9.05) for those with MI only, and 13.41 (95% CI, 10.49 to 17.16) for those with both diabetes and MI. The corresponding RRs for total mortality were 1.91 (95% CI, 1.70 to 2.15), 2.23 (95% CI, 2.03 to 2.45), and 3.13 (95% CI, 2.56 to 3.84), respectively. Duration of diabetes was an independent risk factor for total as well as CHD mortality; the multivariate RRs of CHD mortality for increasing duration of diabetes (< or = 5 years, 6 to 10 years, 11 to 15 years, 16 to 25 years, 26+ years) were 1.63, 1.93, 2.35, 2.31, and 3.87, respectively (p for trend <0.001), compared with nondiabetic participants.

CONCLUSIONS

These findings support that both diabetes and MI are associated with elevated total and CHD mortality, and having both conditions is particularly hazardous. Longer duration of diabetes is a strong predictor of death among diabetic men.

Alcohol consumption and the risk of diabetes by body mass index levels in a cohort of 5,636 Japanese

The association between alcohol consumption and the risk of diabetes in Japanese with a low-body mass index (BMI) (< or = 22.0 kg/m(2)), middle-BMI (22.1-24.9 kg/m(2)) and high-BMI (> or =25.0 kg/m(2)) was investigated among a cohort of 5,636 employees of a Japanese insurance company. Participants were free of diabetes at baseline and were followed up for a mean of 5.7 years with annual assessments of fasting plasma glucose (FPG). The outcome was a clinical diagnosis of diabetes on the basis of a questionnaire administered at each follow-up assessment or a follow-up FPG level of 7.8 mmol/l or more. Relative risks and 95% confidence intervals (95% CIs) were estimated by fitting pooled logistic regression models, which included age, gender, BMI, baseline FPG level, current tobacco use and current alcohol consumption. A total of 264 outcome events were recorded. The relative risk of diabetes associated with current alcohol consumption was 3.19 (95% CI 1.09-9.37) among low-BMI individuals, 0.41 (0.23-0.73) among middle-BMI individuals and 0.74 (0.44-1.25) among high-BMI individuals. In this study, current alcohol consumption was associated with an increased risk of diabetes among low-BMI individuals and a decreased risk of diabetes among middle-BMI individuals. A tendency for an association of alcohol consumption with a decreased risk of diabetes among high-BMI individuals was noted, although without statistical significance.

Population-based study of diabetes and risk characteristics in Turkey: results of the turkish diabetes epidemiology study (TURDEP)

OBJECTIVES

To investigate for the first time the prevalence of diabetes and impaired glucose tolerance (IGT) nationwide in Turkey; to assess regional variations and relationships between glucose intolerance and lifestyle and physical risk factors.

RESEARCH DESIGN AND METHODS

The Turkish Diabetes Epidemiology Study (TURDEP) is a cross-sectional, population-based survey that included 24,788 subjects (age > or =20 years, women 55%, response 85%). Glucose tolerance was classified according to World Health Organization recommendations on the basis of 2-h blood glucose values.

RESULTS

Crude prevalence of diabetes was 7.2% (previously undiagnosed, 2.3%) and of IGT, 6.7% (age-standardized to world and European populations, 7.9 and 7.0%). Both were more frequent in women than men (P < 0.0001) and in those living in urban rather than rural communities (P < 0.001). Prevalence rates of hypertension and obesity were 29 and 22%, respectively. Both were more common among women than men (P < 0.0001). Prevalence of diabetes and IGT increased with rising BMI, waist-to-hip ratio (WHR), and waist girth (P < 0.0001). Multiple logistic regression analysis revealed that age, BMI, WHR, familial diabetes, and hypertension were independently associated with diabetes, age, BMI, WHR, familial diabetes, and hypertension with IGT (except for familial diabetes in women with IGT). Education was related to diabetes in men but was protective for diabetes and IGT in women. Socioeconomic status appeared to decrease the risk of IGT in men while it increased the risk in women. Smoking had a protective effect for IGT in both sexes.

CONCLUSIONS

Diabetes and IGT are moderately common in Turkey by international standards. Associations with obesity and hypertension have been confirmed. Other lifestyle factors had a variable relationship with glucose tolerance.

Improvement of BMI, body composition, and body fat distribution with lifestyle modification in Japanese Americans with impaired glucose tolerance

OBJECTIVE

To determine whether diet and endurance exercise improved adiposity-related measurements in Japanese Americans with impaired glucose tolerance (IGT).

