Diabetes mellitus: an underestimated public health program

An Analysis of The Morbidity and Mortality of Diabetes Mellitus in a Forensic Context

To investigate the spectrum of diseases seen in diabetes mellitus in a forensic context, all autopsy reports of diabetic individuals who presented to Forensic Science, South Australia (FSSA), over a 5-year period from 2005 to 2009 were studied. The leading cause of death was cardiovascular disease (55.0%), followed by unnatural deaths (15.4%) and infections (9.4%). In type 1 diabetics, principal causes of death included cardiovascular disease (44.7%), acute metabolic complications (18.7%), unnatural deaths (17.9%), and infections (8.9%). However, frequencies of these diseases differed in type 2 diabetics, with cardiovascular events responsible for 56.6% of cases, followed by unnatural deaths (15.0%) and infections (10.9%). A larger number of male deaths were seen in all disease categories, except respiratory and gastrointestinal where the frequencies were similar to females. Cardiovascular disease was the leading overall cause of death across all ages except in those under the age of 30 where metabolic complications were more common.

Does Arsenic Exposure Increase the Risk for Diabetes Mellitus?

OBJECTIVE

Long-term arsenic exposure has been reported to associated with prevalence, incidence, and mortality of diabetes mellitus (DM). A tap water supply system was implemented in the early 1960s in the blackfoot disease (BFD) endemic areas. The objective of this study is to examine whether DM mortality decreased after the improvement of drinking water supply system through elimination of arsenic exposure from artesian well water.

METHODS

Standardized mortality ratios (SMRs) for DM were calculated for the BFD endemic area for the years 1971-2000.

RESULTS

The study results show that mortality from DM declined in females (but not in males) gradually after the improvement of drinking water supply system.

CONCLUSIONS

Based on the reversibility criterion, the association between arsenic exposure and DM is likely to be casual for females but not in males.

Mortalidade por diabetes mellitus e outras causas no município do Rio de Janeiro: diferenças por sexo e idade

Objetivo: O diabetes mellitus (DM) é considerado um problema de saúde pública em razão de sua alta prevalência e pelo fato de que a maioria dos seus portadores não está em tratamento adequado e, portanto, exposta ao risco de desenvolver altas taxas de morbidade e mortalidade. A análise dos registros contidos nas declarações de óbito é uma das formas de se avaliar o impacto desta síndrome na sociedade. Este estudo objetiva analisar comparativamente óbitos por DM e outras causas na população geral do Rio de Janeiro (RJ). Materiais, métodos e desenho da pesquisa: Os dados foram obtidos do banco de dados de Mortalidade da Secretaria Municipal de Saúde do RJ. Compararam-se os óbitos por DM como causa básica ocorridos no município do RJ nos anos de 1994, 1995 e 1996 com os óbitos ocorridos na população geral em relação aos critérios de sexo e grupo etário. Resultados: Até os 50 anos as mulheres com DM e aquelas sem DM apresentam mortalidade proporcional semelhante. Após os 50 anos, as mulheres com DM têm valores percentuais mais elevados do que as sem DM. Já entre os homens, os sem DM têm percentuais de mortalidade maiores até os 60 anos, quando então são ultrapassados pelos portadores de DM. Conclusão: No conjunto dos óbitos nos três anos entre os diabéticos, as mulheres apresentam percentual de mortalidade superior ao dos homens. Já entre as demais causas de óbitos nos três anos, o predomínio foi do sexo masculino. Portanto, sugerindo menor sobrevida das mulheres entre os diabéticos e dos homens entre as outras causas de óbitos.

Cause of death in cerebral palsy: a descriptive study

BACKGROUND

Cause specific research on death certification in chronic disease has rarely involved cerebral palsy.

AIMS

To evaluate cause of death information in people known to have cerebral palsy by: describing the cause of death distribution; determining case ascertainment using death certification as the data source; and analysing the choice of wording and its arrangement in the "cause of death statement". STUDY CASES AND SETTING: People with early or late impairment cerebral palsy who died by 30 June 1998, on the population based Mersey Cerebral Palsy Register born 1966-91 to mothers resident locally.

STUDY DESIGN

Descriptive study of the multiply coded cause of death statements from National Health Service Central Register flagging.

