Risk factors for coronary disease and stroke in previously hospitalized African-Americans with Type 1 diabetes: a 6-year follow-up.

AIMS: To report the 6-year incidence of, and risk factors for, cardiovascular disease (CVD), either coronary disease or stroke, in previously hospitalized African-Americans with Type 1 diabetes mellitus. METHODS: African-Americans (n = 483) with Type 1 diabetes were re-examined as part of a 6-year follow-up. At both visits, patients underwent a structured clinical interview, which included history of either coronary disease or stroke, ocular examination and masked grading of seven stereoscopic fundus photographs, blood pressure measurements, and administration of the Beck Depression Inventory. Biological measurements included blood and urine assays. RESULTS: Of the 483 patients who had a 6-year follow-up, 449 had no evidence of CVD at the baseline examination. Of these 449 patients, 51 (11.4%) developed any CVD-42 (9.3%) coronary disease and 14 (3.1%) a stroke. Six-year incidence of any CVD was significantly associated with older age (P < 0.0001) and longer duration of diabetes (P < 0.0001) at baseline. Multiple logistic regression showed that baseline older age, higher body mass index, higher diastolic blood pressure, proteinuria, retinopathy severity and being depressed were significant and independent risk factors for incidence of any CVD. CONCLUSION: Six-year incidence of CVD is high in previously hospitalized African-Americans with Type 1 diabetes. Risk factors appear to include older age, higher body mass index, higher diastolic blood pressure, proteinuria, retinopathy severity and depression.     

Near-normoglycaemic remission in African-Americans with Type 2 diabetes mellitus is associated with recovery of beta cell function.

AIMS: To prospectively determine the frequency of remission and possible mechanism of beta cell recovery in non-Whites with Type 2 diabetes mellitus in the setting of intensive glycaemic regulation using pharmacological agents. METHODS: Twenty-six consecutive, newly diagnosed African-American, Type 2 diabetic patients presenting primarily for severe hyperglycaemia (31.0+/-12.8 mmol/l) were followed for at least 1 year. Initial hospitalization included treatment with insulin, fluids and electrolytes. Outpatient intensive glycaemic regulation included insulin or glibenclamide, diabetes education and diet that altered nutrient content. Plasma glucose and C-peptide responses to an oral glucose tolerance test and HbA1c were measured at < 14, 15-56 and 57-112 days after presentation. Remission was defined as a HbA1c < or = 6.3% and fasting plasma glucose < 6.9 mmol/l, 3 months after discontinuing all pharmacological agents. RESULTS: Eleven of 26 patients (42.3%) developed remission after a mean of 83 days of pharmacological treatment and remained in remission during follow-up for 248-479 days; one relapsed after 294 days. Fifteen patients who did not develop a remission and were followed for 168-468 days, required continuing pharmacological therapy to be well-controlled. (mean HbA1c = 7.1%). There was no significant difference in age, sex, plasma glucose at presentation, initial glycaemic regulation, final body mass index, magnitude of weight change or pharmacological agents used for treatment between the two groups. Plasma C-peptide response to oral glucose was initially (< 14 days) suppressed in all subjects and subsequently increased. The increase was significantly greater in those who underwent a remission than those who did not. Neither significant weight loss nor severe hypoglycaemia was observed in either group during intensive treatment. CONCLUSIONS: Forty-two per cent of newly diagnosed, unselected African-Americans with Type 2 diabetes, treated intensively using pharmacological agents, education and diet developed near-normoglycaemic remission. Remission was associated with a greater recovery of glucose-stimulated insulin secretion suggesting that therapies directed at promoting beta cell recovery and preservation are potentially useful approaches to the treatment of Type 2 diabetes mellitus.     

Predictors of first stroke in Type 1 diabetes: The Fremantle Diabetes Study.

