High prevalence of chronic kidney disease in La Réunion island and its association with the metabolic syndrome in the non-diabetic population: La Réunion Diabetes (REDIA) Study.

AIM: To estimate the prevalence of chronic kidney disease (CKD) in La Réunion island and to investigate the link with the metabolic syndrome in the non-diabetic population. METHODS: The Réunion Diabetes (REDIA) Study included a random sample of 3600 adults aged 30-69 years. Clinical proteinuria (>200 mg/g creatinine), albuminuria (>or=30 mg/g) and estimated glomerular filtration rate (eGFR) were studied in 920 subjects, 411 of whom had diabetes and 509 who did not. Their relations with the metabolic syndrome (as defined by the US National Cholesterol Education Program Adult Treatment Panel III guidelines) were analyzed among those without diabetes. RESULTS: Age-, gender- and diabetes-standardized prevalence of CKD stage 1 or 2 (proteinuria or albuminuria with eGFR>or=60 mL/min/1.73 m2) was 13.8% and, for CKD stage 3 or more (eGFR<60 ml/min/1.73 m2), 10.7%. The adjusted odds ratios (OR) for proteinuria increased with the number of metabolic syndrome traits: 1.5 (95% confidence interval, 0.4-5.2) in non-diabetic participants with one trait compared with those with no trait, 2.0 (CI 0.6-6.6) for two traits and 4.1 (CI 1.3-12.8) for three or more; corresponding ORs for eGFR<60 ml/min/1.73 m2 were 1.9 (CI 0.8-4.5), 0.9 (CI 0.4-2.4) and 2.2 (CI 0.9-5.1), respectively. Clustering of either high blood pressure and triglyceride levels, or high triglycerides and plasma glucose, or all three, conferred the strongest associations with both clinical proteinuria and low eGFR. CONCLUSIONS: CKD prevalence is high in La Réunion island population, and the metabolic syndrome may help to target early diagnosis of CKD in non-diabetic individuals.

Trends and sociocultural factors for childhood overweight in La Reunion Island.

OBJECTIVE: To examine time trends (study 1) and sociocultural factors associated with childhood overweight (study 2) in La Reunion Island. DESIGN: Study 1: a longitudinal analysis of anthropometric data available from health services in the town of Saint-Pierre. Study 2: a case - control study. SUBJECTS: Study 1: 1753 children born between 1977 and 1996. Study 2: 101 six-year old overweight children sex-matched with 101 non-overweight children. MEASUREMENTS: Study 1: overweight at birth (birth weight>4 kg) and at age 4 and 6 using French references and references from the International Obesity Task Force. Study 2: parental and perinatal data, child's lifestyle and representation of food, all collected from the mother. RESULTS: Study 1: a dramatic increase in the prevalence rate of overweight at 4 and at 6 is observed, more severe in girls. Study 2: multivariate logistic regressions showed that mother's overweight was the only variable significantly associated with overweight in both the sexes. The other associated factors were related to sociocultural and family features and sedentarity. Logistic probability functions derived from these data are proposed as a tool for detection of at risk families. CONCLUSION: Our results show the need for a targeted prevention of overweight. We offer a proposal based on education and behaviour modification in La Reunion Island.

Health perceptions of diabetic patients in the REDIA study.

AIM: To explore the beliefs and perceptions of type 2 diabetic patients in La Réunion where the disease is highly prevalent (17.5% among 30-69 yr old subjects) with a strong link to the metabolic syndrome and nutritional habits. METHODS: Two sets of data were analysed. An 80-item questionnaire explored the perceptions of causal factors, knowledge of complications and therapeutic issues in 331 known diabetic patients included in the REDIA study. The data were completed by semi-structured interviews of 40 diabetic patients in a hospital setting. RESULTS: Perceived causal factors of diabetes are mainly sugar excess, heredity and stress or life events. Weight excess and lack of physical activity are virtually never mentioned as causes. Diabetes is predominantly perceived as potentially acute, with risk of coma and death. Its chronic and progressive nature is not appreciated, and chronic complications are not well understood, especially in poorly educated people. Only 33% of males and 42% of females are willing to change their nutritional habits and the role of fats is largely underestimated (30.2%) although 90% consider physical activity as an effective course of action. Most patients are tardy in the way that they adopt medical recommendations and treatment in the course of the disease. CONCLUSION: These results highlight the discrepancy between medical knowledge and patients' perceptions, especially concerning etiological issues and complications. Lifestyle and therapeutic recommendations are not well understood. Educational activities need to consider the knowledge issues and understanding by patients early in the course of chronic diseases like diabetes.

