bluuebunny/crossref_metadata_2025 huggingface dataset:
Evaluation of Protein in Dietary Management of Diabetes Mellitus
Authors: Wylie-Rosett Judith
Published: March 2007

Establishing appropriate recommendations for protein intake in the management of diabetes requires examination of the role that dietary protein plays in overall health, in the control of diabetes, and in the risks to health posed by diabetes. Achieving metabolic control and delaying and/or preventing diabetic complications have previously been established as primary goals for the dietary management of diabetes. Although the primary function of dietary protein is for growth and tissue maintenance, dietary protein may play a role in the regulation of glucose metabolism and in the development of diabetic renal complications. Approximately half of protein intake is considered to be available as glucose. Dietary composition also affects secretion of insulin and counterregulatory hormones. One-third of individuals with insulin-dependent diabetes and one-fifth of those with non-insulin-dependent diabetes develop nephropathy within 15 yr after the diagnosis of diabetes. High protein intake and hyperglycemia can increase the glomerular filtration rate and the work load of the kidney. There is growing evidence from clinical studies that the progression of renal disease is delayed by early protein restriction. More studies are needed to assess early risk of diabetic nephropathy and to determine whether protein restriction alters the course of diabetic nephropathy. A dietary intake of between 12 and 20% protein provides flexibility in food selection but exceeds actual needs. The adult Recommended Dietary Allowance of 0.8 g/kg body wt should provide guidance for determining desired protein intake for individuals with diabetes.
Primary, Secondary, and Tertiary Prevention Program for Diabetes in Pregnancy
Authors: Mazze Roger S , Langer Oded
Published: March 2007

Over the past 2 yr the effectiveness of a program in primary, secondary, and tertiary prevention of diabetes in pregnancy was studied. The purpose of the program was to determine the degree to which preventive medicine in terms of early screening and diagnosis, rapid initiation of treatment, and close follow-up surveillance could reduce the morbidity and mortality associated with pregestational and gestational diabetes. The study compared the program in prevention with previous programs, and its results were measured against national criteria established by the Centers for Disease Control. A significant increase in early identification of gestational diabetes and a decrease in fetal and maternal complications were detected.
Interventions Among Primary-Care Practitioners to Improve Care for Preventable Complications of Diabetes
Authors: Deeb Larry C , Pettijohn F Phillips , Shirah Jerry K , Freeman Garry
Published: March 2007

The National Diabetes Advisory Board recommends that diabetes prevention and control programs focus on the preventable complications of diabetes, i.e., visual impairment, lower-extremity problems, renal problems, ketoacidosis, and adverse outcomes of pregnancy. The Florida Diabetes Control Program chose to focus its efforts on the first three of these complications at the federal- and state-funded primary-care programs in Florida because these programs had access to targeted, public-sector patients and because of fiscal restraints that make the care provider the logical source of entry to the health-care system. This study sought to document the current level of care for complications of diabetes in primary-care settings, provide state-of-the-art professional education along with patient education, and evaluate changes in practice habits. Three intervention and three control primary-care centers were selected. Medical records in each center were reviewed over a 2-yr period. At intervention sites, retinopathy referrals increased from 9 to 43% (P < .001), urinalyses increased from 69 to 94% (P < .001), and examinations of lower extremities increased from 66 to 94% (P < .001). There were no such changes in the control sites. Hypertension was diagnosed in nearly two-thirds of patients, and a last blood pressure of >140 mmHg systolic or >90 mmHg diastolic was present in 64% of the intervention group at yr 1 and declined to 56% at yr 2 (P < .05). The following problems were identified. 1) Despite referrals to ophthalmologists approaching 100%, the actual rate of compliance was only 43%. 2) Significant hypertension existed after intervention. 3) The clinic drop-out rate was 37% after only 1 yr. This study documents the actual care delivered in this sector of medicine and the willingness of providers to change practice habits to comply with recommended standards.
Dietary Carbohydrate, a Big Mac, and Insulin Requirements in Type I Diabetes
Authors: Vlachokosta Frederika V , Piper Cheryl M , Gleason Ray , Kinzel Laura , Kahn C Ronald
Published: March 2007

Using the artificial (β-cell (Biostator), we determined the insulin requirements in five nonobese type I (insulindependent) diabetic subjects who received isocaloric 40 and 60% mixed-carbohydrate diets in a crossover randomized fashion for 4 days, each day consisting of four equal meals. This was followed on day 5 by a “Big Mac Attack” lunch consisting of a Big Mac, french fries, and milk shake. Insulin requirements to maintain normoglycemia were calculated for each 24-h period and for the 2 h after each meal. The mean 24-h insulin requirements to maintain normoglycemia was greater for the 60% carbohydrate diet than the 40% diet. Although the four meals were of equal size, in all patients the insulin required to cover breakfast > lunch > dinner > snack. Expressed as milliunits per kilocalorie, the amount of insulin to cover breakfast was greater for the 60% (P < .05) than the 40% carbohydrate diet and greater for breakfast than the other meals (P < .01). Insulin requirements for the Big Mac meal (43% carbohydrate) were 58% greater than for the 40% carbohydrate diet, even after correction for caloric differences. In summary, 1) increasing dietary carbohydrate from 40 to 60% results in an increased insulin requirement for meals only; 2) insulin requirements are greater in the morning than in the evening, even when meal size is constant; and 3) very large meals with high fat and carbohydrate content result in a major increase in insulin requirement. These data indicate that diet has an important impact on insulin requirements in diabetes.
Determinants of Hospital Admission and Case Fatality in Diabetic Patients With Myocardial Infarction
Authors: Yudkin John S , Oswald George A
Published: March 2007

