The growing burden of diabetes mellitus in the US elderly population.

BACKGROUND: The prevalence of diabetes mellitus is growing worldwide. Consequently, there has been increased emphasis on primary and secondary prevention of diabetes. To our knowledge, whether there have been actual improvements in outcomes in the last decade or so has not been documented in a nationally representative sample. METHODS: We undertook this study to examine trends in rates of occurrence of diabetes and its complications in persons older than 65 years in the United States. National longitudinal analysis of Medicare claims and other Medicare program data for persons first diagnosed as having diabetes during 1994 (n=33 164), 1999 (n=31 722), or 2003 (n=40 058) were compared with 2 control groups of persons of approximately equal sample size who were not diagnosed as having diabetes, alternatively during 1994, 1999, or 2003 or for the entire period from 1994 to 1999 or from 1999 to 2004. The main outcome measures were death and complications of diabetes including cardiovascular, cerebrovascular, ophthalmic, renal, and lower extremity events. RESULTS: The annual incidence of diabetes increased by 23% between 1994-1995 and 2003-2004, and prevalence increased by 62%. The mortality rate after diagnosis in persons having diagnosed diabetes decreased by 8.3% compared with that in the control groups. Complication rates among persons diagnosed as having diabetes generally increased or stayed the same compared with those in the control groups during 1994 to 2004 except for ophthalmic diseases associated with diabetes. Rates for some major complications were high; for example, the rate for congestive heart failure in the diabetes group during 1999 to 2004 was 475 per 1000 persons. In some cases, most notably renal events, including the most serious complications, there were increases in prevalence in both the diabetes and control groups. CONCLUSION: The burden of financing and providing medical care for persons older than 65 in the United States having diagnosed diabetes is growing rapidly as a result of increased incidence and, especially, prevalence of diagnosed diabetes, decreased mortality, and overall lack of improvement in rates of complications in persons having diagnosed diabetes.

Treatment regimen determines the relationship between depression and glycemic control.

UNLABELLED: Several recent studies have suggested that depression is related to poorer glycemic control in patients with type 1 diabetes, but not in type 2 diabetes. We hypothesize that complexity of self-care regimen rather than the type of diabetes, is more important in determining this relationship of depression to glycemic control. METHODS: One thousand thirty-four adults with diabetes were recruited for the study. These patients were treated with: diet and exercise, oral medications, oral medications and insulin, 1-2 daily injections of insulin, and > or =3 daily injections. All participants completed the Beck depression inventory (BDI) and had a hemoglobin A(1c) (HbA(1c)) performed as part of routine clinical care. RESULTS: Pearson correlations between BDI scores and HbA(1c) were low and insignificant in all groups (0.015< or =r< or =0.066) except for those administering three or more daily shots of insulin (r=0.284; p=0.034). DISCUSSION: The results of this study clearly show that while depressive symptoms are significantly correlated to glycemic control in patients taking three or more insulin injections per day, there is no relationship in patients who are taking fewer than three injections per day.

Protease inhibitor-induced diabetic complications : incidence, management and prevention.

Protease inhibitors (PIs) have become a crucial element in the treatment of patients infected with HIV. However, the widespread use of PI therapy has also been associated with a number of metabolic adverse effects, including fat redistribution and hyperglycaemia. The objective of this review is a discussion of the incidence, pathophysiology, management and prevention of PI-associated hyperglycaemia. Initial case reports have been followed by large cross-sectional and cohort studies, which demonstrate that the incidence of PI-induced impaired glucose tolerance, as well as frank diabetes mellitus, is significant and demands attention. Investigations into the pathophysiology behind PI-associated hyperglycaemia have identified an underlying problem of insulin resistance that is presumably caused by both direct PI-induced mechanisms and lipotoxicity. Given this, clinical trials have explored the use of various classes of oral hypoglycaemic agents in the management of PI-induced diabetic complications, and the use of insulin therapy must be considered as well. Newer PI agents are also under development, with the hope of reducing metabolic adverse effects. In the meantime, prevention, in the form of dietary modification, regular physical activity and periodic screening for impaired glucose tolerance, must receive heightened attention in the care plan of patients receiving long-term PI therapy.

In-hospital management of type 2 diabetes mellitus.

The increasing prevalence of type 2 diabetes brings with it a need to understand the particular impact of hospitalization in this patient population. Type 2 diabetes has been shown to increase length of stay, infection, and mortality rates. To optimize inpatient care, it is important to understand target glycemic goals as well as in-hospital glucose monitoring and diabetes management goals. A practical review of regimens for subcutaneous insulin administration,intravenous insulin infusion, and inpatient use of oral agents is presented. Methods for achieving adequate preparation and education of the patient and family for discharge to the outpatient setting are also discussed.