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

Stroke, the third leading cause of death and disability worldwide, is undergoing a change in perspective with the emergence of new ideas on neurodegeneration The concept that stroke is a disorder solely of blood vessels has been expanded to include the effects of a detrimental interaction between glia, neurons, vascular cells, and matrix components, which is collectively referred to as the neurovascular unit Following the acute stroke, the majority of which are ischemic, there is secondary neuroinflammation that both promotes further injury, resulting in cell death, but conversely plays a beneficial role, by promoting recovery The proinflammatory signals from immune mediators rapidly activate resident cells and influence infiltration of a wide range of inflammatory cells (neutrophils, monocytes/macrophages, different subtypes of T cells, and other inflammatory cells) into the ischemic region exacerbating brain damage In this review, we discuss how neuroinflammation has both beneficial as well as detrimental roles and recent therapeutic strategies to combat pathological responses Here, we also focus on time-dependent entry of immune cells to the ischemic area and the impact of other pathological mediators, including oxidative stress, excitotoxicity, matrix metalloproteinases (MMPs), high-mobility group box 1 (HMGB1), arachidonic acid metabolites, mitogen-activated protein kinase (MAPK), and post-translational modifications that could potentially perpetuate ischemic brain damage after the acute injury Understanding the time-dependent role of inflammatory factors could help in developing new diagnostic, prognostic, and therapeutic neuroprotective strategies for post-stroke inflammation

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Neuroinflammation: friend and foe for ischemic stroke

Alcohol is one of the world’s top three priority areas in public health. Even though only half the global population drinks alcohol, it is the world’s third leading cause of ill health and premature death, after low birth weight and unsafe sex, and greater than tobacco. In Europe, alcohol is also the third leading risk factor for disease and mortality after tobacco and high blood pressure. This report presents the latest literature overview of effective alcohol policies, and includes data from the European Union, Norway and Switzerland in the areas of alcohol consumption, harm and policy approaches. The data presented were collected from a survey in 2011.

Alcohol in the European Union: Consumption, Harm and Policy Approaches

Twenty-five years ago, Paul Taylor probed principles for giving “wildlife...a chance to survive alongside the works of human culture” (299) and bringing “human civilization...into harmony with natu...

Respect for Nature: A Theory of Environmental Ethics

Legislating for the present on the basis of predictions for the future can never be other than a dicey business. The suggestion by a British member of parliament in the nineteenth century that London would be waste-high in horse excrement by the 1950s could have been seen as a call for crippling taxes on Hansom cabs, pushing cabbies out of trade while still leaving us choking on exhaust fumes. So should we now be legislating against those exhaust fumes, in fear that by the end of the next century the world will be a flood- and storm-prone hothouse?

Adapting to climate change

Objectives. We sought to determine cardiovascular risk factor prevalence rates among adults in Abu Dhabi, United Arab Emirates.Methods. We used self-reported indicators, anthropometric measures, and blood tests to screen 50 138 adults aged 18 years or older taking part in a population-wide cardiovascular screening program.Results. Participants’ mean age was 36.82 years (SD = 14.3); 43% were men. Risk factor prevalence rates were as follows: obesity, 35%; overweight, 32%; central obesity, 55%; diabetes, 18%; prediabetes, 27%; dyslipidemia, 44%; and hypertension, 23.1%. In addition, 26% of men were smokers, compared with 0.8% of women. Age-standardized diabetes and prediabetes rates were 25% and 30%, respectively, and age-standardized rates of obesity and overweight were 41% and 34%.Conclusions. This population-wide cardiovascular screening program demonstrated a high cardiovascular burden for our small sample in Abu Dhabi. The data form a baseline against which interventions can be implemented and progress...

Weqaya: a population-wide cardiovascular screening program in Abu Dhabi, United Arab Emirates.