AIMS: To examine prospectively the relationship between vascular risk factors and stroke in Type 1 diabetes. METHODS: A community-based sample of 126 adult Type 1 patients was recruited between 1993 and 1996 and followed annually for a mean+/-sd of 7.2+/-1.6 years. Cerebrovascular events before and after recruitment were identified from history and examination findings, hospital morbidity data and death notifications. RESULTS: Six patients suffered a first stroke during follow-up, of which five were ischaemic and one a subarachnoid haemorrhage on cranial computed tomography. Patients were subdivided into those with no history of stroke/transient ischaemic attack (TIA) at baseline and no subsequent ischaemic stroke (Group 1, n=114), those with a history of stroke/TIA at baseline (Group 2, n=7), and those with no history of stroke/TIA at baseline but who suffered a first ischaemic stroke during follow-up (Group 3, n=5). Group 1 patients were the youngest, had the shortest diabetes duration and were the least likely to be taking antihypertensive medication or aspirin. Amongst a range of potential baseline predictors of first stroke including glycated haemoglobin, only serum HDL-cholesterol differentiated Group 3 patients (0.69+/-0.17 mmol/l) from those in the other groups (1.26+/-0.42 and 1.28+/-0.45 mmol/l for Groups 1 and 2 respectively, P<0.05). CONCLUSIONS: The present association between low serum HDL-cholesterol and ischaemic stroke patients suggests that aggressive management of dyslipidaemia may protect against cerebrovascular disease in Type 1 diabetes.     

Six-year incidence of lower extremity arterial disease and associated risk factors in Type 1 diabetic African-Americans

Aims To report the 6-year incidence of, and risk factors for, lower extremity arterial disease (LEAD) in African-Americans with Type 1 diabetes mellitus. Methods African-Americans (n = 483) with Type 1 diabetes were re-examined 6 years after an original visit. At both visits, patients underwent a structured clinical interview which included history of amputation or leg angioplasty because of poor circulation in lower extremities; ocular examination; masked grading of seven stereoscopic fundus photographs; and blood pressure measurements. Biological tests included blood and urine assays. Results Of the 483 patients who had a 6-year follow-up, 457 had no LEAD at the baseline examination. Of these 457 patients, 26 (5.7%) developed LEAD over the 6-year follow-up. Six-year incidence of LEAD was significantly associated with baseline older age (P = 0.0002) and longer duration of diabetes (P < 0.0001). Multiple logistic regression analysis showed that baseline longer duration of diabetes, male gender, higher systolic blood pressure, retinopathy severity, and presence of foot ulcers were significant and independent risk factors for incidence of LEAD. Conclusions Blood pressure control and prevention and treatment of foot ulcers may be helpful in reducing the morbidity associated with LEAD in African-Americans with Type 1 diabetes.     

Epidemiology of gestational diabetes mellitus and its association with Type 2 diabetes.

Gestational diabetes (GDM) is defined as carbohydrate intolerance that begins or is first recognized during pregnancy. Although it is a well-known cause of pregnancy complications, its epidemiology has not been studied systematically. Our aim was to review the recent data on the epidemiology of GDM, and to describe the close relationship of GDM to prediabetic states, in addition to the risk of future deterioration in insulin resistance and development of overt Type 2 diabetes. We found that differences in screening programmes and diagnostic criteria make it difficult to compare frequencies of GDM among various populations. Nevertheless, ethnicity has been proven to be an independent risk factor for GDM, which varies in prevalence in direct proportion to the prevalence of Type 2 diabetes in a given population or ethnic group. There are several identifiable predisposing factors for GDM, and in the absence of risk factors, the incidence of GDM is low. Therefore, some authors suggest that selective screening may be cost-effective. Importantly, women with an early diagnosis of GDM, in the first half of pregnancy, represent a high-risk subgroup, with an increased incidence of obstetric complications, recurrent GDM in subsequent pregnancies, and future development of Type 2 diabetes. Other factors that place women with GDM at increased risk of Type 2 diabetes are obesity and need for insulin for glycaemic control. Furthermore, hypertensive disorders in pregnancy and afterwards may be more prevalent in women with GDM. We conclude that the epidemiological data suggest an association between several high-risk prediabetic states, GDM, and Type 2 diabetes. Insulin resistance is suggested as a pathogenic linkage. It is possible that improving insulin sensitivity with diet, exercise and drugs such as metformin may reduce the risk of diabetes in individuals at high risk, such as women with polycystic ovary syndrome, impaired glucose tolerance, and a history of GDM. Large controlled studies are needed to clarify this issue and to develop appropriate diabetic prevention strategies that address the potentially modifiable risk factors.     

