Patients overtest to a huge degree. Doctors encourage this and need to steer away from it

Type II diabetes is a multifactorial problem. However, self blood-glucose monitoring (SBGM) is the single most expensive aspect of diabetes care to the State. Patients overtest to a huge degree. Doctors encourage this and need to steer away from it, said Prof Donal O’Shea, Consultant Endocrinologist at St Vincent’s Hospital.

For decades, the diagnosis of diabetes was based on plasma glucose criteria — either the fasting plasma glucose (FPG) or the two-hour value in the 75g oral glucose tolerance test (OGTT). It is no longer necessary to measure glucose to make a diagnosis of diabetes, Prof O’Shea said.

Since last year, the American Diabetes Association has recommended using the A1C test to diagnose diabetes, with a threshold of ≥6.5 per cent. The established glucose criteria for the diagnosis of diabetes remain valid as well.

NICE recommends metformin as an option for first-line glucose-lowering therapy where blood glucose is inadequately controlled using lifestyle interventions alone.

Metformin and the thiazolidinediones (TZDs such as pioglitazone) act on the liver to reduce hepatic glucose production. They act to some extent on muscle and fat lipolysis. Type II diabetes is almost a condition of fat failure. TZDs particularly affect fat function.

“Paradoxically, an average patient starting on pioglitazone can put on two kilos and their hbA1c may improve by 0.6 per cent,” Prof O’Shea said. With metformin, vitamin B12 needs to be watched. There is concern about acidosis in patients when they are sick in hospital.

The glucagon-like peptide-1 (GLP-1) analogues, the inhibitors of dipeptidyl peptidase 4, (DPP-4 inhibitors) and the sulphonylureas are effective in the area of insulin secretion. There is sometimes concern about hypos with sulphonylureas. Clearly, long-term cardiovascular mortality is an issue with hypos.

There are two incretins, known as glucose-dependent insulinotropic peptide (GIP) and glucagon-like peptide-1 (GLP-1). Both incretins are rapidly deactivated by an enzyme called dipeptidyl peptidase 4 (DPP4). In type II diabetes, GIP no longer modulates glucose-dependent insulin secretion. This is detrimental to β-cell function, especially after eating. However, compounds have been developed that activate the GLP-1 receptor with a view to improving insulin secretion. The incretin mimetic exenatide is a long-acting agonist of the GLP-1 receptor. The incretin enhancer sitagliptin is a DPP4 inhibitor.

Incretins are going to dominate the field of diabetes over the next five years, Prof O’Shea said. These gastrointestinal hormones stimulate insulin release. Insulin has functions other than in relation to blood sugar. It helps regulate the immune system. It has been shown to be cardioprotective and also to lower blood pressure.

GLP acts centrally in regulating appetite. GLP has a function in relation to many problems which arise in relation to pathogenesis. GLP-1 has a half-life of about a minute.

The active compound GLP-1 (7-36) is very quickly broken down by DPP-4 into the inactive compound GLP-1 (9-36). Incretins, such as exenatide (Byetta) and liraglutide (Victoza) may be given in type II diabetes. Alternatively, the enzyme that breaks down incretin hormones can be blocked. The DPP-IV inhibitors include Januvia (sitagliptin), Onglyza (saxagliptin) and Eucreas — a combination of vildagliptin and metformin.

Lantus, Levemir, NovoRapid and Humalog are analogues of insulin. They have benefits in terms of convenience. All of these agents are used and they all confer a benefit to the A1c — and to cardiovascular and microvascular profiles. Use of rosiglitazone has reduced.

Lowering A1C to below or around 7 per cent has been shown to reduce microvascular and neuropathic complications of diabetes and, if implemented soon after the diagnosis of diabetes, is associated with long-term reduction in macrovascular disease.

The landmark UKPDS trial of type II diabetes observed a 16 per cent reduction in cardiovascular complications (combined fatal or nonfatal myocardial infarction [MI] and sudden death) in the intensive glycaemic control arm. After 10 years of follow-up, the UKPDS showed that for participants originally randomised to intensive glycaemic control — compared with those randomised to conventional glycaemic control — there were long-term reductions in MI (15 per cent with sulfonylurea or insulin as initial pharmacotherapy and 33 per cent with metformin as initial pharmacotherapy). There were also reductions in all-cause mortality (13 per cent and 27 per cent respectively). As is the case with microvascular complications, it may be that glycaemic control plays a greater role before macrovascular disease is well developed.

