Bone mineral density in patients with longstanding type 1 diabetes: Results from the Canadian Study of Longevity in Type 1 Diabetes

AimIt is currently unclear if longstanding type 1 diabetes (T1D) affects bone mineral density (BMD).MethodsBMD measured by dual-energy X-ray absorptiometry and history of fragility fracture was determined in 75 T1D participants with ≥50 years of diabetes duration and 75 age- and sex-matched non-diabetic controls. BMD T-scores were determined for the lumbar spine (LS), total hip (TH) and femoral neck (FN).ResultsT1D participants had median diabetes duration of 54 [52, 58] years, 41 (55%) were females, and mean A_1c was 7.3 ± 0.8%. T1D females had higher LS T-scores compared to female controls (?0.3 ± 1.2 vs. ?1.1 ± 1.4, p = 0.014), lower FN T-scores (?1.5 ± 1.0 vs. ?1.2 ± 0.9, p = 0.042) and more fragility fractures (7 (17%) vs. 1 (2%), p = 0.021). In T1D, higher A1c was associated with higher adjusted odds of fragility fracture (p = 0.006). T1D males and controls showed no difference in BMD or fractures.ConclusionsThere were no substantial differences in T-score between T1D and matched controls; however, T1D females showed higher BMD at the LS and possibly paradoxically higher fragility fractures compared to matched controls. These findings suggest that lower T-scores may not be associated with a history of fragility fracture in females with longstanding T1D and that other factors should be investigated.     

Sex differences in neuropathy & neuropathic pain: A brief report from the Phase 2 Canadian Study of Longevity in Type 1 Diabetes

To evaluate previous results from a questionnaire-based study, we studied objective neuropathy measures to determine sex differences in the prevalence of neuropathy and neuropathic pain in longstanding type 1 diabetes. Despite better neuropathy measures in females compared to males, we confirmed a trend towards higher neuropathic pain in females.     

Calcaneal bone mineral density in patients with Charcot neuropathic osteoarthropathy: differences between Type 1 and Type 2 diabetes.

AIMS: To measure bone density and neuropathy in both feet in Type 1 and Type 2 patients with unilateral Charcot osteoarthropathy and controls. METHODS: Calcaneal bone density, temperature and vibration thresholds were compared between 17 Type 1 diabetic patients with osteoarthropathy and 47 Type 1 controls and between 18 Type 2 diabetic patients and 48 Type 2 controls. As well as the Charcot foot, the non-Charcot foot was studied to assess osteopenia at onset of osteoarthropathy. RESULTS: In Type 1 diabetes, bone density was reduced in the non-Charcot foot compared with controls [Z-score: -1.7 ({-1.9}-{-1.4}) vs. -0.2 ({-1.1}-{0.5}), P < 0.0001, median (interquartile range)]; but not in Type 2 diabetes [Z-score: 0.15 ({-0.45}-{0.85}) vs. 0.3 ({-0.5}-{0.9}), P = 0.675]. Bone density in the Charcot foot was lower compared with the non-Charcot foot in both Type 1 [Z-score: -2.0 ({-2.8}-{-1.4}) vs. -1.7 ({-1.9}-{-1.4}), P = 0.018] and Type 2 diabetes [Z-score: -0.2 ({-1.4}-{0.1}) vs. 0.3 ({-0.5}-{0.9}), P = 0.001]. In Type 1 diabetes, bone density of the non-Charcot foot was reduced compared with that in Type 2 (P < 0.0001). Body mass index was lower in Type 1 than in Type 2 Charcot patients (P = 0.007). Type 2 patients had high temperature (P = 0.001) and vibration thresholds (P < 0.0001) in the non-Charcot foot compared with Type 2 controls whereas Type 1 patients had a high temperature threshold (P = 0.01) but not vibration threshold compared with Type 1 controls (P = 0.077). CONCLUSION: Bone density was reduced in the non-Charcot foot in Type 1 but not in Type 2 diabetes. Type 2 patients had high temperature and vibration thresholds in contrast to Type 1 patients who had a high temperature threshold only.     

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.     

Sex- and gender-differences in chronic long-term complications of type 1 and type 2 diabetes mellitus in Italy

AimsThis review summarizes the contribution of Italian diabetologists devoted to a better understanding of the complex relationship linking sex/gender and long-term complications of type 1 (T1DM) and type 2 diabetes (T2DM) over the last fifteen years.Data synthesisMicrovascular and macrovascular complications of diabetes show sex- and gender-related differences, involving pathophysiological mechanisms, epidemiological features and clinical presentation, due to the interaction between biological and psychosocial factors. These differences greatly impact on the progression of diabetes and its long-term complications, especially in the cardiovascular, renal and liver districts.ConclusionA better knowledge of such sex- and gender-related characteristics is required for a more precise patient phenotypization, and for the choice of a personalized antihyperglycemic treatment. Despite such mounting evidence, current diabetes clinical guidelines do not as yet adequately consider sex/gender differences.     

