Showing papers on "Diabetes management published in 1994"

Insulin Omission in Women With IDDM

Abstract: OBJECTIVE To describe the extent of intentional insulin omission in an outpatient population of women with insulin-dependent diabetes mellitus (IDDM) and examine its relationship to disordered eating, attitudes toward diabetes, other psychosocial factors, long-term complications, and glycemic control. RESEARCH DESIGN AND METHODS Before their routinely scheduled clinic appointments, female IDDM patients who were 13–60 years of age completed a self-report survey (final n = 341). The survey included standardized questionnaires assessing disordered eating attitudes and behaviors, psychological functioning (general distress, diabetes-specific distress, and hypoglycemic fear), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for glycosylated hemoglobin within 30 days of survey completion. Long-term complications were determined through chart review. RESULTS Approximately 31% of the subject sample, representing women of all ages, reported intentional insulin omission, but only 8.8% reported frequent omission. Compared with non-omitters, omitters reported more disordered eating, greater psychological distress (general and diabetes-specific), more hypoglycemic fear, poorer regimen adherence, and greater fears concerning improved diabetes management (which may lead to weight gain). Omitters evidenced poorer glycemic control, more diabetes-related hospitalizations, and higher rates of retinopathy and neuropathy. Multivariate examination revealed only two variables that independently predicted omission: diabetes-specific distress and fear of improved glycemic control (“because I will gain weight”). Of the omitters, approximately half reported omitting insulin for weight-management purposes (weight-related omitters). These subjects evidenced significantly greater psychological distress, poorer regimen adherence (including more frequent omission), poorer glycemic control, and higher rates of complications than did non-weight-related omitters as well as non-omitters. Non-weight-related omitters tended to fall between weight-related omitters and non-omitters on most measures of psychological functioning, adherence, and glycemic control. CONCLUSIONS These findings suggest that insulin omission is common, that it is not limited to younger women, and that the medical consequences of omission, especially frequent omission, may be severe. Although a strong association between omission and disordered eating was observed, these data suggest that this link may be complicated by important diabetes-specific factors. Patients preoccupied with eating and weight concerns may also become emotionally overwhelmed by diabetes and/or fearful of normoglycemia (and the associated weight-related consequences), thus reinforcing the desire to omit insulin and maintain elevated blood glucose levels.

Dietary fat predicts conversion from impaired glucose tolerance to NIDDM. The San Luis Valley Diabetes Study.

Abstract: This decade will bring major changes to the therapy of diabetes. New drugs are likely to include monomeric insulins, fatty-acid-oxidation inhibitors, insulin-secretion inducers, and nutrition modifiers. Likely new devices include improved insulin pens, less invasive methods of insulin administration, and noninvasive blood glucose monitoring. The use of computers will integrate this care, and artificial intelligence will provide new approaches to all of health care. An integrated system for using these new technologies, such as staged diabetes management, will ensure an orderly, cost-effective transition in therapy by the entire health-care community.

Nutrition principles for the management of diabetes and related complications.

Abstract: Health professionals and people with diabetes recognize nutrition therapy as one of the most challenging aspects of diabetes care and education (1). Adherence to meal planning principles requires the person with diabetes to learn specific nutrition recommendations. It may require altering previous patterns of eating and implementing new eating behaviors, which requires motivation for a healthy lifestyle and may also require participation in exercise programs. Finally, individuals must be able to evaluate the effectiveness of these lifestyle changes. Despite these challenges, nutrition is an essential component of successful diabetes management.

Care of People with Diabetes: A Manual of Nursing Practice

Abstract: Contents: Diagnosing and classifying diabetes -- Assessment and nursing diagnosis -- Monitoring diabetes mellitus -- Nutritional aspects of caring for people with diabetes -- Medication commonly used in diabetes management -- Hypoglycaemia -- Hyperglycaemia, diabetic ketoacidosis (DKA), hyperosmolar coma and lactic acidosis -- Long term complications of diabetes -- Management during surgical and investigative procedures -- Special situations and unusual conditions related to diabetes -- Diabetes and sexual health -- Diabetes in the older person -- Diabetes in children and adolescents -- Women, pregnancy, and gestational diabetes -- Psychological and quality of life issues related to having diabetes -- Diabetes education -- Discharge planning -- Community and primary care nursing and home-based care -- Complementary therapies and diabetes -- Managing diabetes in the emergency situations.

The uses of outcomes research for medical effectiveness, quality of care, and reimbursement in type II diabetes.

