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The thermic effect of 1.67 MJ (400 kcal) of carbohydrate (glucose), fat, protein and mixed meal were examined in 11 lean and 11 obese subjects by indirect calorimetry. The changes in metabolic rate in response over 90 min period (30-120 min after the meal) to the different meals were compared with that seen after a similar volume of low calorie drink. The thermic effects of glucose and protein were not significantly different between lean and obese subjects. Obese subjects showed very little increase in metabolic rate following ingestion of fat (-0.9 +/- 2.0%, mean +/- SEM) and this was significantly different from that seen in lean subjects (14.4 +/- 3.4%). The thermogenic response to mixed meal was also significantly lower in obese subjects when expressed as percentage change (12.9 +/- 2.3% compared to 25.0 +/- 4.8%). There was no evidence for delay in gastric emptying times for glucose and fatty meal in the six obese subjects in whom these were measured. We conclude that obese subjects show a reduced thermogenic response to fat.

Many patients believe that their diabetes has been caused by stress or an adverse life event. Whereas there is strong evidence that psychological stress is related to a deterioration in glycaemic control in established diabetes, there is much less evidence that psychological stress can cause diabetes in humans de novo. It seems more likely that psychological stress produces a deterioration in glycaemia in the non-symptomatic patient which in turn makes diabetic symptoms and the diagnosis evident. The pathogenic mechanisms which have been suggested to relate psychological stress to diabetes are described and reviewed.

In a 12-month randomly allocated double-blind trial in 19 obese Type 2 diabetic patients, fluoxetine 60 mg daily compared to placebo produced a significant fall in median body weight after 3 months (3.8 kg), 6 months (6.5 kg), 9 months (7.1 kg) and at 1 year (5.8 kg). Median fasting blood glucose and HbA1c levels fell significantly after 3 months (1.9 mmol l-1) and 1.7%, respectively) and 6 months (1.8 mmol l-1 and 1.7%) but neither showed a significant difference to placebo after 9 or 12 months therapy with fluoxetine. There were no significant changes in serum cholesterol levels in the year but patients on fluoxetine showed a significant fall in serum triglyceride level (0.5 mmol l-1) after 3 months therapy but not thereafter. Compared to placebo there was a significant fall in median energy intake on fluoxetine after 3 months (257 kcal day-1) and 6 months (199 kcal day-1) but this difference was not significant at 9 or 12 months. There was also a significant fall in carbohydrate intake after 3 months (30 g day-1) and 6 months (23 g day-1) on fluoxetine as well as a significant fall in carbohydrate intake expressed as a percentage of the total daily energy intake; 5.9% at 3 months, 6.1% at 6 months, and 4.0% at 9 months. There were no significant effects on protein or fat intake except a significant increase in the intake of fat expressed as a percentage of daily energy intake, 5.9% after 6 months. Two of the nine patients on fluoxetine dropped out of the study due to gastrointestinal side-effects. Fluoxetine might prove to be a useful adjunct therapy in obese Type 2 diabetic patients where short-term weight loss and fall in carbohydrate intake and an improvement in glycaemia are indicated.

SUMMARY The prevalence of oral yeasts and humoral precipitating antibodies to candida was estimated in 204 unselected diabetic patients (172 outpatients and 32 inpatients). Yeasts, mainly Candida albicans, were isolated from the mouths of 41 % of the outpatients and precipitins were found in 17-5 % although none of the patients had clinically overt candidiasis. The extent of oral yeast colonisation and incidence of antibodies was not related to their antidiabetic treatment or to the duration of their diabetes. It was, however, related to the blood glucose and urine sugar levels at the time they were sampled, the highest incidence being among the diabetic inpatients with high blood glucose levels at the time of sampling and the lowest among outpatients with normal blood glucose levels at the time of sampling. There was no such correlation when diabetic control over the previous 12-month period was considered.

Summary. Five glycoproteins have been measured in the blood of 145 diabetic patients with and without clinical evidence of complications. Patients with diabetic complications have higher glycoprotein levels particularly when expressed as a ratio to serum albumin levels. In 32 pairs of patients matched for age, sex, body weight, duration and treatment of diabetes, significantly higher haptoglobin, fibrinogen and caeruloplasmin levels were associated with the presence of diabetic complications, but blood glucose levels were not significantly different, fi-lipoprotein levels were positively correlated with age and a2-macroglobulin levels with the duration of clinical disease, but the type of antidiabetic therapy administered did not significantly alter glycoprotein levels. It is suggested that rising levels of certain glycoproteins in the blood of diabetic patients may indicate the development of diabetic vascular complications, but a prospective study is required before it can be decided whether this change predates the clinical appearance of the complications.

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Prospective 7-day estimated weight food records were computer analysed in 92 diabetic patients, 45 men and 47 women, 25 with Type 1 and 67 Type 2 diabetes, attending a hospital-based diabetic clinic. The nutrient intakes were compared with a national survey in non-diabetic British adults (OPCS) and the current EASD recommendations for the diabetic diet. Only three diabetic patients achieved the recommended 50-60% energy intake as carbohydrate, four achieved less than 30% energy as fat, one patient less than 10% saturated fat and 20 ate greater than 30 g fibre per day. The overall nutrient intakes of these diabetic patients reflected those of non-diabetic subjects except for a greater intake of protein and smaller intakes of sugar and alcohol. These findings reinforce the problems currently faced in achieving the present recommendations for the diabetic diet.