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Aims: To assess the impact of continual major National Health Service reorganization on commissioning, organizational and delivery arrangements for secondary care diabetes services. To explore how consultant diabetologists and diabetes specialist nurses perceive the issues facing diabetes specialist services in 2011 and how these have changed in the preceding decade., Methods: We used a longitudinal case study approach that combined quantitative and qualitative methods. Five locations in England were purposively selected to represent the wider diabetes specialist community, and seven semi-structured interviews were conducted. Interviews were recorded, transcribed verbatim and analysed using Framework analysis. Findings were compared with and contrasted to results from national quantitative surveys of diabetes specialist services undertaken in 2000 and 2006., Results: Clinicians viewed positively the expertise and commitment of multidisciplinary teams and their ability to adapt to new situations. Negative perceptions persisted throughout the decade, relating to the continual change that threatens to dismantle relationships and services which had taken many years to establish. Lack of resources, inadequate manpower planning and poor access to psychological support for people with diabetes remained constant themes from 2000 to 2011., Conclusions: A willingness to innovate and work differently to improve services was identified; however, clinicians must be supported through organizational changes to ensure people with diabetes receive high-quality care. The disruptive nature of organizational change was a recurrent theme throughout the decade. Periods of stability must exist within commissioning to allow relationships, which are key to integration, to be maintained and permit service improvements to develop., (© 2015 The Authors. Diabetic Medicine © 2015 Diabetes UK.)

Aims: The aim of this study was to evaluate an innovative approach to the provision of primary care-based diabetes services in Bradford, UK. The service model differs from others in comprising 19 clinics which offer a specialist service, intermediate between primary and secondary care, to all patients within the Bradford area., Methods: The study included: analysis of referral, attendance and register data; questionnaires to general practitioners (GPs) and specialist clinic providers; qualitative interviews with clinic and other professional staff and patients; and an economic analysis., Results: The 19 clinics adopt a range of organizational models. In the first 3 1/2 years, 2415 patients were referred. There was a significant reduction in out-patient attendances at hospital, but also a significant increase in overall patient attendances. Specialist clinic patients differed from hospital patients in being older and having had diabetes for longer since diagnosis. Ten of the 14 clinics run by practising GPs attracted more referrals from within their practices than from outside. GPs and patients across the city believed the clinics were valuable, the main benefits being geographical accessibility, availability of specialists in a community setting, short waiting times for first appointments at most clinics, and continuity of staff. Their reservations included a lack of strategic planning in the location of clinics, long waiting times at some clinics, and poor communication at some clinics with referring GPs. The cost of the primary care clinics is similar to hospital clinics., Conclusions: This model of specialist primary care services offers an opportunity to develop diabetes services that are convenient to patients, popular with practitioners, and increase capacity. However, the shortcomings as well as the advantages of the model need to be addressed if it is to be implemented elsewhere or for other patient groups.

Aim: To describe diabetes service provision in primary care in the UK., Methods: Postal questionnaires were sent to all UK primary care organizations (PCOs), and to a sample of general practices in England and all practices in Wales and Scotland. The data collection period ended on 30 April 2001., Results: Seventy-nine per cent of the PCOs and 40% of the practices provided usable information. There is evidence that respondents were not significantly biased in relation to their interest in diabetes care. Diabetes was included as a Health Improvement Programme (or equivalent) priority by 62% of PCOs and had been identified as a clinical governance priority by 27%. Sixty-five per cent had information about the ethnic composition of their general population, 57% had an estimate of the number of people with diabetes. Sixty-nine per cent had a local diabetes register but this was said to cover the entire local population in only 64% of these. At least one audit of diabetes care had been carried out (in the previous 5 years) in 75% and, in 76%, clinical guidelines on diabetes care were made available to practices. In the practices, 80% had a designated lead person for diabetes. Seventy-three per cent had at least one general practitioner with a special interest and 87% at least one nurse. Seventy-two per cent of practices ran specific diabetes clinics and 51% had a screening policy. Eighty-six per cent considered that they had adequate systems in place for the delivery of diabetes care. However, only 6% were able to offer a dedicated diabetes telephone help or advice line and only 9% an evening out of hours clinic. Regular practice meetings were held to discuss diabetes in 35%, whereas 39% had a formal shared care protocol. Fourteen per cent held regular joint meetings with the hospital-based team and in 38% there was membership of Diabetes UK for at least one partner or the practice itself. A third (34%) of responding practices were unsure whether a Local Diabetes Services Advisory Group or equivalent existed in their area. Geographical differences in service provision were identified with, for example, practices in London having fewer components in place that were specifically related to the provision of diabetes care. Single-handed practices, wherever they were situated, had in place fewer staff and facilities specifically for diabetes care.

