This document summarizes the findings of a prospective study that observed 4,400 diabetes patients between 1947 and 1973. The study found that the two main factors determining the risk of degenerative complications are the duration and intensity of a patient's diabetes. Treatment that reduces blood glucose levels can significantly diminish the risk of specific microvascular and nerve complications, though it has less impact on accelerated atherosclerosis. While the exact causes of diabetes complications are still uncertain, clinical and experimental evidence refutes objections that the complications are due solely to the underlying disease rather than prolonged hyperglycemia. Duration of hyperglycemia strongly correlates with prevalence and incidence of complications.
This document discusses a protocol for a systematic review that aims to synthesize evidence on the relative risk of mortality in type 2 diabetes mellitus (T2DM). It provides background on the prevalence of T2DM and discusses inconsistencies in reported mortality rates. The systematic review will explore all-cause mortality risk in T2DM expressed as hazard ratios, and examine subgroups based on age, gender, socioeconomic factors and causes of death. The review expects to pool data from large cohort studies to accurately summarize the actual mortality risk in T2DM with limited bias and help direct future research.
Diabetes-related Clinical Complications: Novel Approaches for Diagnosis and M...asclepiuspdfs
Metabolic diseases such as hypertension, obesity, diabetes, and vascular diseases have reached epidemic proportions worldwide. In the past four decades, childhood and adolescent obesity has increased four-fold worldwide. During the same period, obesity in adults has doubled and diabetes has increased by four-fold. In China, India, and the USA, the number of prediabetes is more than diabetics. This population is at considerable risk for developing diabetes, its clinical complications, and acute vascular events. The management of modifiable risks for cardiometabolic risks has improved considerably. Several major studies have demonstrated, that robust management of modifiable risks for cardiovascular diseases (CVDs), significantly reduces premature mortality from CVDs. Considering the progress made in the risk assessment, risk management, we feel strongly, that not much progress is made in the areas of primary prevention and early risk assessment, for clinical complications associated with metabolic diseases, in particular, diabetes. The majority of the clinical complications associated with diabetes are due to dysfunction of the vascular system or nervous system. Complications include vasculopathy leading to subclinical atherosclerosis, heart attacks, and stroke.
Objective: Diabetic nephropathy is one of the most serious complications of diabetes mellitus. It develops in approximately one-third of diabetic patients, years after the onset of metabolic abnormalities.
Study Design: The biopsy specimens were evaluated with the focus on light microscopy. The aim of our study was to reveal differences in the details and the frequency of occurrence of individual histomorphological changes in diabetic nephropathy and other glomerulonephritides.
Results: Diabetic nephropathy accounted for 14 out of 82 analyzed biopsies. Isolated thickening of the glomerular basement membrane was not present in any case, but along with some degree of mesangial expansion, hypercellularity or glomerulosclerosis was seen in 12 out of 14 findings of diabetic nephropathy. In other glomerular diseases, mesangial changes, but without glomerular basement membrane thickening, were the most frequent findings. In addition to glomerular lesions, some of the tubular, interstitial, and vascular changes were seen in 13 out of 14 patients with diabetic nephropathy. In other glomerulonephritides the combination of all these changes was a rare finding.
Conclusion: There are cases where immunofluorescence and electron microscopy cannot be performed or their results are not helpful. In such cases we must rely on light microscopic histomorphological changes.
Dermatoglyphics in diabetes mellitus of type 2CA. Sanjay Ruia
The document discusses a study analyzing dermatoglyphic patterns on the palms of 190 Romanian patients with type 2 diabetes mellitus (T2DM). The results found significant pathological dermatoglyphic distortions and anomalies in the patients compared to a control group. Specifically, over 55% of patients showed a partial suppression of line C, which was more common in women at around 38%. This and other dermatoglyphic markers could help identify individuals at risk for T2DM.
Dermatoglyphics in diabetes mellitus of type 2CA. Sanjay Ruia
The document discusses a study analyzing dermatoglyphic patterns on the palms of 190 Romanian patients with type 2 diabetes mellitus (T2DM). The results found significant pathological dermatoglyphic distortions and anomalies in the T2DM patients compared to controls. Specifically, over 55% of patients had a partial suppression of line C, which was more common in women at 38% compared to 33% in men. While individual dermatoglyphic distortions may serve as markers for early T2DM diagnosis, two differences in overall palm patterns allow differentiation of T2DM from type 1 diabetes mellitus.
There has been an increase in the predominance of diabetes mellitus over the past 40 years worldwide. The worldwide occurrence of diabetes in 2000 was approximately 2.8% and is estimated to grow to 4.4% by 2030. This data interprets a projected rise of diabetes from 171 million in 2000 to well over 350 million in 2030. The presence of hypertension in diabetic patients substantially increases the risks of coronary heart disease, stroke, nephropathy and retinopathy. Indeed, when hypertension coexists with diabetes, the risk of CVD is increased by 75%, which further contributes to the overall morbidity and mortality of an already high risk population. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients. Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes. Lifestyle Modifications and pharmacotherapy are the choice for the Management of Hypertension in Patients with Diabetes.
This document reviews hand manifestations that are commonly seen in patients with diabetes mellitus. It discusses four main conditions - limited joint mobility, Dupuytren's contracture, carpal tunnel syndrome, and trigger finger. For each condition, it describes the typical clinical findings and examines the relationship to diabetic disease, noting that the prevalence of each condition increases with age, duration of diabetes, and presence of other diabetic complications like retinopathy. While the exact causes are unknown, these hand conditions are thought to be related to the disease process of diabetes.
Chronic kidney disease (CKD) is a global public health problem
worldwide. The worldwide prevalence of CKD has increased in
various countries such as the U.S. (13.1%), Taiwan (9.8-11.9%),
Norway (10.2%), Japan (12.9-15.1%) China (3.2-11.3%), Korea (7.2- 13.7%), Thailand (8.45-16.3%), Singapore (3.2-18.6%), and Australia(11.2%)
This document discusses a protocol for a systematic review that aims to synthesize evidence on the relative risk of mortality in type 2 diabetes mellitus (T2DM). It provides background on the prevalence of T2DM and discusses inconsistencies in reported mortality rates. The systematic review will explore all-cause mortality risk in T2DM expressed as hazard ratios, and examine subgroups based on age, gender, socioeconomic factors and causes of death. The review expects to pool data from large cohort studies to accurately summarize the actual mortality risk in T2DM with limited bias and help direct future research.
Diabetes-related Clinical Complications: Novel Approaches for Diagnosis and M...asclepiuspdfs
Metabolic diseases such as hypertension, obesity, diabetes, and vascular diseases have reached epidemic proportions worldwide. In the past four decades, childhood and adolescent obesity has increased four-fold worldwide. During the same period, obesity in adults has doubled and diabetes has increased by four-fold. In China, India, and the USA, the number of prediabetes is more than diabetics. This population is at considerable risk for developing diabetes, its clinical complications, and acute vascular events. The management of modifiable risks for cardiometabolic risks has improved considerably. Several major studies have demonstrated, that robust management of modifiable risks for cardiovascular diseases (CVDs), significantly reduces premature mortality from CVDs. Considering the progress made in the risk assessment, risk management, we feel strongly, that not much progress is made in the areas of primary prevention and early risk assessment, for clinical complications associated with metabolic diseases, in particular, diabetes. The majority of the clinical complications associated with diabetes are due to dysfunction of the vascular system or nervous system. Complications include vasculopathy leading to subclinical atherosclerosis, heart attacks, and stroke.
Objective: Diabetic nephropathy is one of the most serious complications of diabetes mellitus. It develops in approximately one-third of diabetic patients, years after the onset of metabolic abnormalities.
Study Design: The biopsy specimens were evaluated with the focus on light microscopy. The aim of our study was to reveal differences in the details and the frequency of occurrence of individual histomorphological changes in diabetic nephropathy and other glomerulonephritides.
Results: Diabetic nephropathy accounted for 14 out of 82 analyzed biopsies. Isolated thickening of the glomerular basement membrane was not present in any case, but along with some degree of mesangial expansion, hypercellularity or glomerulosclerosis was seen in 12 out of 14 findings of diabetic nephropathy. In other glomerular diseases, mesangial changes, but without glomerular basement membrane thickening, were the most frequent findings. In addition to glomerular lesions, some of the tubular, interstitial, and vascular changes were seen in 13 out of 14 patients with diabetic nephropathy. In other glomerulonephritides the combination of all these changes was a rare finding.
Conclusion: There are cases where immunofluorescence and electron microscopy cannot be performed or their results are not helpful. In such cases we must rely on light microscopic histomorphological changes.
Dermatoglyphics in diabetes mellitus of type 2CA. Sanjay Ruia
The document discusses a study analyzing dermatoglyphic patterns on the palms of 190 Romanian patients with type 2 diabetes mellitus (T2DM). The results found significant pathological dermatoglyphic distortions and anomalies in the patients compared to a control group. Specifically, over 55% of patients showed a partial suppression of line C, which was more common in women at around 38%. This and other dermatoglyphic markers could help identify individuals at risk for T2DM.