As a country, the United Arab Emirates has developed very rapidly from a developing country with a largely nomadic population, to a modern and wealthy country with a Western lifestyle. This economic progress has brought undoubted social benefits and opportunities for UAE citizens, including a high and increasing life expectancy. However, rapid modernization and urbanization have contributed to a significant problem with chronic diseases, particularly obesity-related cardiovascular risk. In response the Health Authority of Abu Dhabi has significantly strengthened its data systems to better assess the baseline and measure the impact of targeted interventions. The unique population-level Weqaya Programme for UAE Nationals living in Abu Dhabi has recruited more than 94% of adults into a screening programme for the rapid identification of those at risk and the deployment of targeted interventions to control that risk. This article describes the burden of non-communicable disease in Abu Dhabi, and the efforts made by the Health Authority of Abu Dhabi to tackle this burden including the development of a whole population cardiovascular screening programme changes to health policy, particularly in terms of lifestyle and behaviour change, and empowerment of the community to enable individuals to make healthier choices. In addition, recommendations have been made for global responsibility for tackling chronic disease.

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A profile and approach to chronic disease in Abu Dhabi

Background and Objectives: Combining laparoscopy and enhanced recovery provides benefit to short-term outcomes after colorectal surgery. Advances in training and techniques have allowed surgeons to operate on cases that are technically challenging and associated with prolonged operative time. Laparoscopic techniques improve the outcome of enhanced recovery after colorectal surgery; however, there are no specifications on the effect of prolonged operations on the outcome. The objective was to elucidate the impact of prolonged surgery and blood loss on the outcome of enhanced recovery after surgery after laparoscopic colorectal surgery. Methods: Four-hundred patients who underwent elective colorectal resection on enhanced recovery after surgery in Yeovil District Hospital between 2002 and 2009 were retrospectively reviewed. Delayed discharge was defined as a prolonged length of stay beyond the mean in this series (≥8 days). Results: Three-hundred eighty-five patients were included. Median operative time was 180 minutes with a median blood loss of 100 mL. Conversion was not associated with a prolonged length of stay. Operative time and blood loss correlated with length of stay in a stepwise fashion. There were 2 cutoff points of operative time at 160 minutes and 300 minutes (5 hours), where risk of prolonged stay increased significantly (odds ratio [OR] = 2.02; 95% confidence interval [CI], 1.05-3.90; P= 027), and blood loss of >500 mL (OR = 3.114; 95% CI, 1.501-6.462, P =.002). Conclusions: Total operative timing impacts negatively on the outcome of enhanced recovery after laparoscopic colorectal resections with increased risk of delayed discharge seen after ~2.5 hours and 5-hour duration. © 2014 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.

The Abu Dhabi Cardiovascular Program: the continuation of Framingham.

This article discusses incentives to help make healthy choices the easy choices for individuals, operating at the levels of the individual, producers and service providers, and governments. Whereas paying individuals directly to be healthier seems to have a limited effect, offering financial incentives through health insurance improves health. Changing the environment to make healthier choices more accessible acts as an incentive to improve health. Employers can provide incentives to improve the health of their employees. Producers and service providers can take voluntary action to make their products less harmful, and they can be nudged into marketing healthier products within a regulatory environment. International agreements and monitoring systems can incentivize governments to do more for health. Lessons from climate change adaptation suggest that multilevel governance and policy integration are greater obstacles to policy change and implementation than knowing what has to be done. Policy change and implementation are triggered by many drivers, many of which are side effects of other policy pressures rather than of the direct policy goal itself. Effective action to reduce noncommunicable diseases will require leveraging social networks into a new ways of thinking about health; making better health prestigious and aspirational, and giving health and wellness a brand that encourages positive behavior change.

Oliver Harrison

Papers

Weqaya: a population-wide cardiovascular screening program in Abu Dhabi, United Arab Emirates.

A profile and approach to chronic disease in Abu Dhabi

Operative time and outcome of enhanced recovery after surgery after laparoscopic colorectal surgery.

The Abu Dhabi Cardiovascular Program: the continuation of Framingham.

Incentives for Health