RESULTS

Death certificate copies were acquired for all 282 (13.4%) of the 2102 registered cases who died. Cerebral palsy was the most common "underlying cause of death" (95 of 282; 33.7%) and was mentioned in a further 61 cases. The underlying cause of death was more likely to be cerebral palsy with increasingly severe disability and was derived from Part II in 16 of 95 cases.

CONCLUSIONS

The potential of death certification for case ascertainment of cerebral palsy is important, but limited, even with multiple cause coding. Mortality data need careful interpretation as a proxy source for examining trends and patterns in cerebral palsy.

Mortality and causes of death in patients with diabetes mellitus in Japan

Although the mortality rate of diabetes mellitus in Japan is much lower than the rates in Western countries, an increasing trend has been evident over the last 40 years as a whole. However, the trend shows variations with age; there is an apparent decreasing trend in subjects of 0-35 years of age at death, while there is a remarkable increasing trend in subjects of 75 years of age and over. It appears that the increase in diabetes mortality is largely due to an elevation in the mortality rate in aged subjects and an increase in the size of the aged population in this country. A population-based study of causes of death, carried out in Osaka Prefecture for the period 1960-1989, indicates a remarkable increase in the age at death and significant changes in the causes of death of diabetic patients. Diseases of the circulatory system were found to be the major causes of death other than diabetes, and, among them, a rapid increase in the frequency of disease of the heart was observed. As a cause of death, tuberculosis decreased sharply, while malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis increased during the same period. Among malignant neoplasms, an increase in neoplasm of the liver was marked.

Contribution of developmental disabilities to childhood mortality in the United States: a multiple-cause-of-death analysis

Although developmental disabilities are among the major chronic health problems affecting children in the United States, the contribution of developmental disabilities to childhood mortality is unknown. To investigate the magnitude of this contribution, multiple cause-of-death data were examined for US children, aged 1-19 years, for 1980 and 1983-1989. The following conditions were included as developmental disabilities: autism, attention deficit disorder, learning disorders, mental retardation, cerebral palsy, epilepsy, muscular dystrophy, blindness and deafness. Based on underlying cause only, it was found that developmental disabilities were the fifth leading cause of nontraumatic death for children between 1 and 14 years of age and the third leading cause of non-traumatic death for children between 15 and 19 years. When a multiple cause approach was used to define developmental disability-related deaths (i.e. when contributing as well as underlying cause was considered), the number of such deaths nearly doubled. On the basis of both underlying- and multiple-cause analyses, cerebral palsy was the developmental disability most frequently cited as a cause of death. Mental retardation ranked second according to the multiple-cause approach but only fourth according to the underlying-cause approach. The least frequent causes of death (autism, attention deficit disorder, learning disorders, blindness, and deafness) were the ones most likely to be coded as contributing rather than underlying causes. Developmental disability-related mortality rates were highest among children aged 1-4 and 15-19 years, highest among blacks and lowest among racial groups other than blacks and whites, and higher among males than females. Although results of multiple-cause-of-death analyses more accurately reflect the proportion of deaths related to developmental disabilities, even this approach may underestimate the degree to which mortality is associated with a developmental disability.

Changes in causes of death in diabetic patients based on death certificates during a 30-year period in Osaka District, Japan, with special reference to cancer mortality

As reported previously, we have conducted studies on causes of death among diabetic patients during the 25-year period, from 1960 to 1984, in Osaka District, Japan. We have now added the most recent 5-year data, for 1985-1989, and analyzed changes in causes of death during the entire 30-year period as a whole. The subjects studied were those for whom a total of 32,222 death certificates had been filed in Osaka Prefecture, from 1960 to 1989, with diabetes mentioned either as the underlying cause or as a contributory condition. The relative number of death certificates mentioning diabetes as the underlying cause, which had been decreasing during the 25-year study period, showed a further decrease, reaching the lowest value, 33.4%, for the period 1985-1989. The mean age at death exceeded 70 years for all causes of death, showing a continuous increasing trend. An increase in disease of the heart and a decrease in cerebrovascular disease were observed, making the difference between the two causes greater since 1980-1984. Malignant neoplasms, ischemic heart disease, and pneumonia and bronchitis also showed steady increases. The O/E ratios (ratio of observed/expected number of deaths) for cirrhosis of the liver and tuberculosis were markedly increased, while that for malignant neoplasms was only about 0.5, suggesting extreme underestimation of the number of diabetic cases with cancer. Among malignant neoplasms, an increasing trend in liver cancer was remarkable and was associated with a relatively high O/E ratio.

