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

Prevalence of type 2 diabetes mellitus in Taiwan: ethnic variation and risk factors

The purpose of this study was to compare the prevalence of diabetes and risk factors for the disease in three ethnic groups in Taiwan; the Hakaas, Fukienese, and aborigines. A cross-sectional study of men and women aged 50-79 years were invited to attend a standardized interview and physical examination. Diabetes mellitus was defined as a fasting plasma glucose (concentration of greater than or = 126) or a previous diagnosis of diabetes. Demographic, socioeconomic, and risk factor data were obtained. A total of 1293 persons (468 Hakaas, 440 Fukienese, and 385 aborigines) completed the examination. Hakaas had the highest age-adjusted prevalence of diabetes, 17.9% in men and 15.5% in women, followed by Fukienese, 14.5% in men and 12.8% in women. Aborigines had a prevalence of 10.0% in men and 13.3% in women. Diabetes prevalence was positively associated with family history of diabetes, obesity, hypertension, and hypertriglyceridemia. The ethnic variation in diabetes prevalence was reduced after adjustment for age, sex and significant factors. The multivariate-adjusted odds ratios (95% confidence interval) were 1.27 (0.76-2.12) for Fukienese and 1.44 (0.89-2.33) for Hakaas compared with aborigines. Diabetes mellitus is a major public health problem in Taiwan and warrants prevention efforts tailored to the country's different ethnic groups.

Beneficial and detrimental effects of intensive glycaemic control, with emphasis on type 2 diabetes mellitus

Diabetes mellitus is a major health problem in the world. Several clinical trials have shown that some of the major complications of diabetes mellitus can be partially prevented or delayed by intensive glycaemic control. However, there are benefits and risks in aiming for near normal blood glucose levels. Intensive glycaemic control delays the onset and progression of retinopathy, nephropathy and neuropathy. Epidemiological and observational studies have shown that cardiovascular events may be correlated with the severity and duration of diabetes mellitus, but major randomised trials have only shown weak and nonsignificant benefits of intensive glycaemic management in decreasing event rates. A modest improvement in lipid profile results from blood glucose control although, in the majority of cases, not enough to reach current targets. Detrimental effects of intensive glycaemic control include bodyweight gain and hypoglycaemia. Controversial issues in the management of patients with diabetes mellitus include the unproven increase in cardiovascular morbidity from sulphonylureas and hyperinsulinaemia, and the still unknown long term effects of newer oral antihyperglycaemic agents alone or in combination with traditional therapies (such as sulphonylureas and metformin). It is important to individualise management in setting glycaemic goals. Control of cardiovascular risk factors through blood pressure and lipid control and treatment with aspirin (acetylsalicylic acid) and ACE inhibitors have consistently shown benefits in the prevention of both macro- and microvascular complications in patients with diabetes mellitus; these measures deserve priority.

Prevention of cardiovascular disease and diabetes: lessons from the Malmö Preventive Project

Major public health problems such as cardiovascular disease and type 2 diabetes pose a challenge to both the medical profession and the health care system of most Western countries. In spite of widespread knowledge about risk factors and pathophysiological processes, it has been difficult to find effective preventive mass strategies based on evidence from controlled clinical trials. In the Malmö Preventive Project, Sweden, 33 346 subjects were screened for risk factors between 1974 and 1992, and a quarter of them were offered preventive help for cardiovascular disease risk or alcohol abuse. The overall finding of the project was that benefits of screening and prevention on mortality risk could only be shown in certain subgroups of younger men and women, not in the total screened cohort, as compared with a nonscreened reference population. These findings therefore question the effectiveness of preventive methods and drugs used during previous decades. New preventive methods are therefore needed and should be properly evaluated to form a basis for evidence-based prevention (EBP) in cardiovascular medicine.

Women with a history of gestational diabetes of European and South Asian origin are shorter than women with normal glucose tolerance in pregnancy

AIMS

It has been reported that short individuals are more likely to have abnormalities of glucose homeostasis. The aim of this study was to examine the relationship between adult height and gestational diabetes mellitus (GDM), taking into account possible artefactual or confounding explanations.

