XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

Risk Factors for Malnutrition in Older Adults: A Systematic Review of the Literature Based on Longitudinal Data

Patients with vertebral, hip, distal radius, and proximal humerus fractures are most common among the osteoporosis-related fractures. The incidences of these fractures increase with age, however, the increase patterns differ between the fracture sites. The prevalence of vertebral fracture for Japanese is similar or slightly higher and the incidences of osteoporosis-related limb fractures are lower than those for Caucacians. A decrease in prevalence of vertebral fractures and an increase in the incidence of limb fractures are the secular trend in Japan. Previous fractures are significant risk factor for both vertebral and hip fractures. Greater physical activity increases the risk of distal radius fractures, and decreases the risk of proximal humerus fractures.

Epidemiology of osteoporotic fractures

Background
Trials have demonstrated the efficacy of rigorous diet and physical activity promotion (D&PA) programs for adults at increased risk for type 2 diabetes to reduce diabetes incidence and improve measures of glycemia.

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Combined Diet and Physical Activity Promotion Programs to Prevent Type 2 Diabetes Among Persons at Increased Risk: A Systematic Review for the Community Preventive Services Task Force

Introduction 
Loneliness is a common, emotionally distressing experience and is associated with adverse physical and mental health and an unhealthy lifestyle. Nevertheless, little is known about the prevalence of loneliness in different age groups in Switzerland. Furthermore, the existing evidence about age and gender as potential effect modifiers of the associations between loneliness, physical and mental health and lifestyle characteristics warrants further investigation. Thus, the aim of the study was to examine the prevalence of loneliness among adults in Switzerland and to assess the associations of loneliness with several physical and mental health and behavioral factors, as well as to assess the modifying effect of sex and age.


Methods 
Data from 20,007 participants of the cross-sectional population-based Swiss Health Survey 2012 (SHS) were analyzed. Logistic regression analyses were used to assess associations of loneliness with physical and mental health or lifestyle characteristics (e.g. diabetes, depression, physical activity). Wald tests were used to test for interactions.


Results 
Loneliness was distributed in a slight U-shaped form from 15 to 75+ year olds, with 64.1% of participants who had never felt lonely. Lonely individuals were more often affected by physical and mental health problems, such as self-reported chronic diseases (Odds ratio [OR] 1.41, 95% confidence interval [CI] 1.30–1.54), high cholesterol levels (OR 1.31, 95% CI 1.18–1.45), diabetes (OR 1.40, 95% CI 1.16–1.67), moderate and high psychological distress (OR 3.74, 95% CI 3.37–4.16), depression (OR 2.78, 95% CI 2.22–3.48) and impaired self-perceived health (OR 1.94, 95% CI 1.74–2.16). Loneliness was significantly associated with most lifestyle factors (e.g. smoking; OR 1.13, 95% 1.05–1.23). Age, but not sex, moderated loneliness’ association with several variables.


Conclusion 
Loneliness is associated with poorer physical and mental health and unhealthy lifestyle, modified by age, but not by sex. Our findings illustrate the importance of considering loneliness for physical and mental health and lifestyle factors, not only in older and younger, but also in middle-aged adults. Longitudinal studies are needed in Switzerland to elucidate the causal relationships of these associations.

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Loneliness is adversely associated with physical and mental health and lifestyle factors: Results from a Swiss national survey.

Introduction: The clinical and epidemiological data show that proper nutrition plays an important role in maintaining health and combating the danger of developing some chronic diseases in the elderly population. Nutrition is an important factor in many physiological and pathological changes that accompany the aging process. More than 50% of elderly patients are suffering from malnutrition which is information that concerns. Due to various factors, older people are potentially vulnerable groups at risk of malnutrition. Loneliness, isolation from society and neglect of parents by children is a big problem to many people in old age. Objective: To determine differences in nutritional status of elderly people living alone compared to those who live in family surroundings. Subject and methods: The study was conducted in the municipality of Tuzla in 2009.-2010, in outpatient family medicine Simin Han. The survey covered a total of 200 elderly subjects (age> 65 years). Subject group consisted of 45% of people living alone, and 55% control group consisted of elderly patients who live in traditional family surroundings. Questionnaires used in this study are General geriatric assessment questionnaire and Mini nutritional status. Results: The average age (} SD) was 75.4 } 6.2 years in subject group, while the same in the control group was 74.9 }5.6 years. In subject group significantly more patients are on the verge of poverty. There are significant differences in the classification of financial status, according to the groups (p =0.043). Members of subject groups have significantly lower BMI categories (p = 0.03) compared with the control group. In our study, people who live alone are at increased risk of malnutrition (p =0030), have reduced the number of daily meals, significantly lower daily intake of protein, fruits and vegetables in the diet in relation to persons living in a family environment. Significantly more patients with loss of appetite live alone. According to the existence of self-reported food problems significantly more people are in subject group. There is a difference value score “Small assessment of nutrition” between the two groups (p = 0.001). About 22% of the total number of respondents said they have not so good health status compared to others. Conclusions: Loneliness is a significant predictor of anorexia nervosa, the risk of malnutrition and malnutrition. Results indicate that it is necessary to work on improving the status and protection of elderly.

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The effect of loneliness on malnutrition in elderly population.