Aims: To examine the provision of, and variations in, dietetic services for diabetes in secondary care in the UK., Method: A postal survey of all secondary care providers of diabetes services., Results: There was a 77% response rate. A dedicated dietician supported diabetes services in 73% of responses, but only 45% were able to see newly diagnosed patients within 1 month. Only 3% of responses documented that dietetic services provided the recommended minimum 22 h weekly input to diabetes care, and an annual dietetic review was said to be available in 15%. An opportunity for more frequent visits was most likely if there was poor glycaemic control (78% of responses), particularly when services were provided by a dedicated diabetes dietician. Although dieticians frequently provided input to patient education (88%), specific training for this purpose and provision for continuing education of these individuals was less common (14% and 63%, respectively). Nutritional guidelines were available in 74%, but only 31% of responses documented current guidelines on obesity management. Of bids for additional dietetic resources, only 21% had been successful. There was evidence of regional variation in service provision, and no greater provision of dietetic services in areas with a large South Asian population and an expected high prevalence of diabetes. In broad terms, dietetic services for diabetes care had not altered in comparison with a similar survey in 1997., Conclusions: The level of dietetic support of secondary care diabetes services remains dramatically lower than recommended in advisory documents, and appears to have changed little over the last 3 years. This is compounded by marked regional differences, and was no better in areas with a higher than average prevalence of diabetes. The survey also highlights the need for more co-ordinated and structured education and training of dieticians as well as more consistency in nutritional guidelines.

Aim: To examine the provision of, and variations in, podiatry and other services for diabetic foot care in the UK., Method: A postal survey of secondary care providers of diabetes services in the UK in 2000., Results: Following two reminders a 77% response rate was achieved. The responses indicated that 97% had a state-registered podiatrist attached to the service, providing three (median) sessions each week for diabetes care, although only 44% had availability at all diabetic clinics, and only 3% had availability at paediatric diabetic services. Podiatry access at all diabetic clinics increased the likelihood of associated preventative as opposed to reactive ('trouble shooting') care (P < 0.05). All individuals with feet at 'high risk' of ulceration had access to 'at least 2 monthly review' in 15% of trusts, and with active foot ulceration at least weekly in 43%. Over 70% used at least one form of equipment to assess peripheral neuropathy, but peripheral blood flow was only formally measured in 13%. Although podiatry input to patient education was common (84%), only 6% had received formal training in education. Guidelines and strategies for management of active foot problems were available in 50-74% of cases. Orthotic input was highly variable, and absent in 15% of responses. Podiatrist fitting and application of foot protective apparatus was only recorded in 22-61% of responses. Access to isotopic and/or MR foot imaging and peripheral angiography and angioplasty was recorded in 75-83% of responses. Separate specialist foot clinics were available in 49%, and where this was the case the use of newer foot ulcer healing applications was higher (P < 0.01). Clear regional differences were apparent in the nature of the service, the use of newer treatments, and in access to an orthotist, a local 'dedicated' foot surgeon or a separate diabetic foot clinic. Of 245 documented bids for service improvements, only 19 related to foot care and only 21% of bids were successful., Conclusions: Despite an increase in podiatry support to diabetes care over the last 10 years, the level of access and the nature of the services provided is much less than recommended in many advisory documents. The strategy of a co-ordinated 'team' approach to foot care still takes place in less than 50% of centres. There are clear regional differences in diabetes foot care services. Both providers and purchasers of diabetes services may not have given sufficient attention to this area, given the relatively small number of documented bids for service improvements in this area, and the very low success rate of such bids.