METHODS

Three hundred and forty-six women with previous GDM (169 European, 102 South Asian, 75 Afro-Caribbean) and 470 control women with no previous history of GDM (282 European, 94 South Asian and 94 Afro-Caribbean) were studied. Post-partum glucose status and height were measured.

RESULTS

European and South Asian women with previous GDM were shorter than control women from the same ethnic groups (European: (mean +/- SD) 162.9 +/- 6.1 vs. 165.3 +/- 6.8 cm, P < 0.0001; South Asian: 155.2 +/- 5.4 vs. 158.2 +/- 6.3 cm, P = 0.003, adjusted for age). A similar, but non-significant trend was observed among Afro-Caribbean women (162.2 +/- 6.2 vs. 163.7 +/- 6.1 cm, P = 0.1). Similar, significant height differences were observed in Europeans and South Asians when analysis was restricted to those GDM women who had received insulin during pregnancy. There was no association between height and glucose tolerance postpartum within the GDM group.

CONCLUSIONS

European and South Asian women with previous GDM are shorter than control women from the same ethnic groups. The data demonstrate that this is unlikely to be an artefact resulting from the use of an fixed 75 g load in women of differing sizes, and suggest that there are likely to be common pathophysiological mechanisms underlying GDM and the determination of final adult height.

Direct medical costs for patients with type 2 diabetes in Sweden

OBJECTIVES

To estimate the total direct medical costs to society for patients with type 2 diabetes in Sweden and to investigate how different factors, for example diabetic late complications, affect costs.

DESIGN

Cross-sectional data regarding health care utilization, clinical characteristics and quality of life, were collected at a single time-point. Data on resource use cover the 6-month period prior to this time point.

SETTING

Patient recruitment and data collection were performed in nine primary care centres in three main regions in Sweden.

SUBJECTS

Only patients with an age at diabetes diagnosis >/= 30 years (type 2 diabetes) were included (n = 777).

RESULTS

The total annual direct medical costs for the Swedish diabetes type 2 population were estimated at about 7 billion SEK (Swedish Kronor) in 1998 prices, which is about 6% of the total health care expenditures and more than four times higher than the former Swedish estimate obtained when using diabetes as main diagnosis for calculating costs. The annual per patient cost was about 25 000 SEK. The largest share of this cost was hospital inpatient care. Costs increased with diabetes duration and were higher for patients treated with insulin compared to those treated with oral hypoglycaemic drugs or with life style modification only. Patients with both macro- and microvascular complications had more than three times higher costs compared with patients without such complications.

CONCLUSIONS

Type 2 diabetes is a serious and expensive disease and the key to reducing costs seems to be intensive management and control in order to prevent and delay the associated late complications.

Epidemiology of diabetes mellitus in Western pacific region: focus on Philippines

The aim of Diabcare-Asia project was to collect data on diabetes control, management and complication status among patients in 12 Asian countries. Information was extracted from medical records, interviews and laboratory assessment. The majority (96%) of patients were diagnosed with type 2 diabetes mellitus, with mean age (+/-SD) of 59.3+/-12.5 years and mean diabetes duration of 9.4+/-7.0 years. Mean body mass index (BMI) was 24.7+/-4.9 kg/m(2) and the majority (60%) had BMI < or =25 kg/m(2). The majority (70%) of patients were treated with oral antidiabetic drugs (OADs), 15% with insulin, 10% with insulin and OAD combination therapy and 5% with diet control. Among OADs-treated patients, most (44%) received two or more medication. Majority of patients (> or =79%) had satisfactory metabolic control of triglycerides (<2.2 mmol/l), total cholesterol (<6.5 mmol/l) and HDL cholesterol (>0.9 mmol/l). Glucose self-monitoring (either urine or blood) was only practiced by 50% of patients. Glycaemic control (HbA1c) was unsatisfactory as majority of patients had HbA1c>7.4% (73%) and 50% had fasting blood glucose (FBG)>7.8 mmol/l. Cataract (26%), neuropathy (42%) and cerebral stroke (6%) were the most frequently reported complications. Clearly, the level of glycaemic control in majority of patients is below satisfaction. Effective education must be emphasised in the management of diabetes.

