Bariatric surgery: an IDF statement for obese Type 2 diabetes

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m² or more.

Bariatric surgery: an IDF statement for obese Type 2 diabetes

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m(2) or more.

Bariatric surgery: an IDF statement for obese Type 2 diabetes

The International Diabetes Federation Taskforce on Epidemiology and Prevention of Diabetes convened a consensus working group of diabetologists, endocrinologists, surgeons and public health experts to review the appropriate role of surgery and other gastrointestinal interventions in the treatment and prevention of Type 2 diabetes. The specific goals were: to develop practical recommendations for clinicians on patient selection; to identify barriers to surgical access and suggest interventions for health policy changes that ensure equitable access to surgery when indicated; and to identify priorities for research. Bariatric surgery can significantly improve glycaemic control in severely obese patients with Type 2 diabetes. It is an effective, safe and cost-effective therapy for obese Type 2 diabetes. Surgery can be considered an appropriate treatment for people with Type 2 diabetes and obesity not achieving recommended treatment targets with medical therapies, especially in the presence of other major co-morbidities. The procedures must be performed within accepted guidelines and require appropriate multidisciplinary assessment for the procedure, comprehensive patient education and ongoing care, as well as safe and standardized surgical procedures. National guidelines for bariatric surgery need to be developed for people with Type 2 diabetes and a BMI of 35 kg/m(2) or more.

Some hormonal influences on glucose and ketone body metabolism in normal human subjects

Control of glucose and ketone body metabolism is integrated by a variety of hormones. Insulin is the major anabolic hormone, and its actions are antagonized by rapidly acting catabolic hormones, such as glucagon and the catecholamines, and by others such as cortisol, growth hormone and the thyroid hormones, which generally have more delayed effects. In the normal human subject, the effects of catabolic hormones to raise blood glucose are limited by a compensatory increase in insulin secretion, and these effects are enhanced in insulin deficiency. Hyperketonaemic actions of the catabolic hormones may result from increased supply of non-esterified fatty acids from lipolysis, although glucagon has a major direct action to increase ketogenesis at the liver. As expected, these actions are also restricted in normal humans by the compensatory rise in insulin secretion. Hyperketonaemia does, however, occur with adrenaline (epinephrine) and noradrenaline (norepinephrine), even in the presence of mildly elevated insulin concentrations. These catecholamines may assume particular importance in mobilization of lipid fuels in milder forms of stress, when insulin secretion is normal or mildly increased. In severe stress, when there is catecholamine-induced suppression in insulin secretion, lipolytic and hyperketonaemic effects of all the catabolic hormones may be manifest. Starvation in humans also results in diminished insulin secretion and increased catabolic hormone secretion. The relative importance of individual hormones in lipid mobilization during starvation is uncertain, although glucagon, growth hormone, noradrenaline and, possibly, dopamine may all play a part.

The hydrogen ion in normal metabolism: a review

The production of hydrogen ions (H+) by metabolic processes is described, with particular emphasis on glycolysis and ketogenesis. Total metabolic production of H+ is approximately 150 g day-1 but utilization closely balances production, so that intracellular and extracellular H+ production is maintained within narrow limits. H+ is generated at several sites in glycolysis but no net H+ production occurs unless the ATP formed is hydrolysed. The other main source of metabolic H+ production is ketogenesis. Here H+ accumulation depends on both the relative dominance of ketone body production over utilization and the loss of base in urine. The H+ is produced during the synthesis of 3-hydroxy-3-methylglutaryl-CoA and not because of dissociation of acetoacetic acid. Lipolysis and re-esterification of fats are additional major producers of H+, while net H+ production also occurs with pathological accumulation and incomplete combustion of other organic acids. Many metabolic systems are sensitive to the changes in pH. These effects have been examined in vivo using an ammonium chloride acidaemia model in the rat. Severe insulin resistance and impaired glucose metabolism in liver and muscle were found. One mechanism involved inhibition, by H+, of the binding of insulin to its receptors. Further mechanisms include inhibition of key glycolytic enzymes including phosphofructokinase. It is concluded that too little attention is paid to metabolic production of hydrogen ions and to their effects, in turn, on metabolism.

The lung, whole-body metabolism and disease

It is well recognized that the lung has its own hormonally responsive endogenous metabolism. Less well recognized is the potential of the lung to influence and, in turn, be influenced by the homeostatic mechanisms of the body. It is suggested that the lung could modulate concentrations of circulating hormones and thereby play an indirect exogenous metabolic role in whole-body metabolism. Investigations of patients undergoing cardiopulmonary bypass as well as studies with the perfused rat lung suggest that the lung could make an important direct contribution to whole-body lactate and perhaps alanine production. The control of the endogenous and exogenous metabolism of the lung may be exerted through circulating hormones, substrates, blood gases and lung movement. Disorders of the lung or the whole body may disturb these relationships. In patients with chronic lung disease circulating blood metabolites are affected and conversely in diabetes there are effects on lung metabolism. The unified concept of lung/whole-body metabolism is discussed in relation to therapeutic approaches for the prevention and investigation of neonatal and adult respiratory distress syndromes.

Substrate utilization by the lung

Intermediary metabolism of the lung and its regulation have received relatively little attention in the past, partly because of difficulty in producing suitable models for study. An in situ perfused rat lung preparation is described which remains viable for four hours or more. Concentration-dependent glucose utilization has been found with this model, associated with marked lactate production. More than half the glucose used appears as lactate, despite the high PO2 and maintenance of normal ATP concentrations. The high rates of glycolysis may be related to glycerol-3-phosphate requirements for lipid synthesis. Glucose clearance from the perfusion medium is dependent on nutritional status, clearance by lungs from 48-hour starved animals being decreased by comparison with lungs of fed controls. Lactate is taken up actively at concentrations of 2 mmol/l or above but is produced at an initial lactate concentration of 0.4 mmol/l. Non-esterified fatty acids (1 mmol/l in the perfusate) are also cleared by lung and may be important as an energy source even though 80% is used for synthetic reactions. Alanine, glycerol and 3-hydroxybutyrate are unimportant as substrates. The lung responds to metabolically important hormones. Insulin and adrenaline cause an acute increase in glucose utilization whereas corticosterone and noradrenaline are inhibitory. Utilization of glucose is also diminished in lungs from diabetic ketoacidotic rats. Further work is required to establish the relative importance of oxidative and synthetic routes for added substrates and the mechanisms of hormonal regulation.

