Time Of Diabetes Diagnosis Research Articles

Early-Adulthood Cardiovascular Disease Risk Factor Profiles Among Individuals With and Without Diabetes in the Framingham Heart Study

OBJECTIVEMany studies of diabetes have examined risk factors at the time of diabetes diagnosis instead of considering the lifetime burden of adverse risk factor levels. We examined the 30-year cardiovascular disease (CVD) risk factor burden that participants have up to the time of diabetes diagnosis.RESEARCH DESIGN AND METHODSAmong participants free of CVD, incident diabetes cases (fasting plasma glucose ≥126 mg/dL or treatment) occurring at examinations 2 through 8 (1979–2008) of the Framingham Heart Study Offspring cohort were age- and sex-matched 1:2 to controls. CVD risk factors (hypertension, high LDL cholesterol, low HDL cholesterol, high triglycerides, obesity) were measured at the time of diabetes diagnosis and at time points 10, 20, and 30 years prior. Conditional logistic regression was used to compare risk factor levels at each time point between diabetes cases and controls.RESULTSWe identified 525 participants with new-onset diabetes who were matched to 1,049 controls (mean age, 60 years; 40% women). Compared with those without diabetes, individuals who eventually developed diabetes had higher levels of hypertension (odds ratio [OR], 2.2; P = 0.003), high LDL (OR, 1.5; P = 0.04), low HDL (OR, 2.1; P = 0.0001), high triglycerides (OR, 1.7; P = 0.04), and obesity (OR, 3.3; P < 0.0001) at time points 30 years before diabetes diagnosis. After further adjustment for BMI, the ORs for hypertension (OR, 1.9; P = 0.02) and low HDL (OR, 1.7; P = 0.01) remained statistically significant.CONCLUSIONSCVD risk factors are increased up to 30 years before diagnosis of diabetes. These findings highlight the importance of a life course approach to CVD risk factor identification among individuals at risk for diabetes.

Prevalence and incidence density rates of chronic comorbidity in type 2 diabetes patients: an exploratory cohort study

BackgroundEvidence-based diabetes guidelines generally neglect comorbidity, which may interfere with diabetes management. The prevalence of comorbidity described in patients with type 2 diabetes (T2D) shows a wide range depending on the population selected and the comorbid diseases studied. This exploratory study aimed to establish comorbidity rates in an unselected primary-care population of patients with T2D.MethodsThis was a cohort study of 714 adult patients with newly diagnosed T2D within the study period (1985-2007) in a practice-based research network in the Netherlands. The main outcome measures were prevalence and incidence density rates of chronic comorbid diseases and disease clusters. All chronic disease episodes registered in the practice-based research network were considered as comorbidities. We categorised comorbidity into 'concordant' (that is, shared aetiology, risk factors, and management plans with diabetes) and 'discordant' comorbidity. Prevalence and incidence density were assessed for both categories of comorbidity.ResultsThe mean observation period was 17.3 years. At the time of diabetes diagnosis, 84.6% of the patients had one or more chronic comorbid disease of 'any type', 70.6% had one or more discordant comorbid disease, and 48.6% and 27.2% had three or more chronic comorbid diseases of 'any type' or of 'discordant only', respectively. A quarter of those without any comorbid disease at the time of their diabetes diagnosis developed at least one comorbid disease in the first year afterwards. Cardiovascular diseases (considered concordant comorbidity) were the most common, but there were also high rates of musculoskeletal and mental disease. Discordant comorbid diseases outnumbered concordant diseases.ConclusionsWe found high prevalence and incidence density rates for both concordant and discordant comorbidity. The latter may interfere with diabetes management, thus future research and clinical practice should take discordant comorbidity in patients with T2D into account.

