Hannah Brown

BARCELONA — Consider measuring testosterone levels in all male type 2 diabetes patients with symptoms of hypogonadism, Dr. Eric Meuleman of the Free University Medical Center, Amsterdam, advised at an international congress on prediabetes and metabolic syndrome.

Untreated hypogonadism can cause substantial distress and social consequences to the men involved, he noted. “People lose jobs and marriages over low testosterone. It is generally something that has been ignored in the past.”

Reductions in testosterone levels happen to all men as they get older, with concentrations dropping by an average of 1% per year after age 50 (J. Clin. Endocrinol. Metab. 2007;92:196–202). Between the ages of 40 and 79 years, 12.3% of men have testosterone levels low enough to produce clinical signs and symptoms such as diminished sexual desire, poor erectile quality, low energy, reduced sense of vitality, and anemia, Dr. Meuleman said. But men with type 2 diabetes seem to be more susceptible to testosterone loss, with an estimated 33% of this group affected by the condition.

Because the symptoms are fairly nonspecific, the syndrome is difficult to diagnose and may not appear to be separate from the effects of diabetes. The Endocrine Society issued guidelines last year on treating symptoms of hypogonadism (low testosterone), listing drops in libido, muscle bulk, and height—along with hot flushes, loss of body hair, gynecomastia, and low work performance—as the main symptoms. Other sources have noted that low testosterone is also accompanied by changes in mood, with concomitant decreases in intellectual activity and cognitive function, as well as sleep disturbances, decreases in lean body mass, and increased fracture risk, he said.

Dr. Meuleman said the wide range of possible symptoms means that physicians must rely heavily on biochemical measurement of testosterone to diagnose the condition. A serum test assessing free bioavailable testosterone can be done clinically and should be carried out before 11 a.m. because of the circadian rhythm of testosterone levels in the blood. One-third of patients eventually diagnosed with low testosterone turn out to have classical causes such as Klinefelter's syndrome, which is undiagnosed in 75% of cases.

Studies looking at the effectiveness of replacing lost testosterone in men who have testosterone deficiencies have shown that testosterone supplementation can delay time to ischemia (Heart 2004;90:871–6). Supplementation also can improve distance in the shuttle walk test, boost mood in patients who are depressed, and improve lipid profiles while significantly decreasing total cholesterol, Dr. Meuleman added.

An ongoing study is looking at whether these findings can be extended to men with metabolic syndrome and type 2 diabetes. The randomized, double-blind, placebo controlled Effect of Transdermal Testosterone Replacement in Hypogonadal Men With Metabolic Syndrome or Type 2 Diabetes Mellitus (TIMES 2) study intends to test testosterone replacement to see if it reduces insulin resistance as measured by homeostatic model assessment (HOMA). Results from the study, which is being funded by ProStrakan Group Ltd., maker of a testosterone replacement gel, are expected to be reported in April 2009, Dr. Meuleman said.

BARCELONA — Consider measuring testosterone levels in all male type 2 diabetes patients with symptoms of hypogonadism, Dr. Eric Meuleman of the Free University Medical Center, Amsterdam, advised at an international congress on prediabetes and metabolic syndrome.

Untreated hypogonadism can cause substantial distress and social consequences to the men involved, he noted. “People lose jobs and marriages over low testosterone. It is generally something that has been ignored in the past.”

Reductions in testosterone levels happen to all men as they get older, with concentrations dropping by an average of 1% per year after age 50 (J. Clin. Endocrinol. Metab. 2007;92:196–202). Between the ages of 40 and 79 years, 12.3% of men have testosterone levels low enough to produce clinical signs and symptoms such as diminished sexual desire, poor erectile quality, low energy, reduced sense of vitality, and anemia, Dr. Meuleman said. But men with type 2 diabetes seem to be more susceptible to testosterone loss, with an estimated 33% of this group affected by the condition.

Because the symptoms are fairly nonspecific, the syndrome is difficult to diagnose and may not appear to be separate from the effects of diabetes. The Endocrine Society issued guidelines last year on treating symptoms of hypogonadism (low testosterone), listing drops in libido, muscle bulk, and height—along with hot flushes, loss of body hair, gynecomastia, and low work performance—as the main symptoms. Other sources have noted that low testosterone is also accompanied by changes in mood, with concomitant decreases in intellectual activity and cognitive function, as well as sleep disturbances, decreases in lean body mass, and increased fracture risk, he said.

Dr. Meuleman said the wide range of possible symptoms means that physicians must rely heavily on biochemical measurement of testosterone to diagnose the condition. A serum test assessing free bioavailable testosterone can be done clinically and should be carried out before 11 a.m. because of the circadian rhythm of testosterone levels in the blood. One-third of patients eventually diagnosed with low testosterone turn out to have classical causes such as Klinefelter's syndrome, which is undiagnosed in 75% of cases.

Studies looking at the effectiveness of replacing lost testosterone in men who have testosterone deficiencies have shown that testosterone supplementation can delay time to ischemia (Heart 2004;90:871–6). Supplementation also can improve distance in the shuttle walk test, boost mood in patients who are depressed, and improve lipid profiles while significantly decreasing total cholesterol, Dr. Meuleman added.

An ongoing study is looking at whether these findings can be extended to men with metabolic syndrome and type 2 diabetes. The randomized, double-blind, placebo controlled Effect of Transdermal Testosterone Replacement in Hypogonadal Men With Metabolic Syndrome or Type 2 Diabetes Mellitus (TIMES 2) study intends to test testosterone replacement to see if it reduces insulin resistance as measured by homeostatic model assessment (HOMA). Results from the study, which is being funded by ProStrakan Group Ltd., maker of a testosterone replacement gel, are expected to be reported in April 2009, Dr. Meuleman said.

BARCELONA — Consider measuring testosterone levels in all male type 2 diabetes patients with symptoms of hypogonadism, Dr. Eric Meuleman of the Free University Medical Center, Amsterdam, advised at an international congress on prediabetes and metabolic syndrome.

Untreated hypogonadism can cause substantial distress and social consequences to the men involved, he noted. “People lose jobs and marriages over low testosterone. It is generally something that has been ignored in the past.”

Reductions in testosterone levels happen to all men as they get older, with concentrations dropping by an average of 1% per year after age 50 (J. Clin. Endocrinol. Metab. 2007;92:196–202). Between the ages of 40 and 79 years, 12.3% of men have testosterone levels low enough to produce clinical signs and symptoms such as diminished sexual desire, poor erectile quality, low energy, reduced sense of vitality, and anemia, Dr. Meuleman said. But men with type 2 diabetes seem to be more susceptible to testosterone loss, with an estimated 33% of this group affected by the condition.

Because the symptoms are fairly nonspecific, the syndrome is difficult to diagnose and may not appear to be separate from the effects of diabetes. The Endocrine Society issued guidelines last year on treating symptoms of hypogonadism (low testosterone), listing drops in libido, muscle bulk, and height—along with hot flushes, loss of body hair, gynecomastia, and low work performance—as the main symptoms. Other sources have noted that low testosterone is also accompanied by changes in mood, with concomitant decreases in intellectual activity and cognitive function, as well as sleep disturbances, decreases in lean body mass, and increased fracture risk, he said.

Dr. Meuleman said the wide range of possible symptoms means that physicians must rely heavily on biochemical measurement of testosterone to diagnose the condition. A serum test assessing free bioavailable testosterone can be done clinically and should be carried out before 11 a.m. because of the circadian rhythm of testosterone levels in the blood. One-third of patients eventually diagnosed with low testosterone turn out to have classical causes such as Klinefelter's syndrome, which is undiagnosed in 75% of cases.

Studies looking at the effectiveness of replacing lost testosterone in men who have testosterone deficiencies have shown that testosterone supplementation can delay time to ischemia (Heart 2004;90:871–6). Supplementation also can improve distance in the shuttle walk test, boost mood in patients who are depressed, and improve lipid profiles while significantly decreasing total cholesterol, Dr. Meuleman added.

An ongoing study is looking at whether these findings can be extended to men with metabolic syndrome and type 2 diabetes. The randomized, double-blind, placebo controlled Effect of Transdermal Testosterone Replacement in Hypogonadal Men With Metabolic Syndrome or Type 2 Diabetes Mellitus (TIMES 2) study intends to test testosterone replacement to see if it reduces insulin resistance as measured by homeostatic model assessment (HOMA). Results from the study, which is being funded by ProStrakan Group Ltd., maker of a testosterone replacement gel, are expected to be reported in April 2009, Dr. Meuleman said.

GLASGOW, SCOTLAND — Regular exercise of moderate to high intensity can improve glycemic control and reduce visceral and adipose fat, Dr. Dinesh Nagi said at the Diabetes U.K. Annual Professional Conference.

Dr. Nagi summarized the evidence supporting use of exercise interventions in type 2 diabetes. Although exercise has long been the cornerstone of management for type 2 diabetes, there is very little robust evidence to prove its beneficial effects or mechanism of action, explained Dr. Nagi, consultant endocrinologist at Pinderfields General Hospital in Wakefield, England.

“There is a limitation of evidence—the pharmaceutical industry is not throwing money at this,” he said. And this means few physicians are aware of the impact of exercise on outcomes such as cardiovascular risk factors, mortality, and quality of life and, crucially, they may be unaware of the risks. “Health professionals often confuse the issue. The risks and benefits of exercise are very different for type 1 and type 2 diabetes,” Dr. Nagi said.

Of the available trials involving type 2 patients, most are small and nonrandomized, involve short-term interventions, and follow-up is for a maximum of 2 years. In addition, there are few data concerning cardiovascular outcomes after exercise. According to Dr. Nagi, this dearth of good data means physicians are reduced to looking at cohort studies for evidence. But in these investigations the case mix is often heterogeneous and patients are on all sorts of different treatments including pills, insulin, and diet, making the results difficult to generalize.

