Asian patients attending a diabetic clinic

Diabetes-science, serendipity and common sense

This paper is dedicated to young researchers in diabetes. One such person was Frederick Banting who, with his colleagues, isolated insulin in 1921, saving the lives of literally millions of people. What factors allowed Banting and other scientists to produce work that has immensely benefited the human race? I propose that it is the combination of good scientific background (the 'prepared mind'), commonly some serendipity taken with a good dose of common sense and supplemented by enthusiasm, tenacity and good mentoring, which drives the 'power of observation' and the ability to take forward the good idea. I give examples from history to support this and then discuss some of the 'truths, perspectives and controversies' within the diabetes arena when I first started in diabetes research in the late 1970s. I describe how my appetite was initially 'whetted' for research by moving to an excellent clinical research environment with encouragement to test ideas and controversies initially in a clinical research programme, followed by more scientific/basic research. The work that I performed as a young doctor and research fellow led to a lifelong professional interest in three major areas-causes and interventions for diabetes vascular disease, studies of the molecular genetics of Type 1 and Type 2 diabetes and work on diabetes in different ethnic groups. I provide a summation of my own and other people's work to demonstrate how research can be progressed and lead to patient benefit as well as providing an incredibly rewarding career. I believe that we need to encourage and put more resources into development of young doctors and scientists wishing to undertake research in our discipline. Areas ripe for much-needed clinical research programmes, for example, include work on best practice/provision of health care, application of the evidence base from clinical trials to achieve public health gains, attention to adherence issues and better-tolerated therapies. Most importantly, a greater emphasis on prevention through public health measures and 'buy in' from the whole population is urgently required.

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

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

Can environmental factors explain the epidemiology of schizophrenia in immigrant groups?

Recent evidence suggests that high rates of schizophrenia in first- and second-generation immigrants could be due to exposure to environmental factors such as viral infections in the host country. These findings are discussed alongside parallel data relating to other diseases such as multiple sclerosis and diabetes mellitus. It is argued that in each case the interaction between the environmental agent and constitutional factors related to the immune system need to be considered.

Cultural and religious influences in diabetes care in Great Britain

Type 2 diabetes is four times more common in people originating from the Indian subcontinent (Asians) than in white English Caucasians. British Asians with diabetes have been shown to have poorer blood glucose control, awareness of diabetes management, and knowledge of complications. This review examines some of the dietary customs that can affect glucose control, problems with communication and diabetic education, and a brief description of health beliefs commonly held by Asian patients that may help the physician understand why some patients appear to show poor compliance with accepted Western medicine. Patients must always be approached as individuals with their own unique needs within the context of their cultural backgrounds.

Some recent advances in non-communicable diseases in the tropics. 2. Diabetes mellitus in the tropics

Diabetes mellitus occurs in all parts of the world, but with striking differences in prevalence and mode of presentation. This article considers the epidemiology of diabetes world-wide and specifically the pattern of diabetes in the tropics which appears to differ from that seen in Europe and the USA. Detailed epidemiological studies will help both in understanding diabetes pathogenesis and in rational management of this very important and common disease.

Asian diabetics attending a British hospital clinic: a pilot study to evaluate their care

A questionnaire survey of 40 Asian and 31 British non-insulin dependent diabetics attending a hospital clinic showed that both groups remembered receiving education about diabetes (90%) but Asian diabetics knew less about glucose monitoring and diabetic complications. Asians also had a more negative attitude towards the clinic, feeling they were made to wait longer than the British. They were frustrated by a lack of communication with the staff. Forty per cent of both Asian and British diabetics felt that diabetes prevented them from leading a normal lifestyle. Twenty seven per cent of both Asian and British diabetics used herbal or alternative medicines, but Asians differed in that they used these medicines specifically for diabetes. A further sample of 50 Asians had poorer glycaemic control than a sample of British diabetics matched for age, sex and type of diabetes. It is concluded that despite receiving the same education as British diabetics, Asians did not understand it as well. The education was often not relevant to their diets or customs. This may contribute to their poorer glycaemic control. Diabetic clinic facilities need to be improved for Asian diabetics, to improve their understanding of diabetes.

Diabetes in the UK West indian community: the Wolverhampton survey

A survey was carried out to determine the prevalence of known diabetes amongst West Indians living in Wolverhampton. Two hundred and fifty-one West Indians with diabetes were identified from a computerized register, which records all diabetic patients in the Wolverhampton area attending either the hospital diabetic clinic or general practitioner mini-clinics, and from questionnaire data obtained through local general practitioners. An estimated 4.4% of the Wolverhampton population are of West Indian origin determined by the 1981 census, giving a prevalence of known diabetes of 2.2% compared with 1.2% in the indigenous UK white Caucasian population. Only 4% of these patients were truly insulin-dependent but 38% were insulin-treated, 43% were on oral hypoglycaemic agents and 19% on diet alone. Only 1.6% were diagnosed below the age of 20 years, with peak frequency of diabetes occurring in the age group 45-64 years. Thirty-eight percent of all patients were obese, 40% were hypertensive, but only 4% had a history of angina or myocardial infarction. In UK West Indians non-insulin-dependent diabetes is common and is predominantly a disease of middle age, whereas insulin-dependent diabetes is relatively uncommon.

