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Objective: To validate a diabetes-specific quality-of-life scale and to assess its psychometric properties in a large sample of patients with type 1 diabetes., Research Design and Methods: To assess the quality of diabetes care in a population-based study, a representative sample of 684 patients with type 1 diabetes was examined. A total of 657 patients (42% female; mean age 36 years; mean diabetes duration 18 years) completed the diabetes-specific quality-of-life scale (DSQOLS), which comprised 64 items on individual treatment goals (10 items), satisfaction with treatment success (10 items), and diabetes-related distress (44 items). Statistical examinations covered factor analysis, internal consistency of subscales, and construct and discriminant validity., Results: Factor analysis of the 44 items on diabetes-specific burdens revealed six reliable components (Cronbach's alpha): social relations (0.88), physical complaints (0.84), worries about future (0.84), leisure time flexibility (0.85), diet restrictions (0.71), and daily hassles (0.70). All six subscales were significantly correlated with a validated well-being scale (r = -0.35 to -0.53, P < 0.001) and treatment satisfaction (r = 0.28 to 0.43, P < 0.001). Physical complaints (r = 0.24) and worries about future (r = 0.17) showed the highest correlations with HbA1c (P < 0.001). A flexible insulin therapy, a liberalized diet, the absence of late complications, and a higher social status were significantly associated with more favorable scores in different domains., Conclusions: The DSQOLS is a reliable and valid measure of diabetes-specific quality of life. The scale is able to distinguish between patients with different treatment and dietary regimens and to detect social inequities. Use of the DSQOLS for assessment of individual treatment goals as defined by the patients may be helpful to identify motivational deficits and to tailor individual treatment strategies.

The objectives of the present analyses were to assess the association between HbA1c levels and severe hypoglycaemia (SH, treatment with glucose i.v. or glucagon injection) and to identify predictors of SH in a prospective multicentre trial. The study population consisted of 636 insulin-dependent diabetic patients who had participated in a structured 5-day in-patient group treatment and teaching programme for intensification of insulin therapy (ITTP) in one of 10 hospitals and who were re-examined after 1, 2, 3, and 6 years including assessment of demographic, disease and treatment related parameters, diabetes-related knowledge, behaviour, and emotional coping. At baseline, age (mean +/- SD) was 27 +/- 7 years, diabetes duration 9 +/- 7 years and HbA1c 8.3 +/- 1.9 %. During the 6-year follow-up, the mean HbA1c value improved to 7.6%, and in patients with a diabetes duration of more than 1 year at entry into the study (n = 538) the incidence of SH decreased from 0.28 cases/patient/year during the year preceding the ITTP to 0.17 cases/patient/year. The patient group was divided into decile groups according to mean follow-up HbA1c values. In each group more than 230 patient years could be analysed. Groups with mean HbA1c values of 5.7, 7.0, 7.4, 7.7 and 8.9% had comparable risks of SH (0.15-0.19 cases/patient/year). In a logistic regression analysis, mean HbA1c during follow-up, a history of SH during the year preceding the ITTP, C-peptide level, emotional coping, carrying emergency carbohydrates (as assessed at the 1-year follow-up), and age at onset of diabetes were significant independent predictors of SH. The incidence of SH between centres varied between 0.05 and 0.27 cases/patient/year. In conclusion, in the present analyses no linear or exponential relationship between HbA1c and severe hypoglycaemia could be identified by using simple group comparisons. Applying complex regression analyses, various patient-related predictors of severe hypoglycaemia were identified.

The objective of the present study was to analyse the association between cigarette smoking and progression of retinopathy and nephropathy, respectively, in a prospective multicentre study including 636 people with Type 1 diabetes: 81% of the original cohort of consecutively referred patients, aged 15 to 40 years and free of severe late diabetic complications. At baseline, all patients had participated in a 5-day in-patient group treatment and teaching programme for intensification of insulin therapy. Patients were examined at recruitment, and after 1, 2, 3 and 6 years including assessment of smoking status, blood pressure, metabolic control, and degree of nephropathy. Degree of retinopathy was assessed by ophthalmoscopy or fundus photography at baseline and after 6 years. Several logistic regression analyses were performed by describing the responses retinopathy and nephropathy, respectively, either as progression yes/no or as actual status at the 6-year follow-up and by using different measures for smoking. Adjustments for important covariables were made. While significant associations between smoking, and retinopathy and nephropathy respectively, were found, the relations were variable depending on the statistical model used. The results show that the real associations between smoking and retinopathy and nephropathy are complex and that more emphasis should be put on the complete description of the response variables and the statistical models used in clinical and epidemiological research.

Objectives: To investigate the effects of smoking on blood pressure and proteinuria in hypertensive diabetic patients with nephropathy., Design: Controlled, randomized, cross-over study., Setting: Tertiary care centre, University Hospital of Düsseldorf, Germany., Subjects: A total of 25 subjects were recruited, each of whom smoked at least 20 cigarettes a day: 10 normotensive healthy volunteers and 15 hypertensive type 1 (insulin-dependent) diabetic outpatients with diabetic retinopathy and persistent micro- or macroalbuminuria; 10 diabetic patients had normal autonomic function test, whilst five patients showed signs of autonomic neuropathy., Interventions: Controlled smoking or nonsmoking over a period of 8 h on separate days., Main Outcome Measures: Blood pressure was measured every 10 min with an automatic device and urine samples were collected every 3 h., Results: Systolic blood pressure increased during smoking in controls (mean) (11.5 mmHg, P = 0.0001) and in diabetic patients without autonomic neuropathy (7.9 mmHg; P = 0.018), but not in patients with autonomic neuropathy (-2.4 mmHg; P = 0.792). Diastolic blood pressure increased during smoking in controls (6.2 mmHg; P = 0.019) but not in diabetic patients (2.5 mmHg; P = 0.204. 0.2 mmHg; P = 0.956). During smoking, median proteinuria and albuminuria increased in diabetic patients without autonomic neuropathy (8.1 mg mmol-1 creatinine, P = 0.002; and 2.6 mg mmol creatinine, P = 0.084). No significant changes in albuminuria or proteinuria occurred in the other two groups., Conclusions: Smoking increases blood pressure values in healthy subjects and in hypertensive patients with diabetic nephropathy and without autonomic neuropathy. This effect of smoking may be partly responsible for the faster progression of diabetic nephropathy in smoking diabetic patients.