Dr. Nagi discussed a recent Cochrane review of 13 trials involving 377 type 2 diabetes patients and controls (Cochrane Database Syst. Rev. 2006 July 19;3:CD002968). Length of the trials ranged from 8 weeks to 1 year; the exercise interventions varied from a mix of aerobic exercise and resistance training to either resistance training or aerobic exercise alone, all at varying levels of intensity and different time intervals. Dr. Nagi noted that the reviewers found that exercise improved glycemic control with an average statistically significant reduction in glycated hemoglobin (HbA_1c) of −0.6%. The glycemic control benefits were independent of weight loss, although exercise also led to average reductions in visceral adipose tissue of −45.5 cm

Data showing improvements in cardiovascular risk factors in patients with type 2 diabetes are scarcer. “There are no long-term studies using exercise that are randomized,” explained Dr. Nagi. However, he said, because many of the causes of cardiovascular malfunction in diabetic patients—ventricular and vascular hypertrophy, arterial stiffening, endothelial dysfunction, disturbance of fibrinolysis, systematic inflammation—are improved by exercise in nondiabetic patients, it is reasonable to assume that it could help in type 2 diabetes too. “There's a good cohort of evidence that if you are active you are less likely to die of coronary artery disease,” he said.

However, Dr. Nagi cautioned that to maintain the benefit, exercise must continue regularly over a long period, raising the question of how to ensure that patients do not decrease their exercise levels over time. Current recommendations for patients with type 2 diabetes to gain the blood glucose reduction benefits from exercise are 150 minutes per week, done with a break of no more than 48 hours between bouts. And the exercise must be of sufficient intensity for the patient to start perspiring. But when introducing these guidelines to patients, appropriate terminology is key. “Doctors should stop using the word exercise,” said Dr. Nagi. “Physical activity is the right term to use because exercise has negative connotations, particularly for women.”

GLASGOW, SCOTLAND — Regular exercise of moderate to high intensity can improve glycemic control and reduce visceral and adipose fat, Dr. Dinesh Nagi said at the Diabetes U.K. Annual Professional Conference.

Dr. Nagi summarized the evidence supporting use of exercise interventions in type 2 diabetes. Although exercise has long been the cornerstone of management for type 2 diabetes, there is very little robust evidence to prove its beneficial effects or mechanism of action, explained Dr. Nagi, consultant endocrinologist at Pinderfields General Hospital in Wakefield, England.

“There is a limitation of evidence—the pharmaceutical industry is not throwing money at this,” he said. And this means few physicians are aware of the impact of exercise on outcomes such as cardiovascular risk factors, mortality, and quality of life and, crucially, they may be unaware of the risks. “Health professionals often confuse the issue. The risks and benefits of exercise are very different for type 1 and type 2 diabetes,” Dr. Nagi said.

Of the available trials involving type 2 patients, most are small and nonrandomized, involve short-term interventions, and follow-up is for a maximum of 2 years. In addition, there are few data concerning cardiovascular outcomes after exercise. According to Dr. Nagi, this dearth of good data means physicians are reduced to looking at cohort studies for evidence. But in these investigations the case mix is often heterogeneous and patients are on all sorts of different treatments including pills, insulin, and diet, making the results difficult to generalize.

Dr. Nagi discussed a recent Cochrane review of 13 trials involving 377 type 2 diabetes patients and controls (Cochrane Database Syst. Rev. 2006 July 19;3:CD002968). Length of the trials ranged from 8 weeks to 1 year; the exercise interventions varied from a mix of aerobic exercise and resistance training to either resistance training or aerobic exercise alone, all at varying levels of intensity and different time intervals. Dr. Nagi noted that the reviewers found that exercise improved glycemic control with an average statistically significant reduction in glycated hemoglobin (HbA_1c) of −0.6%. The glycemic control benefits were independent of weight loss, although exercise also led to average reductions in visceral adipose tissue of −45.5 cm

Data showing improvements in cardiovascular risk factors in patients with type 2 diabetes are scarcer. “There are no long-term studies using exercise that are randomized,” explained Dr. Nagi. However, he said, because many of the causes of cardiovascular malfunction in diabetic patients—ventricular and vascular hypertrophy, arterial stiffening, endothelial dysfunction, disturbance of fibrinolysis, systematic inflammation—are improved by exercise in nondiabetic patients, it is reasonable to assume that it could help in type 2 diabetes too. “There's a good cohort of evidence that if you are active you are less likely to die of coronary artery disease,” he said.

However, Dr. Nagi cautioned that to maintain the benefit, exercise must continue regularly over a long period, raising the question of how to ensure that patients do not decrease their exercise levels over time. Current recommendations for patients with type 2 diabetes to gain the blood glucose reduction benefits from exercise are 150 minutes per week, done with a break of no more than 48 hours between bouts. And the exercise must be of sufficient intensity for the patient to start perspiring. But when introducing these guidelines to patients, appropriate terminology is key. “Doctors should stop using the word exercise,” said Dr. Nagi. “Physical activity is the right term to use because exercise has negative connotations, particularly for women.”

GLASGOW, SCOTLAND — Regular exercise of moderate to high intensity can improve glycemic control and reduce visceral and adipose fat, Dr. Dinesh Nagi said at the Diabetes U.K. Annual Professional Conference.

Dr. Nagi summarized the evidence supporting use of exercise interventions in type 2 diabetes. Although exercise has long been the cornerstone of management for type 2 diabetes, there is very little robust evidence to prove its beneficial effects or mechanism of action, explained Dr. Nagi, consultant endocrinologist at Pinderfields General Hospital in Wakefield, England.

“There is a limitation of evidence—the pharmaceutical industry is not throwing money at this,” he said. And this means few physicians are aware of the impact of exercise on outcomes such as cardiovascular risk factors, mortality, and quality of life and, crucially, they may be unaware of the risks. “Health professionals often confuse the issue. The risks and benefits of exercise are very different for type 1 and type 2 diabetes,” Dr. Nagi said.

Of the available trials involving type 2 patients, most are small and nonrandomized, involve short-term interventions, and follow-up is for a maximum of 2 years. In addition, there are few data concerning cardiovascular outcomes after exercise. According to Dr. Nagi, this dearth of good data means physicians are reduced to looking at cohort studies for evidence. But in these investigations the case mix is often heterogeneous and patients are on all sorts of different treatments including pills, insulin, and diet, making the results difficult to generalize.

Dr. Nagi discussed a recent Cochrane review of 13 trials involving 377 type 2 diabetes patients and controls (Cochrane Database Syst. Rev. 2006 July 19;3:CD002968). Length of the trials ranged from 8 weeks to 1 year; the exercise interventions varied from a mix of aerobic exercise and resistance training to either resistance training or aerobic exercise alone, all at varying levels of intensity and different time intervals. Dr. Nagi noted that the reviewers found that exercise improved glycemic control with an average statistically significant reduction in glycated hemoglobin (HbA_1c) of −0.6%. The glycemic control benefits were independent of weight loss, although exercise also led to average reductions in visceral adipose tissue of −45.5 cm

Data showing improvements in cardiovascular risk factors in patients with type 2 diabetes are scarcer. “There are no long-term studies using exercise that are randomized,” explained Dr. Nagi. However, he said, because many of the causes of cardiovascular malfunction in diabetic patients—ventricular and vascular hypertrophy, arterial stiffening, endothelial dysfunction, disturbance of fibrinolysis, systematic inflammation—are improved by exercise in nondiabetic patients, it is reasonable to assume that it could help in type 2 diabetes too. “There's a good cohort of evidence that if you are active you are less likely to die of coronary artery disease,” he said.

However, Dr. Nagi cautioned that to maintain the benefit, exercise must continue regularly over a long period, raising the question of how to ensure that patients do not decrease their exercise levels over time. Current recommendations for patients with type 2 diabetes to gain the blood glucose reduction benefits from exercise are 150 minutes per week, done with a break of no more than 48 hours between bouts. And the exercise must be of sufficient intensity for the patient to start perspiring. But when introducing these guidelines to patients, appropriate terminology is key. “Doctors should stop using the word exercise,” said Dr. Nagi. “Physical activity is the right term to use because exercise has negative connotations, particularly for women.”

GLASGOW, SCOTLAND — Specific guidelines for patients with diabetes who have a scheduled endoscopy can help avoid an overnight hospital stay and also reduce complications, according to research presented at the Diabetes U.K. Annual Professional Conference.

The usual requirements for patients undergoing endoscopy include preprocedure fasting and bowel preparation, which can make it difficult for diabetic patients to maintain good glucose control, putting them at risk of dysglycemia during or after the procedure. However, developments in the management of diabetes, including use of basal insulins, mean that there are now opportunities to help diabetic patients manage these difficult situations.

Recognizing the inadequacy of current endoscopy guidelines at her hospital, Dionne Wamae, a diabetes specialist nurse (DSN) at Worthing and Southlands Hospitals NHS Trust, Worthing, England, along with fellow DSN Alison McHoy, developed new recommendations to help diabetes patients prepare for endoscopies.

“Before we started our study, patients on insulin were being admitted overnight and the guidelines didn't take account of the many different types of insulin available,” said Ms. Wamae. Furthermore, non-health professionals were frequently giving advice to patients before their procedures, and DSNs were giving varied, non-evidence-based advice, Ms. Wamae added.

Ms. Wamae and Ms. McHoy used literature searches, prescribing information for oral agents and insulins, and existing endoscopy guidelines to put together a set of 16 scenarios for management of patients with diabetes who are going to undergo endoscopy.

