Letters were significantly worse in the partial control group. CSME was bilateral in 55 subjects (110 eyes) and unilateral in 70 (70 eyes). Median interval from diagnosis of diabetes was 10 years (mean 7.2 ⫾ 2.97 years [range 0.5–25.0]) There was statistically significant improvement in bestcorrected visual acuity (BCVA) in the complete control group (P ⬍ 0.001). The improvement of BCVA by three or more lines was achieved in 25 (29.1%) eyes in the complete control group compared with 20 (21.3%) eyes in the partial control group. The BCVA deteriorated by three or more lines in 14 (14.9%) eyes in the partial control group compared with none in the complete control group. The ETDRS (Early Treatment Diabetic Retinopathy Study) (4) reported improvement in visual acuity up to one line in 16%, vision remaining unchanged in 77%, and worsening by three lines in 7% of the treated eyes. Improvement of visual acuity by 15 letters (three lines or one-half the initial visual angle) was uncommon (⬍3%) (5). The ETDRS, however, did not address the issue of systemic control in patients who were candidates for receiving focal laser photocoagulation. In the present series, the complete control group showed three or more lines improvement (one-half the initial visual angle) in 29.1% and stabilization of visual acuity in 70.9%. Even in the partial control group where multifactorial control was attempted, three or more lines of visual acuity improvement was seen in 21.3% of the treated eyes, while the vision remained unchanged in 63.8%. Our study, though limited, has shown better visual outcome than is obtainable by the current standard of care strategies of laser photocoagulation, without enforcing systemic control. In view of our observations, the strategy of multifactorial interventions in CSME before laser photocoagulation needs to be addressed in a larger number of patients. RAMANDEEP SINGH, MD1 VISHALI GUPTA, MD1 AMOD GUPTA, MD1 NISHANT SACHDEV, MD1 MANGAT R. DOGRA, MD1 ANIL BHANSALI, MD2 From the 1Ophthalmology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India; and the 2Endocrinology Department, Post Graduate Institute of Medical Education and Research, Chandigarh, India. Address correspondence to Amod Gupta, MD, Ophthalmology Department, Post Graduate Insti-
tute of Medical Education and Research, Chandigarh, India 160012. E-mail:
[email protected]. DOI: 10.2337/dc06-1302 © 2006 by the American Diabetes Association. ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
References 1. Sinclair SH, Delvecchio C, Malamut R, Li W: Diabetic retinopathy: treating systemic conditions aggressively can save sight. Cleve Clin J Med 72:447– 454, 2005 2. Singh R, Abhiramamurthy V, Gupta V, Gupta A, Bhansali A: Effect of multifactorial intervention on diabetic macular edema (Letter). Diabetes Care 29:463– 464, 2006 3. American Diabetes Association: Standards of medical care for patients with diabetes mellitus. Diabetes Care 26 (Suppl. 1):S33–S50, 2003 4. Early Treatment Diabetic Retinopathy Study Research Group: Treatment techniques and clinical guidelines for photocoagulation of diabetic macular edema: early treatment diabetic macular edema: Early Treatment Diabetic Retinopathy Study report number 2. Ophthalmology 94:761–774, 1987 5. Photocoagulation for diabetic macular edema: Early Treatment Diabetic Retinopathy Study report number 1: Early Treatment Diabetic Retinopathy Study research group. Arch Ophthalmol 103:1796 –1806, 1985
Continuous Glucose Monitoring System With an Alarm A tool to reduce hypoglycemic episodes in pregnancy with diabetes
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ased on strong evidence that hyperglycemia is harmful to the fetus, guidelines recommend strict diabetes regulation during pregnancy, but the rate of severe hypoglycemia is four times the rate before pregnancy (1). A newly developed tool of continuous glucose monitoring with display and alarm might be helpful in reducing the risk of recurrent episodes of severe hypoglycemia during pregnancy. A 32-year-old woman with a history of diabetes for 21 years experienced 18 episodes of severe hypoglycemia the year preceding pregnancy, despite treatment with an insulin pump, frequent home blood glucose measurements, and HbA1c (A1C) ⬃7.5%. Episodes of severe hypoglycemia were prospectively recorded
DIABETES CARE, VOLUME 29, NUMBER 12, DECEMBER 2006
