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Background: Peripheral arterial disease (PAD) is a risk factor for amputation and systemic atherosclerotic disease. Barbados has a high diabetes prevalence, and 89% of diabetes-related hospital admissions are for foot problems. Foot examination is infrequent in Barbados primary care. The prevalence and potential risk factors for PAD in people with diabetes in Barbados were studied., Methods: Multistage probability sampling was used to select a representative population sample of people ≥25 years of age with known diabetes or fasting blood glucose ≥7 mmol/L or HbA1c ≥6.5%. We administered the Edinburgh claudication questionnaire and assessed the ankle brachial pressure index (ABI) and Doppler waveform in both dorsalis pedis and posterior tibial arteries. Participants were classified into categories based on ABI as follows: PAD ≤0.90 in any leg; borderline 0.91 to 0.99 in one leg and the other not ≤0.90 or >0.4; normal 1.00 to 1.40 in both legs; and non-compressible >1.40 in one leg and the other not ≤0.9. Waveforms crossing the zero-flow baseline were categorised as normal. Multivariable logistic regression assessed the associations of potential risk factors with PAD., Results: Of 236 participants (74% response rate, 33% male, median age 58.6 years), 51% had previously diagnosed diabetes. Of nine people with symptoms of definite or atypical claudication, four had PAD and one had non-compressible arteries. ABI prevalence (95% CI) was PAD 18.6% (13.8, 24.6), borderline 21.9% (16.6, 28.4), normal 55.5% (49.4, 61.5) and non-compressible 3.9% (1.6, 9.3). Increasing age and female gender were independently associated with PAD. Over 80% of normal legs (ABI 1.00 to 1.40) had normal posterior tibial and dorsalis pedis waveforms, while only 23% legs with PAD (ABI ≤0.90) had normal waveforms in both arteries (Kappa = 0.43)., Conclusion: Asymptomatic PAD is common in people with diabetes and requires ABI screening to detect it. Female gender is associated with PAD., Competing Interests: None of the authors have financial or personal conflicts of interest that can inappropriately influence the contents of this article., (© 2022 Adams et al.)

Aims: To estimate the number of deaths attributable to diabetes in 20-79-year-old adults in 2019., Methods: The following were used to estimate the number of deaths attributable to diabetes: all-cause mortality estimates from the World Health Organization life table, country level age- and sex-specific estimates of diabetes prevalence in 2019 and relative risks of death in people with diabetes compared to people without diabetes., Results: An estimated 4.2 million deaths among 20-79-year-old adults are attributable to diabetes. Diabetes is estimated to contribute to 11.3% of deaths globally, ranging from 6.8% (lowest) in the Africa Region to 16.2% (highest) in the Middle East and North Africa. About half (46.2%) of the deaths attributable to diabetes occur in people under the age of 60 years. The Africa Region has the highest (73.1%) proportion of deaths attributable to diabetes in people under the age of 60 years, while the Europe Region has the lowest (31.4%)., Conclusions: Diabetes is estimated to contribute to one in nine deaths among adults aged 20-79 years. Prevention of diabetes and its complications is essential, particularly in middle-income countries, where the current impact is estimated to be the largest. Contemporary data from diverse populations are needed to validate these estimates., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Aims: To provide global estimates of diabetes prevalence for 2019 and projections for 2030 and 2045., Methods: A total of 255 high-quality data sources, published between 1990 and 2018 and representing 138 countries were identified. For countries without high quality in-country data, estimates were extrapolated from similar countries matched by economy, ethnicity, geography and language. Logistic regression was used to generate smoothed age-specific diabetes prevalence estimates (including previously undiagnosed diabetes) in adults aged 20-79 years., Results: The global diabetes prevalence in 2019 is estimated to be 9.3% (463 million people), rising to 10.2% (578 million) by 2030 and 10.9% (700 million) by 2045. The prevalence is higher in urban (10.8%) than rural (7.2%) areas, and in high-income (10.4%) than low-income countries (4.0%). One in two (50.1%) people living with diabetes do not know that they have diabetes. The global prevalence of impaired glucose tolerance is estimated to be 7.5% (374 million) in 2019 and projected to reach 8.0% (454 million) by 2030 and 8.6% (548 million) by 2045., Conclusions: Just under half a billion people are living with diabetes worldwide and the number is projected to increase by 25% in 2030 and 51% in 2045., (Copyright © 2019. Published by Elsevier B.V.)

Aims: With regards to insulin initiation in Barbados we explored primary care doctor (PCD) perception, healthcare system factors and predictors of PCD reluctance to initiate insulin., Methods: PCDs completed a questionnaire based on the theory of planned behaviour (TPB) and a reluctance to initiate insulin scale. Using linear regression, we explored the association between TPB domains and the reluctance to initiate insulin scale., Results: Of 161 PCDs, 70% responded (75 private and 37 public sector). The majority felt initiating insulin was uncomplicated (68%) and there was benefit if used before complications developed (68%), but would not use it until absolutely necessary (58%). More private than public sector PCDs (p<0.05) thought that the healthcare system allowed enough flexibility of time for education (68 vs 38%) and initiating insulin was easy (63 vs 35%), but less thought system changes would help initiating insulin (42 vs 70%). Reasons for reluctance to initiate insulin included patient nonadherence (83%) and reluctance (63%). Only the attitudes and belief domain of the TPB was associated with the reluctance to initiate insulin scale (p<0.001)., Conclusions: Interventions focusing on PCD attitudes and beliefs and restructuring services inclusive of the use of diabetes specialist nurses are required., (Copyright © 2016 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

