FIRST DEPARTMEaNT OF PROPAEDEUTIC MEDICINE ATHENS UNIVERSITY P R E V A L E N C E O F D I A B E T E S BaMONG G L Y C O S U R I C INDIVIDUALS IN AN URBAN AREA OF GREECE NICHOLAS KATSILAMBROS HELIAS BEZOS
~OHNSTERYOTIS NICHOLAS MOIRAS GEORGES KONSTANTIN DAIKOS
Studies on the prevalence of diabetes mellitus (PDM) were completely lacking in urban parts of Greece. The present effort was undertaken in order to study P D M in an urban area of this country. One of the suburbs of Athens with a population of medium socio-economic status as compared to other urban areas was selected for this purpose. Due to the fact that only subjects with gIycosuria were submitted to an oral glucose tolerance test ( O G T T ) , the figures given in this study as it concerns P D M - as a whole - represent only a rough estimate, therefore, the main purpose of this paper is to provide data on P D M among subjects with glycosuria in a large population sample and in addition to describe some observations in 135 cases of newly discovered diabetics. Detailed data concerning the prevalence of previously k n o w n diabetes in this area have already been reported 7,
SUBJECTS AND METHODS The total number of subjects included in the survey was 21,410 (10,237 males and 11,173 females). The population of Aegaleo, the suburb where the study was conducted, amounts to approximately 80,000 inhabitants. Persons studied were randomly selected, independently of age and sex. In order further to assure a representative sample, whole families living in randomly pre-selected streets (throughout the whole area of the suburb) were examined. Twenty nurses visited every house (door by door) in every third parallel and every third vertical street throughout the whole town from one end to the other. The information they collected on special cams included: a) name; b) sex; c) age; d) profession; e) presence or absence of previously known diabetes; f) existence of diabetic relatives; g) other serious present or past i]lnesses; h) address; i) telephone number. Each member of the family was provided with a plastic tube with his name on it. A urine sample was collected 2 to 3 hrs after a lunch rich in carbohydrates. The presence of sugar in the urine was detected by both Tes-Tape (Eli Lilly Co., Indianapolis/Ind.,
Key-words: Diabetes prevalence rate; Family history o/diabetes; Glycosuria; Non-diabetic gtycosuria. Received: June 9, 1976. Acta diabet, lat. 14, 211, 1977. 211
PREVALENCE O~F DIABETES AMONG GLYCOS'URIC INDIVIDUALS IN AN URBAN AREA OF GtREECE
U.S.A.) and Clinistix (Ames Co., Division Miles Laboratories, Inc., Elkhart/Ind., U.S.A.). If one or both of these strips showed a positive glucose reaction in individuals who were not known to suffer from diabetes, an OGTT was performed: 50 g of glucose dissolved in water were given to these subjects. Venous blood samples were obtained before as wall as I and 2 hrs after glucose administration. These persons had been prepared with a diet, which included at least 200 g of carbohydrates daily for 2 mostly 3 consecutive days prior to the test. At the end of the OGTT a physical examination was performed, including ophthalmoscopy. Diabetes was assessed according to BDA criteria 3. Lag curves were not considered diabetic. No correction for age of the patients was done. Among the glycosuric subjects 73% accepted the invitation for the OGTT. In subjects aged 0 to 9 years only a fasting venous blood sample was obtained for glucose determination. Glucose was assayed on whole blood by Hoffman's method adapted for Technicon Autoanalyzer L
RESULTS Tab. 1 shows the percent age distribution of the 21,410 subjects according to sex and age. The numbers in brackets indicate the percentage that h a d to be studied if we supposed that our sample was ideally representative. T h e s e last data were provided by the National Statistical Service of Greece. G l y c o s u r i a in t h e p o p u l a t i o n s t u d i e d - Tab. 2 shows the number o f male and female persons who were found to have gtycosuria in each age-group. The first decade of life is not considered in this table because, as already mentioned, no glucose tolerance test was done in children of 0 to 9. I t is a p p a r e n t that altogether 569 subjects ( 3 . 2 0 % ) (323 males and 246 females) had postprandial glycosuria. Previously known diabetics were not i n d u d e d in this group. N e w cases o f d i a b e t e s - I t is obvious from tab. 2 that about one t h i r d of the total n u m b e r of glycosurics had an abnormal O G T T . A m o n g the 417 persons submitted to O G T T , a total of 135 new cases of diabetes w e r e di-
*
age-groups (years)
males
females
< 10
18.3 (17.6)*
15.8 (17.2)
10-19
19.0 (17.9)
16.6 (15.6)
20-29
12.1 (15.4)
15,5 (15.2)
30-39
13.7 (16.4)
14.0 (16.7)
40-49
16.2 (14.1)
15.3 (14.0)
50-59
9.3
(9.3)
8,8
(9.4)
60-69
6.7
(5.9)
7.8
(6.8)
70-79
3.6
(2.3)
4.6
(3.3)
>79
0.8
(0.6)
1.2
(1.4)
numbers in brackets indicate the true age distribution (in
Table 1 - Age distribution (in %) of subjects examined.
