Carbohydrate counting accuracy and blood glucose variability in adults with type 1 diabetes.

AIMS: Carbohydrate counting is an established approach used by patients with type 1 diabetes to improve their glycemic control. The aims of this study were to evaluate, in real life conditions, the accuracy of meal carbohydrate estimate and its impact on glycemic variability. METHODS: In this cross-sectional study, we observed the ability of 50 adults (48% women) with type 1 diabetes (age: 42.7±11.1 years); diabetes duration: 21.4±12.7 years; HbA1c: 7.2±1.2% (60±10 mmol/mol) to accurately estimate carbohydrates by analyzing 72-h food records and their corresponding 72-h blood glucose excursions using a continuous glucose monitor. RESULTS: The mean meal carbohydrate difference, between the patients' estimates and those assessed by a dietitian using a computerized analysis program, was 15.4±7.8 g or 20.9±9.7% of the total CHO content per meal (72.4±34.7 g per meal). Sixty-three percent of the 448 meals analyzed were underestimated. Greater differences in CHO's estimates predicted higher glycemic variability, as measured by the MAGE index and glucose standard deviation, and decreased time with glucose values between 4 and 10 mmol/L (R²=0.110, 0.114 and 0.110, respectively; P<0.05). CONCLUSION: Inaccurate carbohydrate counting is frequent and associated with higher daily blood glucose variability in adults with type 1 diabetes.

Impact of diabetes on crash risks of truck-permit holders and commercial drivers.

OBJECTIVE: The U.S. and some Canadian government agencies have waived commercial license restrictions for some insulin-using diabetic drivers. However, the U.S. Federal Highway Administration is no longer giving waivers. Scientific evidence to support such regulations has been sparse. This article presents detailed analyses of crash risks for users and nonusers of insulin among diabetic truck-permit holders in Québec, Canada. RESEARCH DESIGN AND METHODS: Diabetic truck-permit holders were group-matched by age to a random sample of healthy permit holders. Data on permits, medical conditions, and crashes involving 13,453 permit holder-years in 1987-1990 were extracted from the files of the public insurer for automobile injuries in Québec. Additional health status data were obtained from the provincial public health insurer. A telephone survey was conducted to collect data on driving patterns and exposure. Risk ratios were estimated using negative binomial regression models. RESULTS: Risk ratios for crashes vary by category of diabetes. Permit holders for single-unit trucks (STs) who are diabetic without complications and not using insulin have an increased crash risk of 1.68 when compared with healthy permit holders of the same permit class. When controlling for risk exposure, commercial drivers with an ST permit and the same diabetic condition have an increased risk of 1.76. Insulin use is not associated with higher crash risk. CONCLUSIONS: The increased crash risk for the group with uncomplicated diabetes not using insulin is a new finding. The lack of consistent increases in crash risks among diabetic commercial drivers with complications or who use insulin may be a "healthy worker effect" masking the real risk, because these licensees have a lower participation rate as professional drivers.

Effect of maternal diabetes on the pattern of selected insulin resistance syndrome parameters in normal glucose tolerant subjects of two Algonquin Indian communities in Quebec.

OBJECTIVE: To determine whether a maternal antecedent with diabetes has an effect on insulin resistance syndrome parameters. RESEARCH DESIGN AND METHODS: We studied 352 Algonquin Indians from Quebec aged at least 15 years who had no personal antecedents with diabetes. Data concerned clinical and biological parameters and the parental antecedents with diabetes. RESULTS: For subjects over > 30 years, fasting insulin and cholesterol levels were significantly higher in the group with a maternal history of diabetes than in the group with a paternal history. Significant differences were observed for serum triglyceride, BMI, and subscapular skinfold thickness when comparing subjects with a maternal history and those with no parental history of diabetes. Blood pressure and fasting glucose did not differ according to parental history. CONCLUSIONS: Subjects of maternal antecedents with diabetes have known risk factors for NIDDM. This study does not identify whether there is a genetic or maternal environmental reason for this association.

Medical conditions and the severity of commercial motor vehicle drivers' road accidents.