Aspirin therapy may be considered as a primary prevention strategy in those with type II diabetes who are at increased cardiovascular risk.

Hypertension is a common comorbidity of diabetes, affecting the majority of patients, with prevalence depending on type of diabetes, age, obesity, and ethnicity. Hypertension is a major risk factor for both CVD and microvascular complications. In type II diabetes, hypertension usually coexists with other cardiometabolic risk factors.

In all, 60 per cent of diabetic patients will be on blood pressure medications. There is an argument in diabetes about whether blood pressure management, rather than glycaemic management, should be pre-eminent. The UKPDS study proved that if blood pressure could be controlled, patients did much better.

Patients with more severe hypertension (systolic blood pressure ≥140 or diastolic blood pressure ≥90mmHg) at diagnosis or follow-up should receive pharmacologic therapy in addition to lifestyle therapy. Multiple drug therapy (two or more agents at maximal doses) is generally required to achieve blood-pressure targets. Lifestyle change may reduce the need for blood pressure medications.

The American Diabetes Association says that treatment should include an angiotensin converting enzyme (ACE) or an angiotensin II receptor blocker (ARB). A thiazide diuretic may also be prescribed. Outcome data on renin inhibitors in diabetes patients are due out in 2012. “I leave alpha blockers as a last-line agent,” Prof O’Shea said.

The American Diabetes Association recommends that bariatric surgery may be considered for adults with BMI >35 kg/m2 and type II diabetes

Remission possible with surgery

Gastric reduction surgery, either gastric banding or procedures that involve bypassing, transposing or resecting sections of the small intestine — when part of a comprehensive team approach — can be an effective weight-loss treatment for severe obesity. The American Diabetes Association recommends that bariatric surgery may be considered for adults with BMI >35 kg/m2 and type II diabetes. This is especially the case if the diabetes or associated co-morbidities are difficult to control with lifestyle and pharmacologic therapy.

Lifelong remission from diabetes is possible with bariatric bypass surgery. “Some manipulation of hormones may be involved,” said Connolly Hospital Endocrinologist Dr John McDermott. Although small trials have shown the glycaemic benefit of bariatric surgery in patients with type II diabetes and BMI of 30–35 kg/m2, there is currently insufficient evidence to generally recommend surgery in patients with BMI under 35kg/m2.

Bariatric surgery has been shown to lead to near or complete normalisation of glycaemia in between 55-95 per cent of patients with type II diabetes, depending on the surgical procedure.

“People appear to improve straight after surgery, before they have lost weight. GLP analogues are released from the gut in vivo,” Dr McDermott said.

Patients with type II diabetes who have undergone bariatric surgery need life-long lifestyle support and medical monitoring.

A meta-analysis (H. Buchwald et al. Am J Med 2009) of studies of bariatric surgery involving 3,188 patients with diabetes reported that 78 per cent had remission of diabetes (normalisation of blood glucose levels in the absence of medications) and that the remission rates were sustained in studies that had follow-up exceeding two years. Remission rates tend to be lower with procedures that only constrict the stomach, and higher with those that bypass portions of the small intestine. Additionally, there is a suggestion that intestinal bypass procedures may have glycaemic effects that are independent of their effects on weight, perhaps involving incretins.

One randomised controlled trial (Dixon JB, JAMA 2008) compared adjustable gastric banding to ‘best available’ medical and lifestyle therapy in subjects with type II diabetes diagnosed less than two years before randomisation and with BMI of 30–40 kg/m2. In this trial, 73 per cent of surgically-treated patients achieved ‘remission’ of their diabetes, compared with 13 per cent of those treated medically.

Integrated care pathways needed

Currently, one in 20 of the Irish population has type II diabetes. Our obesity epidemic is resulting in dramatic annual increases in this prevalence. The Expert Advisory Group in Diabetes in its 2007 report recognised the need for a new model of care for people with type II diabetes. This integration across primary, secondary and tertiary care requires agreed clinical guidelines.