from gestational week 7. Three 24-h home blood glucose measurements (eight-point profiles), A1C, and insulin dose were registered prospectively at gestational week 7, 14, 22, 27, and 33. Between 7 and 16 weeks of gestation, the patient experienced seven episodes of severe hypoglycemia without any obvious explanations of the events. Treatment was intramuscular glucagon in four cases and juice in the remaining three. Mean blood glucose was 1.5 mmol/l (range 1.0 –1.9). Based on this experience, continuous glucose monitoring with a display and programmed to alarm at glucose values ⬍4.0 mmol/l was introduced at gestational week 17 (Guardian; Medtronic Minimed, Northridge, CA) (2). During pregnancy, mean blood glucose remained stable between 6 and 8 mmol/l and A1C declined from 6.7 to 6.2%. Insulin dose was 45 IE before pregnancy and 43 IE at week 33. After the Guardian was introduced, the patient only experienced one episode of severe hypoglycemia at gestational week 19 at night while the Guardian was out of function. The observed glucose values below 2.2 mmol/l were eliminated. Spontaneous rupture of membranes occurred at gestational week 36, and a healthy baby of 2,982 g was born. The woman continued carrying the device with no hypoglycemic events for 3 months after delivery. Introduction of a Guardian at gestational week 17 led to a dramatic decrease in the occurrence of episodes of severe hypoglycemia from 1.5 episodes/month to 0.3 episodes/month in the remaining part of pregnancy in combination with a decline in A1C to 6.2%. The device was well tolerated by the patient. Limitations of the Guardian are the ⬍100% safety and accuracy of the device (2). In addition, three daily calibrations are required. A Guardian might be a helpful tool in pregnant patients with type 1 diabetes who are susceptible to frequent episodes of severe hypoglycemia. Also, nonpregnant patients with type 1 diabetes and hypoglycemia unawareness might benefit from a Guardian. Frequent severe hypoglycemic events are expensive from a socioeconomic point of view, and the costeffectiveness using a Guardian would be of interest to evaluate in the future. DORTE WORM, MD, PHD1 LENE RINGHOLM NIELSEN, MD2 ELISABETH R. MATHIESEN, MD, DMSC2 KIRSTEN NØRGAARD, MD, DMSC1 2759
Letters From the 1Department of Endocrinology, Hvidovre University Hospital, Copenhagen, Denmark; and the 2Department of Endocrinology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark. Address correspondence to Dr. Lene Ringholm Nielsen, Department of Endocrinology, University Hospital of Copenhagen Rigshospitalet, Blegdamsvej 9, 2100 Copenhagen, Denmark. E-mail:
[email protected]. DOI: 10.2337/dc06-1408 © 2006 by the American Diabetes Association. ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
References 1. Evers IM, ter Braak EWMT, de Valk HW, van der Schoot B, Janssen N, Visser GHA: Risk indicators predictive for severe hypoglycemia during the first trimester of type 1 diabetic pregnancy. Diabetes Care 25: 554 –559, 2002 2. Bode B, Gross K, Rikalo N, Schwartz S, Wahl T, Page C, Gross T, Mastrototaro J: Alarms based on real-time sensor glucose values alert patients to hypo- and hyperglycemia: the guardian continuous monitoring system. Diabetes Technol Ther 6: 105–113, 2004
Prevalence and Associations of Binge Eating Disorder in a Multiethnic Population With Type 2 Diabetes
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inge eating disorder (BED) is a syndrome characterized by recurrent uncontrollable overeating (1,2), with prevalence rates of ⬃3% in the general population and 10- to 20-fold higher in patients seeking treatment for obesity (1,3). There are limited reports of BED in subjects with type 2 diabetes , particularly in minorities (4,5). We conducted a pilot study to assess BED and its association with obesity, metabolic control, and depression in a triethnic (37% Hispanic, 40% non-Hispanic white, and 19% African American) population with type 2 diabetes (n ⫽ 140). We used the nine-item Questionnaire of Eating and Weight Patterns (QEWP), the Binge Eating Scale (BES), and the Beck Depression Inventory (BDI) to assess our study population. On average, patients were (mean ⫾ SD) 59.1 ⫾ 11.1 years old and had a mean BMI of 34.5 ⫾ 6.2 kg/m2, diabetes duration of 10 ⫾ 7.8 years, and HbA1c (A1C) 7.7 ⫾ 2.0%. Abnormal eating (one or 2760