Body weight change since menopause and percentage body fat mass are predictors of subsequent bone mineral density change of the proximal femur in women aged 75 years and older: results of a 5 year prospective study.

Few studies have evaluated risk factors for bone loss in elderly women. We examined risk factors associated with a 5-year longitudinal change in bone mineral density (BMD) at the hip in healthy women aged 75 years and older. The BMD of 276 women from the French EPIDOS (Epidémiologie des Osteoporoses) study was assessed in Montpellier from 1992 to 1993 and again from 1997 to 1998. BMD was measured at the femoral neck, trochanter, and Ward's area using the same Lunar densitometer. We examined the relationship between clinical and behavioral factors at baseline and their variations during follow-up, with percentage BMD change adjusted for baseline BMD. Depending on the femur subregion studied, a significant decrease in BMD (exceeding the least significant difference, i.e., > 2.8 CV) was observed in 36.2% to 51.1% of women. Multivariate analysis showed that both postmenopausal weight change before baseline and baseline percentage of fat mass were positively correlated with BMD change at the Ward's triangle and the trochanter. Yearly absolute and relative weight changes over the follow-up period were significantly associated with change of trochanter and femoral neck BMD. Our results show that maintenance of body weight throughout the postmenopause period and body fat mass play protective roles against bone loss at the proximal femur in women aged 75 years and older and suggest the value in including assessment of weight change throughout postmenopause and percentage body fat mass in screening programs for elderly women who are at higher risk of accelerated bone loss.

Outcome of patients consulting in an outpatient nutrition clinic for excessive body weight.

OBJECTIVE: Few data are available concerning long-term outcome of patients after individually consulting a nutrition specialist, without entering a structured program. The objective of the present study was to evaluate outcome and predictors of body weight loss (BWL) after consulting in an outpatient nutrition clinic. METHODS: Phone interview of 95 patients (age 46.1 +/- 1.4 years, BMI 33.8 +/- 0.7 kg/m(2)) out of 299 who consulted consecutively for the first time in an outpatient nutrition clinic for excessive body weight. RESULTS: The mean time interval between first visit and phone interview was 2.1 +/- 1.3 years. Average BWL was 6.7 +/- 1.2 kg for the entire group. Forty-eight patients (50.5%) had lost more than 5% of initial body weight and were considered to be successful. Initial BMI was associated with% BWL (r=0.42, p<0.0001). Underreporting of energy-intake at initial dietary history was positively associated with BWL (- 11.8 +/- 1.1 vs. - 5.1 +/- 3.9 kg, p<0.05) as well as the number of visits attended by the patient (p=0.04). No relation was found between sex, age and physical activity at initial visit, past history of dieting or time elapsed since first or last visit and BWL. In multivariate analysis under reporters had 4.3 times more chances to lose more than 5% of their body weight (p<0.05). CONCLUSION: Visiting a nutrition specialist to receive individual counseling and prescription of a balanced low calorie diet is part of a positive behavior change leading to body weight loss.

[Is HbA1c appropriate for the screening of diabetes in general pratice?]. / L'HbA1c peut-elle être utilisée par le praticien pour le dépistage du diabète?

