Ambulatory 24-hour fast using flexible insulin therapy in patients with type 1 diabetes.

AIM: Prolonged fasting may be necessary in life for religious, medical and other reasons. For this reason, our study investigated the feasibility and safety of a 24-h fast conducted at home for patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Thirty-four patients with type 1 diabetes performed a 24-h complete fast at home. Thirteen patients were treated with multiple insulin injections using either glargine (n=12) or NPH (n=1) as basal insulin. The remaining patients were treated with an insulin pump. All patients received their basal insulin only, which was adjusted to 40% of their total daily dose, and were monitored by either a Gold(®) or Guardian(®) continuous glucose monitoring (CGMS) device. Capillary glucose (SMBG) was targeted at 3.9-7.8 mmol/L, with a standardized protocol for correction of hyper- and hypoglycaemia. Interstitial glucose (IG) profiles were compared with the SMBG values; the IG profiles of patients using glargine or a pump and either of the two CGMS devices were also compared. RESULTS: All of the patients completed the 24-h fast with no major incident. At the end of the fast, 80% of the IG values were on target. The route by which insulin was delivered made no difference, but there were more IG values on target in patients monitored by the Guardian(®) device. IG was below target in 104 occurrences and above-target in 34. After a mean intake of 10 g of sucrose, below-target IG was corrected within 30 min [range: 15-40]. The mean insulin dose to correct above-target episodes was 1 U. CONCLUSION: Prolonged fasting is possible at home in patients with type 1 diabetes, provided the basal dose is adjusted. The use of CGMS is not necessary, but offers useful information on the patient's IG profile during the fast.

Therapeutic alliance and glycaemic control in type 1 diabetes: a pilot study.

AIM: Effective diabetes care requires integrating physicians' clinical expertise with patients' concerns and resources. This prospective study examined whether or not two measures of therapeutic alliance could predict glycaemic control after 1 year of follow-up in patients with type 1 diabetes. METHODS: Consecutive type 1 diabetic outpatients were recruited, and their age, gender, level of education, marital status and age at the time of diabetes diagnosis were self-reported. The presence of diabetes complications was ascertained by the patients' physicians. Both patients and physicians completed the revised Helping Alliance Questionnaire (HAQ-R) and the 12-item Working Alliance Inventory (WAI-12) to assess therapeutic alliance. Patients also completed the Center for Epidemiological Studies Depression scale to assess depressive mood. HbA(1c) was measured at baseline and 1 year later. RESULTS: Sixty-four type 1 diabetic outpatients (32 men, 32 women; mean age±standard deviation [S.D.]: 38.2±8.0 years) were included. HbA(1c) level at follow-up (mean±S.D.: 7.56±1.18%) was positively correlated with the HbA(1c) level at baseline (r=0.698, P<0.001), and associated with presence of retinopathy at baseline (8.18±1.24% versus 7.41±1.13%, P=0.036). In addition, the HbA(1c) level at follow-up was negatively correlated with therapeutic alliance, as assessed at baseline by the physicians using either the HAQ-R (r=-0.431, P<0.001) or the WAI-12 (r=-0.365, P=0.003), even after controlling for the HbA(1c) at baseline. CONCLUSION: Although the observational nature of the present study prevents causal conclusions to be drawn, these preliminary results suggest that promoting therapeutic alliance can improve glycaemic control in type 1 diabetes.

Peak-time determination of post-meal glucose excursions in insulin-treated diabetic patients.

OBJECTIVE: This study aimed to determine the optimal time to measure peak blood glucose values to find the best approach for self-monitoring blood glucose after a meal. DESIGN AND METHODS: For this retrospective analysis, 69 ambulatory continuous glucose-monitoring system (CGMS) profiles were obtained from 75 consecutive insulin-treated patients with diabetes. The parameters measured were the peak post-meal blood glucose values, peak time, and rates of increase and decrease to and from the zenith of the resulting curves. RESULTS: The mean peak time after breakfast was 72+/-23 min, which was reached in less than 90 min in 80% of the patients. The apparent glucose rate of increase from pre-meal to the maximum postprandial value was 1.23+/-0.76 mg/dL/min, while the glucose rate of decrease was 0.82+/-0.70 mg/dL/min. Peak time correlated with the amplitude of postprandial excursions, but not with the peak glucose value. Also, peak times were similar after breakfast, lunch and dinner, and in type 1 and type 2 diabetic patients. CONCLUSION: To best assess peak postprandial glucose levels, the optimal time for blood glucose monitoring is about 1h and 15 min after the start of the meal, albeit with wide interpatient variability. Nevertheless, 80% of post-meal blood glucose peaks were observed at less than 90 min after the start of the meal.

Prevalence and predictive factors of sleep apnoea syndrome in type 2 diabetic patients.

