Showing papers on "Diabetes management published in 1993"

The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus.

Abstract: Background Long-term microvascular and neurologic complications cause major morbidity and mortality in patients with insulin-dependent diabetes mellitus (IDDM). We examined whether intensive treatment with the goal of maintaining blood glucose concentrations close to the normal range could decrease the frequency and severity of these complications. Methods A total of 1441 patients with IDDM--726 with no retinopathy at base line (the primary-prevention cohort) and 715 with mild retinopathy (the secondary-intervention cohort) were randomly assigned to intensive therapy administered either with an external insulin pump or by three or more daily insulin injections and guided by frequent blood glucose monitoring or to conventional therapy with one or two daily insulin injections. The patients were followed for a mean of 6.5 years, and the appearance and progression of retinopathy and other complications were assessed regularly. Results In the primary-prevention cohort, intensive therapy reduced the adjusted mean risk for the development of retinopathy by 76 percent (95 percent confidence interval, 62 to 85 percent), as compared with conventional therapy. In the secondary-intervention cohort, intensive therapy slowed the progression of retinopathy by 54 percent (95 percent confidence interval, 39 to 66 percent) and reduced the development of proliferative or severe nonproliferative retinopathy by 47 percent (95 percent confidence interval, 14 to 67 percent). In the two cohorts combined, intensive therapy reduced the occurrence of microalbuminuria (urinary albumin excretion of > or = 40 mg per 24 hours) by 39 percent (95 percent confidence interval, 21 to 52 percent), that of albuminuria (urinary albumin excretion of > or = 300 mg per 24 hours) by 54 percent (95 percent confidence interval 19 to 74 percent), and that of clinical neuropathy by 60 percent (95 percent confidence interval, 38 to 74 percent). The chief adverse event associated with intensive therapy was a two-to-threefold increase in severe hypoglycemia. Conclusions Intensive therapy effectively delays the onset and slows the progression of diabetic retinopathy, nephropathy, and neuropathy in patients with IDDM.

Prevalence of depression in adults with diabetes : an epidemiological evaluation

Abstract: OBJECTIVE To determine the prevalence of depression in adult diabetic populations through a comprehensive literature review and to critically evaluate the methods and findings of such studies from an epidemiological perspective. RESEARCH DESIGN AND METHODS A systematic review of the scientific literature revealed a total of 20 studies, 14 of which had been conducted since 1988. Nine of the studies were controlled investigations, whereas the remaining 11 studies did not contain comparison groups. The studies included both treatment and community samples. RESULTS The range of the prevalence of current depression obtained from structured diagnostic interviews in diabetic samples was 8.5–27.3% ( = 14.0%) in controlled studies and 11.0–19.9% ( = 15.4%) in uncontrolled studies. These rates are at least three times the prevalence of major depressive disorder found in the general adult population of the U.S. Investigations using depression symptom scales corroborated these findings, as the range of clinically significant depression symptomatology in diabetic samples was 21.8–60.0% ( = 32.4%) in controlled studies and 10.0–28.0% ( = 19.6%) in uncontrolled studies. CONCLUSIONS An increased prevalence of depression in diabetes relative to the general population is highly suggested by the literature, but biases and methodological problems commonly encountered in prevalence studies may interfere with the strength of this conclusion. An increased prevalence of depression in diabetes relative to other somatic illnesses remains unproven. The pervasive impact of depression on quality of life and its potential negative effect on diabetes management warrant recognition and treatment of the affective disorder in diabetic individuals.

Self-Monitoring of Blood Glucose by Adults With Diabetes in the United States Population

Abstract: OBJECTIVE To evaluate self-monitoring of blood glucose, which is considered an important practice for patients with diabetes. However, little is known about the frequency or determinants of this technique. RESEARCH DESIGN AND METHODS A detailed questionnaire on diabetes was administered to a representative sample of 2405 diabetic subjects ≥ 18 yr of age in the U.S. population in the 1989 National Health Interview Survey. RESULTS Among subjects with IDDM, 40% monitored their blood glucose at least 1 time/day. Among subjects with NIDDM treated with insulin, 26% monitored at least 1 time/day and among NIDDM subjects not treated with insulin, the percentage was 5%. When stratified by age, little difference was observed between IDDM subjects and insulin-treated NIDDM subjects in the percentage testing at least 1 time/day. By multivariate analysis, age and insulin use were the major determinants of whether diabetic subjects tested their blood glucose. Race and education were also independently related to self-monitoring of blood glucose. Blacks were 60% less likely to test their blood glucose at least 1 time/day compared with non-Hispanic whites and Mexican Americans. Those with college education were 80% more likely to test their blood glucose compared with those with lower education levels. Having had a patient education class in diabetes management and frequent physician visits for diabetes care were positively related to self-testing. Self-monitoring was not related to higher income or having health insurance. CONCLUSIONS A large proportion of patients with diabetes do not test their blood glucose. Financial barriers associated with income and health insurance do not appear to impede the practice of self-monitoring. Because of the importance of blood glucose control in the prevention of diabetes complications and the role of self-monitoring in achieving blood glucose control, it may be prudent for physicians and their patients to make greater use of this technique. Special attention should be directed to the subgroups of patients (blacks, patients not treated with insulin, those with less education, and those with no education in diabetes) in which the frequency of self-monitoring is particularly low.

