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Aims/hypothesis: Patients with GAD antibodies (GADAb) showing clinical features of type 2 diabetes typically exhibit progression to an insulin-dependent state in several months or years. This condition is diagnosed as slowly progressive insulin-dependent (type 1) diabetes mellitus (SPIDDM) or latent autoimmune diabetes in adults, a subtype of adult-onset autoimmune diabetes. However, some patients diagnosed with adult-onset autoimmune diabetes do not progress to an insulin-dependent state. We conducted a retrospective cohort study to identify patients with non-insulin-dependent diabetes among those diagnosed with adult-onset autoimmune diabetes using measurable indicators in routine clinical practice. Methods: We surveyed data from the electronic medical records of all patients with GADAb from eight medical centres in Japan for selecting and analysing patients who matched the diagnostic criteria of SPIDDM. Results: Overall, 345 patients were analysed; of these, 162 initiated insulin therapy (insulin therapy group), whereas 183 did not (non-insulin therapy group) during the follow-up period (median 3.0 years). Patients in the non-insulin therapy group were more likely to be male and presented a later diabetes onset, shorter duration of diabetes, higher BMI, higher blood pressure levels, lower HbA1c levels, lower GADAb levels and lesser antidiabetic agent use than those in the insulin therapy group when GADAb was first identified as positive. A Cox proportional hazards model showed that BMI, HbA1c levels and GADAb levels were independent factors for progression to insulin therapy. Kaplan–Meier analyses revealed that 86.0% of the patients with diabetes having GADAb who presented all three factors (BMI ≥ 22 kg/m2, HbA1c < 75 mmol/mol [9.0%] and GADAb <10.0 U/ml) did not require insulin therapy for 4 years. Conclusions/interpretation: Higher BMI (≥22 kg/m2), lower HbA1c (<75 mmol/mol [9.0%]) and lower GADAb levels (<10.0 U/ml) can predict a non-insulin-dependent state for at least several years in Japanese patients with diabetes having GADAb. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To identify the frequency and factors associated with therapy noncompliance in type-2 diabetes mellitus patients. MATERIAL AND METHODS: A cross-sectional study was carried out in 79 patients with type-2 diabetes mellitus seen in major hospitals of Mexico City. Patients were visited at home, from March 1998 to August 1999, to measure compliance with prescribed therapy. Complying patients were defined as those taking at least 80% of their pills or 80% of their corresponding insulin dose. The degree of compliance with therapy components (diet, amount of exercise, and keeping appointments) was measured. RESULTS: The average age of study subjects was 59 years (SD 11 years); 73% (n=58) were female subjects. The overall frequency of noncompliance was 39%. Noncompliance rates were: 62% for dietary recommendations, 85% for exercise, 17% for intake of oral hypoglycemic medication, 13% for insulin application, and 3% for appointment keeping. Hypertension plus obesity was the only factor significantly associated with noncompliance (OR 4.58, CI 95% 1.0, 22.4, p=0.02). CONCLUSIONS: The frequency of therapy noncompliance was very high, especially for diet and exercise.OBJETIVO: Identificar la frecuencia y factores asociados al incumplimiento terapéutico en pacientes con diabetes mellitus tipo 2. MATERIAL Y MÉTODOS: Se llevó a cabo un estudio transversal en cuatro clínicas y hospitales de la Ciudad de México, en 79 pacientes con diabetes mellitus tipo 2. Se recolectaron datos sobre el cumplimiento terapéutico, para lo cual se visitó el domicilio de los sujetos de estudio entre marzo de 1998 y agosto de 1999, con el fin de contar los medicamentos. Se definió cumplimiento cuando el paciente administró correctamente 80% de las pastillas o de la dosis de insulina que le correspondía. Se midió el grado de cumplimiento para cada una de las medidas terapéuticas (dieta, ejercicio y asistencia a citas). RESULTADOS: La edad promedio del grupo fue de 59 años (DE=11 años); 58 pacientes (73%) fueron del sexo femenino. La frecuencia de incumplimiento global fue de 39%. La frecuencia de incumplimiento en el grupo donde se pudo llevar a cabo el conteo de medicamentos fue 62% para la dieta, 85% para el ejercicio, 17% para la administración de hipoglucemiantes, 13% para la aplicación de insulina y 3% para la asistencia a citas. Sólo la asociación de incumplimiento con la presencia de hipertensión arterial sistémica más obesidad fue estadísticamente significativa (RM= 4.58, IC 95%= 1.0-22.4, p= 0.02). CONCLUSIONES: La frecuencia de incumplimiento fue muy alta, especialmente en lo que se refiere a la dieta y al ejercicio.

It is well known that under the influence of regular, individually measured aerobic physical activity, it is possible to raise the biological efficiency of insulin by several mechanisms: by increasing the number of insulin receptors, their sensitivity and efficiency, as well as by increasing glucose transporters GLUT-4 on the level of cell membrane. The aim of this research was to examine whether decreased insulin resistance could be achieved under the influence of the program of individually measured aerobic physical activity in the 2-week period, in the obese type 2 diabetes patients with the increased aerobic capacity (VO2)max. In 10 type 2 diabetes patients 47.6 ± 4.6 years of age (group E), in the 14-days period, program of aerobic training was applied (10 sessions - 35 min session of walking on treadmill, intensity 60.8 ± 5.7% (VO2)max, frequency 5 times a week ), as well as 1 600 kcal diet. At the same time, other 10 type 2 diabetes patients 45.9 ± 5.5 years of age (group C) were on 1 600 kcal diet. Before and after this period the following was measured in both groups: insulin sensitivity (M/I) by the method of hyperinsulin euglycemic clamp, and (VO2)max by Astrand test on ergocycle. In contrast to the group C, in the second testing of E group subjects a significant increase was obtained in M/I (1.23 ± 0.78 vs. 2.42 ± 0.95 mg/kg/min/mU p

OBJECTIVE: To identify the frequency and factors associated with therapy noncompliance in type-2 diabetes mellitus patients. MATERIAL AND METHODS: A cross-sectional study was carried out in 79 patients with type-2 diabetes mellitus seen in major hospitals of Mexico City. Patients were visited at home, from March 1998 to August 1999, to measure compliance with prescribed therapy. Complying patients were defined as those taking at least 80% of their pills or 80% of their corresponding insulin dose. The degree of compliance with therapy components (diet, amount of exercise, and keeping appointments) was measured. RESULTS: The average age of study subjects was 59 years (SD 11 years); 73% (n=58) were female subjects. The overall frequency of noncompliance was 39%. Noncompliance rates were: 62% for dietary recommendations, 85% for exercise, 17% for intake of oral hypoglycemic medication, 13% for insulin application, and 3% for appointment keeping. Hypertension plus obesity was the only factor significantly associated with noncompliance (OR 4.58, CI 95% 1.0, 22.4, p=0.02). CONCLUSIONS: The frequency of therapy noncompliance was very high, especially for diet and exercise.

Objetivos. Establecer la frecuencia de apego al tratamiento farmacológico en pacientes diabéticos tipo 2, relacionarla con el control metabólico e identificar factores que influyen para el no apego. Material y métodos. Estudio transversal comparativo, efectuado en 150 pacientes con diabetes mellitus tipo 2 de la unidad de medicina familiar No. 33 del Instituto Mexicano del Seguro Social de Chihuahua, Chih., México, hecho entre 1997 y 1998. Se midió el apego con cuenta de tabletas en su domicilio. El control metabólico se midió con hemoglobina glucosilada. Un cuestionario investigó factores relacionados. Se utilizó estadística descriptiva, t de Student y razón de momios. Resultados. El apego correspondió a 54.2%. Los factores asociados al no apego fueron la escolaridad primaria y la falta de información sobre la enfermedad (phttp://www.insp.mx/salud/index.htmlObjective. To establish the frequency of compliance to pharmacological therapy, and to identify non-compliance factors, in relation to metabolic control on patients with type-II diabetes mellitus. Material and methods. A comparative cross-sectional study was conducted between 1997 and 1998, among 150 type-II diabetic patients, at the Family Medicine Unit No. 33, of the Mexican Institute of Social Security, in Chihuahua, Mexico. Compliance to drug therapy was measured by counting tablets at home. Metabolic control was measured through glycosilated hemoglobin. A questionnaire was given to collect data on factors related to compliance. Statistical analysis consisted of descriptive statistics, Student's t and odds ratios. Results. Pharmacological therapy compliance was 54.2%. Factors associated with non-compliance were elementary schooling and lack of information about the disease. Conclusions. Pharmacological therapy compliance was low. Factors related to non-compliance can be modified through education. The English version of this paper is available at: http://www.insp.mx/salud/index.html