Coeliac disease and type 1 diabetes mellitus: epidemiology, clinical implications and effects of gluten-free diet

Coeliac disease (CD) is a gluten sensitive chronic enteropathy that affects between 1:100 and 1:300 individuals in the general population of the western world [1]. It is characterised by an increased mortality [2]. Autoimmune disorders such as autoimmune thyroiditis, type 1 diabetes (T1DM), Addison’s disease, autoimmune liver disease, and Sjogren’s syndrome occur much more frequently in patients with CD than in the general population. The clinical relevance of autoimmunity in coeliac disease is threefold: first, it further deteriorates the clinical course of coeliac disease; second, patients might present only with symptoms of secondary autoimmunity and this could favour the diagnosis of minor coeliac disease; and third, gluten withdrawal could improve the control of some associated autoimmune disorders [3]. The associations between CD and T1DM was recognized over 30 years ago, particularly by paediatricians. The prevalence of CD among adults and children with T1DM varies in different geographical populations and is observed to range between 1 and 11 % [4–7]. This close association has been ascribed to the same HLA pattern, namely HLA-DQ2 and/or DQ8, which predisposes individuals to both disorders. Recently, Greco et al. performed a study in the western part of Sicily where they saw that the prevalence of CD among patients with T1DM is 4.5 %. They studied 492 subjects (children and adult patients) with T1DM who had been followed-up regularly at their diabetes unit over a fiveyear period. They found CD in 22 patients [8]. In addition, in accordance with previous studies, they confirmed that CD is more prevalent in female subjects with T1DM than in males [5] and that the age of onset of T1DM is younger in patients with double the disease than in those with diabetes only [6]. None of Greco’s patients presented gastrointestinal symptoms, only two patients presented extraintestinal symptoms (short stature, anaemia and hyposideraemia) and one female patient developed concurrent herpetiformis dermatitis. In fact, one quarter of CD patients with T1DM are totally asymptomatic but the remainder show gastrointestinal symptoms (such as diarrhoea, anorexia, constipation, vomiting, abdominal distension, pain and malnutrition) or extraintestinal symptoms. The most frequent clues in extraintestinal signs are short stature and iron-deficiency anaemia which are present in approximately 50 % of cases; however, fatigue, pubertal delay and vitamin deficiencies are also common, especially in children. Other systemic signs suggesting CD in T1DM patients are a reduced BMI, diminished mass bone, bleeding due to vitamin K deficiency and raised levels of transaminases [9]. CD symptoms (both gastrointestinal and extraintestinal) seem to be much more frequent in children than in adolescents and adults [10]. In the majority of cases (more than 90 %), the diagnosis of T1DM precedes that of CD and Greco et al. confirmed this finding. However, some studies reported that T1DM onset can frequently occur in patients already diagnosed with CD [5]. These data suggest the importance of screening for CD for patients with T1DM at the time of diabetes diagnosis and then annually for several years after diagnosis. In particular, antibody positivity for CD may appear within 6 years from the initial diagnosis of T1DM [4]. Serologial screening for CD consists of endomysial antibodies, antibodies against tissue transglutaminase and deamidated gliadin peptide antibodies. When these antibodies are positive, small intestinal biopsy is mandatory. CD histology is characterized by different degrees of villous A. Marchese E. Lovati F. Biagi (&) G. R. Corazza First Department of Internal Medicine, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Piazzale Golgi, 19, 27010 Pavia, PV, Italy e-mail: f.biagi@smatteo.pv.it

Transaminase levels in the upper normal range are associated with oral hypoglycemic drug therapy failure in patients with type 2 diabetes