The value of death certification statistics in measuring mortality in persons with diabetes

OBJECTIVE

To study how often deceased diabetic patients have a diagnosis of diabetes on the death certificate and to study factors related to this circumstance.

DESIGN

A community-based clinical diabetes register was checked against death certificate data.

SETTING AND SUBJECTS

Diabetic subjects in the community of Laxå, Sweden, during 1972-1986.

MAIN OUTCOME MEASURES

Recording of diabetes on the death certificate.

RESULTS

Diabetes was recorded on the death certificate in 57% of all known diabetic subjects (men 48% and women 67%, p < 0.05). It was registered significantly more often in females, when there had been insulin treatment, and when an autopsy was not the basis for the certification of cause of death.

CONCLUSION

The population with diabetes recorded on the death certificate is not representative of the actual population who die with the disease. In this study the presence of diabetes was underestimated by half for men and by a third for women.

The effect of diabetes and impaired glucose tolerance on mortality in Malta

A random sample of the middle-aged population of Malta was studied in a diabetic survey in 1981. Among the 1537 survey responders, in 659 men and 878 women aged 40 years or more the prevalence of diabetes was 16% in men and 18% in women, and that of IGT 5% in both sexes. By the end of 1985, 90 subjects (49 men: 41 women) had died. Mortality/100 (95% CI) was among subjects with normal, impaired glucose tolerance and diabetes in the age group 40-59 years 12 (5-19), 25 (23-73), and 61 (17-148), and in the age group of more than 60 years, 102 (68-136), 148 (59-237), and 178 (122-234), respectively. Age standardized mortality/1000 was in men 51, 28, and 100, and in women 34, 33, and 72 in the three categories of glucose tolerance, respectively. Among diabetic subjects aged 40-64 years the risk of death was increased seven-fold as compared with normoglycaemic subjects. Among men there was an inverse association between body mass index and mortality in all categories of glucose tolerance. Among women, no clear trend between body mass index and mortality was found. The relative risk of death for subjects with diabetes adjusting for age, sex, and body mass index was 2.2 (odds ratio: 95% CI 1.40 to 3.42) as compared with non-diabetic subjects. The age-adjusted survival curves for normoglycaemic subjects were similar for men and women. Among subjects with abnormal glucose tolerance the survival was slightly better in women than in men (p = 0.056). About half of the deaths were from cardiovascular disease and 7% from diabetes mellitus.

Underreporting of diabetes on death certificates, King County, Washington

We estimated the reporting of diabetes on death certificates for persons known to have diabetes. Surveillance of 19 hospitals and two paramedic emergency medical services during 12 months in Seattle and King County, Washington, ascertained acute ischemic heart disease events for persons with diabetes and yielded 1235 persons with suspected ischemic heart disease. Mortality was 23.6%, and 41% of death certificates listed diabetes. The reporting of diabetes on the death certificate was not random, and it varied by patient and physician characteristics. Diabetes is strongly linked to fatal ischemic heart disease, but its importance is underrepresented by death certificates for some subgroups.

The proportion of death certificates of diabetic patients that mentioned diabetes in Osaka District, Japan

To determine the accuracy of the stated causes of death in diabetic patients, we analyzed 503 death certificates of diabetic patients who had been followed up for 9.4 years on average at Osaka Medical Center for Adulthood Diseases and had died during the observation period from 1960 to 1984. Of the certificates examined, only 213 (42.4%) mentioned diabetes, either as the underlying cause or as a contributory condition. The proportion of certificates that mentioned diabetes was related to the underlying cause of death; it was 18.7% for malignant neoplasms, 40.5% for cerebrovascular disease and 46.9% for disease of the heart, while it was 81.8% for renal disease. The proportion was higher for females (48.7%) than for males (39.5%), and a significant difference was observed between the sexes in the proportion in the case of disease of the heart. The proportion was not related to any significant extent to the year of death or the age at death. However, it was related to fasting plasma glucose (FPG) level and type of treatment. It was 37.8% and 54.4% for patients with FPG < 200 mg/dl and FPG > or = 200 mg/dl, respectively, 24.1% for those treated with diet, 51.4% for those treated with oral hypoglycemic agent and 80.7% for those treated with insulin. As a result, it was found that the proportion of death certificates that mentioned diabetes was related to the accompanying complications and the severity of diabetes.(ABSTRACT TRUNCATED AT 250 WORDS)

