Prevalence of neuropathy in newly diagnosed NIDDM and nondiabetic control subjects.

We evaluated the prevalence of peripheral neuropathy by clinical and electrophysiological criteria and the prevalence of autonomic parasympathetic nerve dysfunction by heart-rate variation during deep breathing (expiration-to-inspiration ratio [E:1]) in 132 newly diagnosed non-insulin-dependent diabetic (NIDDM) subjects aged 45-64 yr and 142 randomly selected nondiabetic control subjects. The relationship of nerve dysfunction to the degree of hyperglycemia and insulin-secretion capacity were also investigated. Single and scattered symptoms and signs of peripheral neuropathy were found in both diabetic and control subjects. Symptomatic polyneuropathy was found in 1.5% of diabetic subjects but none of the control subjects. Polyneuropathy defined by clinical signs was found in 2.3% of the diabetic subjects and 1.4% of the control subjects. No subjects with both symptoms and signs were seen. Nerve conduction velocities (NCVs) were significantly slower in diabetic than control subjects. Polyneuropathy according to electrophysiological criteria was found in 15.2% of diabetic subjects but was not found in any control subjects. Electromyographic abnormalities were more common in diabetic than control women, but not significant differences were found in men. The resting heart rate was higher in diabetic than control women, but no significant difference was found in men. The mean E:I was significantly lower in diabetic men and women than control men and women. An abnormally low E:I was found in 9.2% of the diabetic men, 3.3% of the control men, 3.3% of the diabetic women, and none of the control women. NCV parameters, but not E:I, were inversely correlated with fasting blood glucose and glycosylated hemoglobin levels. A positive correlation between NCV and fasting and postglucose serum insulin levels was found in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Proteinuria in newly diagnosed type II diabetic patients.

Urinary excretion of albumin, IgG, and beta 2-microglobulin was examined in 132 (69 men, 63 women) newly diagnosed, middle-aged type II diabetic patients and in 144 (62 men, 82 women) nondiabetic control subjects. Both male (N = 57) and female (N = 29) diabetic patients with normal urinary sediment showed an increased excretion of albumin compared with the respective nondiabetic subjects, and male diabetic patients also had an increased IgG excretion. No consistent difference was found in urinary beta 2-microglobulin concentration between the diabetic and nondiabetic subjects. In all, 19.5% of the diabetic subjects with normal urinary sediment (12 men, 5 women) showed urinary albumin concentration exceeding the highest value (35 mg/24 h) found in nondiabetic subjects without renal disease. The urinary excretion of albumin in the diabetic subjects was not associated with the presence of hypertension or coronary heart disease or with the fasting blood glucose or serum insulin levels measured at diagnosis of diabetes. In male diabetic subjects with urinary albumin excretion greater than 35 mg/24 h, a reduced creatinine clearance was found, suggesting the presence of structural damage associated with diabetic nephropathy. The early increase of urinary albumin excretion in type II diabetic patients may be mostly functional in nature. However, some patients may have structural renal damage associated with diabetic nephropathy present at diagnosis.

Medial artery calcification predicts cardiovascular mortality in patients with NIDDM.

OBJECTIVE: To study the predictive value of medial artery calcification (Mönckeberg's sclerosis) in relation to 10-year cardiovascular mortality in patients with non-insulin-dependent diabetes mellitus (NIDDM). RESEARCH DESIGN AND METHODS: We studied the predictive value of thigh medial and intimal artery calcifications to 10-year cardiovascular mortality in a well-characterized group of 133 middle-aged, newly diagnosed patients with NIDDM (70 men and 63 women). RESULTS: At baseline, medial artery calcifications were found in 17% of the patients and intimal-type calcifications were found in 23%. During the follow-up, 21% of the diabetic patients died from cardiovascular causes. The age-adjusted odds ratio for cardiovascular mortality was 4.2 (95% confidence intervals: 1.5-11.3) for medial-type and 1.6 (0.6-4.3) for intimal-type calcifications. In multiple logistic regression analysis, including age, sex, systolic blood pressure, low-density- and high-density-lipoprotein cholesterol, very-low-density lipoprotein triglycerides, smoking, body mass index, fasting serum insulin, blood glucose, urinary albumin, and ischemic ECG changes, as well as the intimal artery calcification, the medial artery calcification was the dominant factor predicting cardiovascular mortality. CONCLUSIONS: In this study medial artery calcification was a strong independent predictor of cardiovascular mortality in patients with newly diagnosed NIDDM. Whether these subjects had a longer duration of hyperglycemia before the diagnosis than those without medial artery calcifications remains unknown.