RESEARCH DESIGN AND METHODS

This study compared the effects of an American Heart Association (AHA) step 2 diet (<30% of total calories as fat, <7% saturated fat, 55% carbohydrate, and < 200 mg cholesterol daily) plus endurance exercise for 1 h three times a week (treatment group) with an AHA step 1 diet (30% of total calories as fat, 10% saturated fat, 50% carbohydrate, and <300 mg cholesterol) plus stretching exercise three times a week (control group) on BMI, body composition (% fat), and body fat distribution at 6 and 24 months of follow-up in 64 Japanese American men and women with IGT, 58 of whom completed the study.

RESULTS

At 6 months, the treatment group showed significantly greater reduction in percent, body fat (-1.4 +/- 0.4 vs. -0.3 +/- 0.3%); BMI (-1.1 +/- 0.2 vs. -0.4 +/- 0.1 kg/m(2)); subcutaneous fat by computed tomography at the abdomen (-29.3 +/- 4.2 vs. -5.7 +/- 5.9 cm(2)), thigh (-13.2 +/- 3.6 vs. -3.6 +/- 3.0 cm(2)), and thorax (-19.6 +/- 3.6 vs. -8.9 +/- 2.6 cm(2)); and skinfold thickness at the bicep (-2.0 +/- 0.6 vs. 1.1 +/- 0.6 mm) and tricep (-3.7 +/- 0.8 vs. -0.9 +/- 0.6 mm), which continued despite moving to home-based exercise for the last 18 months.

CONCLUSIONS

Diet and endurance exercise improved BMI, body composition, and body fat distribution and, thus, may delay or prevent type 2 diabetes in Japanese Americans with IGT.

Diabetes trends in Europe

Estimates and projections suggest an epidemic expansion of diabetes incidence and prevalence in Europe. To evaluate trends in type 1 and type 2 diabetes in seven European countries (Finland, Denmark, the UK, Germany, France, Spain, and Italy), a variety of information is available, including population-based studies on small or large cohorts of subjects representative of the general population in a particular country, European co-operative studies, and sales figures for insulin and oral hypoglycemic agents that allow extrapolation of the number of pharmacologically treated diabetic patients. The incidence of type 1 diabetes in young people is increasing in most European countries, as is its prevalence in all age groups. Type 2 diabetes is the major contributor to the epidemic rise in diabetes. From 1995 to 1999, the prevalence of type 2 diabetes increased considerably, particularly in the UK, Germany, and France. Costs of ambulatory and in-hospital diabetic care (including antidiabetic, antihypertensive, and hypolipidemic agents) have increased even more rapidly than has the number of affected patients. Diabetes trends in Europe are alarming; health care professionals involved in diabetes care must be made aware of these detrimental trends, and health care delivery to patients with diabetes must be improved.

Diabetic retinopathy among self reported diabetics in southern India: a population based assessment

AIMS

To estimate the prevalence of diabetic retinopathy among self reported diabetics in a population of southern India.

METHODS

A cross sectional sample of subjects aged 50 years and older was selected using a cluster sampling technique from Palakkad district of Kerala state. Eligible subjects were identified through a door to door survey. Ocular examinations including visual acuity and anterior and posterior segment examinations were performed at preselected sites within clusters. History of diabetes was elicited, and height, weight, and blood pressure were measured for all subjects.

RESULTS

Among the 5212 examined people (92% response rate), 68 (26.2%) of 260 people with self reported history of diabetes had diabetic retinopathy. The age-sex adjusted prevalence of diabetes among people aged 50 years and older was 5.1% (95% CI 3.9, 6.3, deff 4.33) and of diabetic retinopathy among the diabetics was 26.8% (95% CI: 19.2, 34.4, deff 1.99). Non-proliferative diabetic retinopathy (94.1%) was the most common form of retinopathy seen. Two eyes were blind (presenting vision <6/60) as a result of retinopathy.

CONCLUSION

Preventive strategies have to be evolved to ensure that blindness due to diabetic retinopathy does not become a public health problem in India. Further studies are required to understand the risk factors for retinopathy and vision loss in this population.

Prevalence of overweight in urban Indian adolescent school children

The prevalence of diabetes mellitus (DM) and cardiovascular disease (CVD) is increasing in urban India. Overweight in adolescence is a marker of overweight in adult age, and it shows an association with the above diseases. There have been meagre data from India on the prevalence of childhood obesity. The objective of the study was to quantify the prevalence of overweight and its risk factors in adolescent children in urban India. School students in the age group of 13-18 years (n = 4700, M:F 2382:2318) were studied. Body mass index (BMI) was measured. Data on physical activity, food habits, occupation of parents and their economic status, birth weight of the children and age at menarche in girls were obtained by questionnaire. Age-adjusted prevalence of overweight was 17.8% for boys and 15.8% for girls. It increased with age and was higher in lower tertiles of physical activity and in higher socio-economic group. Birth weight and current BMI were positively associated. The study highlighted the high prevalence of overweight in adolescent children in urban India. Life style factors influenced BMI in adolescent age.