Dermatoglyphics in diabetes mellitus of type 2CA. Sanjay Ruia
The document discusses a study analyzing dermatoglyphic patterns on the palms of 190 Romanian patients with type 2 diabetes mellitus (T2DM). The results found significant pathological dermatoglyphic distortions and anomalies in the T2DM patients compared to controls. Specifically, over 55% of patients had a partial suppression of line C, which was more common in women at 38% compared to 33% in men. While individual dermatoglyphic distortions may serve as markers for early T2DM diagnosis, two differences in overall palm patterns allow differentiation of T2DM from type 1 diabetes mellitus.
There has been an increase in the predominance of diabetes mellitus over the past 40 years worldwide. The worldwide occurrence of diabetes in 2000 was approximately 2.8% and is estimated to grow to 4.4% by 2030. This data interprets a projected rise of diabetes from 171 million in 2000 to well over 350 million in 2030. The presence of hypertension in diabetic patients substantially increases the risks of coronary heart disease, stroke, nephropathy and retinopathy. Indeed, when hypertension coexists with diabetes, the risk of CVD is increased by 75%, which further contributes to the overall morbidity and mortality of an already high risk population. Patients with type 2 diabetes mellitus have a considerably higher risk of cardiovascular morbidity and mortality, and are disproportionately affected by cardiovascular disease. Most of this excess risk is associated with high prevalence of well-established risk factors such as hypertension, dyslipidaemia and obesity in these patients. Hypertension plays a major role in the development and progression of microvascular and macrovascular disease in people with diabetes. Lifestyle Modifications and pharmacotherapy are the choice for the Management of Hypertension in Patients with Diabetes.
This document reviews hand manifestations that are commonly seen in patients with diabetes mellitus. It discusses four main conditions - limited joint mobility, Dupuytren's contracture, carpal tunnel syndrome, and trigger finger. For each condition, it describes the typical clinical findings and examines the relationship to diabetic disease, noting that the prevalence of each condition increases with age, duration of diabetes, and presence of other diabetic complications like retinopathy. While the exact causes are unknown, these hand conditions are thought to be related to the disease process of diabetes.
Chronic kidney disease (CKD) is a global public health problem
worldwide. The worldwide prevalence of CKD has increased in
various countries such as the U.S. (13.1%), Taiwan (9.8-11.9%),
Norway (10.2%), Japan (12.9-15.1%) China (3.2-11.3%), Korea (7.2- 13.7%), Thailand (8.45-16.3%), Singapore (3.2-18.6%), and Australia(11.2%)
This document summarizes a literature review on the causes of high prevalence of Type 2 Diabetes in Turkish and Moroccan immigrants in the Netherlands. The review finds several reasons for the high prevalence, including genetic factors, obesity, lower socioeconomic status, hypertension, and lifestyle factors like diet and physical inactivity. Migration is also found to influence prevalence, as immigrants often adopt a more western diet and lifestyle, which can increase obesity and diabetes risk. Overall, the review concludes that both immigration factors like changes to lifestyle and diet, as well as ethnic factors, contribute to the high rates of Type 2 Diabetes in Turkish and Moroccan immigrants in the Netherlands.
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptxRhoda Isip
1) A fasting blood glucose level of 126 mg/dL or higher on two separate tests.
2) A two-hour plasma glucose level of 200 mg/dL or higher during a 75g oral glucose tolerance test.
3) A random plasma glucose of 200 mg/dL or higher for someone with classic symptoms of hyperglycemia.
Review ArticlePotential role of sugar (fructose) in the ep.docxronak56
Review Article
Potential role of sugar (fructose) in the epidemic of hypertension,
obesity and the metabolic syndrome, diabetes, kidney disease, and
cardiovascular disease1�3
Richard J Johnson, Mark S Segal, Yuri Sautin, Takahiko Nakagawa, Daniel I Feig, Duk-Hee Kang, Michael S Gersch,
Steven Benner, and Laura G Sánchez-Lozada
ABSTRACT
Currently, we are experiencing an epidemic of cardiorenal disease
characterized by increasing rates of obesity, hypertension, the met-
abolic syndrome, type 2 diabetes, and kidney disease. Whereas ex-
cessive caloric intake and physical inactivity are likely important
factors driving the obesity epidemic, it is important to consider
additional mechanisms. We revisit an old hypothesis that sugar,
particularly excessive fructose intake, has a critical role in the epi-
demic of cardiorenal disease. We also present evidence that the
unique ability of fructose to induce an increase in uric acid may be a
major mechanism by which fructose can cause cardiorenal disease.
Finally, we suggest that high intakes of fructose in African Ameri-
cans may explain their greater predisposition to develop cardiorenal
disease, and we provide a list of testable predictions to evaluate this
hypothesis. Am J Clin Nutr 2007;86:899 –906.
KEY WORDS Fructose, uric acid, sugar, arteriosclerosis, en-
dothelial dysfunction, hypertension, obesity, chronic kidney dis-
ease, metabolic syndrome
INTRODUCTION
Despite our best efforts, the epidemic of cardiorenal disease
continues to increase at an alarming rate. Obesity affects one-
third of adults and one-sixth of children in the United States and
continues to increase; although dietary interventions are often
initially successful, they often fail over time because of attrition
(1). Likewise, hypertension affects nearly one-third of the pop-
ulation, but despite the presence of effective antihypertensive
agents, nearly two-thirds of these patients remain either un-
treated or are treated ineffectively (2). Furthermore, even if the
hypertension is controlled, these subjects continue to have in-
creased cardiovascular mortality (3). Diabetes, a complication of
obesity, now affects 7% of our population, with approximately
one-third doomed to develop various complications such as ret-
inopathy or nephropathy (4). Kidney disease also continues to
increase at a deplorable rate, a consequence of the increasing
frequency of hypertension and diabetes (5). Today, nearly 20
million Americans have stage 1 kidney disease or greater (de-
fined as the presence of microalbuminuria or a glomerular fil-
tration rate �90 mL�min�1�1.73 m�2; 6), and, although treat-
ments such as angiotensin-converting enzyme inhibitors are
beneficial, they act primarily to delay the progression to renal
failure as opposed to halting the process (7).
It is our opinion that the potential mechanisms underlying the
epidemic should be carefully reappraised. On the basis of both
the experimental studies performed in our laboratorie ...
Running head illness and disease managementillness and disearyan532920
Chronic kidney disease is a debilitating disease that affects many organ systems and is associated with high risks of cardiovascular disease and early death. It has numerous comorbidities such as diabetes, hypertension, heart disease, and impacts patients' quality of life through disability and high medical costs. About 10% of the global population is affected by CKD, and it is a leading cause of death worldwide. Goals for improving CKD include reducing the disease burden through early detection and treatment of risk factors like diabetes and hypertension.
A COVID Journey in Diabetes: T1D Diabetes Patient 44 years - Winning in Insul...komalicarol
Complications of Hypoglycaemia, Hypoglycaemia
and Neuroglycopenia are often encountered by patients treated
with insulin. It is feared by patients and families often leading to
emotional and mental scars and can affect lifestyle and confidence.
Hypoglycaemia can occur in premature babies, persons with hypopituitarism and Addison’s Disease. Low blood glucose can affect
athletes and the elderly leading to falls. Cases are individual and
often difficult for families, clinicians, lawyers and courts to understand.
Renal disease in diabetes from prediabetes to late vasculopathy complication...nephro mih
This document provides information about Prof Basset El Essawy's qualifications and a lecture on renal disease in diabetes. It discusses epidemiological data on diabetic kidney disease prevalence in the US, summarizes findings from large diabetes treatment trials, and defines insulin resistance and prediabetes. It also covers prediabetes and nephropathy, presents case studies, and examines insulin resistance and vascular calcification.
Weight Loss and Weight Loss Maintenance in Type 2 Diabetesabdelhamidsimouh
In line with our trial, big initial weight loss was a predictor of long-term weight loss in the Look AHEAD trial (90). Interestingly, participants with a high initial weight loss but full regain of weight during follow-up, still had better HbA1c values after 4 years than those with less or no initial weight loss...
Introduction: The objective of this work is to study the epidemiological and clinical aspects of erectile dysfunction in a population of diabetic patients in the Thies region.
Resurge - The Godzilla Of Offers - Resurge weight loss.Med Gaith
Resurge- The Godzilla Offers is a blend of natural products that are helpful to losing weight, boosting the immune system, increasing metabolism, and relieving stress. it is effective against problems that in one way or another are related to weight gain. It is made in the USA and approved by the Food and Drug Administration (FDA).
This document discusses coronary heart disease and the metabolic syndrome. It begins by outlining the increasing prevalence of coronary heart disease globally and in India. It then discusses several objectives of the study, including assessing the prevalence of metabolic syndrome in patients with proven coronary artery disease and the extent of coronary artery disease in patients with metabolic syndrome. The document provides definitions and components of metabolic syndrome from several leading health organizations. It reviews literature on the topic and discusses the prevalence of metabolic syndrome in various populations and age groups.