Dr Velma Harkins of the Irish College of General Practitioners, the National Clinical Lead for Diabetes Prof Richard Firth and Dr John Devlin of the Department of Health published guidelines in regard to diagnosis, targets for clinical care and the interventions that are appropriate at each stage of the disease. “Type II diabetes is a progressive disease with worsening glycaemia over time,” Dr Harkins reported. “Therefore, the addition of medications is the rule, not the exception, if treatment goals are to be met.”

Metformin is contraindicated in those with renal impairment, those at risk of sudden deterioration of renal function and end-stage cardiac and hepatic failure. Long-acting, once-daily sulphonylureas may be useful where concordance with therapy is a suspected problem.

The GLP-1 receptor agonist exenatide is approved for use in type II diabetes as combination therapy in patients unable to achieve adequate control on metformin and/or sulphonureas.

DPP-4 inhibitors such as sitagliptin and vildagliptin are approved as add-on therapy to metformin. The DPP-4 inhibitors are administered orally once daily.

People who drink less than half a litre of water each day might be a good group for targeted diabetes prevention interventions, a large study suggests.

The French study of more than 3,500 people without diabetes found those who drank less than a litre of water each day were at an increased risk of dangerously high glycaemic levels.

The study authors said the results did not prove the association was causal, but suggested they might indicate a group that should be targeted for preventative measures.

Only including patients who had normal glycaemic levels at the start of the study, and then examining them every three years for almost a decade, they found about 550 people were hyperglycaemic during the study and 200 developed diabetes.

Those who reported consuming less than half a litre of water each day were at a 56 per cent increased risk of becoming hyperglycaemic compared to those who consumed between one-half and one litre of water. A similar trend was found among those who developed diabetes during the study, but the small numbers meant the results were not significantly different.

The associations remained after controlling for multiple metabolic risk factors and for consumption of sugary drinks and alcohol.

“This indicates that identification of individuals with a [water intake of less than half a litre] may be widely relevant to target preventative interventions regarding the metabolic risk,” the study authors wrote in the journal Diabetes Care.
Diabetes Care 2011; doi: 10.2337/dc11-0652

Neither vitamin D intake nor 25(OH) D levels are linked with the risk of islet autoimmunity (IA) or progression to type I diabetes in young children, research shows, contrary to some previous studies.

Vitamin D intake and 25(OH)D levels were measured periodically in 198 children who had developed IA during follow-up in the DAISY cohort of 2,644 US infants and young people. This included 128 patients who had plasma 25(OH) D levels assessed at nine months of age.

Neither variable was found to be linked with increased risk of IA, after adjusting for family history of type I diabetes, HLA-DR3/4, DQB1*0302 genotype and ethnicity, the authors noted in Diabetologia.

The study measured autoantibodies at nine, 15 and 24 months of age. Vitamin D intakes were assessed by food frequency questionnaires of parents for children aged 2-9, and of the children themselves when they reached 10.

The authors acknowledged that their findings were “somewhat contradictory” to previous epidemiological studies that suggested a protective effect of vitamin D supplementation in infancy on risk of type I diabetes.

“Our study, which uses a powerful combination of prospectively collected reports of vitamin D intake and a biomarker of vitamin D status, does not support an association between a child’s usual vitamin D intake or 25(OH)D levels… and the risk of IA or progression to type I diabetes,” they concluded.

Additional hypotheses that remained to be tested included the exact role of supplementation during infancy, and whether only very high levels of vitamin D were protective — or conversely, only extremely low levels were a risk, they wrote.

Diabetologia 2011 DOI: 10.1007/s00125-011-2278-2

Monogenic diabetes may soon be easier to distinguish from other forms of diabetes with a simple C-reactive protein test, researchers have said.

The European group had previously shown that HNF1A mutations — the commonest form of monogenic diabetes (HNF1A-MODY) — were associated with substantial CRP reductions.

Now, in a large multicentre study, they have found high-sensitivity CRP (hsCRP) testing can help reliably identify patients with HNF1A-MODY.