We compare the clinical features and hospital outcomes in 83 diabetic patients admitted with acute myocardial infarction and 380 nondiabetic patients with levels of glycosylated hemoglobin (HbA1c) low enough to exclude undiagnosed diabetes. The hospital mortality was 42.2% in diabetic and 24.7% in nondiabetic patients, an odds ratio of 2.22 (Cl 1.37-3.60, P < .002). The excess mortality was due to cardiogenic shock and left ventricular failure (pump failure). There was no difference in peak levels of aspartate transaminase between the groups. Among the diabetic patients, the admission levels of plasma glucose and peak levels of aspartate transaminase were higher among those who developed pump failure or died, but there was no relationship between outcome and gender, disease duration, or treatment. Prior blood glucose control, as judged by levels of HbA1c, was not related to hospital outcome (P > .5). In a further study, the 83 diabetic patients were compared with 249 age- and sex-matched diabetic subjects without myocardial infarction for treatment, disease duration, and control. There was an increased risk of admission with myocardial infarction of 2.35 (Cl 1.41-3.92, P < .005) within the first 5 yr of diagnosis of diabetes. Infarct patients had significantly lower levels of HbA1c than control subjects (P < .005), but treatment did not differ between groups. Neither incidence nor case fatality of myocardial infarction in diabetic patients is positively associated with cumulative glycemic exposure.
Oral Glucose Tolerance Test in Healthy Pregnant Nigerian Women
Authors: Famuyiwa Olufunsho O , Amadin Richard A , Adelusi Babatunde O
Published: March 2007

Oral glucose tolerance tests (OGTTs) with 75 g glucose were performed in 20 healthy pregnant Nigerian women in each trimester of pregnancy and the puerperium; 34 nonpregnant control subjects matched for age and parity were also studied. The blood glucose levels from fasting to 60 min were lower in pregnant subjects, but the 90- and 120-min values were higher. The highest blood glucose values were observed in the first trimester with an apparent improvement in glucose tolerance in the second and third trimesters. This observation is strikingly different from the established pattern of OCTT in pregnant Caucasian women. With pooled data from OGTT results in the three trimesters for the 20 pregnant women (60 OGTTs), a statistically derived criterion (based on mean + 2SD approximated to the nearest 5) for the interpretation of OGTT in pregnant Nigerian women was devised. This criterion defines the upper limits of normal for venous wholeblood glucose in pregnant Nigerian women during an OGTT with a 75-g glucose load as follows: fasting, 90; 30 min, 135; 60 min, 150; 90 min, 145; and 120 min, 125 mg/dl. These values are lower than those recommended for pregnant women by the National Diabetes Data Group (O'Sullivan and Mahan criteria) and the World Health Organization. The results from this study underscore the need for caution regarding uncritical application of data from one racial or ethnic group to others.
Glycosylation of Proteins: Lack of Influence of Aging
Authors: Kabadi Udaya M
Published: March 2007

In elderly nondiabetic individuals, increased glycosylation of hemoglobin has been reported. Most elderly subjects suffer from chronic disorders and consume one or more medications. Thus, it is conceivable that the increased glycosylation of hemoglobin may be secondary to factors other than old age. Furthermore, the data are sparse regarding the effect of aging on glycosylation of other proteins. In this study, glycosylated hemoglobin (GHb), glycosylated protein (GP), glycosylated albumin (GA), and fasting plasma glucose (FPG) concentrations were determined in 93 healthy nondiabetic subjects after an overnight fast. Strict criteria were observed to define the healthy status of these subjects to eliminate the influence of all other factors known to facilitate glycosylation of hemoglobin. No significant correlations were noted between age and FPG, GHb, GP, or GA (P > .05 for all correlations). Furthermore, no significant differences were observed between groups according to age for any of the parameters studied. Therefore, this study demonstrates that aging may not influence glycosylation of proteins in healthy subjects, and the previously observed increase in GHb concentrations in elderly populations may be related to associated factors rather than old age.
Comparison of Fructosamine With Glycosylated Hemoglobin and Plasma Proteins as Measures of Glycemic Control
Authors: Smart Lesley M , Howie Alexander F , Young Robert J , Walker Simon W , Clarke Basil F , Smith Alistair F
Published: March 2007

The relative value of fructosamine as an alternative to glycosylated hemoglobin (HbA1) and other measures of glycemic control was assessed in 100 insulin-dependent (IDDM) and 104 non-insulin-dependent (NIDDM) diabetic patients. We measured HbA1 (by electrophoretic and affinity methods), plasma glucose, glycosylated plasma proteins, and fructosamine in blood taken at a single clinic visit. The values were compared both by correlation analysis and by considering whether the various indices of glycemic control placed the patients in the same clinical decision categories as they were in by the HbA1 (affinity) result. Fructosamine correlated moderately well with HbA1 (affinity; r = .8) and placed 71% of IDDM and 72% of NIDDM patients in the same clinical category of good, moderate, or poor control. Differences can probably be partly attributed to the different periods over which HbA1 and fructosamine reflect average glycemia and partly to imprecision.
Community Diabetes Care in the 1980s
Authors: Anderson Robert M , Hess George E , Davis Wayne K , Hiss Roland G
Published: March 2007