Background: Diabetes is highly prevalent in the Caribbean, associated with a high morbidity and mortality and is a recognised threat to economic and social development. Heads of Government in the Caribbean Community came together in 2007 and declared their commitment to reducing the burden of non-communicable diseases (NCDs), including diabetes, by calling for a multi-sectoral, systemic response. To facilitate the development of effective policies, policymakers are being engaged in the development and use of a system dynamics (SD) model of diabetes for Caribbean countries., Methods: Previous work on a diabetes SD model from the United States of America (USA) is being adapted to a local context for three countries in the region using input from stakeholders, a review of existing qualitative and quantitative data, and collection of new qualitative data. Three country models will be developed using one-on-one stakeholder engagement and iterative revision. An inter-country model will also be developed following a model-building workshop. Models will be compared to each other and to the USA model. The inter-country model will be used to simulate policies identified as priorities by stakeholders and to develop targets for prevention and control. The model and model-building process will be evaluated by stakeholders and a manual developed for use in other high-burden developing regions., Discussion: SD has been applied with success for health policy development in high-income country settings. The utility of SD in developing countries as an aid to policy decision-making related to NCDs has not been tested. This study represents the first of its kind.

Aim: The study tested the hypothesis that doctors using an insulin information checklist during simulated insulin initiation would impart more information regarding insulin use., Methods: A total of 128 simulations were conducted. Doctors (n = 64) were recruited from practitioners recently completing internship (n = 19) and those established in primary care (n = 45). Both groups of doctors were strata randomized to control (n = 32) and intervention groups (n = 32), so that each group contained equal numbers. Doctors in each group experienced two identical simulations of insulin initiation with an intervening period of 10 min. Doctors in the intervention arm were introduced to an insulin initiation checklist, which they reviewed independently and utilized in the second simulation. Trained assessors captured the provision of education in 21 predefined educational areas. Differences in the change of the total education provided between the first and second simulations were assessed using linear regression., Results: The difference in the mean change of education provided between the first and second simulations within the 21 educational areas for the control and treatment groups was 9.7 [95% confidence interval (CI): 8.8-11.1, P < 0.001] - an increase of 46.2%. The difference for the 15 areas relevant to pen use was 7.3 (95% CI: 6.2-8.4, P < 0.001) - an increase of 51.6%., Conclusions: The checklist resulted in doctors providing significantly more education applicable to syringe and insulin pen routes of insulin administration during simulations. Further research is needed on the checklist's impact on healthcare professionals and patient outcomes in the clinical context. (Clinical Trials Registry No: NCT02266303)., (© 2015 Diabetes UK.)

Background: Diabetes (DM) is estimated to affect 10-15% of the adult population in the Caribbean. Preventive efforts require population wide measures to address its social determinants. We undertook a systematic review to determine current knowledge about the social distribution of diabetes, its risk factors and major complications in the Caribbean. This paper describes our findings on the distribution by gender., Methods: We searched Medline, Embase and five databases through the Virtual Health Library, for Caribbean studies published between 2007 and 2013 that described the distribution by gender for: known risk factors for Type 2 DM, prevalence of DM, and DM control or complications. PRISMA guidance on reporting systematic reviews on health equity was followed. Only quantitative studies (n>50) were included; each was assessed for risk of bias. Meta-analyses were performed, where appropriate, on studies with a low or medium risk of bias, using random effects models., Results: We found 50 articles from 27 studies, yielding 118 relationships between gender and the outcomes. Women were more likely to have DM, obesity, be less physically active but less likely to smoke. In meta-analyses of good quality population-based studies odds ratios for women vs. men for DM, obesity and smoking were: 1.65 (95% CI 1.43, 1.91), 3.10 (2.43, 3.94), and 0.24 (0.17, 0.34). Three studies found men more likely to have better glycaemic control but only one achieved statistical significance., Conclusion and Implications: Female gender is a determinant of DM prevalence in the Caribbean. In the vast majority of world regions women are at a similar or lower risk of type 2 diabetes than men, even when obesity is higher in women. Caribbean female excess of diabetes may be due to a much greater excess of risk factors in women, especially obesity. These findings have major implications for preventive policies and research.

Historically, an association between tuberculosis and diabetes was recognised clinically, and the recent global rise in diabetes prevalence has reignited interest. We therefore quantified the tuberculosis-diabetes association using US survey data. A case-control analysis was performed using cross-sectional data from the second National Health and Nutrition Examination Survey (1976-1980; civilian non-institutionalised US population aged 20-74). Cases were respondents ever diagnosed with tuberculosis, and controls were respondents who reported never receiving a tuberculosis diagnosis. Exposure to diabetes and intermediate hyperglycaemia was defined using a self-reported measure, an oral glucose tolerance test, or both. We used logistic regression to estimate an adjusted odds ratio, controlling for potential major confounders. In relation to the main exposure measure, the adjusted odds ratio for the association between tuberculosis and diabetes varied between 2.31 (95% confidence interval 1.36-3.93) and 2.36 (95% confidence interval 1.40-3.97), depending on the model. No association was found for intermediate hyperglycaemia, with adjusted odds ratio varying between 1.33 (95% confidence interval 0.49-3.64) and 1.34 (95% confidence interval 0.50-3.62), depending on model. Irrespective of the exposure measure and the confounders controlled for, diabetes was associated with an increased tuberculosis risk. This study may underestimate the true association due to exposure misclassification.