Hepatotrophic factors: implications for diabetes mellitus

In view of the importance of insulin in hepatic cell proliferation and regeneration, disturbances might be expected in these processes in diabetics. The relative importnace of insulin replacement given intraportally rather than subcutaneously is discussed. Results are presented showing that even when normoglycaemia is achieved with peripheral insulin infusion using the 'artificial pancreas' there are still abnormalities in intermediary metabolism. The incidence of cirrhosis in diabetes is reviewed and it is concluded that the evidence is poor for an increase in diabetics. Finally it is shown that in the normal diabetic rat changes are observed after partial hepatectomy consistent with an increase in redox potential within the regenerating liver. Insulin treatment improves redox status but does not completely reverse the changes shown.

Blood sampling techniques for lactate and pyruvate estimation: a reappraisal

The effects of venestasis and hand exercise on antecubital vein blood lactate and pyruvate concentrations have been re-examined. The results show that venestasis for up to 5 min has no effect, while hand exercise for as little as 20 s causes a marked increase in blood lactate and pyruvate concentrations. The implications of these findings are discussed.

Global and societal implications of the diabetes epidemic

Changes in human behaviour and lifestyle over the last century have resulted in a dramatic increase in the incidence of diabetes worldwide. The epidemic is chiefly of type 2 diabetes and also the associated conditions known as 'diabesity' and 'metabolic syndrome'. In conjunction with genetic susceptibility, particularly in certain ethnic groups, type 2 diabetes is brought on by environmental and behavioural factors such as a sedentary lifestyle, overly rich nutrition and obesity. The prevention of diabetes and control of its micro- and macrovascular complications will require an integrated, international approach if we are to see significant reduction in the huge premature morbidity and mortality it causes.

Development and validation of a questionnaire for the assessment of physical activity in epidemiological studies in Sub-Saharan Africa

OBJECTIVE

To develop and validate a questionnaire for measuring physical activity within Sub-Saharan Africa. Methods We designed the Sub-Saharan Africa Activity Questionnaire (SSAAQ), based upon existing questionnaires and an activity survey carried out in Cameroon. The questionnaire targeted past-year occupation, walking/cycling and leisure-time activities, and was administered by trained interviewers on two occasions, 10-15 days apart to 89 urban and rural consenting Cameroonians aged 19-68 years. Reliability was assessed by inter-interview comparison and repeatability coefficients (standard deviation of the test-retest difference). Validation was performed against a 24-hour heart rate monitoring and accelerometer recording.

RESULTS

The questionnaire was highly reproducible (rho = 0.95; P < 0.001). The inter-interview difference did not differ significantly from 0, with a repeatability coefficient of 0.46-1.46 hours. Total energy expenditure from the questionnaire was significantly correlated to heart rate monitoring (rho = 0.41-0.63; P < 0.05) and accelerometer measures (rho = 0.60-0.74; P < 0.01). Subject's self ranking of their activity did not match the questionnaire's quartiles of activity.

CONCLUSIONS

The present study presents the design and confirms the reliability and validity of SSAAQ in a rural and urban population of Cameroon and shows that subject's self ranking of activity might not accurately serve epidemiological purpose.

The performance of the Rose angina questionnaire in South Asian and European origin populations: a comparative study in Newcastle, UK

BACKGROUND

The Rose angina questionnaire has been extensively used in different cultural settings, but may not perform consistently in different ethnic groups. We set out to assess the performance of the Rose angina questionnaire in UK South Asians compared with Europeans.

METHODS

Data on major ECG abnormalities, possible or definite Rose questionnaire angina and diagnosed angina were collected from an age- and sex-stratified random sample of 1509 adults from European, Indian, Pakistani and Bangladeshi ethnic groups.

RESULTS

The ECG abnormalities were commoner in South Asians than Europeans (6% versus 2% in men). The prevalence in both South Asian and European men of possible Rose angina and diagnosed angina was 18% and 8%, respectively, but definite Rose angina was less common in South Asians (3% versus 6%). Definite Rose angina showed lower sensitivity for other measures in South Asians than in Europeans: sensitivity for a doctor's diagnosis was 21% in South Asian and 37% in European men. For possible Rose angina, the corresponding figures were 81% and 84%. Similar patterns were seen in women.

CONCLUSIONS

The performance of the Rose angina questionnaire was sufficiently inconsistent to warrant further work to achieve greater cross-cultural validity. Possible Rose angina performed more consistently across ethnic groups than definite Rose angina and pending further validation studies may be the most appropriate form to use.

Association of physical activity and serum insulin concentrations in two populations at high risk for type 2 diabetes but differing by BMI

OBJECTIVE

Physical activity and insulin sensitivity are related in epidemiological studies, but the consistency of this finding among populations that greatly differ in body size is uncertain. The present multiethnic epidemiological study examined whether physical activity was related to insulin concentrations in two populations at high risk for diabetes that greatly differ by location, ethnic group, and BMI.

RESEARCH DESIGN AND METHODS

The study populations consisted of 2,321 nondiabetic Pima Indian men and women aged 15-59 years from Arizona and 2,716 nondiabetic men and women aged 35-54 years from Mauritius. Insulin sensitivity was estimated by mean insulin concentration (average of the fasting and postload insulin), and total (i.e., leisure and occupational) physical activity was assessed by questionnaire.

RESULTS

Pima men and women who were more active had significantly (P < 0.05) lower mean insulin concentrations than those less active (BMI and age-adjusted means were 179 vs. 200 and 237 vs. 268 pmol/l). Similar findings were noted in Mauritian men and women (94 vs. 122 and 127 vs. 148 pmol/l). In both populations, activity remained significantly associated with mean insulin concentration controlled for age, BMI, waist-to-thigh or waist-to-hip ratio, and mean glucose concentrations.

CONCLUSIONS

Physical activity was negatively associated with insulin concentrations both in the Pima Indians, who tend to be overweight, and in Mauritians, who are leaner. These findings suggest a beneficial role of activity on insulin sensitivity that is separate from any influence of activity on body composition.

Long-term oral L-arginine administration improves peripheral and hepatic insulin sensitivity in type 2 diabetic patients

The aim of this study was to evaluate whether long-term administration of arginine acting through a normalization of NO/cyclic-guanosine-3' 5'-cyclic monophosphate (cGMP) pathway was able to ameliorate peripheral and hepatic insulin sensitivity in 12 lean type 2 diabetic patients.

