Ketoacidosis occurs in both Type 1 and Type 2 diabetes— a population‐based study from Northern Sweden

Aims To determine the occurrence of diabetic ketoacidosis (DKA) in adult Type 2 and Type 1 diabetic patients in Northern Sweden and to determine whether DKA presents with a different clinical picture in Type 2 compared with Type 1 diabetic subjects. Methods All adult patients from a hospital catchment area in Northern Sweden with diagnosed DKA episodes during 1997–2000 were included in a retrospective study. Medical records and laboratory reports were analysed. Results During the years 1997 to 2000, the average annual incidence rate for DKA was 5.9 per 100 000 adult inhabitants. Twenty‐five patients developed DKA, eight (32%) had Type 2 diabetes, while 17 (68%) had Type 1 diabetes. Type 2 diabetic patients with DKA were older and had higher levels of C‐peptide than Type 1 diabetic patients. On admission because of DKA, a similar degree of hyperglycaemia was present in Type 1 and Type 2 patients. Metabolic acidosis was more severe in Type 1 compared with Type 2 diabetic patients. In 50% of the Type 2 diabetic patients, diabetes was diagnosed at the episode of DKA. Conclusions DKA occurs in Caucasian Type 2 diabetic patients within a Swedish population. Although the frequency of DKA is much higher in Type 1 diabetic patients, Type 2 diabetes may account for as much as one‐third of the overall DKA cases.     

Incidence and trends of childhood Type 1 diabetes worldwide 1990–1999

Aims To examine incidence and trends of Type 1 diabetes worldwide for the period 1990–1999. Methods The incidence of Type 1 diabetes (per 100 000/year) was analysed in children aged ≤ 14 years from 114 populations in 112 centres in 57 countries. Trends in the incidence of Type 1 diabetes were analysed by fitting Poisson regression models to the dataset. Results A total of 43 013 cases were diagnosed in the study populations of 84 million children. The age‐adjusted incidence of Type 1 diabetes among 112 centres (114 populations) varied from 0.1 per 100 000/year in China and Venezuela to 40.9 per 100 000/year in Finland. The average annual increase in incidence calculated from 103 centres was 2.8% (95% CI 2.4–3.2%). During the years 1990–1994, this increase was 2.4% (95% CI 1.3–3.4%) and during the second study period of 1995–1999 it was slightly higher at 3.4% (95% CI 2.7–4.3%). The trends estimated for continents showed statistically significant increases all over the world (4.0% in Asia, 3.2% in Europe and 5.3% in North America), except in Central America and the West Indies where the trend was a decrease of 3.6%. Only among the European populations did the trend in incidence diminish with age. Conclusions The rising incidence of Type 1 diabetes globally suggests the need for continuous monitoring of incidence by using standardized methods in order to plan or assess prevention strategies.     

Chronic complications and mortality in community‐based patients with latent autoimmune diabetes in adults: the Fremantle Diabetes Study

Aims To compare (i) the prevalence and incidence of chronic complications and (ii) cardiac and all‐cause mortality in community‐based patients with latent autoimmune diabetes in adults (LADA) with those in Type 2 diabetic patients without antibodies to glutamic acid decarboxylase (GAD). Methods Of the 1294 patients with clinically‐defined Type 2 diabetes recruited to the longitudinal, observational Fremantle Diabetes Study between 1993 and 1996, 1255 (97%) had GAD antibodies measured at baseline. Complications were ascertained using standard criteria in patients returning for annual assessments until November 2001. Data on hospital admissions and mortality were available to the end of June 2006. Cox proportional hazards modelling was used to determine independent predictors of first occurrence of complications and cardiac and all‐cause mortality. Results Forty‐five (3.6%) subjects had LADA. Compared with the GAD antibody‐negative patients, they had a similar prevalence and incidence of coronary heart (P = 0.48 and 0.80, respectively) and cerebrovascular (P = 0.64 and 0.29) disease and cardiac and all‐cause mortality (P = 0.62 and 0.81, respectively). There was also a similar prevalence and incidence of retinopathy (P = 0.22 and 0.64, respectively) and neuropathy (P = 0.25 and 0.95), but microalbuminuria was less frequent both at baseline and during follow‐up in the LADA subgroup in unadjusted models (P = 0.046) and after adjustment for other risk factors (P = 0.014 and 0.013). Conclusions Except for a lower prevalence and incidence of nephropathy, LADA patients have a similar risk of complications and death to patients with clinically‐diagnosed Type 2 diabetes without GAD antibodies. Cardiovascular risk factor management in LADA should, therefore, be as intensive as that for GAD antibody‐negative patients.     

