Intensive glucose therapy and clinical implications of recent data: a consensus statement from the Global Task Force on Glycaemic Control.

BACKGROUND: There is compelling evidence showing that achieving good glycaemic control reduces the risk of microvascular complications in people with type 1 and type 2 diabetes. Likewise, there is clear evidence to show that achieving good glycaemic control reduces the risk of macrovascular complications in type 1 diabetes. The UKPDS 10-year follow up suggests that good glycaemic control also reduces the risk of macrovascular complications in type 2 diabetes. Despite this, recent results from ACCORD, ADVANCE and VADT present conflicting results and data from the ACCORD trial appear to suggest that very low HbA(1c) targets (<6.0%) may, in fact, be dangerous in certain patient populations. AIM: To review recent results from ACCORD, ADVANCE and VADT and provide clear guidance on the clinical significance of the new data and their implications for the practising physician treating patients with type 2 diabetes. METHODS: A Pubmed search was used to identify major randomised clinical trials examining the association between glycaemic control and diabetes-associated complications. The data was reviewed and discussed by the GTF through a consensus meeting. The recommendations for clinical practice in this statement are the conclusions of these analyses and discussions. RESULTS: Evidence from ACCORD, ADVANCE, VADT and UKPDS suggests that certain patient populations, such as those with moderate diabetes duration and/or no pre-existing CVD, may benefit from intensive blood glucose control. These trials highlight the benefit of a multifactorial treatment approach to diabetes. However, ACCORD results indicate that aggressive HbA(1c) targets (<6.0%) may not be beneficial in patients with existing CVD and a longer duration of diabetes. CONCLUSIONS: Glycaemic control remains a very important component of treatment for type 2 diabetes and contrasting results from the ACCORD, ADVANCE and VADT should not discourage physicians from controlling blood glucose levels.

Incidence of type 1 diabetes mellitus and associated complications among children and young adults: results from Karnataka Diabetes Registry 1995-2008.

The purpose of this study was to estimate incidence of type 1 diabetes mellitus (T1DM) among children and young adults aged 0-25 years and to assess growth, glycaemic control, complications, risk factors and mortality associated diabetes mellitus,based on prospective registration of patients in Karnataka Diabetes Registry during the period 1995-2008. Complications were determined in subgroups serving as cohorts by screening tests and based on physicians' report. There were 1040 patients (514 boys and 526 girls) registered during the period 1995-2008. The overall incidence/prevalence of T1 DM (per 100,000 persons) was 3.8(0.32/10(5)/year) [males 3.7(0.3110(5)/year) and females 4(0.33/10(5)/year)]. On cross-sectional analysis of different cohorts, 88% (90/102) were below 50th percentile height, 95% (114/120) were <50th percentile of weight. Thirty-nine patients (10.7%) had poor glycaemic control (A1c>9%), The prevalence of different complications were as follows: Neuropathy 5.2% (12/230), retinopathy 8.4% (14/166), nephropathy 8.6% (20/230), hypertension 2.6% (6/230). Hypercholesterolaemia and hypertriglyceridaemia were found in 20.2% (24/119) and 41.7% (48/115) cases respectively and 18.1% (19/105) had low HDL. The percentage of patient with micro-albuminuria, high sensitive C-reactive protein were 29.6% (n=233) and 44.4% (20/45) respectively. Poor glycaemic control, hypertension and duration were strong consistent predictors of all complications. Twenty patients died during the period of which 10 deaths were related to diabetes. Though the incidence of diabetes in the young is low in our population compared to the western population, the burden of diabetes is high due to large population in our country. In spite of our best efforts there are still a huge gap between the standard of care and practice. Majority of type 1 diabetics are not reaching the ideal glycaemic targets.

The burden of diabetes and impaired glucose tolerance in India using the WHO 1999 criteria: prevalence of diabetes in India study (PODIS).

This random multistage cross-sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired glucose tolerance (IGT) in subjects aged 25 years and above in India. The study was carried out in 77 centers (40 urban and 37 rural). 18363 (9008 males and 9355 females) subjects were studied. 10617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 h and 2 h after 75 g of oral glucose. Subjects were categorized as having IGT or DM using the World Health Organisation (WHO) (1999) criteria. The standardized prevalence rate for DM in the total Indian, urban and rural populations was 4.3, 5.9 and 2.7%, respectively. The corresponding IGT rates in the three populations was 5.2, 6.3 and 3.7%, respectively. The urban prevalence of DM and IGT was significantly greater than in the rural population (P < 0.001 in both instances). The prevalence of DM was significantly, more than that of IGT (P < 0.001) within both the rural and urban populations. Type 2 diabetes is a major health problem is India.

The burden of diabetes and impaired fasting glucose in India using the ADA 1997 criteria: prevalence of diabetes in India study (PODIS).

This random multistage cross sectional population survey was undertaken to determine the prevalence of diabetes mellitus (DM) and impaired fasting glycemia/glucose (IFG) in subjects aged 25 years and above in India. The study was carried out in 108 centers (49 urban and 59 rural) to reflect the size and heterogeneity of the Indian population. 41,270 (20,534 males and 20,736 females) subjects were studied. 21,516 (10,865 males and 10,651 females) were from urban areas and 19,754 (9669 males and 10,085 females) from rural areas. Blood samples were taken after a fast of 10-12h and the subjects were categorized as having IFG or DM using the 1997 American Diabetes Association criteria. The age and gender standardized prevalence rate for DM and IFG in the total Indian population was 3.3 and 3.6% respectively (P < 0.001). The standardized prevalence of DM and IFG in urban areas was significantly higher than that for the rural population (urban DM prevalence 4.6% versus rural DM prevalence 1.9%, P < 0.001; urban IFG prevalence 4.8% versus rural IFG prevalence 2.5%, P < 0.001). There was no statistically significant difference in the prevalence between DM (4.6%) and IFG (4.8%) in the urban population. The rural prevalence of IFG (2.5%) was significantly (P <0.001) more than the rural prevalence of DM (1.9%). Type 2 diabetes is a major health problem is India.