RESEARCH DESIGN AND METHODS

A double-blind study was performed for 3 months. In the first month, patients were treated with their usual diet. Then they were randomly allocated into to groups. In group 1, patients were treated with diet plus placebo (orally three times per day) for 2 months. In group 2 patients were treated for 1 month with diet plus placebo orally, three times per day) and then for 1 month with diet plus L-arginine (3 g three times per day). At the end of the first and the second month of therapy, patients underwent a euglycemic-hyperinsulinemic clamp combined with [6,6-2H2] glucose infusion. A total of 10 normal subjects underwent the same test as control subjects.

RESULTS

In group 1, no changes in basal cGMP levels, systolic blood pressure, forearm blood flow, glucose disposal, and endogenous glucose production were observed throughout. In group 2, L-arginine normalized basal cGMP levels and significantly increased forearm blood flow by 36% and glucose disposal during the clamp by 34% whereas it decreased systolic blood pressure and endogenous glucose production by 14 and 29%, respectively. However, compared with normal subjects, L-arginine treatment was not able to completely overcome the defect in glucose disposal.

CONCLUSIONS

L-Arginine treatment significantly improves but does not completely normalizc peripheral and hepatic insulin sensitivity in type 2 diabetic patients.

Randomised controlled trial evaluating the effectiveness of behavioural interventions to modify cardiovascular risk factors in men and women with impaired glucose tolerance: outcomes at 6 months

AIMS

To evaluate the efficacy of interventions to promote a healthy diet and physical activity in people with impaired glucose tolerance (IGT).

METHODS

A randomised controlled trial in Newcastle upon Tyne, UK, 1995-98. Participants included 67 adults (38 men; 29 women) aged 24-75 years with IGT. The intervention consisted of regular diet and physical activity counselling based on the stages of change model. Main outcome measures were changes between baseline and 6 months in nutrient intake; physical activity; anthropometric and physiological measurements including serum lipids; glucose tolerance; insulin sensitivity.

RESULTS

The difference in change in total fat consumption was significant between intervention and control groups (difference -21.8 (95% confidence interval (CI) -37.8 to -5.8) g/day, P=0.008). A significantly larger proportion of intervention participants reported taking up vigorous activity than controls (difference 30.1, (95% CI 4.3--52.7)%, P=0.021). The change in body mass index was significantly different between groups (difference -0.95 (95% CI -1.5 to -0.4) kg/m(2), P=0.001). There was no significant difference in change in mean 2-h plasma glucose between groups (difference -0.19 (95% CI -1.1 to 0.71) mmol/l, NS) or in serum cholesterol (difference 0.02 (95% CI -0.26 to 0.31) mmol/l, NS). The difference in change in fasting serum insulin between groups was significant (difference -3.4 (95% CI -5.8 to -1.1) mU/l, P=0.005).

CONCLUSIONS

After 6 months of intensive lifestyle intervention in participants with IGT, there were changes in diet and physical activity, some cardiovascular risk factors and insulin sensitivity, but not glucose tolerance. Further follow-up is in progress to investigate whether these changes are sustained or augmented over 2 years.

The importance of injury as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania

This paper describes rates and causes of injury deaths among community members in three districts of the United Republic of Tanzania. A population-based study was carried out in two rural districts and one urban area in Tanzania. Deaths occurring in the study areas were monitored prospectively during a period of six years. Censuses were conducted annually in the rural areas and biannually in the urban area to determine the denominator populations. Cause-specific death rates and Years of Life Lost (YLL) due to injury were calculated for the three study areas. During a 6 year period (1992-1998), 5047 deaths were recorded in Dar es Salaam, 9339 in Hai District and 11 155 in Morogoro Rural District. Among all ages, deaths due to injuries accounted for 5% of all deaths in Dar es Salaam, 8% in Hai and 5% in Morogoro. The age-standardised injury death rates among men were approximately three times higher than among women in all study areas. Transport accidents were the commonest cause of mortality in all injury-related deaths in the three project areas, except for females in Hai District, where it ranked second after intentional self-harm. We conclude that injury deaths impose a considerable burden in Tanzania. Strategies should be strengthened in the prevention and control of avoidable premature deaths due to injuries.

Blood pressure response to glucose potassium insulin therapy in patients with acute stroke with mild to moderate hyperglycaemia

Insulin is neuroprotective in animal stroke models but its effects in acute stroke in humans are unknown. The Glucose Insulin in Stroke Trial (GIST-UK) is a randomised controlled trial investigating the benefits of maintaining euglycaemia in hyperglycaemic patients with acute stroke. Data are reported from a GIST-UK substudy which sought to determine the influence of glucose potassium insulin (GKI) infusion on blood pressure in acute stroke. All adult patients admitted to hospital with acute stroke with hyperglycaemia (plasma glucose 6.1-17 mmol/l) were potentially eligible. Randomised patients received either a GKI infusion (500 ml 10% glucose, 20 mmol potassium chloride, 16 units of insulin) or control therapy with 154 mmol/l (0.9%) saline at 100 ml/h for 24 hours. BM test strip glucose monitoring was performed 2 hourly, blood pressure monitoring 4 hourly, and plasma glucose sampling 8 hourly. Insulin concentration in the GKI infusate was altered according to test strip values to maintain test strip values between 4-7 mmol/l in the GKI group. Neurological impairment was determined using the European stroke scale (ESS). 145 patients were studied (73 GKI, 72 control). Mean systolic blood pressure was significantly lower during GKI infusion between 4 hours and 24 hours except at 8 hours. Median total ESS scores improved significantly between admission and day 7 in the GKI group (p<0.001) although there was no significant difference in total ESS score between groups at day 7. The significant reduction of systolic blood pressure in acute stroke associated with GKI therapy was not associated with neurological deterioration and may have been beneficial.

Variable effects of the APOC3-482C > T variant on insulin, glucose and triglyceride concentrations in different ethnic groups

AIMS/HYPOTHESIS

The apolipoprotein C3-482C> T variant modulates insulin and glucose concentrations after an oral glucose tolerance test (OGTT) in young healthy white men. We evaluated the effect of this variant in different ethnic groups with different rates of Type II (non-insulin-dependent) diabetes mellitus and coronary heart disease.

METHODS

We investigated the -482C > T in a population-based cross-sectional study of white subjects (n = 462), South Asians (n = 442) and subjects of West African and Afro-Caribbean origin (n = 462), whose OGTT and fasting plasma triglyceride concentrations had been measured.

