The concomitants of raised blood sugar: studies in newly-detected hyperglycaemics: II. Urinary albumin excretion, blood pressure and their relation to blood sugar levels

The albumin excretion rate following an oral glucose load was measured, using a sensitive radio-immunoassay method, in three groups drawn from the population of Bedford. The three groups – normal,borderline diabetic and diabetic – were classified by the level of the blood sugar 2 hours after the 50 -g glucose load. The degree of albumin excretion was positively correlated with the 2-hour blood sugar level, suggesting that hyperglycaemia may cause renal functional abnormality, which may be present at or before the time of diagnosis. In the diabetic group, only, the degree of albumin excretion was also positively correlated with the height of the blood pressure.

Obesity and overweight in relation to disease-specific mortality in men with and without existing coronary heart disease in London: the original Whitehall study

OBJECTIVE

To examine the relations between obesity or overweight and coronary heart disease (CHD) mortality in men with and without prevalent CHD in a prospective cohort study.

METHODS

In the Whitehall study of London-based male government employees, 18 403 middle age men were followed up for a maximum of 35 years having participated in a medical examination in the late 1960s in which weight, height, CHD status, and a range of other social, physiological, and behavioural characteristics were measured.

RESULTS

In age-adjusted analyses of men with baseline CHD there was a modest raised risk in the overweight relative to normal weight groups for all cause mortality (hazard ratio 1.10, 95% confidence interval (CI) 1.00 to 1.20) and CHD mortality (1.28, 95% CI 1.11 to 1.47) but not for stroke mortality (1.01, 95% CI 0.73 to 1.40). Mortality was similarly raised in the obese group. While these slopes were much steeper in men who were apparently CHD-free at study induction, the difference in the gradients according to baseline CHD status did not attain significance at conventional levels (p value for interaction >or= 0.24). The weight-mortality relations were somewhat attenuated when potential mediating and confounding factors were added to the multivariable models in both men with and men without a history of CHD.

CONCLUSIONS

Avoidance of obesity and overweight in adult life in men with and without CHD may reduce their later risk of total and CHD mortality.

Obesity and overweight in relation to organ-specific cancer mortality in London (UK): findings from the original Whitehall study

OBJECTIVE

To examine the relation of obesity and overweight with organ-specific cancer mortality.

METHODS

In the Whitehall prospective cohort study of London-based government employees, 18 403 middle-age men participated in a medical examination between 1967 and 1970. Subjects were followed up for cause-specific mortality for up to 35 y (median: interquartile range (25th-75th centile); 28.1 y: 18.6-33.8).

RESULTS

There were over 3000 cancer deaths in this cohort. There was a raised risk of mortality from carcinoma of the rectum, bladder, colon, and liver, and for lymphoma in obese or overweight men following adjustment for range of covariates, which included socioeconomic position and physical activity. These relationships held after exclusion of deaths occurring in the first 20 y of follow-up.

CONCLUSION

Avoidance of obesity and overweight in adult life may reduce the risk of developing some cancers.

High blood glucose concentration is a risk factor for mortality in middle-aged nondiabetic men. 20-year follow-up in the Whitehall Study, the Paris Prospective Study, and the Helsinki Policemen Study

OBJECTIVE

To assess the association between high but nondiabetic blood glucose levels and the risk of death from all causes, coronary heart disease (CHD), cardiovascular disease, and neoplasms.

RESEARCH DESIGN AND METHODS

We studied the 20-year mortality of non-diabetic, working men, age 44-55 years, in three European cohorts known as the Whitehall Study (n = 10,025), the Paris Prospective Study (n = 6,629), and the Helsinki Policeman Study (n = 631). These men were identified by their 2-h glucose levels following an oral glucose tolerance test and by the absence of a prior diagnosis of diabetes. As the protocol for the oral glucose tolerance test and methods for measuring glucose differed between studies, mortality was analyzed according to the percentiles of the 2-h and fasting glucose distributions, using the Cox's proportional hazards model.

RESULTS

Men in the upper 20% of the 2-h glucose distributions and those in the upper 2.5% for fasting glucose had a significantly higher risk of all-cause mortality in comparison with men in the lower 80% of these distributions, with age-adjusted hazard ratios of 1.6 (95% CI 1.4-1.9) and 2.0 (1.6-2.6) for the upper 2.5%. For death from cardiovascular and CHD, men in the upper 2.5% of the 2-h and fasting glucose distributions were at higher risk, with age-adjusted hazard ratios for CHD of 1.8 (1.4-2.4) and 2.7 (1.7-4.4), respectively.