Background: The authors aimed to determine whether, and by how much, diabetes mellitus (DM) increases the risk of tuberculosis (TB) and conversely whether TB increases the risk of DM., Methods: Retrospective cohort analyses using data from two Oxford Record Linkage Study (ORLS) datasets, containing information on hospital admissions and day-case care between 1963 and 1998 (ORLS1) and between 1999 and 2005 (ORLS2), were carried out. The rate ratio (RR) for tuberculosis after admission to hospital with diabetes and for diabetes after hospital admission with tuberculosis was calculated., Results: In ORLS1, the RR for TB in people admitted to hospital with DM, comparing the latter with a reference cohort, was 1.83 (95% CI 1.26 to 2.60), and in ORLS2 the RR was 3.11 (1.17 to 7.03). RRs for pulmonary tuberculosis (PTB) and extrapulmonary tuberculosis (EPTB) within ORLS1 were similar at, respectively, 1.80 (1.16 to 2.67) and 1.98 (0.88 to 3.92). In ORLS 2 the RR for PTB was 2.63 (0.91 to 6.30). In ORLS1, there was no indication that TB was a risk factor for DM (RR 1.12, 0.76 to 1.60). The ORLS2 dataset was too small to analyse whether TB led to DM., Discussion: DM was associated with a two- to threefold increased risk of TB within this predominantly white, English population. The authors found no evidence that TB increases the risk of DM. Our findings suggest that the risks of PTB and EPTB were both raised among individuals with DM. As DM prevalence rises, this association will become increasingly important for TB control and treatment.

Introduction: Diabetes is a major cause of morbidity and mortality and its global prevalence is growing rapidly. A simple and robust approach to estimate the prevalence of diabetes is essential for governments to set priorities on how to meet the challenges of the disease. The International Diabetes Federation has developed a methodology for generating country-level estimates of diabetes prevalence in adults (20-79 years)., Methods: Using country-level data sources from peer-reviewed studies, national health statistics reports, commissioned studies on diabetes prevalence, and unpublished data obtained through personal communication, we use logistic regression to generate estimates of the prevalence of diabetes. An approach matching countries on ethnicity, geography, and income group is used to fill in gaps where original data sources are not available. The methodology also uses changes in urbanization and population to generate estimates and projections on the prevalence of diabetes in adults., Conclusion: Diabetes prevalence estimates are very sensitive to the data from which they are derived. The revised IDF methodology for estimating diabetes prevalence is a transparent, reproducible approach that will be updated annually. It takes data-driven approaches to filling in gaps where data are not available and where assumptions have to be made. It uses a qualification system to rank data sources so that only the highest quality data are used., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

Background: There is good evidence that diabetes is a risk factor for pulmonary tuberculosis. In England, the rates of both diabetes and tuberculosis vary markedly by ethnic group., Objective: To estimate the proportion of incident cases of pulmonary tuberculosis attributable to diabetes (population attributable fraction, PAF) for Asian, black and white men and women aged > or = 15 years in England., Methods: An epidemiological model was constructed using data on the incidence of tuberculosis, the prevalence of diabetes, the population structure for 2005 and the age-specific relative risk of tuberculosis associated with diabetes from a large cohort study., Results: The estimated PAF of diabetes for pulmonary tuberculosis is highest for Asian men (19.6%, 95% CI 10.9% to 33.1%) and women (14.2%, 95% CI 7.1% to 26.5%). The PAF for all ages is similar in white and black men (6.9%, 95% CI 3.1% to 12.4% and 7.4%, 95% CI 4.6% to 12.9%, respectively) and women (8.2%, 95% CI 3.0% to 15.6% and 8.9%, 95% CI 5.3% to 15.6%, respectively). The similarity of these overall figures, despite a higher prevalence of diabetes in the black population, reflects a much younger mean age of pulmonary tuberculosis in the black population. Overall, of 3461 new cases of pulmonary tuberculosis in England in 2005, 384 (202-780) were estimated to be attributable to diabetes., Conclusion: Given the nature of the data available, considerable uncertainty surrounds these estimates. Nonetheless, they highlight the potential importance of diabetes as a risk factor for pulmonary tuberculosis, particularly in groups at high risk of both diseases. Further research to examine the implications of these findings for tuberculosis control is urgently needed.

The steadily growing epidemic of diabetes mellitus poses a threat for global tuberculosis (TB) control. Previous studies have identified an important association between diabetes mellitus and TB. However, these studies have limitations: very few were carried out in low-income countries, with none in Africa, raising uncertainty about the strength of the diabetes mellitus-TB association in these settings, and many critical questions remain unanswered. An expert meeting was held in November 2009 to discuss where there was sufficient evidence to make firm recommendations about joint management of both diseases, to address research gaps and to develop a research agenda. Ten key research questions were identified, of which 4 were selected as high priority: (i) whether, when and how to screen for TB in patients with diabetes mellitus and vice versa; (ii) the impact of diabetes mellitus and non-diabetes mellitus hyperglycaemia on TB treatment outcomes and deaths, and the development of strategies to improve outcomes; (iii) implementation and evaluation of the tuberculosis 'DOTS' model for diabetes mellitus management; and (iv) the development and evaluation of better point-of-care diagnostic and monitoring tests, including measurements of blood glucose and glycated haemoglobin A(1c) (HbA(1c)) for patients with diabetes mellitus. Implementation of this research agenda will benefit the control of both diseases.

Country and global health statistics underestimate the number of excess deaths due to diabetes. The aim of the study was to provide a more accurate estimate of the number of deaths attributable to diabetes for the year 2010. A computerized disease model was used to obtain the estimates. The baseline input data included the population structure, estimates of diabetes prevalence, estimates of underlying mortality and estimates of the relative risk of death for people with diabetes compared to people without diabetes. The total number of excess deaths attributable to diabetes worldwide was estimated to be 3.96 million in the age group 20-79 years, 6.8% of global (all ages) mortality. Diabetes accounted for 6% of deaths in adults in the African Region, to 15.7% in the North American Region. Beyond 49 years of age diabetes constituted a higher proportion of deaths in females than in males in all regions, reaching over 25% in some regions and age groups. Thus, diabetes is a considerable cause of premature mortality, a situation that is likely to worsen, particularly in low and middle income countries as diabetes prevalence increases. Investments in primary and secondary prevention are urgently required to reduce this burden., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

This short article provides a brief overview of the epidemiology of diabetes and the diabetic foot in developing countries, reviews evidence that diabetic foot care is potentially one of the most cost-effective interventions for people with diabetes in developing countries, and outlines some of the challenges to improving access to foot care and diabetes care in general.

