Objective To assess the policy proposed by the American Diabetes Association of universal screening in general practice of all patients aged over 45 years for diabetes. Design Cross sectional population study. Setting Local general practice in the United Kingdom. Participants All patients aged over 45 not known to have diabetes. Main outcome measures Prevalence of diabetes in the screened population, cardiovascular risk profile of patients diagnosed as having diabetes after screening. Results Of 2481 patients aged over 45 and not known to have diabetes, 876 attended for screening. There were no significant demographic differences between the screened and unscreened patients. Prevalence of diabetes in patients with age as a sole risk factor was 0.2% (95% confidence interval 0% to 1.4%). Prevalence of diabetes in patients with age and one or more other risk factors (hypertension, obesity, or a family history of diabetes) was 2.8% (1.6% to 4.7%). Four hours a week for a year would be needed to screen all people over 45 in the practice's population; about half this time would be needed to screen patients with risk factors other than age. More than 80% of patients newly diagnosed as having diabetes had a 10 year risk of coronary heart disease > 15%, 73% (45% to 92%) were hypertensive, and 73% (45% to 92%) had a cholesterol concentration > 5 mmol/l. Conclusions Screening for diabetes in general practice by measuring fasting blood glucose is feasible but has a very low yield in patients whose sole risk factor for diabetes is age over 45. Screening in a low risk population would best be targeted at patients with multiple risk factors.

Aims/hypothesis. We aimed to estimate incidences of any retinopathy and proliferative diabetic retinopathy (PDR) by direct ophthalmoscopy and relate them to baseline risk factors in re-examined diabetic survivors from 10 centres of the WHO Multinational Study of Vascular Disease in Diabetes. Methods. After a mean follow-up of 8.4 years (11.7 years in Oklahoma), 2877 (71.6 %) survivors were resubmitted to standardised direct ophthalmoscopy as at baseline. The presence of any retinopathy and PDR were recorded at each centre and their incidence estimated in those without retinopathy and PDR at baseline. The independent associations of these incidences with baseline risk factors are expressed as odds ratios derived from multiple logistic regression analyses, within individual centres (which included fasting plasma glucose in 8 and triglyceride in 5) and in pooled data. Results. Of the 4662 original patients, 465 (10.4 %) of those without and 77 (43.0 %) of those with baseline PDR had died (p < 0.001). Any retinopathy was newly reported at follow-up in 47.7 % and PDR in 9.7 % of those free of them at baseline, with reported incidences varying substantially among centres. Incident retinopathy appeared earlier in the known course of diabetes but incidence rates rose more slowly with duration in patients with Type II (non-insulin-dependent) diabetes mellitus than in those with Type I (insulin-dependent) diabetes mellitus. In pooled data and in some individual centres, any retinopathy incidence gave significantly positive odds ratios with age, diabetes duration, systolic pressure, plasma cholesterol, BMI, insulin treatment and proteinuria, and with fasting plasma glucose in the centres where it was measured. Positive odds ratios for PDR were similarly obtained for age, duration, insulin treatment, cholesterol, proteinuria and fasting glycaemia. Smoking status odds ratios were negative for both outcomes. Conclusion/interpretation. Incidence of ophthalmoscopically ascertained any retinopathy varied about twofold and of PDR about threefold among centres. Although, in part attributable to differences between observers, variation in incidence in all centres and in some cases within centres was associated with a number of baseline risk factors. Such associations are not likely due to observer variation or selection biases and emerged despite the imprecision of clinical ophthalmoscopy. Improved detection and control of these risk factors should reduce the impact of diabetic retinopathy and its consequences. [Diabetologia (2001)