Fear of hypoglycaemia among insulin-treated Hong Kong Chinese patients: implications for diabetes patient education

This study investigated fear of hypoglycaemia among insulin-treated Chinese patients in Hong Kong. The study employed a cross-sectional descriptive design. Using structured-interviews, the authors collected data from 120 insulin-treated adults attending a diabetes centre. Results showed that although hypoglycaemic attacks were generally mild, they were common amongst one-third of patients. Fear was predominantly low, however 15% of respondents reported high fear. In addition, fear correlated positively with time since insulin-treatment, frequency of hospitalization due to hypoglycaemia, and frequency of hypoglycaemia affecting working life. Results also showed that although all respondents were insulin-treated, 40% had undesirable metabolic control. No statistically significant differences were found between the respondents' rating of adequacy of their diabetes knowledge among three groups of respondents who had completed, defaulted or were attending an education programme. Implications for diabetes patient education and further study are discussed.

Diabetes--a common, growing, serious, costly, and potentially preventable public health problem

An estimated 135 million people worldwide had diagnosed diabetes in 1995, and this number is expected to rise to at least 300 million by 2025. The number of people with diabetes will increase by 42% (from 51 to 72 million) in industrialized countries between 1995 and 2025 and by 170% (from 84 to 228 million) in industrializing countries. Several potentially modifiable risk factors are related to diabetes, including insulin resistance, obesity, physical inactivity and dietary factors. Diabetes may be preventable in high-risk groups, but results of ongoing clinical trials are pending. Several efficacious and economically acceptable treatment strategies are currently available (control of glycemia, blood pressure, lipids; early detection and treatment of retinopathy, nephropathy, foot-disease; use of aspirin and ACE inhibitors) to reduce the burden of diabetes complications. Diabetes is a major public health problem and is emerging as a pandemic. While prevention of diabetes may become possible in the future, there is considerable potential now to better utilize existing treatments to reduce diabetes complications. Many countries could benefit from research aimed at better understanding the reasons why existing treatments are under-used and how this can be changed.

Genetic variation in the gene encoding calpain-10 is associated with type 2 diabetes mellitus

Type 2 or non-insulin-dependent diabetes mellitus (NIDDM) is the most common form of diabetes worldwide, affecting approximately 4% of the world's adult population. It is multifactorial in origin with both genetic and environmental factors contributing to its development. A genome-wide screen for type 2 diabetes genes carried out in Mexican Americans localized a susceptibility gene, designated NIDDM1, to chromosome 2. Here we describe the positional cloning of a gene located in the NIDDM1 region that shows association with type 2 diabetes in Mexican Americans and a Northern European population from the Botnia region of Finland. This putative diabetes-susceptibility gene encodes a ubiquitously expressed member of the calpain-like cysteine protease family, calpain-10 (CAPN10). This finding suggests a novel pathway that may contribute to the development of type 2 diabetes.

Redefining type 2 diabetes: 'diabesity' or 'obesity dependent diabetes mellitus'?

Type 2 diabetes is considered by diabetes physicians as a complex and heterogeneous disease with a poorly understood aetiology, apart from the fact that there is a strong genetic propensity that becomes overt when exposed to a typical Western lifestyle. Our clinical targets are now moving from controlling the disease to preventing it. Do we need to await more research on the aetiology and pathophysiology before establishing a preventive strategy? No, the pathophysiology may be poorly understood, but there is now solid evidence that type 2 diabetes is a disease of fatness. New, controlled, clinical trials show that as little as 5% weight loss is sufficient to prevent most obese subjects with impaired glucose tolerance developing type 2 diabetes. Since type 2 diabetes is obesity dependent, and obesity is the main aetiogical cause of type 2 diabetes, we propose the term 'diabesity' should be adopted.

Prevalence of retinopathy at diagnosis among type 2 diabetic patients attending a diabetic centre in South India

AIM

To assess the prevalence of retinopathy in newly diagnosed south Indian type 2 diabetic patients attending a diabetic centre.

METHODS

448 consecutive newly diagnosed type 2 diabetic patients were recruited. Four field retinal colour photography was performed and graded using a modified form of the Early Treatment Diabetic Retinopathy Study grading system.