Trends in physician‐diagnosed osteoarthritis incidence in an administrative database in British Columbia,Canada, 1996–1997 through 2003–2004

Objective

Prevalence of osteoarthritis (OA) is expected to increase due to population aging. However, there is little information on the trends in the incidence of OA over time. The purpose of this study was to describe changes in physician‐diagnosed OA incidence rates between 1996–1997 and 2003–2004 in British Columbia (BC), Canada.

Methods

We used data on all visits to health professionals and hospital admissions covered by the Medical Services Plan of BC (population ～4 million) for the fiscal years 1991–1992 through 2003–2004. Rates were standardized to the BC population in 2000. We used 2 definitions of OA: 1) at least 1 visit or hospitalization with a diagnostic code for OA, and 2) at least 2 visits or 1 hospitalization with a code for OA. Incidence rates were calculated with a 5‐year run‐in period to exclude prevalent cases.

Results

Between 1996–1997 and 2003–2004, crude incidence rates of OA based on definition 1 increased from 10.5 to 12.2 per 1,000 in men and from 13.9 to 17.4 per 1,000 in women. The age‐standardized rates did not change in men and increased from 14.7 to 16.7 per 1,000 in women. Incidence rates based on definition 2 were almost 50% lower, but the trends were similar.

Conclusion

We observed an increase in the incidence of OA in both men and women due to population aging and an additional increase in women beyond the effect of aging. These trends have important implications for public health and provision of health services to this very large group of patients.     

Addressing insulin resistance in Type 1 diabetes

Type 1 diabetes is recognised to include an element of insulin resistance. Insulin resistance is an independent risk factor for the development of macro‐ and microvascular complications of Type 1 diabetes and may also contribute to the development of the disease. This understanding comes at a time when the incidence of Type 1 diabetes appears to be rising and the public health burden from its vascular complications is high. A variety of safe and efficacious manoeuvres are available to redress insulin resistance in Type 2 diabetes. So far however, clinical trials addressing insulin resistance in Type 1 diabetes have been small with only short periods of follow‐up. Regardless, these trials have yielded promising results. This review examines the evidence for insulin resistance in the pathophysiology of Type 1 diabetes and its complications, the problems associated with its measurement, and summarizes the trials aimed at reducing insulin resistance in Type 1 diabetes. This includes a meta‐analysis of controlled trials of adjuvant metformin in Type 1 diabetes.     

Childhood body mass index (BMI), breastfeeding and risk of Type 1 diabetes: findings from a longitudinal national birth cohort

Aims To perform a longitudinal analysis of the association between childhood body mass index (BMI) and later risk of Type 1 diabetes, controlling for socio‐economic status, birthweight, height in early and late childhood, breastfeeding history and pubertal status. Methods Analysis of the 1970 British Birth Cohort, followed up at age 5, 10 and 30 years (n = 11 261). Data were available on birthweight, breastfeeding; height, weight, pubertal status, socio‐economic status at age 10 years; self‐report data on history of diabetes (type, age at onset) at age 30 years. Cox proportional hazards models were used to examine relations of childhood growth, socio‐economic status and breastfeeding history to the incidence of Type 1 diabetes between 10 and 30 years of age. Results Sixty‐one subjects (0.5%) reported Type 1 diabetes at 30 years of age; 47 (77%) reported onset ≥ age 10 years. Higher BMI z‐score at 10 years predicted higher risk of subsequent Type 1 diabetes (hazard ratio 1.8, 95% confidence interval 1.2 to 2.8, P = 0.01) when adjusted for birthweight, pubertal status, breastfeeding history and socio‐economic status. Repeating the model for childhood obesity, the hazard ratio was 3.1 (1.0, 9.3; P = 0.05). Birthweight, breastfeeding, height growth and pubertal timing were not associated with incidence of Type 1 diabetes. Conclusions Higher BMI in childhood independently increased the risk of later Type 1 diabetes, supporting suggestions that obesity may provide a link between Type 1 and Type 2 diabetes. This supports observations of a rise in Type 1 diabetes prevalence. Reduction in childhood obesity may reduce the incidence of Type 1 as well as Type 2 diabetes.     