Diabetes mellitus (DM) is a chronic metabolic and vascular disorder affecting various organs and systems. Many studies have shown impairment of pulmonary functions in diabetics subjects, whereas some studies did not show any changes in pulmonary functions. Therefore, objective of the present study is to find out alterations in the pulmonary functions. Methods Design, Setting, and Participants: This cross-sectional study was conducted in a tertiary care hospital among patients attending medicine department. The sample size was 200. A total of 100 known cases of DM without any acute or chronic lung disease and 100 healthy controls were included in the age group of 40–50 years. History of smoking was excluded in both groups. The diabetic subjects had at least 1 year of duration of disease. Intervention: Pulmonary function test (spirometry) was performed with NND TrueFlow Easy One™ diagnostic spirometer. Main Outcome Measures: The forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) were the primary outcome measures to assess the pulmonary functions. Results: In Phase 1 analysis, diabetic subjects did not show any changes in both FVC and FEV1 when compared with controls. In Pearson correlation test, a significant negative correlation between duration of disease and pulmonary functions, FVC at the level of 0.05 and FEV1 at the level of 0.01 were observed. However, in Phase 2 analysis, a significant reduction in FVC and FEV1 was observed in diabetic subjects with duration of diabetes more than 5 years. Conclusion: The decline in FVC and FEV1 in diabetic subjects is more likely to be the effect of DM. The decline is more pronounced with the duration of the disease.
1) Fatty liver, measured using CT scans, was present in 17% of participants.
2) Fatty liver was associated with higher risk of diabetes, metabolic syndrome, hypertension, and insulin resistance even after accounting for other measures of obesity like BMI and visceral fat.
3) Fatty liver was also linked to dyslipidemia (higher triglycerides and lower HDL) and dysglycemia (impaired fasting glucose) independent of other fat depots.
This document summarizes evidence on the risks of COVID-19 for people with diabetes and considerations for managing diabetes during the pandemic. It finds that people with diabetes appear to be at increased risk of severe COVID-19 outcomes. Higher BMI and poorer long-term glucose control are linked to worse COVID-19 outcomes. The pandemic also poses indirect risks to diabetes management through disruptions to healthcare, diet, exercise and increased stress. Countries have adopted strategies like telehealth and educational materials to support diabetes care during this time. More evidence is still needed on reducing infection risk and optimal self-management for people with diabetes during the pandemic.
This document summarizes regional variations in the prevalence, diagnosis, and management of thyroid eye disease (TED). Some key points discussed include:
- The prevalence of TED varies internationally and is influenced by factors like ethnicity, smoking status, and underlying thyroid dysfunction.
- Asian patients may be at higher risk of vision-threatening complications due to anatomical differences.
- Risk factors for more severe TED include smoking, thyroid dysfunction, selenium deficiency, vitamin D deficiency, diabetes, and obstructive sleep apnea.
- Treatment of active TED focuses on glucocorticoids administered orally, intravenously or locally based on disease severity.
Three famous individuals struggled with chronic kidney disease: former rugby player Jonah Lomu who had a transplant, film director Alfred Hitchcock who died of renal failure, and the fictional Tiny Tim from A Christmas Carol who appeared to have chronic kidney disease alongside rickets. Chronic kidney disease can have various causes such as genetics, obesity, diabetes or environmental factors as represented by these three examples. Chronic kidney disease is defined as long term kidney damage and is associated with increased mortality, often progressing to end stage renal disease. It affects millions worldwide and prevalence is expected to increase significantly in coming decades due to aging populations and risk factors like diabetes and hypertension.
This document summarizes peripartum cardiomyopathy (PPCM), a form of heart failure that develops during pregnancy or after delivery. Key points include:
- PPCM is diagnosed if heart failure symptoms develop in the last month of pregnancy or within 5 months postpartum, with no other identifiable cause and left ventricular ejection fraction below 45%.
- Risk factors include advanced maternal age, multiparity, multi-fetal pregnancy, hypertension, and African American race.
- Etiology is unknown but may involve viral myocarditis, immune response, hormonal abnormalities, or malnutrition. Proposed mechanisms include abnormal prolactin signaling.
- Complications can include heart failure, arrhythmias, thromboembolic
Diabetes is a group of metabolic disorders characterized by hyperglycemia. The prevalence of diabetes has risen dramatically worldwide over the past few decades. Diabetes greatly increases the risk of cardiovascular disease like coronary artery disease. Patients with diabetes have a 2-4 times higher risk of cardiovascular disease and it often develops decades earlier than in non-diabetic patients. Diabetes contributes to both microvascular complications like nephropathy and retinopathy as well as macrovascular complications from atherosclerosis.
Evaluation of the risk factors for the development of metabolic syndrome in b...Alexander Decker
This document summarizes a study that evaluated risk factors for metabolic syndrome in Babylon, Iraq in 2012. The study found that 31.1% of patients had a low risk, 50.8% had a moderate risk, and 18.1% had a high risk of metabolic syndrome. There was a significant association between risk of metabolic syndrome and age, as well as associations between risk levels and factors like hypertension, triglycerides, overweight/obesity, central obesity, diabetes, and low HDL cholesterol. The study concluded that the risk of metabolic syndrome in Babylon increased with the number of risk factors present and with advancing age.
A STUDY ON PREVALENCE OF MICRO AND MACRO VASCULAR COMPLICATIONS IN TYPE 2 DI...IJSIT Editor
This study examined the prevalence of microvascular and macrovascular complications in 1200 patients with type 2 diabetes in India. Retinopathy was found in 13.5% of patients, nephropathy in 26%, neuropathy in 31.5%, cardiovascular disease in 19.1%, and peripheral vascular disease in 9.75%. Logistic regression revealed that older age, longer diabetes duration, and hypertension were significantly associated with all complications. Poor glycemic control was associated with higher rates of nephropathy and retinopathy. The study highlights the high prevalence of complications, especially nephropathy and neuropathy, in this population.
Degree of Suspicion of Peripheral Artery Disease among Geriatrics and Policem...Jan Igor Galinato
This document summarizes a study that examined the degree of suspicion of peripheral artery disease (PAD) among geriatrics and policemen in Iligan City, Philippines. The study utilized a descriptive-correlational-comparative research design and purposive sampling to gather data from 40 respondents, including 20 geriatrics and 20 policemen, using a modified standardized questionnaire. The results showed that 50% of respondents were 50 years or older, and 65% were male. Age and lifestyle factors like diet and exercise were found to have a significant relationship with degree of suspicion of PAD, but not other factors like gender, family history of diseases, smoking, or alcohol use. While age cannot be controlled, the study concludes that
The document discusses the benefits of exercise for mental health. It states that regular physical activity can help reduce anxiety and depression and improve mood and cognitive function. Exercise causes chemical changes in the brain that may help boost feelings of calmness and happiness.
This document summarizes a literature review on the causes of high prevalence of Type 2 Diabetes in Turkish and Moroccan immigrants in the Netherlands. The review finds several reasons for the high prevalence, including genetic factors, obesity, lower socioeconomic status, hypertension, and lifestyle factors like diet and physical inactivity. Migration is also found to influence prevalence, as immigrants often adopt a more western diet and lifestyle, which can increase obesity and diabetes risk. Overall, the review concludes that both immigration factors like changes to lifestyle and diet, as well as ethnic factors, contribute to the high rates of Type 2 Diabetes in Turkish and Moroccan immigrants in the Netherlands.
PSEDM-DOH WorkshopDiabetes Management Training Using Insulin v_7 - 20170321.pptxRhoda Isip
1) A fasting blood glucose level of 126 mg/dL or higher on two separate tests.
2) A two-hour plasma glucose level of 200 mg/dL or higher during a 75g oral glucose tolerance test.
3) A random plasma glucose of 200 mg/dL or higher for someone with classic symptoms of hyperglycemia.
Review ArticlePotential role of sugar (fructose) in the ep.docxronak56
Review Article
Potential role of sugar (fructose) in the epidemic of hypertension,
obesity and the metabolic syndrome, diabetes, kidney disease, and
cardiovascular disease1�3
Richard J Johnson, Mark S Segal, Yuri Sautin, Takahiko Nakagawa, Daniel I Feig, Duk-Hee Kang, Michael S Gersch,
Steven Benner, and Laura G Sánchez-Lozada
ABSTRACT
Currently, we are experiencing an epidemic of cardiorenal disease
characterized by increasing rates of obesity, hypertension, the met-
abolic syndrome, type 2 diabetes, and kidney disease. Whereas ex-
cessive caloric intake and physical inactivity are likely important
factors driving the obesity epidemic, it is important to consider
additional mechanisms. We revisit an old hypothesis that sugar,
particularly excessive fructose intake, has a critical role in the epi-
demic of cardiorenal disease. We also present evidence that the
unique ability of fructose to induce an increase in uric acid may be a
major mechanism by which fructose can cause cardiorenal disease.
Finally, we suggest that high intakes of fructose in African Ameri-
cans may explain their greater predisposition to develop cardiorenal
disease, and we provide a list of testable predictions to evaluate this
hypothesis. Am J Clin Nutr 2007;86:899 –906.