CONCLUSIONS

If early intervention aimed at lowering blood glucose concentrations can be shown to reduce mortality, it may be justified to lower the levels of both 2-h and fasting glucose, which define diabetes.

The cardiovascular risk associated with impaired glucose tolerance

Subjects with fasting and/or postprandial plasma glucose levels that are higher than those in normal subjects but less than those in patients with manifest NIDDM are at increased risk of cardiovascular disease (CVD). This association between glucose intolerance and cardiovascular disease was first hypothesized in the 1950s but was not substantiated until the results of several long-term prospective studies became available. The results suggest that there is not a continuously variable association between blood glucose levels and the risk of CVD but that the risk of CVD becomes evident at the upper end of the distribution of glucose tolerance, though different studies yield different threshold levels. With the introduction of the descriptive term Impaired Glucose Tolerance (IGT), studies were undertaken to establish the relations between IGT and CVD. To date most data refer to people of European origin. In several populations CVD has been observed to be more prevalent in subjects with IGT and/or the incidence of CVD is higher in subjects with IGT than in normoglycaemic controls. A causal link between hyperglycaemia and CVD seems unlikely from the published evidence. The most probable explanation of the association is "a common soil', that is, a number of associated metabolic abnormalities which may lead to CVD and IGT/NIDDM or both.

[Why is insulin tied to the prevalence of cardiovascular diseases without being a risk factor for their incidence?]

Insulin is frequently considered to be a risk factor for atherosclerosis (or for coronary and vascular disease). Furthermore, hyperinsulinaemia is claimed to be the primary cause underlying the other features which make up the insulin resistance syndrome. However, if proof of these assertions is based only on prospective studies, its value is limited. Only two studies, both carried out, surprisingly, in policemen, have shown convincingly that insulin was a coronary risk factor. In one of the studies, the Paris Prospective Study, the insulin-coronary disease correlation was shown to subside with increasing duration of follow-up. The other prospective studies have failed to evidence a correlation between insulinaemia and cardiovascular events, even with univariate analysis. One study even showed a negative correlation between insulinaemia and coronary complications. In view of the fact that insulinaemia has been shown repeatedly to be associated with classic cardiovascular risk factors--systolic hypertension, decrease in HDL cholesterol, increase in triglycerides, and abdominal obesity--it is highly surprising that univariate analysis has not been able to show the same correlation between insulin and cardiovascular complications. In fact, the combination of elevated insulinaemia and classic risk factors may result in protection against the deleterious effects of these factors. Another possibility would be that insulinaemia is associated with unknown protective factors. Both hypotheses would account for the existence of a correlation between insulin and current cardiovascular disease, as well as the absence of correlation between insulin and later onset of cardiovascular disease.

Gestational diabetes: a non-entity?

Screening for gestational diabetes is commonly recommended despite the absence of a common definition of gestational diabetes. Furthermore, there is no consensus about management or treatment. Those who recommend screening do so largely on the basis of fetal morbidity, which seems to be predominantly "macrosomia"--another term without an agreed definition. The implications of macrosomia in terms of actual morbidity are also not clear. R J Jarrett reviews the history of the subject and concludes that gestational diabetes is simply impaired glucose tolerance temporally associated with pregnancy. Its main importance is as a predictor of subsequent non-insulin dependent diabetes, but it fails the major tests for a condition suitable for a screening programme.

Risk factors for coronary heart disease in diabetes mellitus

A review of the putative risk factors associated with the development of coronary heart disease in diabetes is presented. Emphasis is given to the effect of nephropathy (persistent proteinuria) and hypertension on cardiovascular mortality in IDDM. Risk factors associated with CHD in NIDDM are also reviewed. Finally, possible reasons to explain the increased incidence of CHD associated with proteinuria in IDDM patients, including lipoprotein abnormalities, increased fibrinogen levels, increased platelet adhesiveness, and altered hemostatic variables, are discussed.