more positive responses) as per QEWP scoring criteria (based on DSM-IV) was 40% overall. When analyzed according to binge-eating status (present or absent), subjects positive for binge eating were younger (55.8 ⫾ 11.2 vs. 61.3 ⫾ 10.5 years, P ⫽ 0.008), had a greater BMI (36 ⫾ 6.6 vs. 33.6 ⫾ 5.8 kg/m2, P ⫽ 0.039), and had a higher A1C (8.2 ⫾ 2.2 vs. 7.3 ⫾ 1.8%, P ⫽ 0.027) compared with those with negative responses. Furthermore, BES score, which assesses binge eating severity on a continuous scale, was significantly associated with A1C (r ⫽ 0.24, P ⫽ 0.021), BMI (r ⫽ 0.36, P ⫽ 0.001), and diastolic blood pressure (r ⫽ 0.22, P ⫽ 0.018). BES scores were higher in those with BDI scores ⱖ19 (suggestive of moderate to severe depression), regardless of BMI and degree of glycemic control. Logistic regression analysis showed that age ⬍60 years (odds ratio 3.4, P ⫽ 0.018) and African-American ethnicity (6.20, P ⫽ 0.004) were independently associated with abnormal eating using the QEWP. The prevalence of binge-eating behaviors appears to be elevated in overweight patients with type 2 diabetes, particularly when subjects are younger or African American. Acknowledging the limitations of questionnaires when compared with structured interviews, we suggest using the QEWP as a quick screening tool to detect abnormal eating habits in patients with type 2 diabetes. Patients may then be referred to the appropriate health provider, who can implement more comprehensive diagnostic evaluation and appropriate interventions (6). LUIGI F. MENEGHINI, MD, MBA1 JENNY SPADOLA, MPH2 HERMES FLOREZ, MD, MPH, PHD3 From the 1Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, University of Miami Miller School of Medicine, Miami, Florida; the 2Health Services Research Center, University of Miami and Humana, Miami, Florida; and the 3 Health Services Research Center, University of Miami and Humana, and Miami Veterans Affairs Medical Center, Miami, Florida. Address correspondence to Luigi F. Meneghini, MD, MBA, 1450 NW 10 Ave., Miami, FL 33136. E-mail:
[email protected]. DOI: 10.2337/dc06-1364 © 2006 by the American Diabetes Association. ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
References 1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC, American Psychiatric Association, 2000
2. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL: Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry 150:1472– 1479, 1993 3. Bruce B, Agras WS: Binge eating disorder: a population-based investigation. Int J Eat Disord 12:365–373, 1992 4. Wing RR, Marcus MD, Epstein LH, Blair EH, Burton LR: Binge eating in obese patients with type II diabetes. Int J Eat Disord 8:671– 678, 1989 5. Herpertz S, Albus C, Wagener R, Kocnar M, Wagner R, Henning A, Best F, Foerster H, Schulze Schleppinghoff B, Thomas W, Kohle K, Mann K, Senf W: Comorbidity of diabetes and eating disorders: does diabetes control reflect disturbed eating behavior? Diabetes Care 21:1110 –1116, 1998 6. Celio AA, Wilfley DE, Crow SJ, Mitchell J, Walsh BT: A comparison of the binge eating scale, questionnaire for eating and weight patterns-revised, and eating disorder examination questionnaire with instructions with the eating disorder examination in the assessment of binge eating disorder and its symptoms. Int J Eat Disord 36:434 – 444, 2004
Waist-to-Height Ratio and BMI Predict Different Cardiovascular Risk Factors in Chinese Children
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ecently, waist-to-height ratio (WHR) has been documented as a better indicator of obesity and cardiovascular risk than BMI in several different pediatric populations. In the present study, we, for the first time, compared the association of nine cardiovascular risk factors with BMI, waist circumference (WC), and WHR in Chinese children. A random sample of 389 Han and 272 Uygur ethnic children aged 7–18 years (mean ⫾ SE 10.7 ⫾ 3.2) were selected stratified by age, sex, and ethnicity from a school-based cross-sectional study performed in Xinjiang Uygur Autonomous Region (the prevalence of obesity was 2.5 and 5.4% for Uygur and Han, respectively). Uygur and Han are the two major ethnic groups in this region (45% for each, 2003 national census). Body weight, height, WC, systolic blood pressure (SBP), dystolic blood pressure (DBP), fasting serum triglyceride, total cholesterol, HDL, LDL, glucose, and insulin were measured or determined
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