Background: The objective of the study was to explore the cultural aspect of compliance, its underlying principles and how these cultural aspects can be used to improve patient centred care for diabetes in Cameroon., Methods: We used participant observation to collect data from a rural and an urban health district of Cameroon from June 2001 to June 2003. Patients were studied in their natural settings through daily interactions with them. The analysis was inductive and a continuous process from the early stages of fieldwork., Results: The ethnography revealed a lack of basic knowledge about diabetes and diabetes risk factors amongst people with diabetes. The issue of compliance was identified as one of the main themes in the process of treating diabetes. Compliance emerged as part of the discourse of healthcare providers in clinics and filtered into the daily discourses of people with diabetes. The clinical encounters offered treatment packages that were socially inappropriate therefore rejected or modified for most of the time by people with diabetes. Compliance to biomedical therapy suffered a setback for four main reasons: dealing with competing regimes of treatment; coming to terms with biomedical treatment of diabetes; the cost of biomedical therapy; and the impact of AIDS on accepting weight loss as a lifestyle measure in prescription packages. People with diabetes had fears about and negative opinions of accepting certain prescriptions that they thought could interfere with their accustomed social image especially that which had to do with bridging their relationship with ancestors and losing weight in the era of HIV/AIDS., Conclusion: The cultural pressures on patients are responsible for patients' partial acceptance of and adherence to prescriptions. Understanding the self-image of patients and their background cultures are vital ingredients to improve diabetes care in low-income countries of Sub-Sahara Africa like Cameroon.

Background: Tuberculosis (TB) remains a major cause of mortality in developing countries, and in these countries diabetes prevalence is increasing rapidly. Diabetes increases the risk of TB. Our aim was to assess the potential impact of diabetes as a risk factor for incident pulmonary tuberculosis, using India as an example., Methods: We constructed an epidemiological model using data on tuberculosis incidence, diabetes prevalence, population structure, and relative risk of tuberculosis associated with diabetes. We evaluated the contribution made by diabetes to both tuberculosis incidence, and to the difference between tuberculosis incidence in urban and rural areas., Results: In India in 2000 there were an estimated 20.7 million adults with diabetes, and 900,000 incident adult cases of pulmonary tuberculosis. Our calculations suggest that diabetes accounts for 14.8% (uncertainty range 7.1% to 23.8%) of pulmonary tuberculosis and 20.2% (8.3% to 41.9%) of smear-positive (i.e. infectious) tuberculosis. We estimate that the increased diabetes prevalence in urban areas is associated with a 15.2% greater smear-positive tuberculosis incidence in urban than rural areas - over a fifth of the estimated total difference., Conclusion: Diabetes makes a substantial contribution to the burden of incident tuberculosis in India, and the association is particularly strong for the infectious form of tuberculosis. The current diabetes epidemic may lead to a resurgence of tuberculosis in endemic regions, especially in urban areas. This potentially carries a risk of global spread with serious implications for tuberculosis control and the achievement of the United Nations Millennium Development Goals.

Background: The objective of the study was to provide baseline and reference data on the prevalence and distribution of overweight and obesity, using different anthropometric measurements in adult urban populations in Cameroon., Methods: The Cameroon Burden of Diabetes Baseline Survey was a cross-sectional study, conducted in 4 urban districts (Yaoundé, Douala, Garoua and Bamenda) of Cameroon, using the WHO Step approach for population-based assessment of cardiovascular risk factors. Body mass index, waist circumference and waist-to-hip ratio were measured using standardized methods. Overall, 10,011 individuals, 6,004 women and 4,007 men, from 4,189 households, aged 15 years and above participated., Results: Based on body mass index, more than 25% of urban men and almost half of urban women were either overweight or obese with 6.5% of men and 19.5% of women being obese. The prevalence of obesity showed considerable variation with age in both genders. Using body mass index provided the highest prevalence of obesity in men (6.5%) and waist-to-hip ratio the lowest prevalence (3.2%). Among women, using waist-to-hip ratio and waist circumference yielded the highest prevalence of obesity (28%) and body mass index the lowest (19.5%). There was a trend towards an increase in age-adjusted odd ratios of being overweight or obese with duration of education in both sexes., Conclusion: The study provides current data on anthropometric measurements and obesity in urban Cameroonian populations, and found high prevalences of overweight and obesity particularly over 35 years of age, and among women. Prevalence varied according to the measure used. Our findings highlight the need to carry out further studies in Cameroonian and other Sub-Saharan African populations to provide appropriate cut-off points for the identification of people at risk of obesity-related disorders, and indicate the need to implement interventions to reverse increasing levels of obesity.

Diabetes, obesity, and physical inactivity are common in urban areas in sub-Saharan Africa. This paper reports an investigation of lay knowledge, attitudes, and behaviors relating to diabetes and its main risk factors of urban Cameroonians. We carried out a qualitative study in four urban health districts, one from each of the main ecological areas of Cameroon. Participants were purposively selected to include a range of community key participants and articulate community members. Data were collected through in-depth interviews by using a pre-tested, semi-structured interview guide. Sixty-two interviews were conducted across the four sites. Awareness of diabetes and knowledge of its causes, clinical course, and complications were limited. Many participants believed diabetes was caused by excessive sugar consumption rather than excessive energy intake, obesity, or physical inactivity. Obesity, particularly in men, was largely perceived positively as a sign of "good living." Many participants underestimated the degree to which they were overweight. Physical activity was mostly viewed positively, although negative views were common about simple methods of increasing physical activity, such as walking. Several constraints to the adoption of healthy behaviors were identified. For diet, these included lack of knowledge of the composition of a healthy diet. Barriers to undertaking more physical activity included lack of facilities and inadequate time available. The results indicate the need for health education about diabetes and its main risk factors in these communities. Health education should be informed by lay perspectives to maximize the appropriateness of the messages and their effect on knowledge, attitudes, and behavior.