The measurement of glycated haemoglobin (HbA(1c)) is a practical and more sensitive tool than fasting plasma glucose (FPG) in screening type 2 diabetes in current practice. Its use has been limited so far by the variability of the analytical methods. The standardization process is going on, and many laboratories are currently using valid methods. Our study is consistent with the results of other groups who recommended this measurement to identify undiagnosed diabetic patients, that are about 25% to 30% in the French population. The demonstration was provided through a survey including a screening step by both HbA(1c) and G0, and a second exam with a 2 hr OGTT in a sample of positive screenees according to at least one criterion (HbA(1c) >=6% or G0 >=1.26 g/L), as well as in a sample of negative screenees. We showed that nine confirmed diabetic subjects out of ten had HbA(1c) >=6% at the screening step, while only a half had G0 >=1.26 g/L. Conversely, 22% of the positive screenees according to HbA(1c) were not confirmed as diabetic by the OGTT, including however more than half with abnormal glucose values. A chart for practical use is proposed to define patients at risk, the process of screening, and the patient follow-up according to the results of the tests.

Light exposure and the risk of age-related macular degeneration: the Pathologies Oculaires Liées à l'Age (POLA) study.

BACKGROUND: The role of light exposure in the development of age-related macular degeneration (ARMD) has been questioned. We present the relationship between lifetime light exposure and ARMD as examined in the Pathologies Oculaires Liées à l'Age (POLA) study. METHODS: The POLA study is a population-based study on cataract and ARMD and their risk factors. It included 2584 residents of the town of Sète, located in the South of France. The presence of early and late ARMD was assessed on the basis of 50 degrees color fundus photographs using an international classification system. A questionnaire about light exposure was administered. RESULTS: Late ARMD (n = 38) was not significantly associated with any light exposure variable. Subjects exposed to high ambient solar radiation and those with frequent leisure exposure to sunlight had a decreased risk of pigmentary abnormalities (odds ratio [OR] = 0.61; 95% confidence interval [CI], 0.39-0.93, and OR = 0.70; 95% CI, 0.52-0.95, respectively) and of early signs of ARMD (OR = 0.73; 95% CI, 0.54-0.98, and OR = 0.80; 95% CI, 0.64-1.00, respectively). Subjects who had used sunglasses regularly had a decreased risk of soft drusen (OR = 0.81; 95% CI, 0.66-1.00). These relationships were not modified by further adjustments for potential confounders. CONCLUSION: Our study does not support a deleterious effect of sunlight exposure in ARMD.

Relationships between physical activity, obesity and diabetes mellitus in a French elderly population: the POLA study. Pathologies Oculaires lieés á l' Age.

OBJECTIVE: To analyse the relationships between body mass index, waist circumference, waist-to-hip ratio, physical activity and the risk of type 2 diabetes in a French elderly population. DESIGN AND SUBJECTS: We conducted a cross-sectional study on 1113 men and 1419 women aged 60 y or more, participating in the POLA Study. RESULTS: The prevalence of diabetes was two-fold higher in men than in women (19.1% and 9.3%, respectively). The anthropometric variables studied-body mass index (BMI), waist circumference (WC) and the waist/hip ratio (WHR)-were all positively related to the prevalence of type 2 diabetes. The strongest relationships were found for BMI in men and WHR in women. In both genders, sport activity and diabetes were inversely linked whereas no relationship was shown between the amount of household activity and diabetes mellitus. CONCLUSION: In the elderly, overall obesity in men and abdominal fat accumulation in women appeared strongly related to diabetes. Sport activity was negatively and independently associated with the prevalence of diabetes mellitus.

Associations of age, smoking habits and diabetes with plasma vitamin C of elderly of the POLA study.

The objective of this study was to determine the associations of age and sex with plasma vitamin C (vit C) concentration taking into account smoking habits and the presence of age-related pathologies, such as diabetes. The POLA study is a population-based study on age-related eye diseases and their risk factors, and plasma Vitamin C evaluation is part of the biological parameters measured in the 1987 volunteer subjects living in Sète (South of France) and aged more than 60 years. Men had lower average plasma vit C levels than women (31.6 microM.L-1 versus 40.3 microM.L-1, p = 0.001). Plasma vit C was stable as a function of age in women but decreased in men (p = 0.02), enhancing the difference in vit C concentration between men and women with advancing age. Smoking more than 10 cigarettes a day was associated to a lower plasma vit C concentration in men (p = 0.001) but not in women, and diabetic subjects tended to have lower vit C concentrations, the difference being significant only in women (p = 0.003). We conclude that there is a clear influence of sex on plasma vit C. This difference may be due to dietary habits, or metabolism, but may also be due to different sensitivity of age, smoking and to some pathologies.