RESULTS

Of the 438 patients with assessable photographs, 32 (7.3%, 95% confidence interval 5.0 to 10. 2) had retinopathy. None of the variables tested showed a significant association with retinopathy on univariate or multivariate logistic regression analysis.

CONCLUSION

The overall prevalence of retinopathy at diagnosis among clinic based south Indian patients with type 2 diabetes appears to be lower than that reported among Europeans.

The diabetic foot: a global view

It is estimated that approximately 15% of the more than 150 million people with diabetes world-wide will at some stage develop diabetic foot ulceration. Foot problems are indeed a global problem and there is no area in the world that does not report the development of foot lesions as a consequence mainly of neuropathy and peripheral vascular disease. The prevalence of active foot ulceration varies from approximately 1% in certain European and North American studies to more than 11% in reports from some African countries. Although there have been many developments in recent years which encourage optimism for future improvement in diabetic foot care, there is still much to be done; the recent data from the Netherlands show that with a concerted team approach, it is possible to increase the numbers of foot clinics with the provision of podiatry services by more than 100%. However, many countries still lack proper podiatry and specialist nursing provision and there remains much to be done in the next millennium to improve the lot of the diabetic patient with foot problems.

Frequency of proteinuria in type 2 diabetes mellitus seen at a diabetes centre in southern India

The frequency of proteinuria was assessed in a cohort of 1848 diabetic patients attending a diabetes centre in south India. A total of 127 (6.9%) patients had evidence of macroproteinuria and 49 (2.5%) patients had microproteinuria. Thus overall 9.4% of patients had diabetes related proteinuria. In addition, 70 patients (3.8%) had evidence of proteinuria with no evidence of retinopathy. The frequency of both microproteinuria and macroproteinuria increased linearly with duration of diabetes. Multiple logistic regression analysis showed that duration of diabetes, serum creatinine, and glycated haemoglobin were risk factors for macroproteinuria.

Treating high-risk diabetic hypertensive patients with comorbid conditions

Diabetes mellitus, a highly prevalent metabolic and vascular disease, affects 155 million people worldwide. Tight blood glucose control can significantly reduce the incidence of diabetic retinopathy, nephropathy, and neuropathy, but does not appear to significantly reduce its macrovascular complications. Several randomized clinical trials indicate that tight blood pressure control can reduce the risk of microvascular and macrovascular complications in patients with diabetes and hypertension. Blockade of the renin-angiotensin system (RAS) with angiotensin-converting enzyme (ACE) inhibitors has proven effective both in lowering blood pressure and in independently slowing the progression of nephropathy. If instituted early, ACE inhibitor therapy potentially may prevent progression to end-stage renal disease in normotensive patients with type 1 or 2 diabetes. Additionally, ACE inhibitors may reduce cardiovascular morbidity and mortality in this patient population. Angiotensin II (Ang II) receptor blockers (ARBs), which attenuate the deleterious effects of the RAS via blockade of the Ang II subtype 1 receptor, may also be beneficial. Clinical trials are under way to evaluate this possibility.

Impact of diabetes on long-term prognosis in patients with unstable angina and non-Q-wave myocardial infarction: results of the OASIS (Organization to Assess Strategies for Ischemic Syndromes) Registry

BACKGROUND

Although unstable coronary artery disease is the most common reason for admission to a coronary care unit, the long-term prognosis of patients with this diagnosis is unknown. This is particularly true for patients with diabetes mellitus, who are known to have a high morbidity and mortality after an acute myocardial infarction.