An association between Type 2 diabetes and α1‐antitrypsin deficiency

Aims α₁‐Antitrypsin (AAT) is a serine protease inhibitor which recently has been shown to prevent Type 1 diabetes development, to prolong islet allograft survival and to inhibit pancreatic B‐cell apoptosis in vivo. It has also been reported that Type 1 diabetic patients have significantly lower plasma concentrations of AAT, suggesting the potential role of AAT in the pathogenesis of Type 1 diabetes. We have investigated whether plasma AAT levels are altered in Type 2 diabetes. Methods The study included patients with Type 2 diabetes (n = 163) and non‐diabetic control subjects matched for age, sex and smoking habits (n = 158) derived from the population‐based Malmö Diet and Cancer study. Plasma samples were analysed for AAT concentration and phenotype and serum glucose, insulin, C‐reactive protein and lipid levels were measured. Glycated haemoglobin was also measured. Results In the diabetic group, the women had higher mean plasma AAT levels than men (P < 0.05). The mean plasma AAT levels did not differ between diabetic and control subjects. However, the number of individuals with low AAT levels (< 1.0 mg/ml) was 50% higher in the diabetic group (P < 0.05) and the frequency of AAT deficiency genotypes was 50% higher (NS) in diabetic compared with control subjects. In the group of diabetic patients with AAT < 1 mg/ml, AAT directly correlated with systolic blood pressure (P = 0.048) and inversely correlated with waist–hip ratio (P = 0.031). Conclusions Our results provide evidence that deficiency of AAT may be associated with an increased risk of developing Type 2 diabetes.     

A multinational,multi‐centre,observational, cross‐sectional survey assessing diabetes secondary care in Central and Eastern Europe (DEPAC Survey)

Aims The objective of this study was to assess diabetes care in outpatient diabetes clinics in the Czech Republic, Estonia, Hungary, Latvia, Lithuania, Poland, Slovakia and Slovenia. Methods Questionnaires for each randomly enrolled patient were completed by an endocrinologist or diabetologist. Data concerning age, sex, diabetes duration, diabetes type, treatment type, glycated haemoglobin (HbA_1c), total cholesterol (TC), low‐density lipoprotein cholesterol (LDL‐C), triglycerides (TG) and high‐density lipoprotein cholesterol (HDL‐C), blood pressure (BP) and short‐ and long‐term diabetes complications were recorded. Questionnaires were analysed centrally for each country and stratified for Type 1 diabetes (T1D), Type 2 diabetes (T2D) and other types of diabetes. Results Data on 10 950 individuals were analysed (mean population age 56.2 years; females 52%; T1D 22.9%; T2D 75.3%; mean time from diagnosis 11 years). Patients with HbA_1c within target (< 6.5%): T1D 13.1%, T2D 21.4%; for TC levels (< 4.5 mmol/l): T1D 37%, T2D 20%; for TG levels (< 1.7 mmol/l): T1D 78%, T2D 44%; for HDL‐C (> 1.1 mmol/l): T1D 81%, T2D 60%; for LDL‐C (< 2.5 mmol/l): T1D 36%, T2D 23%; for BP (< 130/80 mm Hg): T1D 42%, T2D 9%. The prevalence of severe hypoglycaemia (within the last 6 months) was 12% in T1D and 2% in T2D. Prevalence of diabetic ketoacidosis was 0.3–6.6%, blindness 0.15–1.3% and diabetic nephropathy 19–42%. Conclusions The data show the current quality of care and potential areas for improvement. The quality of care is generally comparable with that in Western Europe.     

