Acta Medica Scandinavica. Vol. 176, fasc. 5, 1964

From the Departments of Medicine (Head: N. Soderstrom, M. D.) and Clinical Chemistry (Head: C. G. Holmbcrg, M. D.), University Hospital, Lund, Sweden

A Diabetes Detection Campaign in Southern Sweden

Results of 69,000 Examinations

BY

LARS BRANDT, AKE NORD~N, BENGT SCHERSTBN and NILS TRYDING

Extensive studies of the frequency of diabetes are being carried out in various parts of the world. Even though no agreement has been reached about the ideal test to be used or how to evaluate the data collected, it appears to be of interest to obtain some information about the occurrence in different populations. There seems to be no reason why diabetes should be equally common everywhere. For the planning of health service .schemes each country has to make its .own inventory.

In 1962 a campaign was launched in- tended to cover the 350,000 inhabitants of Malmohus Ian, representing one of the two Southernmost countiesof Sweden. During the first year 68,972 persons have been tested, representing an 82.4 per cent response of the population over 15 years of age. We hope to collect informa- tion about the remaining 17.6 per cent but so far this has not been possible. The number of known diabetics comprised 0.96 per cent in this portion of the Submitted for publication March 16, 1964.

population. The number of previously unknown cases of diabetes requiring treatment which were discovered during the campaign amounted to 0.35 per cent. An intermediate suspect group added another 0.21 per cent, giving a total percentage of 1.5 in the group subjected to the tests.

Material and methods The tests were performed in connection with miniature X-ray examinations of the chest. The population was informed through local meetings and brochures. For the tests a uri- nary sample was collected 2-4 hours after a meal rich in carbohydrates and tested with clinistix (Ames Co.). In addition everybody was asked to fill in a questionnaire on the cards used for the X-ray examinations. Thus information about previously known diabetes and the presence of diabetes in the family was collected.

Those showing a positive clinistix were summoned at a later date for an oral glucose tolerance test at a special laboratory set-up in the University Hospital in Lund. The positive reactors were asked to include bread

555

556 LARS BRANDT ET AL.

TABLE I. Diagnostic criteria

Capillary blood glucose mg/ 100 ml after (min )

Diagnosis 30 60 120 180

Diabetes - > Z O O >155 > l o 5

Diabetes? - 160- 120- 85- 2 00 155 105

Oxyhyper- glycemia >180 <160 <120 <85

Renal glycosuria

-. <160 <120 <85

in every meal for three consecutive days preceding the glucose tolerance test. I t was checked that this instruction was followed. The participants arrived fasting and were given an oral dose of 30 g glucose per ma of body surface as suggested by Klimt et al. (6). They rested comfortably on a couch during the three hours of the test except only for the movements necessary for delivering urinary samples after 60, 120 and 180 minutes. Sam- ples of capillary blood were taken fasting and after 15, 30, 45, 60, 75, 90, 120, 150 and 180 minutes. Blood glucose concentration was determined by the glucose oxidase method according to Marks (9) as modified by Laurel1 (7). The urine was tested with clinistix. The examination also included a physical overhaul and ophthalmoscopy without dilatation of the pupils.

The diagnostic criteria are given in table I and fig. 1.

Cases with positive clinistix tests in the uri- nary samples collected during the glucose tolerance test with a normal blood glucose curve were labelled as renal glycosuria. Glycosuria in samples of urine collected dur- ing fasting was not required for the diagnosis of renal glycosuria.

When the present studies already were under way, some remarkably low fasting blood sugar values were observed. In the technique employed the blood samples were collected

during the three hours of the glucose tolerance test and then analyzed simultaneously. During this period a decrease in the glucose content of the samples was found to take place amounting to between 10 and 20 mg/100 ml during three hours. In each series the first part of the curve is therefore correspondingly lower. Recently all samples have been kept at + 4” C which practically eliminates the changes in glucose concentration. Re- evaluation of the data by introducing a correction factor has been made. For the results this has had only minor consequences, as the values recorded at 60 minutes and later formed the main basis for the diagnosis. A few cases labelled as normal should be regarded as “diabetes?” and some “diabetes? should belong to the true diabetic group, some cases of renal glycosuria should perhaps, belong to the “diabetes?” group.