Cultural and Religious Influences in Diabetes Care in Great Britain

Abstract: Type 2 diabetes is four times more common in people originating from the Indian subcontinent (Asians) than in white English Caucasians. British Asians with diabetes have been shown to have poorer blood glucose control, awareness of diabetes management, and knowledge of complications. This review examines some of the dietary customs that can affect glucose control, problems with communication and diabetic education, and a brief description of health beliefs commonly held by Asian patients that may help the physician understand why some patients appear to show poor compliance with accepted Western medicine. Patients must always be approached as individuals with their own unique needs within the context of their cultural backgrounds.

Self-care Behaviour and Blood Glucose Control in Young Adults With Type 1 Diabetes Mellitus

Abstract: Self-care behaviour, knowledge about diabetes, and blood glucose control were studied in 113 young adults with Type 1 diabetes using a semi-structured interview, self-report questionnaires, and a biochemical measure (glycated haemoglobin). The majority of subjects followed their prescribed regimen reasonably accurately, but individuals followed different aspects of the regimen to different degrees. Subjects were more concerned with the avoidance of hypoglycaemia than with attainment of ‘tight’ blood glucose control. The blood glucose test level at which subjects took remedial action was the best single predictor of symptomatic control. Frequency of nocturnal polyuria appeared to be a reliable indicator of impaired metabolic control. Insulin omission or dose reduction for the purpose of body weight reduction was common among women, who also had worse blood glucose control than men. Elevated glycated haemoglobin levels were associated with higher alcohol consumption in men. Theoretical knowledge about diabetes management was only weakly associated with self-care behaviour and blood glucose control in this population. The blood glucose test result at which subjects take remedial action appears to be the most appropriate behavioural target for intervention to improve control in such subjects.

A Single Visit Diabetes Complication Assessment Service: a Complement to Diabetes Management at the Primary Care Level

Abstract: Modern diabetes management emphasizes the early detection and prompt treatment of diabetic complications. However it is difficult to organize comprehensive screening at the primary care level. To address this problem we established a complication assessment service whereby all the major diabetes-specific complications were assessed in a single 3 h visit. A report with results and recommendations was sent to the general practitioner (GP). Being philosophically a complication-specific service, no attempt was made to intervene with metabolic management. This paper describes our experience with the first 743 patients of whom 92% had been referred from GPs. Of the diabetes-specific complications, 22% of patients had one, 5% had two, and 1% had three major complications. Many of the patients were unaware of the presence of these complications. One hundred and three people had attended the service on more than one occasion with an average time between visits of 1.7 years. The results demonstrated that GPs were very good at following a recommendation to refer a patient for ophthalmic assessment (85% of cases) and improving hypertension but were less successful in treating hyperlipidaemia. This service has proven to be an excellent forum for the collection of data and the teaching of health professionals. It is a move away from the traditional format of hospital-based clinics providing comprehensive diabetes management.

Are the Social Relationships of Young Insulin-dependent Diabetic Patients Affected by Their Condition?

Abstract: In order to compare the social relationships of young adults with Type 1 diabetes with those of healthy controls, 80 young people aged 16-25 years were interviewed in-depth with a semi-structured questionnaire. Results demonstrated that subjects with diabetes had an equally high commitment to social arenas, but were significantly more likely to be socially isolated and were less likely to have very close relationships. Subjects had more attitudinal constraints with regard to having close relationships, and were more likely to report a fear of intimacy. They were less likely to have children, and many voiced their concerns regarding the impact their diabetes might have on both marriage and future parenthood. This study suggests that young adults with diabetes have more negative social experiences which may affect their feelings with regard to having close relationships. The absence of supportive relationships may impact on diabetes management; however this has yet to be fully ascertained in a young adult population.

New Directions in Drug Development: Mixtures, Analogues, and Modeling

Abstract: Success in modern medical research is acheived when basic and clinical information about a given disorder converges, either intentionally or fortuitously, with the availability of technology or other means to design and apply interventions for the disorder in question. A prime example is the discovery of insulin and its replacement in patients with IDDM in 1923. Seven decades later, the focus of diabetes management is on improvement in metabolic control to forestall the chronic complications of the disease and improve the quality of life of patients with the disease. Metabolic control is being addressed through the development of insulin analogues using sophisticated techniques to understand the chemistry of insulin and to modify it using rDNA technology. The objective of these efforts is to simulate normal insulin secretion with subcutaneously injected agonists. Quality-of-life needs are being addressed with delivery devices, insulin mixtures, and insulin analogues. Although none of these improvements parallel the discovery of insulin, they do provide an optimistic outlook for patients with diabetes mellitus.