Serum lipids and lipoproteins in newly diagnosed non-insulin-dependent (type II) diabetic patients, with special reference to factors influencing HDL-cholesterol and triglyceride levels.

Serum and lipoprotein lipids were examined in 133 newly diagnosed (type II) diabetic patients (70 men, 63 women), aged 45-64 yr, and in 144 randomly selected nondiabetic control subjects of similar age (62 men, 82 women). The serum total cholesterol levels in diabetic and nondiabetic subjects were similar, but the HDL-cholesterol levels were lower and the serum total triglyceride levels higher in the diabetic than in nondiabetic subjects. No significant differences were found in apoprotein A-I and A-II levels between the diabetic and nondiabetic subjects. After adjustment for age, alcohol intake, obesity, 2-h postglucose serum insulin, and serum triglycerides, male diabetic subjects still had lower HDL-cholesterol levels than corresponding nondiabetic subjects. On the other hand, female diabetic subjects had higher serum triglycerides than their nondiabetic counterparts, even after adjustment for age, alcohol intake, 2-h postglucose serum insulin, and obesity.

Five-year follow-up study on plasma insulin levels in newly diagnosed NIDDM patients and nondiabetic subjects.

A representative group of middle-aged (45- to 64-yr-old) patients with non-insulin-dependent diabetes mellitus (NIDDM) (n = 133; 70 men, 63 women) were examined at the time of diagnosis and 5 yr afterward for metabolic control and insulin response to oral glucose; 144 nondiabetic control subjects (62 men, 82 women) were similarly examined twice between 5-yr intervals. At the 5-yr examination, 56 of the diabetic patients (36 men, 20 women) were on diet therapy only, 60 (27 men, 33 women) received oral antidiabetic drugs, and 5 were treated with insulin. The metabolic control of diabetic patients was poor at the time of diagnosis and 5-yr examination. Fasting plasma insulin levels were higher in diabetic patients than in control subjects both at baseline (23 +/- 2 vs. 14 +/- 1 mU/L, P less than 0.01, for men; 26 +/- 2 vs. 15 +/- 1 mU/L, NS, for women) and 5-yr examination (19 +/- 1 vs. 16 +/- 2 mU/L, NS, for men; 29 +/- 5 vs. 15 +/- 1 mU/L, P less than 0.05, for women). The frequency of insulin deficiency in diabetic patients based on a postglucagon (1 mg i.v.) C-peptide level less than 0.60 nM was 3.3% at the 5-yr examination, indicating that true insulin deficiency was uncommon during the first years after diagnosis of diabetes in middle-aged subjects.

Lower-extremity amputations in diabetic and nondiabetic patients. A population-based study in eastern Finland.

OBJECTIVE: To study the incidence of LEAs attributable to PVD in diabetic and nondiabetic patients. The age at first amputation, the level of amputation, the number of reamputations, and survival after amputation also were examined in the study populations. RESEARCH DESIGN AND METHODS: This retrospective study was based on a population of 253,000 inhabitants in eastern Finland. All patients with their first LEA performed during the period from 1 January 1978 to 31 December 1984 were identified from the registers of operation theaters in the study area. Furthermore, patient records and death certificates were reviewed. Amputations attributable to causes other than evident atherosclerotic vascular disease were excluded. RESULTS: Altogether, 477 patients (85 diabetic men, 127 nondiabetic men, 169 diabetic women, and 96 nondiabetic women) were identified. The overall LEA rate was 26.9/100,000 per yr, and the incidence increased strongly with age in both diabetic and nondiabetic patients. The age-adjusted amputation incidence per yr was 349.1/100,000 for diabetic men, 33.9/100,000 for nondiabetic men, 239.4/100,000 for diabetic women, and 17.2/100,000 for nondiabetic women. The proportion of peripheral (toe, leg) amputations was markedly higher in diabetic patients who also tended to have more reamputations during the follow-up than did nondiabetic subjects. The diabetic status per se was a statistically significant risk factor for mortality in women, but not in men. CONCLUSIONS: Diabetic men and women had a 10.3- and 13.8-fold higher risk, respectively, for LEA.