212
9~) of
the population of the suburb
N. KATSILAMBROS, J'. STERYOTIS~ N. MOIRAS~ H. BEZOS~ G. K. DAIKOS
males
age group (years)
number of persons
studied
number of glycosurics
number of glycosurics submitted to OGTT 21
0
number of newly discovered diabetics
(0)*
10-19
1,949
27
20-29
1,243
t7
9
0
(0)
1
(4.54)
30-39
1,403
39
22
40-49
1,661
94
68
19 (27.94)
50-59
957
65
48
19 (44.16)
60-69
694
5O
40
19 (47.50)
70-79
370
23
20
9 (45.00)
>79
83
8
5
3 (6O.OO)
total
8,360
323
233
70
(30.04)
1,862
40
35
2
(5.71)
0
(o)
temales I0-i9 20-29
1,735
23
14
30-39
1,570
28
24
6 (25.00)
40-49
1,713
52
41
18 (43.9O)
50-59
985
36
22
11
60-69
881
40
32
17 (53.12)
70-79
515
21
13
10 O1.25)
>79
137
6
3
i
(33.33)
total
9,398
246
184
65
(35.32)
(50.00)
* numbers in brackets denote the percent rates of abnormal OGTTs
Table
2
-
Glycosuric subjects and newly discovered diabetics among the whole population.
scovered. Their sex and age distribution is shown in fig, 1 and tab. 2 (right column). The majority was above age 39. In other words, in glycosuric persons below 29, and even more so below 19, diabetes was found rather infrequently. The fasting blood sugar was above normal in about two thirds of the new cases of diabetes while the remaining third had abnormal values only 60 and 120 min after the glucose load (tab. 3). Most of the newly discovered diabetics were obese as shown in fig. 2. The most important feature as regards 213
PREVALENCE OF DIABETES AMONG GLYCOSURIC INDIVIDUALS IN AN URBAN AREA OF GREECE
2%
[~.j
13 12
7L 6L 4,
al
0
._~
" < I0
10-19
20-29
i!iiiii!
! i!!iiiiii~
30-39
40-49
50-59
60-69
ilililiiii
70-79
> 79
age - groups (years)
Fig. 1 -
Sex and age distribution of the newty discovered diabetics.
complications of diabetes in the newly discovered diabetics was the presence of background retinopathy in 7 out of the 135 cases. D i a b e t e s in t h e w h o l e s a m p l e - The overall prevalence of diabetes mellitus in the sample examined is shown in tab. 4. Assuming that the sample was ideal in terms of sex and age distribution, the 'corrected' prevalence (----95Wo confidence limits) would be 2.83 -----0.10%. N o n - d i a b e t i c glycosuria - The total number of glycosurics submitted to OGTT was 417. As mentioned above, 135 of these were found to be diabetics, who were unaware of their illness. The remaining 282 subjects (163 males and
fasting blood sugar (mg/lO0 ml)
males no.
fem..des ~
no.