RESULTS

The -482T allele frequency differed between the three groups: 0.25 (95 % CI 0.22-0.28) in white subjects, 0.44 (0.41-0.47) in South Asians and 0.71 (0.68-0.74) in black subjects (p < 0.0001). A positive association was found between body mass index and genotype in black women (p = 0.009) and in black men (p = 0.056) but not in white subjects or South Asians. Associations between -482C > T and fasting insulin were found in white subjects, where -482T allele carriers had higher concentrations (adjusted for age and sex, p = 0.007, also including smoking and body mass index, p = 0.038). Higher triglyceride concentrations (p = 0.004 and p = 0.007 in the two models) but not glucose concentrations were also associated with -482C > T. In black subjects, decreased fasting insulin (p = 0.04) and fasting glucose (p = 0.004) were associated with -482C > T. No relation was observed between genotype and any post-load measured. CONCLUSIONS/INTERPRETATION. Allele frequencies of the -482C > T and associations with insulin, glucose and triglyceride concentrations vary considerably among ethnic groups. Although the results are consistent among white subjects across different studies, the associations among black subjects and South Asians differ.

Leptin and other components of the Metabolic Syndrome in Mauritius--a factor analysis

OBJECTIVE

To use factor analysis to examine the putative role of leptin in the Metabolic Syndrome, and to define better the associations among observed variables and the identified factors.

DESIGN

Factor analysis of cross-sectional data from a 1987 survey.

SUBJECTS

Non-diabetic residents of Mauritius who participated in population-based surveys in 1987 and 1992 (1414 men and 1654 women).

MEASUREMENTS

Fasting and 2 h plasma glucose and insulin following a 75 g oral glucose load; seated blood pressure; body mass index (BMI); waist-to-hip ratio (WHR); and fasting serum triglycerides, HDL-cholesterol, leptin and uric acid concentrations.

RESULTS

Principal components factor analysis revealed three factors for men and women that explained between 54 and 55% of the observed variance of the 12 measured variables. General features of these factors were as follows: factor 1, WHR, BMI, leptin, fasting and 2 h insulin, triglycerides, and HDL-cholesterol; factor 2, systolic and diastolic blood pressure, uric acid (men only), and fasting glucose (women only); and factor 3, fasting and 2 h glucose and insulin. Only three variables loaded on more than one factor with a loading > or = 0.4 (fasting and 2 h insulin, fasting glucose in women only). Leptin loaded on one factor only in both men and women.

CONCLUSIONS

Since multiple factors underlie the Metabolic Syndrome, and since no observed variable loads on all three factors, more than one mechanism might account for the observed clustering of risk characteristics. Leptin does not unite features of this syndrome due to its loading on one factor only. Uric acid is related to a different factor in men and women. The absence of gender differences in factor loadings argues for similar mechanisms for the Metabolic Syndrome in men and women in Mauritius. International Journal of Obesity (2001) 25, 126-131

Noncommunicable diseases in sub-Saharan Africa: where do they feature in the health research agenda?

There is no doubt that communicable diseases will remain the predominant health problem for the populations in sub-Saharan Africa, including adults, for the next 10-20 years. Concern has been expressed that the available resources to deal with this problem would be reduced by increasing the emphasis on noncommunicable diseases. The latter, however, already present a substantial burden because their overall age-specific rates are currently higher in adults in sub-Saharan Africa than in populations in Established Market Economies. There is also evidence that the prevalence of certain noncommunicable diseases, such as diabetes and hypertension, is increasing rapidly, particularly in the urban areas, and that significant demands are being made on the health services by patients with these diseases. To ignore the noncommunicable diseases would inevitably lead to an increase in their burden; the provision of health services for them would be largely undirected by issues of clinical and cost effectiveness, and their treatment and prevention would be left to the mercy of local and global commercial interests. Improved surveillance of all diseases within sub-Saharan Africa is needed in order to place noncommunicable diseases properly within the context of the overall burden of disease. Research is needed to guide improvements in the clinical and cost effectiveness of resources currently committed to the care of patients with noncommunicable diseases, and to direct and evaluate preventive measures.

Smoking and alcohol consumption in a UK Chinese population

Little research has been conducted on health in Chinese communities in the UK and there are few representative data on smoking, alcohol consumption or other aspects of lifestyle. We undertook a cross sectional population-based study of 380 Chinese and 625 European men and women aged 25 to 64 y, using self-completion and interview questionnaires in Newcastle upon Tyne, UK between 1991 and 1995. We measured self-reported prevalence of cigarette smoking, number of cigarettes smoked per week and age at starting smoking; self-reported prevalence of alcohol consumption and units of alcohol consumed per week. In age-adjusted comparisons smoking was less common in Chinese (24%) than European men (35%) (P=0.00002) and among Chinese (1%) compared with European women (33%) (P<0.00001). Number of cigarettes smoked was similar among Chinese and European male smokers. Median age at starting smoking was higher among Chinese (18.5 y) compared with European men (15 y) (P=0.00001). Smoking was commonest in older Chinese and in younger Europeans. The prevalence of alcohol consumption was lower among Chinese (63%) than European men (93%) (P<0.00001) and among Chinese (29%) compared to European women (89%) (P<0.00001). Median alcohol consumption was significantly lower among Chinese (2 units/week) than European men (16 units/week) (P<0.00001), and among Chinese (1 unit/week) compared to European women (6 units/week) (P<0.00001). Among those who drank alcohol, Chinese men were less likely to drink above recommended limits than European men (1% vs 39%; P<0.00001). Chinese men and women currently have relatively favourable patterns of smoking compared to European adults in Newcastle. Average alcohol consumption among Chinese who drink is lower than among Europeans, and a substantial proportion of the Chinese population in Newcastle drink no alcohol. Patterns of health related behaviour should be tracked over time in ethnic minority populations to identify changes that pose risk to health and which deserve appropriate intervention.