Gender differences in diabetes self-care in adults with type 1 diabetes: Findings from the T1D Exchange clinic registry

Aims

To evaluate gender differences in diabetes self-care components including glycemic, blood pressure and lipid control, utilization of diabetes technologies and acute diabetes complications in adults with type 1 diabetes.

Evidence of pancreatic neuropathy and neuropathic pain in hereditary chronic pancreatitis

Increased neural density and neural hypertrophy are characteristic features of pancreatic neuropathy in chronic pancreatitis. Here, we present the extraordinary case of prominent pancreatic neuropathy in a 21-year-old female patient with hereditary chronic pancreatitis and intractable pain who underwent total pancreatectomy. The histopathological analysis demonstrated remnant pancreatic tissue which was only composed of prominent intrapancreatic nerves and fibrosis, without any visible remaining functional pancreatic parenchyma. These histological alterations, including nerve hypertrophy and increased neural density, are known for different aetiologies of chronic pancreatitis, e.g. alcoholic, idiopathic and tropic pancreatitis. However, this is the first report of a patient with hereditary chronic pancreatitis demonstrating the characteristic features of pancreatic neuropathy and neuropathic pain.     

Racial differences in incidence of juvenile-onset Type 1 diabetes: epidemiologic studies in southern California

Summary We have studied the epidemiologic characteristics of insulin-dependent (Type 1) diabetic patients aged 0–19 in a city (San Diego, southern California, USA) characterized by an impressive racial diversity and especially mild and constant climatic conditions. Ascertainment was through retrospective review of medical records in 19 hospitals. For the 3 years 1978–1981 the mean annual incidence of diabetes was 7.3 cases/100,000, with no statistical difference between the sexes. The observed incidence rates in the various ethnic groups was significantly different from expected (p<0.03), with an excess of cases among Caucasians and fewer than expected cases among Mexicans, Blacks and Orientals. There was no identifiable seasonal trend. Some of the clinical char acteristics at diagnosis differed between the sexes: males were slightly older (9.3±5.2 years versus 8.8±3.9 for females), had a shorter duration of diabetes-related symptoms and a higher frequency of infections both at the time of diabetes diagnosis and in preceding months. Females tended to have a higher frequency of Type 1 diabetes in first-degree relatives. This study documents for the first time that, among multiple racial groups living in the same environment, Caucasians are at the highest risk of developing juvenile-onset Type 1 diabetes.     

Clustering of microvascular complications in Type 1 diabetes mellitus

Aims

To describe to what extent microvascular complications exhibit clustering in persons with Type 1 diabetes, and to assess whether the presence of one complication modified the strength of the association between the other two.

A Study of Spermatozoal Motility in Type 1 Diabetes Mellitus

The aim of the study was to examine an aspect of male fertility in patients with Type 1 diabetes mellitus (n = 17) compared to healthy control subjects (n = 16) using parameters of sperm motility, measured using a computerized image analysis system (the Hamilton Thorn Research HTM-2030 Motility Analyzer), as indicators of potential fertility. Within the diabetic group no correlations were found between sperm motility and age, age of onset of diabetes, duration of diabetes or glycated haemoglobin. When the diabetic and control groups were compared, track speed, path velocity, progressive velocity, and lateral head displacement were not significantly different, whereas linearity and linear index, measures of straightness of swimming, were significantly greater in the diabetic subjects (59.2% vs 69.8%, p = 0.0005 and 76.4% vs 83.6%, p= 0.0016, respectively). We conclude that diabetic men, in the absence of complications, do not appear to be at a disadvantage in terms of sperm motility compared to healthy individuals.     

Dissecting the genetics of Type 1 diabetes: relevance for familial clustering and differences in incidence

A combination of genetic and environmental factors is most likely the cause of Type 1 diabetes. Results from twin data, familial clustering of the disease and difference in incidence according to ethnicity infer the presence of specific disease genes. The genetic component of Type 1 diabetes cannot be classified according to a classical model of inheritance but is due to an interaction between different genes and environmental factors. The major genes are within the HLA region that are responsible for 40% of the genetic susceptibility, although other genes are important (non-HLA genes). To date, more than 10 specific loci have been localized on different chromosomes. The gene involved has been characterized only for two of such loci, IDDM1 and IDDM2, while in the other cases the presence of some susceptibility genes can be envisaged and their identification represents the goal of genetic research in coming years. Fine mapping of the loci will certainly increase our understanding of the genetics of Type 1 diabetes; the limitation in detecting some of the remaining genes by linkage studies can be overcome by association studies. That is possible via the collection of a large number of affected families (over 1000) in homogeneous populations. © 1998 John Wiley & Sons, Ltd.     