The objectives of the study were to assess the effects of moderate sodium restriction on blood pressure in insulin-dependent diabetic (IDDM) patients with nephropathy and high normal or mildly hypertensive blood pressure (primary objective), and to document possible associated changes of exchangeable body sodium, body volumes, components of the renin-angiotensin-aldosterone system, atrial natriuretic peptide, and catecholamines (secondary objective). Sixteen patients with untreated systolic blood pressure > or = 140 < 160 mmHg and/or diastolic blood pressure > or = 85 < 100 mmHg were included in a double-blind, randomized, placebo-controlled trial. After a 4-week run-in period on their usual diet and a 2-week dietary training period to reduce sodium intake to about 90 mmol/day, eight patients received 100 mmol/day sodium supplement (group 2) and eight patients a matching placebo (group 1) for 4 weeks while continuing on the reduced-sodium diet. Patients were examined at weekly intervals. Main response variables were mean values of supine and sitting systolic and diastolic blood pressure as measured in the clinic and by the patients at home. The differences in blood pressure between the beginning and the end of the blinded 4-week study period were calculated and the differences in changes between the two patient groups were regarded as the main outcome parameters. During the blinded 4-week study period, average urinary sodium excretion was 92 +/- 33 (mean +/- SD) mmol/day in group 1 and 199 +/- 52 mmol/day in group 2 (p = 0.0002). The differences in blood pressure changes between the two patient groups were 3.9(-1.2 to 9) mmHg [mean (95% confidence intervals)] for systolic home blood pressure, 0.9(-3.7 to 5.5) mmHg for diastolic home blood pressure, 4.9(-3.3 to 13.1) mmHg for clinic systolic blood pressure and 5.3(1 to 9.7 mmHg, p = 0.02) for clinic diastolic blood pressure. Combining all patients, there were relevant associations between changes of urinary sodium excretion and blood volume (Spearman correlation coefficient r = 0.57), blood pressure and angiotensin II (diastolic: r = -0.7; systolic: r = -0.48), and exchangeable body sodium and renin activity (r = -0.5). In conclusion, in this study of IDDM patients with nephropathy and high normal or mildly hypertensive blood pressure, a difference in sodium intake of about 100 mmol/day for a period of 4 weeks led to a slight reduction of clinic diastolic blood pressure. Studies including larger numbers of patients with various stages of nephropathy and hypertension are needed to definitely clarify the effects of sodium restriction in IDDM.

In order to describe the natural history of high risk diabetic patients treated for hypertension we have followed a sequential sample of 100 hypertensive Type 2 diabetic patients with elevated urinary protein excretion ( > or = 60 mg 24 h-1) for a period of 1-7 years. Antihypertensive treatment was instituted in all patients and, in addition, the patients were offered the possibility of participation in an intensified antihypertensive therapy programme. After a mean follow-up of 4 years overall mortality was 13%. Nineteen percent of all patients experienced a cardiovascular event and 7% a cerebrovascular event. In conclusion, in this study the overall mortality was lower that previously reported in proteinuric Type 2 diabetic patients. Antihypertensive treatment may account for this outcome.

The overall quality of antihypertensive care in diabetic patients in Germany is poor. Only a minority of unselected hypertensive patients reach permanent normotensive blood pressure control. Previously, we have shown in a prospective randomized 3-year follow-up study in essential hypertension that implementation of a hypertension teaching and treatment program into routine care results in a significant improvement of blood pressure control. Subsequently, we have performed a prospective, controlled 5-year follow-up trial in hypertensive type I diabetic patients with nephropathy. One-half of a sequential sample of about 100 hypertensive patients with overt nephropathy participated in the program based on blood pressure self-monitoring with the goal of normalization of blood pressure values below 140/90 mm Hg (intensified care, IC). The remaining patients followed routine antihypertensive therapy and formed the control group (routine care, RC). During 5 years of follow-up in IC group patients, blood pressure control was significantly improved. The occurrence of primary study end points (need for dialysis and death) was significantly lower in the IC group patients. In conclusion, in patients with diabetic nephropathy, participation in a hypertension teaching treatment program results in a long-term improvement of blood pressure control and a decrease in mortality and morbidity.

Objective: To determine the prognosis of treated hypertensive type 1 (insulin-dependent) diabetic patients with overt nephropathy., Design: A controlled, prospective, parallel, 5-year follow-up trial., Setting: The tertiary care centre of the Heinrich Heine University Hospital in Dusseldorf, Germany., Patients and Interventions: A sequential sample of 91 hypertensive patients with overt diabetic nephropathy participated in a diabetes treatment programme. Thereafter 45 patients received intensified antihypertensive therapy including blood pressure self-monitoring and self-adjustment of antihypertensive drug treatment with the goal of permanent normalization of blood pressure values below 140/90 mmHg. The remaining 46 patients were administered routine antihypertensive therapy and formed the control group. At baseline both groups were comparable in age, sex, metabolic control and renal function. The groups differed at baseline in their duration of diabetes and blood pressure values, which were higher in the intensified antihypertensive therapy group., Outcome Measures: Total mortality and the need for renal replacement therapy., Main Results: Blood pressure control was significantly improved in patients who were subjected to intensified antihypertensive therapy, whereas it deteriorated in the group of patients who received routine antihypertensive therapy. At follow-up, primary end points of the study occurred in five (11%) patients of the intensified therapy group and in 19 (41%) patients of the routine therapy group. According to life table analysis, intensified antihypertensive therapy was associated with less frequent primary end points (P = 0.0058) and longer survival (P = 0.01). The differences between the groups remained significant after adjustment for covariates in the proportional hazards model., Conclusion: Participation in a treatment programme aimed at intensification of antihypertensive therapy is associated with a reduction of mortality in hypertensive type 1 diabetic patients with overt nephropathy.