Psychological distress and risk of pre‐diabetes and Type 2 diabetes in a prospective study of Swedish middle‐aged men and women

Aims To determine the role of psychological distress as a predictor of pre‐diabetes and Type 2 diabetes. Methods This cohort study comprised 2127 Swedish middle‐aged men and 3100 women with baseline normal glucose tolerance measured by oral glucose tolerance test. At follow‐up 8–10 years later, 245 men and 177 women had pre‐diabetes [impaired fasting glucose (IFG), impaired glucose tolerance (IGT) and IFG + IGT] and Type 2 diabetes was detected in 103 men and 57 women. Baseline psychological distress was measured by an index of five questions concerning anxiety, apathy, depression, fatigue and insomnia. Odds ratios (ORs) were estimated for pre‐diabetes and Type 2 diabetes in association with total psychological distress. In addition, ORs of the single‐item questions were calculated. Results In men, adjusted ORs (95% confidence interval) in the highest index group of psychological distress compared with the lowest group were 1.9 (1.2–2.8) and 2.2 (1.2–4.1) for pre‐diabetes and Type 2 diabetes, respectively. Corresponding estimates in women were 1.2 (0.7–2.1) and 0.5 (0.2–1.2). In the middle symptoms groups, adjusted ORs in men were 1.1 (0.8–1.4) for pre‐diabetes and 1.2 (0.7–2.0) for Type 2 diabetes and in women 1.8 (1.1–3.0) and 0.7 (0.3–1.4). When analysed separately, the associations with each of the five single factors were similar. Conclusions The results indicate that psychological distress, including symptoms of anxiety, apathy, depression, fatigue and insomnia, increases the risk of pre‐diabetes and Type 2 diabetes in Swedish middle‐aged men. Increased risks were not present in women, except for pre‐diabetes in the middle index group.     

The clinical utility of C‐peptide measurement in the care of patients with diabetes

C‐peptide is produced in equal amounts to insulin and is the best measure of endogenous insulin secretion in patients with diabetes. Measurement of insulin secretion using C‐peptide can be helpful in clinical practice: differences in insulin secretion are fundamental to the different treatment requirements of Type 1 and Type 2 diabetes. This article reviews the use of C‐peptide measurement in the clinical management of patients with diabetes, including the interpretation and choice of C‐peptide test and its use to assist diabetes classification and choice of treatment. We provide recommendations for where C‐peptide should be used, choice of test and interpretation of results. With the rising incidence of Type 2 diabetes in younger patients, the discovery of monogenic diabetes and development of new therapies aimed at preserving insulin secretion, the direct measurement of insulin secretion may be increasingly important. Advances in assays have made C‐peptide measurement both more reliable and inexpensive. In addition, recent work has demonstrated that C‐peptide is more stable in blood than previously suggested or can be reliably measured on a spot urine sample (urine C‐peptide:creatinine ratio), facilitating measurement in routine clinical practice. The key current clinical role of C‐peptide is to assist classification and management of insulin‐treated patients. Utility is greatest after 3–5 years from diagnosis when persistence of substantial insulin secretion suggests Type 2 or monogenic diabetes. Absent C‐peptide at any time confirms absolute insulin requirement and the appropriateness of Type 1 diabetes management strategies regardless of apparent aetiology.     

Prevalence of known diabetes in German adults aged 25–69 years: results from national health surveys over 15 years

Aims The few studies examining the secular trend in diabetes prevalence in Germany have yielded conflicting results. Therefore, using nationally representative samples of adults, we investigated whether the prevalence of known diabetes has changed over 15 years. Methods Study participants were 25‐ to 69‐year‐old residents participating in nationally representative health surveys performed in the following time periods: 1990–1992, 1997–1999, 2002–2003, 2003–2004 and 2004–2005. Prevalences of diabetes, standardized to the population structure of 2004, and trends over time were assessed for the total study population as well as by gender and other diabetes‐associated factors. Results Between 1990–1992 and 2002–2005, no statistically significant trend in the total (5.16 and 5.34%, P trend = 0.68) or sex‐specific diabetes prevalence (men: 5.43 and 5.73, P trend = 0.62; women: 4.88 and 4.95%, P trend = 0.94) was observed. For each time period, prevalence rose substantially with increasing age, increasing body mass index, lower sporting activity and lower education. Conclusions Our findings reflect no temporal increase in the total prevalence of known diabetes in German adult men and women. However, prevalence estimates were relatively high when compared with other European studies and call for continued efforts for the prevention and management of diabetes.     