Abstract: Randomized controlled trials (RCTs), such as the Diabetes Control and Complications Trial (DCCT), usually evaluate the efficacy of a single treatment strategy. The DCCT, for example, evaluates intensive diabetes management aimed at achieving glucose levels as close to normal as possible to modify specific pathophysiological outcomes--specifically, the development or worsening of microvascular disease. In contrast, longitudinal observational studies, such as the type II diabetes Patient Outcome Research Team (PORT) study, address medical effectiveness; that is, how well prevailing treatments work in clinical practice settings. The PORT relies heavily on patient-reported measures of general and diabetes-specific health status, in addition to using complications as major study outcomes. In the type II diabetes PORT, 4,000 patients with type II diabetes and a wide range of socioeconomic, demographic, and disease characteristics, from three widely dispersed geographic settings and varying systems of care, are being followed for a 2.5-year period. Data are collected from periodic self-administered patient questionnaires and from administrative data bases. In the PORT study, nonmutable confounders, such as case-mix, and potentially mutable features, such as patients' preferences for treatment, health habits, regimen adherence, family support, and physician's interpersonal style, are carefully measured. The PORT study will examine the effectiveness of preventive care and established disease treatment in relation to eye, cardiovascular, and extremity disease, measuring and relating use of health-care services to patient outcomes. The results have the potential for maximizing quality of care and minimizing use of services in type II diabetes by matching physician-level profiles of patient outcomes with medical-care-process data and making this information accessible to practicing physicians.

Staged diabetes management. Toward an integrated model of diabetes care.

Abstract: This paper introduces a new and innovative approach to diabetes management in the primary-care setting. Staged diabetes management (SDM) represents a four-year effort to develop and test a data-based approach to diabetes management that could be easily adapted to a variety of health-care settings in which diabetes management is principally under the direction of primary-care physicians was limited access to specialists. After testing under controlled circumstances at the International Diabetes Center (Minneapolis, MN), SDM was subjected to substantial field trials under conditions that represent the scope and variety of primary-care practices in diabetes. The following represents the work of several investigators who independently undertook a review of SDM.

Diabetes and alternative medicine : cause for concern

Abstract: 'Alternative' medicines are becoming increasingly popular, and in this paper we describe our experience with alternative approaches to orthodox diabetes management. Four patients with insulin-dependent diabetes reduced or stopped their insulin in favour of therapeutic approaches including prayer, faith healing, unusual diets, and supplements of vitamins and trace elements. This resulted in ketoacidosis in three, in one case life-threatening; and weight loss and hyperglycaemia in the other. One patient developed serious retinopathy. Additionally, eight other types of alternative diabetic treatment are described, not as far as we know associated with such serious complications. These include homeopathy, reflexology, meditation, herbal treatment, 'cellular nutrition', 'subconscious healing', 'pearl therapy' (drinking milk in which pearls have been boiled) and 'astrotherapy' (typing pieces of coral around the arm). Diabetes is a chronic incurable disease, for which modern treatments remain somewhat unsatisfactory. It is therefore perhaps not surprising that some patients seek alternative treatments with more attractive claims. Diabetes health professionals need to be aware of the potential dangers associated with some of these treatments.

Increasing children's responsibility for diabetes self-care: the In Control study.

Abstract: The purpose of this pilot study was to test the hypothesis that children can learn to become more independent in their own diabetes self-management without compromising their metabolic control Twenty-four children (ages 8 to 12 years) with insulin-dependent diabetes mellitus (IDDM) were matched by age and race, then randomly assigned either to a 6-week, self-management education program (experimental) or to receive usual care (control) A questionnaire was administered to the parents to determine the frequency with which 35 diabetes management behaviors were performed and the degree to which children assumed responsibility for these behaviors Glycohemoglobin levels were monitored at baseline and at posttreatment, 12 weeks after baseline At the posttreatment, children in the experimental group were found to be assuming significantly more responsibility for their diabetes self-care than were children in the control group No decrease in the frequency with which self-care behaviors were performed was observed, and metabolic control was maintained The results suggest that a diabetes self-management education program for children ages 8 to 12 years can be effective in facilitating children becoming more responsible for their own diabetes management

How Does Provider and Patient Awareness of High-Risk Status for Lower-Extremity Amputation Influence Foot-Care Practice?