Objective: To estimate the global number of excess deaths due to diabetes in the year 2000., Research Design and Methods: We used a computerized generic formal disease model (DisMod II), used by the World Health Organization to assess disease burden through modeling the relationships between incidence, prevalence, and disease-specific mortality. Baseline input data included population structure, age- and sex-specific estimates of diabetes prevalence, and available published estimates of relative risk of death for people with diabetes compared with people without diabetes. The results were validated with population-based observations and independent estimates of relative risk of death., Results: The excess global mortality attributable to diabetes in the year 2000 was estimated to be 2.9 million deaths, equivalent to 5.2% of all deaths. Excess mortality attributable to diabetes accounted for 2-3% of deaths in poorest countries and over 8% in the U.S., Canada, and the Middle East. In people 35-64 years old, 6-27% of deaths were attributable to diabetes., Conclusions: These are the first global estimates of mortality attributable to diabetes. Globally, diabetes is likely to be the fifth leading cause of death.

Background and Aim: There are virtually no epidemiological studies from India assessing the level of awareness of diabetes in a whole population. The aim of the present study was to assess the awareness of diabetes in an urban south Indian population in Chennai., Methods: The Chennai Urban Rural Epidemiology Study (CURES) is an ongoing population based study conducted using a systematic sampling method on a representative population (aged > or = 20 years - 26001 individuals) of Chennai [formerly Madras], the largest city in Southern India. A structured questionnaire was used to obtain information related to demography, education and medical history. The questionnaire included five questions on diabetes awareness., Results: Of the total 26,001 individuals, only 75.5% (19642/26001) of the whole population reported that they knew about a condition called diabetes or conversely nearly 25% of the Chennai population was unaware of a condition called diabetes. 60.2% (15656/26001) of all participants and 76.7% (1173/1529) of the self reported diabetic subjects knew that the prevalence of diabetes was increasing in India. Only 22.2% (5764/ 26001) of the whole population and 41.0% (627/1529) of the known diabetic subjects were aware that diabetes could be prevented. Knowledge of the role of obesity and physical inactivity in producing diabetes was very low, with only 11.9% (3083/26001) of study subjects reporting these as risk factors for diabetes. Only 19.0% (4951/26001) of whole population knew that diabetes could cause complications. Even among the self reported diabetic subjects, only 40.6% (621/1529) were aware that diabetes could produce some complications., Conclusion: Awareness and knowledge regarding diabetes is still grossly inadequate in India. Massive diabetes education programmes are urgently needed both in urban and rural India.

Aims: Suboptimal maternal nutrition and catch-up growth in early childhood predispose to insulin resistance and other components of metabolic syndrome in later life. A central metabolic syndrome (CMS) has been identified comprising obesity, dyslipidaemia and insulin resistance. This study was designed to investigate determinants of risk for CMS., Methods: Persons born in Newcastle in May and June 1947 (n = 358) were followed to 1996-1998. A lifecourse approach was used to estimate the proportion of variance in a summary measure of CMS at age 49-51 years accounted for by factors operating at different stages of life., Results: After adjustment for other early life variables, childhood catch-up growth in men accounted for significant variation in the CMS score independent of adult lifestyle. In adulthood, exercise level in men and smoking in both genders were independently associated with CMS. Over two-thirds of explained variation in the CMS score in women, and almost half in men, was accounted for exclusively by factors measured in adulthood., Conclusions: While risk for CMS in men is compounded by early life disadvantage, promotion of a healthier adult lifestyle and a reduction in the number of people taking up smoking would appear to be the public health interventions most likely to reduce the prevalence of CMS in middle age.

Aims: We aimed to compare levels of urinary albumin excretion and the prevalence of microalbuminuria in UK South Asians and Europeans. Microalbuminuria predicts cardiovascular disease in European origin populations, but evidence from the general population of South Asians is lacking. Coronary heart disease (CHD) mortality is 40-50% higher in UK South Asians compared with the whole population, for reasons that are incompletely understood., Methods: Microalbuminuria was measured using the albumin-creatinine ratio in an age- and sex-stratified random sample of 1509 adults from European (n = 825), Indian (n = 259), Pakistani (n = 305) and Bangladeshi (n = 120) ethnic groups., Results: Levels of urinary albumin excretion were substantially higher in South Asians (geometric mean albumin creatinine ratio (95% confidence interval) 0.83 (0.75, 0.91)) than in Europeans (0.55 (0.51, 0.60)). Microalbuminuria was associated with older age, hypertension and diabetes, but independently of these risk factors urinary albumin excretion was higher in South Asians than Europeans., Conclusions: Urinary albumin excretion is higher and microalbuminuria more frequent in UK South Asians compared with the majority ethnic population. Microalbuminuria may be relevant to the causal pathways leading to the excess of cardiovascular mortality and possibly renal failure in UK South Asians.