[Insulin treatment in type 2 diabetes: epidemiological data]. / Insulinothérapie dans le diabète de type 2: données épidémiologiques.

After several years of disease duration, blood glucose control is difficult without using insulin in type 2 diabetic patients. However, large differences are observed regarding the use of insulin from the south to the north of Europe. A positive effect of insulin therapy on metabolic control compared to oral antidiabetic agents is shown only in clinical trials performed on selected patients. As to degenerative complications, a great excess of retinopathy is observed in insulin-treated patients in several surveys, without possibility to determine the specific effect of treatment from that of disease severity. The UKPDS is the only randomised long-term clinical trial with a large number of patients. The aim was to compare conventional to intensive antidiabetic treatment, whatever the type or drug, insulin or sulfonyureas. After a ten-year follow-up, glycemic control was better with the intensive treatment, the microvascular complications less frequent by 25%, but the benefit on cardiovascular complications or mortality was modest. Another clinical trial from US shows that a too strict insulin regimen could perhaps have no effect or even opposite to the objectives regarding cardiovascular morbidity. Considering these clinical uncertainties and the need for more definite long-term clinical data, it is justified to conduct additional long-term clinical studies in this field. Furthermore after secondary failure of oral anti-diabetic agents in type 2 diabetic patients, it appears reasonable to discuss the rational for insulin treatment based on an individual assessment, particularly in older diabetics, weighing the whole benefits and risks for a given patient of such an important therapeutic change.

Feasibility and reliability of ankle/arm blood pressure index in preventive medicine.

Despite its potential usefulness for assessing preclinical atherosclerosis and cardiovascular risk, the ankle/arm blood pressure index (AAI) has not yet been the matter of study evaluating its feasibility and reliability by nonspecialist doctors in a general population. This study was planned for two steps. In step 1, the measurement of AAI, (ratio between Doppler systolic pressure at the ankle for each lower limb and the highest value of Doppler systolic pressure of the two upper limbs), should be performed by 50 general practitioners (GPs), 50 social security center physicians, and 50 occupational health physicians in 3,000 male smokers, 40 to 59 years, without clinical cardiovascular disease. In step 2, AAI measurement, coupled with echography-Doppler of iliofemoral arteries, should be repeated by a specialist in all subjects with decreased AAI (<0.90) and the first two subjects with normal AAI recruited in step 1 by each nonspecialist. The number of physicians and subjects participating in step 1 was lower than planned (80 physicians and 962 subjects) with the greatest defect for GPs (six physicians and 35 subjects) and the prevalence of decreased AAI was low (28 subjects). AAI measurement was repeated in step 2 in only 12 subjects with decreased AAI in step 1 and in 124 subjects with normal AAI in step 1. Five of the six subjects with decreased AAI in step 2 also had decreased AAI in step 1 and 123 of the 130 subjects with normal AAI in step 2 also had normal AAI in step 1. As regards echographic stenosis, decreased AAI had a sensitivity of 44% and a specificity of 98%. AAI seems more feasible for occupational health physicians and social security center physicians and AAI is also reliable for nonspecialists previously trained, but its predictive value as regards echographic stenosis is poor in asymptomatic subjects, which may limit its usefulness for detecting preclinical atherosclerosis.

Genetic markers of immunoglobulins and diabetes mellitus in the multiracial population of New Caledonia. The CALDIA Study Group.

GM and KM immunoglobulin allotypes, which are the markers, respectively, of the constant parts of the heavy and the light chains of the IgG1, IgG2 and IgG3 subclasses, have been analysed in diabetic mellitus patients and controls living in New Caledonia. We tested 40 Europeans, 256 Melanesians and 44 Polynesians, as well as their 340 matched controls, in order to search for a genetic susceptibility at those polymorphic loci. All the subjects were tested for G1M (1, 2, 3, 17), G2M (23), G3M (5, 6, 10, 11, 13, 14, 15, 16, 21, 24, 28) and KM (1) by the classical hemagglutination method. The frequencies of GM haplotypes and KM alleles have been estimated by a maximum likelihood method. The results are in favour of no influence of the GM and KM loci. The prevalence of diabetes mellitus varies in the populations of New Caledonia: Polynesians are at much higher risk than Melanesians or Europeans. The GM haplotype distribution differs among ethnic groups; so they provide a useful marker to measure genetic admixture. The higher prevalence of diabetes observed among New Caledonians of European origin compared to the prevalence in Europe may be explained by genetic admixture with neighbouring Pacific populations, notably Polynesians (Asian haplotypes are present at a frequency of 9.4%). So, the genetic admixture should be measured in any genetic epidemiological study.