Prognostic significance of microalbuminuria in insulin-dependent diabetes mellitus: a twenty-three year follow-up study

A cohort of 63 Type 1 insulin-dependent diabetic patients were first characterized for overnight urinary albumin excretion rate (AER) in 1967. In 1981, seven out of eight (87%) patients with initial AER greater than or equal to 30 less than or equal to 140 micrograms/min (microalbuminuria) developed clinical proteinuria compared to only 2 out of 55 (4%) patients with initial AER less than 30 micrograms/min. The same cohort of patients was reassessed in 1990 after a total follow-up period of 23 years. The aim was to investigate the role of microalbuminuria in the prediction of total/cardiovascular mortality and the development of renal failure, in addition to clinical proteinuria. The initially microalbuminuric patients had a significantly higher risk of developing not only clinical proteinuria (relative risk 9.3, 95% C.I. 1.36 to 3.10, P less than 0.05), but also of dying from a cardiovascular cause (relative risk 2.94, 95% C.I. 1.18 to 7.34, P less than 0.05). The rate of progression to renal failure was higher but not significantly so in the microalbuminuric (2 of 8) compared to the normoalbuminuric (4 of 53) group (relative risk 3.31, 95% C.I. 0.72 to 15.24, NS). In insulin-dependent diabetic patients microalbuminuria is a powerful predictor of clinically overt diabetic renal disease as well as cardiovascular mortality.

Body weight and coronary heart disease mortality: an analysis in relation to age and smoking habit. 15 years follow-up data from the Whitehall Study

18,403 male civil servants aged 40-64 years were examined in London between 1968 and 1970. Mortality from all causes and specifically from coronary heart disease (CHD) over 15 years of follow-up was initially analysed in relation to deciles of body mass index (BMI = weight/height2) at entry into the study. In older men all causes mortality tended to be higher in those with a low BMI, but this was not so for CHD mortality. The latter was further studied after dividing the population into sub-groups according to age and cigarette smoking. With BMI distribution divided into fifths and five year age groups there were significant positive trends of CHD mortality across the BMI distribution in all age groups except the youngest (40-44 years) and oldest (60-64 years). For analysis by smoking category--never, ex- and current cigarette smoker--three age-specific groups were used: 40-49, 50-59 and 60-64 years. In men aged less than 60 years there were significant positive trends of CHD mortality and BMI in five of the six age and smoking categories, the exception being ex-smokers aged 40-49 years. Associations were strongest in the current smokers. By contrast in men aged 60-64 years there was a significant association between BMI and CHD mortality only in ex-smokers and this was of low order (P = 0.04). The data are compatible with some reports of a lesser association of obesity with mortality risk in older persons and in this data set the observation is not confounded by smoking habit.

Incidence of macrovascular disease in diabetes mellitus: the London cohort of the WHO Multinational Study of Vascular Disease in Diabetics

We report on the incidence of new macrovascular disease among the 497 members of the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics (aged 35-54 years at recruitment) over a mean 8.33 year follow-up period. Overall at the end of the follow-up period the prevalence of macrovascular disease in the cohort was 45%; 43% of the subjects showed evidence of ischaemic heart disease, 4.5% of cerebrovascular disease and 4.2% of peripheral vascular disease. The incidence rates for new disease in those subjects who were free at baseline expressed per 1000 patient years of follow-up were: ischaemic ECG abnormality 23.6 (patients with insulin-dependent diabetes 19.8, patients with non-insulin-dependent diabetes 28.1), myocardial infarction 17.6 (patients with insulin-dependent diabetes 16.5, patients with non-insulin-dependent diabetes 18.8), all ichaemic heart disease 31.7 (patients with insulin-dependent diabetes 30.3, patients with non-insulin-dependent diabetes 33.4), cerebrovascular disease 5.9 and peripheral vascular disease 5.2. Incidence rates were generally similar among men and women except for myocardial infarction in patients with non-insulin-dependent diabetes where men had a significantly higher incidence rate. Macrovascular disease is a major problem in patients with diabetes and in this age group is mainly manifested as ischaemic heart disease.

