The DSQOLS is a reliable and valid measure of diabetes-specific quality of life. The scale is able to distinguish between patients with different treatment and dietary regimens and to detect social inequities. Use of the DSQOLS for assessment of individual treatment goals as defined by the patients may be helpful to identify motivational deficits and to tailor individual treatment strategies.

HbA1c (normal 4.3-6.1%) 8.0 +/- 1.5%, incidence of severe hypoglycaemia (injection of glucose or glucagon) 0.21 cases per patient-year; 62% of patients had participated in a structured group treatment and teaching programme for intensification of insulin therapy; 70% used 3 or more insulin injections per day, 9% were on continuous subcutaneous insulin infusion; 91% reported to have had measurements of HbA1c during the preceding year, and 80% to have had an examination of the retina by an ophthalmologist. Care was insufficient with respect to the quality of blood pressure control (70% of patients on antihypertensive drugs had blood pressure values > or = 160/95 mmHg), patient awareness of proteinuria/albuminuria (27% of patients had not heard about it) and prevention of foot complications (only 42% with a diabetes duration over 10 years had remembered to have a foot examination during the preceding 12 months). There was a pronounced social gradient with respect to micro- and macrovascular complications (prevalence of overt nephropathy 7 vs 20% for highest vs lowest quintiles of social class [OR 3.5, 95% CI 1.6-7.5, p = 0.002]) and diabetes-specific quality of life. HbA1c, blood pressure and smoking accounted for part of the association between social class and microvascular complications. The social class gradient was not due to inequality to access to health services, but to lower acceptance among low social class patients of preventive and health maintaining behaviour. In conclusion, achieved standards of care are high with respect to the implementation of intensified treatment regimens, the level of patient education achieved, treatment control and eye care, whereas areas for improvement are blood pressure control and preventive measures for foot care. A substantial social gradient in diabetes care persists despite equal access of patients to health services.

The objective of the present study was to analyse the association between cigarette smoking and progression of retinopathy and nephropathy, respectively, in a prospective multicentre study including 636 people with Type 1 diabetes: 81 % of the original cohort of consecutively referred patients, aged 15 to 40 years and free of severe late diabetic complications. At baseline, all patients had participated in a 5‐day in‐patient group treatment and teaching programme for intensification of insulin therapy. Patients were examined at recruitment, and after 1, 2, 3 and 6 years including assessment of smoking status, blood pressure, metabolic control, and degree of nephropathy. Degree of retinopathy was assessed by ophthalmoscopy or fundus photography at baseline and after 6 years. Several logistic regression analyses were performed by describing the responses retinopathy and nephropathy, respectively, either as progression yes/no or as actual status at the 6‐year follow‐up and by using different measures for smoking. Adjustments for important covariables were made. While significant associations between smoking, and retinopathy and nephropathy respectively, were found, the relations were variable depending on the statistical model used. The results show that the real associations between smoking and retinopathy and nephropathy are complex and that more emphasis should be put on the complete description of the response variables and the statistical models used in clinical and epidemiological research.

Identification of risk factors of severe hypoglycaemia (SH) is necessary to understand, predict and reduce the frequency of SH in Type I (insulin-dependent) diabetic patients. Several predictors of SH have been described in laboratory and clinical investigations. The most consistently identified risk factor is a previous event of SH [1±3]. Less consistent predictors of SH are lower HbA 1 c values, higher insulin dosages, C-peptide negativity, and longer diabetes duration [1±5]. Patients with impaired awareness of hypoglycaemia could run a particularly high risk of SH [5±7]. Several clinical conditions predispose to SH such as renal insufficiency and early pregnancy [8,9].In the intensively treated patients of the Diabetes Control and Complications Trial (DCCT), however, less than 8 % of the variation in SH could be explained by biological characteristics including HbA 1 c values [2]. Recently, a bio-psycho-behavioural model was proposed to integrate the diverse and complex Diabetologia (1998) Summary The objective of this study was to identify possible risk factors of severe hypoglycaemia (SH) in a prospective population based study of adult Type I (insulin-dependent) diabetic patients. A representative sample of 684 patients (41 % women, mean ± SD age 36 ± 11, diabetes duration 18 ± 11 years), living in the district of Northrhine (9.5 million inhabitants), Germany, were examined in their homes using a mobile ambulance. A comprehensive baseline assessment of possible predictors of SH included sociodemographic and disease related variables, hypoglycaemia awareness, diabetes management, and attitudes and behavioural aspects as expressed by the patients. After a mean of 19 ± 6 months 669 (98 %) patients were interviewed about events of SH since the baseline examination. Using the multiple Cox proportional hazards model, five risk factors of SH were identified: SH during the preceding year [hazard ratio (HR) 2.7, 95 % confidence intervals (CI) 1.8±4.2], any history of SH (HR 1.9, CI 1.1±3.4), C-peptide negativity (HR 4.0, CI 1.2±12.7), social status (HR 0.8 for a difference of 5 units for a value range of 0±24, CI 0.6±0.9), and patients' determination to reach normoglycaemia (HR 0.7 for a difference of 1 unit for a value range of 1±6, CI 0.5±0.9), indicating that the lower the social status and the higher the patients' determination to reach normoglycaemia, the higher the risk of SH. After eliminating the history of hypoglycaemia from the model, impaired hypoglycaemia awareness and patients' inappropriate denial of SH as their particular problem became additional significant risk factors of SH. In conclusion, in this population based study of adult Type I diabetic patients, C-peptide negativity, a previous event of SH, patients' determination to reach normoglycaemia and social class were risk factors of SH. [Diabetologia (1998

In Type 1 diabetic patients who start intensified insulin therapy, nephropathy remains the strongest predictor of mortality and end-stage complications. Glycosylated haemoglobin is a risk factor of end-stage complications but not of mortality. Conventional risk factors comparable to the general population, particularly smoking become operative as predictors of both mortality and end-stage complications.