Se realizó un estudio transversal para conocer la morbilidad oculta por diabetes mellitus no insulinodependiente y tolerancia alterada a la glucosa en el consultorio No. 17 del Policlínico Comunitario Docente Centro durante el año 1998. El universo de estudio lo representaron 196 personas a las que se les realizó una primera glicemia en ayunas, y de acuerdo con sus resultados una segunda determinación o una prueba de tolerancia a la glucosa oral, recogiéndose los resultados en una encuesta que contenía variables tales como: sexo, grupos de edades, factores de riesgo y resultados de ambas pruebas anteriores. Todo ello se procesó de una forma computadorizada. Los antecedentes patológicos familiares y la obesidad fueron los factores de riesgo más frecuentes, con mayor incidencia del sexo femenino, detectándose una morbilidad oculta de 1,53 % por diabetes mellitus no insulinodependiente, y de 2,04 % por tolerancia alterada a la glucosaA cross-sectional study was carried out to know the hidden morbidity from non-insulin-dependent diabetes mellitus and impaired glucose tolerance at the family physician?s office No 17 of the Central Community Teaching Polyclinic during 1998. The universe of study was composed of 196 subjects who underwent a first fasting glycaemia and according to its results a second determination or an oral glucose tolerance test. The results were collected in a survey containing containing variables such as: sex, age groups, risk factors and the results of both previous tests. All this information was processed by computer. Family pathological history and obesity were the commonest risk factors, with a higher incidence of females. It was detected an hidden morbidity of 1,53 % from non-insulin-dependent diabetes mellitus and of 2,04 % from impaired glucose tolerance

Se realiza una encuesta a todas las mujeres diabéticas en edad fértil (de 15 a 45 años) dispensarizadas en 2 áreas de salud de Ciudad de La Habana. Se les interroga acerca de si tenían o no vida sexual activa, uso actual y/o previo de contraceptivos (incluso esterilización) y su deseo actual o no de embarazarse. El grupo de estudio se distribuyó de acuerdo con la vida sexual, esterilización y deseo de embarazo para aplicar medidas en cada grupo como parte de un programa de planificación familiar de la mujer diabética. Los métodos contraceptivos más utilizados fueron la esterilización y los dispositivos intrauterinos, casi un tercio del grupo no utilizaba ningún método contraceptivo en el momento del estudio. Se plantea la necesidad de fomentar el uso de los métodos de barrera en diabéticas nulíparas, y se recomienda el uso de dispositivos intrauterinos en mujeres diabéticas con 1 o más hijos.All diabetic women at fertile age (from 15 to 45 years) classified in two health areas of Havana City were surveyed. They were asked about their active sexual life, the present or previous use of contraceptives (including sterilization), and about their current wish to get pregnant. The case-base study was distributed according to the above mentioned elements so as to apply measures in each group as part of a family planning program for diabetic women. Sterilization and intrauterine devices were the most used contraceptive methods. Almost a third of the group did not use any of these methods at the time of the study. It is expressed the need to promote the use of barrier methods in diabetic nulliparas, and it is recommended the use of intrauterine devices among diabetic women with one or more children.

The metabolic characteristics of type 2 diabetes, insulin resistance, and diminished insulin secretion are costly to measure directly. To evaluate the utility of several simple indices derived from insulin and glucose measurements, the indices were examined from 1982 to 1997 with respect to correlation with more sophisticated measures of insulin sensitivity and secretion in Pima Indians in the Gila River Indian Community of Arizona. Ability to predict the incidence of diabetes in 1, 731 persons was also examined. Indices were calculated from fasting and 2-hour glucose (G0, G120) and insulin (I0, I120) concentrations obtained during an oral glucose tolerance test. Fasting serum insulin concentration and the insulin sensitivity index (104/(I0 × G0)) each showed a moderate correlation with the estimate of insulin sensitivity derived from the hyperinsulinemiceuglycemic clamp (|r| ≈ 0.60). They also strongly predicted the incidence of diabetes (incidence rate ratio comparing the most and least insulin-resistant tertile groups ≈ 3.0). Corrected insulin response (I120/(G120 × (G120 − 70))) was modestly correlated with insulin secretion as measured by an intravenous glucose tolerance test (r = 0.35). Impaired insulin secretion assessed by this index predicted incidence of diabetes, particularly after control for insulin sensitivity index (incidence rate ratio = 1.6). Thus, simple indices of insulin sensitivity and secretion may be responsible surrogates for more sophisticated measures in epidemiologic studies. Am J Epidemiol 2000; 151:190-8. [ABSTRACT FROM PUBLISHER]

This study, conducted in the Netherlands in 1994–1996, assessed the reproducibility, validity, and responsiveness of a food frequency questionnaire (FFQ) used with older subjects with type 2 diabetes. During a period of 6 months, 93 subjects had a stable protein intake according to their urinary urea excretion (UUE). An FFQ was completed before and after this period. Reproducibility was evaluated on the basis of the correlation (0.80) between duplicate FFQ estimates of protein intake. At the group level, the smallest detectable difference was 3 g. For 354 subjects, average protein intake according to the FFQ was similar to that from UUE estimates. Validity was evaluated on the basis of the crude and deatenuated correlations, which were 0.31 and 0.39, respectively. The crude correlation was highest for former smokers (r =0.39) and for patients with a higher body mass index (r =0.37), and it was very low for current smokers (r =0.14 p >0.20). The correlation did not vary with age or gender. Responsiveness was judged on the crude correlation between changes in intake according to the FFQ and UUE; the correlation was 0.22 (n = 134). The responsiveness ratio was 0.73. The authors concluded that FFQ estimates are well reproducible. At the group level, protein intake was estimated correctly, whereas individual protein intake and changes in intake were reflected to a moderate extent only. Am J Epidemiol 1999;150:987-95. [ABSTRACT FROM PUBLISHER]

Purpose: Development of a conceptual model and description of its use to guide the content and format of a community-based intervention. Conceptual Model: We developed a symptom-focused model for type 2 diabetes for older African American women based on the UCSF symptom management model. Key concepts in this model are symptom experience, symptom management, and health outcomes. Methods: Review of literature, intervention protocol. Conclusions: The symptom-focused conceptual model is an innovative approach to tailoring care to a distinct population and to engaging participants in their own self-care. Clinical Relevance: Diabetes is a major cause of morbidity and mortality in African Americans; and diabetes self-management is the cornerstone of care. To better meet the distinct needs of diverse populations and positively affect health outcomes, new tailored approaches should be developed that are culturally sensitive and acceptable. [ABSTRACT FROM AUTHOR]

Introduction Kidney damage from diabetes mellitus is called diabetic nephropathy. At the beginning it is a functional disorder, but later it results in an irreversible damage. The aim of this research was to establish damage to proximal tubular cells in patients with type 2 diabetes mellitus, and various degrees of proteinuria by determining the urinary N-acetyl-β-D-glucose-aminidase and g-glutamyl-transferase; to compare obtained results with the results in healthy examinees; to establish the correlation between these enzymes, and to investigate their sensitivity. Material and methods Patients with type 2 diabetes mellitus and creatinine clearence >80 ml/min were included in the research. Patients were divided into three groups, according to the degree of proteinuria. The first group included diabetics without microalbuminuria; the second - patients with proteinuria <300 mg/24h and microalbuminuria >20 mg/24h, and the third group included patients with proteinuria >300 mg/24h. Healthy examinees were the control group. Results Values of the urinary N-acetyl-b-D-glucosaminidase activity were elevated before microalbuminuria was observed. The highest values were detected in the group of patients with microalbuminuria. Differences among the examined groups were statistically significant, which implies that this enzyme has a high diagnostic importance. Enzyme γ-glutamyl-transferase was less sensitive in this research. The activity of this enzyme was increased only in the group of patients with proteinuria >300 mg/24h, where values increased with diabetes mellitus duration. Conclusion The increased activity of urinary N-acetyl-β-D-glucosaminidase points to early tubular damage, and can be used as a sensitive parameter in its early detection. On the other hand, gamma-glutamyl-transferase was a less sensitive damage indicator. [ABSTRACT FROM AUTHOR]

