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

1. Introduction and Overview. 2. Detecting Influential Observations and Outliers. 3. Detecting and Assessing Collinearity. 4. Applications and Remedies. 5. Research Issues and Directions for Extensions. Bibliography. Author Index. Subject Index.

Regression Diagnostics: Identifying Influential Data and Sources of Collinearity

The polycystic ovary syndrome is one of the most common hormonal disorders affecting women It has multiple components — reproductive, metabolic, and cardiovascular — with health implications for the patient's entire life span This review addresses current concepts regarding the diagnosis, cause, and treatment of the condition

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Polycystic ovary syndrome.

Consensus on women's health aspects of polycystic ovary syndrome (PCOS): The Amsterdam ESHRE/ASRM-Sponsored 3rd PCOS Consensus Workshop Group

Objective: The aim was to formulate practice guidelines for the diagnosis and treatment of polycystic ovary syndrome (PCOS). Participants: An Endocrine Society-appointed Task Force of experts, a methodologist, and a medical writer developed the guideline. Evidence: This evidence-based guideline was developed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system to describe both the strength of recommendations and the quality of evidence. Consensus Process: One group meeting, several conference calls, and e-mail communications enabled consensus. Committees and members of The Endocrine Society and the European Society of Endocrinology reviewed and commented on preliminary drafts of these guidelines. Two systematic reviews were conducted to summarize supporting evidence. Conclusions: We suggest using the Rotterdam criteria for diagnosing PCOS (presence of two of the following criteria: androgen excess, ovulatory dysfunction, or polycystic ovaries). Establishing a diagno...

Diagnosis and treatment of polycystic ovary syndrome: an Endocrine Society clinical practice guideline.

Polycystic ovary syndrome (PCOS) is one of the most common endocrinopathies in women of fertile age. Obesity is encountered in 30–70% of PCOS-affected women, and its presence significantly modifies both clinical and laboratory expression of the syndrome. Obesity increases the risk of co-morbidities associated with PCOS, such as impaired glucose tolerance and type 2 diabetes mellitus, hyperlipidemia and arterial hypertension. The etiopathogenesis of obesity in PCOS has not yet been exactly clarified. There clearly is a vicious circle of abdominal obesity, insulin resistance, and hyperadrogenemia. Differences in ghrelin and neuropeptide Y levels between PCOS patients and those with simple obesity were also described. Weight loss is the first choice recommendation for the treatment of clinical manifestations of PCOS, such as menstrual cycle irregularities, infertility or hirsutism. However, the best treatment approach in obese PCOS patients remains to be defined. Studies concerning different weight loss regimens, antiobesity drugs, bariatric surgery, insulin sensitizers, and hormonal therapy are reviewed.

Obesity and Polycystic Ovary Syndrome

Combined oral contraceptives (COC) are the most often used treatment modality for polycystic ovary syndrome (PCOS). Undisputedly, COC suppress androgen production, thus ameliorating skin androgenic symptoms and improving menstrual dysfunction. On the other hand, there are still many unresolved issues concerning their metabolic effects. COC could decrease insulin sensitivity and deteriorate glucose tolerance, although the negative influence on insulin sensitivity is dependent on other factors (especially obesity) and this need not be expressed in non-obese patients. It is probable that the impairment of glucose tolerance is reversible, as the incidence of diabetes is not increased in past COC users. The effects of COC on the lipid spectrum are dependent on the type of gestagen, but lipid levels usually remain within the reference limits. Combination therapy of COC with weight reduction or insulin sensitizers could further suppress androgen levels and improve metabolic parameters. The establishment of COC after laparoscopic ovarian drilling may further decrease androgen levels. The combination of COC and GnRH analogues is not superior to COC therapy alone. Prospective data about the influence of COC on the risk of diabetes mellitus, coronary artery disease and endometrial cancer in PCOS women are lacking.

