Impact of socio-economic position on health and quality of care in adults with Type 2 diabetes in France: the Entred 2007 study.

AIM: To describe the association between socio-economic position, health status and quality of diabetes care in people with Type 2 diabetes in France, where people may receive full healthcare coverage for chronic disease. METHODS: Data from a national cross-sectional survey performed in people pharmacologically treated for diabetes were used. They combined data from medical claims, hospital discharge, questionnaires for patients (n = 3894 with Type 2 diabetes) and their physicians (n = 2485). Socio-economic position was assessed using educational level (low, intermediate, high) and ability to make ends meet (financial difficulties vs. financially comfortable). RESULTS: People with diabetes reporting financial difficulties were more likely to be smokers (adjusted odds ratio 1.4; 95% CI 1.1-1.6) and obese (adjusted odds ratio 1.3; 95% CI 1.2-1.6) and to have poorer glycaemic control (HbA1c > 64 mmol/mol (8%); adjusted odds ratio 1.4; 95% CI 1.1-1.8), than those who were financially comfortable. They were more likely to have their diabetes diagnosed because of complications (adjusted odds ratio 1.6; 95% CI 1.3-2.0). They were also more likely to have coronary and podiatric complications (adjusted odds ratios 1.3; 95% CI 1.1-1.6 and 1.7; 95% CI 1.4-2.2, respectively). They benefited more often from full coverage (adjusted odds ratio 1.3; 95% CI 1.1-1.6), visited general practitioners more often (ratio of estimated marginal means 1.2; 95% CI 1.1-1.2) but specialists less often (adjusted odds ratio 0.7; 95% CI 0.6-0.8 for a visit to private ophthalmologist). They also felt less well informed about their condition. CONCLUSIONS: Despite frequent access to full healthcare coverage, socio-economic position has an impact on the diagnosis of diabetes, health status and quality of diabetes care in France.

The excess mortality related to cardiovascular diseases and cancer among adults pharmacologically treated for diabetes--the 2001-2006 ENTRED cohort.

AIMS: To compare the 5-year mortality (overall and cause-specific) of a cohort of adults pharmacologically treated for diabetes with that of the rest of the French adult population. METHODS: In 2001, 10 000 adults treated for diabetes were randomly selected from the major French National Health Insurance System database. Vital status and causes of death were successfully extracted from the national registry for 9101 persons. We computed standardized mortality ratios. RESULTS: Over 5 years, 1388 adults pharmacologically treated for diabetes died (15% of the cohort, 32.4/1000 person-years). An excess mortality, which decreased with age, was found for both genders [standardized mortality ratio 1.45 (1.37-1.52)]. Excess mortality was related to: hypertensive disease [2.90 (2.50-3.33)], ischaemic heart disease [2.19 (1.93-2.48)], cerebrovascular disease [1.76 (1.52-2.03)], renal failure [2.14 (1.77-2.56)], hepatic failure [2.17 (1.52-3.00)] in both genders and septicaemia among men [1.56 (1.15-2.09)]. An association was also found with cancer-related mortality: liver cancer in men [3.00 (2.10-4.15)]; pancreatic cancer in women [3.22 (1.94-5.03)]; colon/rectum cancer in both genders [1.66 (1.28-2.12)]. Excess mortality was not observed for breast, lung or stomach cancers. CONCLUSIONS: Adults pharmacologically treated for diabetes had a 45% increased risk of mortality at 5 years, mostly related to cardiovascular complications, emphasizing the need for further prevention. The increased risk of mortality from cancer raises questions about the relationship between cancer and diabetes and prompts the need for improved cancer screening in people with diabetes.

Prevalence of diagnosed type 2 diabetes mellitus in the French general population: the INSTANT study.