KEY WORDS Fructose, uric acid, sugar, arteriosclerosis, en-
dothelial dysfunction, hypertension, obesity, chronic kidney dis-
ease, metabolic syndrome
INTRODUCTION
Despite our best efforts, the epidemic of cardiorenal disease
continues to increase at an alarming rate. Obesity affects one-
third of adults and one-sixth of children in the United States and
continues to increase; although dietary interventions are often
initially successful, they often fail over time because of attrition
(1). Likewise, hypertension affects nearly one-third of the pop-
ulation, but despite the presence of effective antihypertensive
agents, nearly two-thirds of these patients remain either un-
treated or are treated ineffectively (2). Furthermore, even if the
hypertension is controlled, these subjects continue to have in-
creased cardiovascular mortality (3). Diabetes, a complication of
obesity, now affects 7% of our population, with approximately
one-third doomed to develop various complications such as ret-
inopathy or nephropathy (4). Kidney disease also continues to
increase at a deplorable rate, a consequence of the increasing
frequency of hypertension and diabetes (5). Today, nearly 20
million Americans have stage 1 kidney disease or greater (de-
fined as the presence of microalbuminuria or a glomerular fil-
tration rate �90 mL�min�1�1.73 m�2; 6), and, although treat-
ments such as angiotensin-converting enzyme inhibitors are
beneficial, they act primarily to delay the progression to renal
failure as opposed to halting the process (7).
It is our opinion that the potential mechanisms underlying the
epidemic should be carefully reappraised. On the basis of both
the experimental studies performed in our laboratorie ...
Running head illness and disease managementillness and disearyan532920
Chronic kidney disease is a debilitating disease that affects many organ systems and is associated with high risks of cardiovascular disease and early death. It has numerous comorbidities such as diabetes, hypertension, heart disease, and impacts patients' quality of life through disability and high medical costs. About 10% of the global population is affected by CKD, and it is a leading cause of death worldwide. Goals for improving CKD include reducing the disease burden through early detection and treatment of risk factors like diabetes and hypertension.
A COVID Journey in Diabetes: T1D Diabetes Patient 44 years - Winning in Insul...komalicarol
Complications of Hypoglycaemia, Hypoglycaemia
and Neuroglycopenia are often encountered by patients treated
with insulin. It is feared by patients and families often leading to
emotional and mental scars and can affect lifestyle and confidence.
Hypoglycaemia can occur in premature babies, persons with hypopituitarism and Addison’s Disease. Low blood glucose can affect
athletes and the elderly leading to falls. Cases are individual and
often difficult for families, clinicians, lawyers and courts to understand.
Renal disease in diabetes from prediabetes to late vasculopathy complication...nephro mih
This document provides information about Prof Basset El Essawy's qualifications and a lecture on renal disease in diabetes. It discusses epidemiological data on diabetic kidney disease prevalence in the US, summarizes findings from large diabetes treatment trials, and defines insulin resistance and prediabetes. It also covers prediabetes and nephropathy, presents case studies, and examines insulin resistance and vascular calcification.
Weight Loss and Weight Loss Maintenance in Type 2 Diabetesabdelhamidsimouh
In line with our trial, big initial weight loss was a predictor of long-term weight loss in the Look AHEAD trial (90). Interestingly, participants with a high initial weight loss but full regain of weight during follow-up, still had better HbA1c values after 4 years than those with less or no initial weight loss...
Introduction: The objective of this work is to study the epidemiological and clinical aspects of erectile dysfunction in a population of diabetic patients in the Thies region.
Resurge - The Godzilla Of Offers - Resurge weight loss.Med Gaith
Resurge- The Godzilla Offers is a blend of natural products that are helpful to losing weight, boosting the immune system, increasing metabolism, and relieving stress. it is effective against problems that in one way or another are related to weight gain. It is made in the USA and approved by the Food and Drug Administration (FDA).
This document discusses coronary heart disease and the metabolic syndrome. It begins by outlining the increasing prevalence of coronary heart disease globally and in India. It then discusses several objectives of the study, including assessing the prevalence of metabolic syndrome in patients with proven coronary artery disease and the extent of coronary artery disease in patients with metabolic syndrome. The document provides definitions and components of metabolic syndrome from several leading health organizations. It reviews literature on the topic and discusses the prevalence of metabolic syndrome in various populations and age groups.
Diabetes mellitus (DM) is a chronic metabolic and vascular disorder affecting various organs and systems. Many studies have shown impairment of pulmonary functions in diabetics subjects, whereas some studies did not show any changes in pulmonary functions. Therefore, objective of the present study is to find out alterations in the pulmonary functions. Methods Design, Setting, and Participants: This cross-sectional study was conducted in a tertiary care hospital among patients attending medicine department. The sample size was 200. A total of 100 known cases of DM without any acute or chronic lung disease and 100 healthy controls were included in the age group of 40–50 years. History of smoking was excluded in both groups. The diabetic subjects had at least 1 year of duration of disease. Intervention: Pulmonary function test (spirometry) was performed with NND TrueFlow Easy One™ diagnostic spirometer. Main Outcome Measures: The forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) were the primary outcome measures to assess the pulmonary functions. Results: In Phase 1 analysis, diabetic subjects did not show any changes in both FVC and FEV1 when compared with controls. In Pearson correlation test, a significant negative correlation between duration of disease and pulmonary functions, FVC at the level of 0.05 and FEV1 at the level of 0.01 were observed. However, in Phase 2 analysis, a significant reduction in FVC and FEV1 was observed in diabetic subjects with duration of diabetes more than 5 years. Conclusion: The decline in FVC and FEV1 in diabetic subjects is more likely to be the effect of DM. The decline is more pronounced with the duration of the disease.
1) Fatty liver, measured using CT scans, was present in 17% of participants.
2) Fatty liver was associated with higher risk of diabetes, metabolic syndrome, hypertension, and insulin resistance even after accounting for other measures of obesity like BMI and visceral fat.
3) Fatty liver was also linked to dyslipidemia (higher triglycerides and lower HDL) and dysglycemia (impaired fasting glucose) independent of other fat depots.
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1. Special Article
Diabetes Mellitus and Its
Degenerative Complications:
A Prospective Study of 4,400 Patients
Observed Between 1947 and 1973
JEAN PIRART
This article was originally published in French in Diabete et
Metabolisme (vol. 3: 97-107, 173-182, 245-256; 1977).
The Editors of DIABETES CARE thank the author, and the editors
and publisher of Diabete et Metabolisme for granting permis-
sion for us to print this English translation. The paper was trans-
lated by Marjorie Levin of Miami, Florida.
Part I of this translation appeared in the May-June
issue of DIABETES CARE (vol. I: 168-188).
Part 2
DISCUSSION
B
ased on a longitudinal follow-up of 4,400 patients,
our prospective study has shown that the two
essential factors which determine the risk of
degenerative complications are the duration and
the intensity of diabetes. Neither diabetic heredity nor
obesity seems to play a direct role. Neither sex nor age modify
the risk of the specific complications so often associated in
a triopathy, although their role in the development of
coronary and peripheral atherosclerosis is evident. All this is
in agreement with the data in the literature. The controversy
is essentially over the effects of duration and intensity of
diabetes, especially the latter. Now, this intensity can be
considerably diminished by treatment. It is this actual
intensity (glycemic control) and not the inherent severity of
diabetes that seems related to the development of specific
lesions. By contrast, glycemic control does not seem to slow
down accelerated atherosclerosis related to diabetes. A
moderate degree of attenuation of diabetes by treatment
seems already efficacious in the prevention of the specific
microvascular and nervous lesions. It can be achieved in
most diabetic patients, although with a bit of effort.
The pathogenesis of the complications of diabetes in man is
still conjectural for the reasons set forth in the introduc-
tion. Although very suggestive, our statistical correlation ob-
viously cannot furnish proof of a causal link between pro-
longed hyperglycemia and the complications. This causality
has been strongly disputed. The objections generally pre-
sented can be grouped under the following headings:
(1) The specific lesions of diabetes are an integral part of
idiopathic diabetes and are not observed in secondary
diabetes. Therefore "complications" would be considered
concomitants of a constitutional illness which would affect
the insulin-secreting cells, the fibroblasts, the small blood
vessels, and the nerves.39
'169
'179
'197
(2) Since they do not always evolve parallel to the dura-
tion of diabetes, the degenerative lesions that accompany
it can be observed from the onset of diabetes and can even
precede it.
(3) The specific lesions evolve independently of the in-
tensity of the diabetes and are influenced little if at all by the
treatment of the metabolic disorder; viz., a protective effect
of reduction of hyperglycemia has never been demonstrated
by any convincing statistical evidence.
Clinical and experimental work done over the past 10
years has produced a large amount of data that permits the
three objections to be refuted.
(1) Lesions of the kidney, retina, and nerves similar to
those of human diabetes can be obtained in animals in which
diabetes is induced by pancreatectomy, beta-cytotoxic
agents, or growth hormone (table 2). Typical features of
retinopathy, of glomerulosclerosis (even nodular), and of
neuropathy have been observed in human long-term cases of
secondary diabetes, resulting from hemochromatosis, chronic
pancreatitis, or pancreatectomy (table 2).