Abstract: This study was performed to investigate whether transient intensive insulin therapy with an insulin pump (TIIT) can decrease serum tumor necrosis factor-α (TNF-α) and explore whether the decrease of serum TNF-α has correlation with the improvement of islet β-Cell function and the decrease of insulin resistance. Thirty healthy volunteers served as control subjects. One hundred and thirty-eight newly diagnosed type 2 diabetic patients had been treated with TIIT for 2 weeks. TNF-α, free fatty acids (FFAs), glucose, and insulin (INS) had been measured before and after TIIT, respectively. Homeostasis model assessment (HOMA) was used to estimate insulin resistance (HOMA-IR) and islet β-Cell function (HOMA-β). TNF-α was significantly increased in diabetes. After TIIT, TNF-α, fasting blood glucose, FFAs, and HOMA-IR were significantly decreased. HOMA-β and the areas under the curves of INS were significantly increased during intravenous glucose tolerance tests. TNF-α had not only significant negative correlation with the changes of insulin secretion, but also significant positive correlation with the changes of HOMA-IR after adjustment of blood glucose. Partial correlation analyses demonstrated that there was an indepenent relationship between TNF-α and HOMA-IR and HOMA-β. Our study confirms that TIIT can effectively decrease serum TNF-α in type 2 diabetes. It is inferred that the decrease of serum TNF-α might be involved in the improvement of β-Cell function and the decrease of insulin resistance by TIIT. [Copyright &y& Elsevier]

Diabetes has reached epidemic proportions worldwide and is associated with a large economic burden, increased risk of cardiovascular disease, and premature mortality. Hyperglycemia is the hallmark clinical manifestation of diabetes and evolves through a multifactorial etiology of genetic, environmental, and behavioral enablers. Approximately 90% of diabetes cases are the non-insulin-dependent phenotype, which is characterized by a progressive deterioration in insulin-mediated glucose disposal, particularly by peripheral tissues. Our hypothesis is that the most proximal behavioral cause of insulin resistance is physical inactivity. Indeed, several streams of scientific research have demonstrated a role for physical activity in the etiology and prevention of diabetes and its related morbidity. In this review we will discuss some of the key observational and experimental studies that have examined associations among physical activity, cardiorespiratory fitness, and non-insulin-dependent diabetes. [ABSTRACT FROM AUTHOR]

Several observational studies have shown that higher insulin levels are associated with an increased risk of cardiovascular disease. If higher endogenous insulin levels are causally related to cardiovascular disease, one might expect an increased risk of cardiovascular disease in patients treated with insulin, as this results in high circulating insulin levels. Such risk elevation might counteract the benefits of tight glucose control. Our objective was to explore the relationship between insulin therapy and cardiovascular disease in Type 1 and Type 2 diabetes mellitus using information from available literature.Several experimental studies in animals and humans support the presence of a harmful effect of insulin on the vascular endothelium. In prospective follow-up studies increased insulin dosage was associated with increased risks of cardiovascular disease, although confounding by indication could not be excluded. Randomized controlled trials in diabetic patients, comparing conventional with intensive glucose-lowering treatment, although showing a reduction in microvascular disease, showed no significant difference in the incidence of cardiovascular disease. The results with respect to exposure to insulin are, however, difficult to interpret due to insufficient information on exposure to insulin levels as well as confounding by glycaemic control and body mass index. In addition, these studies were not designed to address the question whether higher insulin use relates to increased cardiovascular risk.Published research provides conflicting evidence as to whether exposure to high levels of exogenous insulin in diabetes mellitus affects the risk of cardiovascular disease. The currently available studies have a number of serious methodological restraints that limit accurate interpretation and conclusions in this area.Diabet. Med. (2004) [ABSTRACT FROM AUTHOR]

To examine the prevalence and correlates of self-reported urogenital symptoms (dryness, irritation or itching, discharge, dysuria) among postmenopausal women aged 50–79. Design: A cross-sectional analysis based on n = 98,705 women enrolled in the US-based Women’s Health Initiative observational study and clinical trials. Urogenital symptoms, symptom severity (mild, moderate, severe), and all covariates were self-reported through questionnaires at enrollment. Prevalence rates of each urogenital symptom were examined and logistic regression was used to identify potential correlates. Results: Prevalence rates for each symptom were: dryness, 27.0%; irritation or itching, 18.6%; discharge, 11.1%; and dysuria, 5.2%. Four factors were correlated with two or more symptoms: Hispanic ethnicity (adjusted odds ratio (AOR) = 2.1–3.1 versus white women across all symptoms), obesity (AOR = 2.2 severe discharge versus none, AOR = 3.6 severe irritation/itching versus none), treated diabetes (pills or shots) compared to no diabetes (AOR = 2.4 severe dysuria versus none, AOR = 3.2 severe irritation/itching versus none), and vaginal cream HRT/ERT compared to those who never used HRT/ERT (AOR = 4.4 severe dryness versus none, AOR = 4.6 severe irritation/itching versus none). Factors not associated with the symptoms included sexual activity, age, years since menopause, current smoking, marital status, gravidity, and natural versus surgical menopause. Conclusions: This is the first report to document urogenital symptoms by race/ethnicity among an exclusively postmenopausal population. We found an elevated prevalence of urogenital symptoms among women who are Hispanic, obese, and/or diabetic. Confirmation of our findings in these subgroups, and, if confirmed, analysis on why these populations are at greater risk, are areas for future research. [Copyright &y& Elsevier]

Aim/hypothesis. The aim of this study was to investigate the association between processed and other meat intake and incidence of Type 2 diabetes in a large cohort of women. Methods. Incident cases of Type 2 diabetes were identified during 8 years of follow-up in a prospective cohort study of 91246 U.S. women aged 26 to 46 years and being free of diabetes and other major chronic diseases at baseline in 1991. Results. We identified 741 incident cases of confirmed Type 2 diabetes during 716276 person-years of follow-up. The relative risk adjusted for potential non-dietary confounders was 1.91 (95% CI: 1.42–2.57) in women consuming processed meat five times or more a week compared with those consuming processed meat less than once a week (p<0.001 for trend). Further adjustment for intakes of magnesium, cereal fibre, glycaemic index, and caffeine or for a Western dietary pattern did not appreciably change the results and associations remained strong after further adjustment for fatty acid and cholesterol intake. Frequent consumption of bacon, hot dogs, and sausage was each associated with an increased risk of diabetes. While total red meat (beef or lamb as main dish, pork as main dish, hamburger, beef, pork or lamb as sandwich or mixed dish) intake was associated with an increased risk of diabetes, this association was attenuated after adjustment for magnesium, cereal fiber, glycaemic index, and caffeine (relative risk: 1.44; 95% CI: 0.92–2.24). Conclusion/interpretation. Our data suggest that diets high in processed meats could increase the risk for developing Type 2 diabetes. [ABSTRACT FROM AUTHOR]

Objective: Inflammatory markers predict cardiovascular events in a wide range of patients. Two factors, fibrinogen (FIB) and high-sensitivity C reactive protein (CRP), are currently entering clinical practice as cardiovascular risk predictors. In patients with type 2 diabetes mellitus, we sought to examine the relationship between macrovascular disease, urinary albumin/creatinine ratio (ACR), and FIB or CRP, as well as the relationship of FIB and CRP with traditional risk predictors of these complications of diabetes. Methods: In 202 consecutive patients with type 2 diabetes mellitus from a diabetes clinic, clinical and biochemical data were obtained and a cross-sectional analysis was performed. Results: Patients with macrovascular disease had higher FIB (P=.02) but not higher CRP. They were older, more likely to have retinopathy or elevated serum creatinine, had higher ACR and lower HDL cholesterol. They were more likely to be treated with statins, β-blockers, and ASA. Adjustment for statin therapy did not result in significant differences in CRP levels according to macrovascular disease status. Both FIB (P=.01) and CRP (P=.02) were significantly higher in patients with ACR whose values were in the proteinuria range. In multivariate analysis, both FIB (P=.001) and CRP (P=.03) were positively correlated with ACR, but no association was seen between CRP and ACR when FIB was entered in the model. Other factors positively associated with ACR were age, diastolic blood pressure, retinopathy, and hemoglobin A1c (HbA1c). FIB and CRP were strongly correlated (R=.49, P≤.001) and this effect was independent of statin therapy. CRP was positively associated with body mass index (BMI), serum triglycerides, and sulfonylurea therapy and negatively associated with metformin therapy. Patients on statin therapy had significantly higher FIB and lower CRP. Women on hormone replacement therapy (HRT) had significantly lower FIB and higher CRP. Conclusions: In patients with diabetes: (1) the two markers, FIB and CRP, are interrelated; (2) FIB is significantly associated with presence of microvascular disease, independent of CRP; (3) CRP is strongly associated with metabolic factors but not with complications of diabetes, independently of FIB; (4) statins and HRT were divergently associated with CRP and FIB as HRT was associated with lower FIB and higher CRP, while statins showed the reverse association; and (5) CRP and FIB provide different information about the characteristics and consequences of diabetes mellitus because of divergent associations with biological indicators and therapeutic agents. [Copyright &y& Elsevier]

