[Hyperinsulinism as a major etiopathogenic link with arterial hypertension, hyperlipoproteinemia and hirsutism. II]

The authors analyze mechanism by which hyperinsulinism causes NIDDM, hypertension, hyperlipoproteinaemia and hirsutism (5H syndrome). They demonstrate on a group of their 100 patients with NIDDM and arterial hypertension that, as compared with matched pairs without arterial hypertension, they have significantly higher levels of C-peptide and less favourable parameters of dyslipoproteinaemia. Hirsutism occurs in 10-15% of the adult female population, but in 18.4% women with NIDDM. However, in a group of 48 hirsutic women with NIDDM they did not find, as compared with matched pairs (i.e. women with NIDDM of analogous age, BMI and BP) significantly higher C-peptide and lipid levels. According to the authors congenital insulin resistance modified by numerous endogenous and exogenous factors is eventually manifested in the phenotype, in particular via hyperinsulinism as NIDDM, hypertension, associated with dyslipoproteinaemia and obesity which then, as the main risk factors, condition a high cardiovascular morbidity and mortality. Although hirsutism and the polycystic ovary syndrome are associated with hyperinsulinism, their interrelation is probably less close and thus has not such a negative impact on national health.

[Clinical manifestations of insulin resistance. The hormonal-metabolic syndrome X (5H), its prevalence and impact on cardiovascular morbidity and mortality. I]

Insulin resistance (prereceptor, receptor, postreceptor) is a complex phenomenon. It penetrates into the clinical picture via hyperinsulinism as impaired glucose tolerance, or NIDDM, as hyperlipoproteinaemia, arterial hypertension and hirsutism in women (syndrome 5H) associated with the polycystic ovary syndrome or the HAIR-AN syndrome. Based on a group of their 480 patients with NIDDM, 108 women with hirsutism, 320 patients with myocardial infarction and the results of the national cardiovascular programme the authors estimate the prevalence of the 5H syndrome as follows: in the general population 5-10%, in patients with arterial hypertension 15-30%, in NDDM 65-90%, in hirsutic women 10-20% and in patients with myocardial infarction 30-50%. These figures could be, however, substantially higher if as the criterion the IRI response was taken or that of C-peptide in OGTT or the results of the hyperinsulinaemic euglycaemic clamp. The clinical 5H syndrome is a phenomenon of latent insulin resistance perceived late by doctors and patients.

Impairment of contractile response to carbachol and muscarinic receptor coupling in gastric antral smooth muscle cells isolated from diabetic streptozotocin-treated rats and db/db mice

This work explored the role of the cholinergic pathway, assessed at a post-synaptic level by the use of isolated smooth muscle cells, in the impairment of antral motility associated with diabetic gastroparesis. Contractile response to carbachol--but not to erythromycin, a motilin receptor agonist--was abolished in antral smooth muscle cells isolated from (i) rats previously rendered diabetic by a single i.v. dose of streptozotocin (STZ, 60 mg/kg) and (ii) db/db spontaneously diabetic mice. Insulin treatment of STZ-rats was able to prevent the impairment of the carbachol contractile response, but not to reverse it once established. In STZ-rats, impairment of contractile response was not associated with a change in density of [3H]-N-methyl-scopolamine ([3H]-NMS) binding sites (approximately 1.5 fmol/mg protein). Displacement curve of the [3H]-NMS binding by carbachol was shifted to the right in diabetic rats as compared to controls. The addition of GTP-gamma-S induced a shift to the right of the displacement curve in control but not in diabetic animals. These results strongly suggest that diabetes is associated with an early and specific alteration of the muscarinic control of contraction of antral smooth muscles at a post-synaptic level, associated with an alteration of the GTP-binding proteins coupled to muscarinic receptors.

Capillary recruitment and pain relief on leg dependency in patients with severe lower limb ischemia

BACKGROUND

Patients suffering from severe lower limb ischemia may experience pain relief on leg dependency despite the fact that dependency normally results in arteriolar vasoconstriction. To clarify this possible paradox, skin microcirculation of the limb was investigated in 75 patients with different stages of lower limb ischemia and in 12 asymptomatic subjects.