The results are based on analysis of CRP levels from over 1,500 patients including 457 with HNF1A-MODY, 404 with GCK-MODY, 54 with HNF4A-MODY and 582 with type II diabetes. Patients with HNF1A-MODY had significantly lower hsCRP levels compared with those with type II diabetes and the other subtypes, the study found.

Writing in Diabetologia, the authors said their study established hsCRP as “by far the most robust clinical biomarker identified to date for the diagnosis of diabetes subtypes”.

“Given the modest costs and wide availability, high-sensitivity C-reactive protein could translate rapidly into clinical practice, considerably improving diagnosis rates in monogenic diabetes,” they wrote.

High-sensitivity CRP had sufficient sensitivity and specificity to facilitate more precise targeting of molecular diagnostic testing, they concluded.
Diabetologia 2011; doi: 10.1007/s00125-011-2261-y.

HbA1c levels should be used to classify CVD risk in patients with diabetes rather than assuming they are ‘CHD risk equivalent’, a study suggests.

Using CVD risk calculators that incorporated HbA1c improved prediction compared with current risk calculators – especially among females, the study of almost 25,000 men and women with diabetes found.

The authors said the results of their study were consistent with previously published studies, suggesting that not all diabetic patients were at high risk of future vascular events.

The results might also be helpful in light of ongoing discussion around treatment choices for diabetic patients for prevention of CVD, including the use of statins and aspirin, they said.

“The use of HbA1c levels as part of overall CVD risk scores may improve predictive ability in diabetic patients, whose HbA1c levels are routinely measured in clinical practice,” the study authors wrote in the Archives of Internal Medicine.

An accompanying editorial said that despite several limitations, such as the size of the study and the use of coronary revascularisation as an event, there was “little doubt” that the findings were true.

“Allowing downward reclassification for some diabetic individuals, using a risk equation that included an indicator variable for diabetes and/or HbA1c measurements, should improve the overall accuracy of 10-year CVD risk prediction,” Dr Mark Pletcher of the University of California wrote.

However, he added, what was really important was that risk-prediction algorithms guided clinicians to make the best clinical decisions about prevention interventions for their patients: decisions that were likely to improve their health.

Furthermore, he asked, would it really benefit diabetes patients with low or medium short-term risk to withhold statins?

“As guideline committees grapple with whether to endorse using HbA1c measurement for diabetic patients … they should also consider the more general issue of how to translate CVD risk discoveries more quickly into better population health,” he said. “Updating guidelines once per decade is not conducive, by itself, to rapid translation,” he concluded.

Archives of Internal Medicine 2011; doi:10.1001.

New research shows a direct link between keeping HbA1c levels in a safe range and keeping out of hospital.

Type I diabetes patients with HbA1c levels of 7.7-8.7 per cent had the lowest odds of hospital admission, a study of 24,750 type I diabetes patients in Scotland found.

Compared with patients in this range of measurements, those with the highest HbA1c readings (10.8-18.4 per cent) were almost three times as likely to be admitted to hospital, while those with the lowest readings (4.4-7.1 per cent) were 1.29 times as likely to be admitted.

Looking at admissions for specific conditions, the study showed that patients with the highest HbA1c readings had significantly higher odds of diabetes-related and diabetes ketoacidosis admissions.

Writing in Diabetes Care, the authors concluded that higher levels of HbA1c were a “strong predictor of hospital admissions”.

They said their results suggested that interventions to lower HbA1c in this group might result in “considerably lower hospital admissions and associated costs for the care of people with type I diabetes”.

The study depended on the accuracy of ICD coding, which the authors said was one of its limitations.

The authors were also unable to adjust for possible reverse causality — HbA1c falling in response to major illness.

Diabetes Care 2011; 10.2337/dc10-2099

'GLP-1 agonists may be beneficial in weight reduction as well as glycaemic control'

Dr Deirdre Carroll looks at the relationship between obesity and the development of type II diabetes and examines recent guidance on the management of obesity.

The prevalence of overweight and obesity has increased dramatically over recent decades to what has been described as epidemic proportions.

Some 38 per cent of Irish people are overweight and 23 per cent are obese (according to the National Survey of Lifestyle Attitudes and Nutrition 2007).