“Variations of the guidelines were developed to reflect the most common treatments, the type of procedure, and the time of day for which the patient was booked,” said Ms. Wamae.

For example, one guideline gives advice for someone on a basal-bolus regimen who is scheduled to have an endoscopy in the afternoon. Depending on the specific formulation of treatment they are taking, patients should adhere to normal treatments on the day before the procedure and the following morning, eating and drinking as normal, but omit their lunchtime dose of rapid-acting insulin and take an additional rapid-acting insulin dose with the evening meal after the procedure is complete. Another guideline describes what someone on oral agents for diabetes should do to prepare for a morning procedure. There are also additional recommendations included within the guidelines for monitoring of blood glucose.

There were no baseline standards available to see how diabetes patients fared on standard endoscopy guidelines. However, Ms. Wamae and Ms. McHoy did an audit to assess whether patients following the new guidelines successfully completed their planned procedures without an increase in the frequency of hypoglycemia or hyperglycemia.

The audit was undertaken for 16 weeks between November 2004 and March 2005, and included any adult with diabetes who was being treated with insulin or oral medication and who also was scheduled for an endoscopy or colonoscopy as an outpatient. The study sample included 40 patients.

During the course of the audit, the endoscopy department advised patients to call a DSN for advice 2 weeks prior to their procedure. The nurse instructed patients on how best to modulate their insulin or oral agent treatment in accordance with the new guidelines. Patients were then telephoned 5 days after they should have started their preprocedure preparation and asked about blood glucose control. In all, 68% of patients required preprocedure advice and 40% required advice on follow-up, but 32% asked for no advice at all.

According to Ms. Wamae, the audit showed that the guidelines worked well and improved the safety of patients. “Out of the 40 patients, none had an increase in number of hypoglycemic episodes, and some of the 12 patients who normally experience frequent hypoglycemia had fewer, possibly because of the benefits of having advice,” she said. Two patients experienced an increase in hyperglycemic episodes from the day they began preparation for their endoscopy.

An important finding from the study was that patients were more anxious if their procedure was later in the day, especially if they were on insulin. “All patients treated with insulin should be first on the procedure list in the morning,” said Ms. Wamae.

The guidelines are now hospital policy for both inpatient and outpatient endoscopies, and Ms. Wamae's colleagues at the hospital also have adapted them for day surgery procedures that normally take less than 11/2 hours. “Feedback has been very positive,” she said.

GLASGOW, SCOTLAND — Specific guidelines for patients with diabetes who have a scheduled endoscopy can help avoid an overnight hospital stay and also reduce complications, according to research presented at the Diabetes U.K. Annual Professional Conference.

The usual requirements for patients undergoing endoscopy include preprocedure fasting and bowel preparation, which can make it difficult for diabetic patients to maintain good glucose control, putting them at risk of dysglycemia during or after the procedure. However, developments in the management of diabetes, including use of basal insulins, mean that there are now opportunities to help diabetic patients manage these difficult situations.

Recognizing the inadequacy of current endoscopy guidelines at her hospital, Dionne Wamae, a diabetes specialist nurse (DSN) at Worthing and Southlands Hospitals NHS Trust, Worthing, England, along with fellow DSN Alison McHoy, developed new recommendations to help diabetes patients prepare for endoscopies.

“Before we started our study, patients on insulin were being admitted overnight and the guidelines didn't take account of the many different types of insulin available,” said Ms. Wamae. Furthermore, non-health professionals were frequently giving advice to patients before their procedures, and DSNs were giving varied, non-evidence-based advice, Ms. Wamae added.

Ms. Wamae and Ms. McHoy used literature searches, prescribing information for oral agents and insulins, and existing endoscopy guidelines to put together a set of 16 scenarios for management of patients with diabetes who are going to undergo endoscopy.

“Variations of the guidelines were developed to reflect the most common treatments, the type of procedure, and the time of day for which the patient was booked,” said Ms. Wamae.

For example, one guideline gives advice for someone on a basal-bolus regimen who is scheduled to have an endoscopy in the afternoon. Depending on the specific formulation of treatment they are taking, patients should adhere to normal treatments on the day before the procedure and the following morning, eating and drinking as normal, but omit their lunchtime dose of rapid-acting insulin and take an additional rapid-acting insulin dose with the evening meal after the procedure is complete. Another guideline describes what someone on oral agents for diabetes should do to prepare for a morning procedure. There are also additional recommendations included within the guidelines for monitoring of blood glucose.

There were no baseline standards available to see how diabetes patients fared on standard endoscopy guidelines. However, Ms. Wamae and Ms. McHoy did an audit to assess whether patients following the new guidelines successfully completed their planned procedures without an increase in the frequency of hypoglycemia or hyperglycemia.

The audit was undertaken for 16 weeks between November 2004 and March 2005, and included any adult with diabetes who was being treated with insulin or oral medication and who also was scheduled for an endoscopy or colonoscopy as an outpatient. The study sample included 40 patients.

During the course of the audit, the endoscopy department advised patients to call a DSN for advice 2 weeks prior to their procedure. The nurse instructed patients on how best to modulate their insulin or oral agent treatment in accordance with the new guidelines. Patients were then telephoned 5 days after they should have started their preprocedure preparation and asked about blood glucose control. In all, 68% of patients required preprocedure advice and 40% required advice on follow-up, but 32% asked for no advice at all.

According to Ms. Wamae, the audit showed that the guidelines worked well and improved the safety of patients. “Out of the 40 patients, none had an increase in number of hypoglycemic episodes, and some of the 12 patients who normally experience frequent hypoglycemia had fewer, possibly because of the benefits of having advice,” she said. Two patients experienced an increase in hyperglycemic episodes from the day they began preparation for their endoscopy.

An important finding from the study was that patients were more anxious if their procedure was later in the day, especially if they were on insulin. “All patients treated with insulin should be first on the procedure list in the morning,” said Ms. Wamae.

The guidelines are now hospital policy for both inpatient and outpatient endoscopies, and Ms. Wamae's colleagues at the hospital also have adapted them for day surgery procedures that normally take less than 11/2 hours. “Feedback has been very positive,” she said.

GLASGOW, SCOTLAND — Specific guidelines for patients with diabetes who have a scheduled endoscopy can help avoid an overnight hospital stay and also reduce complications, according to research presented at the Diabetes U.K. Annual Professional Conference.

The usual requirements for patients undergoing endoscopy include preprocedure fasting and bowel preparation, which can make it difficult for diabetic patients to maintain good glucose control, putting them at risk of dysglycemia during or after the procedure. However, developments in the management of diabetes, including use of basal insulins, mean that there are now opportunities to help diabetic patients manage these difficult situations.

Recognizing the inadequacy of current endoscopy guidelines at her hospital, Dionne Wamae, a diabetes specialist nurse (DSN) at Worthing and Southlands Hospitals NHS Trust, Worthing, England, along with fellow DSN Alison McHoy, developed new recommendations to help diabetes patients prepare for endoscopies.

“Before we started our study, patients on insulin were being admitted overnight and the guidelines didn't take account of the many different types of insulin available,” said Ms. Wamae. Furthermore, non-health professionals were frequently giving advice to patients before their procedures, and DSNs were giving varied, non-evidence-based advice, Ms. Wamae added.

Ms. Wamae and Ms. McHoy used literature searches, prescribing information for oral agents and insulins, and existing endoscopy guidelines to put together a set of 16 scenarios for management of patients with diabetes who are going to undergo endoscopy.

“Variations of the guidelines were developed to reflect the most common treatments, the type of procedure, and the time of day for which the patient was booked,” said Ms. Wamae.

For example, one guideline gives advice for someone on a basal-bolus regimen who is scheduled to have an endoscopy in the afternoon. Depending on the specific formulation of treatment they are taking, patients should adhere to normal treatments on the day before the procedure and the following morning, eating and drinking as normal, but omit their lunchtime dose of rapid-acting insulin and take an additional rapid-acting insulin dose with the evening meal after the procedure is complete. Another guideline describes what someone on oral agents for diabetes should do to prepare for a morning procedure. There are also additional recommendations included within the guidelines for monitoring of blood glucose.

There were no baseline standards available to see how diabetes patients fared on standard endoscopy guidelines. However, Ms. Wamae and Ms. McHoy did an audit to assess whether patients following the new guidelines successfully completed their planned procedures without an increase in the frequency of hypoglycemia or hyperglycemia.

The audit was undertaken for 16 weeks between November 2004 and March 2005, and included any adult with diabetes who was being treated with insulin or oral medication and who also was scheduled for an endoscopy or colonoscopy as an outpatient. The study sample included 40 patients.

During the course of the audit, the endoscopy department advised patients to call a DSN for advice 2 weeks prior to their procedure. The nurse instructed patients on how best to modulate their insulin or oral agent treatment in accordance with the new guidelines. Patients were then telephoned 5 days after they should have started their preprocedure preparation and asked about blood glucose control. In all, 68% of patients required preprocedure advice and 40% required advice on follow-up, but 32% asked for no advice at all.

According to Ms. Wamae, the audit showed that the guidelines worked well and improved the safety of patients. “Out of the 40 patients, none had an increase in number of hypoglycemic episodes, and some of the 12 patients who normally experience frequent hypoglycemia had fewer, possibly because of the benefits of having advice,” she said. Two patients experienced an increase in hyperglycemic episodes from the day they began preparation for their endoscopy.

An important finding from the study was that patients were more anxious if their procedure was later in the day, especially if they were on insulin. “All patients treated with insulin should be first on the procedure list in the morning,” said Ms. Wamae.