A workshop was convened by the International Diabetes Federation to review the latest information relating to the risks associated with impaired glucose tolerance (IGT) and impaired fasting glycaemia (IFG) for future diabetes and cardiovascular disease (CVD). The workshop sought to address three questions: (i) are the current definitions of IGT and IFG appropriate; (ii) are IFG and IGT risk factors, risk markers or diseases; (iii) what interventions (if any) should be recommended for people with IFG and IGT? The determinants of elevated fasting glucose and 2-h plasma glucose in an oral glucose tolerance test (2-HPG) levels differ. Raised hepatic glucose output and a defect in early insulin secretion are characteristic of the former, and peripheral insulin resistance is most characteristic of the latter. Therefore, it is not surprising that the concordance between the categories of IFG and IGT is limited. In all prevalence studies to date only half or less of people with IFG have IGT, and even a lower proportion (20-30%) with IGT also have IFG. In the majority of populations studied, IGT is more prevalent than IFG, and there is a difference in phenotype and gender distribution between the two categories. IFG is substantially more common amongst men and IGT slightly more common amongst women. The prevalence of IFG tends to plateau in middle age whereas the prevalence of IGT rises into old age. Both IFG and IGT are associated with a substantially increased risk of developing diabetes, with the highest risk in people with combined IFG and IGT. Because IGT is commoner than IFG in most populations it is more sensitive (but slightly less specific) for identifying people who will develop diabetes. In most populations studied, 60% of people who develop diabetes have either IGT or IFG 5 years or so before, with the other 40% having normal glucose tolerance at that time. The limited published data suggest that both isolated IFG (I-IFG) and isolated IGT (I-IGT) are similarly associated with cardiovascular risk factors, such as hypertension and dyslipidaemia, with the highest risk in those with combined IFG and IGT. However, some data have suggested that I-IGT is more strongly associated with hypertension and dyslipidaemia (features of the metabolic syndrome) than I-IFG. In unadjusted analyses both IFG and IGT are associated with CVD and total mortality. In separate analyses for fasting and 2-HPG adjusted for other cardiovascular risk factors (from the DECODE study) there remains a continuous relationship between 2-HPG and mortality, but an independent relationship with fasting glucose is only found above 7.0 mmol/l. Glycated haemoglobin (HbA1c) levels are continuously and positively associated with CVD and total mortality independent of other CVD risk factors. Life style interventions, including weight loss and increased physical activity, are highly effective in preventing or delaying the onset of diabetes in people with IGT. Two randomized controlled trials of individuals with IGT found that life style intervention studies reduce the risk of progressing to diabetes by 58%. The oral hypoglycaemic drugs metformin and acarbose have also been shown to be effective, but less so than the life style measures. Similar data do not yet exist for the effectiveness of such interventions in people with I-IFG. Larger studies are required to evaluate the effects of interventions on cardiovascular outcomes in people with IGT. Cost effective strategies to identify people with IGT for intervention should be developed and evaluated. The use of simple risk scores to assess who should undergo an oral glucose tolerance test is one promising approach, although these will need to be population-specific. In conclusion, IGT and IFG differ in their prevalence, population distribution, phenotype, and risk of total mortality and CVD. The consensus of the workshop was: 1. The diagnostic thresholds for all categories of glucose intolerance should be revisited in the light of the latest evidence. There was no clear consensus (with current evidence) on whether IFG and IGT should be classified as diseases, but they clearly represent risk factors and risk markers for diabetes and CVD, respectively. 2. Both IGT and IFG are similarly associated with an increased risk of diabetes, but IGT is more strongly associated with CVD outcomes. 3. Risks are higher when IGT and IFG coexist. 4. Life style interventions are highly effective in delaying or preventing the onset of diabetes in people with IGT and may reduce CVD and total mortality, but the latter requires formal testing.

Background: Differences in level of physical activity between European, Indian, Pakistani and Bangladeshi populations living in the UK might contribute to differences in the prevalence of diabetes and cardiovascular disease risk markers that exist in these populations., Methods: Type and level of physical activity (measured by a multidimensional index) and its relationship with selected cardiovascular disease and diabetes risk factors were assessed in a cross-sectional, population-based study of European, Indian, Pakistani and Bangladeshi men and women, aged 25-75, resident in Newcastle upon Tyne., Results: Europeans were found to be more physically active than Indians, Pakistanis or Bangladeshis. On our physical activity index 52 per cent of European men did not meet current guidelines for participation in physical activity compared with 71 per cent of Indians, 88 per cent of Pakistanis and 87 per cent of Bangladeshis. Similar findings are reported for women. In particular, European men and women participated more frequently in moderate and vigorous sport and recreational activities. In general, level of physical activity was inversely correlated with body mass index (BMI), waist measurement, systolic blood pressure, and blood glucose and insulin in all ethnic groups, but did not correlate with high-density lipoprotein (HDL) cholesterol., Conclusions: South Asians in Newcastle report significantly lower levels of habitual physical activity than Europeans. This is likely to contribute to the higher levels of diabetes and cardiovascular risk in these populations. Measures to increase physical activity in these populations are urgently needed.

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.

Background: The aim of this study was to test the hypothesis that in Europeans and South Asians (Indians, Pakistanis, Bangladeshis) alike, worse socio-economic status is associated with a higher prevalence of coronary heart disease (CHD), glucose intolerance (impaired glucose tolerance and diabetes) and related risk factors (the predicted direction of association)., Methods: Cross-sectional data were analysed from a community-based prevalence study seeking associations between social class, education and Townsend deprivation score and ECG evidence of CHD, glucose tolerance test and 12 cardiovascular risk factors. The study population consisted of South Asians (n = 684) comprising Indians (n = 259), Pakistanis (n = 305) and Bangladeshis (n = 120), and Europeans (n = 825), aged 25-74 years in Newcastle. The analysis examined up to 84 associations for each ethnic group. Interactions between ethnicity and socio-economic variables were examined using regression analysis. The main outcome measure was the number of associations in the predicted direction., Results: Europeans fared better in some indicators of socio-economic position, South Asians in others. Indians were socio-economically advantaged compared with Pakistanis and Bangladeshis. Most measures of socio-economic position were associated with health measures in the predicted direction in Europeans [71/84 (85 per cent) associations, 25 statistically significant] and less so in the South Asians combined [58/84 (69 per cent) associations, 12 statistically significant]. In South Asian men 25/42 (60 per cent) of associations were as predicted, seven significantly so, in women 33/42 (79 per cent) were, five being statistically significant. There were apparent differences between Indians 152/78 (67 per cent) of associations as predicted, seven statistically significant], Pakistanis [41/84 (49 per cent), four statistically significant] and Bangladeshis [39/79 (49 per cent), one statistically significant]. In Indians, Townsend deprivation score was mostly associated as predicted [23/27 (85 per cent), five associations statistically significant], more so than social class [14/27 (52 per cent), none statistically significant]. In South Asian men and women combined, associations with anthropometric [18/24 (75 per cent)], biochemical [15/18 (83 per cent)], and lifestyle 114/18 (78 per cent)] measures were often as predicted, but those with blood pressure (4/12, 33 per cent) and CHD and glucose intolerance (7/12, 58 per cent) were less often so. Interactions between socio-economic position and ethnicity were found., Conclusions: The European pattern of inequalities is being established in South Asian men and women, possibly at a different pace in different subgroups. Future studies of inequalities should be large, separate Indian, Pakistani and Bangladeshi populations, study men and women separately and track changes over time.