Aims: A systematic review of the literature was carried out to examine whether published evidence suggests a difference in the frequency and awareness of hypoglycaemia induced by 'human' and animal insulin., Methods: The review identified randomized controlled trials and studies of other designs including observational comparisons, case series and case reports in which the use of 'human' insulin was compared to animal insulin in people with diabetes. These were identified from bibliographic databases and hand-searches of key journals. The main outcome measures were frequency, severity, awareness and symptoms of insulin induced hypoglycaemia., Results: Fifty-two randomized controlled trials, 37 of double-blind design, were identified which included one or more of the relevant outcome measures. Of these, 21 specifically investigated hypoglycaemic frequency and awareness as primary outcomes (six in people with previously reported reduced hypoglycaemic awareness). The remainder of the identified trials reported hypoglycaemic outcomes as a secondary or incidental outcome during comparative investigations of efficacy or immunogenicity. Seven of the double-blind studies reported differences in frequency of hypoglycaemia or awareness of symptoms, although none of the studies which selected subjects on the basis of previously reported impaired awareness demonstrated significant differences between insulin species. Four of the unblinded trials reported differences in hypoglycaemia. This reached statistical significance in two of the studies. A further 56 studies of other designs and case reports were considered. In addition to the 10 case reports describing individuals with impaired hypoglycaemic awareness, nine studies reported differences in the incidence and manifestation of hypoglycaemia during 'human' insulin treatment. Notably, none of the four population time trend studies found any relationship between the increasing use of 'human' insulin and hospital admission for hypoglycaemia or unexplained death among those with diabetes. The largest case series could find no support for the hypothesis that an influence of treatment with 'human' insulin on hypoglycaemia had contributed to any of the 50 deaths investigated. When all types of studies considered are ranked in order of rigour (according to the accepted 'hierarchy of evidence'), it is the least rigorous which lend most support to the notion that treatment with 'human' insulin has an effect on the frequency, severity or symptoms of hypoglycaemia., Conclusions: Evidence does not support the contention that treatment with 'human' insulin per se affects the frequency, severity or symptoms of hypoglycaemia. However, a number of studies, mainly those of less rigorous design, describe an effect when people are transferred from animal insulin to 'human' insulin. It is not possible to state how common this is or whether the phenomenon is specific to 'human' insulin or an effect resulting from stricter glycaemic control (perhaps compounded, in some cases, by neurological complications in long-standing diabetes). This remaining uncertainty makes it essential that insulin from animal sources continues to be available so that clinicians and patients may retain this choice of treatment.

This study aimed to highlight geographical differences in childhood Type 1 (insulin dependent) diabetes mellitus (IDDM) by mapping incidence at 3 different geographical scales, within the northern English county of Yorkshire. Mapping techniques are applied to incident cases from a population-based regional register of childhood IDDM. The Yorkshire Children's Diabetes Register (YCDR) comprises 1310 children (0-14 years) diagnosed with IDDM from 1978-1990. Age standardized incidence rates (cases/100000/year) are given for administrative county, standardized incidence ratios (SIRs) are mapped by local government district and electoral ward. Heterogeneity between areas was assessed by a chi 2 test. At county level, incidence is 25% higher in Humberside (16.82 per 100000 per year) compared to West Yorkshire (12.21 per 100000 per year) (p < 0.001). SIRs for the 22 districts display significant heterogeneity (p < 0.001) with deficits in the urban areas of Kirklees (70 95% CI 57-85) and Bradford (81 95% CI 68-95) and significant excesses in the rural districts of Ryedale (147 95% CI 106-198), Beverley (149 95% CI 113-193), Holderness (166 95% CI 112-237) and Boothferry (186 95% CI 134-250). At the smallest scale, variation between wards is significant (p < 0.001) and low incidence in urban areas is notable. Geographical variation in the incidence of childhood IDDM may provide strong clues to its aetiology. Within Yorkshire, geographical distribution shows significant heterogeneity at three different scales. The magnitude of the variation is not explained by ethnic or genetic differences in the population and underlines the important influence of environmental factors in disease aetiology.