Rural and urban differences in diabetes prevalence in Tanzania: the role of obesity, physical inactivity and urban living

A population-based survey in 1996 and 1997 of 770 adults (aged > or = 15 years) from an urban district of Dares Salaam and 928 from a village in rural Kilimanjaro district (Tanzania) revealed that the prevalence of diabetes, impaired fasting glucose (IFG), overweight, obesity, and physical inactivity was higher in the urban area for men and women. The difference between urban and rural prevalence of diabetes was 3.8 [1x1-6.5]% for men and 2x9 [0x8-4.9]% for women. For IFG, the difference was 2x8 [0x3-5x3]% for men and 3x9 [1x4-6x4]% for women; for overweight and obesity, the difference was 21.5 [15.8-27.1]% and 6.2 [3x5-8.9]% for men and 17x4 [11.5-23.3]% and 12.7 [8x5-16x8]% for women, respectively. The difference in prevalence of physical inactivity was 12x5 [7.0-18.3]% for men and 37.6 [31x9-43.3]% for women. For men with diabetes, the odds for being overweight, obese and having a large waist:hip ratio were 14.1, 5.3 and 12.5, respectively; for women the corresponding values were 9x0, 10x5 and 2x4 (the last not significant) with an attributable fraction for overweight between 64% and 69%. We conclude that diabetes prevalence is higher in the urban Tanzanian community and that this can be explained by differences in the prevalence of overweight. The avoidance of obesity in the adult population is likely to prevent increases in diabetes incidence in this population.

Features of the metabolic syndrome predict higher risk of diabetes and impaired glucose tolerance: a prospective study in Mauritius

OBJECTIVE

To assess the independent and joint effects of the components of the metabolic syndrome, including leptin, which is a recently proposed addition to this syndrome, in predicting the cumulative incidence of impaired glucose tolerance (IGT) and diabetes among individuals with normal glucose tolerance.

RESEARCH DESIGN AND METHODS

This prospective study involved 2,605 residents of Mauritius with normal glucose tolerance who were followed for 5 years for IGT or diabetes onset in relation to total and regional adiposity (BMI, waist-to-hip ratio [WHR]), fasting and 2-h 75-g oral glucose load glucose and insulin, total and HDL cholesterol, blood pressure, serum uric acid, triglyceride, and leptin levels.

RESULTS

A multivariate logistic regression model adjusted for age, sex, ethnicity, and diabetes family history showed a significantly higher linear increase in risk of IGT and diabetes in association with the following variables only: fasting glucose (odds ratio 1.89 [95% CI 1.51-2.34]), 2-h glucose (1.68 [1.50-1.88]), WHR (1.30 [1.10-1.52]), BMI (1.04 [1.00-1.08]), and serum uric acid (1.37 [1.20-1.57]). However, a nonlinear increase was seen with serum triglyceride and plasma leptin concentrations. No risk factors resulted in joint effects that were greater than expected from combining individual effects.

CONCLUSIONS

Metabolic syndrome features independently predict a higher risk of diabetes or IGT in normoglycemic subjects but in combination confer no higher-than-expected risk of these outcomes. At higher concentrations of triglycerides and leptin, risk plateaus and even declines slightly.

Physical activity, metabolic factors, and the incidence of coronary heart disease and type 2 diabetes

OBJECTIVE

To examine the role of nonfasting serum insulin level and components of the insulin resistance syndrome in the relationship between physical activity and the incidence of coronary heart disease and type 2 diabetes.

METHODS

Prospective study of 5159 men aged 40 to 59 years with no history of coronary heart disease, type 2 diabetes, or stroke drawn from general practices in 18 British towns. During an average follow-up period of 16.8 years, there were 616 cases of major coronary heart disease events (fatal and nonfatal) and 196 incident cases of type 2 diabetes.

RESULTS

After adjustment for potential confounders (lifestyle characteristics and preexisting disease), physical activity was inversely related to coronary heart disease rates, with the lowest rates in the men undertaking moderate physical activity and with no further benefit thereafter. For type 2 diabetes, risk decreased progressively with increasing levels of physical activity. Physical activity was associated with serum insulin level and with factors associated with insulin, ie, heart rate, hyperuricemia, diastolic blood pressure, and high-density lipoprotein cholesterol level, and with gamma-glutamyltransferase level, a possible marker of hepatic insulin resistance. Adjustment for insulin and associated factors made little difference to the relationship between physical activity and risk of coronary heart disease. By contrast, these factors together with gamma-glutamyltransferase level appear to explain a large proportion of the reduction in risk of type 2 diabetes associated with physical activity.

CONCLUSIONS

The relationship between physical activity and type 2 diabetes appears to be mediated by serum true insulin level and components of the insulin resistance syndrome. However, these factors do not appear to explain the inverse relationship between physical activity and coronary heart disease.

Age specific prevalence of impairment and disability relating to hemiplegic stroke in the Hai District of northern Tanzania. Adult Morbidity and Mortality Project

OBJECTIVES

To determine the age specific prevalence of impairment and disability relating to hemiplegic stroke in one rural area of Tanzania.

METHODS

During the yearly house to house census of the study population of 148 135 (85 152 aged 15 and over) in August 1994, specific questions were asked to identify those who might be disabled from stroke. People thus identified were subsequently interviewed and examined by one investigator. In those in whom the clinical diagnosis of stroke was confirmed a more detailed interview and examination relating to risk factors and recovery was carried out.

RESULTS

One hundred and eight patients, 61 men and 47 women, were identified with a median age of 70 (range 18-100). Median age at first stroke was 65 years. The age specific rates in this study were lower than previous studies in developed countries. All were cared for at home although 23 (21%) were bedbound.

CONCLUSIONS

Although prevalence of impairment and disability related to stroke in this population as a whole was low this is mainly explained by the age structure, with less than 6% being aged 65 and over. Age standardised rates for stroke with residual disability were about half those found in previous studies in developed countries. Death from stroke in Africa may be higher but data are limited. With the demographic transition stroke is likely to become a more important cause of disability in sub-Saharan Africa.

Stroke mortality in urban and rural Tanzania. Adult Morbidity and Mortality Project

BACKGROUND

Most data for stroke mortality in sub-Saharan Africa are hospital based. We aimed to establish the contribution of cerebrovascular disease to all-cause mortality and cerebrovascular disease mortality rates in adults aged 15 years or more in one urban and two rural areas of Tanzania.

METHODS

Regular censuses of the three surveillance populations consisting of 307,820 people (125,932 aged below 15 years and 181,888 aged 15 or more) were undertaken with prospective monitoring of all deaths arising in these populations between June 1, 1992 and May 31, 1995. Verbal autopsies were completed with relatives or carers of the deceased to assess, when possible, the cause of death.