Objectives: To establish the age and sex specific mortality for people with diabetes in comparison with local and national background populations; to investigate the relationship between mortality and material deprivation in an unselected population with diabetes., Design: Longitudinal study, using a population based district diabetes register., Setting: South Tees, United Kingdom., Participants: All people known to have diabetes living in Middlesbrough and Redcar and Cleveland local authorities on 1 January 1994., Main Outcome Measure: Death, from any cause, between 1 January 1994 and 31 December 1999., Results: Over the six years of the study 1205 (24.9%) of 4842 participants died. All cause standardised mortality ratios for type 1 diabetes were 641 (95% confidence interval 406 to 962) in women and 294 (200 to 418) in men, and those for type 2 diabetes were 160 (147 to 174) in women and 141 (130 to 152) in men. Cause specific standardised mortality ratios were increased for ischaemic heart disease, cerebrovascular disease, and renal disease; no reductions in mortality from other causes were seen. The risk of premature death increased significantly with increasing material deprivation (P<0.001)., Conclusions: Diabetes is associated with excess mortality, even in an area with high background death rates from cardiovascular disease. This excess mortality is evident in all age groups, most pronounced in young people with type 1 diabetes, and exacerbated by material deprivation. Aggressive approaches to the management of cardiovascular risk factors could reduce the excess mortality in people with diabetes.

Considerable evidence suggests that diabetes mellitus and hypertension are influenced by genetic factors. Studies in humans have associated glucocorticoid receptor (GR) polymorphisms with high blood pressure, insulin sensitivity, body mass index, increased visceral fat, and variations in tissue-specific steroid sensitivity. The N363S polymorphism of the GR results in an asparagine to serine amino acid substitution in a modulatory region of the receptor. Phosphorylation of serine residues in this region has been shown to enhance transactivation of GR responsive genes. The aim of this study was to investigate the association between the 363S allele and risk factors for coronary heart disease and diabetes mellitus in a population of European origin living in the northeast of the United KINGDOM: Blood samples from 135 males and 240 females were characterized for 363 allele status. The overall frequency of the 363S allele was 3.0%, 23 heterozygotes (7 males and 16 females) but no 363S homozygotes were identified. The data show a significant association of the 363S allele with increased waist to hip ratio in males but not females. This allele was not associated with blood pressure, body mass index, serum cholesterol, triglycerides, low-density lipoprotein and high-density lipoprotein cholesterol levels, and glucose tolerance status. The results of this study suggest that this GR polymorphism may contribute to central obesity in men. Further studies are required to elucidate the properties of GR(363S) at a molecular level.

NCDs including diabetes, heart disease and stroke are global epidemics of the 21st century. The greatest burden on health will be in developing countries and sub-Saharan Africa is an area of major challenge: We are concerned with planning for the adult victims of the new epidemic and this includes the development of appropriate treatment. Therapy should be cost effective and evidence on the economics of treating chronic conditions in Africa is urgently required. Finally, health promotion, primary prevention and health screening strategies for chronic diseases such as diabetes, stroke and coronary heart disease are required.

A population-based survey in 1996 and 1997 of 770 adults (aged > or = 15 years) from an urban district of Dares Salaam and 928 from a village in rural Kilimanjaro district (Tanzania) revealed that the prevalence of diabetes, impaired fasting glucose (IFG), overweight, obesity, and physical inactivity was higher in the urban area for men and women. The difference between urban and rural prevalence of diabetes was 3.8 [1x1-6.5]% for men and 2x9 [0x8-4.9]% for women. For IFG, the difference was 2x8 [0x3-5x3]% for men and 3x9 [1x4-6x4]% for women; for overweight and obesity, the difference was 21.5 [15.8-27.1]% and 6.2 [3x5-8.9]% for men and 17x4 [11.5-23.3]% and 12.7 [8x5-16x8]% for women, respectively. The difference in prevalence of physical inactivity was 12x5 [7.0-18.3]% for men and 37.6 [31x9-43.3]% for women. For men with diabetes, the odds for being overweight, obese and having a large waist:hip ratio were 14.1, 5.3 and 12.5, respectively; for women the corresponding values were 9x0, 10x5 and 2x4 (the last not significant) with an attributable fraction for overweight between 64% and 69%. We conclude that diabetes prevalence is higher in the urban Tanzanian community and that this can be explained by differences in the prevalence of overweight. The avoidance of obesity in the adult population is likely to prevent increases in diabetes incidence in this population.