Indications of Low Sex Hormone Binding Globulin (SHBG) in Young Females with Type 1 Diabetes,and an Independent Association to Microalbuminuria

Sex hormone binding globulin (SHBG) is normally decreased during puberty and inversely related to insulin resistance. Microalbuminuria is rare before puberty in Type 1 diabetes implicating that sex hormones may contribute to its development. We investigated SHBG levels in young females with >5 years of Type 1 diabetes, and the association to microalbuminuria. Ten diabetic females with, and 15 without microalbuminuria, and 17 healthy controls in pubertal stage 4–5 were compared regarding anthropometric data, fasting serum levels of SHBG, testosterone, insulin, insulin-like growth factor-1 (IGF-1), lipids and lipoproteins. Multiple regression analyses were performed to study variables with independent influences on SHBG and albumin excretion rate (AER), respectively, in Type 1 diabetes. SHBG was lower and testosterone/SHBG ratio higher in normoalbuminuric females with diabetes than in controls. This was further emphasized in diabetic patients with microalbuminuria. IGF-1 was lower in Type 1 diabetes than in controls, and significantly decreased in microalbuminuric as compared to normoalbuminuric diabetic patients. IGF-1 was only correlated to SHBG in healthy controls. In Type 1 diabetes, applying stepwise multiple regression analysis, insulin dose, BMI, and HbA_1c had a significant and independent inverse influence on SHBG (r² = 0.77, p < 0.001). With log AER as the dependent variable, low SHBG, low IGF-1, HbA_1c, and age added to the regression (r² = 0.65, p = 0.004), whereas BMI, insulin dose and blood pressure did not. In conclusion, SHBG is decreased in young females with Type 1 diabetes, influenced by increased insulin requirements, BMI and HbA_1c. In turn, low SHBG seems to be independently associated to elevated AER in these patients. Prospective studies are necessary to confirm our results.     

Type 1 diabetes in the Maltese Islands

The prevalence of Type 1 diabetes in Malta was estimated by identifying all cases aged less than 32 years by the end of 1987 who had attended the island's principal diabetic clinic. The age-adjusted prevalence rate for 0-19 year olds was 110.3 per 100,000 (girls 126.2 (n = 65), boys 95.3 (n = 52]. The mean annual incidence, during the period 1980-1987, in 0-19 year olds was 13.3 per 100,000 (n = 113, girls 14.1 and boys 12.6). Males developed Type 1 diabetes 2.1 years later than females (13.7 +/- 6.9 (+/- SD) vs 11.6 +/- 6.7 years). The commonest age of onset was 10 to 14 years. The peak period of onset occurred during the cooler months of November to February. The incidence rates are close to those in Nordic countries and indicate that Type 1 diabetes in Malta is underestimated.     

Dermatoglyphics in Type 1 Diabetes Mellitus

Although fingerprints and handprints are widely used in criminology, it is only recently that this approach has been applied to the field of medical and genetic diagnoses. In order to investigate dermatoglyphics in Type 1 diabetes mellitus, quantitative characteristics of fingers and palms (ridge count and main line indices) as well as qualitative parameters such as digital and interdigital patterns, the position of the palmar axial triradii and main line courses were analysed in 88 male and 108 female Type 1 diabetic patients and compared with data from 100 male and 99 female normal controls. Type 1 diabetic patients show a lower third finger ridge count (p < 0.05) and a-b ridge count (p < 0.001) and higher transversality of the main lines as indicated by the main line index value (p < 0.001) or the ending of the main line A in a specific sector 5, 5′, and 5′ (p < 0.001) compared with controls. In addition, diabetic patients show higher frequency of palmar axial t' and t' triradii (p < 0.001) and a lower frequency of ‘true’ patterns in the fourth interdigital and thenar area (p < 0.001) than controls. By multivariate analysis of quantitative and qualitative variables a predictive value of 78.6% and 77.3%, respectively, for male, and 81.4% and 82.2%, respectively, for female Type 1 diabetic patients was found. In conclusion, dermatoglyphics seem to be an interesting tool for genetic studies related to Type 1 diabetes.     