FINDINGS

During the 3-year observation period 11,975 deaths were recorded in the three surveillance areas, of which 7629 (64%) were in adults aged 15 years or more (4088 [54%] of these in men and 3541 [46%] in women). In the adults, 421 (5.5%) of the deaths were attributed to cerebrovascular disease, 225 (53%) of these in men and 196 (47%) in women. The yearly age-adjusted rates per 100,000 in the 15-64 year age group for the three project areas (urban, fairly prosperous rural, and poor rural, respectively) were 65 (95% CI 39-90), 44 (31-56), and 35 (22-48) for men, and 88 (48-128), 33 (22-43), and 27 (16-38) for women, as compared with the England and Wales (1993) rates of 10.8 (10.0-11.6) for men and 8.6 (7.9-9.3) for women.

INTERPRETATION

We postulate that the high rates in Tanzania were due to untreated hypertension. Our study assessed mortality over a single time period and therefore it is not possible to comment on trends with time. However, ageing of the population is likely to lead to a very large increase in mortality from stroke in the future.

Continuation of growth hormone (GH) therapy in GH-deficient patients during transition from childhood to adulthood: impact on insulin sensitivity and substrate metabolism

The appropriate management of GH-deficient patients during transition from childhood to adulthood has not been reported in controlled trials, even though there is evidence to suggest that this phase is associated with specific problems in relation to GH sensitivity. An issue of particular interest is the impact of GH substitution on insulin sensitivity, which normally declines during puberty. We, therefore, evaluated insulin sensitivity (euglycemic glucose clamp) and substrate metabolism in 18 GH-deficient patients (6 females and 12 males; age, 20 +/- 1 yr; body mass index, 25 +/- 1 kg/m2) in a placebo-controlled, parallel study. Measurements were made at baseline, where all patients were on their regular GH replacement, after 12 months of either continued GH (0.018 +/- 0.001 mg/kg day) or placebo, and finally after 12 months of open phase GH therapy (0.016 mg/kg x day). Before study entry GH deficiency was reconfirmed by a stimulation test. During the double-blind phase, insulin sensitivity and fat mass tended to increase in the placebo group [deltaM-value (mg/kg x min), -0.7 +/- 1.1 (GH) vs. 1.3 +/- 0.8 (placebo), P = 0.18; deltaTBF (kg), 0.9 +/- 1.2 (GH) vs. 4.4 +/- 1.6 (placebo), P = 0.1]. Rates of lipid oxidation decreased [delta lipid oxidation (mg/kg x min), 0.02 +/- 0.14 (GH) vs. -0.32 +/- 0.13 (placebo), P < 0.05], whereas glucose oxidation increased in the placebo-treated group (P < 0.05). In the open phase, a decrease in insulin sensitivity was found in the former placebo group, although they lost body fat and increased fat-free mass [M-value (mg/kg x min), 5.1 +/- 0.7 (placebo) vs. 3.4 +/- 1.0 (open), P = 0.09]. In the group randomized to continued GH treatment almost all hormonal and metabolic parameters remained unchanged during the study. In conclusion, 1) discontinuation of GH therapy for 1 yr in adolescent patients induces fat accumulation without compromising insulin sensitivity; and 2) the beneficial effects of continued GH treatment on body composition in terms of decrease in fat mass and increase in fat-free mass does not fully balance the direct insulin antagonistic effects.

Hypertension prevalence and care in an urban and rural area of Tanzania

OBJECTIVE

To describe the prevalence, detection, treatment and control of hypertension in an urban and rural area of Tanzania.

DESIGN

Two linked cross-sectional population-based surveys.

SETTING

A middle-income urban district of Dar es Salaam (Ilala) and a village in the relatively prosperous rural area of Kilimanjaro (Shari).

PARTICIPANTS

Seven hundred and seventy adults (> 15 years) in Ilala and 928 adults in Shari were studied.

RESULTS

Hypertension prevalence (blood pressure > or = 140 and/or 90 mmHg, or known hypertensives receiving anti-hypertensive treatment) was 30% (95% confidence interval, 25.1-34.9%) in men and 28.6% (24.3-32.9%) in women in Ilala, and 32.2% (27.7-36.7%) in men and 31.5% (27.8-35.2%) in women in Shari. Age-standardized hypertension (to the New World Population) prevalence was 37.3% (32.2-42.5%) among men and 39.1% (34.2-44.0%) in women in Ilala, and 26.3% (22.4-30.4%) in men and 27.4% (24A-30.4%) in women in Shari. In both areas, just under 20% of hypertensive subjects were aware of their diagnosis, approximately 10% reported receiving treatment and less than 1% were controlled (blood pressure < 140/90 mmHg). Hypertensive subjects were older, had greater body mass indices and waist: hip ratios, and had more risk factors for hypertension and its complications (smoking, heavy alcohol consumption, physical inactivity, obesity and diabetes) than non-hypertensives.

CONCLUSIONS

There is a high prevalence of hypertension in rural and urban areas of Tanzania, with low levels of detection, treatment and control. This demonstrates the need for cost-effective strategies for primary prevention, detection and treatment of hypertension and the growing public health challenge of non-communicable diseases in Sub-Saharan Africa.

Risk of cardiovascular disease measured by carotid intima-media thickness at age 49-51: lifecourse study

OBJECTIVE

To quantify the direct and indirect effects of fetal life, childhood, and adult life on risk of cardiovascular disease at age 49-51 years.

DESIGN

Follow up study of the "Newcastle thousand families" birth cohort established in 1947.

PARTICIPANTS

154 men and 193 women who completed a health and lifestyle questionnaire and attended for clinical examination between October 1996 and December 1998.

MAIN OUTCOME MEASURES

Correlations between mean intima-media thickness of the carotid artery (carotid intima-media thickness) and family history, birth weight, and socioeconomic position around birth; socioeconomic position, growth, illness, and adverse life events in childhood; and adult socioeconomic position, lifestyle, and biological risk markers. Proportions of variance in carotid intima-media thickness that were accounted for by each stage of the lifecourse.

RESULTS

Socioeconomic position at birth and birth weight were negatively associated with carotid intima-media thickness, although only social class at birth in women was a statistically significant covariate independent of adult lifestyle. These early life variables accounted directly for 2.2% of total variance in men and 2.0% in women. More variation in carotid intima-media thickness was explained by adult socioeconomic position and lifestyle, which accounted directly and indirectly for 3.4% of variance in men (95% confidence interval 0.5% to 6.2%) and 7.6% in women (2.1% to 13.0%). Biological risk markers measured in adulthood independently accounted for a further 9.5% of variance in men (2.4% to 14.2%) and 4.9% in women (1.6% to 7.4%).