Trends in mortality from diabetes mellitus in Taiwan, 1960-1988

The increasing trends of mortality from diabetes mellitus in Taiwan are becoming a public health concern. The age-adjusted death rate for diabetes was 3.7 per 100,000 population in 1960, which increased to 23.2 per 100,000 in 1988, a 6.3-fold increase over the past 30 years. The mortality data for diabetes in Taiwan from 1960 to 1988 for both sexes are presented and analysed using an age-period-cohort model in order to gain a better understanding of the possible determinants of the time trends of this disease. Steeply increasing trends which are particularly prominent in the elderly are found in the periods studied. Females and urban dwellers demonstrated greater risks for developing the disease. Significant cohort effects were found which peaked in the birth-cohort 1910-1917. This declined thereafter for females but has levelled since then for males. Further study is necessary to assess the aetiological implications of diet and urbanization on time trends of diabetes.

Suspected synergism between consanguinity and familial aggregation in type 2 diabetes mellitus in Saudi Arabia

A retrospective study of 210 cases of diabetes was carried out at King Khalid University Hospital diabetes clinic to delineate etiologic factors in non-insulin dependent diabetes mellitus (NIDDM). Standardised detailed questionnaires were administered to both cases and controls and the information sought included general demographics, dietary patterns, anthropometric values, family history, consanguinity and familial aggregation of Diabetes Mellitus (DM). Familial aggregation yielded an odds ratio of 6:2 which suggests a causal association with DM. A synergistic effect of familial aggregation was observed which needs to be further explored in future studies.

Frequency of recording of diabetes on U.S. death certificates: analysis of the 1986 National Mortality Followback Survey

We used data from the 1986 National Mortality Followback Survey to estimate the frequency of recording of diabetes on death certificates and to determine factors associated with recording of diabetes among decedents aged 25 years and older who died in the U.S. in 1986. Among 2766 decedents for whom a history of diabetes was provided by a personal informant, diabetes was recorded on an estimated 38.2% of death certificates and was listed as the underlying cause of death on an estimated 9.6%. The frequency of recording of diabetes was strongly related to age and duration of diabetes--among those aged 25-44 years who had had diabetes for 15 or more years, the frequency of recording was 71.9%. When other listed causes of death included conditions that may have been related to diabetes, such as cardiovascular disease, diabetes was recorded between 45 and 70% of the time, depending on the other causes. Diabetes is usually not recorded on death certificates, and the likelihood of recording is related to decedent characteristics, particularly age, duration of diabetes, and co-morbidity.

Certification of cause of death in French diabetic patients

STUDY OBJECTIVE

The aim was to assess the level of mortality related to diabetes in France. In other countries, an underrecording of diabetes on the death certificates of diabetic patients has been reported.

DESIGN AND SETTING

Estimated death rate of diabetic patients was calculated using (a) the actual number of death certificates where diabetes was registered either as an underlying or as a contributory cause of death, and (b) estimates of the prevalence of diabetes in the population, by sex and age group, from which expected numbers of diabetic deaths were determined. Standardised mortality ratios were calculated using 1988 French mortality statistics as reference.

MAIN RESULTS

The estimated standardised mortality ratio for diabetic subjects, with diabetes registered as the underlying cause, was 0.36. This standardised mortality ratio increased to 0.92 if both the underlying and contributory causes were considered. The estimated death rate, by sex and age group, implies that diabetes has a protective effect between the ages of 45 and 64 years, particularly in men.

CONCLUSIONS

Evidence suggests that diabetes is completely omitted on the death certificates of many diabetic subjects, especially for those between the ages of 45 and 64 years. Using mortality statistics underestimates the prevalence of diabetes and its effects on public health. The difference in diabetes mortality between countries will not be reliable until there is a better registration of the causes of death in diabetic patients, and contributory as well as the underlying cause are coded and published.

