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

Hyperglycemia and Adverse Pregnancy Outcomes

The steep rise of type 2 diabetes mellitus (T2DM) and associated complications go along with mounting evidence of clinically important sex and gender differences. T2DM is more frequently diagnosed at lower age and body mass index in men; however, the most prominent risk factor, which is obesity, is more common in women. Generally, large sex-ratio differences across countries are observed. Diversities in biology, culture, lifestyle, environment, and socioeconomic status impact differences between males and females in predisposition, development, and clinical presentation. Genetic effects and epigenetic mechanisms, nutritional factors and sedentary lifestyle affect risk and complications differently in both sexes. Furthermore, sex hormones have a great impact on energy metabolism, body composition, vascular function, and inflammatory responses. Thus, endocrine imbalances relate to unfavorable cardiometabolic traits, observable in women with androgen excess or men with hypogonadism. Both biological and psychosocial factors are responsible for sex and gender differences in diabetes risk and outcome. Overall, psychosocial stress appears to have greater impact on women rather than on men. In addition, women have greater increases of cardiovascular risk, myocardial infarction, and stroke mortality than men, compared with nondiabetic subjects. However, when dialysis therapy is initiated, mortality is comparable in both males and females. Diabetes appears to attenuate the protective effect of the female sex in the development of cardiac diseases and nephropathy. Endocrine and behavioral factors are involved in gender inequalities and affect the outcome. More research regarding sex-dimorphic pathophysiological mechanisms of T2DM and its complications could contribute to more personalized diabetes care in the future and would thus promote more awareness in terms of sex- and gender-specific risk factors.

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Sex and Gender Differences in Risk, Pathophysiology and Complications of Type 2 Diabetes Mellitus.

Within the emerging context of the digitization of health care, electronic health records (EHRs) constitute a significant technological advance in the way medical information is stored, communicated, and processed by the multiple parties involved in health care delivery. However, in spite of the anticipated value potential of this technology, there is widespread concern that consumer privacy issues may impede its diffusion. In this study, we pose the question: Can individuals be persuaded to change their attitudes and opt-in behavioral intentions toward EHRs, and allow their medical information to be digitized even in the presence of significant privacy concerns? To investigate this question, we integrate an individual's concern for information privacy (CFIP) with the elaboration likelihood model (ELM) to examine attitude change and likelihood of opting-in to an EHR system. We theorize that issue involvement and argument framing interact to influence attitude change, and that concern for information privacy further moderates the effects of these variables. We also propose that likelihood of adoption is driven by concern for information privacy and attitude. We test our predictions using an experiment with 366 subjects where we manipulate the framing of the arguments supporting EHRs. We find that an individual's CFIP interacts with argument framing and issue involvement to affect attitudes toward the use of EHRs. In addition, results suggest that attitude toward EHR use and CFIP directly influence opt-in behavioral intentions. An important finding for both theory and practice is that even when people have high concerns for privacy, their attitudes can be positively altered with appropriate message framing. These results as well as other theoretical and practical implications are discussed.

Adoption of electronic health records in the presence of privacy concerns: the elaboration likelihood model and individual persuasion

Obesity is the most common medical condition in women of reproductive age. Obesity during pregnancy has short term and long term adverse consequences for both mother and child. Obesity causes problems with infertility, and in early gestation it causes spontaneous pregnancy loss and congenital anomalies. Metabolically, obese women have increased insulin resistance in early pregnancy, which becomes manifest clinically in late gestation as glucose intolerance and fetal overgrowth. At term, the risk of cesarean delivery and wound complications is increased. Postpartum, obese women have an increased risk of venous thromboembolism, depression, and difficulty with breast feeding. Because 50-60% of overweight or obese women gain more than recommended by Institute of Medicine gestational weight guidelines, postpartum weight retention increases future cardiometabolic risks and prepregnancy obesity in subsequent pregnancies. Neonates of obese women have increased body fat at birth, which increases the risk of childhood obesity. Although there is no unifying mechanism responsible for the adverse perinatal outcomes associated with maternal obesity, on the basis of the available data, increased prepregnancy maternal insulin resistance and accompanying hyperinsulinemia, inflammation, and oxidative stress seem to contribute to early placental and fetal dysfunction. We will review the pathophysiology underlying these data and try to shed light on the specific underlying mechanisms.

Obesity and pregnancy: mechanisms of short term and long term adverse consequences for mother and child

Active management of labor as an alternative to cesarean section for dystocia.

Objective To determine if a low glycaemic index diet in pregnancy could reduce the incidence of macrosomia in an at risk group.

Design Randomised controlled trial.

Setting Maternity hospital in Dublin, Ireland.

Participants 800 women without diabetes, all in their second pregnancy between January 2007 to January 2011, having previously delivered an infant weighing greater than 4 kg. 

Intervention Women were randomised to receive no dietary intervention or start on a low glycaemic index diet from early pregnancy.

Main outcomes The primary outcome measure was difference in birth weight. The secondary outcome measure was difference in gestational weight gain.

Results No significant difference was seen between the two groups in absolute birth weight, birthweight centile, or ponderal index. Significantly less gestational weight gain occurred in women in the intervention arm (12.2 v 13.7 kg; mean difference −1.3, 95% confidence interval −2.4 to −0.2; P=0.01). The rate of glucose intolerance was also lower in the intervention arm: 21% (67/320) compared with 28% (100/352) of controls had a fasting glucose of 5.1 mmol/L or greater or a 1 hour glucose challenge test result of greater than 7.8 mmol/L (P=0.02).

Conclusion A low glycaemic index diet in pregnancy did not reduce the incidence of large for gestational age infants in a group at risk of fetal macrosomia. It did, however, have a significant positive effect on gestational weight gain and maternal glucose intolerance.

Trial registration Current Controlled Trials ISRCTN54392969.

https://www.bmj.com/content/bmj/345/bmj.e5605.full.pdf

Michael E. Foley

Papers

Active management of labor as an alternative to cesarean section for dystocia.

Low glycaemic index diet in pregnancy to prevent macrosomia (ROLO study): randomised control trial

Correlation of decrease in perinatal mortality and increase in cesarean section rates.

Singleton vaginal breech delivery at term: still a safe option

Impact of probiotics in women with gestational diabetes mellitus on metabolic health: a randomized controlled trial