The guidelines are now hospital policy for both inpatient and outpatient endoscopies, and Ms. Wamae's colleagues at the hospital also have adapted them for day surgery procedures that normally take less than 11/2 hours. “Feedback has been very positive,” she said.

GLASGOW, SCOTLAND — Serum fibrosis markers—currently used as a research tool—have high sensitivity and specificity for diagnosing more severe forms of nonalcoholic fatty liver disease, according to a presentation at the Diabetes U.K. Annual Professional Conference.

Diagnosis of the most severe forms of nonalcoholic fatty liver disease (NAFLD), which include the onset of steatohepatitis and subsequent fibrosis and cirrhosis, requires measurement of the extent of inflammation and the presence of fibrosis. Currently, only liver biopsy can identify patients with these symptoms; such patients must be managed more aggressively than patients with less severe forms of the disease, particularly with respect to cardiovascular risk factors. However, biopsy is expensive and dangerous for the patient.

Dr. Christopher Byrne, head of the endocrinology and metabolism unit at the University of Southampton (England), said he believes “in the future, noninvasive serum markers might be better. Research is beginning to suggest that within NAFLD, a scoring system such as that using ELF [enhanced liver fibrosis assay, which looks at several serum biomarkers of fibrosis] might prove useful.” When combined with age as a risk factor, the three markers assessed by the ELF blood test—hyaluronic acid, procollagen III amino terminal peptide (PIIINP), and tissue inhibitor of metalloproteinase 1 (TIMP-1)—have around 85% specificity and sensitivity for moderate to severe NAFLD, he noted.

Alanine aminotransferase (ALT) and GammaGT, plasma markers currently used to help guide diagnosis for NAFLD, are not very accurate, according to Dr. Byrne. “ALT is an extraordinarily poor proxy. Both GammaGT and ALT are in the normal range in patients who have quite extensive NAFLD when they get to biopsy,” he explained.

NAFLD is one of the most common forms of chronic liver disease in developed countries, affecting 10%–24% of the general population, especially people with type 2 diabetes. Liver damage is caused by accumulation of lipids, oxidative stress, and inflammation from the release of proinflammatory cytokines. The associated marked insulin resistance in NAFLD has led some scientists to propose that it might be a malignant form of metabolic syndrome.

“Even adjusting for obesity, patients with NAFLD have marked increases in nonesterified fatty acid accumulation,” said Dr. Byrne. “So release of these from adipocyte depots into circulation is abnormal in these patients. But we don't know why [it is] associated with marked insulin resistance.”

He presented research showing that a group of 1,974 type 2 diabetes patients with NAFLD had a significantly higher prevalence of coronary, cerebral, and peripheral cardiovascular disease than a group of 418 type 2 diabetics without fatty livers. “NAFLD is associated with increased mortality, especially at the more severe end,” said Dr. Byrne. “In these patients, even adjusting for all conventional cardiovascular risk factors and features of the metabolic syndrome, NAFLD is an independent cardiovascular risk factor. If you find NAFLD, think accelerated cardiovascular risk and treat aggressively.”

Treatment recommendations include initial weight loss in patients that are obese; limited evidence suggests that pharmacologic therapy with glitazones also can be used to increase insulin sensitivity and decrease liver fat content. “Glitazones show promise,” said Dr. Byrne. “A new indication for glitazone therapy may prove to be NAFLD.”

GLASGOW, SCOTLAND — Serum fibrosis markers—currently used as a research tool—have high sensitivity and specificity for diagnosing more severe forms of nonalcoholic fatty liver disease, according to a presentation at the Diabetes U.K. Annual Professional Conference.

Diagnosis of the most severe forms of nonalcoholic fatty liver disease (NAFLD), which include the onset of steatohepatitis and subsequent fibrosis and cirrhosis, requires measurement of the extent of inflammation and the presence of fibrosis. Currently, only liver biopsy can identify patients with these symptoms; such patients must be managed more aggressively than patients with less severe forms of the disease, particularly with respect to cardiovascular risk factors. However, biopsy is expensive and dangerous for the patient.

Dr. Christopher Byrne, head of the endocrinology and metabolism unit at the University of Southampton (England), said he believes “in the future, noninvasive serum markers might be better. Research is beginning to suggest that within NAFLD, a scoring system such as that using ELF [enhanced liver fibrosis assay, which looks at several serum biomarkers of fibrosis] might prove useful.” When combined with age as a risk factor, the three markers assessed by the ELF blood test—hyaluronic acid, procollagen III amino terminal peptide (PIIINP), and tissue inhibitor of metalloproteinase 1 (TIMP-1)—have around 85% specificity and sensitivity for moderate to severe NAFLD, he noted.

Alanine aminotransferase (ALT) and GammaGT, plasma markers currently used to help guide diagnosis for NAFLD, are not very accurate, according to Dr. Byrne. “ALT is an extraordinarily poor proxy. Both GammaGT and ALT are in the normal range in patients who have quite extensive NAFLD when they get to biopsy,” he explained.

NAFLD is one of the most common forms of chronic liver disease in developed countries, affecting 10%–24% of the general population, especially people with type 2 diabetes. Liver damage is caused by accumulation of lipids, oxidative stress, and inflammation from the release of proinflammatory cytokines. The associated marked insulin resistance in NAFLD has led some scientists to propose that it might be a malignant form of metabolic syndrome.

“Even adjusting for obesity, patients with NAFLD have marked increases in nonesterified fatty acid accumulation,” said Dr. Byrne. “So release of these from adipocyte depots into circulation is abnormal in these patients. But we don't know why [it is] associated with marked insulin resistance.”

He presented research showing that a group of 1,974 type 2 diabetes patients with NAFLD had a significantly higher prevalence of coronary, cerebral, and peripheral cardiovascular disease than a group of 418 type 2 diabetics without fatty livers. “NAFLD is associated with increased mortality, especially at the more severe end,” said Dr. Byrne. “In these patients, even adjusting for all conventional cardiovascular risk factors and features of the metabolic syndrome, NAFLD is an independent cardiovascular risk factor. If you find NAFLD, think accelerated cardiovascular risk and treat aggressively.”

Treatment recommendations include initial weight loss in patients that are obese; limited evidence suggests that pharmacologic therapy with glitazones also can be used to increase insulin sensitivity and decrease liver fat content. “Glitazones show promise,” said Dr. Byrne. “A new indication for glitazone therapy may prove to be NAFLD.”

GLASGOW, SCOTLAND — Serum fibrosis markers—currently used as a research tool—have high sensitivity and specificity for diagnosing more severe forms of nonalcoholic fatty liver disease, according to a presentation at the Diabetes U.K. Annual Professional Conference.

Diagnosis of the most severe forms of nonalcoholic fatty liver disease (NAFLD), which include the onset of steatohepatitis and subsequent fibrosis and cirrhosis, requires measurement of the extent of inflammation and the presence of fibrosis. Currently, only liver biopsy can identify patients with these symptoms; such patients must be managed more aggressively than patients with less severe forms of the disease, particularly with respect to cardiovascular risk factors. However, biopsy is expensive and dangerous for the patient.

Dr. Christopher Byrne, head of the endocrinology and metabolism unit at the University of Southampton (England), said he believes “in the future, noninvasive serum markers might be better. Research is beginning to suggest that within NAFLD, a scoring system such as that using ELF [enhanced liver fibrosis assay, which looks at several serum biomarkers of fibrosis] might prove useful.” When combined with age as a risk factor, the three markers assessed by the ELF blood test—hyaluronic acid, procollagen III amino terminal peptide (PIIINP), and tissue inhibitor of metalloproteinase 1 (TIMP-1)—have around 85% specificity and sensitivity for moderate to severe NAFLD, he noted.

Alanine aminotransferase (ALT) and GammaGT, plasma markers currently used to help guide diagnosis for NAFLD, are not very accurate, according to Dr. Byrne. “ALT is an extraordinarily poor proxy. Both GammaGT and ALT are in the normal range in patients who have quite extensive NAFLD when they get to biopsy,” he explained.

NAFLD is one of the most common forms of chronic liver disease in developed countries, affecting 10%–24% of the general population, especially people with type 2 diabetes. Liver damage is caused by accumulation of lipids, oxidative stress, and inflammation from the release of proinflammatory cytokines. The associated marked insulin resistance in NAFLD has led some scientists to propose that it might be a malignant form of metabolic syndrome.

“Even adjusting for obesity, patients with NAFLD have marked increases in nonesterified fatty acid accumulation,” said Dr. Byrne. “So release of these from adipocyte depots into circulation is abnormal in these patients. But we don't know why [it is] associated with marked insulin resistance.”

He presented research showing that a group of 1,974 type 2 diabetes patients with NAFLD had a significantly higher prevalence of coronary, cerebral, and peripheral cardiovascular disease than a group of 418 type 2 diabetics without fatty livers. “NAFLD is associated with increased mortality, especially at the more severe end,” said Dr. Byrne. “In these patients, even adjusting for all conventional cardiovascular risk factors and features of the metabolic syndrome, NAFLD is an independent cardiovascular risk factor. If you find NAFLD, think accelerated cardiovascular risk and treat aggressively.”

Treatment recommendations include initial weight loss in patients that are obese; limited evidence suggests that pharmacologic therapy with glitazones also can be used to increase insulin sensitivity and decrease liver fat content. “Glitazones show promise,” said Dr. Byrne. “A new indication for glitazone therapy may prove to be NAFLD.”

GLASGOW, SCOTLAND — The overall prevalence of diabetes among inpatients in Liverpool has increased significantly since 1990, according to a follow-up of one of the few studies of inpatient diabetes done during the 1980s and 1990s.