Aims/hypothesis. Hyperinsulinaemia and insulin resistance usually precede clinical hyperglycaemia and Type 2 diabetes. Thus, plasma insulin concentrations and insulin resistance are important quantitative traits associated with risk of Type 2 diabetes, and represent key measures for genetic analysis of the syndrome. Methods. We carried out a genome-wide search for loci related to plasma insulin concentrations and insulin resistance in 330 extended, community-based pedigrees from the Framingham Heart Study. Normalized deviates of the standardized residuals of plasma insulin concentrations in the fasting state, 2 h after oral glucose challenge and as a measure of insulin resistance were used in linkage analysis with the variance components model implemented in the computer program SOLAR. Results. The results suggest susceptibility loci influencing plasma concentrations of fasting insulin and insulin resistance on chromosomes 11 (LOD 2.43 at 85 cM close to D11S2002) and 17 (LOD 1.8 at 60 cM, close to D17S784); and susceptibility loci influencing 2-h plasma insulin concentrations on chromosomes 9 (LOD 2.8 at 80 cM, close to D9S922) and 19 (LOD 1.8 at 66 cM, close to D19S245). The results of the analysis of 1000 simulations of the trait and an unlinked marker suggest that in a genome scan of 401 markers fewer than one LOD score over 1 would be due to Type 1 error, and be a false positive. Conclusion/interpretation. We conclude that these suggestive regions for quantitative pre-diabetic insulin traits could contain major loci in the pathogenesis of Type 2 diabetes. [ABSTRACT FROM AUTHOR]

In 1993–1996, islet autoantibodies, C-peptide, and HLA-DQ genotypes were evaluated in 345 insulin-treated diabetic patients of all ages from the Skaraborg Diabetes Registry 5–6 years after their diagnosis and in 216 control subjects from the Skaraborg County, Sweden, population. The aims of this study were to clarify the importance of age at diagnosis of diabetes for HLA-DQ associations in patients with classic type 1 diabetes and whether patients considered to have latent autoimmune diabetes of the adult differed in their human leukocyte antigen (HLA) associations. An abnormally low fasting C-peptide value was used as the definition of type 1 diabetes, found in 182 of 345 (53%) patients. No major associations between age at diagnosis and HLA susceptibility or protective genotypes were detected in type 1 diabetic patients. Among the 163 patients with preserved β-cell function, the frequency of HLA protective genotypes was clearly decreased (5% vs. 42%) in the 46 of 163 with islet antibodies compared with the 117 of 163 antibody-negative patients. The authors conclude that there were no major effects of age at diagnosis on HLA-DQ associations in classic type 1 diabetic patients, whereas lack of HLA-DQ protective genotypes was a feature of patients with slow-progressing type 1 diabetes (latent autoimmune diabetes of the adult). [ABSTRACT FROM PUBLISHER]

The authors previously reported an increase in the incidence of diabetes mellitus among Rochester, Minnesota, residents during the period 1970-1989. This study provides updated rates from data collected through 1994. Trends in diabetes surveillance, i.e., the proportion of residents who had a blood glucose measurement in each year between 1987 and 1994, are also provided. The authors reviewed medical records to identify residents aged 30 years or more who first met National Diabetes Data Group criteria for diabetes between January 1, 1970, and December 31, 1994. Age- and sex-adjusted incidence rates were calculated for successive quinquennia (5-year periods), and Poisson regression was used to test for an effect of calendar year; calendar period (1970-1989 vs. 1990-1994) was added to assess whether the association with calendar year varied in the most recent quinquennium. Altogether, 1,992 Rochester residents first met National Diabetes Data Group criteria for diabetes between 1970 and 1994. The age-adjusted incidence per 100,000 person-years increased 67% for males (267.0 vs. 444.8) and 42% for females (225.4 vs. 319.1) between 1970-1974 and 1990-1994. Calendar year (p < 0.001) and calendar period (p = 0.026) were significant, suggesting that rates accelerated during 1990-1994. The proportion of residents with at least one blood glucose measurement per year was unchanged (p = 0.181) from 1987 to 1994, while the incidence of diabetes increased (p = 0.033).Thus, the authors conclude that the increase in diabetes incidence accelerated over the last quinquennium and was not due to increased surveillance. Am J Epidemiol 2002;155:859-65. [ABSTRACT FROM AUTHOR]

Elevated proinsulin and proinsulin/insulin ratios are features of abnormal β-cell function in type 2 diabetes. The participation of genetic factors is disputed. The authors wished to investigate relations between family history of diabetes on one hand and proinsulin as well as proinsulin/immunoreactive insulin ratios on the other. A large, population-based sample of Swedish men aged 35-54 years in 1992 was studied. Subjects without known diabetes were selected either to have a strong family history of diabetes (n = 1,619) or no history of the disease (n = 1,495). An oral glucose tolerance test detected 172 subjects with impaired glucose tolerance and 55 subjects with previously unknown diabetes according to World Health Organization 1985 criteria. In multiple regression analysis, fasting levels of proinsulin and proinsulin/insulin ratios were positively associated both with the 2-hour glucose level (as a continuous variable) and with obesity, whereas a negative association was found with birth weight. No association was found with family history of diabetes or with chronologic age. These findings indicate that elevated proinsulin and proinsulin/insulin ratios are secondary to increased demands on β-cell secretion induced by hyperglycemia and insulin resistance with no discernible influence of family history of diabetes. Am J Epidemiol 2002;155:834-41. [ABSTRACT FROM AUTHOR]

To examine the association between snoring and risk of developing type II diabetes mellitus, the authors analyzed data from the Nurses' Health Study cohort. This analysis included 69,852 US female nurses aged 40–65 years without diagnosed diabetes, cardiovascular disease, or cancer at baseline in 1986. Snoring patterns were ascertained by questionnaire. During 10 years of follow-up, 1,957 women were diagnosed with type II diabetes. In analyses adjusted for age and body mass index, snoring was associated with risk of diabetes (for occasional snoring vs. nonsnoring, relative risk (RR) = 1.48 (95% confidence interval (CI): 1.29, 1.70); for regular snoring vs. nonsnoring, RR = 2.25 (95% CI: 1.91, 2.66); p for trend < 0.0001). Further adjustment for other diabetes risk factors and sleeping-related covariates only slightly attenuated the risk (for occasional snoring, RR = 1.41 (95% CI: 1.22, 1.63); for regular snoring, RR = 2.03 (95% CI: 1.71, 2.40); p for trend < 0.0001). Analyses stratified by body mass index, smoking history, or parental history of diabetes showed a consistent association between snoring and diabetes within the categories of these variables. These results suggest that snoring is independently associated with elevated risk of type II diabetes. [ABSTRACT FROM PUBLISHER]

Evidence regarding the association between alcohol consumption and type 2 diabetes risk remains inconsistent, particularly with regard to male-female differences. The authors conducted a prospective study of type 2 diabetes risk associated with alcohol consumption in a cohort of 12,261 middle-aged participants of the Atherosclerosis Risk in Communities Study (1990–1998), who were followed between 3 and 6 years. Alcohol consumption at baseline was characterized into lifetime abstainers, former drinkers, and current drinkers of various levels. Incident diabetes was determined by blood glucose measurements and self-report. After adjustment for potential confounders, an increased risk of diabetes was found in men who drank >21 drinks/week when compared with men who drank ≤1 drink/week (odds ratio = 1.50, 95% confidence interval: 1.02, 2.20) while no significant association was found in women. This increased diabetes risk among men who drank >21 drinks/week was predominantly related to spirits rather than to beer or wine consumption. The relative odds of incident diabetes in a comparison of men who drank >14 drinks of spirits per week with men who were current drinkers but reported no regular use of spirits, beer, or wine were 1.82 (95% confidence interval: 1.14, 2.92). Results of this study support the hypothesis that high alcohol intake increases diabetes risk among middle-aged men. However, more moderate levels of alcohol consumption do not increase risk of type 2 diabetes in either middle-aged men or women. [ABSTRACT FROM PUBLISHER]