Clinical manifestations and insulin resistance (IR) in polycystic ovary syndrome (PCOS) among South Asians and Caucasians: is there a difference?

OBJECTIVE

Polycystic ovary syndrome (PCOS) is more prevalent in South Asian women residing in the UK than in Caucasians. Insulin resistance (IR) is central to the pathogenesis of PCOS, while type 2 diabetes is commoner in South Asians. We aimed to determine a possible ethnic difference in the clinical and biochemical characteristics of South Asian vs. Caucasian women with PCOS.

PATIENTS AND DESIGN

A case-control cross-sectional observational study of consecutive women with anovular PCOS (47 South Asians, 40 Caucasians) and their age-matched controls (11 South Asians and 22 Caucasians).

MEASUREMENTS

Index subjects: a questionnaire-based interview on clinical symptoms and family history; anthropometric measurements, clinical observations of the presence and degree of acne, hirsutism and acanthosis nigricans; transvaginal pelvic ultrasound; biochemical analyses of fasting blood sugar, fasting plasma insulin, fasting lipids, testosterone, and SHBG concentrations.

CONTROL GROUP

age- and weight-matched unrelated women from the same ethnic backgrounds without PCOS seeking treatment for male infertility were studied by similar methods to those used with the index subjects.

RESULTS

South Asians with PCOS presented at a younger age (age 26 +/- 4 vs. 30.1 +/- 5 years, P = 0.005). Body mass index (BMI) and waist : hip ratios were similar in the two affected cohorts. More South Asians had oligomenorrhoea commencing at a younger age. Hirsutism (Ferriman Gallwey score 18 vs. 7.5, P = 0.0001), acne, acanthosis nigricans and secondary infertility were significantly more prevalent in South Asians. The fasting glucose was similar (4.52 +/- 0.08 vs. 4.62 +/- 0.09 mmol/l, P = 0.25), the fasting insulin higher (89.4 +/- 8.9 vs. 48.6 +/- 4.8 pmol/l, P = 0.0001) and insulin sensitivity (IS) lower (0.335 +/- 0.005 vs. 0.357 +/- 0.002, P = 0.0001) among South Asians. Serum SHBG was significantly less in South Asians (35 +/- 3.3 vs. 55 +/- 9.4 nmol/l, P = 0.02), while serum testosterone was similar (2.69 +/- 0.11 vs. 2.64 +/- 0.13 nmol/l, P = 0.37).

CONCLUSIONS

We conclude that South Asians with anovular PCOS seek treatment at a younger age, have more severe symptoms, and have higher fasting insulin concentrations and lower insulin sensitivity than Caucasians.

Diabetes trends in Africa

Diabetes is an important cause of morbidity and mortality in Africa. Although a dramatic increase in disease burden is projected, it remains to be seen what effect the ongoing devastation of HIV disease will have on the epidemiology of such chronic diseases as diabetes. Recent data on type 2 diabetes prevalence indicate low rates in some rural populations, moderate rates similar to those in developed areas in some countries, and alarmingly high rates in others. The frequent observation of moderate to high prevalence of impaired glucose tolerance, particularly in populations with a low prevalence of diabetes, may indicate the early stage of a diabetes epidemic. Risk factors include urbanization, age, and family history of disease, as well as such modifiable risk factors as adiposity and physical inactivity. For type 1 diabetes, limited data indicate that the prevalence is low in sub-Saharan Africa and that onset occurs later in life there than in other parts of the world. Mortality associated with diabetes is unacceptably high and is disproportionately due to preventable acute metabolic and infective causes. With long duration of disease, there is a high frequency of hypertension and microvascular complications. The apparent low frequency of chronic macrovascular complications needs fuller documentation - as does the apparent high frequency of hypertension even in the non-diabetic population. Efforts to prevent this disease and its complications in Africa are impeded by inadequate health care infrastructure, inadequate supply of medications, absence of educational programs, and lack of available health care facilities and providers.

Diabetes trends in Latin America

The incidence of type 1 diabetes in Latin America ranges from 0.4 to 8.3 cases per 100000 children under 15 years of age, and the prevalence of type 2 diabetes ranges from 1.2% to 8%, with higher prevalence rates in urban areas. The frequency of diabetes in Latin America is expected to increase by 38% over the next 10 years, compared with an estimated 14% increase in the total population. The total number of cases of diabetes is expected to more than double and to exceed the number of cases in the US, Canada, and Europe by 2025. Factors underlying this increase include aging and increased life expectancy of the population, increased urbanization, and lifestyle changes among Native American populations. In many places, only a minority of individuals currently receives treatment for diabetes. Furthermore, the diagnosis of type 2 diabetes often occurs late in the course of the disease, with the result that 10-40% of patients have chronic complications at the time of diagnosis. Hospital costs account for most direct expenditures associated with treatment, and mortality associated with diabetes has increased markedly in some areas over the past 2 decades.