The rise in obesity is reflected in the rising incidence of type II diabetes. It is estimated that 200,000 people in Ireland have a diagnosis of diabetes and that there may be a further 100,000 who are unaware that they have it. Obesity and diabetes have the potential to severely impact the health of individuals, as well as impacting on the workforce, reducing productivity, increasing the pressure on and costs to the health service and the social welfare system.

The increasing rates of obesity and diabetes are multi-factorial. Over-eating and a sedentary lifestyle increase the risk of developing obesity and/or diabetes. Only 41 per cent of Irish adults take part in moderate or strenuous exercise for at least 20 minutes, three or more times a week. Genetic factors, low birth weight and possibly stress may also play a role.

In some patients, there are other contributory factors such as medications, e.g. atypical anti-psychotics, and conditions such as polycystic ovarian syndrome.

Biggest risk factor
Obesity is the single biggest risk factor for the development of type II diabetes. As body mass index (BMI) increases, the risk of type II diabetes increases in a dose-dependant manner by increasing insulin resistance. The prevalence of type II diabetes is three-to-seven times higher in obese adults than in normal-weight adults, and those with a BMI >35kg/m2 are 20 times more likely to develop type II diabetes than those with a BMI between 18 and 24.9.

Large waist circumference (WC) is another important risk factor for type II diabetes (>94cm in men and >80cm in women). The other risk factors are physical inactivity, previous gestational diabetes or ‘pre-diabetes’ (impaired fasting glycaemia or impaired glucose tolerance), family history of diabetes, increasing age, certain ethnicities (Asian, African, African Caribbean, Chinese descent), and being from a lower socio-economic group.

The more risk factors an individual has, the more likely they are to develop diabetes. Obesity and diabetes are important independent and additive cardiovascular risk factors. They both increase obstetric, perinatal and neonatal complications, raise certain cancer risks (e.g. colon) and are associated with an increased risk of dementia and renal disease and with higher mortality rates.

Obesity is also a known risk factor for asthma, depression, gastro-oesophageal reflux disease, reduced fertility, gallstones, osteoarthritis, liver disease and obstructive sleep apnoea.

Chronic problems
In addition, there are the acute risks of diabetes (hypoglycaemia/ketoacidosis) and chronic problems of retinopathy and nephropathy. On average, at the age of 55 years, the life expectancy of people with type II diabetes is five-to-seven years less than for the general population.

Lifestyle interventions to improve diet and to increase the amount of physical activity in an individual with impaired glucose tolerance can more than halve their risk of going on to develop type II diabetes, as seen in the Diabetes Prevention Study.

Public health guidance
NICE has just published public health guidance for ‘Preventing type II diabetes: population and community-level interventions in high-risk groups and the general population’ (PH35 May 2011). It is aimed at a wide-ranging audience including GPs, practice nurses, dieticians, those involved in delivery of physical activity interventions, managers in the health service, national policy makers and also for caterers, food manufacturers and retailers.

Early intervention to prevent type II diabetes is important to prevent a range of non-communicable disease (including cardiovascular disease and some cancers). This guideline recommends both local measures to promote health and preventive measures, and national action to address the adverse environmental factors driving the increasing prevalence of type II diabetes.

It advises an integrated approach with other health promotion campaigns or interventions, and targeting those with shared risk factors.
In addition to this guideline, there is recent SIGN guidance ((CG115) Feb 2010) on the management of obesity. They share much of the same treatment advice:

• Assessment. Classify the extent of obesity (and the risk of obesity-related co-morbidities) using BMI and waist circumference, seek a weight history and previous attempts to reduce weight as well as willingness to change;
• Support behaviour change by helping people understand the consequences of health-related behaviour, helping them to plan for and feel positive about changing their behaviours and planning coping strategies for situations that may undermine the changes they are trying to make;
• Achieve and maintain healthy weight. Base meals on starchy foods, eat fibre-rich foods and five portions of fruit and vegetables a day, eat a low-fat diet, watch calorie intake and portion sizes, and eat breakfast. If weight loss is required, dietary interventions should be calculated to produce a 600kcal/day energy deficit and tailored to the dietary preferences of the patient. Reduction of intake of energy-dense foods, consumption of ‘fast foods’ and alcohol. Adults consulting about weight management should self-weigh regularly;
• Effective weight-loss programmes should be tailored to the individual, identify and address barriers to change. Expect people to lose no more than 0.5-1kg per week. Patients with a BMI over 35kg/m2 will usually need to lose 15-20 per cent of their weight for sustained improvement of co-morbidities. In patients with a BMI of 25-35kg/m2, obesity-related co-morbidities are less likely to be present and a 5-10 per cent weight loss (approximately 5-10kgs) is required for cardiovascular and metabolic risk reduction. People from some ethnic groups, e.g. South Asians develop co-morbidities at lower BMI;
• Physical activity. To achieve general health benefits, one should accumulate at least 30 minutes of moderate-intensity physical activity on at least five days per week. To lose weight, most people need to do at least 45-60 minutes of moderate-intensity activity a day; people who have been obese and have lost weight may need to do 60-90 minutes of activity a day to avoid regaining weight. They should make activities they enjoy part of their routine, e.g. walking, cycling and gardening, and build in activity where possible, e.g. always take the stairs, fit in a walk at lunchtime and minimise sedentary activities, e.g. sitting in front of the television or computer;
• Interventions should be culturally appropriate to take into consideration the person’s cultural or religious beliefs and language and literacy skills.

Orlistat is the only licensed obesity drug available, to be used as an adjunct to lifestyle interventions. It should only be continued beyond 12 weeks if 5 per cent of the body weight has been lost. The XENDOS study showed a reduction in progression to diabetes in those on orlistat by 37 per cent.

Bariatric surgery should be considered in those with a BMI >35kg/m2 who also have severe co-morbidity which would be expected to improve following weight loss (e.g. diabetes, arthritis, severe mobility problems). They should also have evidence of completion of a structured weight management programme without significant and sustained improvement in their co-morbidities.

'Obesity is the most common chronic disorder in childhood and is increasing in prevalence (a 2007 study estimated that one in four Irish children are overweight or obese)'

Children and young people
Obesity is the most common chronic disorder in childhood and is increasing in prevalence (a 2007 study estimated that one in four Irish children are overweight or obese). It is associated with hypertension, increased cardiovascular risk, metabolic syndrome and psychosocial problems. Obese children are at high risk of becoming obese adults and have a worse prognosis than adults who become obese in later life.

For the assessment, it is recommended that the BMI is calculated and plotted on centile charts. A BMI above the 91st centile for age indicates overweight and above the 98th indicates obesity.

The principle recommendations in the SIGN guideline are as for adults, but also state that interventions should be family-based, involving at least one parent/carer, aim to change the whole family’s lifestyle and reduce sedentary behaviour to less than two hours per day or 14 hours per week (‘screen-time’).

The treatment of obesity and diabetes are closely linked: obesity complicates the management of type II diabetes by increasing insulin resistance and blood glucose concentrations. The situation is further complicated by the fact that certain diabetes treatments are associated with weight gain (insulin, sulphonylureas and thiazolidinediones). Therefore, weight reduction interventions are an integral part of diabetes management.

On the other hand, GLP-1 agonists may be beneficial in weight reduction as well as glycaemic control.

Benefits of treatment
Weight reduction has been shown in overweight or obese adults with diabetes to improve glycaemic control and reduce the requirement for glucose-lowering medication, as well as lowering all-cause mortality. Weight loss in obese individuals has also been associated with reductions in blood pressure, lipid profiles, arthritis-related disability, lower mortality from cancer and improved lung function in patients with asthma.

Physical activity or structured exercise programmes for type II diabetics improve glycaemic control and cardiovascular risk factors, even in the absence of weight loss.

Structured diabetes education programmes such as X-PERT, CODE and DESMOND have shown good results in terms of patients’ knowledge and self-management, and X-PERT has been shown to effect a 0.6 per cent reduction in HbA1c.

Given the rising prevalence and impact of these conditions, obesity and diabetes are issues for all health professionals to address. However, as stated in the recent NICE guideline (PH35), the greatest impact on the levels — and associated costs — of type II diabetes is likely to be achieved by addressing the risk factors in whole communities and populations.