AIM: This study aimed to assess the prevalence and characteristics of sleep apnoea syndrome (SAS) in patients hospitalized for poorly controlled type 2 diabetes. METHODS: An overnight ventilatory polygraphic study was systematically performed in 303 consecutive patients. RESULTS: Overall, 34% of these patients had mild SAS, as defined by a respiratory disturbance index (RDI) of 5-15; 19% had moderate SAS (RDI: 16-29) and 10% had severe SAS (RDI>or=30). The SAS was obstructive in 99% of the apnoeic patients. The percentage of patients with excessive daytime sleepiness (Epworth sleepiness scale>10), fatigue or nocturia did not significantly differ among patients with severe, moderate or mild SAS versus non-apnoeic patients. The percentage of patients who snored was significantly higher in patients with severe or moderate SAS versus non-apnoeic patients. HbA(1c), duration of diabetes and the prevalences of microalbuminuria, retinopathy and peripheral neuropathy did not significantly differ among patients with severe, moderate or mild SAS versus non-apnoeic patients. However, patients with severe or moderate SAS had significantly higher values for body mass index, waist circumference and neck circumference than non-apnoeic patients. CONCLUSION: In type 2 diabetic patients with poor diabetic control, obstructive SAS is highly prevalent and related to abdominal obesity, and should be systematically screened for, as it cannot be predicted by the clinical data.

Benefits of Ophdiat, a telemedical network to screen for diabetic retinopathy: a retrospective study in five reference hospital centres.

AIM: One objective of Ophdiat, a telemedical network using digital non-mydriatic cameras in Ile-de-France, is to develop a comprehensive screening programme that provides access to annual fundus examinations to all diabetic patients. The aim of this study was to evaluate the benefits of this programme in a hospital setting. METHODS: A retrospective analysis of 500 case reports of diabetic patients hospitalized before and after Ophdiat setup was performed in five reference hospital centres. At each centre, 100 case reports (50 before, 50 after) of patients aged greater than 18 years, hospitalized for their annual check-up, with no known diabetic retinopathy (DR) before hospitalization and with the last fundus examination performed greater than 11 months previously, were randomly selected. The primary endpoint was the proportion of patients whose fundus examinations were performed during hospitalization; secondary endpoints were the number of cases of DR found and the time taken by ophthalmologists to make the diagnosis. RESULTS: The mean proportion of patients with fundus examinations was 50.4% and 72.4% before and after, respectively, Ophdiat (P<0.01). The prevalence of DR was 11.1% before and 12.7% after (not significant). The mean time taken by an ophthalmologist per diagnosis of DR was 0.90 half-day before and 0.32 half-day after Ophdiat. CONCLUSION: This evaluation shows that Ophdiat, combined with the availability of modern and effective devices, has improved DR screening in diabetology departments in hospitals. Additional human resources would certainly ensure more effective use of the system.

[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.

Motivational effects of 12-week moderately restrictive diets with or without special attention to the Glycaemic Index of foods.

Low glycaemic index (GI) diets may facilitate weight loss via behavioural and/or endocrine mechanisms. This study investigated whether the outcomes of the Weight Watchers POINTS Weight-Loss System could be improved by encouraging dieters to select low GI, high-carbohydrate foods. Ninety-six women (age 20-72 years; BMI 25-40 kg/m2) were recruited as they started the Weight Watchers POINTS programme for 12 weeks. Weekly classes were randomized so that seven (forty-five women) followed the regular programme while seven others (fifty-one women) followed a revised programme encouraging the selection of low GI foods. Anthropometric and biochemical parameters were measured before and after the 12-week diets. Participants rated hunger and desire to eat using visual analogue scales on 1 d per week, several times per d. Attrition was the same in both groups (32 v. 30 %), as well as many benefits (5 % weight loss, decreases in insulinaemia and blood lipids, waist and hip circumferences, blood pressure). Hunger and desire to eat were rated consistently lower in the low GI group over the 12-week diet. Group differences in subjective sensations were especially large in the afternoon. The 12-week weight management yielded many significant anthropometric and biochemical benefits that were not improved by encouraging dieters to select low GI foods. The subjective benefits (lower hunger and desire to eat) of the low GI diet may be a worthwhile contribution to the motivation of dieters that might affect adherence to the diet over the long term.

Effect of baking process on postprandial metabolic consequences: randomized trials in normal and type 2 diabetic subjects.