This is a study of diabetes care and care outcomes for patients under the active care of private physicians. Randomly selected communities, physicians, and patients in Michigan were the subjects of this study. Data on the care practices of physicians and patients and care outcomes were collected from 1980 to 1981 and again in 1985 from eight communities, 61 physicians, and 261 patients. We found that the use of multiple injections of insulin and self-monitoring of blood glucose increased significantly, whereas hospitalizations for diabetes control decreased. The mean glycosylated hemoglobin values for this cohort of patients remained unchanged. The study results suggest that, for patients under the active care of community physicians, modern methods of diabetes care are being implemented, but the results of improved care do not show an impact on blood glucose control as measured by glycosylated hemoglobin values. The study was not designed to establish causation for the decrease in hospitalizations for these patients, but the data suggest that decreases may be more a function of changes in health-care policies rather than changes in patient health.
Frequency of Early-Morning Rise in Blood Glucose in Children With Diabetes at Camp
Authors: Duncan Bruce B , Schmidt Maria Ines , Ellis George J , Davis Clarence E , Heiss Gerardo
Published: March 2007

To estimate the frequency of an early-morning glucose rise (EMR) in relatively unselected children with insulindependent diabetes mellitus (IDDM), we assessed capillary blood glucose (CBG) at midsleep (0200-0430) and prebreakfast (0700-0800) in 97 children with diabetes at camp. The EMR (prebreakfast CBG-midsleep CGB) was inversely related to the midsleep CBG level (r = −.45, P <.001). Of the 49 children with midsleep CBG <200 mg/dl, the mean EMR was 34 ± 60 mg/dl, and 18 of these children had rises of >40 mg/dl. In conclusion, when midsleep glycemia is <200 mg/dl, a rise in blood glucose from midsleep to prebreakfast, often >40 mg/dl, is a common element of glycemic control among children with IDDM. The relative importance of the Somogyi phenomenon, the dawn phenomenon, and mere insulin insufficiency in the early-morning hours cannot be determined from these data.
Metabolic and Cutaneous Events Associated With Hypoglycemia Detected by Sleep Sentry
Authors: Clarke William L , Carter William R , Moll Maria , Cox Daniel J , Gonder-Frederick Linda A , Cryer Philip E
Published: March 2007

Eighteen insulin-dependent diabetic subjects [age (mean ± SD) 33.2 ± 10.6 yr] participated in a study designed to determine the metabolic and cutaneous parameters associated with activation of the nocturnal hypoglycemia monitor Sleep Sentry. Plasma glucose, glucagon, epinephrine, norepinephrine, and pancreatic polypeptide concentrations were determined every 10 min during a 2-h constant intravenous insulin infusion (40 mU kg −1 h−1). In addition, skin temperature and electrical conductance were monitored at the same time intervals, and subjects were asked to rate the degree to which they felt cold and/or sweaty. Ten of the subjects (alarmers) activated the device with a mean plasma glucose nadir of 52.8 ± 13.8 mg/dl, whereas eight (nonalarmers) failed to do so despite a mean plasma glucose nadir of 50.5 ± 8.2 mg/dl. There were no significant differences between alarmers and nonalarmers with respect to initial or nadir plasma glucose levels, rate of fall of plasma glucose, or changes in plasma epinephrine, norepinephrine, or pancreatic polypeptide concentrations. In addition, changes in skin temperature and conductance were similar in both groups as were descriptive variables including age, disease duration, gender, and level of glucose control. No subject reported an increase in coldness, whereas 80% of both groups reported an increase in sweatiness. Three subjects studied on more than one occasion over a year failed to exhibit consistent activation of the alarm. This study suggests that it may not be possible to identify patients for whom the Sleep Sentry would be a reliable addition to their self-management regimen and that physicians should exercise caution in recommending its use.
Relationship of Nocturnal Hypoglycemia to Daytime Glycemia in IDDM
Authors: Lerman Israel G , Wolfsdorf Joseph I
Published: March 2007

In view of the continuing debate about the clinical relevance of nocturnal hypoglycemia as an explanation for high blood glucose (BG) levels before breakfast, we prospectively analyzed 281 overnight BG profiles (blood samples obtained at 2100, 0200–0300, and 0700) in 66 consecutive patients with insulin-dependent diabetes mellitus. Nocturnal hypoglycemia (0200-0300 BG concentration ≤50 mg/dl) occurred in 27 patients (41%) and in 36 profiles (13%). All the patients with nocturnal hypoglycemia received two or more injections of insulin each day. When hypoglycemia occurred at 0200–0300, the preceding BG concentration at 2100 was significantly lower than when nocturnal BG was >100 mg/dl (108 ± 11 vs. 145 ± 12 mg/dl; P < .05; mean ± SE). A BG <120 mg/dl at 2100 preceded nocturnal hypoglycemia in 24 (67%) of 36 profiles. The mean BG at 0700 was significantly lower in the profiles associated with nocturnal hypoglycemia than in those with nocturnal BG levels >150 mg/dl (156 ± 10 vs. 201 ± 11 mg/dl; P < .05). BG values >180 mg/dl at 0700 were infrequently (11 of 143 or 8% of profiles) preceded by nocturnal hypoglycemia, and no instances of major hyperglycemia (BG >300 mg/dl) at 0700 were preceded by nocturnal hypoglycemia. Furthermore, BG at 0700, 1100, and 1500 on the day before the occurrence of nocturnal hypoglycemia were similar to those on the day after. Individuals with nocturnal hypoglycemia whose subsequent BG at 0700 exceeded 180 mg/dl consumed significantly more calories (181 ± 18 vs. 115 ± 12; P < .001) and carbohydrate (39 ± 4 vs. 26 ± 3 g; P < .05) than those with BG <120 mg/dl at 0700. Nocturnal hypoglycemia was not followed by major hyperglycemia at 0700 or higher daytime glycemia than on the previous day. Excessive food intake to treat nocturnal hypoglycemia appears to be an important factor contributing to unacceptably high BG levels before breakfast.
Prevalence of Diabetes Mellitus in Alaskan Eskimos, Indians, and Aleuts
Authors: Schraer Cynthia D , Lanier Anne P , Boyko Edward J , Gohdes Dorothy , Murphy Neil J
Published: March 2007