AIMS: To estimate the prevalence of diagnosed type 2 diabetes mellitus in the French general population. Secondary objectives were to evaluate treatments and diabetic complications. METHODS: In this cross-sectional epidemiological survey, a representative sample of the French adult population was selected using a stratified quota method: 10,038 individuals were evaluated by a standardized face-to-face interview. The diagnosis of type 2 diabetes was determined on the basis of replies to six questions using a specific algorithm. Data were collected on risk factors, diabetes history, familial antecedents and diabetic complications. These patients also identified their treatments from an exhaustive list. RESULTS: The prevalence of type 2 diabetes was 5.08% in men and 4.11% in women, and rose progressively after the age of 50. Of these, 79 patients (13.4%) received no pharmacological treatment, 477 (80.9%) were taking an oral antidiabetic drug and 134 (22.7%) were taking insulin. Renal and ocular complications were reported by 6.8% and 21.0%, respectively, of the patients. Also, 10.4% had been hospitalized at some time of that year for a diabetes-related problem. The most frequently reported treatments were metformin and sulphonylureas, used by more than 50% of the patients. In addition, 380 patients (65.9%) claimed to be following a diet and 228 (39.2%) were consulting a dietitian. CONCLUSION: The prevalence of treated and untreated type 2 diabetes mellitus in France was 4.57%.

How do patients with type 2 diabetes perceive their disease? Insights from the French DIABASIS survey.

AIM: The main purpose of this survey was to describe type 2 diabetes (T2DM) from the patient's standpoint in a representative French panel in 2008. METHODS: Fourteen thousand two hundred and one individuals from the general population aged 45 or older completed a self-questionnaire exploring knowledge about diabetes; 1092 replies were from patients with T2DM. RESULTS: The prevalence of T2DM in this population was 7.7%, with demographics as follows: 60% men; mean age: 66 years; mean age at diagnosis: 55 years; mean BMI: 29 kg/m(2). Eighty-five percent of T2DM patients reported that they wanted more information about at least one aspect of the disease at diagnosis; they reported feeling anxious (30%), frightened (13%), angry (4%) or that the disease was unfair (12%). Half of the patients had modified their dietary habits but 71% found it difficult to engage in regular physical activity. Most patients (90%) were treated with drugs: 81% with oral antidiabetic drugs (OAD) (44% in monotherapy) while 19% received insulin (alone or in combination with OAD). Twenty-three percent complained of weight gain since start of current therapy (average gain of 7.3 kg). Insulin initiation represented a turning point for patients who became more aware of the disease severity, more willing to follow advice and to take greater control over their disease management. The mean time from diagnosis to insulin initiation was 13.8 years. Half of the patients perceived their disease as severe especially women, patients who initially reacted with anxiety, insulin-treated patients and those actively involved in their disease management. Some gender differences emerged: women took the disease more seriously, were more engaged in self-management, and reported a higher impact on daily life. CONCLUSIONS: DIABASIS provides important information for diabetes care by highlighting patients' views of the disease, such as distress at diagnosis, lack of adequate information to cope with this distress and the important supportive role played by the family. A deeper understanding of patients' perception of the disease would help optimize customized care.

French medical practice in type 2 diabetes: the need for better control of cardiovascular risk factors.

AIMS: In type 2 diabetes (T2D), to describe treatments to prevent cardiovascular disease, to compare current practice to French guidelines, and to identify factors associated with recommended treatments. METHODS: In the Echantillon National Témoin Représentatif des Personnes Diabétiques (ENTRED) study, 10,000 adults treated for diabetes (any type) were randomly selected from the French National Health Insurance System database. Deliveries during the last quarter of 2001 of treatments to prevent cardiovascular disease were extracted. Questionnaires were mailed to these people and their care providers. Final populations included 3324 people with T2D and their 1553 care providers. RESULTS: Overall, 18% reported coronary heart disease (CHD) and 44% others were classified as having a high cardiovascular risk; 68% received one or more antihypertensive treatment: ACE inhibitor/angiotensin receptor blocker (ARB), 44%; diuretic, 35%; calcium channel blocker, 25%; beta-blocker, 24%. Among those receiving antihypertensive treatment, 59% had blood pressure greater than 130/80mmHg. Overall, 42% received a hypolipidaemic treatment: statin, 25%; fibrate, 18%. About half the people with a high cardiovascular risk had LDL cholesterol greater than 1g/L, but only 32% were given a statin. Among people with an abnormal albumin/creatinine ratio (11%), 59% received an ACE inhibitor/ARB. Among those with CHD, 35% received the two treatments recommended in 1999 (beta-blockers and antiplatelet agents); in multivariate analyses, this two-treatment delivery was positively associated with male gender, self-reported hypertension and consulting a cardiologist. CONCLUSION: Cardiovascular risk profiles reported by providers in T2D people are high. Despite recent progress, there is a need for major improvement in practices intended to prevent cardiovascular disease in these people, especially in those at greatest CHD risk.