Researchers conducted a point-prevalence study to assess the extent of diabetes among patients admitted to Aintree University Hospital in Liverpool for any reason in 1990. The study was repeated in 2003 to enable comparison of the changes in diabetes prevalence and hospital capacity.

“The strength of the studies is that we went round and examined all the case notes of everyone that was in hospital,” said Dr. Ian McFarlane, a consultant in the department of diabetes and endocrinology at the hospital, who presented the results at the Diabetes U.K. Annual Professional Conference. “But the drawback is that it is just a snapshot view.”

In 1990, the researchers identified 93 diabetes patients in the hospital. Their median age was 74 years and in 26% of cases, the primary admission was related to their diabetes. In 2003, there were more diabetic patients (126 versus 93), but fewer of the admissions—12.6%—were related to diabetes.

Overall, the prevalence of diabetes among inpatients increased significantly from 7% in 1990 to 11.1% in 2003. The proportion of patients referred to the diabetes team also rose: from 10% in 1990 to 27.5% in 2003.

While prevalence of diabetes among inpatients seems to be increasing in line with national trends, the most worrisome figure for Dr. McFarlane was the small proportion of patients who were referred to the specialist team on admission. “Management is suboptimal in patients who are not referred to the diabetes team,” he said. “We considered management inappropriate in 20% of cases in 1990 and 27% in 2003.”

Examples of inappropriate care included high blood sugar being recorded but not followed up on and metformin being given to patients with renal failure. Only 48% of patients had records of diabetes complications present and only 24% had hemoglobin A_1c measurements “even though it should be done in everybody,” said Dr. McFarlane.

While the typical length of stay fell from 16 days in 1990 to 12 in 2003, Dr. McFarlane said this was related more to economic pressures than to better treatment. “The total hospital stay has fallen a bit with all the pressure to turn over beds, but people with diabetes still stay twice as long as those without,” he said.

To enable good management of inpatients with diabetes, Dr. McFarlane recommended the hospital use a multidisciplinary inpatient diabetes team that is on call 24 hours a day. He also suggested using a diabetes specialist nurse and ward-based diabetes “link” nurses to communicate with the specialist team, in addition to developing guidelines for diabetic emergencies and for procedures on wards.

One of the beneficial results of having done the 1990 study was to convince hospital managers that there was a substantial problem. “Having demonstrated the size of the problem, we managed to persuade the powers that be to fund an inpatient specialist nurse,” said Dr McFarlane. “But if nurses turn over all the time, the skills that we help teach the staff nurse on the wards are blown around by all the vagaries of the nurses leaving,” he added.

The changes in diabetes demographics among inpatients have occurred against a background of substantial hospital changes in the United Kingdom. There are fewer hospital beds, increasing acute admissions, dramatic alterations to the out-of-hours care provided by general practitioners, and higher bed occupancy, said Dr. McFarlane. But it is the pressure to discharge early that causes inpatient care to fall apart.

GLASGOW, SCOTLAND — The overall prevalence of diabetes among inpatients in Liverpool has increased significantly since 1990, according to a follow-up of one of the few studies of inpatient diabetes done during the 1980s and 1990s.

Researchers conducted a point-prevalence study to assess the extent of diabetes among patients admitted to Aintree University Hospital in Liverpool for any reason in 1990. The study was repeated in 2003 to enable comparison of the changes in diabetes prevalence and hospital capacity.

“The strength of the studies is that we went round and examined all the case notes of everyone that was in hospital,” said Dr. Ian McFarlane, a consultant in the department of diabetes and endocrinology at the hospital, who presented the results at the Diabetes U.K. Annual Professional Conference. “But the drawback is that it is just a snapshot view.”

In 1990, the researchers identified 93 diabetes patients in the hospital. Their median age was 74 years and in 26% of cases, the primary admission was related to their diabetes. In 2003, there were more diabetic patients (126 versus 93), but fewer of the admissions—12.6%—were related to diabetes.

Overall, the prevalence of diabetes among inpatients increased significantly from 7% in 1990 to 11.1% in 2003. The proportion of patients referred to the diabetes team also rose: from 10% in 1990 to 27.5% in 2003.

While prevalence of diabetes among inpatients seems to be increasing in line with national trends, the most worrisome figure for Dr. McFarlane was the small proportion of patients who were referred to the specialist team on admission. “Management is suboptimal in patients who are not referred to the diabetes team,” he said. “We considered management inappropriate in 20% of cases in 1990 and 27% in 2003.”

Examples of inappropriate care included high blood sugar being recorded but not followed up on and metformin being given to patients with renal failure. Only 48% of patients had records of diabetes complications present and only 24% had hemoglobin A_1c measurements “even though it should be done in everybody,” said Dr. McFarlane.

While the typical length of stay fell from 16 days in 1990 to 12 in 2003, Dr. McFarlane said this was related more to economic pressures than to better treatment. “The total hospital stay has fallen a bit with all the pressure to turn over beds, but people with diabetes still stay twice as long as those without,” he said.

To enable good management of inpatients with diabetes, Dr. McFarlane recommended the hospital use a multidisciplinary inpatient diabetes team that is on call 24 hours a day. He also suggested using a diabetes specialist nurse and ward-based diabetes “link” nurses to communicate with the specialist team, in addition to developing guidelines for diabetic emergencies and for procedures on wards.

One of the beneficial results of having done the 1990 study was to convince hospital managers that there was a substantial problem. “Having demonstrated the size of the problem, we managed to persuade the powers that be to fund an inpatient specialist nurse,” said Dr McFarlane. “But if nurses turn over all the time, the skills that we help teach the staff nurse on the wards are blown around by all the vagaries of the nurses leaving,” he added.

The changes in diabetes demographics among inpatients have occurred against a background of substantial hospital changes in the United Kingdom. There are fewer hospital beds, increasing acute admissions, dramatic alterations to the out-of-hours care provided by general practitioners, and higher bed occupancy, said Dr. McFarlane. But it is the pressure to discharge early that causes inpatient care to fall apart.

GLASGOW, SCOTLAND — The overall prevalence of diabetes among inpatients in Liverpool has increased significantly since 1990, according to a follow-up of one of the few studies of inpatient diabetes done during the 1980s and 1990s.

Researchers conducted a point-prevalence study to assess the extent of diabetes among patients admitted to Aintree University Hospital in Liverpool for any reason in 1990. The study was repeated in 2003 to enable comparison of the changes in diabetes prevalence and hospital capacity.

“The strength of the studies is that we went round and examined all the case notes of everyone that was in hospital,” said Dr. Ian McFarlane, a consultant in the department of diabetes and endocrinology at the hospital, who presented the results at the Diabetes U.K. Annual Professional Conference. “But the drawback is that it is just a snapshot view.”

In 1990, the researchers identified 93 diabetes patients in the hospital. Their median age was 74 years and in 26% of cases, the primary admission was related to their diabetes. In 2003, there were more diabetic patients (126 versus 93), but fewer of the admissions—12.6%—were related to diabetes.

Overall, the prevalence of diabetes among inpatients increased significantly from 7% in 1990 to 11.1% in 2003. The proportion of patients referred to the diabetes team also rose: from 10% in 1990 to 27.5% in 2003.

While prevalence of diabetes among inpatients seems to be increasing in line with national trends, the most worrisome figure for Dr. McFarlane was the small proportion of patients who were referred to the specialist team on admission. “Management is suboptimal in patients who are not referred to the diabetes team,” he said. “We considered management inappropriate in 20% of cases in 1990 and 27% in 2003.”

Examples of inappropriate care included high blood sugar being recorded but not followed up on and metformin being given to patients with renal failure. Only 48% of patients had records of diabetes complications present and only 24% had hemoglobin A_1c measurements “even though it should be done in everybody,” said Dr. McFarlane.

While the typical length of stay fell from 16 days in 1990 to 12 in 2003, Dr. McFarlane said this was related more to economic pressures than to better treatment. “The total hospital stay has fallen a bit with all the pressure to turn over beds, but people with diabetes still stay twice as long as those without,” he said.

To enable good management of inpatients with diabetes, Dr. McFarlane recommended the hospital use a multidisciplinary inpatient diabetes team that is on call 24 hours a day. He also suggested using a diabetes specialist nurse and ward-based diabetes “link” nurses to communicate with the specialist team, in addition to developing guidelines for diabetic emergencies and for procedures on wards.

One of the beneficial results of having done the 1990 study was to convince hospital managers that there was a substantial problem. “Having demonstrated the size of the problem, we managed to persuade the powers that be to fund an inpatient specialist nurse,” said Dr McFarlane. “But if nurses turn over all the time, the skills that we help teach the staff nurse on the wards are blown around by all the vagaries of the nurses leaving,” he added.

The changes in diabetes demographics among inpatients have occurred against a background of substantial hospital changes in the United Kingdom. There are fewer hospital beds, increasing acute admissions, dramatic alterations to the out-of-hours care provided by general practitioners, and higher bed occupancy, said Dr. McFarlane. But it is the pressure to discharge early that causes inpatient care to fall apart.

GLASGOW, SCOTLAND — Want your diabetes patients to get more exercise? Tell them to go get dogs, Dr. Steve Cleland said at the Diabetes U.K. Annual Professional Conference.

Not only do animals require their owners to increase their physical activity, but they also provide companionship, which reduces depression and can aid in diet management, said Dr. Cleland, who is a consultant in diabetes and endocrinology at Stobhill Hospital, Glasgow. One other benefit of dogs is that they also eat leftovers, he added.