The prevalence of diabetes mellitus in Alaska Natives has been thought to be low, but no survey of this condition in all natives has been conducted. Medical records from 1979 to 1985 were reviewed to determine the prevalence of diagnosed diabetes mellitus in Alaska Natives. Computerized outpatient and inpatient medical record data and clinician reports were used to identify cases. As of December 1985, 610 living Alaska Natives fulfilled diagnostic criteria for diabetes. Type II diabetes mellitus was found in 564 subjects, type I diabetes was found in 15 subjects, and unspecified type of diabetes was found in 31 subjects. The overall age-adjusted prevalence of diabetes mellitus, 15.7/1000, was lower than the overall United States rate of 24.7/1000. However, age-adjusted prevalence varied considerably by ethnic group; the prevalence was 27.2/1000 among Aleuts, 22.0/1000 among Alaskan Indians, and 8.8/1000 among Alaskan Eskimos. Rates within the Eskimo subgroups varied by a factor of four. Compared with previous reports, the prevalence of diabetes mellitus in Alaskan Eskimos appears to have increased. Diabetes mellitus is no longer a rare condition among Alaska Natives.
Fasting Plus Prandial Insulin Supplements Improve Insulin Secretory Ability in NIDDM Subjects
Authors: Kawamori Ryuzo , Bando Kazuo , Yamasaki Yoshimitsu , Kubota Minoru , Watarai Takao , Iwama Norimichi , Shichiri Motoaki , Kamada Takenobu
Published: March 2007

To examine how insulin secretory ability is modified by strict glycemic control in non-insulin-dependent diabetes mellitus (NIDDM) subjects, basal and/or prandial insulin was supplemented for 4 wk in 24 diabetic subjects who were secondary failures to sulfonylurea treatment. One intermediate-acting insulin injection a day (n = 7) failed to suppress the rise in plasma C-peptide after meals and did not improve plasma C-peptide responses during a posttreatment oral glucose challenge. Continuous subcutaneous insulin infusion with a premeal bolus (n = 8) suppressed both fasting and meal-related rises in C-peptide and improved C-peptide response during the posttreatment oral glucose challenge. Daily insulin requirements during the 4 wk of treatment were reduced significantly by 52%. A short-acting insulin injection before each meal (n = 9) without basal supplementation suppressed the prandial rise in C-peptide and was associated with a significant reduction in daily insulin requirements during 4 wk of treatment by 28%. Diabetic subjects whose fasting and prandial hyperglycemia were <140 and <200 mg/dl, respectively, showed a significantly higher C-peptide response during oral glucose challenge after treatment than those whose insulin treatment only normalized (<200 mg/dl) prandial but not basal hyperglycemia (>140 mg/dl). These results suggest that a short-term period of meal-related insulin treatment (which normalized prandial glycemia) increases residual β-cell function in NIDDM subjects who failed long-term sulfonylurea administration. A basal insulin supplement alone was not effective. The effectiveness of a prandial insulin supplement may have been further improved by a combined basal and meal-related treatment program
Cardiovascular Conditioning in Individuals With Diabetic Retinopathy
Authors: Bernbaum Maria , Albert Stewart G , Cohen Jerome D , Drimmer Ami
Published: March 2007

The benefit of exercise for individuals with diabetes mellitus and high-risk complications of retinopathy has been questioned. Thirty-nine individuals with diabetes and visual impairment completed a 12-wk rehabilitation program that included cardiovascular conditioning. Preand postprogram assessment of exercise training in 30 subjects included a graded stress test with a bicycle ergometer. There were improvements in exercise tolerance as measured by the work load achieved (from 248 ± 27 to 303 ± 31 kilopond meter [kpm], P < .05). There was a trend toward improvement in METS achieved (from 3.3 ± 0.2 to 3.8 ± 0.3, P = .06). There was no correlation of improvement in exercise tolerance with improvements in glycemic control, lipoprotein balance, and change in body weight. Individuals with diabetic retinopathy may be given the option of entering cardiovascular training programs with appropriate modifications to fit specific needs.
Genetically Programmed Selective Islet β-Cell Loss in Diabetic Subjects With Wolfram's Syndrome
Authors: Karasik Avraham , O'Hara Carl , Srikanta S , Swift Michael , Soeldner J Stuart , Kahn C Ronald , Herskowitz Raymonde D
Published: March 2007