Epidemiologic analyses of risk factors, risk indicators, risk markers, and causal factors. The example of albuminuria and the risk of cardiovascular disease in diabetes

Much of the practice of modern medicine deals with prevention of the consequences of chronic conditions, including diabetes, hypertension, obesity, asthma, chronic bronchitis, and inflammatory bowel diseases. To achieve this end, identifying people at risk for these consequences and then initiating the appropriate, evidence-based preventive therapies are key. Characterization and study of risk factors are at the core of this effort and represent the only way that high-risk individuals can be identified. These risk factors can be any imagined variable, ranging from a genetic mutation to a blood result, a previous disease, exposure to an infectious agent or toxin, a socioeconomic state, ethnicity, birth weight, or country of origin. All causal factors for an outcome are risk factors for that outcome; reducing these risk factors almost certainly reduces the outcome. The converse is usually not true, however: identification of a risk factor reveals little about its causal connection to the outcome in question, and reducing this risk factor may or may not reduce the outcome. Once high-risk individuals are identified on the basis of their risk factor profile, the relevant clinical question relates to which therapies have been identified clearly that will reduce the risk or the outcome. If modification of the level of the risk factor is considered therapeutically, the question of whether the risk factor is also a good surrogate outcome must be answered. Information regarding whether the risk factor causes the disease is highly desirable; however, it is often unavailable and is not required before making therapeutic decisions.

The prevalence of diabetes in the kingdom of Tonga

OBJECTIVE

To determine the prevalence of diabetes, impaired glucose metabolism, and related risk factors in Tonga.

RESEARCH DESIGN AND METHODS

A randomly selected representative national sample of 1,024 people aged >15 years was surveyed. Each participant had fasting blood glucose and HbA(1c) measured. Subjects with a fasting blood glucose >5.0 mmol/l (90 mg/dl) and <11.1 mmol/l (200 mg/dl) or a fasting blood glucose < or =5.0 mmol/l and an HbA(1c) >6.0% and every fifth subject with a fasting blood glucose < or =5.0 mmol/l and a normal HbA(1c) had a 75-g oral glucose tolerance test (OGTT). A total of 472 individuals had an OGTT based on these criteria. Subjects with a fasting blood glucose > or =11.1 mmol/l and an elevated HbA(1c) were diagnosed as having diabetes.

RESULTS

The mean age was 41.3 years, and the mean BMI was 32.3 kg/m(2). The age-standardized prevalence of diabetes was 15.1% (CI 12.5-17.6), 12.2% (8.7-15.8) in men and 17.6% (14.0-21.1) in women (NS), of which only 2.1% was previously diagnosed. A total of 75% of people with newly diagnosed diabetes had a fasting plasma glucose > or =7.0 mmol/l (126 mg/dl). The prevalence of impaired glucose tolerance was 9.4% (7.3-11.5) and of impaired fasting glycemia 1.6% (0.7-2.6). Undiagnosed diabetes was significantly associated with increasing age, obesity, hypertension, and a family history of diabetes.

CONCLUSIONS

The current prevalence of diabetes in Tonga is 15.1%, of which 80% is undiagnosed. A similar survey in 1973 reported a 7.5% diabetes prevalence, indicating a doubling of diabetes over the past 25 years. In addition, lesser degrees of glucose intolerance are common, and much of the community is overweight

Obesity and cardiovascular risk factors in Hong Kong Chinese

The purpose of this cross-sectional study was to examine the risk associations between obesity indexes [body mass index (BMI) and waist circumference (WC)], cardiovascular risk factors [plasma glucose and lipids, blood pressure and urinary albumin excretion (UAE)] and morbidity conditions (Type 2 diabetes mellitus, hypertension, dyslipidaemia and/or albuminuria) in Hong Kong Chinese. Seven-hundred and two Hong Kong Chinese subjects (18-65 years of age, 59.4% of whom had at least one morbidity condition) were recruited from the Prince of Wales Hospital, Hong Kong SAR. The measurements taken of the subjects included: height; weight; waist and hip circumferences; blood pressure; fasting plasma glucose and lipids; and 24-h UAE. The mean BMI was 22.4 and 25.7 kg m(-2) in healthy subjects and patients, respectively. The mean WC measurements of healthy subjects and patients were 77.1 and 86.4 cm in males and 71.0 and 81.8 cm in females, respectively. There were increasing trends between obesity indexes and the severity of cardiovascular risk factors and the prevalence of morbidity conditions (all P-values for trend <0.05). Using 19.0-20.9 kg m(-2) and <70 cm as a referent, subjects with a BMI of > or =25.0 kg m(-2) (in both sexes) and/or a WC of > or =85 cm in males and > or =75 cm in females had an age-adjusted odds ratio between 3.2 and 4.4 for the occurrence of at least one morbidity condition. Patients with a greater number of comorbidities also had higher BMI and WC measurements (all P-values for the trend were <0.05 with adjustment for age and gender). Hence, despite Hong Kong Chinese being less obese than Caucasians, the intimate relationships among obesity, cardiovascular risk factors and morbidity conditions remain. Our data support using lower BMI and WC levels to define obesity and its associated health risks rather than using the criteria established from Caucasians who generally have larger body frames.