The objective was to describe, by means of a retrospective study of three years' routine District information (financial years 1991/92 to 1993/94), the in- and out-patient activity for patients with diabetes, and compare this with the non-diabetic population. The clinical resource usage by patients with diabetes relative to those without was estimated by (a) their relative probability of admission by specialty, (b) attendance rates at out-patient clinics, (c) primary diagnosis, and (d) operations and procedures. The setting was a District Health Authority with a population of 408 000. All in-patient and out-patient records were reclassified as attributable to a patient with or without diabetes by cross-referral to routine records of patients with identified diabetes from separate hospital databases. The main outcome measures were: (a) relative frequency, and crude and age-specific relative probability of admission by specialty, ICD9 primary diagnosis, and OPCS4 primary operation and procedure, and (b) out-patient attendance rates by specialty. Patients with diabetes were responsible for 5.5% of admissions and 6.4% of out-patient attendances. However, because of increased length of stay, patients with diabetes occupy 9.4% of bed days. The relative risk of admission for diabetes related complications was: coronary heart disease 11.8 (95% CI = 11.4-12.3), cerebrovascular disease 11.8 (10.8-12.8), neuropathy and peripheral vascular disease 15.6 (13.6-17.9), eye complications 10.4 (9.3-11.7), and renal disease 14.7 (12.6-17.3). Recognised diabetes related vascular (9.3-11.7), and renal disease 14.7 (12.6-17.3). Recognised diabetes related vascular complications accounted for at least 23% of admissions of patients with diabetes. The relative risk of admission for diagnoses and procedures not known to be related to diabetes were similar for non-diabetic and diabetic patients. The pattern of out-patient activity mirrored that of the relative probability of admission. It is concluded that previous estimates of the proportion of NHS resources used for the treatment of patients with diabetes had been significantly underestimated. Patients with diabetes were found to occupy 1 in 10 non-obstetric, non-psychiatric beds. Many of these admissions were for diagnoses and procedures that are known to be related to diabetes.

The Isle of Ely Diabetes Project is a prospective population-based study of the aetiology and pathogenesis of Type 2 diabetes mellitus. Between 1990 and 1992, 1156 subjects aged between 40 and 65 years underwent a standard 75 g oral glucose tolerance test (OGTT). A total of 1122 individuals who were not known to have diabetes completed the test and were classified according to WHO criteria; 51 subjects (4.5%) had previously undiagnosed diabetes and 188 (16.7%) had impaired glucose tolerance. The subjects with newly diagnosed glucose intolerance were significantly older, more obese, and shorter than those with normal glucose tolerance. Blood pressure, cholesterol, triglyceride, and LDL-cholesterol concentrations were elevated and HDL-cholesterol levels were lower among those with abnormal rather than normal glucose tolerance. In multiple regression analyses stratified by gender and including age, body mass index, and the waist-hip ratio as covariates, there were significant differences between those with normal and abnormal glucose intolerance in blood pressure, triglyceride, and HDL-cholesterol, but not total or LDL-cholesterol. In both male and female subjects, height had a significant independent negative association with the plasma glucose at 120 min after administration of oral glucose (standardized beta coefficient = -0.12, p < 0.01).