Prevalence of macrovascular complications and cardiovascular risk factors in people treated for diabetes and living in France: the ENTRED study 2001.

AIM: The aim of this study is to estimate the prevalence of macrovascular complications and cardiovascular risk factors among people with diabetes living in France and to compare these prevalences with other national estimates. METHODS: We randomly sampled 10,000 people who received one or more reimbursements for insulin or oral hypoglycaemic treatment from the major national medical insurance system during the period October-December 2001; 3646 of the 10,000 people completed a questionnaire; for a subgroup of 1718 people, their care providers completed a medical questionnaire. RESULTS: The prevalence of diagnosed macrovascular complications was of 17% according to patients (angina or myocardial infarction, 15%; coronary revascularization, 9%) and of 20% overall, according to physicians (angina or myocardial infarction, 16%; coronary revascularization, 6%; stroke, 5%). Macrovascular complications were more frequent in people with type 2 than type 1 diabetes, reflecting an age effect. The prevalences of cardiovascular risk factors in type 1 and type 2 diabetes were: current smoking, 35 and 14%; overweight, 28 and 42%; obesity, 9 and 36%; blood pressure superior to 130/80 mmHg, 29 and 59%; LDL cholesterol superior or equal to 3.4 mmol/l, 18 and 26%, respectively. CONCLUSIONS: Compared with other European countries, elevated blood pressure is more frequent in people with diabetes living in France; compared with US estimates, the prevalence of macrovascular complications is lower, glucose control better and blood pressure control poorer in France. These data, observed in a country with widespread access to care and at low cost to the patient, nevertheless demonstrate an urgent need for improving the cardiovascular risk profile of people with type 1 and type 2 diabetes, both with and without macrovascular complications.

[One-year follow-up in real clinical practice conditions of type 2 diabetic patients treated with rosiglitazone: the Avantage study]. / Suivi sur un an dans les conditions de pratique courante d'une cohorte de patients diabétiques de type 2 traités par rosiglitazone: l'étude Avantage.

The Avandia, tolérance à grande échelle (Avantage) study was an observational study conducted in a large cohort of type 2 diabetic patients (T2D) followed for 12 months. Its aim was to assess in real clinical practice conditions, the tolerability of rosiglitazone, an oral antidiabetic agent of the new thiazolidinedione ("glitazone") class, available in France since May 2002. Study was carried out from December 2002 to January 2005. To be included, T2D seen during the inclusion period should start the rosiglitazone treatment (within eight days prior to 15 days after) in agreement with therapeutic indications and drug datasheet information in force at that time. Patient characteristics, clinical and biological data and adverse events (AE) during the 12-month follow-up were recorded. Among the 3845 T2D enrolled from January to November 2003, 3580 constituted the analyzed population (at least one documented rosiglitazone intake). At inclusion, mean age (+/-S.D.) was 62+/-11 years, 52% were male, mean BMI was 29.9+/-5.3kg/m2 and mean HbA1c was 8.5+/-1.4%. Ongoing antidiabetic treatments were mainly a monotherapy (46% of patients, metformin or a sulfonylurea) or a bitherapy (in 47%). Main reasons to prescribe rosiglitazone were insufficient control of diabetes (91% of patients), associated or not with a poor tolerance to the ongoing oral antidiabetic treatment at inclusion (in 29%) and/or with a contraindication to metformin (in 4%). Two thousand four hundred and twenty-four patients (71%) completed the 12-month follow-up. Along the study, 514 T2D (14%) experienced at least one AE, judged related to the treatment in the physician's opinion for 377 patients (11%). Two hundred and fifteen patients dropped out from the study due to AE. AE notified in more than 1% of patients were: weight gain (n=100 patients; 3% of the cohort), nausea (n=57; 2%), edema (n=55; 2%) and anemia (n=40; 1%). A seriousness criteria was reported for 105 patients (3% of the cohort), including 18 (<1%) heart failure. Mean HbA1c level decreased from 8.5+/-1.4% at inclusion to 7.8+/-1.6% at study end. Mean value of the main lipid parameters remained stable. Mean systolic blood pressure (BP) decreased from 137+/-13 to 135+/-12mmHg and diastolic BP from 79+/-8 to 78+/-8mmHg. Mean weight was 82+/-15kg at inclusion and 83+/-17kg at study end (NS), mean waist circumference was not significantly modified. In conclusion, the observational Avantage study, conducted in a large cohort of type 2 diabetic patients treated with rosiglitazone in clinical practice conditions and followed-up for 12 months, confirmed the results of controlled double blind clincal studies, with a clinical and biological tolerability in accordance with the known AE profile and a beneficial effect on metabolic control and arterial blood pressure.