Objective - To study differences in diabetes-related parameters in type 2 diabetic patients treated with the support of a Diabetes Service compared to conventional general practice care. Design - Parallel clinical trial with randomisation at practice level. Setting - Fifteen general practices. Patients - Type 2 diabetic patients, aged < 76 years, treated by a GP. Main outcome measures - Level of glycated haemoglobin (HbA1c). Results - 246 patients entered the study. Final mean HbA1c of all evaluable patients allocated to the intervention (n =84) was 7.1 ± 1.2%, vs 7.5 ± 1.8% in the controls (n = 140) (p = 0.06). Patients who were initially poorly controlled (Fasting Blood Glucose > 10 mmol/l) had a significantly lower final HbA1c if they were in an intervention practice (p =0.001). Fewer patients in intervention practices were referred to hospital specialists (1 vs 14). Conclusions – Support by the Dutch Diabetes Service did not significantly influence glycated haemoglobin. The subgroup of initially poorly controlled patients developed a significantly lower HbA1c in intervention practices (supported by a Diabetes Service) than in control practices. [ABSTRACT FROM AUTHOR]

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OBJECTIVE: To review evidence about the benefit of intensive glycemic control for patients with type 2 diabetes and to develop practice recommendations. PARTICIPANTS: A 9-member panel composed of family physicians, general internists, endocrinologists, and a practice guidelines methodologist was assembled by the American Academy of Family Physicians, the American Diabetes Association, and the American College of Physicians. EVIDENCE: Admissible evidence included published randomized controlled trials and observational studies regarding the effects of glycemic control on microvascular and macrovascular complications and on adverse effects. We followed systematic search and data abstraction procedures. Greater weight was given to clinical trials and to evidence about health outcomes. CONSENSUS PROCESS: Interpretations of evidence and approval of documents were finalized by unanimous vote, with recommendations linked to evidence and not expert opinion. The full report was prepared by the chair and 2 panel members, representing each of the 3 organizations. The initial draft underwent external review by 14 diabetologists and family physicians and changes consistent with the evidence were incorporated. CONCLUSIONS: The evidence demonstrates that the risk of microvascular and neuropathic complications is reduced by lowering glucose concentrations. Whether glycemic control affects macrovascular outcomes is less clear. The potential benefits of glycemic control must be balanced against factors that either preempt benefits (eg, limited life expectancy, comorbid disease) or increase risk (eg, severe hypoglycemia). The magnitude of benefit is a function of individual clinical variables (eg, baseline glycated hemoglobin level, presence of preexisting microvascular disease). Appropriate targets for treatment should be determined by considering these factors, patients' risk profiles, and personal preferences. [ABSTRACT FROM AUTHOR]

BACKGROUND • Clinicians are often concerned that use of alternative treatments by Mexican American patients with diabetes competes with medical treatment. We examined the use and evaluation of alternative treatments for diabetes by a sample of these patients. METHODS • Following a descriptive qualitative design, a convenience sample of 43 low-income Mexican Americans with type 2 diabetes were interviewed. We analyzed interview transcripts for alternative treatment, named, patterns of use, evaluation of those treatments, and the use of biomedical approaches. We crosschecked the results for interrater reliability. RESULTS • Herbs were mentioned as possible alternative treatments for diabetes by 84% of the patients interviewed. However, most had never or rarely tried herbs and viewed them as supplemental to medical treatments. Most said prayer influences health by reducing stress and bringing healing power to medicines. None used curanderos (traditional healers) for diabetes. Most actively used biomedical treatments and were less actively involved in alternative approaches. Statistical tests of association showed no competition between biomedical and alternative treatments, and alternative treatment activity tended to be significantly lower than biomedical. Most study participants emphasized medical treatment and only used alternative treatments as secondary strategies. Those patients very actively using alternative approaches also tended to be very actively using biomedical methods; they were using all resources they encountered. CONCLUSIONS • Traditional attitudes and beliefs were not especially important to the patients in this study and presented no barriers to medical care. For these patients, it also cannot be assumed that belief in alternative treatments and God's intervention indicate fatalism or noncompliance but instead require consideration of individual treatment behaviors. [ABSTRACT FROM AUTHOR]

The metabolic characteristics of type 2 diabetes, insulin resistance, and diminished insulin secretion are costly to measure directly. To evaluate the utility of several simple indices derived from insulin and glucose measurements, the indices were examined from 1982 to 1997 with respect to correlation with more sophisticated measures of insulin sensitivity and secretion in Pima Indians in the Gila River Indian Community of Arizona. Ability to predict the incidence of diabetes in 1,731 persons was also examined. Indices were calculated from fasting and 2-hour glucose (G0, G120) and insulin (I0, I120) concentrations obtained during an oral glucose tolerance test. Fasting serum insulin concentration and the insulin sensitivity index (104/(I0 x G0)) each showed a moderate correlation with the estimate of insulin sensitivity derived from the hyperinsulinemic-euglycemic clamp (absolute value r approximately 0.60). They also strongly predicted the incidence of diabetes (incidence rate ratio comparing the most and least insulin-resistant tertile groups approximately 3.0). Corrected insulin response (I120/(G120 x (G120 - 70))) was modestly correlated with insulin secretion as measured by an intravenous glucose tolerance test (r = 0.35). Impaired insulin secretion assessed by this index predicted incidence of diabetes, particularly after control for insulin sensitivity index (incidence rate ratio = 1.6). Thus, simple indices of insulin sensitivity and secretion may be reasonable surrogates for more sophisticated measures in epidemiologic studies. [ABSTRACT FROM AUTHOR]

BACKGROUND. Combination oral therapy is often used to control the hyperglycemia of patients with type 2 diabetes. We compared the efffectiveness of metformin and troglitazone when added to sulfonylurea therapy for patients with type 2 diabetes who had suboptimal blood glucose control. METHODS. We used a randomized 2-group design to compare the efficacy, safety, and tolerability of troglitazone and metformin for patients with type 2 diabetes mellitus that was inadequately controlled with diet and oral sulfonylureas. Thirty-two subjects were randomized to receive either troglitazone or metformin for 14 weeks, including a 2-week drug-titration period. The primary outcome variable was mean change in the level of glycosylated hemoglobin (Hb A1c) from baseline. Secondary outcomes included mean changes from baseline in fasting plasma glucose and C-peptide levels, renal or metabolic side effects, and symptomatic tolerabiiity. RESULTS. The addition of either troglitazone or metformin to oral sulfonylurea therapy significantly decreased Hb A1c levels. Both treatment regimens also significantly reduced fasting plasma glucose and C-peptide levels. We found no significant differences between the treatment arms in efficacy, metabolic side effects, or tolerability. CONCLUSIONS. Our results demonstrate that troglitazone and metformin each significantly improved Hb A1c, fasting plasma glucose, and C-peptide levels when added to oral sulfonylurea therapy for patients with type 2 diabetes who had inadequate glucose control. [ABSTRACT FROM AUTHOR]

Objective: To determine the value of using risk factors to decide which patients should undergo serum screening for type 2 diabetes.Search Strategies: The MEDLINE and EMBASE electronic databases were searched for original studies of screening for type 2 diabetes on the basis of risk factors. The reference lists of all reviews, letters, editorials, consensus statements, and guidelines for diabetes screening were searched for additional studies. The Cochrane database was also searched for relevant reviews.Selection Criteria: All original studies regarding selective serum screening for type 2 diabetes on the basis of risk factors were included. review. Three studies were cross-sectional in design; 3 employed survey data to develop computerized statistical models that used risk factors to identify cases of type 2 diabetes; and 1 used a similar method, but the resulting model was field tested in a separate population. No study describes a risk-factor-based method or instrument that helps substantially in the diagnosis of type 2 diabetes.Conclusions: Selective screening for type 2 diabetes on the basis of risk factors cannot be recommended. Serum screening can be offered to patients who present with typical symptoms of diabetes. [ABSTRACT FROM AUTHOR]

BACKGROUND. The biopsychosocial model has been a cornerstone for the training of family physicians; however, little is known about the use of this model in community practice. This study, conducted in an urban Native American health center, examined the application of the biopsychosocial model by an experienced family physician (Dr M). METHODS. Interactions between Dr M and 9 Native Americans with type 2 diabetes were audio-recorded following preliminary interviews. Interpretations of the interactions were elicited from Dr M through interpersonal process recall and interpretive dialogue sessions. The author analyzed this data using techniques from interpretive anthropology and narrative discourse analysis. RESULTS. In a preliminary interview, Dr M described a sophisticated biopsychosocial approach to practice. However, she viewed her actual interactions with these patients as imbued with misunderstanding, mistrust, and disconnection. This occurred in spite of her experience and commitment to providing culturally sensitive primary care. CONCLUSIONS. Biopsychosocial models of disease may conflict with patient-centered approaches to communication. To overcome difficulties in her practice environment, Dr M adopted a strategy that combined an instrumental biopsychosocial approach with a utilitarian mode of knowing and interacting with patients. The misunderstandings, mistrust, and constrained interactions point to deeper problems with the way knowledge is formed in clinical practice. We need further understanding of the interrelationships between physicians' clinical environments, knowledge of patients, and theories of disease. These elements are interwoven in the physicians' patient-specific narratives that influence their interactions in primary care settings. [ABSTRACT FROM AUTHOR]

