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. Type 1 diabetes (due to b-cell destruction, usually leading to absolute insulin deficiency) 2. Type 2 diabetes (due to a progressive insulin secretory defect on the background of insulin resistance) 3. Gestational diabetes mellitus (GDM) (diabetes diagnosed in the second or third trimester of pregnancy that is not clearly overt diabetes) 4. Specific types of diabetes due to other causes, e.g., monogenic diabetes syndromes (such as neonatal diabetes and maturity-onset diabetes of the young [MODY]), diseases of the exocrine pancreas (such as cystic fibrosis), and drugor chemical-induced diabetes (such as in the treatment of HIV/AIDS or after organ transplantation)

Classification and diagnosis of diabetes

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Hyperglycemia and Adverse Pregnancy Outcomes

Metformin is a widely-used drug that results in clear benefits in relation to glucose metabolism and diabetes-related complications. The mechanisms underlying these benefits are complex and still not fully understood. Physiologically, metformin has been shown to reduce hepatic glucose production, yet not all of its effects can be explained by this mechanism and there is increasing evidence of a key role for the gut. At the molecular level the findings vary depending on the doses of metformin used and duration of treatment, with clear differences between acute and chronic administration. Metformin has been shown to act via both AMP-activated protein kinase (AMPK)-dependent and AMPK-independent mechanisms; by inhibition of mitochondrial respiration but also perhaps by inhibition of mitochondrial glycerophosphate dehydrogenase, and a mechanism involving the lysosome. In the last 10 years, we have moved from a simple picture, that metformin improves glycaemia by acting on the liver via AMPK activation, to a much more complex picture reflecting its multiple modes of action. More work is required to truly understand how this drug works in its target population: individuals with type 2 diabetes.

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The mechanisms of action of metformin

Exclusive breastfeeding for six months, continued along with top feed up to the age of 2 years and beyond, is strongly recommended by the World Health Organization. Apart from the various benefits that it provides, breast feeding may also serve to prevent the development of type 2 diabetes and metabolic syndrome in mothers, and type 1 diabetes and overweight/ obesity in their offspring. This review discusses the evidence related to breastfeeding and type 2 diabetes. It highlights pertinent aspects of breast feeding management, which can help facilitate optimal use of this natural preventive intervention.

Breast feeding: preventive therapy for type 2 diabetes.

Prevention of Gestational diabetes mellitus holds the key to prevention of the diabetes and metabolic syndrome epidemic sweeping the world. This review discusses prevention of gestational diabetes and provides a scientific framework for the study of this topic. It classifies prevention in various ways, and suggests strategies which fit the different levels of prevention of gestational diabetes. The review also cites recent evidence and best practices to support the feasibility of prevention of gestational diabetes.

Prevention of Gestational Diabetes Mellitus (GDM).

We read the analysis of the Saxagliptin Assessment of Vascular Outcomes Recorded in Patients with Diabetes Mellitus–Thrombolysis in Myocardial Infarction 53 (SAVOR-TIMI 53) trial by Udell et al. (1) with interest. The important finding is the increased risk of hospitalization for heart failure with increasing severity of nephropathy. This highlights yet another association between macrovascular and microvascular complications in diabetes. The initial data by the same group reported a 27% higher incidence of hospitalization for heart failure among patients treated with saxagliptin as compared with placebo (2). The authors have not been able to provide a watertight explanation …

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Comment on Udell et al. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes and moderate or severe renal impairment: observations from the SAVOR-TIMI 53 Trial. Diabetes Care 2015;38:696-705.

In this study we evaluated the antiinflammatory and anti-granuloma activity of standardized Terminalia chebula hydroalcoholic extract (TCHE) in experimental models. Adult male Wistar rats from our ...

https://journals.sagepub.com/doi/pdf/10.1177/1721727X1201000203

Anti-Granuloma Activity of Terminalia Chebula Retz. in Wistar Rats:

This article defines and discusses diabetes self-management education and diabetes self-management support in the context of primary care. It offers practical advice to help primary care physicians begin and enhance the quality of self-management education and support services in their practice.

Yashdeep Gupta

Papers

Breast feeding: preventive therapy for type 2 diabetes.

Prevention of Gestational Diabetes Mellitus (GDM).

Comment on Udell et al. Saxagliptin and cardiovascular outcomes in patients with type 2 diabetes and moderate or severe renal impairment: observations from the SAVOR-TIMI 53 Trial. Diabetes Care 2015;38:696-705.

Anti-Granuloma Activity of Terminalia Chebula Retz. in Wistar Rats:

Self-management of diabetes in primary care.