Recent advances in treatment of youth with Type 1 diabetes: better care through technology.

While treatment of Type 1 diabetes mellitus (T1DM) in children and adolescents is especially difficult, recent technological advances have provided new therapeutic options to clinicians and patients. The urgency to achieve strict diabetes control and the introduction of new and improved insulin pumps have been accompanied by a marked increase in use of continuous subcutaneous insulin infusion (CSII) therapy in youth with diabetes. Results of clinical outcome studies indicate that CSII provides a safe and effective alternative to multiple daily injection (MDI) therapy, even when employed in a regular clinic setting in a large number of children. The safety and efficacy of CSII is further enhanced by the introduction of lispro and aspart insulin. The sharper peaks and shorter duration of action of these very rapid-acting insulin analogues provides a means to achieve better control of post-prandial hyperglycaemia with less late post-prandial and nocturnal hypoglycaemia. Glargine insulin, a soluble and essentially peakless long-acting insulin analogue, may provide a better basal insulin for MDI regimens, but there are limited published data with this agent in children with T1DM. A number of systems for pulmonary delivery of insulin are in development and preliminary results of Phase III studies have been promising. Like CSII, inhaled insulin allows the child to take bolus insulin doses before each meal without having to take a premeal injection. A major obstacle to effective treatment is that self-monitoring of three to four blood glucose levels a day often misses the marked glycaemic excursions that characterize T1DM in young patients. On the other hand, new continuous glucose sensing systems provide a wealth of data that can be used to optimize basal and bolus therapy, regardless of how insulin is administered. Even more important, we may finally be at the threshold of development of a practically applicable artificial pancreas.     

Preprandial vs. postprandial insulin lispro-a comparative crossover trial in patients with Type 1 diabetes.

AIMS: Administration of bolus insulin after eating may be a useful therapeutic option for some patients. This 6-month, crossover study compared metabolic effects of routine use of preprandial vs. postprandial injection of bolus insulin lispro. METHODS: Thirty-one patients with Type 1 diabetes injected insulin lispro either preprandially or postprandially for a 3-month period followed by the alternate regimen for a further 3 months. HbA1c, fructosamine and eight-point self-determined blood glucose profiles were measured and analysed using an anova model appropriate for a crossover design. RESULTS: Mean HbA1c decreased slightly from baseline with preprandial (-0.15 +/- 0.41%) and increased slightly with postprandial (0.11 +/- 0.48%) insulin lispro so that there was a significant (P = 0.008) difference between treatments in final HbA1c level. Mean fructosamine also decreased slightly with preprandial (-15 +/- 31 micro mol/l) but was almost unchanged (1 +/- 39 micro mol/l) with postprandial insulin lispro. Overall daily blood glucose was not different (P = 0.312) for preprandial compared with postprandial administration. However, mean preprandial glucose was lower (7.5 +/- 2.01 vs. 6.6 +/- 1.22 mmol/l; P = 0.026), whereas mean postprandial glucose was higher (7.7 +/- 1.8 vs. 8.7 +/- 2.1 mmol/l; P = 0.031) with postprandial insulin lispro administration. Mean blood glucose excursions were higher with postprandial compared with preprandial insulin lispro, indicating greater daily fluctuations. No difference in incidence of hypoglycaemia was observed with the two treatment regimens. CONCLUSIONS: Postprandial insulin lispro administration appeared to be an acceptable treatment regimen and may be of benefit in certain situations. However, the benefits of postprandial administration may have to be balanced against poorer glycaemic control with continuous long-term use.     