SummaryAims To study whether changes in endogenous insulin secretion at the same glycaemic control affect the plasma concentrations of lipoproteins in patients with Type 2 diabetes mellitus. Methods Fifteen patients, age 59 ± 2 years (mean ± sem), body weight 86.3 ± 3.0 kg, body mass index 29.6 ± 0.9 kg/m2 were treated with sulphonylurea and insulin in combination or with insulin alone in a randomized, double-blind, crossover study. All patients were treated with a multiple daily injection regimen with the addition of glibenclamide 10.5 mg daily or placebo tablets. Results During combination therapy, the dose of insulin was 25% less (P < 0.002) and there was a 29% increase in plasma C-peptide concentration (P = 0.01). Plasma levels of free insulin were not changed. Plasma levels of sex hormone-binding globulin (SHBG) and insulin-like growth factor-binding protein (IGFBP)-1 were lowered. There were no differences in the 24-h blood glucose profiles or HbA1c (6.0 ± 0.2 vs. 6.3 ± 0.2%; P = 0.16). Body weight was similar. There was a significant decrease in plasma LDL cholesterol (3.04 ± 0.24 vs. 3.41 ± 0.21 mmol/l; P = 0.04), apolipoprotein A1 and of lipoprotein(a) but an increase in VLDL-triglycerides (1.36 ± 0.31 vs. 0.96 ± 0.16 mmol/l; P = 0.02) during combination therapy. The ratio between LDL cholesterol and apolipoprotein B concentrations was significantly lower during combination therapy (P < 0.01). Conclusions Combination therapy with insulin and sulphonylureas increases portal insulin supply and thereby alters liver lipoprotein metabolism when compared with insulin therapy alone. [ABSTRACT FROM AUTHOR]

BACKGROUND. Most patients with type II diabetes mellitus receive care by family physicians. The goals of this study were to determine the level of diabetes care provided by family physicians; to assess family physicians' compliance with the Canadian Diabetes Association (CDA) guidelines; and to examine relationships between various aspects of diabetes care and glycemic control. METHODS. A retrospective medical chart review was conducted of 118 patients with type II diabetes mellitus in 10 family practice clinics in Newfoundland. The study population consisted of 55 male and 63 female patients with a mean age of 64 (range 29 to 88) years. Using standardized forms based on the CDA guidelines, information about plasma glucose and lipid levels, presence of diabetes complications, and physician management practices were extracted from patient charts. The main outcome measure was glycosylated hemoglobin (HbA1c) levels. RESULTS. Only 53% patients had HbA1c measurements done in the previous year; these persons had a significantly longer duration of diabetes that those who did not have their HbA1c measured. Eighty-seven percent of patients had optimal or good plasma glucose levels. Compliance with CDA guidelines by physicians was poor; physicians were doing about half the recommended checks and procedures. CONCLUSIONS. Data from the present study seem to suggest that family physicians are doing a good job of providing care for their patients with type II diabetes. The results, however, should be interepreted with caution until further research is done to replicate our findings because of the limitations of this small retrospective study. [ABSTRACT FROM AUTHOR]

This article focuses on a study that was conducted to analyze the effect of second-generation sulfonylurea drugs in non-insulin dependent diabetes mellitus (NIDDM) patients after the onset of secondary failure to first-generation agents. When appropriate diet alone fails to achieve adequate metabolic control in subjects with NIDDM, it is customary to initiate treatment with oral sulfonylurea agents. These drugs have been in use for over 50 years. The study subjects were 55 consecutive patients with NIDDM, 50 men and 5 women, who manifested secondary failure to a first-generation sulfonylurea. Body weight, fasting plasma glucose, glycosylated hemoglobin levels and lipid profiles were not significantly altered following the changeover from first-generation to second-generation drugs in all subjects, irrespective of the specific first and second-generation drugs administered. None of the individual patients in either the glipizide group or the glyburide group showed a clinically significant improvement or achieved adequate metabolic control.

Metformin is a biguanide that can used alone or in combination with sulfonylureas or insulin in the treatment of non-insulin-dependent diabetes mellitus (NIDDM). Since biguanides do not increase pancreatic insulin secretion, they are referred to as antihyperglycemic agents, as opposed to hypoglycemic agents. Biguanides reduce hyperglycemia by increasing insulin sensitivity, decreasing glucose absorption, and inhibiting hepatic gluconeogenesis. Advantages of metformin include achieving glycemic control without exacerbating weight gain or hyperinsulinemia and beneficially affecting serum cholesterol concentrations. Although metformin has the potential to cause lactic acidosis, the incidence is significantly lower compared with phenformin. Risk factors for lactic acidosis include renal serum creatinine >1.5 mg/dL and cardiovascular, pulmonary, and hepatic disease. Metformin should be temporarily discontinued prior to surgery and before administration of radiologic intravenous contrast, and in patients with sepsis, severe gastrointestinal disease, trauma, and acute cardiovascular events. [ABSTRACT FROM AUTHOR]

Twenty-seven obese non-insulin-dependent diabetic patients, treated with dietary carbohydrate restriction and metformin, were recruited from the diabetic outpatient clinic and entered into an open crossover study with gliclazide. Twenty-one patients completed the study. During three months observation on metformin, the mean weight of the group fell by 1.0 kg with 14 patients losing a mean of 1.8 kg, 3 remaining unchanged and 4 gaining a mean weight of 1.1 kg. Over the subsequent three months on gliclazide, the mean weight of the group rose by 1.4 kg with 16 patients gaining a mean of 2.2 kg, two remaining unchanged and 3 losing a mean of 2.0 kg. In addition, 10 patients were heavier after gliclazide than at the time of recruitment (mean 2.6 kg), 3 were unchanged and 8 had lost weight since commencing the trial (mean 2.1 kg), mostly due to greater loss on metformin than gain on gliclazide. Glycaemic control did not improve significantly during the observed period on metformin but lower concentrations of fasting glucose and total glycosylated haemoglobin were achieved with gliclazide. Mean plasma insulin concentration was significantly higher and mean serum lactate was significantly lower during treatment with gliclazide. In conclusion, gliclazide does not support weight loss in obese non-insulin-dependent diabetic patients to the same extent as metformin but the difference between the two drugs is small. Gliclazide is a suitable oral hypoglycaemic agent for use in the obese diabetic who cannot be controlled by diet alone. [ABSTRACT FROM AUTHOR]

The association between weight history and glucose intolerance was examined in a cross-sectional study consisting of 3,128 Swedish men aged 35–56 years, 52 percent of whom had a family background of diabetes mellitus. Oral glucose tolerance testing detected 55 cases of type 2 (non-insulin-dependent) diabetes and 172 cases of impaired glucose tolerance. Among men with no family history of diabetes, the estimated odds ratios for impaired glucose tolerance associated with short (<5 years) and long (≥10 years) durations of obesity (body mass index (weight (kg)/height2 (m2) ≥25.0) were 1.3 (95% confidence interval (CI) 0.2–7.7) and 11.8 (95% CI 3.3–41.9), respectively. Among men with a family history of diabetes, the odds ratios were 2.0 (95% CI 0.8–4.7) and 4.0 (95% CI 1.8–9.1), respectively. Corresponding estimates of the odds of type 2 diabetes, adjusted for family history of diabetes, were 1.9 (95% CI 0.5–7.1) and 7.3 (95% CI 2.2–23.7), respectively. The odds of high (≥30.0 mU/liter) fasting insulin levels in subjects with impaired glucose tolerance were 6.9 (95% CI 0.6–74.2) and 21.0 (95% CI 2.1–206.4) for short and long durations of obesity, respectively. Corresponding estimated odds of low 2-hour insulin response (≥71.9 mU/liter) were 0.7 (95% CI 0.2–2.9) and 3.3 (95% CI 1.2–8.9). Homeostasis model assessment of insulin resistance yielded an odds ratio of 6.7 (95% CI 0.6–73.4) for a short duration of obesity and 20.0 (95% CI 2.0–200.6) for a long duration. Examination of β-cell function with homeostasis model assessment resulted in odds ratios of 0.2 (95% CI 0.0–1.6) and 2.0 (95% CI 0.7–5.4) for short and long durations of obesity, respectively. These data indicate that obesity decreases glucose tolerance by way of progressively increased insulin resistance and, in the case of prolonged duration, by decreased insulin secretion as well. Am J Epidemiol 1998;148:539–45. [ABSTRACT FROM AUTHOR]