A careful review of the literature will uncover no argu-
ment in favor of a hereditary predisposition to neuropathy,151
nephropathy,20
'67
'100
'159
'202
or retinopathy4
'19
'100
'123
'159
'161
'166
with the sole exception of the beautiful study by Pyke and
Tattersall.153
These authors studied 13 pairs of identical
twins both of whom had diabetes and 10 pairs of identical
twins of whom only one had diabetes. In those 26 twins of
concordant pairs they found a family history of diabetes in
252 DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978
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2. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
addition to retinopathy (in particular severe retinopathy)
more frequently than in the 10 diabetic twins of the dis-
cordant pairs. In our cases, overall prevalence (all durations)
and annual prevalence show no correlation whatever with a
family history of diabetes. It is striking to note that whatever
TABLE 2
Complications arising in cases of nonidiopathic diabetes
its origin, hereditary or not—and half of the idiopathic cases
are not hereditary187
—idiopathic diabetes, like secondary
diabetes, leads to specific complications which are a function
of the duration of hyperglycemia (table 2).
(2) Our study demonstrates a strict correlation between the
Animals: Experimental diabetes produced by pancreatectomy, beta-cytotoxins, or growth hormone
Retinopathy Nephropathy Neuropathy
Hausler et al., 1963
Hausler et al., 1964
Engerman and Bloodworth, 1965
Gibbset al., 1966
Osterby'Hansen and Orskov, 1967
Toussaint, 1968
Bloodworth et al., 1969
Bloodworth and Engerman, 1971
Mann and Goddart, 1949
Mann et al., 1951
Janes, 1969
Greenberg, 1962
Beaser et al., 1963
Beaser et al, 1964
Osterby-Hansen et al., 1966
Gibbset al., 1966
Bloodworth et al., 1969
Bloodworth and Engerman, 1971
Tseng et al., 1972
Mauer et al, 1972
Hagg, 1974 (p. 211)
Mauer et al., 1975
Preston, 1967
Hildebrandet al., 1968
Sahgaletal, 1972
Jakobsen, 1975
Fox et al., 1975
Man: Secondary diabetes resulting from various pancreatic and extrapahcreatic diseases
Retinopathy Nephropathy Neuropathy
Pancreatectomy
Chronic pancreatitis
Hemochromatosis
Cushing's syndrome or
acromegaly
Intense and prolonged
corticosteroid therapy
Rynearson, 1957 (cited by Duncan, 1958)
Burton et al, 1957
Duncan etal, 1958
Dec/cert, 1960
Dett^ler, 1964
Turin et al., 1967
Lubetzki et al., 1968
Seveletal., 1971
Geevarghese and Mathew, 1973
Verbonfcetal., 1975
Wellmann and Volk, 1976
Hudson, 1953
Dunlop, 1957 (cited by Duncan, 1958)
Dec/cert, i960
Gallon, 1965
Turin et al., 1967
Pirart and Barbier, 1971
Gri#thsetal., 1971
Simon et al., 1973
Passaet al., 1975
McCulIagh, 1956
Goto and Yamagata, 1964
Toussaint and Famir, 1966
Doyle et al., 1964
Duncan etal, 1958
DecJcert, 1960
Shapiro and Smith, I960
Dettwyler, 1964
Ireland etal, 1967
Turin et al., 1967
Enniset al., 1969
Wellmann and Volk, 1976
Becker and Miller, I960
Turin et al., 1967
Ireland etal., 1967
Simon et al., 1967
Doyle et al., 1964
Deckert, 1960
Dettwykr, 1964
Lubetzki et al., 1968
Galton, 1965
Turin et al., 1967
Dymocketal., 1972
Pirart, 1976
Recordier et al., 1976
McCulIagh, 1956
References in italics refer to long-term cases.
DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978 253
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3. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
known duration of hyperglycemia on the one hand and the
prevalence and incidence of nervous and vascular complica-
tions on the other. Thus we confirm the impression gleaned
from review of numerous clinical studies. Most of these,
however, pertain only to one or two of the three specific
complications and to large subgroups of duration (more than
20 years, more than 30 years, etc.). None, except for
the one by Knowles et al. ,86
provides figures for annual
prevalence and annual incidence as we do.
The observations that cast doubt on the effect of duration
concerning neuropathy have to do with some severe pre-
cocious cases, often reversible once the treatment of diabetes
has been initiated (reference in Pirart, 1970139
)144
; or they
have to do with some subclinical cases studied by electro-
physiologic techniques.125
The clinical observations, in
general, show correlations between known duration of dia-
betes and glomerulosclerosis (frequency and severity). The
rare disagreements concern only a small number of clinical
cases observed after the 10th year of childhood diabetes.90
Morphological studies on the other hand show frequent
discordance between the known duration of diabetes and the
intensity of the lesions demonstrated by light micros-
copy76
'144
'147
'148
or electron microscopy.141
'147
'148
Some very
careful quantitative studies82
'110
have shown, nevertheless,
that the initial glomerular lesions—a thickening of the capil-
lary basement membrane—did not exist at the beginning of
diabetes except in middle-aged subjects. In addition they
have shown that this lesion could develop rapidly, and
that its progression is clearly a function of the duration of
diabetes.164
No discordance appears for retinopathy in the 43 studies
dealing with it. Finally, the duration factor is a determinant
in the development of nervous and vascular complications
of secondary diabetes, whether clinical or experimental
(table 2).
The discovery of specific lesions at the time of diagnosis is
not a serious argument against the theory which makes those
lesions authentic complications of a metabolic disorder evolv-
ing as a function of its intensity and duration. None of the
26 reports concerning "precocious complications" bear proof
of the absence of diabetes, not even in the year preceding
the simultaneous discovery of hyperglycemia and complica-
tions. To the contrary, some authors emphasize the need
for a careful search into the medical records which might
uncover proof of diabetic antecedents which the patient
had hidden, ignored, or forgotten.
The experience in all diabetes centers agrees with the
results of detection drives: when accompanied by typical
symptoms, diabetes can go unrecognized for a long time,
and even much longer in the case with no glycosuria. This
is frequent in the elderly, who pay a higher price for
ii • M 1* • 17 $n 17^1
precocious complications.1
''o<J
'i
'J
We put forward three additional arguments suggesting
that the underestimation of duration could be the artifact
responsible for the "precocious" lesions: (a) These are all
the more frequent in patients who were more obese before
the discovery of diabetes; (b) middle-aged subjects had a
higher glycemia at the discovery of diabetes, if the illness
was already accompanied by complications; (c) in the first
years of diabetes, the "old" patients already had more compli-
cations (prevalence) than the "young" ones, although those
who were still unaffected by complications did not develop
them any sooner (incidence) than the "young" ones. This
is compatible with the idea of an unrecognized long dura-
tion responsible for the precocious complications. Extrap-
olation towards the left of our ascending curves for the
prevalence of the three specific complications (figures 14 and
15) as a function of duration of diabetes in the "old" is
reminiscent of extrapolation to the left of the gentle slope
of increasing thickness of basement membrane of the
glomerular capillaries in adults as compared with the steep-
ness of this rise in children and adolescents (Lazarow,97
see
his figure 3). The development of specific lesions before the
appearance of hyperglycemia will not be discussed here. A
meticulous analysis of the publications that do mention this
shows that almost all such cases can be explained by at least
one of the two following possibilities: either the complica-
tion was not specific, or diabetes was probably preexistent.
In an overwhelming majority of the 60 reports dealing
with the subject (table 3), the authors found a correlation
between poor control of diabetes and the prevalence of its
complications. However, it must be recognized that none of
them offers statistical data that fulfill most of the require-
ments set forth in the introduction. Some even conclude that
they did not find any correlation.86
Our study is the only
one that satisfies 22 of the 23 criteria defined above. In fact,
the only problem we could not solve was that of dropouts.
The present study has specific features: magnitude, dura-
tion, continuity, homogeneity, use of objective criteria to
estimate the degree of chronic hyperglycemia, effort to sepa-
rate the two aspects of diabetic intensity (inherent severity
and degree of glycemic control), and careful statistical
analysis. This study, which Spiro182
has called ambitious,
could in such a way add more convincing original data to
the studies as yet published.
Magnitude of the Present Study
The particular circumstances in which our subjects came to
us allowed us for a long time to avoid a highly selective
recruitment, which is the norm in renowned clinics. We have
reasons to believe that our material constitutes a representa-
tive sample of the diabetic population of the Brussels
area (age, sex, duration of diabetes, severity of diabetes,
complications, etc.). All the patients whom we were able
to care for were questioned and examined. No one was ex-
cluded and no file was left out of the collection.