Diabetes in South Asians

Economic, dietary and other lifestyle transitions have been occurring rapidly in most South Asian countries, making their populations more vulnerable to developing Type 2 diabetes and cardiovascular diseases. Recent data show an increasing prevalence of Type 2 diabetes in urban areas as well as in semi‐urban and rural areas, inclusive of people belonging to middle and low socio‐economic strata. Prime determinants for Type 2 diabetes in South Asians include physical inactivity, imbalanced diets, abdominal obesity, excess hepatic fat and, possibly, adverse perinatal and early life nutrition and intra‐country migration. It is reported that Type 2 diabetes affects South Asians a decade earlier and some complications, for example nephropathy, are more prevalent and progressive than in other races. Further, prevalence of pre‐diabetes is high, and so is conversion to diabetes, while more than 50% of those who are affected remain undiagnosed. Attitudes, cultural differences and religious and social beliefs pose barriers in effective prevention and management of Type 2 diabetes in South Asians. Inadequate resources, insufficient healthcare budgets, lack of medical reimbursement and socio‐economic factors contribute to the cost of diabetes management. The challenge is to develop new translational strategies, which are pragmatic, cost‐effective and scalable and can be adopted by the South Asian countries with limited resources. The key areas that need focus are: generation of awareness, prioritizing health care for vulnerable subgroups (children, women, pregnant women and the underprivileged), screening of high‐risk groups, maximum coverage of the population with essential medicines, and strengthening primary care. An effective national diabetes control programme in each South Asian country should be formulated, with these issues in mind.     

The association of physical activity and depression in Type 2 diabetes

Aims Physical inactivity and depressed mood are both associated with a higher likelihood of diabetes‐related complications; the association between physical activity and depressed mood in Type 2 diabetes has not been reviewed previously. We have reviewed (i) the strength of this association and (ii) the impact of depression‐specific management and physical activity interventions on mood and activity levels in overweight adults with Type 2 diabetes. Methods Studies published between January 1996 and September 2007 were identified (Ovid ‐medline , Psych‐ Info and embase ) using pertinent search terms (keyword/title). Results Of the 12 studies included (10 cross‐sectional, two trials), most employed a standardized questionnaire for depressed mood but only one item for physical activity. In adults with Type 2 diabetes, the inactive are 1.72 to 1.75 times more likely to be depressed than the more active; the depressed are 1.22 to 1.9 times more likely to be physically inactive than the non‐depressed. Two randomized trials demonstrated that a depression management programme improved mood, but only one demonstrated increased physical activity. Conclusions Studies to date suggest an association between depressed mood and physical inactivity in adults with Type 2 diabetes, although objective measures of physical activity have not been employed. Depression‐specific management may improve mood and possibly activity. A trial comparing the impact of depression‐specific management compared with exercise intervention on depressed mood and activity in Type 2 diabetes is justified.     

Hypoglycaemia in insulin-treated Type 2 diabetes: frequency,symptoms and impaired awareness