METHODS AND RESULTS

Using nailfold capillary video microscopy, red blood cell-perfused capillary density and diameter and red blood cell velocity were assessed in supine and sitting positions. Capillary density increased by changing from the supine to the sitting position, especially in patients with limb-threatening ischemia (showing a 4.5-fold increase versus a 1.5-fold increase in asymptomatic subjects). In subjects without or with mild ischemia, capillary perfusion was two to four times lower in the sitting than in the supine position. In patients with limb-threatening ischemia, perfusion was strongly reduced, being slightly higher in the sitting position. Patients with relief of pain while sitting did not always have a higher capillary perfusion but did have a higher capillary density in the sitting position.

CONCLUSIONS

The arteriolar postural vasoconstrictive mechanism at the nutritive level is still intact in subjects without or with mild ischemia but not in patients with severe ischemia. Capillary recruitment rather than disturbed arteriolar vasoconstriction could explain why patients with severe leg ischemia prefer leg dependency.

Skeletal muscle density: effects of obesity and non-insulin-dependent diabetes mellitus

Obesity is associated with increased lean mass but its effects on lean-tissue density are less clear. To examine the effects of obesity and non-insulin-dependent diabetes mellitus (NIDDM) on lean-tissue composition and density, cross-sectional computed tomography (CT) scans of the midthigh were obtained in 20 men of various weights. Obesity was associated with increases in thigh-adipose (r = 0.75) and lean-tissue volumes (r = 0.52) and with reduced density of lean tissue (r = -0.73). The increased lean tissue in obesity was due to a nonadipose tissue component with a density below the normal range of muscle, an effect compounded by NIDDM, whereas normal-density muscle volume was unchanged.

Continuous ambulatory peritoneal dialysis (CAPD) in patients with diabetic nephropathy

A 3-centre study was done to analyse the results of 70 patients with end-stage renal disease caused by diabetic nephropathy and treated with CAPD. Fifty patients had insulin-dependent diabetes (mean age 42, mean duration of diabetes 24 yr); 20 had non-insulin-dependent diabetes (mean age 61, mean duration 15 yr). Total treatment time was 1563 months and ranged from one to 83 months (median 18). Patient survival was 86% at 1 yr and 33% at 4 yr. Technique survival was 87% and 63%. Cox's multiple hazard regression analysis showed that age above 45 yr (relative risk 2.2), systolic hypertension (2.6) and cardiac disease (2.2) at the start of CAPD were associated with shorter patient survival. Metabolic control was good. Haemoglobin rose during the first 3 months. Plasma creatinine concentration increased with time, probably due to the loss of residual renal function. HbA1c levels were in the normal range for 60% of the patients. Mean hospital stay was 42 days per year, 26 as a consequence of vascular complications and 16 due to peritonitis and catheter-related problems. We conclude that CAPD is a good renal replacement modality for patients with diabetic renal failure. The patient survival is dependent on age, systolic hypertension and cardiac disease at the start of CAPD.

[Level of knowledge of patients with type II diabetes mellitus in primary care]

A personal interview to 148 patients was carried out with the aim of getting to know the level of information of type II diabetic patients at an Urban Health Center in Santander. A validated questionnaire made up of 14 questions on general aspects of diabetis, dietetic habits and capability to handle complications was used. The Cronbach's alpha coefficient of questionnaire was 0.69. The correct answer average was 6.3 (IC = 5.9-6.5). Patients were best informed about general aspects and had much less information with regard to the handling of complications and to their diet. The differences among these three sections of questions were significative (p less than 0.001). The patients under diet treatment obtained worse results than those treated with oral hipoglucemiants and insulin. Our results are worse than those reported by other similar populations at a national level. Also, and due to the differences in knowledge within this group, we believe that the establishment of groups and subgroups when educating diabetic patients is possible and also highly recommended.