Risk factors for macrovascular disease in diabetes mellitus: the London follow-up to the WHO Multinational Study of Vascular Disease in Diabetics

We have examined the relationship between baseline variables and the incidence of new macrovascular complications amongst the 497 members of the London cohort of the WHO Multinational Study of Vascular Disease in Diabetics over a mean 8.33-year follow-up. In univariate logistic regression analysis the incidence of new ischaemic electrocardiographic abnormality was significantly associated with systolic and diastolic blood pressure, diabetes duration and hypertension in patients with insulin-dependent diabetes, and with smoking in patients with non-insulin-dependent diabetes. New myocardial infarction was associated with systolic blood pressure, plasma cholesterol, proteinuria and smoking in patient with non-insulin-dependent diabetes; there were no significant associations among patients with insulin-dependent diabetes. All new ischaemic heart disease was associated with hypertension in patients with insulin-dependent diabetes, and plasma cholesterol and smoking in patients with non-insulin-dependent diabetes. New cerebrovascular disease was associated with systolic and diastolic blood pressure, ECG abnormality and hypertension. New peripheral vascular disease was associated with smoking. Multivariate analysis showed the following significant associations 1) in patients with insulin-dependent diabetes: ECG abnormality; hypertension, myocardial infarction; smoking, ischaemic heart disease; hypertension, diabetes duration and smoking, 2) in patients with non-insulin-dependent diabetes: ECG abnormality; smoking, myocardial infarction; serum cholesterol, proteinuria and smoking ischaemic heart disease; smoking. For new cerebrovascular disease, proteinuria and ECG abnormality were significant predictors in multivariate analysis. Patients with diabetes share many of the established risk factors for nondiabetic subjects, in addition proteinuria may be of significance in the prediction of macrovascular disease in diabetes.

Are conventional risk factors for mortality relevant in type 2 diabetes?

One-hundred and ninety-one men with Type 2 (non-insulin-dependent) diabetes mellitus, participants in the Whitehall Survey, were followed for 15 years. Age-adjusted all-cause and ischaemic heart disease (IHD) mortality rates were significantly increased in the diabetic men. Of four putative risk factors for IHD ascertained in the survey (plasma cholesterol, systolic blood pressure, cigarette smoking, body mass index) only blood pressure was a significant predictor in univariate Cox regression analysis. A review of comparable studies revealed lack of consistency in the association of these risk factors (derived from studies in non-diabetic populations) and mortality in individuals with Type 2 diabetes. Given the absence of clinical trial data, risk factor intervention in Type 2 diabetes is currently based upon inference derived from studies in non-diabetic subjects.

Low physical activity and worsening of glucose tolerance: results from a 2-year follow-up of a population sample in Malta

The relationship between the level of habitual physical activity and glucose intolerance was examined cross-sectionally and during a 2-year follow-up among a sample of 388 subjects in Malta. At baseline, the subjects were classified into three categories of physical activity, which was inversely related to the 2-h post challenge blood glucose (P = 0.02). In a multivariate analysis, age (standardized regression coefficient 0.23; P less than 0.001), family history of diabetes (0.20; P less than 0.001), and physical activity (-0.18; P = 0.002) were the strongest predictors of the 2-h blood glucose at baseline. The age standardized 2-year risk of glucose intolerance, i.e. impaired glucose tolerance or diabetes was consistently and inversely related to the level of physical activity. Among subjects with normal glucose tolerance at baseline (n = 127) those with low physical activity had a 2.7 times higher risk of glucose intolerance during follow-up than those with high physical activity (P = 0.1), and even a 3.7-fold risk of glucose intolerance at baseline (n = 196) when both the subjects with normal and impaired glucose tolerance at baseline were considered together (P = 0.005). Similar trends were observed for the risk of diabetes. The suggested protective effect of physical activity was independent of body mass, a family history of diabetes and gender. Within the limits of this small study we conclude that physical activity may have some importance in the primary prevention of impaired glucose tolerance and, possibly, non-insulin-dependent diabetes mellitus.

Male-type fat distribution is associated with cardiovascular risk factors and the prevalence of cardiovascular disease in noninsulin-treated diabetics

Abdominal fat distribution estimated by the waist/hip ratio (WHR) was studied in 85 subjects (55 men, 30 women) with treated noninsulin-dependent diabetes mellitus (NIDDM), and its association with cardiovascular disease and cardiovascular risk factors was analyzed. In men, WHR was highly correlated with the body mass index (BMI; r = 0.697), but this was not true in women (r = 0.091). In men, WHR was significantly and positively correlated with mean diastolic blood pressure (DBP) level. In women, this correlation was also positive, but of lesser degree. Fasting plasma insulin was highly correlated with BMI and WHR in men, but not in women. In both sexes, WHR was positively correlated with fasting serum triglyceride and negatively correlated with serum high-density lipoprotein cholesterol. In addition, mean WHR, but not BMI, was significantly greater in subjects with cardiovascular disease (positive electrocardiographic signs and/or history of angina, myocardial infarction, stroke, intermittent claudication).