A review of the metabolic syndrome.

While the concept of this syndrome has been described more than 60 years ago, and more formally almost 20 years ago, the controversy continues as to its utility, which of the various syndrome definitions should be used and their ability to predict diabetes and/or cardiovascular disease. The metabolic syndrome, of cardiovascular risk factors, provides an early warning of at risk subjects and emphasises the need to treat more aggressively (by at least lifestyle modification) patients with multiple abnormalities even though the abnormalities might be slight. Further, the syndrome can be easily used in clinical practice and when it is assessed against the background of the patient's age, sex and smoking habits, it provides an evaluation of potential cardiovascular risk. Prospective intervention studies are the only means of definitively accepting or refuting the usefulness of the syndrome. The metabolic syndrome is an entity which merits attention from both the medical profession and public health authorities.

Weight change and changes in the metabolic syndrome as the French population moves towards overweight: the D.E.S.I.R. cohort.

BACKGROUND: How weight change affects the metabolic syndrome (MS) and its parameters is unknown, particularly, in a leaner European population such as the French prospective D.E.S.I.R. cohort. METHODS: In 3770 D.E.S.I.R. participants (sex ratio=1) averaging 47.5 years (range 30-64), with measured weight and MS parameters at baseline (D0) and at 6 year follow-up (D6), we assessed this relationship across five weight-change classes, using stable weight as the referent group (-2 to +2 kg). We used analysis-of-covariance to assess changes in each MS parameter and logistic regression to assess incident MS, according to the National Cholesterol Education Program (NCEP). We also assessed weight-change effect on MS status between D0 and D6. RESULTS: At D0, average weight was 68.4 kg (SD 12.3); BMI was 24.8 kg/m2 (SD 3.5). From D0-D6, the cohort gained a mean 2.1 kg (median 2.0; SD 4.4). After adjustment for age and D0 weight, there was a strong linear relationship with weight change and worsening of the following MS parameters at D6: fasting insulin, waist girth, fasting glucose, fasting triglycerides, HDL cholesterol, and systolic and diastolic blood pressure (P<0.0001). After age adjustment, for every kilogram gained over 6 years, risk of developing the NCEP Syndrome increased 22% (OR 1.22; 95% CI 1.18-1.25). NCEP-MS was incident in 3% of those with stable weight compared with 21% among those gaining >9 kg; 10% of those who lost >2 kg reverted to non-NCEP-MS. CONCLUSIONS: All continuous MS measures are linearly related to weight change, and MS can resolve with modest weight loss, underscoring the importance of maintaining lifelong normal weight.

Epidemiological data on postprandial glycaemia.