Risk factors for cortical, nuclear, and posterior subcapsular cataracts: the POLA study. Pathologies Oculaires Liées à l'Age.

The POLA (Pathologies Oculaires Liées à L'Age) Study is a population-based study of cataract and age-related macular degeneration and their risk factors being carried out among 2,584 residents of Sète, southern France, aged 60-95 years. Recruitment took place between June 1995 and July 1997. Cataract classification was based on a standardized lens examination by slit lamp, according to Lens Opacities Classification System III. This paper presents results obtained from cross-sectional analysis of the first phase of the study. In polytomous logistic regression analyses, an increased risk of cataract was found for female sex (cataract surgery: odds ratio (OR) = 3.03; cortical cataract: OR = 1.67), brown irises (cortical, nuclear, and mixed cataracts: OR = 1.61), smoking (cataract surgery: OR = 2.34 for current smokers and OR = 3.75 for former smokers), known diabetes of 10 or more years' duration (posterior subcapsular, cortical, and mixed cataracts and cataract surgery: OR = 2.72), use of oral corticosteroids for at least 5 years (posterior subcapsular cataract: OR = 3.25), asthma or chronic bronchitis (cataract surgery: OR = 2.04), cancer (posterior subcapsular cataract: OR = 1.92), and cardiovascular disease (cortical cataract: OR = 1.96). Decreased risk of cataract was found with higher education (all types of cataract and cataract surgery: OR = 0.59), hypertension (cataract surgery: OR = 0.57), and high plasma retinol levels (nuclear and mixed cataracts and cataract surgery: OR = 0.75 for a 1-standard-deviation increase). Most of the risk factors identified in this study confirm the findings of other studies. The association of cataract with plasma retinol level requires further investigation.

Light exposure and the risk of cortical, nuclear, and posterior subcapsular cataracts: the Pathologies Oculaires Liées à l'Age (POLA) study.

BACKGROUND: Exposure to light may be an important risk factor for the development of cataracts. OBJECTIVE: To present the relation of ambient solar radiation and professional and leisure exposures to light with the different types of cataracts. METHODS: Pathologies Oculaires Liées a l'Age (POLA) is a population-based study on cataract and age-related macular degeneration and their risk factors in 2584 residents of Sète (southern France). Cataract classification was based on lens examination at slitlamp according to Lens Opacities Classification System III. A questionnaire about light exposure was administered. RESULTS: After multivariate adjustment, participants who had higher ambient solar radiation had a 2.5-fold (95% confidence interval [CI], 1.2-5.0), 4.0-fold (95% CI, 2.0-8.0), and 2.9-fold (95% CI, 1.5-5.3) increased risk of cortical and mixed cataract and cataract surgery, respectively. Solar ambient radiation was not significantly associated with posterior subcapsular and nuclear cataracts. By contrast, posterior subcapsular cataracts were significantly associated with professional exposure to sunlight (odds ratio [OR], 1.63; 95% CI, 1.01-2.63) and frequent use of sunglasses (OR, 0.62; 95% CI, 0.43-0.90). Mixed cataract was also associated with professional exposure to artificial light (OR, 3.02; 95% CI, 1.03-8.82). CONCLUSION: Our study further confirms the role of sunlight exposure in the pathogenesis of cataract, in particular in its cortical localization.

Analysis of mortality in French diabetic patients from death certificates: a comparative study.