We compare the prevalence of vascular disease and associated risk factors in a Chinese diabetic cohort with the results from the WHO Multinational Study of Vascular Disease in Diabetes (WHO MSVDD) which involved 14 centres from 13 countries [3]. Results. Compared with the WHO MSVDD centres, the Chinese cohort was slightly older, had a shorter duration of known diabetes and had fewer insulintreated patients. Arterial pressure, total blood cholesterol and body mass index were substantially lower. Large vessel disease rate for age, sex and duration adjusted data (17.9 %) was about half that of the combined WHO MSVDD centres (33.5 % p < 0.001). However, retinopathy (47.4 % vs 35.8 % p < 0.001) and proteinuria (57.1 vs 24.9 % p < 0.001) rates were significantly higher. Conclusion/interpretation. Relatively low arterial pressures and blood cholesterol are likely contributors to the notably low arterial disease rates in this Chinese diabetic cohort; they reflect low rates in the Chinese mainland general population and resemble the Tokyo and Hong Kong centres of the WHO MSVDD. The high rates of retinopathy and proteinuria could relate to later diagnosis, degree of hyperglycaemia and/or increased susceptibiltiy to microangiopathy. [Diabetologia (2001) Methods

The one-step WHO test for glucose tolerance during pregnancy was abnormal in a greater percentage of women with adverse outcomes than the more cumbersome two-step NDDG test. The one-step test has the added advantage of being directly comparable to the standard glucose tolerance test used in nonpregnant women.

In a multinational study, fasting plasma glucose values in 3583 diabetic patients, aged 34-56 years, were related to the characteristics of these subjects and to the presence and severity of microangiopathy as ascertained by standardised methods. The patients were from nine different populations and ranged in number from 193 to 686 per population (London, Warsaw, Berlin (FRG), New Delhi, Tokyo, Havana, Oklahoma Indians, Arizona Pima Indians, and a national sample in Switzerland). In the total group, mean fasting plasma glucose was 8.1 mmol/l for those on diet alone, 9.7 mmol/l for those on oral agents, and 12.7 mmol/l for insulin-treated patients, of whom 25% had values exceeding 16.5 mmol/l. Since many variables were measured in each patient, it was possible to take into account many confounding factors in evaluating the relationship of plasma glucose levels to retinopathy and nephropathy.

In industrial societies more than 12 % of new cases of blindness are attributable to diabetes and the risk of blindness is about 30 times higher in people with diabetes than in the general population [1,2, 3]. The WHO Multinational Study of Vascular Disease in Diabetes (WHO MSVDD), designed to compare the vascular complications of diabetes in different ethnic groups using standardised methods, included an estimate of visual function in the baseline assessment [28]. This was repeated in the follow-up study [4], conducted at 10 of the original 14 centres, providing an opportunity to ascertain incidence and progression of visual impairment and its risk factors in these cohorts. Diabetologia (2001) Methods. Visual function was ascertained at followup in 2994 (77.9 %) of the 3845 eligible participating survivors of the 4709 originally recruited for the WHO MSVDD using the same baseline enquiry method. The associations between incident severe visual impairment, follow-up prevalence of all grades of impairment and baseline risk factors were examined by univariate and stepwise multiple logistic regression analysis. Results. Overall, 8.4 year incidence of severe visual impairment was 1.94 % and showed statistically significant univariate correlations with age at diagnosis, diabetes duration, systolic blood pressure, fasting blood glucose and cholesterol, insulin treatment and strongly with baseline retinopathy. Baseline retinopathy, systolic pressure and cholesterol were statistically significant in multivariable analysis. Differences between centres (0.3 % to 3.45 %) were not significant. Ultimate prevalence of all grades of impairment differed between centres and within almost all of them was correlated in multivariable analysis with baseline retinopathy and proteinuria. Conclusion/interpretation. Comparisons of incident severe visual impairment between centres are restricted by selective mortality, low incidence rates and relatively small numbers in each centre but before retinopathy, baseline systolic pressure and cholesterol predicted severe visual impairment. Followup prevalence of all degrees of impairment varied among centres and were associated with prior retinopathy and renal disease at baseline. [Diabetologia (2001)

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The World Health Organisation (WHO) [1] consultation group and the American Diabetes Association (ADA) [2] have recently published revised criteria for the classification and diagnosis of diabetes. If widely implemented, these recommendations, together with earlier and improved treatment, could have a profound impact on the morbidity and mortality associated with the disease. The changes in classification stem from an increased knowledge of the aetiology and pathogenesis of diabetes, which signals the move away from a classification system based on pharmacological dependency towards one that is based on the underlying causes of the disease.