Aims Hypoglycaemia is considered to be less common in people with insulin-treated Type 2 diabetes than in Type 1 diabetes. A retrospective survey was made of 215 people with insulin-treated Type 2 diabetes to quantify the frequency and nature of hypoglycaemia experienced. Methods The frequencies of mild (self-treated) and severe (required assistance) hypoglycaemia during the preceding year were estimated retrospectively. The usual symptoms of hypoglycaemia and state of awareness of hypoglycaemia were scored using validated questionnaires and any history suggestive of impaired hypoglycaemia awareness was documented. Results In this cohort, 157 (73%) had experienced hypoglycaemia since commencing insulin, the frequency of which increased with duration of diabetes and of insulin therapy and was inversely related to current HbA_1c (all P < 0.05). During the preceding year, 32 individuals (15%) had experienced severe hypoglycaemia, with an estimated incidence for the entire group of 0.28 episodes/patient/year. Principal components analysis revealed two underlying symptom groups (autonomic and neuroglycopenic), similar to those reported previously by young adults with Type 1 diabetes, but the total symptom score declined with advancing age. Of the 157 with a history of hypoglycaemia, the 13 (8%) individuals who gave a history of impaired awareness of hypoglycaemia had experienced a ninefold higher incidence of severe hypoglycaemia than those with normal awareness, and reported experiencing mainly neuroglycopenic symptoms. Conclusions While the overall frequencies of mild and severe hypoglycaemia were lower in insulin-treated Type 2 diabetes than have been reported previously in Type 1 diabetes, the risk of hypoglycaemia was greater with increasing duration of diabetes and of insulin therapy. Although impaired awareness of hypoglycaemia was uncommon, it was associated with a higher incidence of severe hypoglycaemia. Diabet. Med. 20, ***–*** (2003)     

Latent autoimmune diabetes in adults (LADA) in South Wales: incidence and characterization

Aim To define the incidence and characteristics of latent autoimmune diabetes in adults (LADA). Methods We estimated the incidence of LADA by examining the incidence of Type 2 diabetes and calculating the proportion that were antibody positive. The incidence of Type 2 diabetes was calculated by analysis of computer records of 35 out of 36 general practices in Swansea. In addition, thirty‐two practices participated in recruiting people with Type 2 diabetes to have glutamic acid decarboxylase (GAD) antibody testing. Results The crude proportion of Type 2 patients testing positive for GAD antibodies (GADA) was 4.0% (28/683). This figure did not change when we analysed only the practices that tested more than 60% of all eligible patients. In these practices, 79% (387/487) of all eligible patients were GADA tested and 14/387 [3.6% (95% confidence interval: 2.1–6.1%)] were classified as having LADA. This gives an incidence of LADA of 9 per 100 000 (95% confidence interval: 4.4–17.8 per 100 000) people per year registered with a general practitioner. Patients testing positive for GADA were more likely to have a lower body mass index, other antibodies, to present with acute symptoms and to have higher glycated haemoglobin. Conclusions This is the first study of the incidence of LADA in primary care. People with LADA make up a significant proportion of people with apparent Type 2 diabetes. Patients with LADA are likely to be symptomatic, have poorer glycaemic control and have other autoimmune antibodies.     

The prevalence of coronary heart disease in Type 2 diabetic patients in Italy: the DAI study

Aims Type 2 diabetes is associated with at least a twofold increase in risk of coronary heart disease (CHD). We aimed to estimate the prevalence of CHD in the population of Type 2 diabetics cared for by the Italian network of outpatient diabetic units. Methods The DAI ( D iabetes and Informatics study group, Italian A ssociation of Diabetologists, and I talian National Institute of Health) study is a multicentre cohort study of patients with Type 2 diabetes. Patients were classified as having CHD if they had: (i) a history for hospital admission for either an acute myocardial infarction (AMI) or angina; (ii) a positive ECG for prior AMI or angina; (iii) a positive history for coronary artery bypass graft; or (iv) a positive history for percutaneous transluminal coronary angioplasty. Results A cohort of 19 468 patients was analysed: 3157 patients had CHD. The majority of events (80%) had occurred after the diagnosis of diabetes and were considered in the CHD prevalence estimate. The prevalence of CHD, adjusted by age and sex, was 9.9%: 11.0% male and 9.0% female. Angina without AMI occurred in 1306 patients; this condition was more frequent in females while a documented AMI was more frequent in males. Therapeutic procedures were performed more frequently in males. A positive association with CHD was found for gender, age at visit, duration of diabetes, hypertension, relatives with CHD, tryglicerides and microvascular complications. Conclusions The prevalence of CHD in this cohort is lower than previously reported; nevertheless, patients attending the diabetic care units may not be fully representative of the general diabetic population in Italy. Revascularization is less frequent in females than in males; microvascular complications and a worse metabolic control are significantly associated with CHD.     