[Multiple causes of death in diabetics in the municipality of Recife, 1987]

In 1987, diabetes mellitus was mentioned in 492 death certificates of the population of the city of Recife, Brazil, 202 of them for males and 290 for females. Diabetes mellitus was the underlying cause of death according to 80 certificates for men and 290 for women, as a result of which premature death occurred in 16.2% of men and 11.1% of women. Multiple cause of death analysis showed that cardiovascular diseases were the most frequent underlying cause of death in individuals over 50 years of age and acute complications of diabetes mellitus in individuals under 50. Cerebrovascular diseases were the most frequent in the cardiovascular group, particularly in females. Arterial hypertension was the most frequent associated cause of death appearing in death certificates mentioning diabetes mellitus (not as the underlying cause of death), also more often in females. The acute complications of diabetes mellitus (keto-acidosis and coma) and peripheral circulatory disorders peculiar to this disease caused 23% and 30% of the deaths, respectively, in cases where diabetes mellitus was the underlying cause. Infectious and parasitic diseases were the most frequent associated causes of death according to those certificates which gave diabetes mellitus as the underlying cause.

A changing pattern of causes of death among diabetic during a 25-year period in the Osaka District, Japan

A total of 23,577 death certificates mentioning diabetes, in 10,927 cases as the underlying cause and in 12,650 cases as a contributory condition, were selected from approximately 1,000,000 death certificates filed in Osaka Prefecture, Japan, during a 25-year period between 1960 and 1984. These certificates were analyzed by use of a multiple coding system. The proportion of deaths associated with diabetes, which was only 0.88% of the total deaths in the period 1960-1964, increased to 3.49% in the period 1980-1984. It was also notable that the proportion of certificates with diabetes as the underlying cause of death to the total number of certificates mentioning diabetes decreased strikingly, from 60.8% in 1965-1969 to 36.8% in 1980-1984. Among diabetic subjects, the proportion of patients aged 65 years or over at death increased markedly during the same period, from 47.2% to 68.8%, and a clear increase in the mean age at death was apparent during the 25-year period. Remarkable changes in the underlying causes of death among diabetics were observed during the study period; an increase in disease of the circulatory system, and especially in disease of heart was noted. In the period 1980-1984, disease of heart exceeded cerebrovascular disease which had been the most frequent cause of death in diabetic subjects until that period. An increase in renal disease, including diabetic nephropathy, which was not observed in the standard analysis of underlying causes, was confirmed in the analysis of contributory conditions which was based on the multiple coding system.

Certified cause of death in children and young adults with cerebral palsy

The status of 732 children suffering from cerebral palsy from the South East Thames region (births from 1970-9) was ascertained at the end of 1989, and copies of death certificates of the 73 children who have died, aged 4 weeks to nearly 16 years, were obtained. Infantile cerebral palsy (ICD Code 343-) was coded as the underlying cause of death in only 16 (22%) cases. On 28 (38%) certificates there was no mention of any form of cerebral palsy, the proportion in which it was not mentioned increasing with age. In 20 (28%) cases the coded underlying cause of death was respiratory, hence in published national statistics the number of deaths from respiratory causes is inflated. A postmortem examination was known to have been performed in 23 cases, but the recorded information was in some cases limited to a 'terminal event'. The importance of good data on the death certificate, and the significance of published national statistics, need to be communicated to all those involved in the certification process if cerebral palsy and other chronic conditions, which raise the relative risk of death, are not to be under-represented.

[Mortality analysis: when is single evaluation of the basic cause of death allowable, when should multi-causality be assessed?]

Data quality is often a critical point in mortality studies. The purpose of the present report is to present criteria for assessing the value of death-certificate-based mortality studies. For this purpose all 57,454 Swiss death certificates of the year 1979 were analysed. Reliability of the diagnosis listed on the death certificate was investigated by comparing for each case of a linked sample of 12,478 deaths the cause of death with medical information available from the hospital record. Retrieval rates (percentage of cases for which the given diagnosis appears in both registries) were calculated for the primary diagnoses named in each data set. These can be considered as measures of reliability of diagnoses. The graphs given indicate a high reliability for cancers and accidents. Reliability was lower for other causes of death such as cardiovascular diseases, diabetes mellitus, rheumatic diseases. Restriction to the primary cause of death can be accepted for most cancers, accidents and violent deaths. For other causes of death, decisions must be made individually and multicausal analysis may be indicated. In addition, knowledge of the reliability of the diagnoses of interest is necessary for the interpretation of results derived from death certificate-based mortality studies.