Prevalence of diabetic nephropathy in non-insulin dependent diabetics

Renal involvement was studied in 538 consecutive NIDDM subjects (271 males and 267 females). The mean (SD) age of males was 55.4 (11.0) and of females 51.0 (10.5). Diabetic nephropathy was present in 8.9 per cent of the patients (urinary albumin excretion greater than 200 micrograms/min) and another 19.7 per cent had microalbuminuria (20-200 micrograms/min). Male predominance was striking in the macroalbuminuric group (P less than 0.001). The age of the patients and duration of diabetes in patients with micro and macroalbuminuria were significantly higher as compared to those in normoalbuminuric group (P less than 0.001). Patients with micro and macroalbuminuria had significantly elevated blood sugars and blood pressures (P less than 0.01). The prevalence of vascular complications were found to be higher in the macroalbuminuric group (P less than 0.01). Male sex, older age, longer duration of diabetes, poor glycaemic control and raised blood pressure were significant risk factors in the development of diabetic nephropathy.

Candida albicans pacemaker site infection

A 69-year-old man with a history of diabetes and episodic lymphocytopenia underwent pacemaker implantation for complete heart block. Despite prophylactic antibiotics, pocket irrigation, and strict sterile technique, a fungal (Candida albicans) pacemaker site infection developed that required pacemaker explanation and systemic amphotericin B therapy. After 3 days of temporary pacing, a second pulse generator was implanted on the opposite side. At 2-year follow-up, he has had no recurrence of pacemaker infection. This report underscores the predilection of diabetics for infections, and in particular, their susceptibility to Candida albicans.

Drug consumption in elderly subjects with occult fasting hyperglycaemia

Drug consumption was studied in 87 persons with occult fasting hyperglycaemia and compared with sex- and age-matched non-diabetic controls all selected by screening a well-defined population aged 60-74 years. The daily use of prescribed and nonprescribed drugs was established by questionnaires and interviews. Sixty-nine percent of subjects with fasting hyperglycaemia used drugs daily compared with 46% of controls (P less than 0.005). The difference was most pronounced among men. The median use of defined daily doses in those using drugs was not significantly different in the two groups. The main drug usage in both subjects with fasting hyperglycaemia and controls was in the cardiovascular medication group. More than half (59%) of the subjects with fasting hyperglycaemia used cardiovascular drugs compared with 27% of controls (P less than 0.0001). There were no significant differences in the other medication groups. Our results may reflect an increased morbidity from cardiovascular diseases among the elderly with occult fasting hyperglycaemia, and they seem to be comparable with the results on drug consumption found in the elderly with known diabetes.

Sensory neuropathy in non-insulin-dependent diabetes mellitus. The San Luis Valley Diabetes Study

A screening neurologic examination capable of detecting distal symmetric (sensory) neuropathy in a large population-based study of non-insulin-dependent diabetes mellitus in San Luis Valley, Colorado, in 1984-1986 is described and validated. The examination, completed in 279 diabetics and 577 controls, had 90% agreement with a standard neurologic examination completed on a subsample of 38 patients. Independent validation of neuropathy status was obtained with the Optacon tactile (vibration) stimulator. Mean, age-adjusted vibration threshold was significantly greater in those with neuropathy than in those without. The subtests of the examination most sensitive in detecting neuropathy were a combination of a positive history of neuropathy symptoms and decreased or absent deep tendon reflexes in both ankles. Age-adjusted prevalence of neuropathy in controls, those with impaired glucose tolerance, and diabetics was 3.9%, 11.2%, and 25.8%, respectively. Prevalence odds ratios were 3.5 and 10.6 for the presence of neuropathy in persons with impaired glucose tolerance and diabetes, respectively, compared with persons with normal glucose tolerance. Neuropathy was significantly associated with age, duration of diabetes, male sex, and glycemic control, but not with Anglo/Hispanic status.

Who joins the BDA?

A comparison of demographic and clinical characteristics was made between a random sample of members and non-members of the British Diabetic Association (BDA) of working age (17-65 years) who responded to a questionnaire concerning their employment. There were large regional variations in BDA membership, but overall 27% of responders were BDA members. Of the responders, BDA members were more likely to be women than men (30 vs 25%, p = 0.04) and under rather than over the age of 36 years (38 vs 21%, p less than 0.001). A greater proportion of insulin-treated patients with diabetes were BDA members compared with patients who were not treated with insulin (37 vs 13%, p less than 0.001). Unemployment was significantly less amongst BDA members compared with non-members (12 vs 20%, p less than 0.001). Membership decreased with decreasing social status, with significantly more house-owners being BDA members compared with those living in rented accommodation (31 vs 23%, p less than 0.001).