A controlled trial on the effects of patient education in the treatment of insulin-dependent diabetes.

The effect of patient education on diabetic control in insulin-treated diabetic adults was studied in 77 subjects randomized into two groups: intensive patient education (group A) and control (group B). The subjects in group A received intensive patient instruction, both individually and in small groups, from a team of physicians, teaching nurses, and a dietitian. The patients in group B received a short instruction course consisting mainly of printed material. A highly significant improvement in diabetic control was observed in both groups immediately after the education programs, with gradual return to the original level during the following 3-6 mo. No difference was observed between the two groups in any of the measured parameters during the 18-mo investigation. Factors related to good control during the study included the length of school education, the quality of the control at the beginning of the study, and the high degree of self-confidence and lack of signs of anxiety in the psychological tests. The results demonstrate that the effects of educational programs are of limited value if they do not lead to permanent changes in attitudes and motivation, which are critical factors affecting long-term diabetic control.

Metabolic and nutritional effects of long-term use of guar gum in the treatment of noninsulin-dependent diabetes of poor metabolic control.

Thirty-nine patients with noninsulin-dependent diabetes on oral drug treatment were randomly allocated to either guar gum or placebo treatments for 3 mo. After 3 mo the placebo group was switched to guar gum treatment and both groups were followed for 10 mo (open trial). No significant difference occurred in the fasting blood glucose or glycosylated hemoglobin A1 levels between the two groups at 3 mo. Serum total cholesterol level decreased in the guar gum group from 6.55 +/- 1.45 to 5.69 +/- 1.2 mmol/L (p less than 0.001) but no changes were observed in the placebo group (6.55 +/- 1.2 vs 6.26 +/- 1.4 mmol/L, NS) during 3 mo. At the end of the open trial (n = 33), serum cholesterol was still approximately 7% lower than before guar gum treatment. No consistent changes occurred in serum HDL-cholesterol or triglycerides. Serum vitamin A level was slightly lowered and plasma zinc level elevated during the open trial. Serum vitamin E level was decreased only in the group switched to guar gum at 3 mo.

Aortic and lower limb artery calcification in type 2 (non-insulin-dependent) diabetic patients and non-diabetic control subjects. A five year follow-up study.

The purpose of the present study was to assess among a representative group of middle-aged newly diagnosed type 2 diabetics and control subjects the baseline prevalence and 5-year incidence of arterial calcifications of aorta and lower limb and their relationship to cardiovascular morbidity. The relationship of baseline risk factors to the development of arterial calcifications was also studied. At the time of diagnosis the age-adjusted prevalence of aortic and lower limb intimal calcifications was higher in diabetics than in control subjects (aortic calcifications: 29 vs. 17% for men, P = 0.05; 26 vs. 19% for women, P = 0.06; lower limb intimal calcifications: 24 vs. 12% for men, P = 0.02; 10 vs. 7% for women; P = NS), whereas no significant difference in baseline prevalence of lower limb medial calcifications was observed (15 vs. 21% for men, 9 vs. 10% for women). The 5-yr incidence of aortic calcifications in both sexes and of lower limb calcifications in men was similar in diabetic and control subjects, but the incidence of lower limb calcifications was higher in diabetic women than in control women (intimal: 33 vs. 11%, P = 0.009: medial: 29 vs. 14%, P = 0.05). The baseline prevalence of abdominal aortic (37 vs. 22%, P = NS for diabetics; 42 vs. 16%, P = 0.02 for control subjects), lower limb intimal (24 vs. 16% for diabetics, P = NS; 15 vs. 7% for control subjects, P = NS) and medial calcifications (23 vs. 7% for diabetics, P = 0.03) were higher in subjects who developed intermittent claudication during the follow-up than in those free of it at the 5-yr examination. Abnormalities in VLDL-metabolism and high systolic blood pressure were associated with the development of aortic calcification in diabetic subjects. In conclusion, already at the time of diagnosis atherosclerotic calcifications are more prevalent in type 2 diabetics than in nondiabetic subjects. During the follow-up diabetic women, but not men, had higher incidence of lower limb intimal and medial calcifications than non-diabetic subjects. Arterial calcifications tended to be associated with the development of intermittent claudication during the follow-up in diabetic and control subjects.