The broad range of the study is unique: 21,000 annual
neurovascular evaluations on 4,400 patients. Our material is
254 DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978
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4. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
TABLE 3
Comparison of the Brussels study with the U.G.D.P. study (retinopathy only)
U.G.D.P. Brussels
Period of observation
Admission criteria
Incipient cohort (no. of cases followed since
year one)
Erosion of subject pool
Still followed at year 5
Still followed at years 5—8
Still followed at year 10
Still followed at year 15
Retinal examination
Place of examination
Observers
Goals of the study
Evaluate a certain type of treatment
Evaluate the effect of hyperglycemia
Methods
Random allocation of one treatment to
randomized groups
Systematic effort to obtain better control
1961-1974
Borderline and overt diabetes
Known for <1 year
Not insulin-dependent
716*
1947-1973
Overt diabetes
All durations
All degrees of severity
2,795
499T
211"
None
None
Photograph of the central part
of the right retina
12 clinics
±40 doctors
Yes
Secondary goal
Yes
No
547
360
219
97
Direct opthalmoscopy
of both eyes, dilated
2 clinics
2 private practices
±2 doctors
No
Main goal
No
Yes
* Diabetes (Suppl. 2) 19: 771 (table 28), 1970.
t J. Am. Med. Assoc. 218: 1402 (table 2), 1971.
11
J. Am. Med. Assoc. 217: 783 (table 6), 1971.
N.B. —The data published in Article V of the U.G.D.P. Study (Diabetes 24 (Suppl. 1), 1974) are useless because duration of diabetes is not defined (see pp.
101, 102, tables 21, 22, and on p. 128, table B17. This holds true also for table 9, p. 1139 of Article VI (Diabetes 25: 1129, 1976) which concerns the first
appearance of a retinal abnormality (see p. 1131, paragraph 2) with no mention of the duration of diabetes at that moment.
more extensive than that of 15 longitudinal studies published
to date: their subject populations range from 21 to 990. Our
260 patients who had diabetes before 21 years of age and
our 497 patients who had diabetes before 31 are to be com-
pared with the 132 "children" of Hardin et al.62
and to
the 78 "children" of Knowles et al.,86
which are the largest
groups of cases of juvenile diabetes followed for several years.
Our cross-sectional study of long-term cases, whether fol-
lowed up or not, also prevails over the majority of others
with respect to the number of patients. At the 15th year of
diabetes, we have 339 patients of whom 298 could be studied
for the degree of control, while Dunlop,36
Lestradet and
Billaud,100
and Lundbaek103
mention, respectively, 167,
86, and 234 cases of various durations greater than 15 years.
By contrast, at the 20th year of diabetes, we have only 164
cases of whom 138 can be studied for the degree of control,
while Pense et al.135
and Constam25
had, respectively,
180 and 434 cases with duration of 20 years or more. It must
be added that the degree of cumulative control could not be
estimated on all the patients observed by these authors,
whose denominators are sometimes much lower than the
number of subjects.
No continuous longitudinal study (inception cohort) has
been pursuedfor as long a time as ours, since the one by Spoont
et al.183
was on 50 cases followed for more than 10 years
and those of the U.G.D.P. published to date195
are on 211
cases in which follow-up on the retina continued for from five
to eight years and on 379 cases with follow-up on the
kidneys for the same amount of time. All such cases were ob-
served from the beginning of diabetes (table 3).
We have simultaneously studied, year by year, neuropathy,
microangiopathy in two areas, macroangiopathy in two
DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978 255
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5. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
other areas, and various clinical and biological parameters.
Most of the published studies dealt only with one or two
kinds of complications, and only seven of them concerned
the three specific complications. No longitudinal study has
evaluated, for a prolonged length of time, both the triopathy
and the arteriopathies.
Kaplan and Feinstein81
pointed out that in most published
studies the denominator is not stable: not all the cases were
studied for each of the various complications reported on. In
the longitudinal studies that were more or less continuous,
the "denominator," i.e., that fraction of the subject popula-
tion in which a complication was observed, is variable not
only from one complication to another but from one year to
the next. We believe that we accomplished the rarely at-
tained maintenance of the denominators at roughly 100 per
cent of our available population for all complications, for
all durations of diabetes, and at all years of the continuous
follow-up. It was a rare exception if any examinable patient
was left out of the denominator by omission of a periodic ex-
amination, and this reinforces the homogeneity of our statis-
tics. The study of the annual incidence of the five compli-
cations could not have been carried out otherwise, and that is
why we are the only ones to have done it. The denomina-
tors of our studies of incidence are naturally always much
lower than those of our studies of prevalence, because once
a patient had escaped from us one year, he became definitively
lost from the study of incidence.
Prevalence of Diverse Complications in our Series
At the discovery of diabetes we observed prevalences of 7.5
per cent for neuropathy, 7.2 per cent for retinopathy, and
1 per cent for nephropathy, which agree with the observa-
tions made in other diabetes clinics in industrialized
countries.
After 20 to 25 years of diabetes, our whole population
(the two cohorts pooled) show neuropathy only in about 45
per cent of cases, retinopathy only in about 55 per cent of
cases, and nephropathy only in about 15 per cent. This could
be compared with the figures commonly found in the litera-
ture (table 5, p. 205 in Lestradet, 1959; table 22, p. 263
in Knowles, 1965; table 10, p. 312 in Burditt, 1958; figures
6.1 to 6.4 in Caird, Pirie, and Ramsell, 1969, among others).
The reported figures go from 30 to 60 per cent for neuropathy,
50 to 100 per cent for retinopathy, and 20 to 40 per cent
for nephropathy.
Our "inception cohort," consisting of patients whom we
personally cared for since the discovery of their diabetes,
shows for these same durations of 20 to 25 years about 60 per
cent neuropathy, about 60 per cent retinopathy, and about 5
per cent nephropathy. These figures are therefore less favor-
able than those of the additional cohort, which doubtless
reflects my inexperience at the beginning of my career and/
or a selection bias that made us keep the more difficult cases
for a longer time.
Continuity of Observations
In almost all diabetes clinics, record-keeping is delegated to
interns or medical students or to temporary assistants who
are little interested in a long-term study and poorly qualified I
in the practice of diabetes care. They are the ones who ex-
amine and really treat the patients under the supervision of a
small number of senior physicians who, unfortunately, no
longer have much contact with the patients. We have suc-
ceeded in avoiding this particular snag so as to attain greater *
value and homogeneity in our observations. Undoubtedly it
is also the continuity of personal doctor-nurse-patient rela-
tionships which explains the relatively slow attrition of our
subject population, especially of the insulin-dependent per-
sons who were much more motivated than the mild cases.
Table 3 compares our study with that of the U.G.D.P.
which was carried out with a deployment of personnel
and financial means incomparably superior to ours. Inci-
dentally, this table underlines some differences in the proto-
col adopted and in the way in which it was carried out. To
simplify the table, only retinopathy was considered from
the multiple "non-fatal events" that occurred to the
U.G.D.P. patients since their entry into the study.195
Criteria of Intensity of Diabetes
We are convinced of the variability of the degree of inherent
severity and of its durable attenuation by the slow effects
of treatment in numerous cases, especially in the first years
of evolution. That is why we cannot agree with Miki et al.m
who adopt as an index of diabetes severity the mean fasting
blood glucose before the treatment starts.
In any case, we have carefully avoided the confusion that
often arises between insulin treatment and true insulin
dependence.
The degree of glycemic control was measured by objective
and continuous methods and assessed year by year, which
makes our study much more reliable than the majority of the
preceding ones, as table 4 shows.
The methods used to estimate the degree of glycemic control
observed throughout the patient's career and/or the results of
this estimate are not made clear in 16 out of the 60 studies
analyzed in this table. In certain studies, it was based on very
subjective data, such as discipline and desire to cooperate
on the part of the patient and those around him, the degree
of initiative he takes in the management of insulin, his feel-
ing of well-being, and his place in society. There are, on
the other hand, objective data such as body weight, values
of glycemia and glycosuria, etc., recorded episodes of
ketoacidosis or hypoglycemia, frequency of medical visits and
urine tests performed between visits, and whether the diet
was actually followed. Many authors do not clearly separate
the means prescribed (and supposed to be applied) from the
results obtained. What do the means matter (whether diet was
followed, insulin or pills taken, dosage adjusted, lapses in
treatment rapidly corrected, frequency of visits and urine
256 DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978
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6. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
and blood tests recorded) if the results are poor! It is evident
that the state of the susceptible tissues cannot be influenced
by the goals, the methods, and the applications of treatment,
but only by metabolic results—glycemia, lipemia, in-
sulinemia, etc. —which are largely independent of these. Our
own observations agree with those of Francois et al.44
on their
children: there is not necessarily any correlation between the
degree of control obtained and the means used to obtain it,
in particular the intensity of supervision. Now what is
important to derive from these tests is some kind of con-
tinuous "film" record showing as continuously as possible the
variations of glycemia, glycosuria, and acetonuria (includ-
ing during acute episodes) and of body weight, and other
measurements during the life of the diabetic patient. The
frequency and the reliability of observations made by the
patient and by the doctor furnish a certain number of
"snapshots" more or less representative of this continuing
picture.
Such factors as lifestyle, appetite, and mildness or intrinsic
stability of the diabetes play an important role in obtaining
good or poor control, either one often undeserved. Even
when the objective means of estimating the degree of control
were identified in a text, the evaluation sometimes seemed
unreliable because of the intrusion of subjective judgment,
hazardous extrapolation of punctual observations over long
periods,122
or because of the "penalization" of a habitual agly-
cosuria if it is accompanied by frequent hypoglycemia or by
rare episodes of hyperglycemia that is serious but of short
duration.