In this research we studied the association between commercial motor vehicle drivers' medical conditions and crash severity. Some aspects of medical condition were considered. To our knowledge, no study has ever isolated this association. The severity of a crash was measured by the total number of victims (injured and dead). We estimated nonlinear regression models (specifically, Poisson and negative binomial) which incorporated, simultaneously, information on drivers' characteristics, crash circumstances and health status, in order to isolate the association between health status and crash severity. Our results show that crashes of truck drivers with binocular vision problems and bus drivers with hypertension are more severe than those of healthy drivers. No other medical condition considered in this study was significantly associated with crash severity. Many variables describing crash circumstances were also significant.

Prevalence estimates of diabetes and of other cardiovascular risk factors in the two largest Algonquin communities of Quebec.

OBJECTIVE: To compare the prevalence of non-insulin-dependent diabetes mellitus (NIDDM) in the two largest Algonquin communities of Quebec (Canada) with that of other native groups and to describe the different patterns of NIDDM and other cardiovascular risk markers in these communities (River Desert [RD] and Lac Simon [LS]). RESEARCH DESIGN AND METHODS: The population-based study targeted all residents aged 15 years and older. In the age-group considered here (30-64 years), there were 480 eligible subjects and 299 participants (50.8% in RD and 86.9% in LS). All except those with confirmed diabetes underwent an oral glucose tolerance test. Serum triglyceride and lipoprotein cholesterol levels, blood pressure, body mass index (BMI), and waist-to-hip ratio (WHR) were measured. RESULTS: The age-standardized (world population) prevalence of NIDDM in women was twice as high in LS as in RD (48.6% vs. 23.9%). In men, it was 23.9% in LS and 16.3% in RD. Upper-body obesity followed the same pattern. In contrast, high-risk serum low-density lipoprotein (LDL) and high-density lipoprotein (HDL) cholesterol levels were significantly more prevalent in RD than in LS, particularly among men. The rate of high blood pressure was twice as high in men as in women, with little community differences. When we controlled for age, sex, diabetic, and obesity status, mean fasting serum glucose remained significantly higher triglycerides and LDL cholesterol lower in LS than in RD. There was also an independent community effect on WHR but no on BMI. CONCLUSIONS: The prevalence of NIDDM in LS women reaches the rate observed in Pima Indian women. The observed differences between two Algonquin communities suggest a highly heterogeneous pattern of NIDDM and cardiovascular disease risk factors in Amerindian populations, even within a given tribe and a limited geographic area.

[Diabetes and road safety]. / Diabète et sécurité routière.

The purpose of this study is to analyse the driving habits of a group of diabetic individuals, insulin and noninsulin treated, compared with the driving habits of an equivalent group of individuals in good health. Specific attention is given to the evaluation and management of stress related to driving. The analysis relies mainly upon the answers of 307 persons of both sex on a questionnaire regarding their driving habits and concerning twenty more or less risky behaviors. The diabetic subjects were sampled among the patients of an endocrinology clinic, and the pilot group (in good health) was gathered among the patients from the clinic of a general practitioner. The subjects were aged between 25 and 65. All were in possession of a driving licence and had a driving experience of over two years. The results show, on one hand, that the evaluation of stress related to a risky behavior is associated to the taking of risk at the wheel, and on the other hand, that compared with the other subjects in the study the diabetic subjects had a lesser tendency to taking risks in driving. The subjects avoided the behaviors they judged risky. Beside avoiding dangerous road behaviors, the latter brought special attention to food and relaxation needs and they showed a great alertness towards climatic and road conditions. Finally, they are especially careful in preventing and curing hypoglycaemic states.

Prevalence of non-insulin-dependent diabetes mellitus and impaired glucose tolerance in two Algonquin communities in Quebec.