Data from a population-based case-control study of Wisconsin women were used to evaluate the relation of diabetes to the risk of endometrial cancer on the basis of body mass index (BMI). Cases (n = 723) were identified from a statewide tumor registry; controls (n = 2,291) were selected randomly from population lists. Diabetes status, weight, height, and other factors were ascertained by telephone interview. Subjects were categorized as not overweight (BMI, <29.1), overweight (BMI, 29.1–31.9), or obese (BMI, >31.9) according to the BMI distribution of middle-aged white women in the Second National Health and Nutrition Examination Survey. Joint associations between diabetes status, BMI, and endometrial cancer were evaluated using unconditional logistic regression models that controlled for age, parity, use of hormone replacement therapy, education, and smoking. Compared with persons without diabetes, those with diabetes had an adjusted odds ratio of 1.86 (95% confidence interval (CI) 1.37–2.52) for endometrial cancer. This association was modified by BMI (p interaction = 0.04). Compared with nonoverweight nondiabetic subjects, nonoverweight and overweight women who reported diabetes had nonsignificant elevated risks of endometrial cancer (nonoverweight, odds ratio (OR) = 1.10, CI 0.66–1.86; overweight, OR = 1.58, CI 0.81–3.05). In contrast, elevated risk estimates were observed for obese diabetic women (OR = 2.95, CI 1.60–5.46). These data contradict earlier reports and suggest that diabetes confers no additional risk of endometrial cancer in women who are neither overweight nor obese. Am J Epidemiol 1998;148:234–40. [ABSTRACT FROM AUTHOR]

This study examines the prevalence of, and risk factors for, diabetic retinopathy in Asian Indian, Chinese, and Creole Mauritians in whom there is an increasing prevalence of non-insulin-dependent diabetes mellitus (NIDDM). As part of a population-based survey on the Indian Ocean Island of Mauritius in 1992, glucose tolerance was classified using a 75-g oral glucose tolerance test on 6,553 persons. Subjects with newly diagnosed (n = 358) or known diabetes (n = 388), and a random sample of one in four subjects with imparied glucose tolerance (n = 165), had stereoscopic 45° retinal photographs taken of three fields in the right eye after mydriasis. Photographs were graded according to a modified version of the Airlie House criteria. The prevalence of nonproliferative and proliferative retinopathy was: 14.5% and 0.3%, respectively, in newly diagnosed diabetic subjects; 42.0% and 2.3%, respectively, in known diabetic subjects; and 9.1% and 0% respectively, in persons with impaired glucose tolerance. Muslim Indians had the lowest prevalence of retinopathy (10.8% and 34.0% for new and known diabetes, respectively), Univariate analysis revealed significant differences between diabetic with and withour retinopathy in mean age, body mass index, fasting and 2-hour plasma glucose levels, systolic and diastolic blood pressure, fasting triglycerides, serum creatinine, and urinary albumin levels. For known diabetes, mean duration of diabetes and the proportion using insulin were also greater in those with retinopathy. Multivariate analysis using logistic regression confirmed that increasing duration of diabetes, fasting plasma glucose, systolic blood pressure, and urinary albumin concentration, and decreasing body mass index, were independently associated with retinopathy. The high prevalence of diabetic retinopathy observed in all major ethnic groups in Mauritius portends a serious public health problem, given the relative recency of the NIDDM epidemic in that country and the limited resources for laser photocoagulation. Strategies to minimize this problem among those already known to have diabetes should include strict control of plasma glucose and blood pressure. Am J Epidemiol 1998; 147:448–57. [ABSTRACT FROM PUBLISHER]

Factor analysis has previously identified four independent factors that characterize the insulin resistance syndrome in women, interpreted as 1) weight/waist, 2) lipids, 3) insulin/glucose, and 4) systolic and diastolic blood pressure. Because it is not known whether similar factors emerge for men, or for diabetics, factor analysis was used to investigate the clustering of features characterizing the insulin resistance syndrome using data from 3,159 elderly (71–93 years) Japanese-American men participating in the fourth examination of the Honolulu Heart Program during 1991–1993. Consistent with previous results, factor analysis reduced eight risk factors (insulin, glucose, systolic blood pressure, diastolic blood pressure, triglycerides, high-density lipoprotein cholesterol, weight, and waist circumference) to four uncorrelated factors that explained 78.2% and 74.7% of the variance in nondiabetics (n = 2,760) and diabetics (n = 399), respectively. These factors were interpreted as 1) weight/waist, 2) blood pressure, 3) lipids, and 4) insulin/glucose. Modest differences in the associations between fasting insulin and factors 1, 3 and 4 were noted for diabetics. These consistently identified composite factors may represent markers for underlying pathophysiologic mechanisms of the insulin resistance syndrome and risk of non-insulin-dependent diabetes mellitus. Am J Epidemiol 1998; 147:441–7. [ABSTRACT FROM PUBLISHER]

This population-based retrospective study investigates temporal trends in adult-onset diabetes melirtus prevalence, incidence, and survival. The complete community-based medical records, including laboratory results, of all Rochester, Minnesota, residents with a clinical diagnosis of diabetes or diabetes-like condition were reviewed to identify incidence cases aged 30 years or more from 1945 to 1989 (n=1,847) and prevalence cases aged 45 years or more on January 1, 1970 (n=465), January 1, 1980 (n=689), or January 1, 1990 (n=973). Glucose values and case definitions were standardized throughout. Observed 10-year survival for 1970 and 1980 prevalence cases was compared with that expected for Minnesota white populations in 1970 and 1980, respectively. Age-adjusted prevalence rose 65% for men and 37% for women between 1970 and 1990. There were marked differences among prevalence groups in treatment type, the proportion diagnosed using glucose tolerance tests, and the proportion categonzed as obese. Relative survival for 1980 prevalence cases was not greater than that for 1970 prevalence cases. Age-adjusted incidence rates rose 47% for men and 26% for women between 1960 and 1965 and 1985 and 1989. These findings emphasize the need for heightened surveillance and intervention to reduce the burden of illness from adult-onset diabetes mellitus in the population. Am J Epidemiol 1997;146:12–22. [ABSTRACT FROM AUTHOR]

Obesity is an established risk factor for non-insulin-dependent diabetes mellitus (NIDDM). Anthropometric measures of overall and central obesity as predictors of NIDDM risk have not been as well studied, especially in women. Among 43,581 women enrolled in the Nurses' Health Study who in 1986 provided waist, hip, and weight information and who were initially free from diabetes and other major chronic diseases, NIDDM incidence was followed from 1986 to 1994. After adjustment for age, family history of diabetes, smoking, exercise, and several dietary factors, the relative risk of NIDDM for the 90th percentile of body mass index (BMI) (weight (kg)/height (m)2) (BMI = 29.9) versus the 10th percentile (BMI = 20.1) was 11.2 (95% confidence interval (CI) 7.9–15.9). Controlling for BMI and other potentially confounding factors, the relative risk for the 90th percentile of waist: hip ratio (WHR) (WHR = 0.86) versus the 10th percentile (WHR = 0.70) was 3 1 (95% CI 2.3–4.1), and the relative risk for the 90th percentile of waist circumference (36.2 inches or 92 cm) versus the 10th percentile (26.2 inches or 67 cm) was 5.1 (95% CI 2.9–8.9). BMI, WHR, and waist circumference are powerful independent predictors of NIDDM in US women. Measurement of BMI and waist circumference (with or without hip circumference) are potentially useful tools for clinicians in counseling patients regarding NIDDM risk and risk reduction. [ABSTRACT FROM AUTHOR]

The effects of smoking on the 8-year (1984–1992) incidence of non-insulin-dependent diabetes mellitus (NIDDM) were investigated in a cohort of 2,312 male employees of an electrical company in Japan. The incidence rate was 2.2/1,000 person-years. After controlling for other known risk factors for NIDDM, a proportional hazards regression analysis indicated that those who were currently smoking 16–25 cigarettes per day had a 3.27 times higher risk of developing NIDDM during the follow-up period than never smokers (p < 0.05); the hazard ratio was similar (3.21) for those who were currently smoking ≥26 cigarettes per day. Among ever smokers, proportional hazards regression analysis also indicated that younger age at starting smoking was associated with an increased risk of NIDDM (p for trend = 0.09). These findings suggest that number of cigarettes smoked per day is important in the relation between smoking and NIDDM incidence, although the risks did not increase above a given amount of smoking. Starting smoking at a younger age also might be independently associated with an increased risk of NIDDM. Am J Epidemiol 1997; 145: 103–9. [ABSTRACT FROM AUTHOR]