Objective: To document that strict dietary regimen are not necessary in the context of intensified insulin therapy., Design: German multicentre, prospective cohort study; 6 years follow-up., Setting: Ambulatory examination using a mobile ambulance., Subjects: A total of 636 type 1 diabetic patients (age 33 +/- 7 years, diabetes duration 15 +/- 7 years; mean +/- SD), who had participated in a structured, 5-day, in-patient, group treatment and teaching programme for intensification of insulin therapy and liberalization of the diabetes diet 6 years prior to follow-up., Main Outcome Measures: Relations between the extent to which patients practise a liberalized diet, the degree of metabolic control (HbA1c, severe hypoglycaemia, body mass index, cholesterol), and the patients' perceived burden through dietary treatment., Results: In the total patient group, HbA1c was 7.9 +/- 1.6%, and the incidence of severe hypoglycaemia was 0.17 cases per patient during the preceding year; 31% patients injected insulin < or = 3 times per day, 58% 4-7 times per day, and 11% used insulin pump therapy. Only 11% patients reported following a meal plan, whereas 89% continually changed timing and amount of carbohydrate intake; only 5% had the same number of meals every day, whereas as many as 20% varied the number of meals per day by four or more; 53% skipped main meals; 85% habitually consumed sugar or sugar containing foods. Patients with a higher degree of diet liberalization injected insulin or used an insulin pump therapy more frequently, and perceived their dietary treatment to be less burdensome. No clinically significant associations were found between the extent of diet liberalization and metabolic control., Conclusions: Under the conditions where type 1 diabetic patients have the opportunity to participate in an intensified insulin treatment and teaching programme, liberalization of the diabetes diet is not associated with adverse effects on glycaemic control, but is associated with less perceived burden through dietary treatment.

The Diabetes Education Study Group (DESG) of the European Association for the Study of Diabetes (EASD) was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. Within the DESG, a number of models for structured diabetes treatment and teaching programmes were developed. Concerning the care of persons with Type 1 diabetes, substantial emphasis was placed upon the 5-day in-patient treatment and teaching programme for groups of 6 to 10 patients as originally introduced at the University of Geneva and further developed for general use at the University of Düsseldorf. During the early 1980s, this programme was based upon intensified insulin therapy including a stepwise liberalization of previously rigid rules for nutrition and life schedules. In several European centres the programme was continuously evaluated and shown to be effective as documented by significant reductions of glycated haemoglobin values, episodes of ketoacidosis, hospitalizations, and sick-day leaves. In contrast to the Diabetes Control and Complications Trial (DCCT) the improvement of glycated haemoglobin values was not associated with an increased risk of severe hypoglycaemia. Possible reasons for this favourable outcome are discussed. During recent years the 5-day treatment and teaching programme for Type 1 diabetes has been translated into the general health care system of Germany without any loss of its efficacy. In addition, in various other European countries, model centres of diabetes care have implemented the 5-day programme, and for a number of these centres, its efficacy to improve the overall quality of diabetes care has been published or presented at meetings.

The aim of the study was to identify predictors of long-term glycaemic control in Type 1 diabetic patients after participation in an intensified insulin treatment and teaching programme. The study population consisted of 697 Type 1 diabetic patients (mean age 26 +/- 7 (SD) years, duration of diabetes 8 +/- 7 years) who participated in the same structured intensified insulin treatment and teaching programme in 10 hospitals and who were re-examined after 1, 2, and 3 years. Multiple and logistic regression analyses were performed including a set of demographic, disease-related, social, and psychosocial variables as potential predictors. As dependent variables the average HbA1 values during the 3-year follow-up period and a composite variable (average HbA1 values/frequency of severe hypoglycaemia)--dividing patients into three groups with good, moderate or poor metabolic control--were considered. Regression analysis of average HbA1 values revealed significance (p < 0.05) for seven independent predictors in descending order: smoking, age at onset of diabetes, frequency of home blood glucose monitoring, socioeconomic status, diabetes-related knowledge, perceived coping abilities, and sex (R2 (percentage of variation explained by the model) = 17%). In a second regression model, HbA1 values before the intervention programme were added to the model and achieved the highest standardized regression coefficient (0.38), increasing R2 to 29%. In the logistic regression models considering both HbA1 and severe hypoglycaemia as a composite dependent variable, diabetes-related knowledge, HbA1 values before the intervention, smoking, perceived coping abilities, age at onset of diabetes, and C-peptide levels were the strongest predictors of glycaemic control. In conclusion, the relationship between demographic, disease-related, psychosocial, and social variables and metabolic control is complex. Therefore, simplistic concepts of linear causality should be abandoned. In addition to HbA1 values before the intervention, smoking, diabetes-related knowledge, home blood glucose monitoring, age at onset of diabetes, perceived coping abilities and C-peptide levels were the most significant and consistent predictors of glycaemic control.

The article provides an overview of recent scientific information on the role of cigarette smoking in the prognosis of diabetes. Data sources included an English-language MEDLINE search for 1989 through 6/1993, supplemented by manual search of bibliographies of pertinent articles. Only studies of humans were considered. Cigarette smoking is related to the development and progression of diabetic nephropathy. Therefore, smoking status has to be taken into account in clinical studies on the course of nephropathy. The association between smoking and retinopathy is less consistent. Evidence is accumulating that cigarette smoking influences insulin action. Several large prospective cohort studies have shown that the relative risk for all-cause mortality is about twice as high for smoking compared to non-smoking diabetic patients. Strong associations are consistently found between cigarette-pack years and complications. It has been calculated that the theoretical benefit of stopping smoking is the most (cost-)effective risk factor intervention for diabetic patients. However, available programmes to help diabetic patients to stop smoking are unsuccessful.

Objective: To investigate the association between cigarette smoking and the progression of diabetic nephropathy., Research Design and Methods: A prospective, follow-up study over one year was conducted in a sequential sample of 34 smokers, 35 nonsmokers, and 24 ex-smokers with type I diabetes, hypertension, and diabetic nephropathy. Progression of renal disease was defined according to the stage of nephropathy as an increase in proteinuria or serum creatinine or a decrease in the glomerular filtration rate., Results: Progression of nephropathy was less common in nonsmokers (11%) than in smokers (53%) and patients who had quit smoking (33%), P < 0.001. In a stepwise logistic regression analysis, cigarette pack years, 24-h sodium excretion, and GHb were independent predictive factors for the progression of diabetic nephropathy. Because blood pressure (BP) was well controlled in these patients and most values were within a normotensive range, neither standing, sitting, nor supine BP values were associated with progression of nephropathy., Conclusions: Cigarette smoking represents an important factor associated with progression of nephropathy in treated hypertensive type I diabetic patients.