METHODS AND RESULTS

Prospectively collected data from 6 different countries in the Organization to Assess Strategies for Ischemic Syndromes (OASIS) registry were analyzed to determine the 2-year prognosis of diabetic and nondiabetic patients who were hospitalized with unstable angina or non-Q-wave myocardial infarction. Overall, 1718 of 8013 registry patients (21%) had diabetes. Diabetic patients had a higher rate of coronary bypass surgery than nondiabetic patients (23% versus 20%, P:<0.001) but had similar rates of catheterization and angioplasty. Diabetes independently predicted mortality (relative risk [RR], 1.57; 95% CI, 1.38 to 1.81; P:<0.001), as well as cardiovascular death, new myocardial infarction, stroke, and new congestive heart failure. Moreover, compared with their nondiabetic counterparts, women had a significantly higher risk than men (RR, 1.98; 95% CI, 1.60 to 2.44; and RR, 1.28; 95% CI, 1.06 to 1.56, respectively). Interestingly, diabetic patients without prior cardiovascular disease had the same event rates for all outcomes as nondiabetic patients with previous vascular disease.

CONCLUSIONS

Hospitalization for unstable angina or non-Q-wave myocardial infarction predicts a high 2-year morbidity and mortality; this is especially evident for patients with diabetes. Diabetic patients with no previous cardiovascular disease have the same long-term morbidity and mortality as nondiabetic patients with established cardiovascular disease after hospitalization for unstable coronary artery disease.

Early detection of undiagnosed diabetes mellitus: a US perspective

Undiagnosed Type 2 diabetes has become a common condition in the US, comprising one-third of all cases of the disease. We believe that screening for and detection of undiagnosed Type 2 diabetes is an important endeavor. In this review we provide evidence that diabetes is a condition that is appropriate for population screening and detection. This includes evidence that: 1. Type 2 diabetes is a significant health problem. It affects more than 16 million adults in the US and places these individuals at high risk for serious complications of the eyes, nerves, kidneys, and cardiovascular system. 2. There is a latent phase before diagnosis of Type 2 diabetes. During this period of undiagnosed disease, risk factors for diabetic micro- and macrovascular complications are markedly elevated and diabetic complications are developing. 3. Diagnostic criteria for diabetes have been established and are based on plasma glucose values. These criteria define a group of individuals with significant hyperglycemia who also have a high frequency of risk factors for micro- and macrovascular disease. 4. The natural history of Type 2 diabetes is understood. In most patients, diabetes proceeds inexorably from genetic predisposition, through the stage of insulin resistance and hyperinsulinemia, to beta cell failure and overt clinical disease. 5. There are effective and acceptable therapies available for Type 2 diabetes and its complications. Treating hyperglycemia to prevent complications is more effective than treating these complications after they have developed. Furthermore, guidelines for treatment to prevent cardiovascular disease in people known to have diabetes are more stringent than in those individuals who are not known to have diabetes. 6. There is a suitable test for screening for undiagnosed Type 2 diabetes that has high sensitivity and specificity - measurement of fasting plasma glucose. Guidelines for identifying persons at high risk for diabetes have been established.

Cutaneous manifestations of diabetes mellitus

A broad spectrum of cutaneous disorders may be encountered in patients with both type 1 and type 2 diabetes mellitus. On occasion, these dermatologic findings may even precede any clinical or biochemical evidence for diabetes. Cutaneous manifestations of diabetes mellitus can be classified as conditions with strong associations with diabetes mellitus; infectious causes of skin lesions; dermatologic disorders related to complications of diabetes mellitus; and skin conditions related to the treatment of diabetes mellitus. This article provides a concise review of the epidemiology, clinical findings, histopathologic features, differential diagnostic considerations, and therapeutic approaches to specific dermatologic disorders seen in diabetic patients. This article also provides a framework for an effective approach to the majority of cutaneous manifestations encountered in patients with diabetes mellitus in a typical primary care setting.

Recombinant human platelet-derived growth factor-BB (becaplermin) for healing chronic lower extremity diabetic ulcers: an open-label clinical evaluation of efficacy

Topically applied recombinant human platelet-derived growth factor-BB (becaplermin) is a new pharmacologically active therapy for chronic, neuropathic, lower extremity diabetic ulcers. In previous studies, becaplermin gel was administered once daily but dressings were changed twice daily. In the present study of 134 patients with diabetes mellitus and full thickness lower extremity ulcers, dressings were changed only once per day, simplifying the treatment regimen. Efficacy criteria included the percentage of patients achieving complete healing within the 20-week treatment period, the time to achieve complete healing, the rate of ulcer recurrence during the 6-month period following healing, and treatment compliance. Complete healing of ulcers was achieved in 57. 5% of patients, with a mean time to closure of 63 days and a recurrence rate of 21% at 6 months. Of the potential factors affecting ulcer healing, only drug compliance (p < 0.001), dressing compliance (p < 0.01), the presence of infection (p < 0.01), baseline ulcer area (p < 0.05), and baseline total wound evaluation score (p < 0.05) were significantly associated with healing. Results of this study further confirm the efficacy and safety of becaplermin gel for the treatment of lower extremity diabetic ulcers.