The short insulin tolerance test lacks validity in adolescents with Type 1 diabetes.

AIMS: The short insulin tolerance test (SITT) has been found to be a simple and valid method for determining insulin sensitivity in healthy adults and patients with Type 2 diabetes. In this study we evaluated the reproducibility and validity of SITT in 16 adolescents with Type 1 diabetes. METHODS: Thirteen patients underwent two SITT and eight patients were examined with both SITT and a euglycaemic hyperinsulinaemic clamp. At the SITT insulin sensitivity was measured from the slope of arterialized blood glucose concentrations determined for 16 min after an intravenous bolus injection of short-acting insulin, 0.1 U/kg body weight, and expressed as glucose disappearance rate (KITT). RESULTS: There was a significant correlation between the insulin sensitivity estimations made at the two SITT (r = 0.73, P = 0.003). The reproducibility was low, however, with a coefficient of variation of 38.7%. KITT showed a strong inverse correlation to the fasting blood glucose concentration (r = -0.74, P < 0.0001). We found no correlation between insulin sensitivity measured by SITT and that measured by the euglycaemic clamp. CONCLUSIONS: We conclude that the short insulin tolerance test cannot be used in adolescent patients with Type 1 diabetes for a simple estimation of insulin sensitivity.     

Treatment satisfaction and psychological well-being with insulin glargine compared with NPH in patients with Type 1 diabetes.

AIMS: To assess satisfaction with treatment and psychological well-being associated with insulin glargine and Neutral Protamine Hagedorn (NPH). Insulin glargine, a new long-acting insulin analogue, provides constant, peakless insulin release following once-daily administration and is associated with fewer hypoglycaemic episodes, despite metabolic control equivalent to that achieved with NPH human basal insulin. METHODS: The Diabetes Treatment Satisfaction Questionnaire (DTSQ) and Well-being Questionnaire (W-BQ) were completed at baseline and at weeks 8, 20 or 28 by 517 patients with Type 1 diabetes participating in a randomized, controlled European trial comparing insulin glargine and NPH. Analysis of covariance was performed on change from baseline scores (main effects: treatment and pooled site; covariate: baseline scores). RESULTS: Treatment satisfaction improved with insulin glargine at all time points, including endpoint, but deteriorated slightly with NPH. These differences were significant throughout the study (change from baseline to endpoint: +1.27 vs. -0.56; P = 0.0001). Outcomes were better with insulin glargine for the DTSQ items, Perceived Frequency of Hyperglycaemia and Hypoglycaemia, with statistically significant differences at week 28 and endpoint for hyperglycaemia (P = 0.0373 and 0.0379) and at week 20 for hypoglycaemia (P = 0.0024). There was no difference in psychological well-being between the treatment groups, with mean scores increasing in both. CONCLUSIONS: Study participants had treatment-independent improvements in General Well-being. Advantages for insulin glargine were seen in significantly improved Treatment Satisfaction throughout the study, together with lower Perceived Frequency of Hyperglycaemia than for patients on NPH, without a significant increase in Perceived Frequency of Hypoglycaemia.     