In a prospective controlled trial the effects of a 5-day in-patient treatment and teaching programme for Type 1 (insulin-dependent) diabetes mellitus on metabolic control and health care costs were studied in Moscow. Two different intervention programmes were compared, one based upon urine glucose self-monitoring (UGSM, n = 61) and one using blood glucose self-monitoring (BGSM, n = 60). Follow-up was 2 years. A control group (n = 60) continued the standard treatment of the Moscow diabetes centre and was followed-up for 1 year. Costs and benefits with respect to hospitalizations and lost productivity (according to average wage) were measured in November 1992 rubles (Rb.), with respect to imported drugs and test strips in 1992 German marks (DM). In the intervention groups there were significant decreases of HbA1 values [UGSM: 12.5% before, 9.4% after 1 year, 9.2% after 2 years (p < 0.0001); BGSM: 12.6% before, 9.3% after 1 year, 9.2% after 2 years (p < 0.0001) compared to no change in the control group (12.2% before, 12.3% after 1 year)], and of the frequency of ketoacidosis. The frequency of severe hypoglycaemia was comparable between the UGSM (10 cases during 2 years), BGSM (10 cases during 2 years), and the control group (8 cases during 1 year).(ABSTRACT TRUNCATED AT 250 WORDS)

Despite the availability of multiple nonpharmacological and pharmacological antihypertensive regimens large scale control of BP on a population basis is still unsatisfactory. To achieve a better quality in hypertension care we have developed and evaluated a structured outpatient hypertension treatment and teaching programme. This programme aims at improving of patients' compliance to antihypertensive therapy and is based on four groups sessions mainly conducted by paramedical personnel. This programme was evaluated in three different settings: in patients with hypertension, diabetes mellitus and poor compliance to antihypertensive drug therapy; in blind patients with diabetic nephropathy and severe hypertension; and in patients with essential hypertension as treated by primary healthcare physicians in general practice. In all three studies a significant improvement in compliance to antihypertensive therapy and, hence, in BP control was demonstrated leading to preservation of renal function in diabetic nephropathy and fewer drug prescriptions in essential hypertension. In conclusion, studies evaluating the effect of large scale implementation of such structured treatment and teaching programmes on the quality of hypertension care in the community should be carried out.

Objectives: To evaluate the efficacy of a structured behaviour therapy programme on smoking cessation in diabetic patients., Design: Prospective, randomized, controlled intervention study., Setting: University out-patient diabetes clinic., Subjects: A total of 794 consecutive insulin-treated smoking diabetic patients were invited to participate in a smoking cessation programme. Eighty-nine patients agreed to participate and were randomized in two groups., Interventions: Forty-four patients were randomized to a structured extensive behaviour therapy anti-smoking intervention and 45 patients to a control group that received a single unstructured anti-smoking advice session given by a physician., Main Outcome Measures: After 6 months, nine patients were confirmed not to be smoking (i.e. urine cotinine concentration below 20 ng ml-1, 2 [5%] in the behaviour therapy intervention group and 7 [16%] in the control group., Conclusions: In diabetic patients an extensive behaviour therapy intervention for smoking cessation is no more successful than an unstructured physician's advice.

The Diabetes Education Study Group of the European Diabetes Association was founded in 1979 with its major goal to make effective patient training an integral part of any diabetes therapy. However, even today, in many places diabetes education is not an obligatory part of treatment, but is regarded as an optional service to the patient which is frequently fragmentary and haphazard. On the other hand, many physicians still subject their patients to rigid dietary instructions and obedience training, an approach which is mistaken for diabetes education. Several misconceptions about diabetes education keep counteracting the spread and hence the availability of effective treatment and teaching programmes for all Type 1 diabetic patients. One such misconception is that diabetes education could compensate for deficiencies of inappropriate insulin treatment regimens. Studies failing to demonstrate the impact of diabetes education on metabolic control, typically used an insulin treatment regimen with only one or two insulin injections per day, the predominant use of intermediate acting insulin preparations, and without (day-to-day) adjustment of insulin dosages by the patients themselves. A further reason for a lack of success of diabetes education is an unstructured approach which is frequently mistaken for individualized care. The deleterious effects of putting patients on intensified insulin therapy without offering them sufficient and systematic training have manifested themselves at various places by an excessive increase in the risk of severe hypoglycaemia, and of ketoacidosis during therapy with continuous subcutaneous insulin infusion. The effective and safe performance of insulin therapy requires both a rational system of insulin substitution and intensive training of the patients to carry it out. The injection of regular insulin before main meals and the use of intermediate or long-acting insulin preparations for the substitution of basal insulin requirements combined with daily metabolic self-monitoring and (day-to-day) adaptation of insulin dosages by the patients themselves allow a substantial improvement of glycaemic control without an increase in the risk of severe hypoglycaemia and the adoption of a more flexible life style largely freed from forcing and directive dietary and other impositions. Each diabetes centre should continuously evaluate the quality of care offered to their patients as a basis for a specific and systematic improvement of its treatment and education programmes. Such quality control measures must include a recording of the patients' degree of metabolic control and the frequencies of severe hypoglycaemia and ketoacidosis.(ABSTRACT TRUNCATED AT 400 WORDS)

Up to now all published experience with intensified insulin therapy has originated from specialized diabetes centres. However, even in diabetes centres and under research conditions intensification of insulin therapy may substantially increase the risk of severe hypoglycaemia. The aim of the present study was to demonstrate the feasibility of effectively and safely transferring intensified insulin therapy based upon a 5-day in-patient treatment and teaching programme from a University diabetes centre to non-specialized general hospitals. A total of nine general hospitals were recruited; the University diabetes centre served as a reference centre. From each general hospital a nurse and a dietitian were trained as diabetes educators, and a diabetes unit with about 10 beds was organized within each department of internal medicine. A total of 697 consecutively admitted Type 1 (insulin-dependent) diabetic patients (age 26 +/- 7 years, duration of diabetes 8 +/- 7 years) who participated in the programme either in one of the general hospitals (n = 579) or in the reference centre (n = 118) were re-examined after 1, 2 and 3 years. Insulin therapy was intensified to a similar extent in the reference centre and the general hospitals; at the 3-year follow-up about 80% of the patients injected insulin at least three times daily or used continuous subcutaneous insulin infusion (10%), and about 70% reported measuring blood glucose levels more than twice per day. HbA1 levels were lowered (p < 0.0001) to comparable levels, i.e. from 10.6% (reference centre) and 9.9% (general hospital), respectively, at baseline to 9.4% and 9.3%, respectively, at the 3-year follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