Incident diabetes and the worsening of diabetes have recently been linked to hepatic steatosis. Aim of our study was to determine whether oral hypoglycemic agent failure is associated with higher transaminase levels (valid measure of liver steatosis). We selected 200 patients, attenders (3 consecutive annual evaluations) in our clinic, with type 2 diabetes among which 100 with oral hypoglycemic agents failure and 100 who were still responsive to oral therapy. Failure to therapy was defined as glycated hemoglobin >7.5% despite maximal-dose oral therapy. We analyzed patient histories and laboratory data. Compared with oral-therapy-responsive patients, those with failure had a significantly higher level mostly of alanine aminotransferase at the time of therapy failure and 2 years before. They were more likely to have had symptoms of hyperglycemia at the time of diabetes diagnosis. Regression analysis indicated that each 5-unit increase in transaminase levels independently increased the risk for oral hypoglycemic agents failure by 1.70. Higher liver transaminase levels, especially in patients who had symptomatic hyperglycemia at diabetes diagnosis, associate with oral hypoglycemic agent failure. The possible pathogenetic link between transaminase and declining islet function might consist of insulin resistance and increased circulating fatty acid levels, in turn causing liver steatosis and beta-cell dysfunction.

Poor prognosis of pregnancy in women with autoimmune type 1 diabetes mellitus masquerading as gestational diabetes

Aim To describe the clinical presentation and the prognosis of autoimmune type 1 diabetes (T1D) that was first revealed during pregnancy masquerading as gestational diabetes mellitus (GDM). Methods We reviewed the files of 21 women in whom diabetes was revealed during a pregnancy (“index pregnancy”) and progressed to T1D after delivery, and in whom GAD and/or IA-2 autoantibodies were found. Results The median age and BMI of the women were 31 years and 19.8 kg/m 2. Eleven women had at least one risk factor for GDM. Eight of the 12 multiparous women had had an abnormal outcome of previous pregnancy, including GDM in five. GDM was diagnosed at week 26 (range: 4–38) of gestation by screening in 18, because of macrosomia in two and during hyperglycaemic crises in three. All were treated with insulin, from the time of diabetes diagnosis in 10 and after 4 weeks (range: 2–15) in 11. Term of delivery was 38 (range: 26–41) weeks. Abnormal outcomes occured in 14 pregnancies, including two fetal deaths, four preterm deliveries and eight macrosomic infants. No congenital malformations were reported. After delivery, insulin therapy was stopped in 18 women for 6 months (range: 2–48). The diagnosis of the autoimmune origin of diabetes was established during the index pregnancy in only eight cases. Conclusion T1D may reveal as GDM in women with or without risk factors for GDM and is associated with a poor prognosis, partly because the correct diagnosis and treatment are delayed. Whether screening for autoimmune markers of T1D should be performed more systematically in women with GDM deserves to be studied.

Therapeutic alliance and glycaemic control in type 1 diabetes: A pilot study

Aim Effective diabetes care requires integrating physicians’ clinical expertise with patients’ concerns and resources. This prospective study examined whether or not two measures of therapeutic alliance could predict glycaemic control after 1 year of follow-up in patients with type 1 diabetes. Methods Consecutive type 1 diabetic outpatients were recruited, and their age, gender, level of education, marital status and age at the time of diabetes diagnosis were self-reported. The presence of diabetes complications was ascertained by the patients’ physicians. Both patients and physicians completed the revised Helping Alliance Questionnaire (HAQ-R) and the 12-item Working Alliance Inventory (WAI-12) to assess therapeutic alliance. Patients also completed the Center for Epidemiological Studies Depression scale to assess depressive mood. HbA 1c was measured at baseline and 1 year later. Results Sixty-four type 1 diabetic outpatients (32 men, 32 women; mean age ± standard deviation [S.D.]: 38.2 ± 8.0 years) were included. HbA 1c level at follow-up (mean ± S.D.: 7.56 ± 1.18%) was positively correlated with the HbA 1c level at baseline ( r = 0.698, P < 0.001), and associated with presence of retinopathy at baseline (8.18 ± 1.24% versus 7.41 ± 1.13%, P = 0.036). In addition, the HbA 1c level at follow-up was negatively correlated with therapeutic alliance, as assessed at baseline by the physicians using either the HAQ-R ( r = -0.431, P < 0.001) or the WAI-12 ( r = -0.365, P = 0.003), even after controlling for the HbA 1c at baseline. Conclusion Although the observational nature of the present study prevents causal conclusions to be drawn, these preliminary results suggest that promoting therapeutic alliance can improve glycaemic control in type 1 diabetes.