Survey of glargine use in 115 pregnant women with Type 1 diabetes

Aim To examine pregnancy outcome in women with Type 1 diabetes treated with glargine. Methods Glargine use in pregnancy was surveyed over 2 years in 20 UK obstetric‐diabetes centres. Outcomes, including maternal complications, miscarriage, congenital abnormalities, perinatal morbidity and mortality, were recorded in a standardized format. Results Outcomes on 109 babies from 115 women with Type 1 diabetes were collected. Insulin glargine was used prior to pregnancy in 69% of women, started during pregnancy in 30%, and stopped at booking in one patient. Insulin aspart was the bolus insulin in 45%, lispro in 42% and human soluble in 8% of women. HbA_1c fell from 8.1 ± 0.2% at booking to 6.8 ± 0.1% during the third trimester. Background retinopathy developed in one patient, worsened in seven and laser photocoagulation was required in three women. Preeclampsia occurred in 12%, and 14% of women had more than one episode of severe hypoglycaemia. One hundred and nine babies were live born, with six miscarriages and no neonatal deaths. The mean gestational age was 37.5 weeks, and mean birth weight was 3500 g. Three babies had congenital abnormalities (malformation rate = 28/1000). Neonatal hypoglycaemia was seen in 46% and hyperbilirubinaemia in 22% of babies. No major adverse outcome was noted in a smaller subset of five Type 2 and seven gestational diabetes patients on glargine. Conclusions The use of glargine in Type 1 diabetes during pregnancy was not associated with any unexpected adverse maternal or fetal outcome in this study.     

The complement component C4 in black Americans with Type 1 (insulin-dependent) diabetes mellitus

Summary The complement component C4 variants C4A4, C4B 4 and C4B QO were found to be significantly increased in 64 black patients with Type 1 (insulin-dependent) diabetes compared with 169 black control subjects, yielding relative risks of 3.3, 2.9 and 3.4, respectively. The increased frequencies of C4B 4 and C4B QO in black Type 1 diabetic patients are similar to those found in Caucasoid Type 1 diabetic patients. The data suggest that Type 1 diabetes in black Americans may be partially due to admixture of genes from whites.     

School attendance in children with Type 1 diabetes.

AIMS: To determine whether children with Type 1 diabetes mellitus (DM) miss more school than their non-DM siblings and peers and to identify factors associated with school absenteeism in children with DM. METHODS: School absenteeism data for the 2000-01 school year were obtained for 78 children with DM, 38 non-DM siblings and 118,269 age-matched peers in Toronto, Ontario. Questionnaires and hospital records were utilized to evaluate child-, family- and diabetes-related factors associated with school absenteeism in children with DM. RESULTS: Children with DM missed only slightly, albeit significantly more school than both their non-DM siblings (mean +/-sd: 10.9 +/- 8.9 vs. 8.1 +/- 8.1 days, P < 0.001) and peers (median: 8.8 vs. 5.5 days, P = 0.0005). A multiple regression analysis indicated that school absenteeism in children with DM was associated with their parents' attitudes towards school attendance (P = 0.002), poorer metabolic control (P = 0.006), shorter disease duration (P = 0.006) and a lack of aggressive behaviour (P = 0.02). CONCLUSIONS: With current management strategies, near normal school attendance is a reasonable goal for all children with DM and should be strongly encouraged by parents, educators and health care professionals.     

No evidence for accumulation of insulin glargine (LANTUS): a multiple injection study in patients with Type 1 diabetes.

AIMS: Insulin glargine is a long-acting insulin analogue that is metabolically active for at least 24 h. We investigated the multiple-dose pharmacokinetic properties of insulin glargine to determine whether daily injections lead to the accumulation of circulating insulin levels and a corresponding decrease in blood glucose levels in patients with Type 1 diabetes. METHODS: Fifteen patients using preprandial insulin lispro (mean age 36 +/- 9 years, body mass index 24.6 +/- 2.2 kg/m(2)) completed the study. Each patient's optimal insulin glargine dose was determined during a dose-finding phase. After a washout period, patients were treated over 12 days with a constant daily dose of insulin glargine injected in the abdominal subcutaneous adipose tissue at 22:00 h, and with preprandial insulin lispro. Free serum insulin (FSI) and blood glucose concentrations were assessed hourly after the first, fourth, and eleventh injection, after which patients fasted for 24 h and did not use any other insulin preparation. RESULTS: There were no changes in daily insulin doses during the dose-finding phase (insulin glargine: initial dose 24 +/- 6 IU, mean change 0 +/- 3 IU; insulin lispro: 18 +/- 9 IU, 0 +/- 7 IU). The time course of FSI was comparable on the three pharmacokinetic study days. Notably, the trough FSI at the end of the sampling periods was almost identical (day 1, 79 +/- 56 pmol/l, day 4, 77 +/- 56 pmol/l, day 11, 86 +/- 60 pmol/l). No changes occurred in any of the pharmacokinetic parameters studied. CONCLUSIONS: There is no evidence that insulin glargine accumulates after multiple injections over 12 days. These results indicate that the predetermined dose of insulin glargine will not need to be reduced after commencing treatment because of a risk of accumulation.     