[Type 2 diabetes mellitus: incidence and diagnosis at a primary care center]

OBJECTIVE

To find the annual incidence and reasons for type-2 Diabetes Mellitus (DM2), and the methods used to diagnose it, on the basis of the validation of a computerised record for 1991-1995.

DESIGN

Retrospective, longitudinal study.

SETTING

Primary care centre.

MEASUREMENTS AND MAIN RESULTS

Of the 387 diabetics registered as new cases in the 1991-1995 period out of 17031 people over 14 who were seen, 21 were not diabetics, 60 were cases of late diagnosis or late recording, 75 came from another centre and 9 were type-1. All these were excluded. The mean age of the 222 (57.4%) real new cases was 59 (ED 11.4). 53% were women. The most common causes of diagnosis were the existence of previous with diagnostic hiperglycemia (50.9%) and the application of protocols for other cardiovascular risk factors (19.8%). The diagnostic methods were two basal glucaemias > or = 140 mg/dl (70.7%), 1 glucaemia > or = 200 mg/dl with typical clinical picture (6.7%) and oral overload of glucose (23%). 97% of cases were diagnosed at the centre itself. The density of annual incidence was 30.1 per 10,000 inhabitants. Prevalence at start and end of the study was 4.4 and 4.9%.

CONCLUSIONS

The incidence and prevalence described are greater than described in other studies. The most common reasons for diagnosis were the existence of previous nondiagnostic hyperglycemia and the application of protocols for other risk factors.

The importance of insulin resistance in the pathogenesis of type 2 diabetes mellitus

Many patients with type 2 diabetes have hyperglycemia as a result of deficiencies in both insulin secretion and insulin action, that is, beta-cell dysfunction and insulin resistance. Insulin resistance is a state of reduced insulin sensitivity, an inability of insulin to lower plasma glucose levels through suppression of hepatic glucose production and stimulation of glucose utilization in skeletal muscle and adipose tissue. Insulin resistance stems from genetic and environmental causes, and its extent varies considerably among individuals. Studies have shown that enhanced insulin secretion can compensate for insulin resistance and that enhanced insulin sensitivity can mask defects in beta-cell function. However, insulin resistance is essential to the development of the majority of cases of type 2 diabetes. Numerous epidemiologic studies have demonstrated an increase in the prevalence of insulin resistance and type 2 diabetes in various ethnic populations that have migrated from their native lands to more urbanized and westernized regions of the world. Type 2 diabetes has already reached epidemic proportions worldwide. By 2025, an estimated 300 million people will have diabetes, most of whom will inhabit China, India, and the United States. These studies have also demonstrated the complex interrelationship of hyperinsulinemia, obesity (primarily visceral adiposity), and free fatty acids with beta-cell dysfunction, insulin resistance, and the development of type 2 diabetes. Although little can be done to avert a genetic predisposition to type 2 diabetes, normoglycemia can be preserved in individuals who remain insulin sensitive. Lifestyle changes can be implemented and medications can be administered to improve insulin sensitivity, insulin secretion, and glucose utilization and reduce the prevalence of type 2 diabetes.

Clinical profile of diabetic foot infections in south India--a retrospective study

AIMS

The aim of the study was to determine the profile of diabetes foot infections in south Indian diabetic subjects. The causative factors for delayed wound healing and the recurrence of infection were also studied.

METHODS

During a period of 6 months, 374 patients who had undergone some surgical procedure for foot infection were available for follow-up (M:F 227:147, mean age 54.9 +/- 9.4 years, diabetes duration 10.9 +/- 7.7 years). All of them had records of clinical and treatment details, laboratory data including biothesiometry, Doppler tests and electrocardiogram (ECG) records. Foot ulcers were classified according to Wagner's classification.