OBJECTIVE: To assess and compare the prevalence of non-insulin-dependent diabetes mellitus (NIDDM) and impaired glucose tolerance (IGT) in two native Indian communities. DESIGN: Population-based study. SETTING: Two Algonquin communities in Quebec: River Desert and Lac Simon. PARTICIPANTS: All native Indian residents aged at least 15 years were eligible; 621 (59%) of them volunteered to enroll in the study. The participation rate was 49% in River Desert and 76% in Lac Simon. MAIN OUTCOME MEASURES: Fasting blood glucose level and serum glucose level 2 hours after 75-g oral glucose tolerance test, as described by the World Health Organization, in all subjects except those with confirmed diabetes. Other measures included body mass index (BMI), fat distribution and blood pressure. MAIN RESULTS: The age-sex standardized prevalence rate of NIDDM was 19% in Lac Simon (95% confidence interval [CI] 16% to 21%); this was more than twice the rate of 9% in River Desert (95% CI 7% to 11%). The IGT rates were comparable in the two communities (River Desert 5%, Lac Simon 6%). NIDDM and IGT were uncommon under the age of 35 years. Only in Lac Simon was the NIDDM prevalence rate significantly higher among the women than among the men (23% v. 14%); almost half of the women aged 35 years or more had diabetes. In Lac Simon the rate of marked obesity (BMI greater than 30) was significantly higher among the women than among the men (37% v. 19%; p < 0.001); this sex-related difference was not found in River Desert (rates 31% and 23% respectively). Previously undiagnosed NIDDM accounted for 25% of all the cases. NIDDM and IGT were significantly associated with high BMI, sum of skinfold thicknesses and waist:hip circumference ratio (p < 0.001). The subscapular:triceps skinfold ratio, however, did not display such an association, nor did the age-adjusted systolic blood pressure. CONCLUSIONS: The prevalence of NIDDM is high in Algonquin communities and may vary markedly between communities. Although widespread, particularly in women, obesity cannot entirely explain the much higher rate of NIDDM in Lac Simon. Family and lifestyle risk factors, in particular diet and activity patterns, are being analysed in the two communities.

Epidemiology of insulin-using commercial motor vehicle drivers. Major variability of state licensing requirements in the U.S.

OBJECTIVE: Licensing agencies in many areas, including the U.S., prohibit insulin-using individuals from driving CMVs or large trucks. This study examined the debate over the risks of licensing insulin-using individuals to drive CMVs as an occupation, and the variations in regulations of different states. RESEARCH DESIGN AND METHODS: As part of an ongoing review of the regulations governing interstate commerce in the U.S., we surveyed all 50 states and Washington, D.C. to determine the regulations concerning intrastate driving. We received responses from 48 states and D.C., representing 95% of the U.S. population. RESULTS: Only 9 states reported preventing insulin users from acquiring a CMV license, whereas 39 states and D.C. permitted licensing within state boundaries. Of the states allowing insulin users to drive, 26 placed special requirements on CMV licensing. CONCLUSIONS: The results indicate that, despite a standardized U.S. federal law for driving across states, enormous variability exists in the policies for driving within states, ranging from no restrictions to a complete ban on CMV driving for insulin users.

[Diabetes mellitus and pancreatic cancer: a case-control study in greater Montreal, Quebec, Canada]. / Diabète sucré et cancer du pancréas: une étude cas-témoins dans le grand Montréal, Québec, Canada.

In a population-based case-control study of dietary risk factors in French Canadians in Montreal, a total of 179 cases and 239 controls were interviewed between 1984 and 1988. It was found that the frequency of diabetes was almost three times higher in cases of pancreatic cancer (16%) than in the controls (6%), with an Odds Ratio (OR) of 2.52 and a Confidence Interval (CI) of 1.04-6.11. Fifty per cent of the pancreatic cancer cases had this disease before the cancer was diagnosed, compared with 71% of the controls at the time of the study. Those aged 50 years and over accounted for 75% of the cases and 71% of the controls (diabetic subjects); 68% of the cases were treated with a combination of diet and oral hypoglycemic agents compared with 86% of the controls. Insulin was used by 32% of the cases and 14% of the controls. These results suggest that diabetes may play a major role in the etiopathogenesis of pancreatic cancer in this urban population. A lot of controversy remains about the precise role of diabetes, and further studies are needed for a better assessment and understanding of the mechanisms of this association.

Food habits and esophageal cancer: an overview.