[Prevalence of diabetes at the time of death in a Swiss hospital: regional differences]

Linked records (n = 12,478) from hospital records and death certificates show important regional differences in the prevalence of diabetes at death in Swiss hospitals (German-speaking area 15.0%, French-speaking area 10.5%, Italian-speaking area 10.4%, p less than 0.002). Reasons for these differences are unclear and call for further research.

Diabetes patient education: a health care provider perspective

Diabetes patient educa tion, a preventive health service, is an integral component of the overall program of care for the diabetic patient. Affecting both biomedical and psychosocial status, it may be analyzed through its knowledge- and behavior-based com ponents. Both are impor tant to the overall result, and each involves distinct provider knowledge and skills for successful, effec tive application. This application optimally in cludes a reproducible process involving a needs assessment, educational content planning, im plementation strategies, and appropriate evaluative methods. Familiarity with these concepts and tech niques will benefit the interested health care provider.

Causes of death in Japanese diabetics. A 20-year study of death certificates

Death certificates filed between 1960 and 1979 in Osaka, Japan were analyzed to study causes of death in diabetic patients. It was observed that diseases of the circulatory system increased continuously from 15.2% in 1960-1964 to 27.2% in 1975-1979. Cerebrovascular disease and disease of heart were the leading causes of death throughout the study period. The rate of increase was much faster for disease of heart than for cerebrovascular disease, and there was only a small difference between them as cause of death in diabetic patients at the end of the observation period. Malignant neoplasms, cirrhosis of the liver, and pneumonia and bronchitis increased, whereas tuberculosis decreased sharply according to age-adjusted mortality rate during the 20-year period. Analysis based on O/E ratios suggested higher risk of dying from ischemic heart disease, tuberculosis and cirrhosis of the liver in Japanese diabetics than in the general population in this country.

Epidemiologic characteristics of mortality from diabetes with acidosis or coma, United States, 1970-78

Deaths due to diabetes with acidosis or coma (DAC) in the United States from 1970 through 1978 were analyzed to determine epidemiologic characteristics associated with mortality likely to be due to diabetic ketoacidosis (DKA), a complication of diabetes mellitus considered largely preventable. Annual age-adjusted rates for DAC deaths decreased during the study period, and the secular trend was significant in all regional, race, and sex groups examined. General population-based mortality rates increased linearly with age, were higher in non-Whites than in Whites among persons aged greater than 14, were higher in females, and increased significantly with age in both races and both sexes. By region, rates were lowest in the West. DAC mortality rates specific to estimated diabetic populations decreased annually from 1970 to 1978 in all race and sex groups, and were highest at age greater than or equal to 65, but did not show significant linear increases with age, except in non-Whites. These results indicate declining secular trends, as well as age, race, sex, and regional differences in the risk of such deaths. Further studies are warranted to determine factors contributing to these differences.

Diabetes mortality in persons under 45 years of age

A detailed review of death certificates in Washington State for the years 1968-1979 was undertaken to analyze diabetes mortality for persons under 45 years of age. Diabetics in this age group had a mortality rate from medical causes eight times higher than that of the comparable general population. Almost one-third of the deaths were due to acute complications for which there is definitive medical therapy. Over the 12-year period there was no consistent decline in mortality rates or in deaths from acute complications, nor was there evidence of increased survivorship as reflected in the average age at death. Although residence in areas of sparse medical resources was not associated with high mortality rates, a significant proportion of deaths in all geographical areas occurred at home or before arrival at a hospital. Mortality rates and the proportion of deaths from acute, potentially preventable causes were higher in this study than in other recently published series, suggesting that early diabetes mortality may be a more serious problem than has been previously recognized. Diabetes mortality in this age group can be considered a "sentinel health event" and should call attention to potential problems in health care delivery.