RESULTS

Majority of the patients had grade II and III ulcers (50% and 26.5%, respectively), grade IV was seen in another 21.9%. The median healing time was 44 days. Recurrence of infection which occurred in 53% was more common in patients with neuropathy and peripheral vascular disease (PVD).

CONCLUSIONS

Recurrence of foot infection was common among south Indian Type 2 diabetic subjects and was related to the presence of PVD and neuropathy. There is also a need for improvement in footwear and foot care education.

Prevalence of type 2 diabetes mellitus and impaired glucose tolerance in a rural area of Japan. The Funagata diabetes study

PURPOSE

To determine the prevalence of type 2 diabetes and impaired sucrose tolerance (IGT) among people aged 40 and over in a rural area, Funagata, Japan, by using a 75-g oral glucose tolerance test (OGTT), and to compare the prevalence to that obtained from a more urban area, Hisayama, Japan.

METHODS AND RESULTS

Total eligible subjects for the Funagata study were 3526. Among them, 140 were confirmed to have diabetes judged by the 1985 WHO criteria. A 75-g OGTT was conducted, excluding the 140 known cases of diabetes. The 1985 WHO criteria were used to classify the current diabetes status of participants. The overall participation rate was 74.4%. The prevalence of diabetes (known and newly diagnosed cases combined) was 9.1% for men and 10.8% for women. The prevalence of IGT was 12. 0% for men and 16.5% for women. Age-adjusted prevalence (using 1990 Japanese census) of diabetes and IGT in men in Hisayama is two times higher than in Funagata (12.8% vs. 6.8% for diabetes, 19.5% vs. 10. 3% for IGT). Age-adjusted prevalence of IGT in women in Hisayama is significantly higher than in Funagata.

CONCLUSIONS

The prevalence of type 2 diabetes among people aged 40 and over is approximately 10% even in a rural area of Japan. Prevalence of diabetes and IGT is much higher in an urban area than in a rural area in Japan.

Obesity, insulin resistance and diabetes--a worldwide epidemic

Obesity is now commonly defined in adults as a BMI > 30 kg/m2. The prevalence of obesity in established market economies (Europe, USA, Canada, Australia, etc.) varies greatly, but a weighed estimate suggests an average prevalence in the order of 15-20%. The prevalence in these countries generally shows increasing trends over time. Obesity is also relatively common in Latin America, but much less so in sub-Saharan Africa and Asia where the majority of the world population lives. Nevertheless obesity rates are increasing there as well and, more importantly, rates of diabetes are increasing even more quickly, particularly in Asian countries. The risks of type 2 diabetes mellitus in these countries tend to increase sharply at levels of BMI generally classified as acceptable in European and North American white people. There have been suggestions to adopt specific classifications of obesity in Asians (e.g. BMI 23 for overweight and 25 or 27 kg/m2 for obesity) and this will greatly affect the prevalence estimates of obesity worldwide (currently at about 250 million people). Particularly for health promotion purposes BMI may be replaced by a classification based on waist circumference, but also specific classifications for different ethnic groups may be necessary. The number of diabetics has been projected to increase from 135 million in 1995 to 300 million in 2025. Much of this increase will be seen in Asia. In summary, both obesity and type 2 diabetes are common consequences of changing lifestyles (increased sedentary lifestyles and increased energy density of diets). Both are potentially preventable through lifestyle modification on a population level, but this requires a coherent and multifaceted strategy. Such strategies are not developed or implemented. These developments point toward the great urgency to develop global and national plans for adequate prevention and management of obesity and type 2 diabetes mellitus.

Globalization, coca-colonization and the chronic disease epidemic: can the Doomsday scenario be averted?