There are few studies on the effects of postprandial hyperglycaemia, and usually it is assumed that its effects are the same as those of post-glucose-load hyperglycaemia, following a standard 75 g oral glucose tolerance test. There is some evidence from a study with blood drawn following ingestion of a standardised "diabetes screening product" or a 75 g oral glucose load, that the glucose concentrations during the 2-hour period of these two tests are highly correlated. There is epidemiological evidence that the 2-hour post-load-glucose is more predictive of cardiovascular mortality than fasting glucose, but it would appear that they are equally predictive of retinopathy. While hyperglycaemia is related with cardiovascular mortality, clinical trials lowering glucose levels in type 2 diabetic patients, have not succeeded in reducing cardiovascular disease rates, in contrast to the beneficial effects on micro-vascular disease. STOP-NIDDM, a clinical trial testing the prevention of type 2 diabetes, used the glucose lowering agent acarbose, a drug which lowers postprandial glucose. There was a beneficial effect on cardiovascular outcomes, however, the number of events was extremely small and the study was not designed to test this effect. Confirmatory studies are required before it is possible to conclude that acarbose is effective in cardiovascular prevention, and that indeed it is the treatment of postprandial glucose which is beneficial. The cardiovascular disease in diabetic patients may be due to the presence of other cardiovascular risk factors associated with diabetes.

Cardiovascular risk markers associated with the metabolic syndrome in a large French population: the "SYMFONIE" study.

OBJECTIVE: The SYMFONIE study was designed to analyze the clinical and biological characteristics, and the cardiovascular risk markers, in men and women with the metabolic syndrome compared to control subjects. RESEARCH DESIGN AND METHODS: The study population included 101,697 men and women, 18 to 80 years of age, who had a health checkup at the Centre d'Investigations Preventives et Cliniques (Paris, France) between 1997 to 2002. The metabolic syndrome was defined according to the ATpiiI-NCEP 2001 criteria. RESULTS: Out of the 66,202 men (47.4+/-11.8 years) and 35,495 women (48.5+/-13.6 years) included in this population, 6761 men (10.2%) and 2155 women (6.1%) presented the metabolic syndrome. Among subjects < or =40 years of age, the prevalence of the metabolic syndrome was 5.0% in men and 2.2% in women, and rose to 14.1% and 12.0%, respectively, among men and women >70 years of age. After adjustment for age, patients with the metabolic syndrome presented higher pulse pressure (systolic minus diastolic blood pressure), higher heart rate, lower vital respiratory capacity, lower physical activity, an increase in inflammatory status assessed through leukocyte count and dental inflammation, hepatic abnormalities, and increased levels of stress and depression. CONCLUSION: In this large French population, the prevalence of the metabolic syndrome is lower than in North American and northern European populations. Patients with the metabolic syndrome present several additional hemodynamic, inflammatory and psychological risk markers which could contribute to the poor cardiovascular prognosis of these subjects.

Insulin initiation in type 2 diabetic patients admitted in hospital in France and follow-up at 1 year.

OBJECTIVES AND METHODS: The IDAHO 2 epidemiological survey was conducted in departments of diabetology in insulin-naïve type 2 diabetics for whom insulin was initiated. The objective was to assess the patients' profile, the treatments proposed during hospital stay and after one year. RESULTS: 797 patients were analysed. Their characteristics were: age 64+/-12 years, 49% males, weight: 78+/-17 kg, BMI: 29+/-6 kg/m2, diabetes duration 11 years, prevalence of complications: 68%, fasting blood glucose 13+/-6 mmol/l, HbA1c: 10+/-2.2%; treatment prior to insulin comprised: at least 2 OHA: 71% of cases, one: 21%, no OAD: 8%. At hospital discharge, 54% of the patients used basal insulin. After 1 year, 670 continued on insulin. The insulin initiation was accompanied by a decrease in the FBG level (baseline: 13+/-6 mmol/l; final: 8.5+/-2.75 mmol/l; P<0.0001) and a HbA1c improvement (baseline: 10+/-2.2%; final: 7.9+/-1.4%; P<0.0001). This was observed du-ring the first 6 months (HbA1c: 7.8%, P<0.0001 versus baseline). 80% of the patients remained on the same insulin regimen after 1 year: 35% had 1 injection/day, 44% had 2, 12% had 3 and 9% had a complex regimen. The weight gain, the final daily dose and hypoglycaemias increased with the number of injections. The mean daily insulin dose was 33 U/day (24 U with 1 injection/day). CONCLUSION: The IDAHO study shows that insulin is effective in type 2 diabetics however, management is inadequate with insulin therapy being initiated too late and at doses which are low after one year.

Agreement and discrepancy in the evaluation of normal and diabetic oral glucose tolerance test.