CONCLUSIONS

Adult lifestyle and biological risk markers were the most important determinants of the cardiovascular health of the study members of the Newcastle thousand families cohort at age 49-51 years. The limited overall effect of early life factors may reflect the postwar birth year of this cohort.

Impaired fasting glucose: how low should it go?

OBJECTIVE

Impaired fasting glucose (IFG) has been recently introduced as a stage of abnormal carbohydrate metabolism, but the evidence on which its glucose limits (fasting plasma glucose [FPG] 6.1-6.9 mmol/l) are based is not strong. The aim of this study was to determine if 6.1 mmol/l represents a clear cutoff in terms of the risk of future diabetes and in terms of elevated cardiovascular risk factor levels, and to examine the use of other lower limits of IFG.

RESEARCH DESIGN AND METHODS

A population-based survey of the island of Mauritius was undertaken in 1987, with a follow-up survey 5 years later. On both occasions, an oral glucose tolerance test was performed and cardiovascular risk factors were measured.

RESULTS

Data were available from 4,721 nondiabetic people at baseline, and from 3,542 at follow-up. At baseline, blood pressure, lipids, and obesity increased in a linear fashion with increasing FPG, with no evidence of a threshold effect. The risk of developing hypertension at follow-up was greater for those people with baseline FPG > or =6.1 mmol/l (P<0.001). The risk of developing diabetes at follow-up increased with increasing baseline FPG, but there was little evidence of a threshold near 6.1 mmol/l.

CONCLUSIONS

Cardiovascular risk and risk of future diabetes increase continually with increasing FPG, and there is no threshold value on which to base a definition of IFG. If a lower limit of approximately 5.8 mmol/l is used, the category defines a group more similar to the group with impaired glucose tolerance, with regard to total prevalence and the risk of subsequent diabetes.

Twenty-four-hour insulin secretion rates, circulating concentrations of fuel substrates and gut incretin hormones in healthy offspring of Type II (non-insulin-dependent) diabetic parents: evidence of several aberrations

AIMS/HYPOTHESIS

Insulin resistance is a common feature in relatives of patients with Type II (non-insulin-dependent) diabetes mellitus and abnormalities in beta-cell function can also exist. Insight into non-fasting carbohydrate metabolism in these potentially prediabetic subjects relies almost exclusively on studies in which glucose is infused or ingested or both. We aimed to characterize insulin secretion and aspects of hormonal and metabolic patterns in relatives using a physiological approach.

METHODS

We examined profiles of insulin, C peptide, proinsulin, gut incretin hormones and fuel substrates in 26 glucose tolerant but insulin resistant (clamp) relatives and 17 control subjects during a 24-hour period including three meals.

RESULTS

During the day plasma glucose was slightly raised in relatives (p < 0.05). Overall insulin secretion calculated on the basis of C peptide kinetics were increased in relatives (p < 0.0005) whereas incremental insulin secretion after all three meals were similar. Peak incremental insulin secretion tended, however, to be reduced in relatives (p < 0.10). Despite considerably increased insulin concentrations in relatives (70 %, p < 0.001), serum NEFA did not differ. Postprandial proinsulin concentrations (p < 0.05), but not proinsulin:insulin ratios, were increased in relatives. After meals concentrations of glucose-dependent-insulinotropic polypeptide (p < 0.05) were increased in relatives. Glucagon-like peptide-1 concentrations were similar.

CONCLUSION/INTERPRETATION

Several hormonal and metabolic aberrations are present in healthy relatives of Type II diabetic patients during conditions that simulate daily living. Increased concentrations of glucose-dependent-insulinotropic polypeptide could indicate a beta-cell receptor defect for glucose-dependent-insulinotropic polypeptide in the prediabetic stage of Type II diabetes. Incremental insulin secretion after mixed meals appear normal in relatives, although a trend towards diminished peak values possibly signifies early beta-cell dysfunction. [Diabetologia (1999) 42: 1314-1323]

A comparison of proxy measures of abdominal obesity in Chinese, European and South Asian adults

AIMS

To assess whether four proxy measures of abdominal obesity (waist circumference; waist-to-hip ratio (WHR); waist-to-height ratio and C index, a measure of body shape) were uniformly associated with features of the metabolic syndrome (triglycerides, high density lipoprotein (HDL) cholesterol, 2-h glucose) in three ethnic groups.

METHODS

Anthropometric and biochemical data were collected in 629 Europeans (320 men, 309 women), 380 Chinese (183 men, 197 women) and 597 South Asians (275 men, 322 women) aged 25-64 years in Newcastle upon Tyne, UK. Linear regression models were used to determine whether relationships differed between ethnic groups.

RESULTS

Linear regression analysis showed that most proxy measures of abdominal obesity were associated with features of the metabolic syndrome. There were significant interactions between WHR and ethnicity and C index and ethnicity in the relationship with log triglycerides when comparing European and Chinese women. Interactions existed between all proxy measures and ethnicity in the relationship with log triglycerides and HDL cholesterol when comparing European and South Asian women. In men, interactions between ethnicity and waist circumference, WHR and C index when comparing Europeans and South Asians, and between ethnicity and WHR and C index when comparing South Asian and Chinese for log 2-h glucose were significant (P < 0.001). All interactions remained significant when differences in smoking, alcohol and physical activity were taken into account.

CONCLUSIONS

Not all the proxy measures of abdominal obesity were consistently related to features of the metabolic syndrome across the ethnic groups studied. However, waist circumference and waist to height ratio were the most consistent and WHR the least when comparing across the ethnic groups.

Serum true insulin concentration and the risk of clinical non-insulin dependent diabetes during long-term follow-up

BACKGROUND

There is considerable evidence that insulin resistance with compensatory hyperinsulinaemia is an early and modifiable defect in the pathogenesis of non-insulin dependent diabetes (NIDDM). Current data, however, are largely based on studies that have used insulin assays which cross-react with proinsulin and other insulin precursors. Using a specific assay, we have addressed the hypothesis that an elevation of serum true insulin concentration, reflecting insulin resistance, is an early event in the pathogenesis of NIDDM.

METHODS

We have used a prospective cohort study design in which a group of 5550 non-diabetic men aged 40-59 years, from 18 British towns, have been followed for incident cases of physician-diagnosed NIDDM for an average of period of 14.8 years (range 13.5-15 years). We have estimated the incidence of physician-diagnosed NIDDM by quintile of non-fasting serum true insulin concentration at entry into the study.