Aims: To examine the implications for epidemiological studies of the American Diabetes Association (ADA) recommendation that the fasting blood glucose at a lowered level becomes the main diagnostic test for diabetes on cross-sectional-based data from sub-Saharan Africa., Methods: Data from 11 surveys conducted in rural, peri-urban and urban Cameroon (n = 1804), South Africa (n = 3799) and Tanzania (n = 10013) which measured fasting (ADA criteria) and 2-h blood glucose concentrations during a standard 75 g OGTT (old WHO criteria) were analysed., Results: The prevalence of diabetes was higher in eight of the 11 surveys when applying the new ADA compared to the old WHO criteria. With the exception of one population (Mara, Tanzania) the absolute difference in prevalence between the two classifications tended to be small (< 2%). There was considerable variation in the categorization of individuals using the ADA and old WHO criteria. The level of agreement between the two ranged from fair to good (Kappa statistic 0.17-0.86). The prevalence of impaired fasting glycaemia (IFG) was lower than that of impaired glucose tolerance (IGT) in 10 of the surveys and the agreement between the two was fair, < or = 0.26 in all the surveys., Conclusions: Although the use of the new ADA fasting criteria for prevalence surveys is an attractive and practical option, particularly in Africa, further information is required on the characteristics and prognosis of individuals classified as IFG or diabetic by the fasting criteria, prior to wide adoption of the ADA criteria. Ideally measurement of both fasting and two low glucose concentrations should remain the standard for epidemiological studies.

Objective: To establish the relation between socioeconomic status and the age-sex specific prevalence of type 1 and type 2 diabetes mellitus. The hypothesis was that prevalence of type 2 diabetes would be inversely related to socioeconomic status but there would be no association with the prevalence of type 1 diabetes and socioeconomic status., Setting: Middlesbrough and East Cleveland, United Kingdom, district population 287,157., Patients: 4313 persons with diabetes identified from primary care and hospital records., Results: The overall age adjusted prevalence was 15.60 per 1000 population. There was a significant trend between the prevalence of type 2 diabetes and quintile of deprivation score in men and women (chi 2 for linear trend, p < 0.001). In men the prevalence in the least deprived quintile was 13.4 per 1000 (95% confidence intervals (95% CI) 11.44, 15.36) compared with 17.22 per 1000 (95% CI 15.51, 18.92) in the most deprived. For women the prevalence was 10.84 per 1000 (95% CI 9.00, 12.69) compared with 15.48 per 1000 (95% CI 13.84, 17.11) in the most deprived. The increased prevalence of diabetes in the most deprived areas was accounted for by increased prevalence of type 2 diabetes in the age band 40-69 years. There was no association between the prevalence of type 1 diabetes and socioeconomic status., Conclusion: These data confirm an inverse association between socioeconomic status and the prevalence of type 2 diabetes in the middle years of life. This finding suggests that exposure to factors that are implicated in the causation of diabetes is more common in deprived areas.

There is evidence that the prevalence of certain non-communicable diseases, such as diabetes and hypertension, is increasing rapidly in parts of sub-Saharan Africa. Others, such as asthma and epilepsy, are known to be common but to be poorly managed. This paper describes a project, funded by the Department for International Development of the British Government, which aims to provide costed and evaluated treatment packages for use at primary health care level, methods and materials for evaluating the quality of non-communicable disease care, and a protocol for the assessment for national opportunities for the prevention of hypertension, heart disease and diabetes. Methods are being developed and piloted in urban and rural Tanzania and Cameroon.

The American Diabetes Association have recommended that the fasting plasma glucose level for the diagnosis of diabetes is lowered and that this becomes the main diagnostic test. We have used population-based data from three ethnic groups in Newcastle upon Tyne to examine the implications of this change. Data were available on 824 European (25-74 years), 375 Chinese (25-64 years), and 680 South Asian (25-74 years) subjects. All subjects apart from those reporting a prior diagnosis of diabetes underwent a standard 75 g oral glucose tolerance test (WHO criteria) which included the measurement of fasting glucose. The prevalence of diabetes was higher in all three ethnic groups using the new ADA criteria compared to the WHO criteria: 7.1% vs 4.8% in Europeans; 6.2% vs 4.7% in Chinese; and 21.4% vs 20.1% in South Asians. There was much variation in individuals categorized by the ADA and WHO criteria. Agreement between the two for the diagnosis of previously unknown diabetes was only moderate (kappa statistics 0.42 to 0.59). Thus in the populations studied the new criteria would increase the prevalence of diabetes in addition to classifying some individuals diabetic by current criteria as non-diabetic. It should be stressed however that diagnosis of the individual should not be based on a single test.

The aim of this study was to determine the contribution of diabetes mellitus to all-cause mortality and diabetes mortality rates in adults 15 years and above living in one urban and two rural areas of Tanzania (Dar es Salaam, Hai and Morogoro Rural Districts). The three surveillance populations comprised 307,912 persons. Prospective monitoring of all deaths between 1 June 1992 and 31 May 1995 was carried out. Cause of death was determined by verbal 'autopsy' conducted with relatives of the deceased. In total, 4299 deaths were recorded in children (aged < 15 years) and 8054 in adults. In children there were no reported deaths associated with diabetes (due to or in children with diabetes). The adult male mortality rates associated with diabetes were 34, 30, and 15 per 100,000 per year in Dar es Salaam, Hai and Morogoro Rural Districts respectively. The figures in women were 21, 18, and 4 per 100,000 per year, respectively. The percentages of all adult male deaths associated with diabetes were 2.6%, 2.1% and 0.7% respectively. In women the percentages were 1.7%, 1.8%, and 0.2% respectively. Acute metabolic complications, infection, and stroke each accounted for approximately 30% of all diabetic deaths. Thus diabetes mortality rates varied between the three surveillance areas, being lowest in the poorest rural area. Rates were higher in men in all areas. While care is required in the comparison of mortality rates between countries, it was noteworthy that Tanzania, a country with a low diabetes prevalence, had diabetes mortality rates which were higher than or comparable to rates in Mauritius and the United States. Most patients died from preventable causes, indicating a need for improved case-management of diabetic emergencies as well as better detection and treatment of hypertension.