A long-term follow-up study of Japanese diabetic patients: mortality and causes of death

A systematic 20-year follow-up study of 1,221 diabetic patients was carried out in Osaka, Japan. The mean annual mortality rates were 2.55% for men and 1.64% for women. The ratios of observed to expected numbers of deaths were 1.50 for men and 1.39 for women, indicating an excess mortality for diabetic patients of both sexes, and higher mortality in men than in women. Factors that predisposed diabetic patients to premature death were early age of onset, albuminuria, diabetic retinopathy and fasting glucose level greater than 11.1 mmol/l at the initial examination. Insulin dependence was also associated with poor prognosis. Cerebro-cardiovascular and renal diseases were the major causes of death in the diabetic patients; heart disease was the cause of death in 16.9%, cerebrovascular disease in 16.4% and renal disease in 11.9%. The relatively high incidence of renal disease as cause of death in diabetic patients was striking. Malignant neoplasms of liver and of pancreas and cirrhosis were also associated with increased ratio of observed to expected number of deaths in the patients.

Diabetes mortality: new light on an underestimated public health problem

Mortality from diabetes is underestimated four- to fivefold by methods of analysis of death certification data which use only underlying cause of death. This problem is partially overcome by coding all conditions mentioned on death certificates. For a sample of deaths in England and Wales over the years 1972-1977, the observed proportion of certificates with specific underlying causes of death for certificates mentioning diabetes was compared with the expected proportion for all certificates. These observed/expected ratios were significantly increased in each sex for circulatory diseases and were significantly reduced for neoplasms. For 'nephritis' they were also increased, especially below 45 years of age. These results were confirmed by an analysis of underlying cause of death in a cohort of nearly 6,000 members of the British Diabetic Association. Of the 2,134 deaths in this cohort, diabetes was not mentioned on 33% of the death certificates. For the period 1972-1977, death rates for circulatory diseases associated with diabetes increased by 6% for males but remained constant for females.

Absence of correlation between coronary arterial atherosclerosis and severity or duration of diabetes mellitus of adult onset

The relation between the severity and duration of diabetes mellitus and the severity of ischemic heart disease is uncertain. The clinical findings and the findings at autopsy were studied in 185 patients with diabetes mellitus of adult onset who ranged in age from 37 to 91 years and had a clinical diagnosis of diabetes established for a few days to 50 years before death. No statistically significant association was demonstrated either by simple correlation or by multivariate regression analysis between the clinically diagnosed severity or duration of diabetes and either the overall coronary disease, the number of diseased vessels or the number of myocardial infarctions. The presence of other expected correlations in the multivariate analysis suggested that the results of this study were not spurious. However, comparison with 185 age- and sex-matched control patients revealed that on the average, diabetic patients have more overall coronary disease (p < 0.002), more diffuseness of coronary disease (p < 0.005), more coronary collateralization (p < 0.001), more vessels involved by atherosclerosis (p < 0.001) and more myocardial infarcts (p < 0.001). The results suggest that although diabetes mellitus of adult onset is a condition in which the larger coronary arteries are subject to more atherosclerosis than are those in nondiabetic subjects, the progression of the atherosclerotic disease is unrelated to the duration or severity of the diabetes mellitus.

The possible role of the catecholamines of the corpora in penile erection

The etiology of impotence, which effects 50 per cent of the men with diabetes, is unknown. The neurotransmitter (norepinephrine) released from adrenergic neurons is thought to be the most direct regulator of vascular smooth muscle. We have measured the norepinephrine content of the erectile tissue of diabetic men. Our results indicate the presence of a dual neural regulator mechanism of the corpora that controls penile erection.

Colonic cancer--hypotheses of causation, dietary prophylaxis, and future research

Colonic cancer is rare in primitive populations. In western populations it was uncommon in the past, but now accounts for about 3% of all deaths. The cause almost certainly lies with dietary changes. Probably, alterations in bowel milieu interieur, from interaction between metabolites and microbacteria, promote carcinogenesis. Changes in intakes of protein, fat, sugar, refined cereal products, and crude fiber have been advanced as predisposing or causative factors. Evidence suggests that (i) fall in fiber intake, but (ii) rise in fat intake, in their ability to increase fecal concentrations of bile acids and sterols (possible precursors of carcinogens) are most likely to be culpable. As preventive measures, a significant rise in fiber intake is practicable only from regular bran ingestion. A major reduction in fat intake is grossly unlikely. Even were rigorous dietary changes implemented, an early fall in colonic cancer incidence is highly improbable due to the long-term character of the disease. Future research must include characterization of the diet, metabolism, and disease pattern of segments of western populations who have low colonic cancer mortality rates; also, elucidation of the bearing of various intakes of different food components on the biochemistry and microbiology of the feces.