Results

In 661 instances or 0.96 per cent of the 68,972 individuals taking part in the examination, reports were obtained about already known cases of diabetes. A posi- tive clinistix test was recorded in 620 cases not previously suspected of suffering from diabetes (0.90 yo). Glucose toler- ance tests were performed on 595 persons, while 25 did not appear €or further examination,

Diabetes unquestionably requiring treatment was found in 242 cases (0.35 yo). Fig. 2 illustrates the glucose tolerance curves obtained in 20 consecutive cases in the 40 to 50 year age group. I t seems remarkable that even in this age group there were people who had had no symp- toms or only such vague feelings of dis- comfort that they had not spontaneously sought medical advice. After closer questioning some admitted that they had been slightly more thirsty than usual. In

A DIABETES DETECTION CAMPAIGN 557

TRUE GLUCOSI mg I"

100 ml

blood CJpllllry I NOMENCLATURE

200

150

100

5 0

DIABETES

I

0 60 120 180 Min 0

Fig. 1. Glucose tolerance test. 30 g glucose per m2 0 15 30 45 60 75 90 120 150 180Min. of body surface orally.

Fig. 3. Glucose tolerance test. Diabetic? response in 20 persons. Further checking required.

1 0 0 a DIABETES

TRUE GWCOS mg in 100 ml

blood WW

4 5 0

4 0 0

3 5 0

300

2 50

200

1 5 0

100

5 0

0 . , . , . , 15 30 45 60 75 90 120 150 180Min.

Fig. 2. Glucose tolerance tests. Diabetic response

0 SUSPECTED DIABETES

5 0 4 0 3 0 2 0 1 0 0 . . . . . . . . . .

15 25 35 65 55 65 75 n5 95 YEARS

Fig. 4. Newly discovered cases of diabetes and of suspected diabetes.

Nurnberl

300 1

. . . . . . . . i 5 25 35 15 55 65 75 85 95 rEpas

Fie. 5. Aee and sex distribution of diabeta in20 persons 40-50 years old. (kGown anld newly discovered cases).

558

Per cer

5 0 0

4 00

3.00

2.00

1.00

0.50

1RUE GWCOSE mg 8"

100 ml c4plllar" blood

2 5 0 -

0

LARS BRANDT ET AL.

. . . 15 25 35 45 55 65 75 YEARS

Fig. 6. Cases of diabetes as a percentage of the number of persons examined. Age distribution.

200

150

100

5 0

0 0 15 30 45 60 75 90 120 150 180Min.

Fig. 7. Glucose tolerance tests. Renal glucosuria. Twenty persons 40 ~ 50 years old.

1.00 -

0.50 -

0.25

0 15 25 35 65 55 65 75 a5 95 YEARS

Fig. 8. Cases ofrenal glycosuria as a percentage o f the number of persons examined. Age distribu- tion.

Numberl .

m MEN

0 WOMEN

- 15 25 35 45 55 65 75 85 95 YEARS

Fig. 9. Age and sex distribution ofrenal glycosuria.

TRUE GLUCOSE rng I"

100 rnl Cap,ll.r" blood

2 5 0 - h

200

150

100

5 0

0 15 30 45 60 75 90 120 150 180 Mm

Fig. 10. Glucose tolerance tests. "Oxyhyper- glycemic" reponse in 10 persons earlier subjected to gastric resection.

A DIABETES DETECTION CAMPAIGN 559

the group of 242 cases with newly dis- covered diabetes 14 cases of diabetic retinopathy were found. In two instances gangrene of a toe was discovered. One of these had been treated a month earlier a t a hospital without the diabetes being diagnosed, the other had not previously been recognized. In this group 57 patients reported that diabetes had occurred in the family (23.5 yo).

“Diabetes?” was found in 142 instan- ces (0.21 %). Typical glucose tolerance curves are presented in fig. 3. According to the criteria of Conn (2) these persons were actually diabetic but it was felt that they could be kept under observation and submitted to a new test after a suitable in- terval. No treatment was instituted. That this group is close to the diabetic group is suggested by the report in 22.5% of the cases that diabetes had occurred in the family. The entire material gave this in- formation in 5.4 yo.