Secular trends, disease maps and ecological analyses of the incidence of childhood onset Type 1 diabetes in Northern Ireland, 1989-2003.

AIMS: To investigate secular trends in the incidence of Type 1 diabetes in Northern Ireland over the period 1989-2003. To highlight geographical variations in the incidence of Type 1 diabetes by producing disease maps and to compare incidence rates by relevant area characteristics. METHODS: New cases of Type 1 diabetes in children aged 0-14 years in Northern Ireland were prospectively registered from 1989 to 2003. Standardized incidence rates were calculated and secular trends investigated. Bayesian methodology was used to produce maps of disease incidence using small geographical areas (582 electoral wards). Ecological analyses were conducted using Poisson regression to investigate incidence rates by area characteristics at a finer geographical subdivision (5022 census output areas). RESULTS: In Northern Ireland during 1989-2003, there were 1433 new cases, giving a directly standardized incidence rate of 24.7 per 100,000 person-years. This incidence rate increased by a mean of 4.2% per annum. Disease maps highlighted higher incidence rates in the predominately rural north-east of the province and lower incidence rates in the urban areas around Belfast in the east and Derry in the north-west of the province. Ecological analysis identified higher incidence in rural areas (P < 0.001), areas with low migration rates (P = 0.002), affluent areas (P < 0.0001), sparsely populated areas (P = 0.0001) and remote areas (P = 0.005). CONCLUSIONS In Northern Ireland the incidence of Type 1 diabetes is increasing. The observed higher incidence in rural, affluent, sparsely populated and remote areas may reflect a reduced or delayed exposure to infections in these areas.     

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem.

Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes.     

Mortality in Israeli Jewish patients with Type 1 (insulin-dependent) diabetes mellitus diagnosed prior to 18 years of age: a population based study

Summary A total of 614 Jewish patients under the age of 18 with Type 1 (insulin-dependent) diabetes mellitus, diagnosed in Israel during the period 1 January 1965 to 31 December 1979, were identified by exhaustive screening of all possible sources. Mortality experience of this cohort was updated to 31 March 1988 through the Central Population Registry and 14 deaths were identified. The ascertainment rate for diagnosed cases as well as for deaths is estimated at about 95%. There was a significantly higher (p<0.001) by 3.2-fold excess mortality relative to the age and sex-adjusted mortality as expected the general Jewish population in Israel. This excess was due to three cause-of-death categories: diabetic ketoacidosis (n = 3; p<0.001), cardiovascular diseases (n – 3; p<0.001) and infections (n = 2; p = 0.03). The rate of malignancies (n = 2), external causes (n = 3) and other general causes (n = 1) did not differ significantly from that expected. During the first 15 years of the disease cumulative mortality resembled that of the general population, with a subsequent steep increase so that by 20 years disease duration, the rate was four-fold higher than expected. This mortality pattern was similar irrespective of age at onset, sex and ethnic group (Ashkenazi vs non-Ashkenazi Jews). A factor contributing to the lack of increase in mortality rate in the first 15 years of Type 1 diabetes may be the comprehensive multidisciplinary treatment approach employed for most juvenile diabetic patients in Israel leading to early referral and an overall better metabolic control.The study was supported by a grant from the NIH — National Institute of Diabetes and Digestive and Kidney Diseases, No. 5 RO1 DK3905-04.     