Insulin-producing (5-cells were selectively absent from the islets of Langerhans in postmortem specimens from two patients with Wolfram's syndrome. In families with multiple cases of this syndrome, we found a very high concordance rate (r = .910, P < .001) among siblings for age at onset of diabetes mellitus. Taken together with the lack of markers for an autoimmune process, these findings suggest that diabetes mellitus in this syndrome results from genetically programmed selective p-cell death.
Carriage of Staphylococcus aureus and Inflamed Infusion Sites With Insulin-Pump Therapy
Authors: Faassen Ineke van , Razenberg Peter P A , Simoons-Smit Alberdina M , Veen Eduard A van der
Published: March 2007

The most common complication of continuous subcutaneous insulin infusion (CSII) is inflammation at the infusion site. To determine possible risk factors to these infections, we studied several factors in the management of CSII and compared the pyogenic skin inflammation rate, the carriage rate of Staphylococcus aureus, and the HbA, level among 50 CSII-treated diabetic patients, 50 diabetic patients on insulin injections, 48 diabetic patients on oral medication, and 40 healthy volunteers. There was no increased carriage rate of S. aureus among CSII-treated patients (42%) as compared with the other groups. An unexpected inverse relationship existed between HbA, level and carriage rate in the CSII-treated group (HbA, 5–8%, n = 16, 69%; HbA, 8–10% n = 15, 40%; HbA, >10, n = 19, 21% P = .02). Pyogenic skin inflammations were reported by 24 (48%) CSII-treated patients, of which 18 had infected infusion sites, 6 (12%) insulin injecting patients, 2 (4%) patients on oral medication, and 3 (8%) healthy volunteers (P < .01). The occurrence of inflamed infusion sites was not associated with carriage of S. aureus, the indwelling time of the needle, or the insulin dosage per day. There was an association, however, with the type of insulin preparation classified according to the added preservative: m-cresolcontaining insulin (n = 24, 54%); methyl phydroxybenzoate- containing insulin (n = 26, 19%, P = .02). We concluded that the carriage of S. aureus is not increased among diabetic patients on CSII treatment and is not a risk factor in the occurrence of inflammation at the infusion site. The type of preservative in the insulin preparation seems to be of importance in the development of these local inflammations.
NIDDM and Prevalence of Nasal Staphylococcus aureus Colonization: San Luis Valley Diabetes Study
Authors: Boyko Edward J , Lipsky Benjamin A , Sandoval Rodney , Keane Ellen M , Monahan Janet S , Pecoraro Roger E , Hamman Richard F
Published: March 2007

Previous studies of hospitalized and ambulatory patients have found a higher prevalence of Staphylococcus aureus nasal colonization in diabetic than nondiabetic subjects. We examined this association in a geographically based study among 551 residents of the San Luis Valley of Colorado and found no statistically significant increase in the relative risk of nasal S. aureus colonization in 188 non-insulin-dependent diabetic (NIDDM) versus 363 nondiabetic subjects (relative risk 1.3, 95% confidence limits 0.9–1.8). Adjustment for confounding by age, sex, ethnicity, county of residence, and frequency of hospitalizations or physician visits in the previous year did not affect the results. Among the diabetic subjects, S. aureus colonization was not associated with type of treatment for diabetes, level of glucose control, clinical duration of diabetes, or frequency of hospitalizations or physician visits in the previous year. In this population-based study, diabetes mellitus did not increase S. aureus nasal colonization, suggesting that factors other than diabetes mellitus may have caused the higher colonization rate found in previous clinic-based studies.
Severe Hypoglycemia in IDDM Children
Authors: Bergada Ignacio , Suissa Samy , Dufresne Jackie , Schiffrin Alicia
Published: March 2007

The incidence of severe hypoglycemia was determined in a 1-yr prospective study of 350 insulin-dependent diabetic (IDDM) children. There were no significant differences in mean glycosylated hemoglobin, age, and duration of disease between the patients who had severe hypoglycemia and those who did not. There were 25 episodes in 24 patients (6.8%). Their insulin doses at the time of the episode (U · kg−1 · day−1) were significantly higher than those of the nonhypoglycemic group (mean ± SD 1.01 ± 0.30 vs. 0.89 ± 0.29; P = .04). The hypoglycemic group had a significantly higher mean number of previous episodes of severe hypoglycemia than the nonhypoglycemic group (0.92 ± 1.18 vs. 0.25 ± 0.68; P = .01). In only 64% of the episodes, an unusual circumstance such as strenuous physical activity or missed or delayed meals preceded the event. Multivariate analysis of the data by logistic regression showed risks of developing hypoglycemia of 2.5 per 0.5 U/day insulin and of 2.0 per previous episode of severe hypoglycemia. We conclude that severe hypoglycemia may be a recurrent problem in some diabetic children, but it does not appear to be related to age or blood glucose control. The presence of previous episodes may be a guide to identify patients at greater risk of developing severe hypoglycemia. Adherence to regular testing, strict spacing and consistency of meals, and extra food for extra activity may reduce this serious complication.
Importance of Cardiovascular Autonomic Dysfunction in IDDM Subjects With Diabetic Nephropathy
Authors: Zander Echkard , Schulz Bernd , Heinke Peter , Grimmberger Eckhard , Zander Gudrun , Cottschling Hans Detlef
Published: March 2007

