Cardiorespiratory fitness, all-cause mortality, and risk of cardiovascular disease in Trinidadian men--the St James survey

BACKGROUND: This study examined whether cardiorespiratory fitness is a risk factor for cardiovascular disease, myocardial infarction, and all-cause mortality in a low- to middle-income Trinidadian community of African, South Asian Indian, and European origin. Those of Indian descent have a distinctively high rate of myocardial infarction. METHODS: The St James Study is a prospective total community survey located in Port-of-Spain, Trinidad, West Indies. A random sample of 626 men aged 35-69 years, without angina of effort, previous myocardial infarction, partial or complete atrio-ventricular conduction defect, complete heart block, or exercise-induced asthma, was used for the assessment of cardiorespiratory fitness by cycle ergometry. Surveillance for morbidity and mortality was maintained for an average of 7.3 years. RESULTS: When the subjects were grouped into those with an age- and fat-free mass-adjusted peak oxygen uptake above and below the mean of 60.4 mmol/min (1.34 l/min), the hazard ratios (below/above) (95% confidence interval) for all-cause mortality, cardiovascular disease incidence, and incidence of myocardial infarction, after allowance for conventional cardiovascular risk factors, were 2.08 (1.23-3.52), 2.13 (1.22-3.69), and 2.36 (0.84-6.67), respectively. For those unable to achieve a level of work requiring an oxygen uptake of 67 mmol/min (1.5 l/min) during progressive exercise, the respective hazard ratios were 3.49 (1.57-7.76), 2.29 (1.21-4.33), and 5.45 (1.22-24.34). Indian ethnicity remained a predictor of myocardial infarction after allowance for cardiorespiratory performance. CONCLUSION: Low cardiorespiratory fitness is a risk factor for cardiovascular disease morbidity and mortality in the low- to middle-income developing community of Trinidad.

A five-year evaluation of intervention in diabetes care in Trinidad and Tobago [see comments]

AIMS: To evaluate an intervention to improve diabetes care in government-run health centres in Trinidad and Tobago over 5 years. METHODS: A cross-sectional survey of 690 subjects with clinical diabetes attending nine health centres was carried out in 1993. The intervention was: reports to the Ministry of Health, dissemination of management guidelines and annual training workshops for healthcare staff. Re-evaluation was through a survey of 1579 subjects with diabetes, attending 23 health centres in 1998. RESULTS: Comparing 1993 with 1998, foot examinations in the previous year increased from 38 (6 percent) to 346 (22 percent) and fundoscopy from 6 (1 percent) to 139 (9 percent). For subjects attending for 1 year or less, 34/96 (35 percent) had dietary advice recorded in 1993 compared with 77/143 (54 percent) in 1998. Exercise advice was recorded for 3/96 (3 percent) in 1993 and 48/143 (34 percent) in 1998. In 1993, 329 (48 percent) were taking chlorpropamide but this fell to 57 (4 percent) in 1998. Glibenclamide use increased from 214 (31 percent) to 856 (54 percent) and gliclazide from 4 (1 percent) to 205 (13 percent). In 1993, 198/338 (56 percent) of hypertensive subjects were taking Brinerdin, this fell to 56/829 (7 percent) in 1998 while use of thiazide diuretics, methyldopa and angiotensin-converting enzyme (ACE) inhibitors increased. There were no changes in indicators of metabolic control, blood pressure control or body weight. CONCLUSIONS: Use of audit data to inform health policy and practice, linked with educational interventions, may modify patterns of care in government-run primary care health centres in a middle-income country with a high prevalence of diabetes. (AU)

Differences in mortality and morbidity in African Caribbean and European people with non-insulin dependent diabetes mellitus : results of 20 year follow up of a London cohort of a multinational study

OBJECTIVE: To examine differences in morbidity and mortality due to non-insulin dependent diabetes in African Caribbeans and Europeans. DESIGN: Cohort study of patients with non-insulin dependent diabetes drawn from diabetes clinics in London. Baseline investigations were performed in 1975-7; follow up continued until 1995. PATIENTS: 150 Europeans and 77 Africans with non-insulin dependent diabetes. MAIN OUTCOME MEASURES: All cause and cardiovascular mortality; prevalence of microvascular and macrovascular complications. RESULTS: Duration of diabetes was shorter in African Caribbeans, particularly women. African Caribbeans were more likely than the Europeans to have been given a diagnosis after the onset of symptoms and less likely to be taking insulin. Mean cholesterol concentration was lower in African Caribbeans than in Europeans. 59 Europeans and 16 African Caribbeans had died by the time of follow up. The risk ratio for all cause mortality was 0.41 (95 percent confidence interval 0.23 to 0.73) (P = 0.02) for African Caribbeans v Europeans. This was accentuated to 0.59 (0.32 to 1.10) (P = 0.1) after adjustment for sex, smoking, proteinuria, and body mass index. Further adjustment for systolic blood pressure, cholesterol concentration, age, duration of diabetes, and treatment made little difference to the risk ratio. CONCLUSIONS: African Caribbeans with non-insulin dependent diabetes maintain a low risk of heart disease. Management priorities for diabetes developed in one ethnic group may not necessarily be applicable to other groups (AU).