Impaired long-chain fatty acid oxidation and contractile dysfunction in the obese Zucker rat heart

We investigated whether decreased responsiveness of the heart to physiological increases in fatty acid availability results in lipid accumulation and lipotoxic heart disease. Lean and obese Zucker rats were either fed ad libitum or fasted overnight. Fasting increased plasma nonesterified fatty acid levels in both lean and obese rats, although levels were greatest in obese rats regardless of nutritional status. Despite increased fatty acid availability, the mRNA transcript levels of peroxisome proliferator-activated receptor (PPAR)-alpha-regulated genes were similar in fed lean and fed obese rat hearts. Fasting increased expression of all PPAR-alpha -regulated genes in lean Zucker rat hearts, whereas, in obese Zucker rat hearts, muscle carnitine palmitoyltransferase and medium-chain acyl-CoA dehydrogenase were unaltered with fasting. Rates of oleate oxidation were similar for hearts from fed rats. However, fasting increased rates of oleate oxidation only in hearts from lean rats. Dramatic lipid deposition occurred within cardiomyocytes of obese, but not lean, Zucker rats upon fasting. Cardiac output was significantly depressed in hearts isolated from obese rats compared with lean rats, regardless of nutritional status. Fasting increased cardiac output in hearts of lean rats only. Thus, the heart's inability to increase fatty acid oxidation in proportion to increased fatty acid availability is associated with lipid accumulation and contractile dysfunction of the obese Zucker rat.

The economic cost of diabetes in Canada, 1998

OBJECTIVE

In Canada, diabetes poses a significant health problem, and current estimates of its economic burden have not incorporated the total cost of the disease. The objective of this study was to quantify the direct medical- and mortality-related productivity cost of diabetes in Canada for 1998.

RESEARCH DESIGN AND METHODS

Direct medical costs included hospital services, physician services, and medicines consumed by people with diabetes. These costs were based on a top-down costing methodology that allocated 1998 total medical expenditures to diabetes. The prevalence of diagnosed and undiagnosed diabetes and the relative risk of complications in people with diabetes were used to estimate the proportion of medical services that were consumed by people with diabetes. Mortality-related productivity losses were calculated using the human capital approach.

RESULTS

After varying the assumptions in a sensitivity analysis, the total economic burden (in U.S. dollars) of diabetes and its chronic complications in Canada for 1998 was likely to be between $4.76 and $5.23 billion. In those people just with diagnosed diabetes, the direct medical costs associated with diabetes care, before considering any complications, were $573 million. Of the costs associated with the complications of diabetes, cardiovascular disease was by far the greatest, at $637 million.

CONCLUSIONS

Cardiovascular disease was the major contributor to the direct costs of diabetes. The preventive management of diabetes should receive priority attention, and the prevention of cardiovascular disease in the patient with diabetes should become an imperative.

Digital retinal images and teleophthalmology for detecting and grading diabetic retinopathy

OBJECTIVE

Detecting and grading of diabetic retinopathy (DR) by means of digital retinal images sent via the Internet.

RESEARCH DESIGN AND METHODS

Four nonstereoscopic digital retinal images (45 degrees field each) of 126 eye fundus images from 70 diabetic patients were obtained with a nonmydriatic camera at two peripheral units. The images were sent via the Internet using a web-based system to a reference center, where they were diagnosed and graded by one ophthalmologist. These results were compared with those obtained by two other ophthalmologists, one at each peripheral unit, after direct examination of the patients. A modified severity scale of Airlie House was used for grading DR in all cases. Agreement between observers was assessed using unweighted kappa for categorical data and the intraclass correlation coefficient (ICC) for continuous data.

RESULTS

Presence of DR was detected in 69 eyes (55%). All eyes with DR (69 of 69, 100%) were correctly identified (kappa = 1) by inspecting the digital images. In 118 eyes (118 of 126, 94%), 57 with no DR and 61 with DR, there was an agreement between the gradation made after the direct examination and the gradation made after the inspection of the images (ICC = 0.92). In eight eyes with DR (8 of 126, 6%), there was disagreement in the grading made with both techniques.