Dental status in a group of adult diabetic patients

The aim of this study was to determine the prevalence of dental caries, DMFT score and treatment needs in a group of diabetic patients (n = 222), mean age 46.9 yr, and to compare them to those recorded in a control group (n = 189), mean age 43.9 yr, using WHO criteria. Relations between the type and duration of diabetes mellitus, diabetic complications (retinopathy and neuropathy), diabetic control, and the subjects' DMFT status were separately studied. The results obtained revealed no difference in the prevalence of caries between the group of diabetics and the control group. Neither was any difference found in the mean numbers of teeth with fillings, but the number of extracted teeth per subject was significantly higher in the group of diabetics (12.3) than in the control group (9.7) (P less than 0.01). Type I diabetics were found to have a significantly higher number of teeth with fillings (4.05 vs. 2.22) than the non-insulin dependent diabetics (P less than 0.001). Type II diabetics, however, had a significantly higher number of extracted teeth (14.1 vs. 10.4) (P less than 0.001). There was no difference in the caries experience regarding duration of diabetes, diabetic control, or diabetic complications.

[Incidence and developmental interdependence of peripheral nerve disorders in type 2 diabetics]

In 1987-1988 160 type 2 diabetics, dispensarized in diabetological out-patient departments of the medical clinic of the Institute for Postgraduate training were subjected to neurological examinations. The selection of the group was governed by an effort to reduce to a minimum the association of other neurotoxic influences. The group therefore comprised subjects under 60 years of age; diabetics with other diseases with a possible neurotoxic action, drug abuse, alcohol abuse, etc. were eliminated. After a detailed neurological examination signs of affection of the peripheral nervous system were detected in 87.5%, clinically manifest diabetic neuropathy was found in 78 diabetics (48.75%); 12 had moreover mononeuropathy of the median nerve. The clinical picture was uniform: impaired perception of vibrations on the acra of the lower extremities with ascendent propagation, reduction to disappearance tendinous-muscular reflexes on the lower extremities. Subjectively more frequently cramps of the feet than paraesthesias were reported. The authors revealed that long-term compensation of diabetes, the duration of diabetes and the biological age of the diabetics were statistically significant for the manifestation of diabetic neuropathy. This significance was proved for the factor of biological age (p less than 0.05); there was also a significant correlation between the long-term state of compensation of type 2 diabetes and the manifestation of neuropathy (p = 0.06).

Gestational diabetes in the BHE rat: influence of dietary fat

Two studies were performed to assess the effect of fat feeding on glucose tolerance before, during, and after gestation of BHE rats. In the first study 5% or 22% fat diets were fed from 3 weeks before mating until after gestation. In the second study, these diets were fed from weaning until 400 days of age. Glucose tolerance before and after gestation was not affected by diet in the short-term study. At 19 days' gestation, glucose tolerance had deteriorated in the pregnant rats that were fed with 22% fat diet. In the long-term study, abnormal glucose tolerance was observed before mating in rats that were fed the 22% fat diet. Tolerance improved during gestation and post partum, but still was not normal. Fertility and pup survival were significantly (50%) reduced in rats that were fed the 22% fat diet. These findings suggest that either short-term or long-term feeding of a 22% fat diet to BHE rats results in a model for human gestational diabetes that might be worthy of further study.

"Making sense" about diabetes: Dakota narratives of illness

Diabetes, as it has increasingly affected Dakota (Sioux) in a North Dakota community, is deliberated upon by patients in commentaries that range beyond the more familiar biomedical "boundaries" of a given health condition. These commentaries--or "narrative reconstructions"--following Williams and Wood's (1986) considerations of patients "making sense" of illness and the disruption it may cause, touch upon larger concerns of Dakota regarding culture history and identity. While individuals' interpretations regarding etiology, illness experience, and efficacy of treatments vary, diabetes emerges as a symbol that conveys meaning at many levels. That diabetes treatment may impinge on customary foodways makes imagery of diabetes perhaps more salient. Health workers, trained within the "culture of biomedicine" (Hagey 1984), may learn to recognize key elements in such narratives for cooperative efforts in diabetes education and treatment.