UK prospective diabetes study xii: differences between Asian, Afro-Caribbean and White Caucasian type 2 diabetic patients at diagnosis of diabetes

Clinical and biochemical variables and prevalence of complications at diagnosis of diabetes were assessed in 5098 Type 2 diabetic patients in the UK Prospective Diabetes Study of Whom 82 percent were white Caucasian, 10 percent Asian of Indian origin, and 8 percent Afro-Caribbean. The Asian patient were (p<0.001) younger (mean age 52.3, 47.0, 51.0 years), less obese (BMI 29.3, 26.7, 27.9 Kg m-2), had a greater waist-hip ratio, lower blood pressure (systolic 145, 139,144 diastolic 87, 86, 89 mmHg) and prevalence of hypertension. They were more often sedentary (19, 39, 15 percent), more often abstained from alcohol (21, 55, 25 percent) and had a greater prevalence of first degree relatives with known diabetes (36, 44, 34 percent). The Afro-Caribbean patients had (p<0.001) higher fasting plasma glucose (11.9, 11.3, 12.5, mmol -1), more severely impaired á-cell function (45, 35, 28 percent normal) and less impaired insulin sensitivity(23,19,27 percent normal) by homeostasis model assessment, lower triglyceride (1.8, 1.8, 1.3 mmol-1), and higher HDL-cholesterol (1.05, 1.03, 1.17 mmol 1-1). Prevalence of a history of myocardial infarction, stroke or intermittent claudication at diagnosis was similar. The prevalence of ischaemic ECG (minnesota code), microabuminuria (urine albumin >50 mgl-1), retinopathy ('191' grading of retinal photographs), and neuropathy (abnormal vibration perception threshold or absent leg reflexes) was also similar. At diagnosis of Type 2 diabetes there were no differences in prevalence of complications between white Caucasian, Asian, and Afro-Caribbean patients although differences were found in other clinical and biochemical variables (AU)

Haemorrheological disturbance in diabetes mellitus - abstract

Diabetes mellitus is one of several metabolic diseases in which haemorrheological disturbances have been observed. In diabetes, particularly of long duration, there are marked alterations of the microcirculation. These changes are associated, at least in part, with rheological disturbances. Diabetic microangiopathy affects the retina, the enal glomeruli, the nerves and probably the entire network of capillaries. Rheological studies in both insulin-dependent (IDDM) and non-insulin-dependent (NIDDM) diabetics have shown a decrease in red cell deformability, an increase in red cell aggregation and plasma fibrinogen concentration. These alterations are aggravated by concurrent hypertension and the severity of the disease. The combined effect of these changes is the development of a hyperviscosity syndrome in the diabetic patient. The clinical significance of diabetic hyperviscosity is a marked impairment in blood-flow, in particular, across the microcirculation; hence diminished tissue perfusion (AU)

Black West Indian and matched white diabetics in Britain compared with diabetics in Jamaica: body mass, blood pressure, and vascular disease

This study was designed to compare the prevalence of obesity, high blood pressure, diabetic vascular disease, and risk factors in Black West Indians who had emigrated to Britain (WIB) with those in Whites in England and among diabetic Jamaicans in Jamaica. Seventy-seven consecutive WIB patients were matched for age, sex, known duration of diabetes, and type of treatment of diabetes with 74 Whites from the same diabetes clinic in England. In Jamaica, a systematic random sample (95 women, 36 men) was studied. There was no difference in age at diagnosis between WIBs and Jamaicans. Effort chest pain (possible angina) was less frequent in WIBs (9 percent) or Jamaicans (3 percent) than in whites (25 percent). Cigarette smoking was more common in WIBs than in Whites but still low in Jamaicans. Body mass index was greatest in WIB women (85 percent), significantly more than in matched white (52 percent) or Jamaican women (45 percent); 40 percent of white men and WIB men were obese, significantly more than Jamaicans (15 percent obese). Systolic blood pressure was similar, but diastolic blood pressure was significantly greater in WIBs than in matched White subjects. The prevalence of casual hypertension was high (greater than 40 percent) in all groups, often despite treatment. Cataracts were significantly more frequent in WIB and Jamaican groups than in whites. Total background retinopathy after correcting for duration of diabetes did not differ between groups and there were no significant differences in other complication rates levels of HBA1 were lower in Whites than in the other groups. Regression analysis showed that systolic blood pressure was most consistently related to complications, particularly retinopathy, independent of ethnic group and duration.(ABSTRACT TRUNCATED AT 250 WORDS)(AU)

Foot ischaemia - a need for early rehabilitation

Ischaemia of the foot usually affects the elderly. The correlative study based on clinical data and pathological study has shown that maturity onset, diabetic foot ischaemia is usually due to severe arteriosclerosis. Because of the late presentation, most patients show end-stage obliterative vascular changes when first hospitalized which makes reconstructive surgery impossible. By early referral of all diabetic patients with infection, the number of below-knee or above-knee amputations can be reduced. Early prosthetic fitting is essential for the early rehabilitation of the patient. This paper was presented in part at the Commonwealth Caribbean Medical Research Council Meeting held at Bridgetown, Barbados in April, 1978. (AU)