Predictors of mortality of patients newly diagnosed with clinical type 2 diabetes: a 5-year follow up study

BackgroundAt diabetes diagnosis major decisions about life-style changes and treatments are made based on characteristics measured shortly after diagnosis. The predictive value for mortality of these early characteristics is widely unknown. We examined the predictive value of patient characteristics measured shortly after diabetes diagnosis for 5-year all-cause and cardiovascular mortality with special reference to self-rated general health.MethodsData were from a population-based sample of 1,323 persons newly diagnosed with clinical diabetes and aged 40 years or over. Possible predictors of mortality were investigated in Cox regression models.ResultsMultivariately patients who rated their health less than excellent experienced increased all-cause and cardiovascular mortality. These end-points also increased with sedentary life-style, relatively young age at diagnosis and presence of cardiovascular disease (CVD) at diagnosis. Further predictors of all-cause mortality were male sex, low body mass index and cancer, while cardiovascular mortality increased with urinary albumin concentration.ConclusionsWe found that patients who rated their health as less than excellent had increased 5-year mortality, similar to that of patients with prevalent CVD, even when biochemical, clinical and life-style variables were controlled for. This finding could motivate doctors to discuss perceptions of health with newly diagnosed diabetic patients and be attentive to patients with suboptimal health ratings. Our findings also confirm that life-style changes and optimizing treatment are particularly relevant for relatively young and inactive patients and those who already have CVD or (micro)albuminuria at the time of diabetes diagnosis.

Glycaemic variability using continuous glucose monitoring and endothelial function in the metabolic syndrome and in Type 2 diabetes

Subjects who are at increased risk of developing diabetes may have increased glycaemic variability associated with endothelial dysfunction and possibly subclinical atherosclerosis, which may lead to increased cardiovascular risk observed at the time of diabetes diagnosis. To investigate this hypothesis, we measured endothelial function, carotid intima-media thickness and glycaemic variability using 48-h continuous subcutaneous glucose monitoring in 3 groups of overweight or obese subjects--those without the metabolic syndrome, and those with the metabolic syndrome with or without newly diagnosed Type 2 diabetes. Consecutive subjects, aged 30-65 years with a body mass index >or= 25 kg/m(2) were recruited. Patients were classified as with or without the metabolic syndrome,or as metabolic syndrome with newly diagnosed Type 2 DM. Glycaemic variability was calculated in terms of the coefficient of variation. Endothelial function was measured using brachial artery flow-mediated dilation. We identified 75 subjects. Mean flow mediated dilation decreased (P < 0.001) and carotid intima-media thickness increased (P < 0.05) across groups. Flow mediated dilation predictors included mean 48-h continuous subcutaneous glucose monitoring values (beta = -0.022; P < 0.005) and the coefficient of variation (beta = -0.10; P = 0.01). Carotid intima-media thickness predictors included age (beta = 0.009; P < 0.001) and flow mediated dilation (beta = -0.014; P = 0.076). Patients re-stratified according to cut-offs for mean 48-h glycaemia and variability demonstrated that subjects with high mean glycaemia but low coefficient of variability had similar flow mediated dilation and carotid intima-media thickness to subjects with low mean glycaemia but high coefficient of variation. This study suggests that glycaemic variability influences endothelial function even in non-diabetic subjects. Such variability may explain the increased cardiovascular risk observed in patients prior to developing overt Type 2 diabetes.

Early Risk Factors for Nonadherence in Pediatric Type 1 Diabetes: A Review of the Recent Literature

Nonadherence to different aspects of the diabetes regimen is common. Problems early in the course of illness predict later difficulties with nonadherence; conversely, good management early on protects against later complications. Screening for early risk factors at the time of diabetes diagnosis is therefore critical for promoting the health of children with type 1 diabetes. The purpose of this paper is to review and synthesize the recent empirical literature on early risk factors for nonadherence in type 1 diabetes, with a focus on three specific adherence behaviors: insulin administration, blood glucose monitoring, and clinic attendance. Risk factors are considered within several broad categories: sociodemographic barriers that limit access to care; child and parent factors that affect adherence both directly and indirectly via their impact on the development of family teamwork; and family interactions with their health-care providers. We integrate the different findings into a "simple model" that can be used to develop efficient screening protocols that can in turn guide efforts at preventive intervention.