Serum Th1 (CXCL10) and Th2 (CCL2) chemokine levels in children with newly diagnosed Type 1 diabetes: a longitudinal study

Aims Cell‐mediated immunity and pro‐inflammatory cytokines are implicated in the pathogenesis of Type 1 diabetes. The aim of this study was to investigate whether circulating chemokines involved in T‐helper 1 (CXCL10) and T‐helper 2 (CCL2) autoimmunity are increased in children with Type 1 diabetes at onset and follow‐up. Methods Serum CXCL10 and CCL2 were measured in 96 children with newly diagnosed Type 1 diabetes, 59 age‐matched first‐degree relatives of diabetic children and 40 age‐matched non‐diabetic children with no family history of diabetes. In the diabetic children, an additional serum sample was obtained a median of 16 months after diagnosis. Results Serum CXCL10 levels were significantly higher in Type 1 children than in relatives or control children (P < 0.001); 44.7% of patients had a serum CXCL10 level ≥ 2 standard deviation above the mean value of the control group vs. 3.4% of relatives (P < 0.0001). In contrast, serum CCL2 levels were similar in patients, relatives and control subjects. In the Type 1 diabetic patients at follow‐up, CXCL10 was significantly reduced vs. baseline (P = 0.01), while CCL2 did not change. Conclusions In children with newly diagnosed Type 1 diabetes, raised serum CXCL10 and normal CCL2 concentrations signal a predominant T‐helper 1‐driven autoimmune process, which shifts toward T‐helper 2 immunity over the first 1–2 years from diagnosis.     

The locus of control in patients with Type 1 and Type 2 diabetes managed by individual and group care

Aims The locus of control theory distinguishes people (internals) who attribute events in life to their own control, and those (externals) who attribute events to external circumstances. It is used to assess self‐management behaviour in chronic illnesses. Group care is a model of systemic group education that improves lifestyle behaviour and quality of life in patients with Type 1 and Type 2 diabetes. This study investigated the locus of control in Type 1 and Type 2 diabetes and the possible differences between patients managed by group care and control subjects followed by traditional one‐to‐one care. Methods Cross‐sectional administration of two questionnaires (one specific for diabetes and one generic for chronic diseases) to 83 patients followed for at least 5 years by group care (27 Type 1 and 56 Type 2) and 79 control subjects (28 Type 1 and 51 Type 2) of similar sex, age and diabetes duration. Both tools explore internal control of disease, the role of chance in changing it and reliance upon others (family, friends and health professionals). Results Patients with Type 1 diabetes had lower internal control, greater fatalistic attitudes and less trust in others. Patients with either type of diabetes receiving group care had higher internal control and lower fatalism; the higher trust in others in those with Type 1 diabetes was not statistically significant. The differences associated with group care were independent of sex, age and diabetes duration. Conclusions Patients with Type 1 diabetes may have lower internal control, fatalism and reliance upon others than those with Type 2 diabetes. Receiving group care is associated with higher internal control, reduced fatalism and, in Type 1 diabetes, increased trust in others.     

Medical strategies to reduce amputation in patients with Type 2 diabetes

Lower extremity amputation is a common and disabling complication of Type 2 diabetes. Whilst the introduction of specialist multidisciplinary teams has led to a reduction in the incidence of lower extremity amputation in some centres, the overall prevalence of diabetes‐related amputation has actually increased in recent decades. The aetiology of diabetes‐related amputation is complex, with neuropathy, macrovascular and microvascular disease contributing significantly. Ulceration, previous amputation, increasing diabetes duration and poor long‐term control of glycaemia and lipids are important risk factors for amputation in populations with diabetes. Major randomized intervention trials of blood glucose‐lowering or anti‐hypertensive therapies in populations with diabetes have shown limited reductions in neuropathy and/or macrovascular disease, and no benefit on amputation rates. In contrast, a recent analysis from the Fenofibrate Intervention and Event Lowering in Diabetes (FIELD) study showed a significantly reduced rate of minor, but not major amputations in patients with Type 2 diabetes treated with fenofibrate. Mechanistic studies are clearly needed to understand the basis of this benefit.