Screening asymptomatic subjects for diabetes is often undertaken using a random capillary whole blood sample for glucose estimation. The test characteristics of this method for screening were assessed using a glucose oxidase method among 3425 Europeans and 3469 South Asians who gave such a sample during the Coventry Diabetes Study, a house-to-house diabetes prevalence study. Glucose tolerance test were performed on those with a high blood glucose and 10% of others. Previously undiagnosed diabetes was found in 73 Europeans and 110 South Asians. If the random glucose was > or = 7.0 mmol l-1, 8.0% of Europeans and 6.7% of South Asians would need a further diagnostic test and the sensitivity of this cut-off was 51.7 (95.0% CI: 43.5-59.9)% in Europeans and 68.4 (60.6-76.2)% in South Asians. Sensitivity was increased in South Asians but not Europeans by defining the time since last meal (South Asians < 2 h: 83.9 (72.3-92.0)%; > or = 2 h: 54.9 (42.7-66.8)%). Sensitivity was poorest among Europeans aged > or = 65 years (40-64 years 69.0 (49.2-84.7)%, > or = 65 years 49.4 (38.2-60.6)%). Screening asymptomatic individuals using an isolated capillary random whole blood glucose measure is a poor test for diabetes, although slight improvement can be obtained among South Asians by testing within 2 h of a meal.

Hospital admission rates and hospital bed utilization rates are presented for all admissions assigned to diabetes mellitus as principal cause in the North Western Region from 1980/81 to 1990/91. Data are derived from Hospital Activity Analysis (1980/81-1986/87) and from the Regional Information System (1988/89-1990/91). Admission rates for all categories of diabetes combined showed little change until 1986/87 after which they rose progressively each year. Hospital bed utilization rates fell progressively from 1986/87 onwards, the number of bed days attributed to diabetes falling from 1.9% to 0.8% of the total for all causes. Most of the rise in admission rates from 1988/89 onwards was attributable to diabetes with ophthalmic complications (ICD 250.4). This was heavily influenced by the enumeration of day cases in the Regional Information System. When these are discounted, admission rates for the more recent years are stable. Diabetes without mention of complications (ICD 250.0) showed the most dramatic decline in its contribution to hospital bed utilization. This may be the result of increasing outpatient support from diabetes specialist nurses whose numbers increased in inverse proportion to the fall in bed utilization attributed to ICD 250.0.

The proportion of the population aged 65 years and over is increasing. The Coventry Diabetes Study was able to investigate the prevalence of diagnosed and undiagnosed diabetes among elderly (aged > or = 65 years) Europeans (n = 1600) and South Asians (n = 288) in Foleshill, Coventry. The total prevalence of diabetes was higher in South Asians than Europeans among males (30.7 (95% CI 24.0-37.9)% vs 7.7 (95% CI 5.8-10.0)%, respectively) and females (24.0 (95% CI 17.5-32.4)% vs 12.5 (95% CI 10.6-14.8)%, respectively). The proportion with diagnosed diabetes was higher among South Asians than Europeans (55% vs 33%, p < 0.001), possibly because of their earlier onset. These findings suggest that detection of diabetes in elderly Europeans in urban areas may be inadequate.

A working group was established in order to suggest the process and outcome variables most appropriate for the continuing audit of diabetes services. The proposed audit is being piloted in hospitals in selected United Kingdom Health Districts. The main process and outcome measures suggested are: waiting and consultation times; missed or cancelled appointments; information given to patients and the primary care team; knowledge of diabetes and risks of smoking; recording of key examinations and investigations, i.e. levels of glycosylated haemoglobin (or equivalent), serum cholesterol, body mass index, blood pressure, albumin excretion rate, presence and extent of retinopathy, history of coronary artery, cerebrovascular or peripheral vascular disease; history of severe hypoglycaemia; presence of foot problems; psychological well-being; patient satisfaction; admission rates and hospital bed days for hyperglycaemic and other diabetes related emergencies.