CONCLUSIONS

Inspection of digital retinal images sent via the Internet allowed diagnosis and grading of DR. The presence or absence of DR was correctly assessed by inspection of the images in all instances. We also found agreement, in most cases, between retinopathy gradation made from the images and the gradation made by direct examination of the eyes. These findings suggest that this technique is suitable for screening procedures.

Predicting incident diabetes in Jamaica: the role of anthropometry

OBJECTIVE

To evaluate the performance of the body mass index (BMI), waist circumference, waist-to-hip ratio (WHR), and waist-to-height ratio (WHTR) in predicting incident diabetes in Jamaica.

RESEARCH METHODS AND PROCEDURES

A cohort of 728 nondiabetic adults (290 men and 438 women), ages 25 to 74 years and residents of Spanish Town, Jamaica, were followed for a mean of 4 years. Participants had fasting and 2-hour postchallenge glucose concentrations measured at baseline and follow-up.

RESULTS

There were 51 cases of incident diabetes (17 men and 34 women). All indices were independent predictors of diabetes, and none was clearly superior. The area under the receiver operating characteristics curves (95% confidence interval) for BMI was 0.74 (0.59 to 0.88) for men and 0.62 (0.51 to 0.72) for women. For waist circumference, these values were 0.78 (0.65 to 0.91) in men and 0.61 (0.50 to 0.71) in women. Similar results were obtained for WHR and WHTR. "Optimal" cut-off points for BMI were 24.8 kg/m(2) (men) and 29.3 kg/m(2) (women). For waist circumference, these were 88 cm and 84.5 cm for men and women, respectively. Corresponding values for WHR were 0.87 and 0.80 and for WHTR were 0.51 and 0.54, respectively.

DISCUSSION

Cut-off points for waist circumference and WHR were similar to those proposed in developed countries for women but lower in men. Waist circumference could be useful in health promotion as an alternative to BMI.

The Australian Diabetes, Obesity and Lifestyle Study (AusDiab)--methods and response rates

The Australian Diabetes, Obesity and Lifestyle Study (AusDiab) addresses the urgent need for data on diabetes prevalence, risk factors and associated conditions in Australia. Here we describe the methods used and the response rates obtained. AusDiab was a population-based cross-sectional survey of national diabetes mellitus prevalence and associated risk factors in people aged > or =25 years, conducted between May 1999 and December 2000 in the six states and the Northern Territory of Australia. The study involved an initial household interview, followed by a biomedical examination that included an oral glucose tolerance test (OGTT), standard anthropometric tests, blood pressure measurements and the administration of questionnaires. Of the 20347 eligible people (aged > or =25 years and resident at the address for > or =6 months) who completed a household interview, 11247 (55.3%) attended for the biomedical examination. Of those who completed the biomedical examination 55.1% were female. Comparisons with the 1998 Australian population estimates showed that younger age responders were under-represented at the biomedical examination, while the middle-aged and older age groups were over-represented. Weighting of the AusDiab data for age and gender have corrected for this bias. AusDiab, which is the largest national diabetes prevalence study undertaken in a developed nation to have used an OGTT, provides a valuable national resource for the study of the prevalence and possible causes of diabetes, as well as identifying possible risk factors that may lead to diabetes. Furthermore, it generates the baseline data for a prospective 5-year cohort study. The data will be important for national and regional public health and lifestyle education and health promotion programs.

Intake of refined carbohydrates and whole grain foods in relation to risk of type 2 diabetes mellitus and coronary heart disease

Recent survey data indicate that more than 50% of all adult Americans are overweight or obese. In parallel with this epidemic of weight gain in the general population, the incidence rate of type 2 diabetes mellitus (DM) is rapidly rising. Although their precise contributions are unclear, dietary factors are thought to affect body weight and the development of insulin resistance. Recent epidemiological data indicate that diets rich in high-fiber whole grains are associated with lower risk of coronary heart disease (CHD) and type 2 DM. These data are consistent with results from recent metabolic experiments, suggesting favorable lipid profiles and glycemic control associated with higher intake of whole grains, but not with refined grains. It seems prudent, therefore, to distinguish whole-grain rather than refined-grain cereal products for the prevention of chronic diseases.

Serum fructosamine as a marker of 5-year risk of developing diabetes mellitus in patients exhibiting stress hyperglycaemia

AIMS

We examined whether the level of random serum glucose (RSG) in subjects exhibiting stress hyperglycaemia is a useful marker of the future risk of developing diabetes mellitus (DM), and whether serum fructosamine is of any additional value.

METHODS

All non-diabetic adults attending Accident and Emergency in 1994-1995, who had venesection, were studied. Serum fructosamine and RSG were routinely measured in all such patients. Using the laboratory biochemistry database the number of subjects with stress hyperglycaemia (RSG > 11.1 mmol/l) was determined, and their corresponding fructosamine values were recorded. The number of subjects who developed DM over the following 5 years was determined.