A prospective study of mortality among middle-aged diabetic patients (the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) II: Associated risk factors

Potential risk factors have been examined for association with mortality over a 10-12 year follow-up of the patients of the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics (aged 35-54 years at entry to the study). Proteinuria has the strongest association with all-cause mortality in univariate analysis being significant in patients of both sexes with Type 2 (non-insulin-dependent) diabetes mellitus and in women with Type 1 (insulin-dependent) diabetes mellitus; both systolic blood pressure (men) and hypertension (both sexes) (as a categorical variable) are significant in Type 1 diabetes. Hypertension is also significantly associated with all-cause mortality in multivariate analysis in both sexes with Type 1 diabetes as proteinuria is in women with Type 2 diabetes. There is an unexpected negative association between plasma creatinine and all-cause mortality in men with Type 2 diabetes. Systolic blood pressure and hypertension are also significantly linked with cardiovascular mortality in Type 1 diabetes, hypertension having an estimated relative risk of 4.6 [corrected] in multivariate analysis. Serum cholesterol and proteinuria showed the strongest associations with cardiovascular mortality in Type 2 diabetes. Proteinuria is associated with non-cardiovascular mortality in both types of diabetes in univariate but not multivariate analysis. In multivariate analysis hypertension (Type 1 diabetes) and diabetes duration (Type 2 diabetes) are associated with non-cardiovascular mortality. Hypertension and proteinuria have the most consistent associations with mortality in the different analyses with the effect of hypertension appearing stronger in Type 1 diabetes and proteinuria in Type 2 diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

A prospective study of mortality among middle-aged diabetic patients (the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics) I: Causes and death rates

The 497 members of the London Cohort of the WHO Multinational Study of Vascular Disease in Diabetics have been followed for mortality from 1975 to 1987. During this period 92 patients died. The most common cause of death was myocardial infarction: 36 (39.1%) deaths, heart disease was responsible for 51.1% of deaths and all cardiovascular disease for 55.4%. Neoplastic disease accounted for 25% of the deaths and diabetic nephropathy for 5.4%. Age-standardised mortality rates were higher in men than in women in both Type 1 (insulin-dependent) diabetes and Type 2 (non-insulin-dependent) diabetes. Standardised mortality ratios for the first and second five year follow-up periods were higher for men than for women in Type 2 diabetes but were higher for women than men in Type 1. The results suggest that the female survival advantage seen in the general population may persist in Type 2 but not in Type 1 diabetes.

Microalbuminuria and cardiovascular risk factors in type 2 diabetes mellitus

Prospective studies have shown that increased urinary albumin excretion is a risk factor for cardiovascular morbidity and mortality in patients with Type 2 diabetes mellitus, but the nature of the association remains unknown. Eighty-five patients aged less than 65 years and not treated with insulin were studied. The overnight albumin excretion rate (AER) was measured in each patient and analysed in relation to several putative risk factors for cardiovascular disease. AER was used both as a continuous variable and after dividing patients into high-risk (AER greater than or equal to 10 micrograms min-1) and low-risk (AER less than 10 micrograms min-1) groups. By both methods of analysis AER was significantly correlated with both seated and supine diastolic blood pressure levels and with resting heart rate. Body mass index and waist-hip ratio appeared higher and HDL-cholesterol lower in the at-risk group, but differences were not statistically significant. The level of Factor VII was not significantly lower in the at-risk group. Little of the cardiovascular risk associated with raised AER can be attributed to associations with conventional risk factors.

Plasma lipid and coagulation factor concentrations in insulin dependent diabetics with microalbuminuria

OBJECTIVE

To determine whether insulin dependent diabetics with microalbuminuria have significant abnormalities in concentrations of lipoproteins, apolipoproteins AI and B, fibrinogen, and clotting factor VII which could result in increased cardiovascular risk.