The correlation with the control of diabetes has been
studied for the three specific complications in 10 published
studies, in which three report partially on the same sample.
Only two complications, most often microangiopathy, were
studied in 18 publications; only one complication, usually
retinopathy, was studied with relation to the degree of control
in 33 publications, of which seven have to do with groups of
patients selected precisely because they had this complica-
tion. The control group not affected was more or less well
defined.
Among the 41 reports in which the relationship between
poor control and complication(s) seems to have been studied
fairly seriously, the only one that concludes that there is no
correlation between retinopathy and degree of control is the
one by Knowles et al.86
But the glycemic control was so
poor among all patients in that study that it was impossible to
oppose two groups of patients, good control and poor control.
Two others among the least reliable conclude a doubtful
positive correlation. All the others show that good metabolic
control (reflected by blood and urine glucose) prevents
specific complications.
We have attempted to detect statistical bias in the recruit-
ment and the maintenance of our subject pool or in estimating
the degree of control. Such bias could have influenced the
correlation between control and complications in our ma-
terial. Recruitment and maintenance of subjects could have
gained us some cases with poor control suffering from complica-
tions (who were seeking help from those whom they believed
qualified to give it) and could have lost us cases with
complications and however good control. This is unlikely be-
cause of our connections with the ophthalmology and surgery
clinics and the various in-patient departments. We see no
reason to have drawn patients with good control and no
complications. We may have lost some cases who had no
complications and did not accept our restrictions, believing
that they were all right. Maybe we have also drawn easy-
to-control patients with complications and some unstable
cases who were poorly controlled but who escaped com-
plications.
As for biases in estimating the degree of control, we suspect
that there are three: (1) Had we estimated the metabolism of
those patients suffering from diabetic complications only
while they were hospitalized for complications—which in-
cluded infection or trauma (artery occlusion for example) —
we could have believed their degree of control to be worse
than it was as a rule. This is not the case, as our judgment
on glycemic balance was based principally on ambulatory
periods outside of acute episodes. (2) We could also have
underestimated hyperglycemia in the patients with an ele-
vated renal threshold, but it is precisely these patients
who are inclined to show complications of arteriosclerosis
and diabetic nephropathy, such that this bias worked against
our hypothesis. (3) We feel that our patients tended
consciously or not, to make us overestimate the quality
of their glycemic control (cheating in the notation of urine
tests, treatment followed more rigorously prior to the visit)
but we do not see why this error of estimation would have
been more frequent in those patients free of any complications.
It is impossible for us to evaluate the importance of these
statistical biases on the final evaluation. Our impression is
that they could have cancelled each other out in such a way
that the correlations we found correspond to reality.
It has often been emphasized that the patient who obtains
good glycemic control is often more careful of his health
and for this reason has better general hygiene, which could
prevent him from getting certain complications. This is true
for gangrene and infections (not studied here) and possibly
for atherosclerosis (a poor diet of saturated fats), but one
cannot understand how better hygiene and better care of
health could protect the patient from retinopathy, glomerulo-
sclerosis, or neuropathy. As it turns out, our study demon-
strates the correlation between good glycemic control and
the three specific complications, precisely those not
believed to be influenced by general hygiene, and the
study shows no correlation between good glycemic control
and atherosclerosis.
Atherosclerosis
Peripheral and coronary atherosclerosis in our diabetic patients
increased very strongly in prevalence and in incidence with
DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978 257
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7. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
TABLE 4
Prevalence of one, two, or all three specific complications as a function of chronic hyperglycemia and its control (if any)
Reference
No.
of
patients
Ages
at
onset
Dura-
tion of
diabetes
(yrs.)
Method of estimating degree of control
Subjective
(S)or
objective
(Ob)
Based on
means (M)
or on
results (R)
Annual and
cumulative
(AC) or
global (G) Validity
Effect on
Neur. Neph. Retin. Remarks
Root et al.
Dunlop
Matthews
Matthews
Pirart and Schoys-
man-De Boek
1954
1954
1954
1955
155 Juv.
1955
Rogers and Holcomb 1960
Aagenaes
Pirart
Constant
1963
1965(a)
1965
Constam m
Pirart and Coers 1969
Constam
Dolger
Wilson et al.
Keiding et al.
Jordan
1972
1947
1951
1952
1936
167
545
1,145
114
33
1,135
300
623
434
247
451
200
All
All
All
All
All
All
All
All
All
<50
<30
<30
All
(137)
All
All
>25
Long
All
>20
>20
>20
All
All
S & Ob M & R
Ob R
(Not defined)
Ob
S&Ob
S
Ob
Ob
Ob
Ob
S&Ob
S&Ob
S&Ob
S&Ob
R G
M & R G
(Not defined)
M G
R G
R
M&R G
(Poorly defined)
M&R
M&R
M & R G ?
(Degrees of control not defined)
Rundles
Martin
Fry et al.
Greenbaum
Pirart
Noel et al.
Root et al.
Appel
Spoont et al.
Mellinghoff
Schwarz
Lundbaek
Lambie and
McFarlane
Hardin et al.
Mohnike
El Mahallawy
and Sabour
McNeal and Rogers
Sauer
Skouby
Buschmann et al.
Paul and Presley
Downie and Martin
1945
1953
1962
1964
1965(a)
1971
1959
1950
1951
1953
1953
1953
1955
1956
1957
1960
1955
1956
1956
1958
1958
1959
125
150
62
80
58
22
840
370
50
22
43
234
120
132
2,600
391
103
58
286
1,547
29
47
All
All
All
All
All
All
All
All
All
All
All
All
All
<15
All
All
*
<40
All
Juv.
Juv.
All
All
All
All
All
All
All
All
>10
>9
>10
>15
All
>10
All
All
All
>10
All
All
>25
>20
Ob
?
Ob
Ob
S & O b
Ob
Ob
Ob
Ob
Ob
Ob
Ob
Ob
Ob
S & O b
Ob
S & O b
(Not defined)
(Not defined)
R G
7
?
±
? G ?
(Degrees of control not defined)
R
R
M & R
(Not defined)
R
R
R
R
R
R
R
R
R
G
G
G
AC
G
G
G
G
AC
G
AC
G
(Poorly defined)
M & R G
(Not defined)
M & R G
(R not defined)
R G
±
±
±
0
+
±
±
±
±
±
+
±
0
0
7
0
±
• A
A A
A A
A A
Selected: all affected with triopathy
Taking into account fluctuations of control
over the years
Selection: all suffering from neuropathy
Selection: all suffering from proliferative
retinopathy
Large initial cohort
Out of 267 patients, duration >10 years
Autopsies; glycemic control known in 78 cases
According to their data, but not their
conclusions
258 DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978
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8. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
TABLE 4 (Continued)
Reference
Lestradet
Markman et al.
1959
1959
No.
of
patients
420
210
Ages
at
onset
<15
All
Dura-
tion of
diabetes
(yrs.)
All
All
Subject™
(S)or
objective
(Ob)
Ob
Ob
Method of estimating degree of control
Based on Annual and
means (M) cumulative
or on (AC) or
results (R) global (G) Validity
Effect on
Neur. Neph. Retn Remarks
Cugudda and
Stramignoni
Johnsson
Collyer and Hazlett
Lestradet and Billaud
Thieffry et al.
Leonetti,
Francois et al.
1959
1960
1961
1968
1972
19731
1976 1
373
159
100
86
269
204
All
<40
<16
<15
<15
<16
All
All
Schlesinger et al.
Mulder et al.
Munck et al.
Darnaud et al.
Knowles et al.t
Thomsen
Olaffesson and
Petersen
Gamstorp et al.
Szabo et al.
Burditt et al.
Caird et al.
Balodimos et al.
Miki et al.t
Goto et al.
Jarrett
Jarrett and Keent
Miki et al.
Pense et al.
Lauvauxt
Pirartt
(present study)
1960
1961
1961
1963
1965
1965
1966
1966
1967
1968
1969
1969
1969
1970
1972
1975
1973
1973
1976
1976
41
103
419
76
78
102
66
107
324
990
299
152
289
285
207 1
248 J
333
180
398
<40
All
±40
<18
<16
All
<15
<17
All
All
All
**
*
All
*
*
**
All
All
All
>10
All
All
>10
>10
All
All
All
>10
All
>10
>8
All
All
5
10
All
>20
All
>15
(339)
>20
(164)
R G ±
R G ±
(Weakened by penalty for hypoglycemia)
S & Ob M & R
S M
Ob M & R G
(Criteria of control not defined)
Ob
S &Ob
R
0
(Vague)
Ob R G ±
(Criteria of good control undemanding and
weakened by penalty for hypoglycemia)
Ob R G ±
(Not defined) 0
Ob R ?
