DIABETES

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Abstract

IN this week's and next week's issues of the Journal we are publishing a unique collection of papers on various aspects of diabetes-papers from workers in many different disciplines in medicine, and from all parts of Australia. It will be appreciated that it has not been possible to embrace all aspects of the current knowledge on the subject, but emphasis has been placed on the frequency of the condition and on the role of the general practitioner in its detection. Research in diabetes over the last ten years has made most previous knowledge quite obsolete, and the physician who cares for a diabetic must keep abreast of modern developments in therapy. But despite the intensive research and new concepts of pathogenesis, there is still no universal opinion as to what constitutes diabetes. It is extremely difficult to find a satisfactory definition, embracing the disturbance of all aspects of metabolism, the relative or absolute lack of insulin, the protean clinical manifestations and the almost universal occurrence of vascular pathological change. Well aware of these problems, we still attempt to diagnose diabetes by the disturbance of carbohydrate metabolism. The oral glucose tolerance test is the standard test used, but because of difficulties in interpretation, other tests have been suggested-the intravenous glucose tolerance test or the intravenous tolbutamide test. However, difficulties in performance and interpretation have restricted their use to research at present. The problems of interpretation of the oral glucose tolerance test are discussed in papers in these issues, and every practitioner must at some stage of his career have been faced with what we may call "a funny curve"-not normal, but not diabetic. The criteria by which a curve should be regarded as normal vary from place to place, and as no one set of criteria is right and none is wrong, we would do well to adopt the criteria of the National Health and Medical Research Council in this country. But we will still be left with the "funny curve", and it is wrong to dismiss this as entirely normal, or regard it as a laboratory error. On follow up, over months or years, patients exhibiting such results have a great likelihood of developing diabetes. The reproducibility of the glucose tolerance test has also been questioned, and is the subject of a report by McDonald et alii.l Using a "captive" population and performing tests every two months over a period of a year, they arrived at the following conclusion: "Blood glucose levels for individuals varied considerably. On single tests, some of the men exhibited borderline or diagnostic test readings, but in no case was this consistent over all tests." They go on to ask the questions: Is it typical for persons progressing into a diabetic state to exhibit vacillation between abnormal and normal blood glucose levels? And if so, can one rely on a single test result for the very group that should be identified through use of the test? Obviously, we do not have the answers to these questions, and can only give the advice that a person with a "funny test" should have it repeated in three months, and continue to do so until it is clear that the response is normal or diabetic. The problem faced by the general practitioner is what to do for the newly diagnosed diabetic. Gone are the days of the attitude "It's just a touch of sugar-it doesn't matter". Although the relation between control of diabetes and development of complications, which will be discussed later, is by no means clear, it should not prevent the physician from striving for ideal control with a minimal disturbance of the patient's way of life.