Two postal questionnaire surveys of facilities and staff available to hospital physicians responsible for the care of adults with diabetes in the United Kingdom have been carried out under the auspices of the British Diabetic Association. These surveys, in 1982-83 and 1990, achieved 92% and 94% responses, respectively, giving information on around 95% of UK health districts or their equivalent. Levels of provision and the use of existing facilities had, in general, improved over that time though several important deficiencies still remain. Respondents providing out-of-hours clinics and combined clinics with other specialties increased as did the availability of dietetic advice in outpatient clinics. Although the proportion of respondents reporting no specialist diabetes nursing assistance fell from 53% to 14%, this still left 29 reporting none at all. Access to blood glucose and HbA1 results, facilities for retinal examination, and access to photocoagulation had all improved but there was little change in the availability of adequate examination and educational facilities although this may have been due to a rise in expectations. Chiropodial care was less readily available in 1990 with 17% of respondents (compared with 11%) reporting a complete lack in the clinic. A recommendation that no locality should be without at least one physician with a special interest in diabetes was fulfilled in 81.9% of localities but some were still relatively poorly staffed.

The prevalence of Type 2 (non-insulin-dependent) diabetes in different South Asian (Asian) communities was compared during the Coventry Diabetes Study, a cross-sectional house to house screening programme for diabetes. Screening was by capillary whole blood glucose measurement with oral glucose tolerance tests when concentrations were greater than or equal to 6.0 mmol l-1 within 2 h of a meal or greater than or equal to 5.0 mmol l-1 2 h or more after a meal and a random 10% of others. Of the 4395 resident Asians, 94% were represented by five communities: Punjabi Sikhs, Punjabi Hindus, Gujerati Moslems, Gujerati Hindus, and Pakistani Moslems. Response to screening was 77-89% and to glucose tolerance test was 59-79%. Differences in anthropometry, socioeconomic circumstances, and migratory patterns were found, but all groups had a higher prevalence of Type 2 diabetes than Europeans. Gujerati Moslems had the highest age-adjusted prevalence (per 1000) of Type 2 diabetes (males: 160 (95% CI 107-228), females: 204 (95% CI 144-283)) when compared with the other Asian groups (males: Punjabi Sikhs 89(72-110), Pakistani Moslems 91(67-120), Gujerati Hindus 84(57-120), Punjabi Hindu 113(74-171); females: Punjabi Sikhs 75(60-94), Pakistani Moslems 103(78-133), Gujerati Hindus 88(62-122), Punjabi Hindu 116(77-174)). That all the Asian groups had a high prevalence of diabetes, in spite of their known dietary, cultural, and socioeconomic differences, suggests that the Asian predisposition to Type 2 diabetes is inherited although environmental factors may be necessary for this to be expressed.

As part of a District-based audit of diabetes care all attendances (of diabetic and non-diabetic patients) at a local Accident and Emergency department were monitored over a 3-month period. A total of 9505 attendances took place of which 62 (0.7%) were by people with diabetes. This was no different from the expected number of attendances (61.5) based on the rates seen in non-diabetic individuals. Of these 62 attendances, 20 (by 15 individuals) were directly related to diabetes (hypoglycaemia 17, hyperglycaemia 1, for supplies of insulin or equipment 2). When these diabetes-specific attendances were removed from the total, the number of attendances (42) was significantly (p = 0.004) less than that expected. Diabetic males aged 0-19 years attended significantly more often than non-diabetic individuals of the same age but this excess was solely attributable to diabetes.