1
o~
32.50
110
22
3t .42
21
110-150
23
32.85
21
32.50
151-200
!1
15.71
18
27.69
201-250
I1
15.71
7
10.76
250
3
4.28
4
6.15
Table 3 - Fasting blood sugar levels in
214
,1
the newly discovered diabetics.
N. KATSILAMI~ROS~ J. STERYOTiS, N. MOIRAS~ H. BEZOS~ G. K. DAIKOS
m
rn
50-59
60"69
16 16 14 12 10 8 6 4 2 0
36-39
40-49
70-79
> 79
age - - groups (years)
Fig.
2 - Absolute numbers of obese person (relative body weight ~ 1 2 0 % of ideal body weight) among newly discovered diabetics according to age and sex (gray areas indicate number of obese persons).
a) males
2.80*
(2.45 to 3.15)**
females
3.57
(3.38 to 3.76)
total
3.20
(2,99 to 3.41)
males
2.41
(2.12 to 2,70)
females
3.24
(2.92 to 3.56)
total
2.83
(2.73 to 2.93)
b)
* mean; ** 959$ confidence limits T a b l e 4 - a) Diabetes prevalence rates (07o) in the whole group, b) 'Corrected' prevalence rates ( % ) according to the real composition of the population studied.
215
PREVALENCE OF DIABETES AMONG GLYGOSURIC INDIVIDUALS
I N AN U R B A N A R E A O F
GREECE
%
sl 41 al q
2~
01
~0-19
f
~
1
t
I
1
I
20-29
30-39
40-49
50-59
60-69
70-79
> 79
,,
age -groups (years)
Fig. 3 . Sex and age distribution of the subjects with non-diabetic glycosuria.
119 females) had normal OGTTs in spite of glycosuria and were accepted as belonging to the category of non-diabetic glycosuria (NDG). NDG is more frequent in men than in women (2.70% and 1.60%, respectively) with an overall prevalence of 2.16% in our sample of 17,758 persons (aged over 10). The prevalence rates are shown in fig. 3. Most cases of NDG were probably of the renal type. In addition, in 19 families NDG was observed in more than one member. FamEy history ot diabetes - The prevalence rates of a family history of diabetes (FHD) were 11.44% in the males and t3.63% in the females without glycosuria, 19.84 % in male and 21.33 % in female diabetics (difference against non-glycosurics highly significant, p
~OHNSTERYOTIS NICHOLAS MOIRAS GEORGES KONSTANTIN DAIKOS
Studies on the prevalence of diabetes mellitus (PDM) were completely lacking in urban parts of Greece. The present effort was undertaken in order to study P D M in an urban area of this country. One of the suburbs of Athens with a population of medium socio-economic status as compared to other urban areas was selected for this purpose. Due to the fact that only subjects with gIycosuria were submitted to an oral glucose tolerance test ( O G T T ) , the figures given in this study as it concerns P D M - as a whole - represent only a rough estimate, therefore, the main purpose of this paper is to provide data on P D M among subjects with glycosuria in a large population sample and in addition to describe some observations in 135 cases of newly discovered diabetics. Detailed data concerning the prevalence of previously k n o w n diabetes in this area have already been reported 7,
SUBJECTS AND METHODS The total number of subjects included in the survey was 21,410 (10,237 males and 11,173 females). The population of Aegaleo, the suburb where the study was conducted, amounts to approximately 80,000 inhabitants. Persons studied were randomly selected, independently of age and sex. In order further to assure a representative sample, whole families living in randomly pre-selected streets (throughout the whole area of the suburb) were examined. Twenty nurses visited every house (door by door) in every third parallel and every third vertical street throughout the whole town from one end to the other. The information they collected on special cams included: a) name; b) sex; c) age; d) profession; e) presence or absence of previously known diabetes; f) existence of diabetic relatives; g) other serious present or past i]lnesses; h) address; i) telephone number. Each member of the family was provided with a plastic tube with his name on it. A urine sample was collected 2 to 3 hrs after a lunch rich in carbohydrates. The presence of sugar in the urine was detected by both Tes-Tape (Eli Lilly Co., Indianapolis/Ind.,