Management of cystic fibrosis-related diabetes in children and adolescents

TheDepartment of Pediatrics, University of Minnesota Children’sHospital, Minneapolis, USACorresponding author:Dr. Stephen MP O’Riordan MRCPI, MDThe Developmental Endocrinology and Research GroupThe Department of Clinical and Molecular GeneticsThe Institute of Child Health, University College London30 Guliford StreetLondon WC1N 1EH.Tel: +44-020-7242-9789, ext. 0732;fax: +44-020-7404-6191;e-mail: s.oriordan@ich.ucl.ac.ukAcknowledgments:PeterHindmarsh,MehulDattani,HilaryHoeyand Nicola Bridges.Conflicts of interest: The authors have declared no conflictsof interest.Editors of the ISPAD Clinical Practice Consensus Guide-lines 2009 Compendium: Ragnar Hanas, Kim Donaghue,Georgeanna Klingensmith, and Peter Swift.This article is a chapter in the

Early microvascular complications of prediabetes in mice with impaired glucose tolerance and dyslipidemia

Microvascular complications are an important cause of morbidity in diabetic patients and can be detected in a significant number of patients at the time of diabetes diagnosis. However, little is known about the alterations in the microvasculature previous to the clinical manifestation of diabetes mellitus type 2. To obtain more insights into the early microvascular deterioration resulting from prediabetes, morphological and functional microvascular parameters were monitored using intravital fluorescence microscopy through a dorsal skin-fold chamber preparation in the uncoupling promotor-driven diphtheria toxin A chain (UCP1/DTA) mice. At the age of 12 weeks, the UCP1/DTA-mice were characterized by impaired glucose tolerance with concurrent unchanged fasting glucose, as well as dyslipidemia, hyperinsulinemia, hypertension and obesity. Prediabetic mice displayed combined hypertriglyceridemia and hypercholesterinemia. Associated with these prediabetic metabolic alterations, we demonstrate that microvascular density showed a dramatic decrease due to a reduction in perfused small vessels. A reduction in vascular density combined with unaltered blood flow in single vessels resulted in impaired tissue perfusion. Endothelial dysfunction with subsequently increased microvascular permeability and leukocyte-endothelium interactions were found. Our results of profound microvascular alterations at stages of normal fasting glucose underline the importance of early screening for prediabetes and associated microvascular complications.

Diabetes and Obesity

Diabetes and Obesity

Decreased NO signaling leads to enhanced vasoconstrictor responsiveness in skeletal muscle arterioles of the ZDF rat prior to overt diabetes and hypertension.

Approximately 40% of patients with type 2 diabetes present with concurrent hypertension at the time of diabetes diagnosis. Increases in peripheral vascular resistance and correspondingly enhanced vasoconstrictor capacity could have profound implications for the development of hypertension and the progression of insulin resistance to overt diabetes. The purpose of this study was to determine whether skeletal muscle arteriolar vasoconstrictor dysfunction precedes or occurs concurrently with the onset of diabetes and hypertension. Male Zucker diabetic fatty (ZDF) rats were studied at 7, 13, and 20 wk of age to represent prediabetic and short-term and long-term diabetic states, respectively. Conscious mean arterial pressure (MAP), fasted plasma insulin and glucose, vasoconstrictor responses, and passive mechanical properties of isolated skeletal muscle arterioles were measured in prediabetic, diabetic, and age-matched control rats. Elevated MAP was manifest in short-term diabetes (control 117 +/- 1, diabetic 135 +/- 3 mmHg) and persisted with long-term diabetes (control 113 +/- 2, diabetic 135 +/- 3 mmHg). This higher MAP was preceded by augmented arteriolar vasoconstrictor responses to norepinephrine and endothelin-1 and followed by diminished beta-adrenergic vasodilation and enhanced myogenic constriction in long-term diabetes. Furthermore, we demonstrate that diminished nitric oxide (NO) signaling underlies the increases in vasoconstrictor responsiveness in arterioles from prediabetic and diabetic rats. Arteriolar stiffness was not different between control and prediabetic or diabetic rats at any time point studied. Collectively, these results indicate that increases in vasoconstrictor responsiveness resulting from diminished NO signaling in skeletal muscle arterioles precede the development of diabetes and hypertension in ZDF rats.