Diabetic nephropathy (DNP) is associated with increased cardiovascular mortality. This may be contributed to by associated cardiovascular autonomic dysfunction (CAD). The aim of this study was to investigate the prevalence of CAD in patients with insulin-dependent diabetes mellitus (IDDM) at different stages of DNP. We studied patients with incipient DNP (group 1, n = 10), overt DNP (group 2, n = 20), renal insufficiency (group 3, n = 27), and end-stage renal failure (group 4, n = 12) and compared them with 30 IDDM patients without clinical signs of DNP (group 5) and with 17 nondiabetic controls (group 6). All groups were matched for age and diabetic groups were matched for duration of diabetes. Assessments of CAD included beat-to-beat variation during forced respiration, heart-rate response to standing, heart-rate response to Valsalva maneuver, basal heart rate, and blood pressure response to standing. Clinical evaluation included assessment of the history and an examination for peripheral polyneuropathy. We found mean impairment of heart-rate variation during respiration, in response to Valsalva maneuver, and in heart-rate response to standing in all diabetic groups compared with nondiabetic controls (P < .01). Heart-rate responses differed significantly between patients with renal insufficiency (groups 3 and 4) and with other patient groups (group 5; P < .01). CAD was shown to be more prevalent in patients with DNP, more so as DNP progresses. To some extent, it is already present in the early stages of DNP. CAD may be a contributory factor for increased cardiovascular mortality in patients with DNP. Patients with incipient DNP should be followed prospectively, with respect to CAD, to further elucidate their relationship and the impact on cardiovascular mortality.
Measuring Diabetic Neuropathy: Assessment and Comparison of Clinical Examination and Quantitative Sensory Testing
Authors: Maser Raelene E , Nielsen Viggo K , Bass Eric B , Manjoo Qurashia , Dorman Janice S , Kelsey Sheryl F , Becker Dorothy J , Orchard Trevor J
Published: March 2007

The need for a standardized and valid means of assessing diabetic neuropathy has been increasingly recognized. To identify potential components of such an assessment, interobserver variation (neurologist and internist) of a standard neurologic examination and the comparability of this examination with vibratory and thermal sensitivity testing was studied. The study population comprised the first 100 participants in a neuropathy substudy of 25- to 34-yr-old subjects with insulin-dependent diabetes mellitus taking part in a cohort follow-up study. Symptoms of dysesthesias, paresthesias, and burning, aching, or stabbing pain revealed good interobserver agreement. Signs of neuropathy, more prevalent in the great toe than index finger, showed poor interobserver agreement for vibration, but fair interobserver agreement for touch and pinprick. Mean quantitative sensory thresholds differed significantly by clinical category of abnormal vibratory and pinprick sensations. Threshold testing showed twice the prevalence of abnormality compared with clinical examination. It is concluded that components of the clinical examination can be identified that, along with quantitative sensory-threshold testing, may provide a satisfactory core assessment for use both in epidemiologic studies and incorporation into more in-depth protocols required for clinical research and practice. The clinical relevance of the greater prevalence of abnormalities on threshold testing will be established by long-term follow-up.
Metabolic Effects of Fructose Supplementation in Diabetic Individuals
Authors: Anderson James W , Story Linda J , Zettwoch Nancy C , Gustafson Nancy J , Jefferson Beverly S
Published: March 2007

With new diabetes diet guidelines recommending high carbohydrate intake, questions arise regarding acceptable intake of simple sugars. Whereas several short-term studies report flattened glycemic and insulin response to fructose consumption, some also report increased serum triglyceride levels. Few studies examine the effects of long-term fructose consumption. We evaluated the long-term safety of fructose consumption in 14 middle-aged men with diabetes. Subjects followed an ambulatory high-fiber high-carbohydrate control diet at home for 8 wk, entered the hospital for 5 days on this diet, and spent the next 7 days on a similar diet supplemented with 50–60 g fructose. They continued the fructose diet at home for 23 wk, then resumed a postcontrol diet for an additional 16 wk. In the hospital, glycemic control improved significantly on the fructose-supplemented diet compared with the hospital control diet. In the ambulatory setting, no significant differences in plasma glucose, glycohemoglobin, serum cholesterol, triglycerides, lactate, or urate occurred between precontrol, fructose, or postcontrol periods. Fasting serum lactate was higher by 0.5 meq/L during the ambulatory fructose period than during the precontrol period. Body weight also increased during the ambulatory fructose period due to higher calorie intake. Adherence to fructose consumption was excellent and improved adherence to carbohydrate and fat recommendations. If total calorie intake is controlled to promote desirable body weight, crystalline fructose used with a high-carbohydrate high-fiber low-fat diet appears to be safe and acceptable for diabetic individuals.
Effect of Guar Gum on Mineral Balances in NIDDM Adults
Authors: Behall Kay M , Scholfield Daniel I , Mclvor Michael E , Duyn MaryAnn S Van , Leo Theresa A , Michnowski Lane E , Cummings Charles C , Mendeloff Albert I
Published: March 2007

The self-selected diet of 16 subjects with noninsulin- dependent diabetes mellitus (NIDDM) was supplemented for 6 mo with either a granolalike bar containing 35.5 g carbohydrate and 6.6 g guar gum/bar or a placebo bar containing carbohydrate but no guar gum. Subjects consumed a mean of 4.8 bars/day. Average guar gum consumption at the end of the study was 31.7 g/day. One week before and at the end of the study, subjects were admitted to a metabolic ward and fed a controlled diet similar to their self-selected diet. Food, feces, and urine were composited for analysis of iron, zinc, copper, calcium, magnesium, and manganese. Eight subjects consuming the guar gum supplement and 6 subjects consuming the placebo bar completed collections for mineral balance. Neither consumption of guar gum nor placebo bar significantly changed apparent mineral balance for iron, copper, zinc, calcium, manganese, or magnesium from prestudy levels to 6-mo levels, and no significant differences were observed between the two groups. With the exception of copper, men consumed significantly more minerals than women. We conclude that consumption of guar gum by patients with NIDDM does not adversely affect apparent mineral balance.
Abnormal Nerve Conduction in Impotent Patients With Diabetes Mellitus
Authors: Daniels John S
Published: March 2007