Abstract: OBJECTIVE To assess whether patients with diabetes at high risk for lower extremity amputation received more intensive medical care or self-care instruction and to determine the association between foot care and risk of lower-extremity amputation. RESEARCH DESIGN AND METHODS Patients with diabetes were seen at the Seattle Veterans Affairs Medical Center (VAMC) between October 1984 and April 1987; 67 patients were seen for initial non-traumatic amputation, and 236 consecutive control subjects were seen for non-traumatic but medically necessary surgery unrelated to diabetes. Data collection included patient interview and medical record review. High-risk status, defined as presence of peripheral neuropathy, peripheral vascular disease, or prior foot ulcer, was temporally fixed at 2 years before study enrollment. RESULTS Peripheral neuropathy, peripheral vascular disease, and prior foot ulcer were independently associated with risk of lower-extremity amputation: peripheral neuropathy odds ratio (OR) = 1.4 (95% confidence interval (CI) 0.7-2.7), peripheral vascular disease OR = 2.6 (95% CI 1.5-4.5), and prior foot ulcer OR = 10.9 (95% CI 4.6-25.5). Patients with a prior foot ulcer were significantly more likely to have seen a podiatrist and to have received outpatient diabetes education at the Seattle VAMC; their providers were more likely to prescribe clipping toenails, regular foot washing, and elevating feet during the day ( X 1 2 for proportions P x 1 2 for proportions P > 0.20). CONCLUSIONS When clinicians were aware of a patient9s very elevated risk for lower-extremity amputation (evidenced by prior history of foot ulcer), they were more likely to prescribe preventive foot-care behaviors, but awareness of other risk factors (peripheral neuropathy or peripheral vascular disease) did not necessarily increase preventive care. Physicians and patients should receive periodic education and reinforcement of diabetes management skills to modify care delivered to individuals at highest risk for lower-extremity amputation.

Contributions of psychology to diabetes management

Abstract: Three contributions of psychology to diabetes management are considered in some detail: (a) measurement of psychological outcomes and processes, (b) optimizing blood glucose monitoring and (c) stress management. Two further applications are introduced: (d) weight management and (e) psychological treatments for sexual dysfunction. Six further applications of psychology to diabetes care are mentioned. The psychosocial, physical health and economic gains expected to result from the contributions considered are specified.

Beliefs about smoking and diabetes care.

Abstract: The purpose of this study was to address the following questions: 1) Do smokers with diabetes believe that cigarettes have favorable outcomes associated with diabetes management? 2) Do smokers with diabetes believe that quitting smoking negatively impacts diabetes management? 3) Do smokers with diabetes perceive significant Others as being supportive ofattempts to quit smoking? and 4) What is the relationship between these factors and attitude toward quitting smoking?Patients with insulin-dependent diabetes mellitus (IDDM) completed a measure of Attitude Toward Quitting Smoking, which assessed desire and confidence in ability to achieve cessation, and the Diabetes and Smoking Beliefs Questioltllaire, which assessed beliefs regarding cigarettes and diabetes management. Smokers whose attitudes reflected less desire to quit and less confidence in doing so reported that cigarettes had utilit y in diabetes management, that quitting has negative effects on diabetes, and perceived significant others as only mode...

Developmental issues in managing children with diabetes.

Abstract: Children who are newly diagnosed with insulin dependent diabetes mellitus (IDDM) are expected to learn a substantial amount of new information within a few hospital days. It is important for nurses who design lesson plans for the child with IDDM to assess the child's developmental capabilities in relation to the necessary skills required of diabetes management and understand the family influence on the child's ability to perform self-care.

'White coat' hyperglycemia.

Abstract: A visit to a physician's office may provoke an increase in blood pressure. Stress is also a well-known glycemic aggravation, and managing diabetes with ongoing stress is often difficult. Two patients with diabetes mellitus in whom anxiety and stress contributed to transient hyperglycemia that impacted adversely on their diabetes management are presented. "White coat" hyperglycemia should be suspected when the clinical glucose levels are higher than the glucose levels measured by the patient at home and the clinical glycohemoglobin levels. The recognition of white coat hyperglycemia is especially important with the recent findings that intensive therapy effectively delays the onset and slows the progression of diabetic complications in patients with insulin-dependent diabetes mellitus. Failure to appreciate white coat hyperglycemia will increase the risk of hypoglycemic episodes, some of which may be severe and life threatening.

The young diabetic subjects in the Israel Army.

Abstract: Between 1978 to 1986, 145 of the Type 1 diabetic patients under our care reached the age of 18 (military service recruitment age). Of the 77 (45 men, 32 women) who decided to volunteer for service, 60 (35 men, 25 women) responded to a questionnaire relating to the conditions of their military service following its completion-these comprised Group A. Of the 68 patients who did not volunteer for service (20 men, 48 women), 44 patients comprised Group B (10 men, 34 women). Group A and Group B were compared in regard to their diabetes history and diabetes management and control during two periods, 17-18 years and 18-20 years. Group A was also evaluated regarding military employment, working and accommodation conditions and diabetes management during army service. The patients in Group A came from a higher socioeconomic level (p < 0.009) and had a significantly higher educational level (p < 0.008). The men in Group A achieved significantly better diabetes control, as evaluated by HbA1, in both periods compared to all the others in both groups. During army service the patients in Group A underwent fewer hospitalizations than the others and only two of them developed complications, whereas among those in Group B 5 patients developed complications. Our data demonstrate that youngsters with Type 1 diabetes can maintain satisfactory diabetes management and control and can function not only adequately, but often far beyond, in the stressful situations with which they are confronted within the rigid authoritative system of military service. Our data also indicated that diabetic patients wishing to volunteer for such service constitute a selected group with a higher socioeconomic background and a higher motivation to prove themselves.