• Dr Deirdre Carroll, Liberties Primary Care Team, Dublin 8.

Children presenting with type I diabetes that is missed during a medical consultation have a three-fold increased risk of re-presenting with ketoacidosis, a review has found.

This risk was independent of the presence or absence of infection preceding diagnosis, but diagnostic error was significantly more likely to occur in younger children, the review authors noted.

Conversely, children with a first-degree relative with diabetes had a six-fold decreased risk of presenting with ketoacidosis at diagnosis.

Writing in BMJ, they noted that ketoacidosis is the “commonest cause of diabetes-related death in children” and that it remained unclear why some present in ketoacidosis while others do not.

The review of 46 studies including 24,000 children in 31 countries found that as well as delayed diagnosis and diagnostic error, the most common risk factor was age at presentation.

Children under two years of age had an odds ratio of 3.41 of presenting with ketoacidosis compared with older children and this association continued up to age five years (OR 1.59).

The authors noted that reasons for this are “probably multifactorial”, including that clinicians may have lower index of suspicion for diabetes among younger children and that the classic symptoms of diabetes may be subtle and difficult to distinguish from other acute illnesses at that age.

The review findings have implications for clinicians in both primary and secondary care “as the vast majority of children who develop type I diabetes will have consultation before diagnosis”, and they should be particularly vigilant in children under five, from ethnic minorities and of low socioeconomic status.

The authors acknowledged that although it seems intuitive that an earlier diagnosis of diabetes should lead to decreased risk of ketoacidosis, “our review still leaves unanswered the major question of whether [it] is a consequence of delayed diagnosis and treatment or whether it reflects a more aggressive form of diabetes”.

BMJ 2011 doi: 10.1136/bmj.d3278

Bariatric surgery should not be seen as a last resort in obese patients with type II diabetes but instead added to treatment algorithms, the International Diabetes Federation (IDF) has found.

Led by Paul Zimmett from Baker IDI in Melbourne, the authors said research had shown that bariatric surgery in people with severe obesity and type II diabetes could lead to large weight loss and remission of diabetes in many cases.

Oral hypoglycaemic drugs and insulin had a role in treatment but were not effective in many cases, the authors said.

“The appeal of bariatric surgery is unsurprising: it can have a striking effect on glycaemic control and other cardiovascular risk factors and is cost effective,” they wrote.

An IDF statement on bariatric surgery made in 2010 recognised that bariatric surgery was an appropriate treatment for obese people with type II diabetes who do not achieve recommended targets with available therapies, especially in cases with other major co-morbidities.

Surgery should also be accepted as an option in people with diabetes and a body mass index of at least 35kg/m2, the statement said.

The IDF stresses the need for long-term multidisciplinary care and use of safe and standardised surgical procedures. It also recommends including surgery in treatment algorithms.

“Inclusion of surgery in treatment algorithms could transform diabetes care at large, making physicians give increased attention to risk stratification, individual characteristics of patients, and responsiveness to patients,” the authors concluded in a comment piece in the Lancet.

“Bariatric surgery could now be considered earlier in the treatment of type II diabetes and should no longer be seen as a last resort,” they added.

Lancet 2011; 378:108-109.

Patients who take high-dose statins face an increased risk of developing diabetes compared with lower doses, research finds.

In a meta-analysis of five trials, patients on high-dose statin therapy had a 12 per cent increased risk of new-onset diabetes compared with those on moderate doses, over an average of five years.

Almost 500 patients would need to be treated with high-dose statins for one year to cause one case of new-onset diabetes, the analysis of more than 30,000 patients showed. Just 155 patients would need to be treated with high-dose statins for one year to spare one person a cardiovascular event.

The authors said the research extended earlier findings of an increased incidence of diabetes with statin therapy. They noted that another recent meta-analysis, involving 90,000 patients, found the risk of developing diabetes was 9 per cent higher over four years in patients treated with statins compared with those receiving placebo or standard care.

The researchers said the mechanism for the findings was not yet established, but suggested it could relate to a direct influence of statins on either muscles or liver insulin action.

JAMA 2011; 305:2556-64