Dr. Cleland's theory arose after observing that in his career only five of his patients had managed to improve their metabolism through exercise, and all of them have dogs. He explained that for many patients with diabetes, formal exercise can seem daunting. “For someone who is 50, carrying excess weight, and not used to it, exercise can be difficult,” he said. However, simply increasing activity levels—as opposed to embarking on a specific training regime—can burn calories. Dr. Cleland accused diabetologists of having “failed in being evangelists for exercise” in their efforts to encourage their diabetic patients to give up their sedentary lifestyles.

There is a precarious balance between taking in enough calories to replace those burned by moving around, and taking in too many calories, according to Dr. Cleland. “When humans become overweight, obese, and inactive, energy supply exceeds demand,” he said. “Fat cells spewing out fatty acids that are not being used in muscle contraction [cause problems].”

Among these problems are reduced mitochondrial capacity, as well as abnormal changes in the sympathetic nerve system and in the neuroendocrine and adipocyte feedback systems—in addition to the obvious accumulation of fat in places where it does not belong. The results, said Dr. Cleland, are accelerated aging of cells, heart problems, and perhaps cancer and dementia.

Exercise involves a balance between two states: catabolic and metabolic, both of which involve hormones. And the body has developed many biologic backup mechanisms to respond to exercise, he said.

GLASGOW, SCOTLAND — Want your diabetes patients to get more exercise? Tell them to go get dogs, Dr. Steve Cleland said at the Diabetes U.K. Annual Professional Conference.

Not only do animals require their owners to increase their physical activity, but they also provide companionship, which reduces depression and can aid in diet management, said Dr. Cleland, who is a consultant in diabetes and endocrinology at Stobhill Hospital, Glasgow. One other benefit of dogs is that they also eat leftovers, he added.

Dr. Cleland's theory arose after observing that in his career only five of his patients had managed to improve their metabolism through exercise, and all of them have dogs. He explained that for many patients with diabetes, formal exercise can seem daunting. “For someone who is 50, carrying excess weight, and not used to it, exercise can be difficult,” he said. However, simply increasing activity levels—as opposed to embarking on a specific training regime—can burn calories. Dr. Cleland accused diabetologists of having “failed in being evangelists for exercise” in their efforts to encourage their diabetic patients to give up their sedentary lifestyles.

There is a precarious balance between taking in enough calories to replace those burned by moving around, and taking in too many calories, according to Dr. Cleland. “When humans become overweight, obese, and inactive, energy supply exceeds demand,” he said. “Fat cells spewing out fatty acids that are not being used in muscle contraction [cause problems].”

Among these problems are reduced mitochondrial capacity, as well as abnormal changes in the sympathetic nerve system and in the neuroendocrine and adipocyte feedback systems—in addition to the obvious accumulation of fat in places where it does not belong. The results, said Dr. Cleland, are accelerated aging of cells, heart problems, and perhaps cancer and dementia.

Exercise involves a balance between two states: catabolic and metabolic, both of which involve hormones. And the body has developed many biologic backup mechanisms to respond to exercise, he said.

GLASGOW, SCOTLAND — Want your diabetes patients to get more exercise? Tell them to go get dogs, Dr. Steve Cleland said at the Diabetes U.K. Annual Professional Conference.

Not only do animals require their owners to increase their physical activity, but they also provide companionship, which reduces depression and can aid in diet management, said Dr. Cleland, who is a consultant in diabetes and endocrinology at Stobhill Hospital, Glasgow. One other benefit of dogs is that they also eat leftovers, he added.

Dr. Cleland's theory arose after observing that in his career only five of his patients had managed to improve their metabolism through exercise, and all of them have dogs. He explained that for many patients with diabetes, formal exercise can seem daunting. “For someone who is 50, carrying excess weight, and not used to it, exercise can be difficult,” he said. However, simply increasing activity levels—as opposed to embarking on a specific training regime—can burn calories. Dr. Cleland accused diabetologists of having “failed in being evangelists for exercise” in their efforts to encourage their diabetic patients to give up their sedentary lifestyles.

There is a precarious balance between taking in enough calories to replace those burned by moving around, and taking in too many calories, according to Dr. Cleland. “When humans become overweight, obese, and inactive, energy supply exceeds demand,” he said. “Fat cells spewing out fatty acids that are not being used in muscle contraction [cause problems].”

Among these problems are reduced mitochondrial capacity, as well as abnormal changes in the sympathetic nerve system and in the neuroendocrine and adipocyte feedback systems—in addition to the obvious accumulation of fat in places where it does not belong. The results, said Dr. Cleland, are accelerated aging of cells, heart problems, and perhaps cancer and dementia.

Exercise involves a balance between two states: catabolic and metabolic, both of which involve hormones. And the body has developed many biologic backup mechanisms to respond to exercise, he said.

GLASGOW, SCOTLAND — Vulnerable individuals need personalized help and information presented in appropriate formats to enable them to manage their own diabetes, Madeline Turton said at the Diabetes U.K. Annual Professional Conference.

Ms. Turton, a diabetes patient and chair of Diabetes U.K.'s West Dorset Group, Weymouth (England), presented the results of a qualitative investigation into the attitudes of vulnerable groups to information about their diabetes. She defined vulnerable adults as any person older than 18 who may be in need of community care services and unable to take care of themselves or protect themselves against harm or exploitation.

Included in the survey were people from nomadic communities who are transient and hard to reach; people with learning difficulties for whom accessing appropriate information is a problem; and prisoners, of whom a disproportionate number come from ethic groups that have a high prevalence of diabetes. The exact number of patients surveyed was not available.

Through a series of interviews, Ms. Turton sought to ascertain how health professionals could most productively help support these groups. Several points were repeatedly cited by interviewees as potential areas for improvement.

First was the need to meet health professionals in an environment in which they felt comfortable and empowered, usually in the patients' own community. Health clinics frequently do not meet these criteria, said Ms. Turton.

She said the most common request from vulnerable individuals was that health professionals should “use language and resources with which I am familiar and will facilitate my understanding.” In addition, the survey highlighted that vulnerable people want messages repeated in “a supportive and nonjudgmental way.”

An issue that particularly affects disabled people and those with learning disabilities was the need to maintain their independence, according to Ms. Turton. “Vulnerable people with diabetes need help to gain the support of family and friends without them taking over,” she said. “People with learning disabilities were worried about parents taking them back home, and elderly people were scared of children putting them in homes or taking them in.”

Vulnerability can be affected by various factors, including level of understanding and state of health (either physical or psychological), Ms. Turton said. But for all groups, communication is vitally important to helping them manage their diabetes.

“Generalization is not helpful, and it is important to realize that people may belong to one or several vulnerable groups,” she said.

Ms. Turton said the message to diabetes professionals was that they cannot improve compliance among their vulnerable patients—but they can help their patients to manage themselves. “You can get people into a place where they can better manage their own diabetes and promote personal empowerment through appropriate formatting of information,” she concluded.

GLASGOW, SCOTLAND — Vulnerable individuals need personalized help and information presented in appropriate formats to enable them to manage their own diabetes, Madeline Turton said at the Diabetes U.K. Annual Professional Conference.

Ms. Turton, a diabetes patient and chair of Diabetes U.K.'s West Dorset Group, Weymouth (England), presented the results of a qualitative investigation into the attitudes of vulnerable groups to information about their diabetes. She defined vulnerable adults as any person older than 18 who may be in need of community care services and unable to take care of themselves or protect themselves against harm or exploitation.

Included in the survey were people from nomadic communities who are transient and hard to reach; people with learning difficulties for whom accessing appropriate information is a problem; and prisoners, of whom a disproportionate number come from ethic groups that have a high prevalence of diabetes. The exact number of patients surveyed was not available.

Through a series of interviews, Ms. Turton sought to ascertain how health professionals could most productively help support these groups. Several points were repeatedly cited by interviewees as potential areas for improvement.

First was the need to meet health professionals in an environment in which they felt comfortable and empowered, usually in the patients' own community. Health clinics frequently do not meet these criteria, said Ms. Turton.

She said the most common request from vulnerable individuals was that health professionals should “use language and resources with which I am familiar and will facilitate my understanding.” In addition, the survey highlighted that vulnerable people want messages repeated in “a supportive and nonjudgmental way.”

An issue that particularly affects disabled people and those with learning disabilities was the need to maintain their independence, according to Ms. Turton. “Vulnerable people with diabetes need help to gain the support of family and friends without them taking over,” she said. “People with learning disabilities were worried about parents taking them back home, and elderly people were scared of children putting them in homes or taking them in.”

Vulnerability can be affected by various factors, including level of understanding and state of health (either physical or psychological), Ms. Turton said. But for all groups, communication is vitally important to helping them manage their diabetes.

“Generalization is not helpful, and it is important to realize that people may belong to one or several vulnerable groups,” she said.

Ms. Turton said the message to diabetes professionals was that they cannot improve compliance among their vulnerable patients—but they can help their patients to manage themselves. “You can get people into a place where they can better manage their own diabetes and promote personal empowerment through appropriate formatting of information,” she concluded.

GLASGOW, SCOTLAND — Vulnerable individuals need personalized help and information presented in appropriate formats to enable them to manage their own diabetes, Madeline Turton said at the Diabetes U.K. Annual Professional Conference.

Ms. Turton, a diabetes patient and chair of Diabetes U.K.'s West Dorset Group, Weymouth (England), presented the results of a qualitative investigation into the attitudes of vulnerable groups to information about their diabetes. She defined vulnerable adults as any person older than 18 who may be in need of community care services and unable to take care of themselves or protect themselves against harm or exploitation.

Included in the survey were people from nomadic communities who are transient and hard to reach; people with learning difficulties for whom accessing appropriate information is a problem; and prisoners, of whom a disproportionate number come from ethic groups that have a high prevalence of diabetes. The exact number of patients surveyed was not available.