Cataract associated with type-1 diabetes mellitus in the pediatric population

To report 14 cases (28 eyes) of cataract associated with type-1 diabetes mellitus in young children and adolescents. Retrospective review of the medical records of 14 patients from seven institutions. All patients under the age of 18 years who met the inclusion criteria of type-1 diabetes mellitus and cataract were included. Mean age at the time of diabetes diagnosis was 9.8 years (range, 0.5-14 years), and mean age at cataract diagnosis was 11.7 years (range, 5-16 years). Two patients presented with cataracts one month before the diagnosis of diabetes; seven after the diagnosis of diabetes; and in five patients the cataract was found at the time the diabetes was diagnosed by the pediatrician. Nineteen out of 23 operated eyes had a best corrected post operative visual acuity of 20/40 or better. Two patients (4 eyes) developed diabetic retinopathy postoperatively. Although cataract formation in type-1 diabetes is rare, it is treatable and potentially sight-saving in young children and adolescents.

Disability and Quality of Life in Canadian Aboriginal and Non-Aboriginal Diabetic Lower-Extremity Amputees

Meatherall BL, Garrett MR, Kaufert J, Martin BD, Fricke MW, Arneja AS, Duerksen F, Koulack J, Fong HM, Simonsen JN, Nicolle LE, Trepman E, Embil JM. Disability and quality of life in Canadian Aboriginal and non-Aboriginal diabetic lower-extremity amputees. Objective To compare and contrast disability and quality of life (QOL) in Aboriginal and non-Aboriginal subjects with diabetes who had lower-extremity amputation (LEA) and were living in urban and rural communities in Canada. Design Descriptive study using an interviewer-administered questionnaire and hospital medical record review. Setting Tertiary care center. Participants Forty-four diabetic subjects (minimum age, 18y) not receiving dialysis, including 21 Aboriginal (8 urban, 13 rural) and 23 non-Aboriginal (16 urban, 7 rural) subjects. Subjects were living in their current residence and had undergone LEA above the level of the ankle 6 months or more before interview. Interventions Not applicable. Main Outcome Measures Qualitative and quantitative data about symptoms, impairment, and QOL. Results Aboriginal subjects were younger than non-Aboriginal subjects at the time of diabetes diagnosis (Aboriginal, 42±10y; non-Aboriginal, 52±14y; P<.005) and first major LEA (Aboriginal, 57±7y; non-Aboriginal, 64±11y; P<.015). All subjects received rehabilitation after amputation. More rural non-Aboriginal subjects (83%) used their prosthesis both in and outside the home for all movements than other subjects ( P<.048). Rural non-Aboriginal subjects had the lowest and urban non-Aboriginal subjects had the highest frequency of walking-aid use outside the home. Assistance with personal care was required by a minority of subjects, but assistance with daily housework was required by the majority of subjects. Qualitative analysis revealed that participants were, in most cases, comfortable with their postamputation life. Conclusions Although the majority of participants in this study generally felt satisfied with their current status, major functional changes were noted after LEA that had a large negative impact on QOL.

Immune responses to glutamic acid decarboxylase and insulin in patients with gestational diabetes.