Knowledge about the nature, symptoms, complications, and treatment of diabetes was assessed among United Kingdom Europeans and Asians with and without diabetes during the Coventry Diabetes Study. An open questionnaire was validated for use among Asians and Europeans and a 'Knowledge Index' constructed. The questions were answered by 3814 (87%) of 4395 Asians and 3783 (69%) of 5508 Europeans. Among those with known diabetes, 216 (96%) of 223 Asians and 98 (94%) of 104 Europeans answered the questions. The nature of diabetes was unknown in 30% of Europeans and 44% of Asians with diabetes, and 42% and 67%, respectively, could not name a single complication. Most of those without diabetes were unable to name either a complication (Europeans 66%, Asians 89%) or a single symptom (66% and 83%, respectively). The Knowledge Index was highest in Europeans, increased with increasing educational achievement, and was lowest in non-diabetic subjects without a family history of diabetes. Even those with diabetes had a low Knowledge Index.

The care of patients with diabetes was assessed in eight general practices intending to establish mini-clinics. Seven of these practices subsequently participated in a mini-clinic scheme incorporating continuing education and audit. After 3 years further data were collected and compared with the baseline assessment. Seven other local practices which had not set up mini-clinics were also studied. During the time between the baseline survey and the 3-year assessment the proportion of non-insulin-treated patients registered with the mini-clinic practices and receiving regular review in general practice increased from 54 to 84%. The proportions of patients with a record of body weight, blood pressure, urinary glucose, urinary protein, blood glucose, HbA1, visual acuity, examination of the fundus through dilated pupils, examination of the feet, and a consultation with a dietitian within the previous year increased significantly and were higher in mini-clinic than in comparison practices although, for a substantial number of patients in both groups of practices, these remained unrecorded. This study shows that organized and audited general practice mini-clinics can improve the process of care for diabetic patients.

Data from the clinical records of patients known to have diabetes and admitted to hospital in North West London, Cambridge or Newcastle were compared with data on the same admissions taken from the system responsible for recording information on all acute hospital admissions (Hospital Activity Analysis). In 89 out of 751 admissions (12%), either the sex, date of birth or marital status of the patient was incorrectly recorded. The diagnosis of diabetes was omitted in 32 (10%) of 315 admissions in which diabetes or a complication of diabetes was regarded as the principal cause of admission and in 12 (23%) out of 53 in which the principal cause was closely related to diabetes. These included cases in which the diagnosis had not been stated (by the clinician) on the discharge summary (the source document for Hospital Activity Analysis) as well as instances in which the coding clerk had failed to record the diagnosis. The validity of information collected on hospital admissions is dependent on the presentation of data by the clinician to the coding clerk. There may be a lack of awareness of the importance of the clinical discharge summary as a source document for such systems.

Hospital admissions data for 1981 reveal that, for the population of East Anglia, 1.6% of hospital bed days were attributed to diabetes mellitus as the principal cause for admission. Admissions for diabetes without complications or with ketoacidosis or other coma accounted for about 60% of bed days while the other specified complications of diabetes accounted for the remainder. Admissions with diabetes as a subsidiary diagnosis accounted for 2.6 times as many bed days as those for which the disease was the principal diagnosis. Ischaemic heart disease or cerebrovascular disease was recorded as principal diagnosis significantly more often than would be expected from the general population experience, particularly for female diabetics. On an average day, 5.6% of beds were occupied by diabetic patients. The diabetic population of East Anglia used, on average, 5.1 hospital bed days per person year compared with 1.1 days for the non-diabetic population.

The glycaemic responses of 12 C-peptide negative insulin-dependent diabetics were studied following four breakfasts with different carbohydrate sources. Total energy content of the meals was the usual for each subject, carbohydrate supplying 55% and fat 32%. The meals comprised: wholemeal bread with margarine; white bread with margarine; marmalade made with sucrose, and cheddar cheese; and marmalade (22% of total energy) on wholemeal bread with margarine. The study demonstrated powerfully that there were no statistically significant or clinically relevant differences between the meals in post-prandial glucose peak elevation, or in incremental area under the blood glucose curve to 120 mins. On these grounds, sucrose, in amounts considered acceptable to the general population, need not be prohibited from diabetic diets.