RESULTS

Three hundred and seventeen patients had stress hyperglycaemia, and follow-up data were available on 224 patients. Of these patients, 63 (28%) had developed DM over the 5 years follow-up period. RSG and fructosamine levels at baseline of patients subsequently developing DM were (mean +/- sd (range)) 16.7 +/- 7.0 (11.2-55.0) mmol/l and 3.3 +/- 0.6 (1.3-4.5) mmol/l, respectively. The patients who did not develop DM had a similar baseline RSG, 15.9 +/- 3.3 (11.2-30.6) mmol/l; P = 0.170, but lower baseline fructosamine, 2.4 +/- 0.4 (1.6-3.8) mmol/l; P < 0.001. Receiver-operating characteristics showed that a serum fructosamine > or = 2.8 mmol/l was a useful marker of the future risk of DM (75% sensitivity, 74% specificity, 53% positive and 88% negative predictive power).

CONCLUSIONS

The level of RSG in stress hyperglycaemia does not predict the future development of DM. Raised serum fructosamine is a more useful marker of future DM risk than RSG alone. Further prospective studies are needed.

Cardiovascular risk profile assessment in glucose-intolerant Asian individuals--an evaluation of the World Health Organization two-step strategy: the DECODA Study (Diabetes Epidemiology: Collaborative Analysis of Diagnostic Criteria in Asia)

AIMS

To assess the cardiovascular (CVD) risk factor profile in individuals with diabetes and impaired glucose tolerance (IGT) identified by a one-step (fasting plasma glucose (FPG)) or a two-step strategy (including an oral glucose tolerance test (OGTT) in subjects with impaired fasting glucose (IFG)) as recommended by the World Health Organization (WHO).

METHODS

Twelve population-based studies in six countries (17 512 subjects, age 30-89 years, without known diabetes, with OGTT (fasting and 2-h plasma glucose (2-h PG))). Age, gender, and centre-adjusted means of CVD risk factors were compared according to the level of glucose intolerance.

RESULTS

Diabetes was found in 1270 individuals and IFG or IGT in 3158. In the diabetic group 55.1% had a FPG > or = 7.0 mmol/l (range between countries 36.2-67.0%), 20.5% were identified through the stepwise strategy (range 0-32%), while 24.4% would remain undiagnosed (FPG < 6.1 mmol/l) (range 9.0-40.0%). The two-step strategy identified 60-91% of all newly diagnosed diabetic subjects with 5-12% of the population requiring an OGTT. Mean body mass index (BMI), blood pressure, and total cholesterol did not differ between diabetic individuals diagnosed by FPG or OGTT. The step-wise strategy identified < 50% of the subjects with impaired glucose regulation, and the cardiovascular risk profile (BMI, blood pressure, and cholesterol) did not differ between those identified and those not identified in the screening process.

CONCLUSIONS

Applying an OGTT in subjects with IFG will fail to detect every fourth diabetic individual and every second individual with impaired glucose regulation. Individuals not diagnosed had a cardiovascular risk profile identical to those identified in the diagnostic process. Lower thresholds for an OGTT may be necessary in Asian populations.

Physical activity and its relationship with obesity, hypertension and diabetes in urban and rural Cameroon

OBJECTIVES

To evaluate and compare physical activity patterns of urban and rural dwellers in Cameroon, and study their relationship with obesity, diabetes and hypertension.

METHODS

We studied 2465 subjects aged >or=15 y, recruited on the basis of a random sampling of households, of whom 1183 were urban dwellers from Yaoundé, the capital city of Cameroon and 1282 rural subjects from Bafut, a village of western Cameroon. They all had an interviewer-administered questionnaire for the assessment of their physical activity and anthropometric measurements, blood pressure and fasting blood glucose determination. The procedure was satisfactorily completed in 2325 (94.3%) subjects. Prevalences were age-adjusted and subjects compared according to their region, sex and age group.

RESULTS

Obesity was diagnosed in 17.1 and 3.0% urban and rural women, respectively (P<0.001), and in 5.4 vs 1.2% urban and rural men, respectively (P<0.001). The prevalence of hypertension was significantly higher in urban vs rural dwellers (11.4 vs 6.6% and 17.6 vs 9.1% in women and men, respectively; P<0.001). Diabetes was more prevalent in urban compared to rural women (P<0.05), but not men. Urban subjects were characterized by lower physical activity (P<0.001), light occupation, high prevalence of multiple occupations, and reduced walking and cycling time compared to rural subjects. Univariate analysis showed significant associations between both physical inactivity and obesity and high blood pressure. The relationship of physical inactivity with hypertension and obesity were independent in both urban and rural men, but not in women. Body mass index, blood pressure and glycaemia were higher in the first compared with the fourth quartiles of energy expenditure.

