Edited by David S. Cooper, MD, and Catherine D. DeAngelis, MD, MPH
Diabetic ketoacidosis and severe hypoglycemia are acute life-threatening
complications of type 1 diabetes mellitus. In this analysis of prospectively
collected data from a large cohort of children with type 1 diabetes, Rewers
and colleagues found that the incidence of ketoacidosis was 8 episodes per
100 person-years and of severe hypoglycemia, 19 episodes per 100 person-years.
Potentially modifiable risk factors for these complications included underinsurance,
the presence of psychiatric disorders, and extremes of the hemoglobin A1C distribution.
Higher rates of microvascular complications of diabetes mellitus have
been reported for blacks and Hispanics relative to whites. Karter and colleagues
assessed ethnic differences in the incidence of 5 major diabetic complications
in a 3-year longitudinal study of adults with diabetes who had uniform health
care coverage through enrollment in a prepaid health care organization. Patterns
of ethnic differences were not consistent across complications. The incidence
of end-stage renal disease was elevated among ethnic minorities compared with
whites, consistent with previous studies, but rates of the other complications
were similar or lower.
Previous studies suggest that microvascular abnormalities may play a
role in the pathogenesis of type 2 diabetes mellitus. In this report from
the Atherosclerosis Risk in Communities study, a prospective cohort study
of adults aged 49 to 73 years without diabetes, Wong and colleagues found
that retinal arteriolar narrowing as measured on digitized retinal photographs
was independently associated with risk of incident diabetes after a median
follow-up of 3.5 years.
Reduced fetal growth has been associated with subsequent risk for type
2 diabetes mellitus among older adults. In this case-control study of healthy
women completing a first pregnancy, Innes and colleagues found that a woman's
own birth weight was strongly and inversely related to her risk of gestational
diabetes, which is a major predictor of type 2 diabetes.
The CDC Diabetes Cost-effectiveness Group used data from the United
Kingdom Prospective Diabetes Study and other studies to estimate the incremental
cost-effectiveness of 3 medical interventions for patients with type 2 diabetes
mellitus. In a hypothetical cohort of adults aged 25 years or older with newly
diagnosed type 2 diabetes, intensified hypertension control was found to reduce
costs and improve health outcomes compared with moderate hypertension control.
Intensive glycemic control and reduction of serum cholesterol level were also
found to improve health outcomes, but at increased costs.
Therapeutic footwear is often dispensed to patients with diabetes mellitus
to prevent foot ulcers. In this randomized clinical trial, Reiber and colleagues
compared therapeutic shoes with customized cork inserts, therapeutic shoes
with prefabricated polyurethane inserts, and usual footwear in patients with
diabetes who had a history of foot ulcer but who did not have severe foot
deformity. All patients continued to receive regular health care and foot
care. The 2-year cumulative reulceration incidence was low (14% to 17%) and
not significantly different in the 3 study groups.
Research is helping to uncover the molecular miscues that can cause
neural tube defects in infants of diabetic women, and advances in prevention
and therapy may mitigate the risk heart disease carries for patients with
In a randomized crossover trial, daily moderate alcohol intake reduced
fasting insulin levels and improved insulin sensitivity in postmenopausal
women without diabetes.
In the Diabetes Control and Complications Trial, risk of microvascular
complications of type 1 diabetes mellitus was significantly reduced with intensive
therapy compared with conventional therapy. This risk reduction has persisted
through 7 years of observational follow-up even though the difference in mean
HbA1C levels in the 2 former randomized treatment groups progressively
decreased and became nonsignificant.
A review of atherosclerosis and diabetes mellitus stresses the importance
of aggressive treatment of dyslipidemia, hypertension, and hypercoagulability,
in addition to glycemic control, to reduce the risk of cardiovascular morbidity
and mortality in patients with diabetes.
For your patients: Information about diabetes.
This Week in JAMA. JAMA. 2002;287(19):2461. doi:10.1001/jama.287.19.2461