Autoantibodies in Indian-Asians with insulin-dependent diabetes in the UK

Classical insulin-dependent diabetes mellitus (IDDM) is relatively uncommon in Indian-Asians whether in India or in the UK and this may be related to immunogenetic factors. We have studied the presence or absence of islet cell antibodies and other auto-antibodies in 36 subjects with IDDM and 41 controls, all of Indian origin. Islet cell antibodies (ICA-IgG) were found in 8 subjects with IDDM but in none of the controls. Four of the 8 patients with ICA-IgG also possessed the complement fixing variety (CF-ICA). There was no definite association between possession of ICA and HLA-DR antigens. Thyroid antibodies were commoner in patients (22%) compared with controls (7%) as were parietal cell antibodies (8.3% vs 4.8%). None of the patients or controls had adrenal antibodies. The frequency of organ-specific antibodies in Indian-Asians with IDDM is similar to that of white Caucasians. The overall frequency of ICA is, however, lower than that reported for white Caucasians although the temporal distribution is similar. We conclude that even though the prevalence of IDDM in Indian-Asians is lower than in white Caucasians there is no evidence that different immunological mechanisms are involved in the pathogenesis of IDDM in the two groups.

Comparative prevalence of non-insulin-dependent diabetes mellitus in Asian and white Caucasian adults

The prevalence of diabetes mellitus in adults was determined within a specific area of Leicester City, containing 20,053 Asians and 18,068 White Caucasian over the age of 16 years in the 1981 census. Subjects who had ever had classical symptoms with a random venous plasma glucose greater than or equal to 11.1 mmol/l were taken as diabetic. Exact numbers were ascertained from an analysis of diabetic clinic records and specialist health visitor records. The latter have formed an important part of community care for diabetics in Leicester for the last 30 years, and patients are referred by hospital consultants and nursing staff, and by general practitioners. Diabetes was ascertained in 967 Asians and 1194 White Caucasians. Age-adjusted relative risk of diabetes (95% confidence interval) increased in Asians over 45 years of age and was 1.6 (1.3-1.8) and 2.7 (2.5-3.2) for those aged 45-64 years and over 65 years, respectively. Relative risk of NIDDM was significantly higher (approximately x 2) in Asians in all age-groups. Our study shows that in Asians the prevalence of diabetes rises above 45 years of age and that NIDDM occurs more frequently in adult Asians. The causes and long-term effects of this require further analysis.

The HLA-D associations of type 1 (insulin-dependent) diabetes in Punjabi Asians in the United Kingdom

Type 1 (insulin-dependent) diabetes is less common in Asian Indians than in white Caucasoids. Forty-five Punjabi Asians with Type 1 diabetes and 96 racially matched control subjects were HLA-DR typed. DR3 was increased in diabetic patients vs control subjects (82% vs 38%, p less than 10(-5)) with relative risk 7.7 and etiological fraction 0.72. DR4 was increased in diabetic patients vs control subjects (31% vs 7%, p less than 0.003) with relative risk 5.7 and etiological fraction 0.26. DR2 showed a negative association (relative risk 0.19, etiological fraction -0.28), as did DR7 (relative risk 0.21, etiological fraction -0.33). HLA-DQ beta-chain gene probing using restriction enzyme BamHI in 43 diabetic patients and 90 control subjects showed that the DR1-associated 6.2 and 3.2 kb fragments were less common in diabetic patients than in the control subjects (12% vs 36%, p less than 0.02). A 12 kb fragment was associated with DR4 in both diabetic patients and control subjects. DR3 is the major susceptibility factor for Type 1 diabetes in Punjabi Asians and DR4 is a second marker. Gene probing indicates that the same DR4 subset is associated with the condition as in white Caucasoids. DR1 and its associated DQ beta restriction fragments are reduced in Asian Type 1 diabetic patients making it unlikely that DR1 haplotypes carry a predisposing factor in this racial group. We conclude that the genetic component of Type 1 diabetes in Punjabis shows differences from that of the white Caucasoid population and that the lower frequency of DR4 in this population may contribute to the lower prevalence of Type 1 diabetes.

Prevalence of insulin-dependent diabetes mellitus in Asian children

A survey was conducted in 1984-85, within Leicester City boundaries, which contains 64,535 children below the age of 15 years (20,267 Asian and 44,268 White Caucasian) to ascertain the prevalence of insulin-dependent diabetes mellitus (IDDM) using a central register maintained for the changeover to U-100 insulin, diabetic health visitor index cards, hospital admissions of diabetic children, and individual registers maintained by us. Overall prevalence per thousand for children aged 0-15 years was 0.54 for Asian and 0.99 for White Caucasians; for ages 10-15 years they were 0.97 and 1.87, and for ages 0-9 years, 0.31 and 0.38, respectively. This was not statistically different at the 5% level. Ours is the first population based study of its kind in Asian children, and challenges the view that there is a large difference in the prevalence of IDDM between Asians and White Caucasians. A wider analysis of this observation incorporating a large population base is suggested.

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

A house to house inquiry for patients with known diabetes was carried out in a defined area of Southall, west London, which contained over 34 000 Asians and 27 000 Europeans in the 1981 Census: 1143 diabetic patients were ascertained, of whom 761 were Asian and 324 European. The prevalence adjusted for age of known diabetes in Asians was at least 3.8 times higher than that in Europeans. For patients aged between 40 and 64 years it was at least five times higher, was over 12% in Asians aged 60-69, and over 8% in those aged 50-59. These data are important in planning for the care of diabetic patients in health districts with large Asian communities. The causes and later consequences of this exceptionally high prevalence require further study.