There are at present approximately 110 million people with diabetes in the world but this number will reach over 220 million by the year 2010, the majority of them with type 2 diabetes. Thus there is an urgent need for strategies to prevent the emerging global epidemic of type 2 diabetes to be implemented. Tackling diabetes must be part of an integrated program that addresses lifestyle related disorders. The prevention and control of type 2 diabetes and the other major noncommunicable diseases (NCDs) can be cost- and health-effective through an integrated (i.e. horizontal) approach to noncommunicable diseases disease prevention and control. With the re-emergence of devastating communicable diseases including AIDS, the Ebola virus and tuberculosis, the pressure is on international and regional agencies to see that the noncommunicable disease epidemic is addressed. The international diabetes and public health communities need to adopt a more pragmatic view of the epidemic of type 2 diabetes and other noncommunicable diseases. The current situation is a symptom of globalization with respect to its social, cultural, economic and political significance. Type 2 diabetes will not be prevented by traditional medical approaches; what is required are major and dramatic changes in the socio-economic and cultural status of people in developing countries and the disadvantaged, minority groups in developed nations. The international diabetes and public health communities must lobby and mobilize politicians, other international agencies such as UNDP, UNICEF, and the World Bank as well as other international nongovernmental agencies dealing with the noncommunicable diseases to address the socio-economic, behavioural, nutritional and public health issues that have led to the type 2 diabetes and noncommunicable diseases epidemic. A multidisciplinary Task Force representing all parties which can contribute to a reversal of the underlying socio-economic causes of the problem is an urgent priority.

Changing pattern of end-stage renal disease in central and eastern Europe

BACKGROUND

The epidemiology of end-stage renal disease (ESRD) is changing all over the world. Particularly dramatic changes of the epidemiology of ESRD have occurred in central and eastern Europe (CEE). The aim of the present study was (i) to document the further expansion of renal replacement therapy (RRT) noted in recent years in CEE and (ii) to analyse in some detail treatment modalities and underlying renal conditions.

METHODS

Three independent surveys were performed in 1995, 1997 and 1998. Fifteen CEE countries participated. The data were mainly obtained from national registries which are based on centre and patient questionnaires.

RESULTS

The data collected from 15 CEE countries document further expansion of RRT in this region. The report includes data on the availability of RRT in Byelorussia, Estonia, and Russia which have become available for the first time. The epidemiology of dialysed patients has changed remarkably. In the majority of countries the number of diabetic patients has increased, most dramatically so in the Czech Republic (31% of all dialysed patients), in the majority of the other countries 10-14%. The number of ESRD patients with the diagnosis of hypertensive nephropathy has also increased and this was accompanied by an increase in proportion of elderly (>65 years) patients, i.e. 46% in the Czech Republic and 12-25% in most other countries.

CONCLUSION

Dramatic changes of the availability of RRT treatment have occurred in central and eastern Europe. The proportion of diabetic nephropathy and elderly patients has risen. Large differences in RRT exist between individual CEE countries and this appears mainly dependent on the level of economic development.

Impact of the new WHO classification and diagnostic criteria

The World Health Organisation (WHO) [1] consultation group and the American Diabetes Association (ADA) [2] have recently published revised criteria for the classification and diagnosis of diabetes. If widely implemented, these recommendations, together with earlier and improved treatment, could have a profound impact on the morbidity and mortality associated with the disease. The changes in classification stem from an increased knowledge of the aetiology and pathogenesis of diabetes, which signals the move away from a classification system based on pharmacological dependency towards one that is based on the underlying causes of the disease.

Nutrition and exercise in individuals with diabetes

Individuals with type 1 (insulin-dependent diabetes mellitus [IDDM]) and type 2 (non-insulin-dependent diabetes mellitus [NIDDM]) diabetes should be encouraged to exercise. Although there is an absence of consistent evidence that adaptations to routine exercise improve glucose control in type 1 diabetes, there is evidence that shows improved glucose control in individuals with type 2 diabetes. Although both groups benefit from exercise, the merit and suitability of routine exercise is measured by the extent to which the advantageous adaptive effects of regular exercise surpass the risks of a sole bout of exercise. In addition, when considering acute versus routine exercise, special considerations must be given to children with diabetes and older adults at risk for insulin resistance. Finally, a greater research focus is needed on engaging in competitive and recreational sports so that children and adults with diabetes may participate safely in activities such as baseball, swimming, basketball, soccer, and hockey.