(Extrapolated from observations in the hospital)
Ob M&R G +
0
0
Ob
&Ob
Ob
Ob
Ob
Ob
Ob
Ob
R
M & R
(Not defined)
R
R
R
R
R
R
G
G
G
G
G
G
G
G
(Not defined)
(Only initial glycemia)
Cannot
be ex-
trapolated
Ob R
Ob R
Ob R
G
iy 5-yr.
classes
AC
A
0
A
A
A
A
+
+
A
A
A
A
A
+
A
A
A
A
A
A
0
A
A
A
A
A
A
A
A
A
+
A
±
+
0
A
A
A
+
+
+
+
+
A
+
Initial cohort of 93 cases
Two groups treated successively
were compared
Questionnaires sent to several centers
Selection for neuropathy
Selection: all insulin-dependent
All poor control, so comparison is impossible
Renal biopsies
Subclinical neuropathy
Comparison of first five years with
following years
Prospective for evolution, retrospective for
prevalence
Pinpointed cases of limited diabetes
Cases with borderline diabetes compared
with 116 true diabetes all screened in a
detection drive
Retrospective for prevalence
Continuous follow-up
Continuous follow-up, large initial cohort
Neur., neuropathy; Neph., nephropathy; Retin., retinopathy.
* Especially middle age.
** Middle age.
t Those few studies that were prospective.
" Number of patients in parentheses.
A Complications not studied.
The validity of the affirmed or denied relationship between glycemic control and complication was assessed according to objective (reproducible) value of the estimated control (reliability, frequency,
and schedule of blood sugar and urine sugar tests), statistical methods (in particular the constitution of comparable groups), and validity of the conclusions drawn from the data as presented. No judgment is
implied either of the quality of care given or of the observations. A severe critique does not necessarily contradict the authors' opinion of their own work, which could have been pursuing other
principal goals other than the study of control or could have met with insurmountable difficulties in the evaluation of glycemic control.
DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978 259
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9. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
age whatever the duration of diabetes, which agrees with
all that is known about vascular disease in both the general
and diabetic populations.12
'53
*80
*101
'103
*175
The effect of age
cannot be studied except in large samples not biased by selec-
tive recruitment of diabetic patients or by the selective
research of vascular disease among those who complain of it.
A comparison of the mean ages of appearance of an occlusive
arteriopathy in juvenile diabetes and in maturity-onset
diabetes102
or between insulin-dependent and mild cases does
not make any sense unless both groups are of comparable
age at the time of the study, which is generally not the
case. Besides, it is difficult to eliminate the duration fac-
tor in juveniles when observed at middle or advanced age.
The development of arteriopathy increases with the dura-
tion of diabetes12
*101
'158
'184
but so slowly that this rise is not
discernible in small samples53
'154
'175
especially if these are
heavily loaded with a great number of "precocious" cases,
i.e. those suffering from nonspecific complications either
before diabetes or at "onset." And this is all the more so
as the discovery of one of the two illnesses often entails the
discovery of the other. In our series, arteriopathy is more fre-
quent in cases of mild diabetes since the onset of the illness,
and it appears later more often in mild cases than in insulin-
dependent ones. This agrees with the consensus of a greater
frequency of arterial lesions in diabetes, even in mild
cases, than in the control population,131
and of a correlation
between coronary atherosclerosis and mature age.204
Arteriopathy is more frequent in diabetes, even in mild or
borderline diabetes, than among subjects whose glucose tol-
erance is normal. Numerous studies of glucose tolerance in
patients with atherosclerosis as well as studies of athero-
sclerosis in subdiabetic and diabetic subjects have shown
this with perfect agreement.77>81
*83
*93
*102
~103
*131
Artery dis-
ease seems to be more frequent in cases of true diabetes
than in cases of borderline diabetes, as much in prevalence82
as in incidence.49
'71
However, among the clearly hyperglycemic subjects,
arteriopathy is not in any way related to the severity of
diabetes. On the contrary65
'88
'158
'175
-184
-188
'198
peripheral
artery disease and coronary insufficiency are therefore very
often related to mild diabetes.
This relationship between atherosclerosis and mild dia-
betes is only in part explicable by middle age, which is a
common feature of both, for we have found it at all ages and
at all durations of diabetes. It is not explained by obesity
either, for we have found only a weak correlation with
maximum weight reached before diabetes and no correlation
between arterial disease and present obesity (in spite of the
frequent association between obesity and hypertension and in
spite of the effect of overweight on the appearance of angina
on exertion, which facilitates the detection of it). We thus
confirm diverse studies on coronary artery101
'198
and on
peripheral artery12
*65
disease. Nevertheless, in cases of long-
term diabetes, almost all of which have been treated with
insulin, two groups135
-159
have observed a clearly unfavor-
able effect of present obesity, which was not explainable by
a lesser degree of glycemic control. Isolated obesity (dis-
sociated from hypertension, from high cholesterol, and from
old age) plays a reduced role in the general population, as
Yater et al. ,206
Spain et al. ,181
and the extended research of
the Framingham study78
'79
have shown.
Finally, we were not able to show the least favorable ef-
fect of good glycemic control on the prevalence and the
incidence of both arterial lesions, which confirms the majority
of previous observations.31
'65
-106
-119
-135
'154
'172
That does not at all exclude an effect of the intensity of
diabetes (severity and degree of glycemic control) on the
development of Monkeberg's nonocclusive medial sclerosis.
We did not study it. It shows up on X-rays of the most distal
arteries of the upper and lower limbs in long-term severe
diabetes84
'103
-123
-202
-205
and as a reduced arterial elasticity
measurable by an increased speed of propagation of the pulse
in diabetic patients, even without hypertension, and even
more so in insulin-dependent diabetic patients.171
In patients with juvenile diabetes for more than 15 years84
and among diabetic patients of middle age affected for more
than five years,171
medial sclerosis is related to poor glycemic
control. There are some correlations (same arteries in the
same subjects) between medial sclerosis and atherosclerosis54
in the same way that there is a correlation between micro-
and macroangiopathy in young, long-term diabetic pa-
tients.104
It is, therefore, possible that arteriosclerosis in its
diverse forms can be influenced by the treatment of diabetes,
but its multifactorial origin49
*79
and its strong association
with aging render a demonstration of this difficult. It stands
out clearly from our work as well as from that of Pense et al.135
that the three specific complications on the one hand and the
two localizations of atherosclerosis on the other hand behave
very differently with regard to the intensity of diabetes.
Everything indicates that arteriopathy, either in the presence
or the absence of diabetes, is determined by factors much
more complex (genetic or not) than the specific complica-
tions of diabetes. These latter seem to have a similar fre-
quency in all the populations of the world, while artery
disease is distributed very unequally in the diverse diabetic
populations so far studied.71
'201
CONCLUSIONS
A
fter careful analysis of the enormous literature
dedicated to the specific and nonspecific
complications of diabetes, two impressions
emerge: (1) The rigor of most of the statistics
leaves something to be desired particularly in the contro-
versial sphere of the effects of metabolic control. No one
satisfies most of the methodological requirements set out in
the introduction. (2) Despite the apparent chaos resulting
from the study of different populations examined by dif-
260 DIABETES CARE, VOL. 1 NO. 4, JULY-AUGUST 1978
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10. DIABETES MELLITUS AND ITS DEGENERATIVE COMPLICATIONS / JEAN PIRART
ferent methods, one finds however a general agreement on
the relationship between the three specific lesions and the
duration and intensity of diabetes.
Our study fulfills 22 of the 23 criteria of validity re-
quested by the most severe critics. It conclusively proves
that diabetic triopathy and not atherosclerosis is a func-
tion of the duration and intensity of diabetes and more
precisely of hyperglycemia.
Of course, this can be lessened by treatment. This fact
should encourage physicians to strive toward normoglycemia
in diabetes therapy, while at the same time recommending
various methods of hygiene which could slow down the
development of atheromatosis and of hypertension.
A
C
K
N
O
W
L
E
D
G
M
E
N
T
S
: It is impossible for us to acknowledge each
of the many people whose collaboration enabled us to
achieve a study of this magnitude. Therefore, the names
of the many assistants who helped at our clinics will not
necessarily appear on the articles to be published on
each of the problems dealt with in this survey. We were
fortunate enough to have access to valuable records which
our predecessors had carefully kept at their practices:
at the Cesar De Paepe Clinic (Dr. Purnal), at the Brugmann
Hospital (Dr. Rutman), and at the Saint-Pierre Hospital
(Doctors Mahaux and Corvilain). We have relied on the
precise ophthalmological descriptions from the two uni-
versity hospitals (Prof. Danis) as well as on those from the
Cesar De Paepe Clinic (Dr. Claessen). It is thanks to the
diligence of our nurses that we were able to keep ourfilesup to
date. Some of these nurses have welcomed our patients for
more than 20 years. Numerous colleagues responded with
precision to our requests for information on the medical
history of our patients or on the hiatus of their curriculum
vitae. Finally, the regularity of our periodic examinations is
due in large part to the punctuality of our patients, even
those who followed our advise poorly. It is their discipline
and their goodwill which made this research possible.
From the Cesar de Paepe Hospital, Brussels, Belgium.
Reprints are not available from the author.
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