Pregnancy is a natural state of immunoprotection and tolerance. We studied subjects with gestational diabetes (GDM) to evaluate the influence of pregnancy on the humoral immune response to the autoantigen GAD and to injected insulin. Antibodies against glutamic acid decarboxylase (GADA) subclasses and epitope reactivity were determined in 34 GADA-positive pregnant patients with GDM, in 20 GADA-positive relatives of people with TID and in 25 GADA-positive patients with newly diagnosed TID. Partum levels of insulin antibodies (IA), IgG1- and IgG4-IA were measured in 131 women with GDM treated with human insulin from the time of diabetes diagnosis (including 22 with GADA) and were compared to 19 patients with TID after 3 months of insulin treatment. GADA titre and subclasses were similar among all groups. GADA in GDM patients bound fewer epitopes than GADA in relatives of patients with TID (all epitopes being present in 23%versus 65%, P < 0.01). In particular, antibodies to the minor GADA epitopes GAD6596-249, GAD651-100 and GAD67 were less frequent in patients with GDM compared to relatives (P < 0.01). Antibodies to insulin (IA) were found in 17% of patients with GDM. They were more frequent in GDM patients with GADA compared to GADA-negative patients (41%versus 12%, P < 0.005). IgG1 was the dominant insulin antibody subclass response in both patients with GDM and TID but levels of IgG1-IA and IgG4-IA were significantly lower in patients with GDM compared to patients with TID (P < 0.004). Antibody responses in women with gestational diabetes appear to be dampened and restricted, but without change in subclass usage.

Type 1 diabetes mellitus.

1. Francine Ratner Kaufman, MD* 1. *Professor of Pediatrics, The Keck School of Medicine of University of Southern California; Head, Center for Diabetes, Endocrinology and Metabolism, Children’s Hospital of Los Angeles, Los Angeles, CA After completing this article, readers should be able to: 1. Describe the pathogenesis of type 1 diabetes. 2. Review intensive diabetes management protocols, new insulin preparations, and insulin delivery systems. 3. Describe the importance of home glucose and ketone monitoring and the new monitoring methodologies. 4. Elucidate the key elements of the outpatient diabetes examination and screening for diabetes complications. 5. Characterize the importance of the multidisciplinary team in the management and education of children who have type 1 diabetes and their families. Many advances have been made since the Diabetes Control and Complications Trial (DCCT) provided irrefutable evidence of the benefits of following a system of diabetes management that allows for optimal glycemia for patients who have type 1 diabetes. These advances include an ever-increasing armamentarium of types of insulin that have varying onsets and durations of action, insulin delivery systems, improved methods for monitoring glycemia at home, and potential agents that could be used for diabetes prevention or to preserve residual beta-cell function at the time of diagnosis. These exciting advances have enabled the development of comprehensive, intensive diabetes regimens. To increase the success rate for patients and families with these regimens, it is imperative for the multidisciplinary diabetes team and the primary care clinician to work together to support and educate all those who help manage or affect patients. The pathogenesis of diabetes is reviewed in this article, emphasizing the nearness of expanding efforts at primary prevention and beta-cell preservation at the time of diabetes diagnosis. This is followed by an explanation of current and evolving diabetes management protocols, focusing on insulin regimens and delivery systems that can be used for children to improve glycemic control while minimizing hypoglycemia. Finally, the components of the outpatient visit are reviewed to elucidate methods of screening for diabetes complications to allow early intervention that provides …

Heterogeneity in associations between macronutrient intake and lipoprotein profile in individuals with type 2 diabetes.