Psychosocial factors and diabetes-related outcomes following diagnosis of Type 1 diabetes in adults: the Edinburgh Prospective Diabetes Study.

AIMS: To examine prospectively the relationships between psychosocial variables and diabetes-related outcomes in adults with newly diagnosed Type 1 diabetes. METHODS: A total of 84 adults (48 male) with a median (range) age of 30.8 (17-51) years with newly diagnosed Type 1 diabetes were recruited for the study. Shortly after initial diagnosis each participant's personality, cognitive ability, and recent psychiatric distress were assessed. At 4 months (n = 69) and at 12 months (n = 66) after diagnosis diabetes-related outcomes were measured, including each respondent's knowledge of diabetes, satisfaction with diabetes treatment and diabetes-related quality of life. Glycated haemoglobin (HbA1c) was recorded at each clinic attendance. RESULTS: Social class (Spearman's correlation r = -0.30 and -0.28, respectively, P < 0.05) and scores on the National Adult Reading Test (r = 0.38 and 0.36, respectively, P < 0.01) were consistently associated with knowledge of diabetes at 4 months and at 12 months after diagnosis. Hierarchical regression revealed that alcohol consumption recorded at diagnosis and knowledge of diabetes at 4 months were independent predictors of glycaemic control at 12 months (adjusted r2 = 0.16). Total scores on the Diabetes Treatment Satisfaction Questionnaire (DTSQ) at 12 months were significantly predicted by age at diagnosis (adjusted r2 = 0.08). High neuroticism at diagnosis was consistently associated with poorer self-reported diabetes quality of life at 4 months and at 12 months after diagnosis (rs between -0.30 and -0.39, P < 0.05). CONCLUSIONS: Long-standing psychosocial factors have a significant influence on self-reported outcomes during the 12 months following diagnosis of Type 1 diabetes but may not be reliable predictors of glycaemic control. Further follow-up is necessary to determine the longer-term predictors of objective (e.g. glycaemic control) and subjective (e.g. quality of life) indicators of coping in people with diabetes.     

Clinical and Metabolic Characteristics of Type 1 and Type 2 Diabetes: An Epidemiological Study From the Närpes Community in Western Finland

Clinical and metabolic characteristics of all known Type 1 and Type 2 diabetic patients in a well-defined area in Western Finland are described. Retrospective data from the time of diagnosis and follow-up data were examined. Overall prevalence of diabetes was 25.4 cases per 1000 population. Patients were defined as having Type 1 or Type 2 diabetes based upon early insulin requirement and C-peptide levels. Applying these criteria 84% of the patients had Type 2 diabetes. Onset before the age of 40 years was observed in only 3% of Type 2 diabetic patients. This age limit therefore had a sensitivity of 97% and a specificity of 90% in correctly predicting Type 2 diabetes. At diagnosis, hypertension was observed in 2% of Type 1 and in 75% of Type 2 diabetic patients; the corresponding numbers at follow-up were 6 and 63%. At investigation, 27% of Type 1 and 22% of Type 2 diabetic patients had microalbuminuria. Retinopathy was observed in only 12% of Type 2 compared with 54% of Type 1 diabetic patients. The presence of retinopathy was associated with longer diabetes duration both among Type 1 and Type 2 diabetic patients. A significant decrease in C-peptide concentration was observed in Type 2 diabetic patients with increasing diabetes duration. The data therefore suggest that Type 2 diabetes is associated with a deterioration of beta-cell function with time.     

Type 1 Diabetes and Driving Experience: an Eight-year Cohort Study

The driving habits of 250 drivers with Type 1 diabetes were reviewed 8 years after a previous assessment. At least 45 patients had died and 18 patients could not be traced. A postal questionnaire of the 187 survivors elicited a response from 89%. Fifty-six patients (34%) still held an unrestricted driving licence, demonstrating that a significant proportion of diabetic drivers had not declared diabetes to the licensing authority and/or their motor insurer and continued to ignore the statutory regulations. Fewer patients held Heavy Goods Vehicle licences than 8 years previously. Twenty-four patients had ceased driving as their driving skills had diminished with advancing age and ill health. This was a voluntary decision by all but two patients whose driving licences had been revoked. Thirty-nine patients admitted to a total of 55 road traffic accidents since 1979; 9 accidents (16%) were attributed to hypoglycaemia. Although dependent on patients' honesty and the accuracy of recall, the disclosed accident rates of 4.9 per million miles driven for male drivers and 6.3 per million miles for female drivers are comparable to the accident rate of a non-diabetic driving population of similar age.