CONCLUSION

Obesity, diabetes and hypertension prevalence is higher in urban compared to rural dwellers in the populations studied. Physical activity is significantly lower and differs in pattern in urban subjects compared to rural. Physical inactivity is associated with these diseases, although not always significant in women.

Age, body mass index and glucose tolerance in 11 European population-based surveys

AIMS

To describe the variation in the estimated prevalence of diabetes and impaired glucose regulation (IGR) within Europe in relation to age and body mass index (BMI).

METHODS

Cross-sectional data from European population-based studies with both fasting and 2-h glucose after a standard 75-g oral glucose tolerance test were included (9449 men, 7752 women).

RESULTS

There was a large variation in the estimated prevalence of diabetes and impaired glucose regulation among 11 European centres, ranging from 2% to 24% for diabetes and 5% to 43% for IGR. In cross-sectional analysis the estimated prevalence of diabetes and IGR increased with age and BMI. The impact of age did not differ between centres with similar age range, and the impact of BMI was similar in most centres.

CONCLUSIONS

Differences in age and BMI within Europe partly explained the variation in estimates of the IGR and diabetes prevalence. The impact of age and BMI did not differ between centres. Variations in prevalence must therefore be due to other factors that we could not adjust for, such as methodology, differences in diet, physical activity and genetic predisposition.

Coping with Type II diabetes: the patient's perspective

AIMS/HYPOTHESIS

The Cost of Diabetes in Europe-Type II study is the first coordinated attempt to assess the total costs of Type II (non-insulin-dependent) diabetes mellitus in Europe. Although gaining a clearer understanding of the economics of diabetes was the goal of the study, a secondary objective was to consider the impact of Type II diabetes from the patient's perspective.

METHODS

The protocol included a health status questionnaire completed by the patient, the EQ-5D instrument, which assessed health-related quality of life by asking the patient to consider five dimensions: mobility, self-care, usual activities, pain and discomfort, as well as anxiety and depression.

RESULTS

A total of 4189 patients in five of the eight countries completed the EQ-5D questionnaire for assessing the quality of life. Overall, patients with Type II diabetes reported scores between good and fair states of health, although the average score (0.69) was lower than that of the similarly aged, healthy population in the United Kingdom. However, these values were higher (0.76) in Type II diabetic patients without complications. The onset of either microvascular or macrovascular complications adversely affected quality of life (0.69 and 0.69, respectively), and the presence of both types of complications further reduced the quality of life score to 0.59. Treatment with insulin was also associated with a reduced quality of life (0.62). Multivariate analysis showed that the following factors, in order of importance, independently pre-dict a poorer quality of life: gender, complications, treatment type, age, obesity and hyperglycaemia.

CONCLUSION/INTERPRETATION

The results showed that health-related quality of life is an important issue in Type II diabetes and this decreases with disease progression. The implication for policy-makers is that reducing or preventing the complications of diabetes is the key to improving patient quality of life.

Fears and worries associated with hypoglycaemia and diabetes complications: perceptions and experience of Hong Kong Chinese clients

AIM

This paper reports the second phase of a study that explored the perceptions and experience of Hong Kong Chinese insulin-treated clients who demonstrated fear of hypoglycaemia and worry about diabetes complications.

BACKGROUND

The first phase of the study, a descriptive survey (n = 120), identified 15% of respondents as simultaneously sustaining fears and worries associated with hypoglycaemia and diabetes complications. Although a small percentage, given the increasing number of clients using insulin treatment, this finding suggests a pocket of clients suffering from undesirable emotional health. However, a search of the literature identified few studies exploring Chinese clients' perceptions and experience in this area.

DESIGN

The second phase of the study employed a purposive sampling method and semi-structured interviews to collect data from 13 participants experiencing these fears and worries. FINDINGS; Two researchers independently used content analysis to code and categorize data. Six categories identified were: the influence of perceptions of glycaemic control on emotion, hypo- and hyperglycaemia as a constant threat, keeping optimal glycaemic control or maintaining a working life, financial and psychological burden of blood glucose self-monitoring, being alone with the threat and finally distancing as the coping method. An overriding issue, a sense of losing control, emerged from the findings that described participants' perceptions and experience. This issue and two major health needs, developing self-efficacy and emotional support from nurses, were drawn from the findings for discussion. It is suggested that self-efficacy theory can be adopted as a conceptual framework to guide nursing practice for enhancing clients' capacity to exercise control over diabetes self-management.

CONCLUSIONS

Findings obtained from the second phase of the study illuminated those from the first phase. Implications for nursing practice were identified, including facilitating both technical and psychosocial self-efficacy, assessing clients' total life situation, strengthening competence in counselling skills and forming alliances with clients.