Through a series of interviews, Ms. Turton sought to ascertain how health professionals could most productively help support these groups. Several points were repeatedly cited by interviewees as potential areas for improvement.

First was the need to meet health professionals in an environment in which they felt comfortable and empowered, usually in the patients' own community. Health clinics frequently do not meet these criteria, said Ms. Turton.

She said the most common request from vulnerable individuals was that health professionals should “use language and resources with which I am familiar and will facilitate my understanding.” In addition, the survey highlighted that vulnerable people want messages repeated in “a supportive and nonjudgmental way.”

An issue that particularly affects disabled people and those with learning disabilities was the need to maintain their independence, according to Ms. Turton. “Vulnerable people with diabetes need help to gain the support of family and friends without them taking over,” she said. “People with learning disabilities were worried about parents taking them back home, and elderly people were scared of children putting them in homes or taking them in.”

Vulnerability can be affected by various factors, including level of understanding and state of health (either physical or psychological), Ms. Turton said. But for all groups, communication is vitally important to helping them manage their diabetes.

“Generalization is not helpful, and it is important to realize that people may belong to one or several vulnerable groups,” she said.

Ms. Turton said the message to diabetes professionals was that they cannot improve compliance among their vulnerable patients—but they can help their patients to manage themselves. “You can get people into a place where they can better manage their own diabetes and promote personal empowerment through appropriate formatting of information,” she concluded.

GLASGOW, SCOTLAND — Implementation of a dedicated multidisciplinary foot clinic working in collaboration with a community foot protection team cut amputation rates by up to 75% at a hospital in the eastern English town of Ipswich, according to data reported at the Diabetes U.K. Annual Professional Conference.

Ipswich Hospital National Health Service Trust initially set up a foot clinic for patients with diabetes in 1987, but the arrangement did not work very well, according to Dr. Gerry Rayman, a consultant in diabetes and endocrinology at the hospital.

“It was only done once a week with only one treatment room, so the clinic was overcrowded, appointments were delayed, and there was insufficient time to counsel patients, thereby increasing cross-infection risk,” said Dr. Rayman.

Other problems included delayed or inappropriate referrals, conflicts over wound care, and low levels of awareness about the clinic on the hospital's wards. “People were sent out from hospital with dressings not appropriate in the community, and patients were kept in hospital far too long,” he continued. The result was that “patients admitted to hospital with diabetes would end up with heel problems, even though it was preventable, and there were several unnecessary amputations.”

In 1997, Dr. Rayman and his colleagues agreed to develop the patient-centered foot service by giving it a designated area, running it 5 days a week, and appointing a specialized podiatrist and a part-time diabetes specialist nurse linked to the foot clinic and the wards. The team also worked on improving communication between community and inpatient services with a series of meetings and education programs involving surgeons, interventional radiologists, family doctors, and practice nurses.

The team started surveying the wards twice a week to find patients in need of the service, and took quick action: angioplasty and intervention within a week on urgent cases, within 24 hours on limb-threatening cases, and usually within 2–3 weeks in other cases.

There has been a steady increase in usage since the service was set up. New patient referrals have climbed from just over 100 a year in 2000 to 250 in 2005, and total patient visits have risen from 2,500 to just below 5,000.

“What we have seen is a dramatic increase in new referrals. Not surprisingly, follow-up outpatient appointments have increased dramatically too,” said Dr. Rayman.

A prospective audit of the new program was performed during 1997–2000 and then again during 2002–2006, after a break enforced by funding problems. The audit involved identification of all inpatients with diabetic foot problems through visits and phone calls to relevant wards twice a week.

“Everyone coming in who required amputation was identified [without] relying on hospital coding, which misses about 20%,” said Dr. Rayman. The results were striking.

“When audit started, there was a fall in amputation rates, particularly in major amputations. When we lost inpatient surveillance [from 2000 to 2002], amputations went up, but now they have gone down again,” said Dr. Rayman. “We have had a 50%–75% reduction in amputation rates compared to 1995.”

Dr. Rayman said he is convinced that the findings are robust. “We have a very small community, with no cross-boundary referrals, so we can easily identify people who leave our community. Therefore we feel our data are very reliable.”

However, he added, “This is just one model. … This system may not be applicable in other geographical locations or with other personnel.”

GLASGOW, SCOTLAND — Implementation of a dedicated multidisciplinary foot clinic working in collaboration with a community foot protection team cut amputation rates by up to 75% at a hospital in the eastern English town of Ipswich, according to data reported at the Diabetes U.K. Annual Professional Conference.

Ipswich Hospital National Health Service Trust initially set up a foot clinic for patients with diabetes in 1987, but the arrangement did not work very well, according to Dr. Gerry Rayman, a consultant in diabetes and endocrinology at the hospital.

“It was only done once a week with only one treatment room, so the clinic was overcrowded, appointments were delayed, and there was insufficient time to counsel patients, thereby increasing cross-infection risk,” said Dr. Rayman.

Other problems included delayed or inappropriate referrals, conflicts over wound care, and low levels of awareness about the clinic on the hospital's wards. “People were sent out from hospital with dressings not appropriate in the community, and patients were kept in hospital far too long,” he continued. The result was that “patients admitted to hospital with diabetes would end up with heel problems, even though it was preventable, and there were several unnecessary amputations.”

In 1997, Dr. Rayman and his colleagues agreed to develop the patient-centered foot service by giving it a designated area, running it 5 days a week, and appointing a specialized podiatrist and a part-time diabetes specialist nurse linked to the foot clinic and the wards. The team also worked on improving communication between community and inpatient services with a series of meetings and education programs involving surgeons, interventional radiologists, family doctors, and practice nurses.

The team started surveying the wards twice a week to find patients in need of the service, and took quick action: angioplasty and intervention within a week on urgent cases, within 24 hours on limb-threatening cases, and usually within 2–3 weeks in other cases.

There has been a steady increase in usage since the service was set up. New patient referrals have climbed from just over 100 a year in 2000 to 250 in 2005, and total patient visits have risen from 2,500 to just below 5,000.

“What we have seen is a dramatic increase in new referrals. Not surprisingly, follow-up outpatient appointments have increased dramatically too,” said Dr. Rayman.

A prospective audit of the new program was performed during 1997–2000 and then again during 2002–2006, after a break enforced by funding problems. The audit involved identification of all inpatients with diabetic foot problems through visits and phone calls to relevant wards twice a week.

“Everyone coming in who required amputation was identified [without] relying on hospital coding, which misses about 20%,” said Dr. Rayman. The results were striking.

“When audit started, there was a fall in amputation rates, particularly in major amputations. When we lost inpatient surveillance [from 2000 to 2002], amputations went up, but now they have gone down again,” said Dr. Rayman. “We have had a 50%–75% reduction in amputation rates compared to 1995.”

Dr. Rayman said he is convinced that the findings are robust. “We have a very small community, with no cross-boundary referrals, so we can easily identify people who leave our community. Therefore we feel our data are very reliable.”

However, he added, “This is just one model. … This system may not be applicable in other geographical locations or with other personnel.”

GLASGOW, SCOTLAND — Implementation of a dedicated multidisciplinary foot clinic working in collaboration with a community foot protection team cut amputation rates by up to 75% at a hospital in the eastern English town of Ipswich, according to data reported at the Diabetes U.K. Annual Professional Conference.

Ipswich Hospital National Health Service Trust initially set up a foot clinic for patients with diabetes in 1987, but the arrangement did not work very well, according to Dr. Gerry Rayman, a consultant in diabetes and endocrinology at the hospital.

“It was only done once a week with only one treatment room, so the clinic was overcrowded, appointments were delayed, and there was insufficient time to counsel patients, thereby increasing cross-infection risk,” said Dr. Rayman.

Other problems included delayed or inappropriate referrals, conflicts over wound care, and low levels of awareness about the clinic on the hospital's wards. “People were sent out from hospital with dressings not appropriate in the community, and patients were kept in hospital far too long,” he continued. The result was that “patients admitted to hospital with diabetes would end up with heel problems, even though it was preventable, and there were several unnecessary amputations.”

In 1997, Dr. Rayman and his colleagues agreed to develop the patient-centered foot service by giving it a designated area, running it 5 days a week, and appointing a specialized podiatrist and a part-time diabetes specialist nurse linked to the foot clinic and the wards. The team also worked on improving communication between community and inpatient services with a series of meetings and education programs involving surgeons, interventional radiologists, family doctors, and practice nurses.

The team started surveying the wards twice a week to find patients in need of the service, and took quick action: angioplasty and intervention within a week on urgent cases, within 24 hours on limb-threatening cases, and usually within 2–3 weeks in other cases.

There has been a steady increase in usage since the service was set up. New patient referrals have climbed from just over 100 a year in 2000 to 250 in 2005, and total patient visits have risen from 2,500 to just below 5,000.

“What we have seen is a dramatic increase in new referrals. Not surprisingly, follow-up outpatient appointments have increased dramatically too,” said Dr. Rayman.

A prospective audit of the new program was performed during 1997–2000 and then again during 2002–2006, after a break enforced by funding problems. The audit involved identification of all inpatients with diabetic foot problems through visits and phone calls to relevant wards twice a week.

“Everyone coming in who required amputation was identified [without] relying on hospital coding, which misses about 20%,” said Dr. Rayman. The results were striking.

“When audit started, there was a fall in amputation rates, particularly in major amputations. When we lost inpatient surveillance [from 2000 to 2002], amputations went up, but now they have gone down again,” said Dr. Rayman. “We have had a 50%–75% reduction in amputation rates compared to 1995.”

Dr. Rayman said he is convinced that the findings are robust. “We have a very small community, with no cross-boundary referrals, so we can easily identify people who leave our community. Therefore we feel our data are very reliable.”