Key-words: Diabetes prevalence rate; Family history o/diabetes; Glycosuria; Non-diabetic gtycosuria. Received: June 9, 1976. Acta diabet, lat. 14, 211, 1977. 211
PREVALENCE O~F DIABETES AMONG GLYCOS'URIC INDIVIDUALS IN AN URBAN AREA OF GtREECE
U.S.A.) and Clinistix (Ames Co., Division Miles Laboratories, Inc., Elkhart/Ind., U.S.A.). If one or both of these strips showed a positive glucose reaction in individuals who were not known to suffer from diabetes, an OGTT was performed: 50 g of glucose dissolved in water were given to these subjects. Venous blood samples were obtained before as wall as I and 2 hrs after glucose administration. These persons had been prepared with a diet, which included at least 200 g of carbohydrates daily for 2 mostly 3 consecutive days prior to the test. At the end of the OGTT a physical examination was performed, including ophthalmoscopy. Diabetes was assessed according to BDA criteria 3. Lag curves were not considered diabetic. No correction for age of the patients was done. Among the glycosuric subjects 73% accepted the invitation for the OGTT. In subjects aged 0 to 9 years only a fasting venous blood sample was obtained for glucose determination. Glucose was assayed on whole blood by Hoffman's method adapted for Technicon Autoanalyzer L
RESULTS Tab. 1 shows the percent age distribution of the 21,410 subjects according to sex and age. The numbers in brackets indicate the percentage that h a d to be studied if we supposed that our sample was ideally representative. T h e s e last data were provided by the National Statistical Service of Greece. G l y c o s u r i a in t h e p o p u l a t i o n s t u d i e d - Tab. 2 shows the number o f male and female persons who were found to have gtycosuria in each age-group. The first decade of life is not considered in this table because, as already mentioned, no glucose tolerance test was done in children of 0 to 9. I t is a p p a r e n t that altogether 569 subjects ( 3 . 2 0 % ) (323 males and 246 females) had postprandial glycosuria. Previously known diabetics were not i n d u d e d in this group. N e w cases o f d i a b e t e s - I t is obvious from tab. 2 that about one t h i r d of the total n u m b e r of glycosurics had an abnormal O G T T . A m o n g the 417 persons submitted to O G T T , a total of 135 new cases of diabetes w e r e di-
*
age-groups (years)
males
females
< 10
18.3 (17.6)*
15.8 (17.2)
10-19
19.0 (17.9)
16.6 (15.6)
20-29
12.1 (15.4)
15,5 (15.2)
30-39
13.7 (16.4)
14.0 (16.7)
40-49
16.2 (14.1)
15.3 (14.0)
50-59
9.3
(9.3)
8,8
(9.4)
60-69
6.7
(5.9)
7.8
(6.8)
70-79
3.6
(2.3)
4.6
(3.3)
>79
0.8
(0.6)
1.2
(1.4)
numbers in brackets indicate the true age distribution (in
Table 1 - Age distribution (in %) of subjects examined.
212
9~) of
the population of the suburb
N. KATSILAMBROS, J'. STERYOTIS~ N. MOIRAS~ H. BEZOS~ G. K. DAIKOS
males
age group (years)
number of persons
studied
number of glycosurics
number of glycosurics submitted to OGTT 21
0
number of newly discovered diabetics
(0)*
10-19
1,949
27
20-29
1,243
t7
9
0
(0)
1
(4.54)
30-39
1,403
39
22
40-49
1,661
94
68
19 (27.94)
50-59
957
65
48
19 (44.16)
60-69
694
5O
40
19 (47.50)
70-79
370
23
20
9 (45.00)
>79
83
8
5
3 (6O.OO)
total
8,360
323
233
70
(30.04)
1,862
40
35
2
(5.71)
0
(o)
temales I0-i9 20-29
1,735
23
14
30-39
1,570
28
24
6 (25.00)
40-49
1,713
52
41
18 (43.9O)
50-59
985
36
22
11
60-69
881
40
32
17 (53.12)
70-79
515
21
13
10 O1.25)
>79
137
6
3
i
(33.33)
total
9,398
246
184
65
(35.32)
(50.00)
* numbers in brackets denote the percent rates of abnormal OGTTs
Table
2
-
Glycosuric subjects and newly discovered diabetics among the whole population.