A case-control study was carried out to analyse leucocyte counts in relation to proteinuria and smoking in type 1 (insulin-dependent) diabetes. The subjects were 180 smoking (87 women, age 32 +/- 11 years, diabetes duration 14 +/- 6 years) and 188 nonsmoking (88 women, age 32 +/- 11 years, diabetes duration, 14 +/- 6 years) type 1 diabetic patients. Leucocyte counts were higher in smokers than in nonsmokers, both in women (7.6 +/- 2.3 vs 6.8 +/- 1.9 x 10(9)/l, P < 0.01) and in men (8.1 +/- 2.7 vs 6.4 +/- 2.0 x 10(9)/l, P < 0.0001). Leucocyte counts correlated with the number of cigarettes smoked per day (r = 0.32, P < 0.0001), but were unrelated to glycosylated haemoglobin levels. Among nonsmokers, leucocyte counts were comparable between patients with normal proteinuria (6.7 +/- 2.2 x 10(9)/l, n = 106), microproteinuria (6.3 +/- 1.7 x 10(9)/l, n = 66) and macroproteinuria (6.8 +/- 1.1 x 10(9)/l, n = 16). Among smokers, patients with macroproteinuria or microproteinuria had higher leucocyte counts than those with normal proteinuria [8.9 +/- 3.0 x 10(9)/l, (n = 36) vs 8.4 +/- 2.7 x 10(9)/l (n = 61) vs 7.0 +/- 1.9 x 10(9)/l (n = 83); P < 0.0001)], a finding which was not due to differences in the number of cigarettes smoked per day. It is concluded that in these type 1 diabetic patients leucocyte counts were higher in smokers than in nonsmokers. Among nonsmokers leucocyte counts were comparable between patients with normal proteinuria and increased proteinuria, whereas among smokers leucocyte counts were higher in patients with increased proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)

Objective: Evaluation of a structured hypertension treatment and teaching programme in general practice., Design: Prospective controlled trial; follow-up period 18 months., Setting: 10 primary health care practices. PRACTICES AND PATIENTS: From each practice 20 patients (30 to 60 years old, mean of the last two blood pressure measurements at or above 160 and/or 95 mmHg) were randomly selected; in 5 practices these patients were to participate in the treatment and teaching programme; in the remaining 5 practices hypertension care was continued without the availability of such a programme (controls)., Intervention: Structured treatment and teaching programme based upon four group sessions for patients mainly conducted by paramedical personnel., Main Outcome Measures: Blood pressure, body weight, prescription of antihypertensive drugs - as documented in the patient's records., Main Results: Of the 100 control patients 26 and of the 100 intervention patients 14 were lost to observation; 46 patients had agreed to participate in the programme. The mean number of prescribed antihypertensive agents per patient decreased in the intervention group (1.8 +/- 1.3 at baseline, vs 1.2 +/- 1.2 at follow-up) compared to the control group (1.6 +/- 1.3 vs 1.8 +/- 1.6); difference 0.8 (95% CI 0.4 to 1.1), p < 0.0001. In the control group 9% and in the intervention group 33% of patients had documented reductions of body weight (p < 0.0001). Blood pressure decreased in the intervention group (162 +/- 14/100 +/- 7 mmHg at baseline, vs 154 +/- 16/95 +/- 9 mmHg at follow-up) compared to the control group (161 +/- 13/98 +/- 7 mmHg vs 158 +/- 18/96 +/- 11 mmHg); differences for systolic blood pressure 5 (95% CI 0 to 10) mmHg, p = 0.071; for diastolic blood pressure 4 (1 to 7) mmHg, p = 0.018., Conclusions: The introduction of a structured hypertension treatment and teaching programme in general practice may lead to significant improvements of hypertension care.

Using a mobile ambulance the quality of diabetes care was evaluated, according to the recommendations of the St. Vincent Declaration, in 95% of all known diabetic patients (n = 395) in a geographically defined rural area of Austria with 7871 inhabitants. Fourteen of the 395 patients had Type 1 (insulin-dependent) diabetes with age at onset of diabetes below 30 years. Of the 375 patients examined (women 61%, age 66 +/- 13 years, median diabetes duration 6 years) 16% were treated with insulin and 47% with oral agents; HbA1c levels were 7.3 +/- 1.7%. Prevalence of known hypertension was 54%; 68% of these patients had their blood pressure uncontrolled (systolic greater than or equal to 160 and/or diastolic greater than or equal to 95 mmHg); a further 15% of patients with previously unknown hypertension had blood pressure values of greater than or equal to 160 and/or greater than or equal to 95 mmHg. Urinary albumin concentrations of greater than 200 mg/l were found in 15% of patients, 2% had a serum creatinine level of greater than 177 mumol/l, no patient had renal replacement therapy. Six patients (1.5%) were blind. Screening for retinopathy identified six patients (out of 317 in whom the retina could be evaluated) for whom consultation with an ophthalmologist as soon as possible was recommended. Of the total patient group (n = 395) 20 patients (5%) had foot complications (amputations and/or ulcers): 14 patients had a total of 21 lower limb amputations (eight above knee, six below knee, seven below ankle); eight of these 14 patients lived in a nursing home; 11 patients had a total of 13 foot ulcers.(ABSTRACT TRUNCATED AT 250 WORDS)

We investigated the accuracy of blood glucose self monitoring in 131 patients (mean +/- SD age 65 +/- 7 years, duration of diabetes 11 +/- 6 years) who participated in a 5-day inpatient group treatment and teaching programme especially designed for elderly insulin-treated patients. Patients' estimations and laboratory blood glucose measurements were compared on day 1 (after theoretical and practical introduction into blood glucose self monitoring) and on day 4 of the programme. Patients were trained in the visual reading of Haemoglukotest 20-800R; blood glucose meters were recommended only exceptionally. Error grid analysis showed a high accuracy of visually assessed blood glucose values, both on day 1 (94% of measurements in zone A, 5% in zone B) and on day 4 (95% in zone A, 4% in zone B). Patients with no prior experience in blood glucose self monitoring (n = 67) showed a significant improvement (p less than 0.02) in accuracy from day 1 to day 4. Values determined by blood glucose meters were less accurate, although this trend did not reach statistical significance. A second group of 94 consecutive patients was reexamined 5 years after participation in the treatment and teaching programme. 55 patients were still alive and 42 could be evaluated. Accuracy of blood glucose estimations was assessed in all 26 patients practising blood glucose self monitoring (age 69 +/- 5 years, diabetes duration 18 +/- 8 years), either at their homes (n = 23) or at our diabetes outpatient clinic (n = 3). Error grid analysis showed a high accuracy by visual reading (n = 21, 95% zone A, 5% zone B).(ABSTRACT TRUNCATED AT 250 WORDS)