To evaluate associations between macronutrient intake and lipoprotein profile among individuals with type 2 diabetes who participated in the San Luis Valley Diabetes Study (SLVDS) or the Insulin Resistance Atherosclerosis Study (IRAS). Diet was assessed by 24-h recall in the SLVDS (n = 421) and by validated food frequency interview in the IRAS (n = 437). Analyses adjusted for kilocalories, age, sex, and other covariates were conducted separately for the two study groups. For the SLVDS, repeated observations were included in mixed model analyses (865 observations). For the IRAS, standard regression analyses were conducted. Recent weight history and time of diabetes diagnosis were evaluated as possible modifiers of associations between nutrient intake and lipoprotein profile. Higher reported intake of total dietary fat was related to significantly higher levels of LDL cholesterol (P < 0.05) in both studies and in all subgroups. Reported intake of total and saturated fat was associated positively with total cholesterol, although statistical significance was not reached for all subgroups. Higher reported carbohydrate intake was associated with increased triglyceride concentrations (P < 0.01) only among individuals with previously undiagnosed diabetes in the SLVDS (n = 69) and only among individuals who gained weight (> 5 lb, n = 87) during the previous year in the IRAS. Toward the goal of optimizing the lipoprotein profile of individuals with diabetes, these results emphasize the potential importance of reducing fat intake while recognizing that individualized approaches to diet are important to minimize the risk of cardiovascular disease.

A retrospective-cohort study on the development of cataracts in dogs with diabetes mellitus: 200 cases.

The objective of the study was to determine the incidence and estimated median time to cataract formation in dogs with diabetes mellitus. The animals studied were 200 dogs with diabetes mellitus which were referred to a university teaching hospital between 1985 and 1995. Medical records from dogs with a diagnosis of diabetes mellitus were reviewed and, where necessary, further follow-up information was gathered from the referring veterinarian. Incidence rate and median time to diabetic cataract formation was calculated using survival-analysis techniques in a retrospective cohort study design. Among the 200 dogs in the study population, 23 had cataracts at the time of diabetes diagnosis that were presumed to be related to other disease processes. Of the remaining 177 dogs, 132 had documented cataract development with features suggestive as being secondary to diabetes. Twenty-three dogs did not have obvious cataracts at the time of their last examination while 22 dogs did not have cataracts at the time they were lost to follow-up. These 55 cases contributed to the statistical models as noncases of cataracts until the last date for which an examination was available. Half of the population had developed cataracts by the 170th day postdiagnosis of diabetes mellitus, while 75% and 80% of the population developed cataracts by 370 days and 470 days, respectively. The results of this study suggest that the majority of dogs with diabetes will develop cataracts within 5-6 months from the time of diagnosis of the disease, and that approximately 80% of dogs will develop cataracts within 16 months of diagnosis.

Metabolic control in children with insulin‐dependent diabetes mellitus 5y after diagnosis. Early detection of patients at risk for poor metabolic control

Children (n= 38) aged 3‐15 y were randomly chosen, at the time of diabetes diagnosis, for conventional management at a hospital ward, or for treatment partly in a training apartment where the family was offered problem‐based education and special therapeutic support. HbA1c, blood glucose stability, urinary C‐peptide excretions and incidence of hypoglycaemic attacks and diabetes ketoacidosis (DKA) were monitored and some standardized, self‐estimated psychological tests were performed during the first 2 y after diagnosis. During the 3 y thereafter, HbA1c, presence of DKA, microalbuminuria, retinopathy and hypertension were monitored. None of the patients demonstrated signs of diabetes microangiopathy or DKA. The overall mean HbA1c level was 7.2% 5 y after diagnosis and 30% of the children had HbA1c values &lt; 6.3%. There were no differences in the HbA1c values for the patients treated by the different management regimens. Blood glucose variability (SD) was also similar, with 75% of the values in the range of 3–10 mmol/l. Patients with poor glycaemic control (mean HbA1c &gt;8.3%) year 5 after diagnosis had already the second year after diagnosis significantly higher HbA1c values and blood glucose variability. The fathers of these patients demonstrated a higher degree of maladjustment. On the basis of increasing HbA1c values, high blood glucose variability and psychosocial risk factors such as their fathers’emotional responses, patients at risk for poor metabolic control in the future can be identified within 2 y after diagnosis. Efforts and resources can thus be focused at an early stage on this group.