Systematic analysis with a five-hour OGTT of 340 subjects representative of people likely to be examined in a center specialized in diabetes detection was performed by multiple discriminant analysis, which provides indices of discrimination for different sets of blood glucose (BG) values. The relative sensitivity and the relative specificity of six different diagnostic methods: Fajans and Conn, Wikerson, WHO, British Diabetic Association, UGDP, and European Study Group of Diabetes Epidemiology were computed, giving a quantitative determination for the degree of discrepancy in the definition of diabetes: only 48 per cent of the subjects are classified in the same way by any of the diagnostic criteria. The time(s) of sampling and the index or indices of OGTT which are the most efficient in screening diabetes were estimated from homogeneous groups of subjects universally recognized as nondiabetic (URND) or as diabetic (URD) according to the different diagnostic methods. Better discriminating power (DP) between URD and URND compared with the maximum DP as measured by D2 of Mahalanobis from the seven BG values of the OGTT is given by the two-hour (70.2 per cent) than by the one-hour (49.5 per cent) BG value when a single value is used; the one-two-hour BG value is the best set of two times (80.7 per cent). The different indices now in use for the classification of the OGTT have been found less effective than the weighted sum of one-two-hour BG values. The difficulty in obtaining highly specific diagnostic tests is discussed in relation to the consequences on a partly automated screening in large populations.

Effect of multiple daily insulin injections on the course of diabetic retinopathy.

Forty-two diabetic patients on insulin once a day in the early stage of diabetic retinopathy were randomly assigned to one of two kinds of insulin regimen, i.e., single or multiple daily injections. Retinal changes were quantitatively estimated by counting the microaneurysms (MAs) observed on fluorescein angiograms at the posterior pole of the more diseased eye. Baseline characteristics of the two groups were not significantly different. These included duration of diabetes, age at diagnosis, daily dose of insulin, amount of urinary sugar excreted in 24 hours, fasting blood sugar (FBS), and number of MAs. During the follow-up (mean duration of three years) the mean yearly progression in the number of MAs was significantly less in the multiple- than in the single-injection groups: 1.8 +/- 0.7 versus 7.2 +/- 1.9 (p less than 0.01; nonparametric test: p less than 0.02). Final values were, respectively, MAs: 15.2 +/- 4.9; 33.0 +/- 7.9; glycosuria (gm./24 hrs): 20.6 +/- 2.5; 27.5 +/- 4.3; FBS (mg./100 ml.): 154 +/- 15; 195 +/- 11. P values comparing the two groups were less than 0.02, less than 0.02, and less than 0.05. Thus, in this clinical trial, made under routine treatment conditions, the use of divided daily insulin injections was effective in improving diabetic control and delaying retinal changes.

Risk factors for NIDDM in white population. Paris prospective study.

Risk factors for non-insulin-dependent diabetes mellitus (NIDDM) were assessed in a population of 5042 middle-aged white men, initially nondiabetic, who were followed 3 yr. The subjects were participants in the Paris Prospective Study I. Sixty-three subjects developed diabetes during the follow-up. Plasma glucose concentration in the years before the occurrence of the disease was a major risk factor. Subjects with normal glucose tolerance but elevated fasting plasma glucose exhibited a similar risk of developing NIDDM as did subjects classified as having impaired glucose tolerance on the basis of 2-h postload glucose. In a multiple logistic regression, a high fasting plasma insulin concentration and a low 2-h plasma insulin concentration after a glucose load in association with a high body mass index were independent predictors of conversion to NIDDM from impaired glucose tolerance. Previously, this result had been found only in Nauruans, Pima Indians, and Japanese. This demonstrates for the first time in a white population that a high fasting and low 2-h insulin concentration is predictive of conversion to NIDDM from impaired glucose tolerance.

Features of insulin-resistance syndrome in men from French Caribbean Islands. The Telecom Study.