The objective of this study was to evaluate a structured treatment and teaching programme for adult patients with moderate to severe asthma. The design consisted of a prospective, before-after trial: the same consecutive patients were studied before and after intervention with observation periods 1 year before and 1 year after intervention. The investigation took place within a tertiary care centre (university hospital). A total of 142 consecutive patients were referred for in-patient treatment of their asthma, of whom 132 (93%) patients participated in the follow-up examination. The intervention consisted of a structured 5-d in-patient treatment and teaching programme presented by a specialized nurse educator. The aim of the programme was for the patient to assume greater responsibility for disease management, including self-monitoring of peak expiratory flow and qualified self-adaptation of drug therapy. The main outcome measures were the frequency of severe asthma attacks, hospitalization, and absenteeism from work (data provided by health insurance companies), patients' compliance and management skills. During the year before and the year after the intervention 71% and 36%, respectively of patients had one or more severe asthma attacks (mean difference 35%, 95% CI: 25-45%, P less than 0.0001). The percentage of patients who were hospitalized because of asthma decreased from 39% to 22% (mean difference 17%, 95% CI: 7-27%, P less than 0.002). The percentage of employed patients (n = 67) who were absent from work because of asthma decreased from 60% to 43% (mean difference 17%, 95% CI: 4-30%, P less than 0.04). The patients' adherence to maintenance drug therapy and their management skills improved significantly. It was concluded that the participation of patients with moderate to severe asthma in a structured treatment and teaching programme resulted in a substantial reduction in asthma morbidity in the year following the intervention.

Objectives: To compare hypoglycemic warning symptoms (main objective) and incidence of severe hypoglycemia (secondary objective) between patients treated with animal and human insulin preparations., Research Design and Methods: Two hundred forty-seven patients on treatment with animal insulin preparations and 276 patients on human insulins, matched for duration of diabetes (16 +/- 11 vs. 15 +/- 10 yr), were recruited for the study. Patients were interviewed with a standardized questionnaire., Results: When asked which symptom usually occurs first during hypoglycemia, 19% of the animal insulin group and 22% of the human insulin group answered "sweating," 19 and 17%, respectively, answered "trembling," and 15 and 11%, respectively, answered "unrest." According to the patients' perception, in both groups, their most reliable hypoglycemic warning symptoms were "trembling" (26 and 22%) and "sweating" (15 and 18%). Six and eight percent of patients, respectively, reported hypoglycemia unawareness and 17 and 18%, respectively, impaired awareness of hypoglycemia. The incidence of severe hypoglycemia was 0.45 cases/patient-yr in patients treated with animal insulins and 0.46 cases/patient-yr in patients treated with human insulin preparations. The differences were not statistically significant., Conclusions: This study shows that hypoglycemic warning symptoms and the incidence of severe hypoglycemia are comparable between patients on treatment with human and animal insulin preparations.

Objective: To assess the frequency and possible risk indicators of severe hypoglycemia in insulin-dependent (type I) diabetic patients with impaired kidney function., Research Design and Methods: Retrospective follow-up examination of case subjects and control subjects with mean follow-up periods of 2.9 and 1.3 yr, respectively. The setting was the diabetes center at the Düsseldorf University hospital. Subjects were consecutive type I diabetic patients. Case subjects consisted of 44 patients with initial serum creatinine levels of greater than or equal to 133 microM and pathological proteinuria. Control subjects consisted of 46 patients with normal serum creatinine levels matched for age, duration of diabetes, and hypertension; 57% of case subjects and 67% of control subjects were being treated with beta-blockers. Incidence of severe hypoglycemia (cases/patient-yr) was assessed through an interviewer-administered questionnaire., Results: At comparable levels of HbA1c (7.9 +/- 1.8 vs. 7.6 +/- 1.1%), case subjects had a fivefold higher incidence of severe hypoglycemic episodes (1.28 vs. 0.25 cases/patient-yr, P less than 0.02) than control subjects. Within the group with impaired kidney function, patients with severe hypoglycemic episodes had lower HbA1c levels (7.4 +/- 1.6 vs. 8.7 +/- 2.0%, P less than 0.03) and a lower body mass index (22.0 +/- 3.4 vs. 24.4 +/- 3.8 kg/m2, P less than 0.04) than those without severe hypoglycemic episodes, whereas serum creatinine levels, body weight-related insulin dosage (U x kg-1 x day-1), prevalence of blindness, autonomic neuropathy, and treatment with beta-blockers were comparable., Conclusions: Type I diabetic patients with impaired kidney function are at an excessively high risk of severe hypoglycemia. In addition to low HbA1c levels, a low body mass index appears to be a risk indicator for this adverse effect of insulin therapy.

In patients with diabetic nephropathy, near-normalization of blood pressure (BP) and blood sugar may have a beneficial impact on changes in kidney function, but visually impaired patients may face difficulties when striving for optimal control of hypertension and hyperglycemia. In a prospective feasibility study, we followed a group of nine blind Type I (insulin-dependent) diabetic patients (mean age 30 +/- 4 years) with overt diabetic nephropathy and uncontrolled hypertension. All patients received intensified insulin therapy after a structured diabetes treatment and teaching program, and adapted their antihypertensive drug treatment to self-monitored BP values. At recruitment, HbA1c values were 5.8 +/- 0.6%, and remained stable at 6.3 +/- 1.7% after a mean observation period of 27 months. BP pressure decreased from 150 +/- 14/99 +/- 14 mmHg to 130 +/- 17/86 +/- 10 mmHg after 1 year, and to 140 +/- 14/92 +/- 9 mmHg at the last examination, (p less than 0.05). Serum creatinine and creatinine clearance remained stable over the observation period at 165 +/- 56 mumol/L and 0.8 +/- 0.4 ml/s/1.72m2 at recruitment, and 152 +/- 47 mumol/L and 1.0 +/- 0.5 ml/s/1.72m2 at the final examination. Proteinuria decreased from 3.2 to 1.4 g/24 h (p less than 0.05). No patient needed renal replacement therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

The frequency of smoking in diabetic patients is not appreciably different from that in the general population. As in non-diabetic subjects, smoking is a major cardiovascular risk factor in diabetic patients. For young diabetic patients, smoking has been identified as a risk for macroproteinuric nephropathy. In respect of retinopathy, study results are more controversial. Recent studies also suggest smoking as a risk indicator for extra-articular connective tissue changes and neuropathy. Patients who already present with vascular complications, pregnant women, and women who use oral contraceptive drugs appear to run a particularly high risk by smoking. Stopping smoking reduces the risk of vascular morbidity and mortality in non-diabetic subjects. Although no comparable studies are available for diabetic populations, it should be assumed that the beneficial effects of stopping smoking are applicable to diabetic patients as well. Programmes to encourage diabetic patients to stop smoking are scarce and have not been successful.