Nutrition management of insulin-dependent diabetes mellitus in adults: Review by the diabetes care and education dietetic practice group

Abstract: Insulin-dependent diabetes mellitus (IDDM) is a chronic disease in which insulin production from the pancreas is diminished or absent. Insulin-dependent diabetes mellitus is most often diagnosed in childhood, but it also occurs in adults. Treatment requires the use of exogenous insulin coordinated with food intake and physical activity. Management goals for IDDM are to attain metabolic control of glucose and lipid levels and to prevent or delay the onset of medical complications associated with diabetes. Because the type and amount of food consumed directly affect blood glucose levels, meal and snack planning, along with an appropriate insulin regimen and physical activity program, is necessary to achieve management goals. Nutrition assessment, initial education, implementation of a meal plan, and ongoing nutrition education and counseling are part of the process of nutrition management of diabetes. The registered dietitian who has a working knowledge of nutrition and diabetes management serves as an integral part of the diabetes health care team.

Knowledge on diabetes and performance among health professionals in non-diabetological departments.

Abstract: We tested the level of knowledge on diabetes and professional skills in a group of 60 non-diabetological health care professionals at the Policlinic of Pisa regarding the recognition and treatment of hypoglycaemia, the storage, mixing and administration of insulin, blood glucose stick monitoring, and the prevention and treatment of diabetic foot. The evaluation was carried out using a multiple-choice questionnaire and observation of the jubjects, performance by means of pre-defined observation of a blend of rapid-intermediate insulin, the use of blood glucose sticks and the management of a simulated hypoglycaemic crisis. As regards hypoglycaemia, 90% of subjects did not give a correct definition, 88.3% were unaware of the existence of asymptomatic hypoglycaemia, and 96.6% did not give a complete answer as to the treatment of hypoglycaemia. For insulin, 51.7% did not know the standards for correct storage of insulin, 88.3% did not know the difference between “clear” and “opaque” insulins, and 91.7% ignored the required interval between administration of regular insulin and meals. For foot care, 45% admitted that the problems with diabetics' feet were frequently not controlled, and between 21.7% and 63.3% did not known the hygiene rules for feet. Assessment of the performance of the subjects using schedules revealed incorrect use of sticks and administration of insulin (80.2% mixed and 92.4% injected the insulin incorrectly). There is clearly a need for education of non-diabetological health professionals regarding the disease. This is supported by the health professionals themselves, 94.5% of whom wished to participate in a course on diabetes.

The diabetes project at Fort Totten, North Dakota, 1984-1988.

Abstract: OBJECTIVE— To characterize demographic, therapeutic, and complication features of patients in the Fort Totten Diabetes Project and to assess the longitudinal impact of intervention strategies. RESEARCH DESIGN AND METHODS— Individuals ( n = 215) of varying American Indian ethnic origin and a quantum of mean age 53 yr (range 14–86 yr), 62% women, with type II diabetes of 9 yr average duration were studied. Annual chart audits of the complete diabetic population were conducted from 1984 to 1988. RESULTS— Obesity is a major problem complicating diabetes management (average BMI 32 ± 0.9), but BMI does not correlate with glucose control as assessed by total GHb ( r = 0.014, NS). Individuals lost an average of 3.7 kg ( P P CONCLUSIONS— Diabetes mellitus in American Indians living in a rural, economically deprived area can be identified and cared for with success similar to that published for urban populations.

Decision support in diabetes management for optimal glycaemic control by insulin administration

Abstract: Optimal glycaemic control is achieved by diet manipulation and insulin administration. The potential benefits in using decision support systems for diabetic patient management are the cost saving they provide in terms of expensive man hours of verbal instruction by medical experts and the support in terms of objective and consistent decision making by the experts. This paper describes an expert system to assist diabetic patient management by blood glycose monitoring through insulin administration. The system incorporates decision making situations of patient management in Greece where diet, life style and administration of insulin differ from Northern European countries. This application is carried out at the First Propaedeutic Medical Clinic, the Ahepa General Hospital of Thessaloniki, Greece. >

Treatment of glucose intolerance in pregnancy: staged diabetes management.

Abstract: Current methods for the treatment of glucose intolerance first discovered in pregnancy are reviewed and a systematic data-based approach is introduced. Gestational diabetes mellitus (GDM) is a leading cause of adverse perinatal outcome in 5% of all pregnancies in the United States. Early detection and initiation of treatment meant to restore euglycemia will prevent many of the major complications associated with hyperglycemia. Staged Diabetes Management (SDM) is introduced in this paper as an innovative approach for the detection and treatment of GDM and glucose intolerance in pregnancy. Relying on self-monitored blood glucose data, SDM guides the primary care physician through increasingly more complex regimens until euglycemia is reached. Computer-based technologies assist the clinical decision-making by producing Ambulatory Glucose Profiles (AGP), which are graphic representations of glycemic control. SDM combined with AGP technology are meant to significantly reduce the threefold greater risk of adverse outcome in pregnancy experienced by women with GDM.