Body mass index in non-insulin dependent diabetics in Kenya

Weights and heights of 674 consecutive non-insulin dependent diabetics and 358 control urban healthy Kenyans were recorded prospectively. Weights and heights of a further 162 healthy rural adults were compared retrospectively. The body mass index (weight/height2) of the non-insulin dependent diabetic was lower than that of the corresponding urban control subject. The body mass index of the rural folk was consistently lower than that of the urban dweller. This study concluded that obesity may not be a significant factor in non-insulin dependent diabetes in the African black.

Report of the American Diabetes Association's Task Force on Nutrition

Writing in the sixteenth century B.C., the Egyptians described diabetes as the dissolving of flesh in urine and promoted its treatment with diets high in carbohydrate as a means of combating the loss of fuels. Early in the first century, Aretaeus of Cappadocca endorsed these suggestions, recommending a diet of milk, cereals, and starch. By the early twentieth century, the whimsical rice, potato, and oatmeal diets had evolved from these beginnings and reached the apex of their popularity. The noted physician Willis—possibly more famous for the description of a circle of blood vessels at the base of the brain—endorsed such diets on the basis of the appearance of sweetness of the urine. Thus, many a medical student was obliged to taste urine before the advent of more advanced technology. Now a more sophisticated method is employed in which a treated strip of paper inserted in the urine is transposed, to a degree proportional to the quantity of glucose present, into one of the colors of the rainbow—a facility not generally endowed to the human taste bud.

Development, validation and application of computer-linked knowledge questionnaires in diabetes education

Multiple choice questionnaires (MCQs) capable of being marked manually or by a newly developed optical mark reader, or by use of an inexpensive inter-active microcomputer system have been developed for the separate assessment of insulin-dependent and non-insulin-dependent patient knowledge. Forty-six insulin-related and non-insulin-related multiple choice questions covering six main areas of knowledge were constructed for inclusion into draft questionnaires. From the responses of a total of 180 completed questionnaires, piloted in 18 randomly selected clinics in 14 Regional Health Authorities in England, psychometric analysis was performed to determine reliability, discrimination coefficients, and facility indices. Seventy-three per cent of insulin-dependent diabetic patients (IDDM) and 92% of non-insulin-dependent diabetic patients (NIDDM) MCQ correct options had facility indices within the acceptable range of 30 to 90%. 82% IDDM and 93% NIDDM correct options had discrimination coefficients exceeding 0.2. Questionnaire reliability (internal consistency) using the Kudor-Richardson (KR20) formula was IDDM 0.87 and NIDDM 0.82. Evidence in support of the IDDM questionnaire's criterion validity was based on significant differences (p less than 0.05) identified between a number of knowledge area scores stratified according to HbA1 levels. Prescriptive correction for screen display and automatic hard copy feedback was designed for both incorrect and omitted question options, providing both educational (patient) and analytical (clinic) documentation. Both technical and psychometric properties of these knowledge assessment instruments should be acceptable for diabetic knowledge evaluation and instruction.

Type II diabetic subjects lose less weight than their overweight nondiabetic spouses

To determine whether diabetic individuals have more difficulty losing weight than nondiabetic individuals, 12 overweight diabetic subjects (6 men, 6 women) and their overweight nondiabetic spouses were treated together in a behavioral weight-control program. Diabetic and nondiabetic subjects did not differ in age, weight, or percent overweight. Weight losses of nondiabetic spouses were significantly greater than those of diabetic patients (13.4 +/- 1.7 vs. 7.5 +/- 1.4 kg; P less than .01). Differences emerged by wk 5 and became greater over the 20-wk program. Nondiabetic subjects reduced their intake significantly more than diabetics, suggesting that differences in dietary adherence were responsible for the differences in weight loss.

Evaluation of an Audiovisual Diabetes Education Program: negative results of a randomized trial of patients with non-insulin-dependent diabetes mellitus

A randomized controlled trial was conducted to determine whether an education program specifically designed for patients with non-insulin-dependent diabetes and limited literacy could improve and sustain glucose and weight control. From a referral clinic, 120 obese (greater than 130 per cent of ideal body weight) diabetic patients who were not taking insulin were recruited. Of these, 55 per cent were female and 49 per cent were black; the mean age was 53 years. Mean glycosylated hemoglobin (HbA1%) was 10.2 per cent. Each subject was assigned to one of three groups: monthly group sessions with videotapes for diabetic persons with low literacy skills; monthly group sessions without videotapes; or no monthly sessions. After seven months, there had been 16 dropouts (13 per cent). Differences in weight changes between groups were significant (p less than 0.05); group 1 lost a median of 1 kg of weight (p less than 0.05) compared with a 0.1-kg loss and no change in groups 2 and 3, respectively. This weight loss was not sustained at 11 months. There was no significant change in HbA1%. Age, education, and compliance beliefs did not predict outcome. The authors conclude that the patient education programs did not result in sustained glucose or weight control.