However, he added, “This is just one model. … This system may not be applicable in other geographical locations or with other personnel.”

BARCELONA — Physicians and other health care workers should use clinical consultations to identify all individuals at high risk of developing type 2 diabetes, according to an International Diabetes Federation (IDF) consensus statement released at an international congress on prediabetes and metabolic syndrome.

Speaking at a press conference to mark the report's launch, Dr. Paul Zimmet, director of the International Diabetes Institute, Melbourne, stressed that renewed advocacy is needed to combat worldwide projected increases in diabetes, which he labeled “the largest and fastest-growing disease epidemic in history.”

“Since the 1980s, the number of people with diabetes has grown threefold. … With 246 million people with diabetes now and 380 million people with diabetes [predicted] by 2025, diabetes is set to bankrupt national economies,” warned Dr. Zimmet. And if numbers of people with impaired glucose tolerance, or prediabetes, are added to that sum, the at-risk population swells to 800 million by 2025, he said.

The IDF consensus recommends a two-pronged approach to prevention aimed at halting the rise in diabetes and associated conditions, targeting both at-risk individuals and the whole population. Central to the high-risk approach is to identify the target group, explained Dr. George Alberti, senior research fellow at Imperial College, London, and coauthor of the IDF statement. However, he said, this is “difficult because so many people won't have any obvious signs.”

The one external feature that does indicate high risk of diabetes is waist measurement. “The easiest way for most people is to look and see if they can see their feet,” Dr. Alberti said. The IDF suggests that this method should be the main one used by resource-poor countries to identify their at-risk populations, but physicians can also use validated questionnaires to assess risk status.

Once suspicion of risk is identified, explained Dr. Alberti, physicians should then measure blood glucose in their patients to identify existing undiagnosed metabolic syndrome or diabetes. This group can then be targeted with interventions to induce lifestyle changes and increase weight loss. “It is easy. Eat less and walk more,” Dr. Alberti said.

Population-wide efforts need to focus on national plans, he added. Governments must support the idea of healthy lifestyle education in schools, encouraging people to walk around more, and leaning on the food industry to act responsibly when it comes to advertising its products. However, he said, nongovernmental organizations and charities have an important role to play in raising awareness of the issue.

“It is about getting the [nongovernmental organizations] and the diabetes organizations to keep prodding away at the government. The key is repetitive actions,” he said. “There is no point in saying something once to politicians; you have to say it over and over again.”

The IDF calls for all countries to adopt national diabetes prevention plans that bring together strategies for prevention, secondary prevention, and treatment of diabetes as associated disorders. Stressing that healthy environments are key to achieving population-wide behavior change, Dr. Jean-Claude Mbanya, president-elect of the IDF and vice dean of the faculty of medicine and biomedical sciences, University of Yaounde, Cameroon, said a key feature of these plans should be collaboration between all government sectors, including health, education, sports, and agriculture.

Avi Friedman, Ph.D., professor of architecture at McGill University, Montreal, who supports the IDF call for a broad view on health improvement, said, “Inadvertently, our own government authorities may have contributed to this epidemic by allowing developers to create urban social problems. … Urban sprawls are part and parcel of new developments without proper attention to building design, sidewalks, bike paths, public transport corridors, playing fields, and friendly exercise areas that are essential and need to be accessible to people who want to maintain a healthy lifestyle.”

BARCELONA — Physicians and other health care workers should use clinical consultations to identify all individuals at high risk of developing type 2 diabetes, according to an International Diabetes Federation (IDF) consensus statement released at an international congress on prediabetes and metabolic syndrome.

Speaking at a press conference to mark the report's launch, Dr. Paul Zimmet, director of the International Diabetes Institute, Melbourne, stressed that renewed advocacy is needed to combat worldwide projected increases in diabetes, which he labeled “the largest and fastest-growing disease epidemic in history.”

“Since the 1980s, the number of people with diabetes has grown threefold. … With 246 million people with diabetes now and 380 million people with diabetes [predicted] by 2025, diabetes is set to bankrupt national economies,” warned Dr. Zimmet. And if numbers of people with impaired glucose tolerance, or prediabetes, are added to that sum, the at-risk population swells to 800 million by 2025, he said.

The IDF consensus recommends a two-pronged approach to prevention aimed at halting the rise in diabetes and associated conditions, targeting both at-risk individuals and the whole population. Central to the high-risk approach is to identify the target group, explained Dr. George Alberti, senior research fellow at Imperial College, London, and coauthor of the IDF statement. However, he said, this is “difficult because so many people won't have any obvious signs.”

The one external feature that does indicate high risk of diabetes is waist measurement. “The easiest way for most people is to look and see if they can see their feet,” Dr. Alberti said. The IDF suggests that this method should be the main one used by resource-poor countries to identify their at-risk populations, but physicians can also use validated questionnaires to assess risk status.

Once suspicion of risk is identified, explained Dr. Alberti, physicians should then measure blood glucose in their patients to identify existing undiagnosed metabolic syndrome or diabetes. This group can then be targeted with interventions to induce lifestyle changes and increase weight loss. “It is easy. Eat less and walk more,” Dr. Alberti said.

Population-wide efforts need to focus on national plans, he added. Governments must support the idea of healthy lifestyle education in schools, encouraging people to walk around more, and leaning on the food industry to act responsibly when it comes to advertising its products. However, he said, nongovernmental organizations and charities have an important role to play in raising awareness of the issue.

“It is about getting the [nongovernmental organizations] and the diabetes organizations to keep prodding away at the government. The key is repetitive actions,” he said. “There is no point in saying something once to politicians; you have to say it over and over again.”

The IDF calls for all countries to adopt national diabetes prevention plans that bring together strategies for prevention, secondary prevention, and treatment of diabetes as associated disorders. Stressing that healthy environments are key to achieving population-wide behavior change, Dr. Jean-Claude Mbanya, president-elect of the IDF and vice dean of the faculty of medicine and biomedical sciences, University of Yaounde, Cameroon, said a key feature of these plans should be collaboration between all government sectors, including health, education, sports, and agriculture.

Avi Friedman, Ph.D., professor of architecture at McGill University, Montreal, who supports the IDF call for a broad view on health improvement, said, “Inadvertently, our own government authorities may have contributed to this epidemic by allowing developers to create urban social problems. … Urban sprawls are part and parcel of new developments without proper attention to building design, sidewalks, bike paths, public transport corridors, playing fields, and friendly exercise areas that are essential and need to be accessible to people who want to maintain a healthy lifestyle.”

BARCELONA — Physicians and other health care workers should use clinical consultations to identify all individuals at high risk of developing type 2 diabetes, according to an International Diabetes Federation (IDF) consensus statement released at an international congress on prediabetes and metabolic syndrome.

Speaking at a press conference to mark the report's launch, Dr. Paul Zimmet, director of the International Diabetes Institute, Melbourne, stressed that renewed advocacy is needed to combat worldwide projected increases in diabetes, which he labeled “the largest and fastest-growing disease epidemic in history.”

“Since the 1980s, the number of people with diabetes has grown threefold. … With 246 million people with diabetes now and 380 million people with diabetes [predicted] by 2025, diabetes is set to bankrupt national economies,” warned Dr. Zimmet. And if numbers of people with impaired glucose tolerance, or prediabetes, are added to that sum, the at-risk population swells to 800 million by 2025, he said.

The IDF consensus recommends a two-pronged approach to prevention aimed at halting the rise in diabetes and associated conditions, targeting both at-risk individuals and the whole population. Central to the high-risk approach is to identify the target group, explained Dr. George Alberti, senior research fellow at Imperial College, London, and coauthor of the IDF statement. However, he said, this is “difficult because so many people won't have any obvious signs.”

The one external feature that does indicate high risk of diabetes is waist measurement. “The easiest way for most people is to look and see if they can see their feet,” Dr. Alberti said. The IDF suggests that this method should be the main one used by resource-poor countries to identify their at-risk populations, but physicians can also use validated questionnaires to assess risk status.

Once suspicion of risk is identified, explained Dr. Alberti, physicians should then measure blood glucose in their patients to identify existing undiagnosed metabolic syndrome or diabetes. This group can then be targeted with interventions to induce lifestyle changes and increase weight loss. “It is easy. Eat less and walk more,” Dr. Alberti said.

Population-wide efforts need to focus on national plans, he added. Governments must support the idea of healthy lifestyle education in schools, encouraging people to walk around more, and leaning on the food industry to act responsibly when it comes to advertising its products. However, he said, nongovernmental organizations and charities have an important role to play in raising awareness of the issue.

“It is about getting the [nongovernmental organizations] and the diabetes organizations to keep prodding away at the government. The key is repetitive actions,” he said. “There is no point in saying something once to politicians; you have to say it over and over again.”

The IDF calls for all countries to adopt national diabetes prevention plans that bring together strategies for prevention, secondary prevention, and treatment of diabetes as associated disorders. Stressing that healthy environments are key to achieving population-wide behavior change, Dr. Jean-Claude Mbanya, president-elect of the IDF and vice dean of the faculty of medicine and biomedical sciences, University of Yaounde, Cameroon, said a key feature of these plans should be collaboration between all government sectors, including health, education, sports, and agriculture.

Avi Friedman, Ph.D., professor of architecture at McGill University, Montreal, who supports the IDF call for a broad view on health improvement, said, “Inadvertently, our own government authorities may have contributed to this epidemic by allowing developers to create urban social problems. … Urban sprawls are part and parcel of new developments without proper attention to building design, sidewalks, bike paths, public transport corridors, playing fields, and friendly exercise areas that are essential and need to be accessible to people who want to maintain a healthy lifestyle.”