Plasma concentrations of immune-reactive trypsin (IRT) were determined in 212 patients with juvenile-onset, insulin-dependent diabetes (Type I) and in 158 patients with maturity onset diabetes (Type II) in comparison to 121 healthy individuals. Significantly increased IRT levels were obtained in the type I diabetics, whereas IRT concentrations were normal or increased in the type II diabetic patients. Hypotrypsinemia occurred predominantly in type I diabetics with high IgG-insulin antibodies or islet-cell antibodies. No correlation was noted between the IRT-levels and the beta-cell residual capacity in the type-I diabetics.

Concentrations of HDL cholesterol, apolipoprotein (apo) A-I and apo A-II were found to be significantly decreased in patients with insulin-dependent diabetes (IDD) and non-insulin-dependent diabetes (NIDD) compared with carefully selected controls matched for sex, age and body weight. LDL cholesterol and apo B levels did not differ significantly between diabetics and controls. Concentrations of lipoprotein Lp(a), an independent risk factor for coronary artery disease in non-diabetics, were above 20 mg/dl in only 14% of diabetics and in 5% of controls. LCAT activity was normal in diabetics, irrespective of type of diabetes, sex and age of patients. No correlation between HbA1 and either HDL cholesterol or A-I and A-II was found in IDD and NIDD. A positive correlation between HbA1 and either triglyceride or VLDL triglyceride was noted in IDD and NIDD. There was also a positive correlation between insulin dosage in IDD and HDL cholesterol, apolipoprotein A-I and A-II.

The effect of bezafibrate on plasma lipids, lipoproteins, apolipoproteins AI, AII and B, and LCAT activity was investigated in 16 hyperlipidemic, non-insulin-dependent diabetes, who were treated for 8 weeks with either placebo or bezafibrate in a double-blind cross-over design. Bezafibrate induced a significant decrease in plasma triglycerides (P less than 0.01), cholesterol (P less than 0.05), VLDL triglycerides (P less than 0.05) and VLDL cholesterol (P less than 0.01), and a significant increase in HDL cholesterol (P less than 0.01), whereas LDL cholesterol remained unchanged. The apolipoprotein AI/apolipoprotein B ratio increased significantly (P less than 0.05), although individual changes in these apolipoproteins were not significant. Apolipoprotein AII increased significantly (P less than 0.05), although individual changes in these apolipoproteins were not significant. Apolipoprotein AII increased significantly (P less than 0.0001) and the apolipoprotein AI/apolipoprotein AII ratio decreased (P less than 0.0001), indicating an increase in the HDL3 rather than the HDL2 fraction. No significant change in LCAT activity was observed.

Glycosylated haemoglobin provides an integrative measure of long-term glycaemic levels and complements conventional glucose monitoring in the management of diabetes. The present study was determined to review nomenclature, biochemistry and the analytic methods available for measurement of HbA1. Clinical studies are reported that relate HbA1 concentrations to various parameters of glucose control, diabetes type and diabetes therapy. Moreover, this review considers nondiabetic disorders that are associated with falsely abnormal HbA1 levels and in addition, the value of HbA1 in predicting complications of diabetes and in the diagnosis of subclinical diabetes is discussed.

A follow-up study of 116 Type 1 (insulin-dependent) diabetic patients on long-term continuous subcutaneous insulin infusion was conducted after 4.5 +/- 0.2 years. The average HbA1c-value of these patients decreased by 1% to 6.7 +/- 0.1% during this observation period. Typical side effects of continuous subcutaneous insulin infusion such as skin inflammation at the catheter insertion site occurred with similar frequency as has been reported previously by other authors. Diabetic ketoacidosis (0.14 per patient year) and disabling hypoglycaemia (0.1 per patient year, including 0.05 hypoglycaemic coma per patient-year) occurred at substantially lower rates than in other comparable studies with Type 1 diabetic patients at a similar degree of metabolic control. Subgroup evaluation suggested that a normal (less than 5.6%) HbA1c-value at follow-up was associated with increased incidence of disabling hypoglycaemia, whereas poor metabolic control (HbA1c greater than 7.5%) was associated with increased rates of skin complications and hospital treatment for ketoacidosis. Thus, under the policies of this diabetes centre, continuous subcutaneous insulin infusion has proved to be beneficial to a large proportion of experienced adult Type 1 diabetic patients, who voluntarily had opted for, and continued with, this particular mode of insulin treatment.

Unselected type I diabetics were hospitalized for group training and treatment programme during which blood-sugar was self-monitored with the Haemo-Glukotest 20-800; quality of self-monitoring improved appropriately. The patients had taken part in either the standard training programme (67 patients) or in the "intensive" training programme (101 patients). At the beginning of the training week, after the first theoretical and practical instructions, the quality of blood-sugar self-monitoring was equally poor among patients of both programmes. At the end of the "standard" training week, self-monitoring results were still unsatisfactory, though slightly better than at the onset. Because of these poor results, the training programme was intensified. Optimal quality of self-monitoring was then achieved at the end of the training period. In 69 others, also unselected, type I diabetics the quality of self-monitoring was determined 14 months after their participation in the training programme. Using the Haemo-Glukotest 20-800 (57 patients), self-monitoring gave excellent results; using a blood-glucose measuring instrument (12 patients) it was slightly worse. Assuming intensive training, even unselected type I diabetics can obtain accurate blood-sugar measurements using test-strips.