Cancer of the esophagus has a more varied geographical distribution and incidence than any other commonly occurring cancer. Its incidence rate is increasing in many countries, especially among males. Esophageal cancer has been found to be associated with the consumption of alcohol and tobacco, particularly when combined, and in the last decade the role of nutrition and diet in the etiology of this disease has attracted worldwide attention. Regions with a large incidence of this disease are generally located in poor parts of the world, and their inhabitants share several dietary characteristics. They subsist on a diet high in starch and almost without fresh fruit or vegetables, eat rapidly without sufficient mastication, and consume many foods (rice gruel) and drinks (tea) at very high temperatures. Hard and scratchy foods also are consumed frequently. In the high-risk region of northern Iran, where the frequency of esophageal cancer is higher among women than men, the main food during pregnancy contains strong black pepper and sharp crushed pomegranate seeds, which irritate the esophagus.

[Exposure to the risk of traffic accidents, a fundamental epidemiological parameter, and one difficult to measure]. / L'exposition au risque d'accident de la route, un paramètre épidémiologique fondamental et difficile à mesurer.

This is a review of the literature dealing with exposure to the risk of traffic accidents. We present the principal definitions of this concept, the different measures of risk exposure, indicators of the risk of traffic accidents, and the advantages and disadvantages of the methods used for the collection of data. The validity of the measure of exposure to risk is analyzed as well. We conclude that while distance travelled is the principal measure of exposure to risk accepted by the research community, it is necessary to use a composite measure which also takes into account the risk associated with the driver.

[Impact of diabetes mellitus on driving safety]. / L'impact du diabète sucré sur la sécurité routière.

Driving ability is controlled by specific regulations. Therefore disabled individuals or those with certain chronic diseases may be affected by these regulations. These latter are based on assumption that the existence and the nature of certain diseases may cause particular hazard; and this could be prevented by introducing certain driving regulations. This hypothesis has not been tested properly, considering the proposed and suspected risk factors. Diabetes mellitus is a good example of the interested medical condition in this field. Review of the literature do not provide adequate information to allow us to conclude whether the insulin treated diabetic person is at higher risk to develop traffic accident, compared with non diabetic individual; and there is no definite explanation whether hypoglycaemia play a causative role in the etiology of traffic accident among insulin treated diabetics. Perhaps the lack of knowledge in this field is due to use of non-standardized methodologies and small sample size studies which make the comparisons difficult. The existing regulations in different countries are based on empirical knowledge and common sense. This often leads to conflictual situations and apparently discriminatory decisions regarding diabetics. Further comparative and prospective studies are needed.

Obesity, hypertension, hyperuricemia and diabetes mellitus among the Cree and Inuit of northern Québec.

In the last thirty years, sociocultural and political changes have profoundly affected the way of life of the Cree and Inuit of Northern Québec. Their health status profile has also changed. This study presents the main results of a health survey performed among the Cree and Inuit in 1982-1984 by a multidisciplinary team. Obesity, arterial hypertension, hyperuricemia and diabetes mellitus while almost unknown in the past, have now been added to the list of Cree and Inuit health problems. Crees have the highest risk for obesity, hypertension and diabetes mellitus. Hyperuricemia for unknown reasons seems more prevalent among the Inuit. Our findings suggest that further in-depth studies of chronic conditions in these communities are needed.

Overview of diabetes mellitus and exercise.

Diabetes mellitus is a common chronic disorder the primary therapeutic principles of which have long been based on the combination of physical activity with appropriate diet. Although exercise in insulin-dependent diabetes mellitus (IDDM) may be associated with metabolic deterioration in the case of lack of adequate provision of insulin and carbohydrate in balanced amounts, the beneficial effects of exercise in diabetes are numerous. Exercise facilitates the utilization of glucose as the main source of energy for contracting muscles and decreases peripheral insulin resistance. Limited epidemiological studies have demonstrated that lack of physical activity may be involved in the epidemic outburst of non-insulin-dependent diabetes mellitus (NIDDM) in some unusual populations. Long-term studies are still needed to show that lifelong physical training and exercise reduce morbidity and mortality in diabetes.