The maintenance of improved metabolic control after intensified diet therapy in recent type 2 diabetes.

Altogether 86 patients with recently diagnosed NIDDM, aged 40-64 years were randomised after 3 months of basic education to intensified diet (Int. group, 21 men, 19 women) or conventional treatment groups (Conv. group, 28 men, 18 women). The aim was to examine whether an intensified diet education would result in a better metabolic control and greater reduction in cardiovascular risk factors than conventional treatment for obese patients with recently diagnosed type 2 diabetes mellitus. Furthermore, both groups were re-examined after a second year of observation period to find out the maintenance of the results after intervention. After basic education, Int. group participated in 12-months diet education, while Conv. group was treated in local health centres. During the intervention period, only Int. group showed further weight reduction. Only 20% of patients in Int. and 6% of patients in Conv. group had BMI < 27 kg/m2 at the end of the intervention, while 75% of patients in Int. and 52% of patients in Conv. group had achieved a good metabolic control (fasting blood glucose < 6.7 mmol/l; P = 0.005 between groups). Serum total cholesterol did not change significantly, but the changes in HDL-cholesterol, triglycerides and apolipoprotein B level were significant in Int. group only. The proposed acceptable values for serum lipids were achieved by 52 to 88% of patients without major differences between the two groups. During the second year of observation, weight gained in both groups and a deterioration was seen in metabolic control. Despite that a greater proportion of patients in the Int. group still was in good metabolic control (55.3% vs. 31.8%, P = 0.016), furthermore Int. group was receiving less frequently oral drugs for hyperglycaemia than Conv. group. No differences in serum lipids were observed between the groups after the observation period. HDL-cholesterol showed a persistent improvement in both groups.

Epidemiological considerations in the prevention of coronary heart disease among the elderly.

Coronary heart disease is a major health problem among the elderly, the importance of which increases with the rising proportion of old people. The significance of traditional cardiovascular risk factors has been documented in younger age groups, and it seems they are effective at least in 'young' elderly people (aged between 65 and 80 years), whereas their role is less well known in people over 80 years because other end-points such as stroke and cancer become increasingly important and coronary heart disease cannot be considered in isolation. Pharmacological treatment of hypertensive elderly patients can reduce the incidence of strokes significantly, but reduction of coronary heart disease incidence is less clear. There are many uncertainties relating to lipid-lowering medication in old people. Nonpharmacological means (modest lifestyle, healthy diet and regular exercise) are unlikely to be of harm in the prevention of coronary heart disease in the elderly.

More exercise for the diabetics? Physical activity and prevention of ischaemic heart disease.

Epidemiologic studies suggest that a high level of physical activity would protect against coronary heart disease. There is accumulating evidence that habitual physical training may reduce some risk factors of atherosclerosis in both non-diabetic and in diabetic subjects. In this article the relationship of exercise to cardiovascular risk factors in diabetic patients is reviewed.

Repeatability of C-peptide response in glucagon stimulation test.

Measurement of the plasma C-peptide level before and after iv administration of 1 mg of glucagon was repeated four times in 10 elderly non-diabetic subjects and in 20 elderly non-insulin-dependent diabetics treated with diet or oral drugs to assess the repeatability of the C-peptide responses. Plasma C-peptide levels before and after glucagon administration and C-peptide glucose ratios in the four measurements did not differ significantly from test to test either in diabetic or non-diabetic subjects. The results of the present study indicate that the repeatability of C-peptide response to glucagon is very good both in non-insulin-dependent diabetics and in non-diabetic subjects.