Failure of genetically selected miniature swine to model NIDDM

Ten young adult miniature swine from a line reported to be genetically selected for glucose intolerance and eight normal controls were obtained from Colorado State University. They were consecutively exposed to 4 mo of a high-fiber, low-fat standard swine diet; 4 mo of a high-sucrose, high-fat, low-fiber diabetogenic diet; and 4 mo of excess diabetogenic diet for obesification. Results of oral glucose tolerance and intravenous insulin tolerance tests conducted at the end of each regimen were compared. Hyperglycemia was not observed in any animals after any manipulation. Insulin sensitivity was also not influenced by diet. We conclude that F7 low-K miniature swine from this colony fail to model human non-insulin-dependent diabetes.

The diabetes education team in the management of non-insulin-dependent diabetes mellitus

Non-insulin-dependent diabetes mellitus (NIDDM) is a complex disease that lasts a lifetime. It can be controlled but not cured. Treatment involves extensive changes in the patient's lifestyle, particularly in the areas of diet and exercise, which can often result in noncompliance with treatment regimens. Efforts to bring about these lifestyle changes usually require an enormous amount of time and attention on the part of the physician, and thus, are best carried out with the help of a diabetes education team. An ideal team would consist not only of the physician, patient, and family, but also a diabetes educator, a nutritionist or dietitian, an exercise therapist, a psychologist or social worker, a podiatrist, and an ophthalmologist or retinologist. A smaller number of team participants can offer a viable alternative by doubling up discipline areas, and by using interested members of the community as a referral source.

Peripheral neuropathy in tropical pancreatic diabetes

Electrophysiological evaluation of peripheral neuropathy was done in 16 patients with tropical pancreatic diabetes (TPD) and the data compared with those of a matched group of 16 NIDDM patients. Peripheral neuropathy was present in 6 TPD and 5 NIDDM patients. Abnormal motor conduction velocity in the lateral popliteal nerve was seen in 9 TPD patients and in 8 NIDDM patients and biothesiometry was abnormal in 7 patients in each group. One TPD patient had an abnormal F wave in the lower limb. An abnormal sensory potential was recorded in the sural nerve in 6 TPD and 8 NIDDM patients. The study showed that occurrence of peripheral neuropathy in TPD was similar to that in NIDDM. Subclinical neuropathy could be detected by electromyographic recording in both groups of patients.

Effects of meals on hemodynamics: implications for antihypertensive drug studies

The ingestion of food is known to affect blood pressure and heart rate, but food is often allowed in patients under observation for antihypertensive drug effects. Seventy-seven patients with essential hypertension were observed for 8 hours after a 16-hour fast. Thirty-six continued to fast, 20 ate a high-carbohydrate meal, and 21 ate a meal of their own choice. Blood pressure and heart rate did not change during fasting, but both meals lowered mean supine and standing diastolic blood pressures during the subsequent 4 hours by 3 to 7 mm Hg (P less than 0.001). The high-carbohydrate meal reduced supine systolic blood pressure by 6 mm Hg (P less than 0.0001). Both meals increased supine and standing heart rates by 5 to 8 bpm (P less than 0.001). After the self-selected meal, standing systolic blood pressure increased in younger patients but decreased in older patients. Food ingestion during antihypertensive drug studies may interfere with the interpretation of results and should be avoided whenever possible.

Anaesthesia and the diabetic patient

Since it is estimated that 1 out of every 2 diabetic patients will require surgery at some point in his lifetime, it is imperative that the anaesthetist should understand the disease process as well as the anaesthetic problems associated with it. This article emphasizes the medical, surgical and anaesthetic aspects of the treatment of patients with diabetes mellitus.