Mortality of Type 1 (insulin-dependent) diabetes mellitus in Denmark: A study of relative mortality in 2930 Danish type 1 diabetic patients diagnosed from 1933 to 1972

Summary This study included 2930 (1642 male, 1288 female) Type 1 (insulin-dependent) diabetic patients diagnosed before the age of 31 years and between 1933 to 1972. The patients were followed from first admission to Steno Memorial Hospital until death, emigration, or until 1 January 1983. Relative mortality was studied, and the influence of calendar year of diagnosis, diabetes duration, age at diagnosis, current age and sex were studied. Relative mortality decreased continuously during the period, and patients diagnosed after 1956 had a relative mortality 30–40% lower than patients diagnosed from 1933 to 1946. Relative mortality increased with increasing diabetes duration until about 20 years of duration, after which it declined. It also increased with increasing age until 31–40 years. It decreased with increasing age at diabetes onset. Factors like calendar year of diabetes onset, age at diagnosis, current age and sex had no influence on relative mortality within the first 15 years of duration, although the relative mortality increased with diabetes duration. In the interval of 16 to 40 years of diabetes duration, the relative mortality decreased with increasing calendar year of diagnosis and age at diagnosis. In patients with a diabetes duration of more than 40 years, the relative mortality decreased with increasing age and diabetes duration. These results show that the prognosis of Type 1 diabetic patients has improved considerably during the last 40 years. Furthermore, they show that diabetes duration is the most important determinant of relative mortality.     

Relative mortality of Type 1 (insulin-dependent) diabetes in Denmark: 1933–1981

Summary The relative mortality of Type 1 (insulin-dependent) diabetes in Denmark during the period 1933–1981 was studied using a modification of Cox's regression model on the basis of two patient populations, ascertained in different ways and independently of each other. Initial analysis showed that the two groups could be combined completely into one common analysis. Relative mortality was the same for both sexes. The additional variables studied were age at diagnosis, current age, calendar year at diagnosis and calendar time during follow-up. All these interrelated variables were accounted for in the analysis. The analysis showed that relative mortality (a) decreased with increasing age at diagnosis; (b) increased from 1933 to a maximum in about 1965, after which it decreased; (c) increased with increased duration of diabetes to a maximum at 15–25 years, after which it declined.     

Many patients with Type 1 diabetes estimate their prandial insulin need inappropriately

Background: Many factors contribute to the need for prandial insulin in Type 1 diabetes. However, patients’ success in achieving normal postprandial glucose concentration is understudied. The aim of the present study was to determine how often patients with Type 1 diabetes achieve normal postprandial glucose concentrations and to evaluate factors associated with postprandial hypo‐ and hyperglycemia. Methods: Data on food intake, physical activity, insulin administration, and blood glucose concentration were collected using a self‐administered questionnaire from 331 patients with Type 1 diabetes (43% men; mean age 49 ± 12 years; mean diabetes duration 32 ± 13 years). Of these, 179 provided data on blood glucose concentrations measured 110–150 min postprandially. One such meal per patient was randomized for analyses. Results: Hypoglycemia (<4.0 mmol/L), normoglycemia (4.0–7.9 mmol/L), and hyperglycemia (≥8.0 mmol/L) were observed after 23%, 36%, and 41% of meals, respectively. The three postprandial glycemia groups did not differ with respect to the meal composition or the timing of the postprandial blood glucose measurement. In women, postprandial hyperglycemia was associated with shorter diabetes duration and higher preprandial blood glucose concentration, whereas postprandial hypoglycemia was associated with higher physical activity. No single factor explained the postprandial glycemic state in men. Conclusions: A total of 64% of patients estimated their prandial insulin need inappropriately, suggesting that estimation of the optimal prandial insulin dose is not easy, even after a long duration of diabetes.