Quantitative electrocardiographic and vectorcardiographic study on newly-diagnosed non-insulin-dependent diabetic and non-diabetic control subjects.

Quantitative electrocardiographic (ECG) and vectorcardiographic (VCG) analysis was carried out in 113 newly diagnosed, middle-aged, non-insulin-dependent diabetics (61 men, 52 women) and 125 non-diabetic control subjects (56 men, 69 women) in order to explore changes attributable to non-coronary heart disease (diabetic cardiomyopathy) in diabetics. Diabetic men had a prolonged PQ interval and women a more negative P-terminal force and a more leftward frontal QRS axis than their non-diabetic counterparts, but no other significant differences we found between diabetic and non-diabetic subjects in various quantitative ECG and VCG variables when the effect of confounding factors (age, obesity, coronary heart disease, hypertension, drugs) was taken into account. The more negative P-terminal force and left axis deviation in diabetic women could be explained by a concomitant left ventricular hypertrophy among them. Non-insulin-dependent (type 2) diabetes, which is commonly preceded by a long duration of asymptomatic hyperglycaemia, is not associated, early in its clinical course, with major ECG and VCG abnormalities suggestive of diabetic cardiomyopathy.

Left ventricular function in newly diagnosed non-insulin-dependent (type 2) diabetics evaluated by systolic time intervals and echocardiography.

Systolic time intervals (STI) and echocardiography were recorded in 133 (70 men, 63 women) newly diagnosed non-insulin-dependent diabetics aged 45-64 years and in 144 (62 men, 82 women) non-diabetic control subjects of the same age. Both male and female diabetics had significantly increased pre-ejection period/left ventricular ejection time ratio (PEP/LVET) in STI as compared with the respective non-diabetic control subjects. Male diabetics showed a reduced ejection fraction (EF) in echocardiography, but no significant difference was found in this respect between female diabetics and controls. A significant negative correlation was found between 2-hour postglucose serum insulin level and EF in male and female diabetics. After adjusting for the effect of age, coronary heart disease, hypertension, obesity and haemoglobin concentration, male diabetics still had a higher PEP/LVET ratio and a lower EF than male controls. In women, no significant differences were found between diabetics and controls in the PEP/LVET ratio or EF adjusted for the above factors. The results of this study are compatible with the view that impaired left ventricular function may be an early phenomenon in the clinical course of non-insulin-dependent diabetes.

Hyperglycaemic symptoms before diagnosis of non-insulin-dependent (type 2) diabetes mellitus in relation to 5-year outcome.

A group of newly diagnosed patients with non-insulin-dependent (type 2) diabetes mellitus (n = 133) were divided into two groups according to the symptoms of diabetes mellitus at diagnosis; a group (26 men and 17 women) with hyperglycaemic symptoms (polydipsia, polyuria, weight loss and tiredness) and a group (44 men and 46 women) without such symptoms. At the time of diagnosis, symptomatic patients tended to be leaner (P = NS), and they were more hyperglycaemic (P less than 0.001-0.06) and had lower insulin responses to an oral glucose load (P less than 0.01-0.05) than asymptomatic patients, but after 5 years no difference in these respects was found. No significant differences in the frequency of islet-cell antibodies or cardiovascular diseases were found between the two diabetic groups. At the 5-year examination, the initially symptomatic patients were receiving pharmacological treatment for hyperglycaemia more often than asymptomatic patients. No consistent differences in clinical characteristics and 5-year outcome were observed between those diabetic patients who were diagnosed on the basis of hyperglycaemic symptoms and those who were diagnosed for other reasons. In conclusion, in middle-aged patients with newly diagnosed diabetes mellitus classified as non-insulin-dependent, diabetic symptoms at diagnosis did not predict the 5-year outcome of the patients in terms of metabolic control or cardiovascular events.