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

Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

A number of apparently diverse personality scales—variously called trait anxiety, neuroticism, ego strength, general maladjustment, repression-sensitization, and social desirability—are reviewed and are shown to be in fact measures of the same stable and pervasive trait. An integrative interpretation of the construct as Negative Affectivity (NA) is presented. Extensive data indicate that high-NA individuals are more likely to experience discomfort at all times and across situations, even in the absence of overt stress. They are relatively more introspective and tend differentially to dwell on the negative side of themselves and the world. Further research is needed to explain the origins of NA and to elucidate the characteristics of low-NA individuals. Rorer and Widiger (1983) recently bemoaned that in the field of personality "literature reviews appear to be disparate conglomerations rather than cumulative or conclusive integrations" (p. 432). We intend this review to be an exception to this discouraging statement. Distinct and segregated literatures have developed around a number of specific personality measures that, despite dissimilar names, nevertheless intercorrelate so highly that they must be considered measures of the same construct. Following Tellegen (1982), we call this construct Negative Affectivity (NA) and present a comprehensive view of the trait that integrates data from a wide variety of relevant research. We are not the first to note this broad and pervasive personality trait. The Eysencks, for example, (e.g. Eysenck & Eysenck, 1968) have done extensive research in the area, traditionally calling the dimension "Neuroticism," although in their most recent revision (Eysenck & Eysenck, 1975) they suggest a label, "emotionality," that is similar to our own. Nonetheless, in discussing the relation between our interpretation and previous views of the domain, we argue for the preferability of our term, Negative Affectivity. We also present

Negative affectivity: The disposition to experience aversive emotional states

Past behavior guides future responses through 2 processes. Well-practiced behaviors in constant contexts recur because the processing that initiates and controls their performance becomes automatic. Frequency of past behavior then reflects habit strength and has a direct effect on future performance. Alternately, when behaviors are not well learned or when they are performed in unstable or difficult contexts, conscious decision making is likely to be necessary to initiate and carry out the behavior. Under these conditions, past behavior (along with attitudes and subjective norms) may contribute to intentions, and behavior is guided by intentions. These relations between past behavior and future behavior are substantiated in a meta-analytic synthesis of prior research on behavior prediction and in a primary research investigation. In everyday explanations of behavior, habits denote one's customary ways of behaving. Claiming that one performed a behavior because of habit provides an understandable explanation for an act that otherwise might seem irrational or even harmful. Habits also are featured in the popular psychology literature in the form of self-help books designed to identify readers' existing habits, evaluate habits' effectiveness in meeting goals, and establish more desirable habits. Habits are not, however, important constructs in most contemporary social psychological models of human behavior. Early in their careers, most psychology graduate students learn that frequency of past behavior, a standard indicator of habit strength (Triandis, 1977, 1980), is the best predictor of

/pdf/habit-and-intention-in-everyday-life-the-multiple-processes-1xuobe1ggh.pdf

Habit and intention in everyday life: The multiple processes by which past behavior predicts future behavior.

Most current models in health psychology assume that stress adversely affects physical health. We re-examined this assumption by reviewing extensive data from the literature and from six samples of our own, in which we collected measures of personality, health and fitness, stress, and current emotional functioning. Results indicate that self-report health measures reflect a pervasive mood disposition of negative affectivity (NA); self-report stress scales also contain a substantial NA component. However, although NA is correlated with health compliant scales, it is not strongly or consistently related to actual, long-term health status, and thus will act as a general nuisance factor in health research. Because self-report measures of stress and health both contain a significant NA component, correlations between such measures likely overestimate the true association between stress and health. Results demonstrate the importance of including different types of health measures in health psychology research.

Health complaints, stress, and distress: exploring the central role of negative affectivity.

• The National High Blood Pressure Education Program has released three Joint National Committee reports and a task force report on the detection, evaluation, and treatment of high blood pressure. Like its predecessors, the 1988 Joint National Committee report was developed using the consensus process; it is based on the latest scientific research and reflects the state of the art regarding hypertension management. This report updates findings of previous reports in several respects: it broadens the step-care approach to provide more flexibility for clinicians; encourages greater patient involvement in the treatment program; emphasizes a consideration of the quality of life in the management of patients; and addresses the cost of care. It also provides more emphasis on control of other risk factors for cardiovascular disease; includes a discussion of the new cholesterol guidelines; recommends a reduction in alcohol consumption; and discusses the use of calcium and fish oil supplementation. This document expands earlier reports on special populations, including blacks and other racial and ethnic minority groups, young and elderly patients, pregnant patients, surgical candidates, and hypertensive patients with cerebrovascular disease, coronary artery disease, left ventricular hypertrophy, congestive heart failure, peripheral vascular disease, renal disease, chronic obstructive pulmonary disease or bronchial asthma, gout, diabetes mellitus, and hyperlipidemia. The report also updates previous drug tables to include new drugs, revised recommended doses of some drugs, and drug interactions. Consideration of step-down therapy after blood pressure has been controlled is suggested. This report is intended as a guide for practicing physicians and other health professionals in their care of hypertensive patients and as a reference for those participating in the many community high blood pressure control programs throughout the country. (Arch Intern Med1988;148:1023-1038)

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/609809/archinte_148_5_006.pdf

The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

Since publication of the 1980 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure, 1 several events have occurred that affect successful management of hypertension: publication of major clinical trial results, introduction of new antihypertensive agents, evidence concerning effectiveness of nonpharmacologic treatment, and further analysis of the epidemiologic data-base relating BPs with the risk of premature morbidity and mortality. These events led the director of the National Heart, Lung, and Blood Institute (NHLBI), as chairman of the National High Blood Pressure Education Program Coordinating Committee, to establish a new Joint National Committee to revise earlier recommendations. This report includes recommendations on the following topics: (1) screening and referral procedures, (2) classification according to BPs, (3) use of nonpharmacologic therapies, (4) revised stepped-care approach, (5) management of mild hypertension, (6) patient-professional interaction, and (7) management of BP in special groups, including blacks, children, and pregnant

The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

Coronary-prone behavior

Handbook of research methods in cardiovascular behavioral medicine

Behavioral Medicine is the field concerned with the development of behavioralscience knowledge and techniques relevant to the understanding of physical health and illness and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation. Psychosis, neurosis and substance abuse are included only insofar as they contribute to physical disorders as an endpoint.

Stephen M. Weiss

Papers

The 1988 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

The 1984 Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure

Coronary-prone behavior

Handbook of research methods in cardiovascular behavioral medicine

Behavioral Medicine Revisited: An Amended Definition