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Combined oral contraceptives in the treatment of polycystic ovary syndrome

The aim of our study was to compare insulin sensitivity in lean and obese European polycystic ovary syndrome (PCOS) women with lean healthy women We performed the euglycemic hyperinsulinemic clamp in 83 women with PCOS [53 lean with body mass index (BMI) of 215 +/- 18 kg/m2 and 30 obese with BMI of 296 +/- 37 kg/m2] and in 15 healthy women with BMI of 216 +/- 18 kg/m2 to determine glucose disposal (M) and the insulin sensitivity index (ISI) Statistical evaluation was done using Kruskal-Wallis ANOVA followed by Kruskal-Wallis multiple-comparison z-value test The basal blood glucose was significantly higher in lean and obese PCOS women than in controls (P < 002) Fasting insulin was significantly higher in both lean and obese PCOS women than in controls (P < 0000001) Obese PCOS women were more insulin resistant than controls (P < 002 for M and P < 00008 for ISI); lean PCOS women did not differ from controls in M or ISI Posthepatic insulin delivery was significantly higher in both lean and obese PCOS women compared with controls (P < 0000008) We conclude that lean PCOS women are not more insulin resistant than healthy controls Insulin hypersecretion, on the other hand, is present even in lean PCOS women

Insulin Sensitivity in Women with Polycystic Ovary Syndrome

OBJECTIVE —To evaluate insulin sensitivity (IS) and β-cell function (βF) in lean and obese women with polycystic ovary syndrome (PCOS), either separately or by using a disposition index (DI). RESEARCH DESIGN AND METHODS —A total of 64 women with PCOS and 20 healthy women were examined by anthropometry, oral glucose tolerance tests (OGTTs), and insulin tolerance tests. Statistical analysis used one-way ANOVA, Kruskal-Wallis, and Mann-Whitney U tests, as appropriate. RESULTS —A significantly higher waist-to-hip ratio ( P P P P 30–0 , where I is insulin and G is glucose]; P P P –3 ). CONCLUSIONS —Increased βF was found even in lean individuals with PCOS. Insulin hypersecretion is thus probably connected to the pathogenesis of PCOS.

https://care.diabetesjournals.org/content/diacare/25/7/1217.full.pdf

Insulin Sensitivity and β-Cell Function in Women With Polycystic Ovary Syndrome

BACKGROUND: Neither oral contraceptives (COC) nor metformin are an optimal modality for the long-term treatment of polycystic ovary syndrome (PCOS). The aim of this study was to evaluate whether a combination of both is beneficial over COC monotherapy. METHODS: Altogether, 30 women were included in the study and 28 finished the protocol. The patients were randomly assigned to two groups treated with either COC (COC group) or COC and metformin (1500 mg/day) (METOC group) for 6 months. Anthropometric parameters, androgens, lipids, fasting insulin, glucose and sex hormone binding globulin (SHBG) concentrations were measured before and at the end of the sixth cycle of treatment. The insulin sensitivity index was evaluated using the euglycaemic clamp. RESULTS: There were no significant changes in anthropometric parameters, fasting glucose or insulin sensitivity in either group. Total testosterone, free androgen index, androstenedione and dehydroepiandrosterone decreased and SHBG increased significantly in both groups. When comparing the effect of both treatments, only a more pronounced decrease in free androgen index was found in the METOC group. CONCLUSIONS: Adding metformin slightly modified the treatment effect of COC, causing a more significant decrease in the free androgen index but having no additional positive impact on lipids, insulin sensitivity, SHBG or testosterone. The available data do not offer enough evidence to advocate the standard use of combined treatment in PCOS. Whether the combination might be beneficial for specific subgroups of patients is of further interest.

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The effect of combination therapy with metformin and combined oral contraceptives (COC) versus COC alone on insulin sensitivity, hyperandrogenaemia, SHBG and lipids in PCOS patients

Jana Vrbikova

Papers

Obesity and Polycystic Ovary Syndrome

Combined oral contraceptives in the treatment of polycystic ovary syndrome

Insulin Sensitivity in Women with Polycystic Ovary Syndrome

Insulin Sensitivity and β-Cell Function in Women With Polycystic Ovary Syndrome

The effect of combination therapy with metformin and combined oral contraceptives (COC) versus COC alone on insulin sensitivity, hyperandrogenaemia, SHBG and lipids in PCOS patients