The age distribution of the newly dis- covered cases of “diabetes” and “dia- betes?” is illustrated by fig. 4. Cases were disclosed even in the 30-to-40 year group but the majority appeared in the 5040- 60-to-70 year age groups. The rapid rise a t 50 years was not due to a domination of female diabetics, as is seen from fig. 5 which also includes the already known cases of diabetes. The rise in the fre- quency of diabetes with increasing age is seen from fig. 6.

Renal glycosuria was found using the criteria already mentioned in 149 cases or 0.22 %. The results of tests in 20 per- sons are summarized in fig. 7. Renal glyco- suria was not found to increase with ad- vancing age; it may diminish slightly (fig. 8) .Renal glycosuria was predominantly

TABLE 11. Summary of findings

No of cases %

Diabetes already known Diabetes not previously known Diabetes? Renal glycosuria Oxyhyperglycemia Not diabetes Not appearing for glucose

Total no. taking part tolerance test

66 I 242 142 149 20 42

25 68,972

0.96 0.35 0.2 I 0.22 0.03 0.06

0.04 100.00 -

found among men, as is seen from fig. 9. There were 20 women and of them 8 were known to be pregnant - which might reduce the number of women belonging to the group of renal glyco- suria. In the group with renal glycosuria information about diabetes in the family was obtained in 15 yo of the cases. So far, however, we do not know whether the relatives had renal glycosuria or true diabetes.

Oxyhyperglycemia (“oxy” from Greek oxus = sharp) appeared in 20 persons, 10 of whom had been operated on be- cause of gastric ulcer. An additional two had had gastric ulcer but had not been operated. The typical response in this group is illustrated by fig. 10.

Discussion

The present search for previously un- known cases of diabetes has given the results summarized in table 11. By and large they are in agreement with similar reports (table 111). Earlier studies from the Scandinavian countries have recently been summarized by Jorde (5).

560 LARS BRANDT ET AL.

TABLE 111. Some published reports on frequency of diabetes using different methods

Method

Author

4 Age $ Percentage groups ’5 ,; 3 with

Region N ~ . (p) 8 5 3 diabetes

Dahlbrrg et al. (3) Silwer & Oscarsson ( I 1 ) Walker & Kerridge ( 1 3) Scherstth (10) Wilkerson & Krall (14) Jorde (5) Tabor & Frankhauser ( 1 2) Chesrow & Bleyler (1)

Sweden Kristianstad Ian, Sweden Ibstock, England Blekinge, Sweden Oxford, Mass., USA Bergen, Norway Ottawa, Canada Oak Forrest, Ill., USA

- -

4,105 100,000 3,516 5,930

1,000 550

- + - - 0.35 - + - - 0.46-0.57 > 5 - + - 1.39 >I0 - + - 1.7

- + + 2.0 >I4 - -t 4- 1.62-1.77 >40 - + + 4.0 >60 - + + 6.4

-

The number of cases found depends on the method used for screening and the fraction of the population appearing for examination. If blood samples are includ- ed in the screening a much greater num- ber of cases in the older age groups will of course be found. The 242 cases of florid diabetes in the present series, picked up by a positive clinistix test when urine had been collected after a meal rich in carbohydrates, showed a negative urinary clinistix in 76 cases when report- ing back fasting for the glucose tolerance test. Had fasting urinary samples been used for the screening, one-third of the cases with florid diabetes would have been missed.

The present study gives an incomplete picture of the frequency of diabetes in the region, as no information is available concerning the 17.6 yo not taking part in the survey. The percentage figures re- fer to those examined. With this reserva- tion the newly discovered cases of florid

diabetes represented 0.35 yo. An inter- mediate group labelled “diabetes?” formed another 0.21 yo. They probably also belong to the group of true diabetics. As no blood glucose determinations were included in the screening, only the more advanced cases have been spotted. The figure of 1.5 yo must be regarded as too low and not representative of the fre- quency of diabetes in Malmohus lan. In a study of 100,000 persons carried out in a similar way in the neighbouring county of Blekinge, Schersttn (10) arrived at a figure of 1.7 %. Walker and Kerridge (13) attempted to track down all the diabetics among the 4,105 inhabitants of Ibstock in England. A figure of 1.39 yo was found. Jorde (5) examined urinary samples and capillary blood from 5,930 inhabitants in Bergen and found a diabetes prevalence of 1.62 % for men and 1.77 yo for women.