Control of arterial blood pressure at near-normal levels is of importance for the prognosis of patients with Type 1 (insulin-dependent) diabetes mellitus. In non-diabetic populations patient compliance to antihypertensive therapy is frequently poor, especially in young people. Thirty-seven consecutive eligible patients with longstanding Type 1 diabetes and persistently uncontrolled hypertension were questioned about their preferences regarding hypertension treatment. Throughout they expressed a strong desire for more information about hypertension and for active participation in monitoring of blood pressure and therapeutic decision-making. In addition, they showed considerable reluctance to accept a pharmacological intervention. Therefore, in order to improve blood pressure control, the patients participated in a structured outpatient hypertension treatment and teaching programme for groups of about 6 patients consisting of four teaching sessions at weekly intervals. The programme comprised home-monitoring of blood pressure and involvement of the patients in treatment decision-making. In 34 patients who had a complete follow-up examination after an average of 16 months, mean sitting arterial pressure had decreased from 111 to 101 mmHg (p less than 0.001) and 53% of the patients were below 140/90 mmHg. The number and dosage of prescribed antihypertensive agents remained unchanged by the intervention. Sodium intake was not reduced during the study, but pulse rate decreased significantly in patients treated with beta-adrenergic blockers and serum uric acid rose in patients on diuretic therapy, suggesting increased adherence of the patients to prescribed antihypertensive drug therapy. In 34 comparable Type 1 diabetic patients who were not subjected to a hypertension treatment and teaching programme mean arterial blood pressure remained unchanged during a 12-month period.

Recently new radioimmunoassay methods have been established to measure plasma concentrations of beta-thromboglobulin (beta-TG) and platelet factor 4 (PF4), platelet release products which are set free when platelets aggregate. Plasma concentrations of beta-TG and PF4 were investigated in disorders with increased thromboembolic risk. Extremely high concentrations of these platelet proteins were found in patients with venous thrombosis, pulmonary embolism, polycythemia vera, and chronic renal failure. Moderately increased beta-TG and PF4 levels were observed in patients with peripheral vascular disease, coronary artery disease, chronic rheumatoid arthritis, multiple myeloma, and diabetes mellitus. These data indicate, that plasma concentrations of beta-TG and PF4 are useful parameters for the evaluation of the "in vivo" platelet activity. By using these new methods for clinical applications special blood sampling conditions have been taken into account; moreover one has to consider that the plasma levels of the platelet "release products" are dependent from renal function.

Objective data on duration of hospital stay and of incapacity to work were collected for 137 type I diabetics who had taken part in a structured diabetes treatment and training scheme. Before the training period the average hospital stay had been 0.76 per patient per year, duration per stay 21 days, number of episodes of work incapacity 1.6 per patient per year, duration of incapacity 23.6 days. For a subgroup of patients (62) the influence of the training programme could be demonstrated: hospital stay fell to 0.49 per patient per year, duration per stay to 12.0 days, number of incapacity episodes to 1.4 per patient per year, and the days lost from work to 12.1 per patient per year.

Pharmacokinetics and bioavailability of 1 mg glucagon injected intramuscularly (i.m.), subcutaneously (s.c.), or intravenously (i.v.) were studied in 6 nondiabetic men rendered hypoglycemic by s.c. injection of 10 U regular insulin. At 90 min after the insulin injection, when blood glucose levels had fallen to a mean of 49 mg/dl, glucagon was administered. Ten minutes later plasma glucagon levels had risen from a mean of 246 to 3233 pg/ml (s.c. experiment) and from 250 to 2638 pg/ml (i.m. experiment). Accordingly, there was no difference in blood glucose behavior whether glucagon was injected s.c. or i.m. In the i.v. experiment, plasma glucagon levels were significantly higher during the first 15 min after the glucagon injection when compared with the other experiments. The initially high levels of plasma glucagon after i.v. administration were associated with a steeper rise of glycemia during the first 5 min after glucagon injection; the maximal increase of blood glucose was, however, not different when compared with the s.c. or i.m. route of glucagon administration. Thus, in case of severe hypoglycemia, therapeutically administered glucagon will be most efficient when injected i.v., but there is no difference between the i.m. and s.c. routes of administration with regard to the efficacy to increase blood glucose levels.

It has been questioned whether aiming at near-normoglycaemia by intensified insulin treatment regimens is feasible and safe for the majority of patients with insulin-dependent diabetes. In this study, intensified insulin injection therapy (including blood glucose self-monitoring and multiple insulin injections) based upon a 5-day inpatient group teaching programme was evaluated in Type 1 (insulin-dependent) diabetes mellitus in the centralised health care system of Bucharest. One hundred patients (group A, initial HbA1 12.5%) were followed for 1 year on their standard therapy (individual teaching, no metabolic self-monitoring), and thereafter for 1 year on intensified therapy. Another 100 patients (group B, HbA1 12.3%) were followed for 2 years on intensified therapy. A third 100 patients (group C, HbA1 11.7%) were assigned to a basic 4-day inpatient group teaching programme with conventional insulin therapy (including self-monitoring of glucosuria and acetonuria) and followed for 1 year. Mean HbA1 remained unchanged after standard treatment (group A: 12.8% at 12 months), but decreased during intensified therapy (group A: 10.1% at 24 months; group B: 9.3% at 12 months, 9.5% at 24 months; p less than 0.0001). In group C, no change was found compared to standard treatment (i.e. group A at 12 months). Incidence rates of ketoacidosis were 0.16 episodes per patient per year during standard treatment, 0.01 during intensified treatment (p less than 0.01) and 0.04 in group C (p less than 0.025). Hospitalisation rates were reduced by 60% during intensified therapy and by 40% in group C. Frequency of severe hypoglycaemia was not significantly different between the three treatment regimens. Thus, under the condition that insulin treatment is based upon a structured and comprehensive training of the patient, intensified insulin injection therapy performed as routine treatment of Type 1 diabetes significantly lowers HbA1 levels without increasing the risk of severe hypoglycaemia.

Any successful treatment of type-I diabetic patients has to be based upon a detailed education of the diabetic patient in order to enable him to selfmanage his disease as much as possible. The goals of diabetes-therapy (i.e. near-normalization of glycaemia in order to prevent diabetic microangiopathy at as high a quality of life as possible) can only be achieved by actively involving the patient in his/her therapy. Thus patient education becomes the cornerstone of modern diabetes-care. The evaluation of diabetes-education has--eventually--be based upon an assessment of the quality of metabolic control. A number of studies have proven that effective diabetes-education programmes can substantially improve long-term metabolic control and the incidence of acute complications in type I diabetic patients. At present, it appears that the most efficient way to improve the overall quality of diabetes-care is to improve diabetes-education delivered to the patients.