scovered. Their sex and age distribution is shown in fig, 1 and tab. 2 (right column). The majority was above age 39. In other words, in glycosuric persons below 29, and even more so below 19, diabetes was found rather infrequently. The fasting blood sugar was above normal in about two thirds of the new cases of diabetes while the remaining third had abnormal values only 60 and 120 min after the glucose load (tab. 3). Most of the newly discovered diabetics were obese as shown in fig. 2. The most important feature as regards 213
PREVALENCE OF DIABETES AMONG GLYCOSURIC INDIVIDUALS IN AN URBAN AREA OF GREECE
2%
[~.j
13 12
7L 6L 4,
al
0
._~
" < I0
10-19
20-29
i!iiiii!
! i!!iiiiii~
30-39
40-49
50-59
60-69
ilililiiii
70-79
> 79
age - groups (years)
Fig. 1 -
Sex and age distribution of the newty discovered diabetics.
complications of diabetes in the newly discovered diabetics was the presence of background retinopathy in 7 out of the 135 cases. D i a b e t e s in t h e w h o l e s a m p l e - The overall prevalence of diabetes mellitus in the sample examined is shown in tab. 4. Assuming that the sample was ideal in terms of sex and age distribution, the 'corrected' prevalence (----95Wo confidence limits) would be 2.83 -----0.10%. N o n - d i a b e t i c glycosuria - The total number of glycosurics submitted to OGTT was 417. As mentioned above, 135 of these were found to be diabetics, who were unaware of their illness. The remaining 282 subjects (163 males and
fasting blood sugar (mg/lO0 ml)
males no.
fem..des ~
no.
1
o~
32.50
110
22
3t .42
21
110-150
23
32.85
21
32.50
151-200
!1
15.71
18
27.69
201-250
I1
15.71
7
10.76
250
3
4.28
4
6.15
Table 3 - Fasting blood sugar levels in
214
,1
the newly discovered diabetics.
N. KATSILAMI~ROS~ J. STERYOTiS, N. MOIRAS~ H. BEZOS~ G. K. DAIKOS
m
rn
50-59
60"69
16 16 14 12 10 8 6 4 2 0
36-39
40-49
70-79
> 79
age - - groups (years)
Fig.
2 - Absolute numbers of obese person (relative body weight ~ 1 2 0 % of ideal body weight) among newly discovered diabetics according to age and sex (gray areas indicate number of obese persons).
a) males
2.80*
(2.45 to 3.15)**
females
3.57
(3.38 to 3.76)
total
3.20
(2,99 to 3.41)
males
2.41
(2.12 to 2,70)
females
3.24
(2.92 to 3.56)
total
2.83
(2.73 to 2.93)
b)
* mean; ** 959$ confidence limits T a b l e 4 - a) Diabetes prevalence rates (07o) in the whole group, b) 'Corrected' prevalence rates ( % ) according to the real composition of the population studied.
215
PREVALENCE OF DIABETES AMONG GLYGOSURIC INDIVIDUALS
I N AN U R B A N A R E A O F
GREECE
%
sl 41 al q
2~
01
~0-19
f
~
1
t
I
1
I
20-29
30-39
40-49
50-59
60-69
70-79
> 79
,,
age -groups (years)
Fig. 3 . Sex and age distribution of the subjects with non-diabetic glycosuria.
119 females) had normal OGTTs in spite of glycosuria and were accepted as belonging to the category of non-diabetic glycosuria (NDG). NDG is more frequent in men than in women (2.70% and 1.60%, respectively) with an overall prevalence of 2.16% in our sample of 17,758 persons (aged over 10). The prevalence rates are shown in fig. 3. Most cases of NDG were probably of the renal type. In addition, in 19 families NDG was observed in more than one member. FamEy history ot diabetes - The prevalence rates of a family history of diabetes (FHD) were 11.44% in the males and t3.63% in the females without glycosuria, 19.84 % in male and 21.33 % in female diabetics (difference against non-glycosurics highly significant, p