RESULTS

There were 168 cases of clinically diagnosed NIDDM among the group of 5550 men during follow-up. Mean serum insulin at entry (geometric mean and 95% range, adjusted for time of sampling) was significantly higher in men who subsequently developed NIDDM than in the rest of the cohort, 19.5 mU/l (4.3-88.2) versus 12.2 mU/l (2.7-54.0), P < 0.0001. There was a highly significant linear trend of increasing risk of NIDDM by quintile of serum insulin which was not attenuated substantially after adjustment for age and body mass index (BMI) and additional lifestyle and biological factors associated with serum insulin and risk of NIDDM. However, in men with non-fasting serum glucose > or =6.1 mmol/l at baseline (80th percentile, n = 1125, 82 cases), the risk of NIDDM, adjusted for age and BMI, was higher in the first quintile of serum insulin than in all other quintiles.

CONCLUSION

These findings are consistent with the hypothesis that the majority of cases of adult onset NIDDM in this population are characterized by the early development of insulin resistance with compensatory true hyperinsulinaemia.

Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi, and European origin populations: cross sectional study

OBJECTIVE

To compare coronary risk factors and disease prevalence among Indians, Pakistanis, and Bangladeshis, and in all South Asians (these three groups together) with Europeans.

DESIGN

Cross sectional survey.

SETTING

Newcastle upon Tyne.

PARTICIPANTS

259 Indian, 305 Pakistani, 120 Bangladeshi, and 825 European men and women aged 25-74 years.

MAIN OUTCOME MEASURES

Social and economic circumstances, lifestyle, self reported symptoms and diseases, blood pressure, electrocardiogram, and anthropometric, haematological, and biochemical measurements.

RESULTS

There were differences in social and economic circumstances, lifestyles, anthropometric measures and disease both between Indians, Pakistanis, and Bangladeshis and between all South Asians and Europeans. Bangladeshis and Pakistanis were the poorest groups. For most risk factors, the Bangladeshis (particularly men) fared the worst: smoking was most common (57%) in that group, and Bangladeshis had the highest concentrations of triglycerides (2.04 mmol/l) and fasting blood glucose (6.6 mmol/l) and the lowest concentration of high density lipoprotein cholesterol (0.97 mmol/l). Blood pressure, however, was lowest in Bangladeshis. Bangladeshis were the shortest (men 164 cm tall v 170 cm for Indians and 174 cm for Europeans). A higher proportion of Pakistani and Bangladeshi men had diabetes (22.4% and 26.6% respectively) than Indians (15.2%). Comparisons of all South Asians with Europeans hid some important differences, but South Asians were still disadvantaged in a wide range of risk factors. Findings in women were similar.

CONCLUSION

Risk of coronary heart disease is not uniform among South Asians, and there are important differences between Indians, Pakistanis, and Bangladeshis for many coronary risk factors. The belief that, except for insulin resistance, South Asians have lower levels of coronary risk factors than Europeans is incorrect, and may have arisen from combining ethnic subgroups and examining a narrow range of factors.

Training in academic medicine: a way forward for the new millennium. A discussion document from the Academic Medicine Committee of the Royal College of Physicians

Three schemes are presented for discussion whereby physicians undergoing postdoctoral training can combine a period of research training with their clinical training and so enable those who wish to follow a career in academic medicine to do so, or alternatively to revert to a clinical career. The training arrangements for those wishing to take up clinical academic medicine have hitherto been uncertain and hence unattractive to some. As well as encouraging more high-calibre trainees into academic medicine, the training programmes described are intended to bring greater clarity to those responsible for academic and clinical training and to those who fund research.

The amylin analog pramlintide improves glycemic control and reduces postprandial glucagon concentrations in patients with type 1 diabetes mellitus

To explore further the effects of the human amylin analog pramlintide on overall glycemic control and postprandial responses of circulating glucose, glucagon, and metabolic intermediates in type 1 diabetes mellitus, 14 male type 1 diabetic patients were examined in a double-blind, placebo-controlled, crossover study. Pramlintide (30 microg four times daily) or placebo were administered for 4 weeks, after which a daytime blood profile (8:30 AM to 4:30 PM) was performed. Serum fructosamine was decreased after pramlintide (314+/-14 micromol/L) compared with placebo (350+/-14 micromol/L, P = .008). On the profile day, the mean plasma glucose (8.3+/-0.7 v 10.2+/-0.8 mmol/L, P = .04) and postprandial concentrations (incremental areas under the curve [AUCs] from 0 to 120 minutes) were significantly decreased during pramlintide administration (P < .01 for both) despite comparable circulating insulin levels (359+/-41 v 340+/-35 pmol/L). Mean blood glycerol values were reduced (0.029+/-0.004 v 0.040+/-0.004 mmol/L, P = .01) and blood alanine levels were elevated (0.274+/-0.012 v 0.246+/-0.008 mmol/L, P = .03) after pramlintide versus placebo. Blood lactate concentrations did not differ during the two regimens. During pramlintide administration, the AUC (0 to 120 minutes) for plasma glucagon after breakfast was diminished (P = .02), and a similar trend was observed following lunch. In addition, peak plasma glucagon concentrations 60 minutes after breakfast (45.8+/-7.3 v 72.4+/-8.0 ng/L, P = .005) and lunch (47.6+/-9.0 v 60.9+/-8.2 ng/L, P = .02) were both decreased following pramlintide. These data indicate that pramlintide (30 microg four times daily) is capable of improving metabolic control in type 1 diabetics. This may relate, in part, to suppression of glucagon concentrations. Longer-term studies are required to ascertain whether these findings are sustained over time.

Tackling the emerging pandemic of non-communicable diseases in sub-Saharan Africa: the essential NCD health intervention project

There is evidence that the prevalence of certain non-communicable diseases, such as diabetes and hypertension, is increasing rapidly in parts of sub-Saharan Africa. Others, such as asthma and epilepsy, are known to be common but to be poorly managed. This paper describes a project, funded by the Department for International Development of the British Government, which aims to provide costed and evaluated treatment packages for use at primary health care level, methods and materials for evaluating the quality of non-communicable disease care, and a protocol for the assessment for national opportunities for the prevention of hypertension, heart disease and diabetes. Methods are being developed and piloted in urban and rural Tanzania and Cameroon.