This study was implemented in France to determine the causes of death in diabetic patients, whether diabetes was mentioned or not on the death certificate, and to assess the underestimation of the prevalence of diabetes at death. Two stratified random samples of death certificates were selected in the national mortality data base. The first included certificates mentioning diabetes as a cause of death (cases). The second, included certificates with no mention of diabetes (controls). For each certificate, a record form was sent to the certifying physician to ascertain diabetes in the first group and to trace unrecorded diabetes in the second group. In case of diabetes, the characteristics of the patient and his disease were collected (age at onset, treatment, complications ...). We obtained complete data for 325 cases and 959 controls. Among cases, 1% of the subjects were not confirmed as diabetic, while almost 10% of the controls were identified as having diabetes. The corresponding ratio of the corrected prevalence at death to that provided by the French statistics was estimated to 4.0 in men and 3.1 in women. Particular features are that 2% of the total diabetic decedents died from acute metabolic complications (diabetic or hyperosmolar coma, acidoketosis, or acute hypoglycemia), and that 33% of the unreported diabetic decedents under 45 died from trauma or poisoning. These results show that in France, the death rates published in the statistics for diabetes dramatically underestimate the impact of diabetes. A high risk of death is linked to this disease, particularly in people aged under 45, a problem that health deciders should address.

Age-related macular degeneration and antioxidant status in the POLA study. POLA Study Group. Pathologies Oculaires Liées à l'Age.

OBJECTIVE: To give the levels of antioxidant nutrients in relation to age-related macular degeneration (AMD). METHODS: Pathologies Oculaires Liees a l'Age is a population-based study on cataract and AMD and their risk factors, carried out on 2584 inhabitants of Sete, France. Age-related macular degeneration was defined by findings from fundus photographs according to an international classification. Biological measurements were taken from fasting blood samples. RESULTS: After multivariate adjustment, plasma alpha-to-copherol levels showed a weak negative association with late AMD (P = .07). Lipid-standardized plasma alpha-tocopherol levels showed a significant negative association with late AMD (P= .003): the risk of late AMD was reduced by 82% in the highest quintile compared with the lowest. Similarly, lipid-standardized plasma alpha-tocopherol levels were inversely associated with early signs of AMD (odds ratio, 0.72 [95% confidence interval, 0.53-0.98]; P=.04). No associations were found with plasma retinol and ascorbic acid levels or with red blood cell glutathione values. COMMENT: These results suggest that vitamin E may provide protection against AMD. Only randomized interventional studies could prove the protective effect of vitamin E on AMD.

Differences between polyunsaturated fatty acid status of non-institutionalised elderly women and younger controls: a bioconversion defect can be suspected.

OBJECTIVE: To evaluate the polyunsaturated fatty acid (PUFA) status in non-institutionalised elderly women and to detect a possible essential fatty acid bioconversion defect. DESIGN AND SUBJECTS: The fatty acid composition of total plasma lipids, plasma triglycerides (TG), cholesterol esters (CE), phospholipids (PL), and erythrocytes was determined by capillary column gas-liquid chromatography in a sample of 200 non-institutionalised healthy elderly women over 75 years of age. The data were compared with those of a control group of 50 young female volunteers aged 20-48 y. RESULTS: In elderly women, the n-6 series precursor, linoleic acid (18:2 n-6), was lower in TG and CE (P = 0.029 and 0.014, respectively). In CE, this fatty acid was highly correlated with vegetable and vegetal fat intakes (P < 0.0001), suggesting a lower dietary supply than in controls. Higher percentages of 16:1 n-7 were found in all the plasma lipid fractions in elderly women, especially in CE (P < 0.0001). The ratios 20:4 n-6/20:3 n-6 and 22:6 n-3/20:5 n-3 were significantly lower in PL from elderly women (P < 0.005 and P < 0.002, respectively), raising the question of the efficiency of the terminal steps of 20:4 n-6 and 22:6 n-3 biosynthesis. Dietary investigations in elderly women indicated that a high dietary protein intake via meat probably contributed to the supply of 20:4 n-6 and thus maintained the status of this fatty acid, despite the suspected altered biosynthesis. CONCLUSION: The PUFA status in the elderly women group could be more fragile and dependent on exogenous supply of long-chain PUFAs than previously suspected.