OBJECTIVE: To determine the impact of the form, fibre content, baking and processing on the glycaemic, insulinaemic and lipidaemic responses of different French breads. DESIGN AND SUBJECTS: First study: Nine healthy subjects were randomized to consume in a crossover design one of six kinds of French bread (each containing 50 g available carbohydrate): classic baguette, traditional baguette, loaf of wholemeal bread (WM-B), loaf of bread fermented with yeast or with leaven, a sandwich and a glucose challenge as reference. RESULTS: The glycaemic index (GI) values ranged from 57+/-9% (mean+/-s.e.m.), for the traditional baguette, to 85+/-27% for the WM-B. No significant difference was found among the different tested bread. The insulinaemic index (II), however, of the traditional baguette and of the bread fermented with leaven were lower than the other breads (analysis of variance: P<0.01). Postprandial plasma triglycerides showed similar profiles. The traditional baguette tended to decrease postprandial free fatty acids compared to levels after the classic baguette. RESULTS: The GI of the traditional baguette was lower than that of the classic baguette (n=8, venous blood: 70+/-4 vs 75+/-4, P=0.002; capillary blood: 69+/-5 vs 83+/-6, P=0.028, respectively). CONCLUSIONS: Some varieties of French bread (the TB) have lower II, in healthy subjects, and lower GI, in type 2 diabetic subjects, than that of the other varieties. These results might be due to bread processing difference rather than fibre content. SPONSORSHIPS: Supported by grants from the National French Milling Association.

Postprandial glycaemia: a plea for the frequent use of delta postprandial glycaemia in the treatment of diabetic patients.

Postprandial hyperglycaemia is a phenomenon often neglected by patients as well as doctors. While patients only voluntarily measure morning and preprandial capillary glycaemia, physicians do not encourage the measurement of anything further. The specific role of postprandial hyperglycaemia in the determination of late diabetes complications, such as micro- and macroangiopathy, remains controversial. It is however undeniable that the postprandial glycaemic excursion plays an important role in total hyperglycaemia reflected by an increase in glycated haemoglobin. The postprandial glycaemia measurement or, more appropriately, the postprandial glycaemic excursion (the difference between postprandial and preprandial glycaemia, also called the postprandial delta glycaemia), is important to measure and there are specific tools to correct it when abnormal. Postprandial delta glycaemia should lie between 30 and 50 mg/dl. It is thus suggested to measure it not necessarily on a daily basis, but when it is expected that the glycaemic couple, or "pre-postprandial couple", is high. The specific tools for treatment of postprandial hyperglycaemia can be dietetic (carbohydrate quantity reduction or ingestion of fiber-rich and/or low glycaemic index foods) or medicinal. Among the specific medicinal treatments are the alpha-glucosidase-inhibitors (which can be used for both type 1 and type 2 diabetic patients), glinides and fast-acting insulins. Rather than first treating fasting and interprandial hyperglycaemia, as has been commonly done by physicians, the authors recommend the simultaneous treatment of pre-, inter- and postprandial hyperglycaemia. The optimal time at which to evaluate postprandial glycaemia is approximately 1 h and 15 minutes for type 1 and type 2 diabetic patients.

Glycaemic index methodology.

The glycaemic index (GI) concept was originally introduced to classify different sources of carbohydrate (CHO)-rich foods, usually having an energy content of >80 % from CHO, to their effect on post-meal glycaemia. It was assumed to apply to foods that primarily deliver available CHO, causing hyperglycaemia. Low-GI foods were classified as being digested and absorbed slowly and high-GI foods as being rapidly digested and absorbed, resulting in different glycaemic responses. Low-GI foods were found to induce benefits on certain risk factors for CVD and diabetes. Accordingly it has been proposed that GI classification of foods and drinks could be useful to help consumers make 'healthy food choices' within specific food groups. Classification of foods according to their impact on blood glucose responses requires a standardised way of measuring such responses. The present review discusses the most relevant methodological considerations and highlights specific recommendations regarding number of subjects, sex, subject status, inclusion and exclusion criteria, pre-test conditions, CHO test dose, blood sampling procedures, sampling times, test randomisation and calculation of glycaemic response area under the curve. All together, these technical recommendations will help to implement or reinforce measurement of GI in laboratories and help to ensure quality of results. Since there is current international interest in alternative ways of expressing glycaemic responses to foods, some of these methods are discussed.

Non food-related environmental stimuli induce increased meal intake in healthy women: comparison of television viewing versus listening to a recorded story in laboratory settings.

The objective of the present study, performed under laboratory conditions, was to assess the impact of two non food-related environmental stimuli (television and auditory stimulus) on meal intake. Normal weight women (N = 48) ate lunch in the laboratory once a week for four weeks. All lunches were identical and included popular traditional foods, of which participants could eat ad libitum. The first and last lunches were eaten in the absence of the environmental stimuli (control conditions); in the other two tests, presented in random order, subjects ate while either watching television or listening to a recorded story. Energy intakes were determined for each meal, as were ratings of hunger, satiety and meal palatability. Subjects filled out the Three Factor Eating Questionnaire at the end of the meal series. Meal size was significantly larger in the presence of both environmental stimuli than in both control conditions (+11.6%, 280 kJ, p < 0.01). Television viewing induced a significant stimulation of intake, equal to, but not greater than the effect of the auditory stimulus. Ratings of hunger, satiety, and palatability were not significantly different between conditions, despite the differences in intake. These results suggest that environmental, non food-related stimuli could stimulate intake regardless of hunger-satiety or palatability conditions. Environmental stimulation of eating should be tested in other populations, eg subjects with weight control problems, and other conditions, e.g. free-living.