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

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 now recognized as an important metabolic as well as reproductive disorder conferring substantially increased risk for type 2 diabetes. Affected women have marked insulin resistance, independent of obesity. This article summarizes the state of the science since we last reviewed the field in the Endocrine Reviews in 1997. There is general agreement that obese women with PCOS are insulin resistant, but some groups of lean affected women may have normal insulin sensitivity. There is a post-binding defect in receptor signaling likely due to increased receptor and insulin receptor substrate-1 serine phosphorylation that selectively affects metabolic but not mitogenic pathways in classic insulin target tissues and in the ovary. Constitutive activation of serine kinases in the MAPK-ERK pathway may contribute to resistance to insulin's metabolic actions in skeletal muscle. Insulin functions as a co-gonadotropin through its cognate receptor to modulate ovarian steroidogenesis. Ge...

Insulin Resistance and the Polycystic Ovary Syndrome Revisited: An Update on Mechanisms and Implications

Polycystic ovary syndrome (PCOS) is characterized by a constellation of clinical symptoms that include irregular menses due to chronic oligo-ovulation, phenotypic features of hyperandrogenism, and obesity The term “polycystic ovary” refers to ovarian morphology with increased ovarian stroma and a ring of cortical follicles Core biochemical features include hyperandrogenism and insulin resistance The pathogenesis of PCOS remains a topic of debate Treatment of PCOS typically focuses on mitigating the impact of hyperandrogenism, insulin resistance, and chronic oligo-ovulation and restoring fertility when desired

/pdf/polycystic-ovary-syndrome-1tb4ywt6qn.pdf

Polycystic ovary syndrome.

The aim of the study was to determine the prevalence of non-insulin dependent diabetes mellitus (NIDDM), arterial hypertension, coronary artery disease and the risk factors for these diseases in perimenopausal women with a history of polycystic ovary syndrome (PCOS) treatment A group of 28 women was selected from a large group of patients who had undergone wedge ovarian resection A total of 752 controls was selected by age (45-59 years) from a random female population sample There was no difference between the two groups in body mass index, waist circumference or waist-hip ratio Both groups were found to have identical family histories of NIDDM, hypertension, and coronary artery disease and identical smoking habits We did not find a difference between the mean concentrations of lipids and fasting glucose The two groups did not differ in the proportions of women with elevated lipid concentrations The prevalence of NIDDM and coronary artery disease was significantly higher in PCOS women In conclusion, women in the general population have the same level of risk factors at perimenopausal age as PCOS women Patients with markedly expressed clinical symptoms of PCOS made up a subgroup in the general population at high risk for developing NIDDM and coronary artery disease

/pdf/increased-risk-of-non-insulin-dependent-diabetes-mellitus-1j6rgamuuj.pdf

Increased risk of non-insulin dependent diabetes mellitus, arterial hypertension and coronary artery disease in perimenopausal women with a history of the 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

BACKGROUND: The aim of this study was to compare the pregnancy outcome, especially the prevalence of gestational diabetes mellitus (GDM), in a group of patients with polycystic ovary syndrome (PCOS), with a group of healthy weight-matched women. METHODS: Retrospectively, we evaluated the pregnancies of 66 women with PCOS, who had been treated for infertility and who delivered at our department. These were compared with a group of 66 age- and weight-matched controls. RESULTS: We did not find any significant differences in the prevalence of pregnancy complications such as gestational diabetes mellitus, pregnancy-induced hypertension (PIH) and premature deliveries between the group of PCOS patients and the controls. CONCLUSION: When differences in age and weight between PCOS patients and controls are negligible, PCOS is not associated with a higher risk of pregnancy complications.

/pdf/pregnancy-outcome-in-women-with-pcos-and-in-controls-matched-15w041fm53.pdf

Pregnancy outcome in women with PCOS and in controls matched by age and weight

Background Although many arguments have been put forth supporting the role of androgens in the aetiology of acne, their part in determining the severity of the disease is not well established. Objectives The aim of our study was to evaluate the relationship between acne severity and the clinical and laboratory markers of androgenicity in a large group of patients. Methods Ninety women over 17 years of age with acne were enrolled into the study. The levels of testosterone, androstenedione, dehydroepiandrosterone, dehydroepiandrosterone sulphate and sex hormone binding globulin (SHBG) were measured. Menstrual cycle regularity, hirsutism score, acne severity and ultrasound evaluation of polycystic ovaries were recorded. One-way analysis of variance, chi(2)-test and correlation analysis were used for data processing. Results Hirsutism was documented in 19 (21%) subjects, elevated levels of at least one androgen in 73 (81%) subjects, an irregular cycle was reported by 43 (48%) women, and polycystic ovaries were found in 45 (50%) women. The patients were divided into three groups according to acne severity. Acne was graded using the Leeds technique as minor in 43 (48%) cases, mild in 27 (30%) and moderate in 20 (22%). We did not demonstrate a positive correlation between the grade of acne severity and any of the clinical or laboratory markers of androgenicity assessed. On the contrary, women with a higher grade of acne severity showed lower values of the index of free testosterone, a lower hirsutism score and higher SHBG levels. Conclusions Our study suggests that the severity of acne manifestation in adult women is not determined by androgen production.

The role of androgens in determining acne severity in adult women.

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.

/pdf/the-effect-of-combination-therapy-with-metformin-and-2g7vc8fqbz.pdf

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

M. Fanta

Papers

Increased risk of non-insulin dependent diabetes mellitus, arterial hypertension and coronary artery disease in perimenopausal women with a history of the polycystic ovary syndrome

Insulin Sensitivity in Women with Polycystic Ovary Syndrome

Pregnancy outcome in women with PCOS and in controls matched by age and weight

The role of androgens in determining acne severity in adult women.

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