In the present study, 23.5 yo of the members of the group of newly discovered

A DIABETES DETECTION CAMPAIGN 56 1

cases of diabetes reported that the disease was already known to occur in the family, which is in accordance with general experience (8). Our group “Diabetes ?” had a family incidence of 22.5 %. The figure given by the entire 68,972 was 5.4 yo. The number of cases with renal glycosuria agrees with Scher- stCn’s (10) report of 0.28 yo. In 42 instances no signs of diabetes or any other disturbance of the glucose tolerance were discovered. This group must have been due to false positive reactions in the original urinary test.

Summary

In a diabetes detection survey in the Southern part of Sweden 82.4 per cent of the population over 10 years of age or 68,972 persons were examined by urinary clinistix tests. Information about already known diabetes was obtained from 661 persons (0.95 %). In 620 instances a positive clinistix was recorded. 595 per- sons were further studied by a 3-hour oral glucose tolerance test and 242 cases of florid diabetes were found (0.35 %) ; 142 labelled “diabetes?” (0.21 %), 149 as renal glycosuria (0.22 %), 20 as oxyhyperglycemia (0.03 %), while 42 showed a normal test and were presuma- bly pseudopositive in the original clinistix test (0.06 yo).

References 1. CHESROW, E. J. & BLEYLER, J. M.: Diabetes

case finding among 1,000 patients over 60. Geriatrics 10: 479, 1955.

2. CONN, J. W.: The Banting Memorial Lecture 1958. The prediabetic state in man: Def- inition, interpretation, and implications. Diabetes 7: 347, 1958.

3. DAHLBERC, G., JORPES, E., KALLNER, S. & LICHTENSTEIN, A. : Diabetes mellitus in Sweden. Statistical data on the number of diabetics, their state of health, working ca- pacity, diet and treatment. Acta Med. Scand. Suppl. 188. 1947.

4. Editorial: Recent statistics on diabetes. Diabetes 11: 66, 1962.

5. JORDE, R.: The diabetic survey in Bergen, Norway, 1956. Norwegian Universities Press, Bergen-Oslo 1962.

6. KLIMT, C. R., WOLPF, F. W., SILVERMAN, C. & CONANT, J.: Calibration of a simplified cortisone glucose tolerance test. Diabetes 10: 351, 1961.

7. LAURELL, S. : Personal communication. 8. LOEB, R. F.: Diabetes mellitus, in Cecil, R. L.

& Loeb, R. F.: A Textbook of Medicine. 10th edit. W. B. Saunders Company, Philadelphia and London 1959, p. 609.

9. MARKS, V.: An improved glucoseoxidase method for determining blood, CSF, and urine glucose levels. Clin. Chim. Acta 4: 395, 1959.

10. SCHERST~N, BERTIL: Untersuchungen uber die Diabetesfrequenz in einem schwedischen Bezirk von 145,000 Einwohnern. 4 e Con- grts de la Fkdkration Internationale du Diabtte, Geneve 10-14 Juillet, 1961, I: 249, 1961.

11. SILWER, H. & OSCARSSON, P. N.: Incidence and coincidence of diabetes mellitus and pulmonary tuberculosis in a Swedish county. Acta Med. Scand. Suppl. 335, 1958.

12. TABOR, E. C. & FRANKHAUSER, K. H.: Detection of diabetes in a nutrition survey. Pub. Health Rep. 65: 1330, 1950.

13. WALKER, J. B. & KERRIDCE, D.: Diabetes in an English community, a study of its inci- dence and natural history. Leicester Uni- versity Press 1961.

14. WILKERSON, H. L. C. & KRALL, L. P. : Dia- betes in a New England town. J.A.M.A. 135: 209, 1947.

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