The prevalence of diabetes is known to be high in the West Indies, whereas CVD seems relatively rare. This apparently contradicts the existence of the insulin-resistance syndrome, a cluster of metabolic abnormalities supposedly favoring both diabetes and cardiovascular complications. To address the question of whether this contradiction could be accounted for by specific features of this syndrome, we compared 1505 Caucasian and 181 Afro-Caribbean men, all participants in the French Telecom Study. The Afro-Caribbeans were of the same age and had the same BMI as the Caucasians; they also had significantly higher subscapular skin-fold thickness and fasting insulin level, but similar BP and blood glucose level, and significantly lower plasma triglyceride level. Thus, although some features of the insulin-resistance syndrome were present (central adiposity and high insulin levels), none of the associated metabolic abnormalities were present. However, within the Afro-Caribbean group, subjects with plasma insulin concentrations above the median (> 52 pM) had higher mean BP and glucose and triglyceride levels compared with subjects with insulin concentrations < or = 52 pM (P < 0.001). After adjustment for age and BMI, these differences, though smaller, still were statistically significant. These findings confirm that higher insulin concentrations are associated with higher levels of potentially atherogenic and diabetogenic metabolic parameters. However, depending on ethnic origin, the mean levels of these parameters seem to be different, with the consequence that, even if they are elevated with increasing insulin levels, they may not reach values high enough to determine a substantial risk of disease.

Epidemiology and costs of diabetes treated with insulin in France.

Extrapolating from the results of the 1998 and 2000 French National Sickness Insurance Fund surveys, it can be estimated that at the end of 2002, 3.4% of the French population, i.e. 2,150,000 individuals, had diagnosed type 1 or type 2 diabetes mellitus. Among these individuals, 2,050,000 were taking drug treatments and about 100,000 were treated with diet alone. About 16.3% of diabetics given drug treatments were taking insulin, alone or in combination with oral antidiabetic drugs, i.e. approximately 447,000 individuals including 316,000 (70.6%) with type 2 diabetes. Regarding all individuals with type 2 diabetes, the percentage treated with insulin (alone or in combination with oral antidiabetic drugs) increased from 12.3% in 1998 to 16.5% in 2002, for a mean increase of 7.4% per year. This rate is globally corroborated, although the study periods are not exactly comparable, by changes in sales volumes for insulin observed over recent years showing an even more rapid mean annual growth of 13.4%. The difference between these two estimates suggests that either the mean dose of insulin delivered is increasing or that the increase in the number of treated diabetics is underestimated by the National Sickness Insurance Fund. Mean age of patients treated with insulin alone (type 1 and type 2 diabetics considered together) was 56.3 years with a median of 60 years and a sex ratio (M/F) close to 1 (0.9). There are no national data detailing monitoring practices in insulin-treated patients. Published analyses focus on type 2 diabetics treated with oral antidiabetic drugs and often exclude patients taking insulin. Blood glucose control is poor (HbA1c>8%) in approximately one-third of patients with type 2 diabetes and different studies have shown that in France among subjects with type 2 diabetes 3.1% are taking two oral antidiabetic drugs or more at maximal doses and have poorly controlled blood glucose levels. The percentage of insulin-treated diabetics is increasing steadily, but remains lower than observed in other European countries (generally reported in the 24% to 30% range). This special situation in France could fade out in upcoming years with better awareness of the importance of metabolic control, improved insulin therapy in this context, and improved conditions for use of insulin.

Hepatic markers and development of type 2 diabetes in middle aged men and women: a three-year follow-up study. The D.E.S.I.R. Study (Data from an Epidemiological Study on the Insulin Resistance syndrome).

AIM: It has been shown, mainly in men, that gamma-glutamyltransferase (gammaGT) and alanine-aminotransferase (ALT) predict the development of type 2 diabetes. This study investigates the association between hepatic markers and the 3-year risk of diabetes. METHODS: Incident diabetes was studied in 2071 men and 2130 women without diabetes at baseline from the D.E.S.I.R. cohort. RESULTS: Adjusting on age, only gammaGT was predictive of diabetes in both sexes, whereas ALT and aspartate-aminotransferase (AST) were only predictive in men, and bilirubin was not predictive. After adjustment on classical confounding factors and on ALT activity, the odds ratios (OR) for incident diabetes increased across baseline gammaGT quartiles: 1, 3.1, 2.6, 5.0 in men (P<0.0003) and 1, 0.9, 3.2, 3.5 in women (P<0.01). The relations with ALT and AST were not significant after adjusting on gammaGT. Additional adjustment on markers of insulin resistance, BMI or fasting plasma glucose attenuated the risk associated with gammaGT in both sexes, and it remained significantly predictive only in the men. Pooling men and women, those with gammaGT above the median had adjusted ORs of developing diabetes of 13.7 (1.8-99.8) if WHR > =0.85 and 1.7 (0.6-4.8) if WHR<0.85 (interaction P<0.007). CONCLUSION: gammaGT was the main hepatic risk marker for type-2 diabetes in both sexes, especially in subjects with central adiposity.