The etiology of impotence in the diabetic population has not been clearly defined. To assess this problem, 24 impotent diabetic subjects, 21 nonimpotent diabetic subjects, and 10 subjects with psychogenic impotence were compared with nocturnal monitoring of penile tumescence and rigidity, penile arterial blood flow, and nerve conduction of the pudendal nerve. There was no statistical difference in mean age or durationof diabetes among the various study groups. All diabetic subjects who presented with complaints of impotence had severe abnormalities on nocturnal erection monitoring. There was no significant difference in the mean penile brachial index between impotent and nonimpotent diabetic subjects (P = .335). In contrast, there was a significant difference in bulbocavernosus-reflex latency times (P < .001) between impotent (meanlatency 48.4 ms) and nonimpotent (mean latency 38.7 ms) diabetic subjects. This studystrongly suggests that impotence in the diabetic population is secondary to functional abnormalities of pelvic nerves and that the bulbocavernosus-reflex latency time is an excellent diagnostic test for assessing function of pelvic nerves in the diabetic individual.
Impaired Glucose Tolerance in the U. S. Population
Authors: Harris Maureen I
Published: March 2007

Impaired glucose tolerance (IGT) constitutes two-thirds of all glucose intolerance in the United States and is a major risk factor for diabetes. Despite these findings, the clinical and epidemiological significance of IGT has not been well investigated. The Second National Health and Nutrition Examination Survey, a cross-sectional study in which 75-g 2-h oral glucose tolerance tests (OGTTs) were performed, has provided an opportunity to examine the characteristics of IGT in the U. S. population. Data from the survey have been extrapolated to represent all U. S. residents. The findings indicate that ∼11.2% of Americans aged 20–74 yr have IGT compared to 6.6% with diabetes. Rates of IGT increased with age for White men and women and Black men but declined for Black women >54 yr of age, possibly because greater obesity in Black women precipitated earlier conversion of IGT to diabetes. The distribution of 2-h glucose values showed IGT to be part of a continuum of glucose intolerance extending from normal to diabetes. Individuals with IGT had rates of risk factors for non-insulin-dependent diabetes (age, plasma glucose, past obesity, family history of diabetes, physical inactivity) that were intermediate between those of individuals with normal glucose tolerance and those with diabetes, although current obesity was similar for IGT and diabetes. The proportion of people with medical histories of diabetes-related conditions did not differ between IGT and normal glucose tolerance. However, several cardiovascular findings were more prevalent in individuals with IGT than in those with normal glucose tolerance, including hypertension, serum cholesterol, angina, abnormal heart findings, and medical history of arteriosclerosis and stroke. Both obesity and reported family history of diabetes were associated with higher rates of IGT, with the effect of weight gain on the prevalence of IGT occurring at lower levels than for diabetes.
Adjustment to Diabetes Mellitus in Preschoolers and Their Mothers
Authors: Wysocki Tim , Huxtable Karen , Linscheid Thomas R , Wayne Wynola
Published: March 2007

Although preschool-aged children with diabetes might be at increased risk for both general and disease-specific psychological adjustment difficulties, this issue has not been investigated. We evaluated both general and diabetes-related adjustment of 20 preschool-aged children and their mothers. The mothers completed the Child Behavior Checklist, Parenting Stress Index, Parents' Diabetes Opinion Survey, and the Preschool D abetes Behavior Checklist. The latter measure was constructed specifically for this study to measure the frequency of oppositional and avoidance behaviors of children regarding diabetes management tasks. Mothers reported that their children displayed significantly more i ternalizing behavior problems (anxiety, depression, withdrawal) and were a significantly greater source of parental stress compared with corresponding nondiabetic normative group samples. Also, certain maternal attitudes about diabetes and its treatment were correlated with the children's disease-specific behavior problems. The children's general psychological adjustment, however, was not predictive of these diabetes-specific behavior problems.
Effects of Dose of Ingested Glucose on Plasma Metabolite and Hormone Responses in Type II Diabetic Subjects
Authors: Gannon Mary C , Nuttall Frank Q , Westphal Sydney A , Neil Brian J , Seaquist Elizabeth R
Published: March 2007

Ten untreated type II (non-insulin-dependent) diabetic subjects were given 15, 25, 35, and 50 g glucose orally. Plasma glucose, insulin, C-peptide, glucagon, urea n trogen, a-amino acid nitrogen, and lactate concentrations were measured, and net 5-h postprandial areas were calculated. The net glucose-area response to the ingested glucose dose (with the 0-time value as a constant baseline) was best described by a second-order polynomial equation, whereas insulin-area response was best described by a third-order equation. In a separate study, 5 untreated type II diabetic subjects were given only water, and the same metabolites and hormones were measured. Data from this study indicated that the baseline was not constant during the 5 h of study but decreased progressively. The net glucose-area and insulin-area responses to ingested glucose dose (with the decreasing baseline) were then best described by third-order equations. Glucagon, α-amino acid nitrogen, and lactate concentrations were exquisitely sensitive to a rise in glucose and insulin concentrations. These were all decreased with the lowest concentration of glucose used. At this dose of glucose, the increase in insulin was only 15 μU/ml.
Employment Spectrum of IDDM
Authors: Songer Thomas J , LaPorte Ronald E , Dorman Janice S , Orchard Trevor J , Becker Dorothy J , Drash Allan L
Published: March 2007