Comparing the ADA 1997 and the WHO 1999 criteria: Prevalence of Diabetes in India Study.

This random multistage cross-sectional population survey was undertaken to determine the prevalence of type 2 diabetes mellitus (DM) in subjects aged 25 years and above in India. The study was carried out in 77 centres (42 urban and 35 rural) to reflect the size and heterogeneity of the Indian population. 18,363 (9008 male and 9355 female) subjects were studied. 10,617 (5379 males and 5238 females) were from urban areas and 7746 (3629 males and 4117 females) from rural areas. Blood samples were taken after a fast of 10-12 and 2 h after 75 g of oral glucose. Subjects were categorized as having impaired fasting glycemia (IFG) or DM using the 1997 ADA or having impaired glucose tolerance (IGT) or DM using the 1999 WHO criteria. The age- and gender-standardized prevalence rate for DM using the ADA criteria was 3.6% whilst that using the WHO criteria was 4.3% (P < 0.001). The respective standardized prevalence of DM, using the two criteria was, 4.7 and 5.6%, respectively (P < 0.001) in the urban Indian population and 2.0 and 2.7% (P < 0.02) in the rural Indian population. Using the WHO criteria, 581 subjects were newly diagnosed whilst the ADA criteria newly diagnosed 437 subjects. The respective numbers for the urban population were 425 and 323, and for the rural population were 146 and 114, respectively. The ADA criteria could diagnose 75.2, 76.0 and 73.0% of the subjects who had DM as per the WHO criteria. Of 739 Indian subjects who had IFG, 106 (14.3%) were diagnosed as having DM by the WHO criteria whilst 505 (68.3%) had values compatible with a diagnosis of IGT. Of the 536 urban subjects with IFG, 74 (13.8%) had DM and 350 (65.3%) had IGT using the WHO criteria. Of the 302 rural subjects with IFG, 32 (15.8%) had DM and 155 (76.3%) had IGT using the WHO criteria. 505 (49.9%) of 1012 Indian subjects with IGT as per the WHO criteria had IFG. 350 (47.7%) of 733 urban subjects and 155 (55.5%) of 279 rural subjects with IGT had values compatible with IFG as per the ADA criteria. Type 2 diabetes is a major health problem is India. The use of the ADA criteria would underestimate the prevalence of DM by not diagnosing subjects showing a poor response to a glucose challenge. This along with the discrepancies between subjects showing IGF or IGT could be a challenge to any prevention program.

Role of family in the management of Type-I diabetes: an Indian experience.

The role of the family in the management of Type-I diabetes is gaining recognition. In countries where the adolescent is dependent on the family for medical needs, the family's role is all the more important. At times, when the family is uncooperative, the care of the adolescent is hampered, making psychosocial intervention even more difficult. The following case study illustrates the difficulty encountered while working with a young diabetic belonging to an Indian family. The issues related to parental role and management of diabetes-related problems are discussed.

Behavioural intervention in the management of compliance in young type-I diabetics.

OBJECTIVES: a) To examine the efficacy of a behavioural intervention programme in the management of compliance in young Type I diabetics, b) To examine the efficacy of a behavioural management programme in enhancing metabolic control in young Type I diabetics, c) To examine the effect of behavioural intervention on level of diabetes knowledge and quality of life in young Type I diabetics. METHODS: A total of 40 patients (Experimental group n = 20, Control group n = 20) was selected from local hospitals' pediatric, endocrinology and diabetology units. The experimental group received 15 individual sessions of behavioural intervention, consisting of behavioural counseling for family and significant others, relaxation, diabetes education and specific behavioural and cognitive strategies such as reinforcement, target-setting and cognitive restructuring. Assessment was carried out on various psychological measures as well as the glycosylated hemoglobin test (HbA1), at pre and post treatment periods. RESULTS: The scores of the two groups were compared at post treatment point. Results indicate that there was significant improvement in the experimental group in compliance and metabolic control. There were also significant changes noted in the level of diabetes knowledge as well as the reported quality of life. These changes in compliance and metabolic control were maintained at a three month follow-up period. CONCLUSIONS: Behavioural intervention can be included as an effective adjunct to routine medical care in the management of young Type I diabetics, especially in the management of compliance and metabolic control, enhancement of knowledge and quality of life.

Renal artery stenosis in hypertensive diabetics.

The incidence of atherosclerotic renal artery stenosis was compared in consecutive renal angiography of 28 hypertensive diabetics and 104 hypertensive non-diabetics. Mean age and sex distribution were comparable. Angiographic evidence of atherosclerotic renal artery stenosis was present in 10 diabetics (36 per cent) and 50 non-diabetics (48 per cent). Stenosis was considered hemodynamically significant if the renal vein renin ratio of the involved to uninvolved side was 1.4:1.0 or more. A renal vein renin ratio equal to or more than 1.4 was observed in 4 of 7 diabetics (57 per cent) and 31 of 47 non-diabetics (67 per cent). Fibromuscular hyperplasia was not seen in diabetics but was present in 12 per cent of the non-diabetics. Hypertension was treated surgically and improved in 2 of 3 diabetics (67 per cent) and in 17 of 19 non-diabetics (89 per cent) with angiographic and hemodynamic evidence of renal artery stenosis. In this series the incidence of atherosclerotic renal artery stenosis of physiologic consequence was not significantly different in hypertensive diabetics when compared to hypertensive non-diabetics.