DESIGN

Case-control study.

SETTING

Outpatient department of a metabolic ward.

PATIENTS

Group of 20 insulin dependent diabetics with urinary albumin excretion rates greater than 30 micrograms/min (microalbuminuria) and 20 individually matched insulin dependent diabetics with normal urinary albumin excretion rates (below 30 micrograms/min) matched for age, sex, and duration of diabetes.

INTERVENTIONS

Fasting venous blood samples were taken for determination of concentrations of glucose, glycated haemoglobin, lipoproteins, apolipoproteins AI and B, fibrinogen, and factor VII. Height, weight, arterial pressure, and usual insulin dose were recorded, and each patient was given a dietary questionnaire to be completed at home.

END POINT

Comparison of blood pressure and concentrations of lipoproteins, apolipoproteins AI and B, and fibrinogen in the diabetics with microalbuminuria and the controls.

MEASUREMENTS AND MAIN RESULTS

Patients with microalbuminuria had significantly higher concentrations of low density lipoprotein cholesterol (mean 3.33 (SE 0.20) v 2.84 (0.12) mmol/l) and very low density lipoprotein cholesterol (0.30 (0.05) v 0.17 (0.03) mmol/l) than controls but significantly lower concentrations of high density lipoprotein 2 subfraction cholesterol (0.32 (0.04) v 0.54 (0.04) mmol/l). Concentrations of total triglyceride (1.11 (0.14) v 0.68 (0.08) mmol/l), very low density lipoprotein triglyceride (0.56 (0.10) v 0.30 (0.05) mmol/l), apolipoprotein B (0.88 (0.06) v 0.67 (0.03) g/l) and fibrinogen (2.2 (0.1) v 1.9 (0.1) g/l), and diastolic arterial pressure (80 (2) v 74 (2) mm Hg), were also higher in patients with microalbuminuria.

CONCLUSIONS

Cardiovascular risk factors--namely, disturbances in lipoprotein and apolipoprotein concentrations, increased fibrinogen concentration, and increased arterial pressure--are already present in insulin dependent diabetics with microalbuminuria. The increased risk of coronary heart disease in patients with clinical proteinuria may result from prolonged exposure to these risk factors, which are present before any impairment of renal function.

Epidemiology and public health aspects of non-insulin-dependent diabetes mellitus

NIDDM is the predominant form of diabetes mellitus in all populations, almost exclusively so in some. Its prevalence varies enormously, with particularly high rates in populations whose lifestyle has drastically changed since World War II. Epidemiologic data from the developed countries of Europe and North America are not adequate to determine whether their incidence rates have also increased. Genetic factors are clearly implicated in the etiology of NIDDM, but their location and mode of expression remain to be determined. The two variables most strongly related to the incidence of NIDDM are age and degree of obesity, although there is emerging evidence of an independent association with fat distribution. Whether the nature of the habitual diet and the degree of physical activity influence the incidence of NIDDM remains uncertain and should be further researched. Cardiovascular disease is strongly associated with NIDDM in most populations, but there are between-population differences in the degree of association and the relative excess in the two sexes. There is increasing evidence, in particular for coronary heart disease, that increased risk precedes the onset of hyperglycemia; the implication of this is that NIDDM and atherosclerosis share common antecedents. The specific complications of NIDDM--eye and renal disease--are important causes of morbidity and mortality and for those populations, often relatively poor, in which NIDDM is already or is becoming very common will pose substantial problems in provision of health care.

Hypertension in diabetic patients and differences between insulin-dependent diabetes mellitus and non-insulin-dependent diabetes mellitus

In insulin-dependent diabetes mellitus (IDDM), BP levels in subjects with normal or only mildly increased levels of albumin excretion do not differ systematically from those in non-diabetic reference populations. However, it is not known whether increased albuminuria and raised blood pressure are causally related. Several studies have observed higher average BP levels in glucose-intolerant subjects, even allowing for effects of age and adiposity. This applies to subjects with glucose intolerance below and above the World Health Organization criteria for diagnosing non-insulin-dependent diabetes mellitus (NIDDM). However, there are very few satisfactory studies comparing established patients with NIDDM with appropriate reference populations, and although it is widely believed that high BP (or hypertension) is a feature of NIDDM, the evidence for this belief is scant.