The prevalence of diabetes mellitus was assessed in the multiracial population of New Caledonia in the South Pacific with the use of a two-step procedure. The first step included 9,390 subjects aged 30–59 years who were visited at home for screening with glucose strips. All subjects who had a fasting capillary blood glucose value ≥110 mg/dl were invited to come to the health center for a more detailed examination. In non-fasting subjects, a capillary blood glucose value of 140 mg/dl was chosen as the cut-off point for further examination. A 2-hour glucose tolerance test was performed according to World Health Organization (WHO) recommendations on 424 positive screenees as well as in a sample of 517 negative screenees. In all, 219 previously known diabetic subjects were found; among subjects classified as positive at the first step, 277 were detected as new cases of diabetes. After correction to take into account false negative subjects, the age-adjusted prevalence rate of diabetes was estimated to be 8.9% overall; Polynesians (15.3%) were found to be more at risk than Melanesians or Europeans (8.4% in the two other groups). A higher prevalence of diabetes was found in Melanesians who lived in the urban area compared with Melanesians who lived in villages. This finding confirms the deleterious effect of western life in this population subject to rapid modernization. [ABSTRACT FROM AUTHOR]

The association of obesity with mortality was investigated in population-based samples of Micronesian Nauruans (n = 1,400), Melanesian Fijians (n = 1,279), and Indian Fijians (n = 1,182), over 10 years from 1982 in Nauru, and 11 years from 1980 in Fiji. At the end of follow-up, vital status was known for all Nauruans and all but 3.5% of Fijians. Mortality rates were higher in Nauru than Fiji, and in Melanesians than Indians. The mean body mass index of decedents was similar to or less than (Nauruan men, p < 0.001) that of survivors in each sex-ethnic group. Crude mortality rates showed an inverse relation with body mass index in Nauruan men, with inconsistent relations in other sex-ethnic groups. After stratification by diabetes status, there was no relation between mortality and obesity in nondiabetic subjects, but an inverse relation was observed among diabetic subjects in each population. These findings persisted even after the exclusion of subjects who died within the first 2 years of follow-up. After controlling for age, smoking, and diabetes status in Cox proportional hazard models, body mass index (as a continuous variable) was not related to mortality in any sex/ethnic group and tended to be negatively associated with mortality risk. Interactions of body mass index with age, smoking, and diabetes status were not significant. Mortality risk was significantly increased in older subjects and in diabetic subjects, and cigarette smoking also increased risk in some groups. Stratification of analyses according to cigarette smoking did not alter the nature of the results. The association of mortality and body mass index categorized by quartiles was also investigated. After adjusting for age alone, or age, smoking, and diabetes status, the lower quartiles of body mass index were consistently associated with the highest relative risk for mortality. Quadratic terms for body mass index did not improve Cox models in subjects with normal glucose tolerance. Relations with cardiovascular disease mortality were also assessed and results were inconsistent, although positive trends were observed in Nauruan women (p = 0.02) and Melanesian men (p = 0.06). Overall, there was little evidence to suggest that obesity was a risk factor for total or cardiovascular mortality in these populations. However, obesity is clearly associated with a high risk of diabetes and other morbid conditions and at least on this basis it would seem desirable to prevent obesity in these and other Pacific populations. Am J Epidemiol 1996; 143:442–55 [ABSTRACT FROM AUTHOR]

Background: Heredity, obesity and fat distribution may interact with each other in their association with diabetes risk. Therefore we tried to elucidate the role of familial diabetes as effect modifier in the association of obesity, glucose metabolism and lipoproteins with non-insulin-dependent diabetes mellitus.Methods: A cross-sectional study was carried out among 468 elderly men. Within strata of family history, men with diabetes and normal glucose tolerance were compared with respect to anthropometry, characteristics of glucose metabolism and serum lipids.Results: Of the participants, 14.5 percent were diabetic. In diabetic men a family history of diabetes occurred more often (22.1 percent) than in men with normal (6.8 percent, P < 0.001) or impaired glucose tolerance (8.5 percent). In diabetic men with a family history, the ratio of fasting insulin to glucose and the ratio of areas under the insulin and glucose curves during oral glucose tolerance testing were lower compared to men with normal glucose tolerance. In men without a family history, these differences were smaller (interaction P = 0.06). In diabetic men without a family history, fasting insulin levels were markedly elevated (P < 0.001), whereas in men with a family history there was only a slight elevation. The presence of a family history resulted in more severe deteriorations in lipids, especially in fasting triglycerides (interaction P = 0.075). No interaction between indices of obesity and a family history was observed.Conclusions: Our findings suggest that elderly diabetic men with a family history of diabetes represent a different subgroup than elderly men without such a history, characterized by larger deteriorations in indices for beta-cell function and higher triglyceride levels. [ABSTRACT FROM AUTHOR]

Purpose: To summarise current knowledge of interventions that should improve the care of patients with type II diabetes mellitus. Interventions lie within the realms of preventions, screening, and treatment, all of which are focused on office practice.Methods: Review of the literature by a multidisciplinary team involved in the care of patients with diabetes, followed by synthesis of the literature into a clinical care guideline. Literature was identified through consultation with experts and a focused MEDLINE search.Main Results: An algorithm-based guideline for screening and treatment of the complications of diabetes was developed. The emphasis is on prevention of atherosclerotic disease, and prevention, screening, and early treatment of microvascular disease. Implementation of these practices has the potential to significantly improve quality of life and increase life expectancy in patients with type II diabetes mellitus. [ABSTRACT FROM AUTHOR]

There is no information on the mutual occurrence and the development of autonomic and peripheral somatic neuropathies based on long-term follow-up of patients with non-insulin-dependent diabetes mellitus (NIDDM). We investigated the relation between the changes in autonomic function values and electrodiagnostic values, and the relation between the occurrence of autonomic neuropathy and peripheral somatic polyneuropathy in a group of patients with newly diagnosed NIDDM ( n = 133, aged 45–65 years) at baseline and 5 and 10 years later. Parasympathetic autonomic neuropathy was diagnosed on the basis of heart rate variability during deep-breathing and sympathetic autonomic neuropathy on the basis of fall in systolic blood pressure while changing from supine to standing. Polyneuropathy was diagnosed on the basis of both clinical criteria and electrodiagnostic studies (nerve conduction velocity and response-amplitude values). In 10 years 36 patients died, mainly from cardiovascular causes. Altogether 78 patients completed the study. At 10 years, parasympathetic autonomic neuropathy was diagnosed in 61.3 % of those with polyneuropathy and 66.7 % of those without. Likewise, the frequency of sympathetic autonomic neuropathy was similar in those with polyneuropathy (21.9 %) and those without (26.5 %). The respective figures for combined (both parasympathetic and sympathetic) autonomic neuropathy were 10.0 % and 18.8 %. The worsening of parasympathetic and sympathetic autonomic function values was not related to the worsening in electrodiagnostic results with time. In conclusion, the development of autonomic and peripheral somatic neuropathies was divergent in patients with NIDDM suggesting different pathophysiological processes for these neuropathies. [Diabetologia (1997) 40: 953–958] [ABSTRACT FROM AUTHOR]

Recent studies have suggested an association between a deletion (D) variant of the angiotensin-converting-enzyme (ACE) gene and diabetic nephropathy. However, this finding has not been confirmed by all investigators. Furthermore, an M235T variant of the angiotensinogen (AGT) gene has been associated with hypertension, an important risk factor for the development and progression of diabetic nephropathy. The objective of our study was therefore to examine the relationship between these genetic variants of the renin-angiotensin system and diabetic nephropathy and hypertension, respectively, in a large (n = 661) group of Caucasian patients with insulin-dependent (n = 360) or non-insulin-dependent (n = 301) diabetes mellitus. The study had a power of 0.8 to detect a doubling of risk of nephropathy or hypertension in patients with the ACE-DD or AGT-235TT genotype, respectively. Allelic frequencies of the ACE-D and AGT-235T alleles were similar between patients with and without nephropathy in either type of diabetes, and accordingly, there was no significant association between diabetic nephropathy and the ACE or AGT genotype. Likewise, there was no significant association between the ACE or AGT genotype and hypertension. Thus, our data, in this large and ethnically homogeneous group of patients, do not support the hypothesis that these genetic variants of the renin-angiotensin system are strongly associated with either nephropathy or hypertension in patients with insulin-dependent or non-insulin-dependent diabetes mellitus. These genetic markers are therefore unlikely to serve as clinically useful predictors of either nephropathy or hypertension in Caucasian patients with diabetes. [Diabetologia (1997) 40: 193–199] [ABSTRACT FROM AUTHOR]