Occupational issues in 158 insulin-dependent diabetes mellitus (IDDM) individuals and 158 matched nondiabetic siblings were examined in a case-control design to evaluate the role of diabetes in the employability of people with IDDM. Overall, the IDDM cases were more likely to report refusal for a job at some point in their lives (56 vs. 42%, P = .02) than were the nondiabetic control siblings. Surprisingly, individuals who told job interviewers about their diabetes were more likely to report job refusal than their siblings (64 vs. 42%, P = .005), whereas individuals who did not mention their diabetes reported rates of refusal similar to their siblings (44 vs. 41%). IDDM cases were also less likely to be employed full time compared with siblings (55 vs. 73%, P = .001). Reduced employment in IDDM respondents was related to work disability. Reported work disability was more than seven times greater in the IDDM than the sibling group. The presence of diabetic complications was the primary factor related to work disability. Although 13% of IDDM respondents were unable to work because of disability, absenteeism among IDDM cases currently working did not differ from that of the nondiabetic siblings. Diabetes was not significantly associated with career levels or household income levels reported by the IDDM group. Disability, however, had a strong detrimental influence on these variables. The results suggest that hiring practices by employers may still be discriminatory toward individuals with IDDM. Once hired, the employment experiences of the IDDM population appear to be similar to the experiences of the nondiabetic population, provided thedevelopment of disabling diabetic complications has not taken place.
Efficacy of Bedtime NPH Insulin With Daytime Sulfonylurea for Subpopulation of Type II Diabetic Subjects
Authors: Riddle Matthew C , Hart Lean S , Bouma Donald J , Phillipson Beverley E , Youker Gerald
Published: March 2007

Although insulin and sulfonylureas often have additive clinical effects when used in combination for type II (non-insulin-dependent) diabetes, these results are variable and a clinical role for this approach is not yet established. This study tests the efficacy of a specific combined regimen for a subpopulation of patients with a randomized double-masked placebo-controlled crossover design and under conditions similar to those of clinical practice. Twenty subjects with limited duration (<15 yr) type II diabetes who were moderately obese (<160% ideal wt) and proved imperfectly controlled on 10 mg glyburide twice daily completed two 4-mo crossover protocols, comparing a single injection of NPH insulin in the evening plus 10 mg glyburide in the morning with insulin plus placebo. Insulin dose was adjusted by experienced endocrinologists seeking the best glycemic control consistent with safety. All subjects had glycosylated hemoglobin values ≤150% of the control mean on combined therapy, and combined therapy was superior to insulin alone (fasting plasma glucose 8.0 ± 0.3 vs. 11.1 ± 0.6 mM, P < .01; glycosylated hemoglobin 9.8 ± 0.1 vs. 10.6 ± 0.2%, P < .01). Despite greater weight gain on combined therapy, blood pressure and plasma lipid concentrations were the same on the two regimens. These results suggest this simple regimen offers another option, besides multiple injections of insulin, for patients of this kind who are unsuccessful with a sulfonylurea or a single injection of insulin alone.
Meaningful Degrees of Prevention or Improvement of Nerve Conduction in Controlled Clinical Trials of Diabetic Neuropathy
Authors: Dyck Peter James , O'Brien Peter C
Published: March 2007

Use of nerve conduction in assessing therapy in preventing or ameliorating neuropathy is desirable because abnormalities of nerve conduction are associated with severity of neuropathic symptoms and deficits. Assuming that a therapy is associated with a statistically significant improvement of nerve conduction, what degree of nerve conduction change is clinically meaningful? We suggest that in controlled clinical trials, a mean change of 2 points on the neurologic disability score is clinically detectable and meaningful. Based on our previously published crosssectional epidemiological data, this corresponds to a change of motor nerve conduction velocity of the average ulnar median and peroneal nerves of 2.9 m/s and peroneal nerve of 2.2 m/s. The corresponding changes of amplitude were 1.2 and 0.7 mV, respectively. Smaller degrees of nerve conduction change were found when only insulin-dependent patients were evaluated.
Use of Experimental Padded Hosiery to Reduce Abnormal Foot Pressures in Diabetic Neuropathy
Authors: Veves Aristidis , Masson Ewan A , Fernando Devaka J S , Boulton Andrew J M
Published: March 2007

High pressures under the feet of diabetic patients with neuropathy are associated with the development of plantar ulceration. The aim of management is the reduction of such stresses with orthoses and insoles. An American hosiery manufacturer has developed socks designed to reduce stress on athletes' feet, and we report a preliminary evaluation of this technique in the reduction of elevated plantar pressure in 27 neuropathic diabetic patients. With a computerized optical pedobarograph, three footsteps on each side were recorded under three conditions: 1) barefoot, 2) wearing the patients' own hosiery, and 3) wearing experimental patented padded hosiery. The patients' own hosiery did not have a significant effect on plantar pressure, but the experimental hosiery reduced both peak forefoot pressure and the area under the timepressure curve (P < .001) by a mean of 26 and 29%, respectively. We conclude that the experimental hosiery is effective in reducing vertical pressures under the diabetic foot and, in conjunction with established orthotic techniques, may be a useful addition to the treatment of the diabetic patient at risk for foot ulceration.