Evaluation of a screening program for diabetic retinopathy in a primary care setting Dodia (Dépistage ophtalmologique du diabète) study.

OBJECTIVES: The aim of this observational study was to evaluate the screening for diabetic retinopathy (DR) using eye fundus photography taken by a nonmydriatic camera and transmitted trough the Internet to an ophthalmological reading centre, as compared to a dilated eye examination performed by an ophthalmologist. METHODS: A total of 456 and 426 diabetic patients were included by two different groups of primary care physicians (PCPs), 358 being screened with the non-mydriatic camera (experimental group) and 320 with dilated eye fundus exam (control group). RESULTS: The proportion of screened patients for whom PCPs received a screening report within the 6-month follow-up period was 74,1% for the experimental group and 71,5% for the control group. Screening for DR was negative in 77,6% of patients with eye fundus photographs vs 89,6% with dilated eye examination. DR was diagnosed in 62 patients (17,3%) with eye fundus photographs versus 31 with dilated eye examination (10,4%). Referral to an ophthalmologist was required in 59 reports of patients with photographs (16.5%), 23 of them due to high grade DR. Finally, the non-mydriatic camera was found of little inconvenience by patients. CONCLUSION: The telemedical approach to DR screening proved to be effective in providing primary care practitioners with information about their patient's eye status. This screening method allowed to identify patients requiring prompt referral to the ophthalmologist for further complete eye examination. In conclusion, this study provided successful results of DR screening using fundus photography in primary care patients, and strongly supports the need to further extend this screening program in a larger number of French sites.

Accumulation of triglyceride-rich lipoprotein in subjects with abdominal obesity: the biguanides and the prevention of the risk of obesity (BIGPRO) 1 study.

The present study represents a new insight into the Biguanides and the Prevention of the Risk of Obesity (BIGPRO) 1 study population at inclusion. This population, selected basically on the basis of a high waist-to-hip ratio (>/=0.95 for men and >/=0.80 for women), is supposed to represent a group of patients with insulin resistance. The present study was undergone to establish whether apolipoprotein C-III (apoC-III) and apolipoprotein E (apoE) associated with apo B (apoC-III LpB and apoE LpB, respectively), considered to be markers of remnant accumulation, play a role in the hypertriglyceridemia associated with insulin resistance and whether they are related to other biological abnormalities frequently observed in this syndrome. In this population, the concentration of the markers of remnant accumulation increases with triglyceride levels. Therefore, correlation studies were realized to assess the relative effect of insulin and the markers of remnant accumulation on triglyceride plasma level. As a first attempt, a simple correlation analysis revealed that insulin is positively related to the markers of remnant accumulation only in hypertriglyceridemic patients (triglycerides >/=1.7 mmol/L). To assess the independent contribution of these markers, insulin, and other parameters related to the plasma triglyceride concentration, a stepwise multiple regression analysis was run. Results revealed that insulin and the markers of remnant accumulation (specifically, apoE LpB) are independent contributors to the plasma triglyceride concentration. Markers of the endothelial damage, plasminogen activator inhibitor-1, tissue plasminogen activator, and von Willebrand factor, which are often increased in the case of insulin resistance, were tested for their correlation with the markers of remnant accumulation. Plasminogen activator inhibitor-1 is positively correlated with these markers only in hypertriglyceridemic male subjects. It is concluded that increased insulin levels found in insulin resistance syndrome are associated with an increased production of triglyceride-rich lipoproteins enriched in apoC-III and apoE. The accumulation of these remnants and/or their abnormal composition in apoC-III and apoE could be an explanation for the development of hypertriglyceridemia in this syndrome.