Introduction Bosnia and Herzegovina has one of the highest unemployment rates in the Balkan region (43.2%), so unemployment is one of the most serious public concerns in our country. Aim To analyze the influence of unemployment on mental health of the working age population who attend primary care center. Material and methods The study was carried out in the municipality of Bosanska Krupa, which has the highest unemployment rate in the Federation of Bosnia and Herzegovina (56%), and included 510 randomly selected working age patients (aged 23-65 years). We used the General Health Questionnaire-28 (GHQ-28) to evaluate mental health of the working age population. Results There were significantly more women than men (53.5% vs. 46.5%; p=0.02). The mean age of participants was 51.04±12.84 years. The experimental group included 318 (62.35%) unemployed working age participants: 160 (50.3%) had been unemployed for more than 5 years and had had no work experience, while 158 (49.7%) unemployed participants had had a previous work experience of more than five years. The control group included 192 (37.65%) employed working age participants. Unemployment had a significant influence on mental health of the working age population. The unemployed participants had a significantly poorer mental health compared to the employed (p=0.0003). A predictor of impaired mental health was a job loss. A significantly greater mental health impairment occured in the group of unemployed participants with previous work experience of more than five years compared to the unemployed participants who had had no work experience (p=0.001) and employed (p=0.000). Conclusion Unemployment has a negative impact and leads to impaired mental health of the working age population in Bosnia and Herzegovina. A job loss has a predictive role. It indicates that social and health policies must be developed in order to improve well-being of the working age population.

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Influence of Unemployment on Mental Health of the Working Age Population.

Study comparing the results of Coronary artery bypass grafting (CABG) with and without cardiopulmonary bypass (CPB) in the treatment of left main stenosis (LMS) has not yet been made in Bosina and Herzegovina. The main aim of this study was to compare result of CABG performed by these methods in LMS group of patients in the early and late postoperative period. The study was divided in two parts. In the first part early postoperative period (30 days after the surgery) have been analysed, which consider results of CABG in 92 patients revascularisied without CPB (OPCAB) method (Group A), and 84 patients with LMS revascularisied with CPB method (ONCAB, CCAB) (Group B). In the second part late postoperative period (one year after surgery) have been analysed. Patients from both groups have been contacted and interviewed. Total number (276 versus 278) same as average number of grafts per patients (3.0 }1.45 versus 3,31 }0.86, p=0.096) was insignificantly higher in group B. Perioperative and postoperative results revealed significant differences between two groups with in the meaning of reduced mechanical ventilation time (2.9 versus 7.3 hours, p=0.039), less blood transfusion requirement (200.3 versus 419.9 ml, p=0.035) and postoperative length of stay (7.4 versus 8.3 days). Inotropic support requirement was significantly higher in group B during the surgery (14.1% versus 29.8%, p=0.019) and postoperative period longer than 12 hours (7.6 versus 22.6%; p=0.009). The most frequent postoperative complication was rhythm disturbance within the definition of atrial fibrillation (23.9 versus 32.1, p=0.295). There was significant difference in mortality in early postoperative period in group A ( 0.0 versus 5.95%, p=0.023). Recurrent angina was among the most frequent postoperative complications and side effect after coronary artery bypass grafting. Significant differences haven’t been revealed between two groups for total appearance of recurrent angina pectoris (25.0 versus 31.2%, p=0.479), for any of additional procedure (7.9 versus 7.8, p=0.802), for the major complications (8.0 versus 9.1%; p=0.985), for mortality (7.9 versus 5.2%; p=0.692). Patients’ survival after CABG for period of 12, 24, 36 and 48 months after surgery was not statistically significant (97.0 versus 96.1%, p= 0.802; 95.5 versus 96.1%, p=0.857; 93.2 versus 94.8%, p=0.913; 92.0 versus 94.8%, p= 0.692). In conclusion, CABG without CABG in treatment of LMS have several advantages compared to conventional method: reduced mechanical ventilation time, less blood transfusion requirement, less inotropic support requirement, shortened postoperative length of stay, reduced mortality in early postoperative period. In the late postoperative period no statistically significant difference was noticed within the mean of recurrent angina, additional procedures, major complications and mortality. Survival rate after CABG was not statistically different in patients operated with or without CPB.

Clinically silent deep vein thrombosis in patients with superficial thrombophlebitis and varicose veins at legs.

Conflict of interest: none declared.

Introduction
The incidence of diabetes type 2 (diabetes mellitus type 2 – DM 2) is rapidly increasing worldwide. Physical inactivity and obesity are the major determinants of the disease. Primary prevention of DM 2 entails health monitoring of people at risk category. People with impaired glycemic control are at high risk for development of DM 2 and enter the intensive supervision program for primary and secondary prevention.

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Prevention of diabetes in family medicine.

Introduction:
Osteoporosis is a disease characterized by a decrease in bone mineral density, making bones become less rigid, and therefore susceptible to fractures, either spontaneously or with force, which is lower than otherwise needed for healthy bones fractured. Nearly 10% of the world population and 30% of women after menopause, suffer from osteoporosis. Clinical assessment of osteoporosis in family medicine is key to prevention, early detection and treatment of osteoporosis.

Esad Alibasic

Papers

The effect of loneliness on malnutrition in elderly population.

Influence of Unemployment on Mental Health of the Working Age Population.

Clinically silent deep vein thrombosis in patients with superficial thrombophlebitis and varicose veins at legs.

Prevention of diabetes in family medicine.

Assessment of Osteoporosis in Family Medicine Obtained by Ultrasound Densitometry