Anästhesie und Diabetes mellitus

Abstract: There are two types of diabetes mellitus. Type I, insulin-dependent diabetes (IDDM), which becomes manifest before the age of 40, is the result of an absolute deficiency of insulin. Type II, the non-insulin-dependent diabetes (NIDDM), develops in the elderly and is caused by a relative insulin deficiency. Patients with type-I diabetes are prone to the development of ketoacidosis, while type II causes hyperglycaemic, hyperosmolar, nonketotic coma. Apart from these acute metabolic alterations, the long-term complications of diabetes are of concern to the anaesthesiologist. Hypertension, coronary artery disease, renal insufficiency and autonomic neuropathy are common and can result in myocardial ischaemia, cardiovascular instability and gastroparesis, with an increased risk of aspiration. Limited movement of the atlanto-occipital joint can cause difficult intubation. To avoid perioperative metabolic catastrophy, blood glucose concentration should be kept between 6.7 and 10 mmol.l-1 (120-180 mg.dl-1). Hypoglycaemia can result in neurological damage, whereas hyperglycaemia causes impaired wound healing and susceptibility to infections and worsens ischaemic damage to the myocardium and brain. Perioperative diabetes management depends on the severity of the surgical procedure and the type of diabetes. All type-I diabetics, whatever operation being performed, need insulin. The intravenous route is recommended as it allows better adjustment. After determination of the fasting blood glucose level, insulin is given at a dosage of 0.5-1 U.h-1 (at gluc 16.7 mmol.l-1). In addition, 5-10 g glucose.h-1 is given. In type-II diabetes the oral antidiabetic drug is withheld. During minor surgery the blood glucose concentration is monitored frequently, and if necessary insulin (with gluc > 13.9 mmol.l-1) or glucose is given. In most cases of major surgery insulin therapy will be necessary. Administration should follow the guidelines listed for type-I diabetes. Whether the intravenous or the subcutaneous route is used for insulin, repeated glucose determinations are mandatory. If ketoacidosis develops the volume depletion is treated with normal saline. For hyperglycaemia and acidosis insulin (3-6 U.h-1) with 10-20 mmol.h-1 potassium phosphate is given. Bicarbonate is only indicated when the serum pH is lower than 7.1. It must be borne in mind that perioperative management of diabetes does not end with postanaesthesia care.

Anaesthesia and the diabetic patient

Abstract: There are two types of diabetes mellitus. Type I, insulin-dependent diabetes (IDDM), which becomes manifest before the age of 40, is the result of an absolute deficiency of insulin. Type II, the non-insulin-dependent diabetes (NIDDM), develops in the elderly and is caused by a relative insulin deficiency. Patients with type-I diabetes are prone to the development of ketoacidosis, while type II causes hyperglycaemic, hyperosmolar, nonketotic coma. Apart from these acute metabolic alterations, the long-term complications of diabetes are of concern to the anaesthesiologist. Hypertension, coronary artery disease, renal insufficiency and autonomic neuropathy are common and can result in myocardial ischaemia, cardiovascular instability and gastroparesis, with an increased risk of aspiration. Limited movement of the atlanto-occipital joint can cause difficult intubation. To avoid perioperative metabolic catastrophy, blood glucose concentration should be kept between 6.7 and 10 mmol⋅l−1 (120 – 180 mg⋅dl−1). Hypoglycaemia can result in neurological damage, whereas hyperglycaemia causes impaired wound healing and susceptibility to infections and worsens ischaemic damage to the myocardium and brain. Perioperative diabetes management depends on the severity of the surgical procedure and the type of diabetes. All type-I diabetics, whatever operation being performed, need insulin. The intravenous route is recommended as it allows better adjustment. After determination of the fasting blood glucose level, insulin is given at a dosage of 0.5 – 1 U⋅h−1 (at gluc 16.7 mmol⋅l−1). In addition, 5 – 10 g glucose⋅h−1 is given. In type-II diabetes the oral antidiabetic drug is withheld. During minor surgery the blood glucose concentration is monitored frequently, and if necessary insulin (with gluc>13.9 mmol⋅l−1) or glucose is given. In most cases of major surgery insulin therapy will be necessary. Administration should follow the guidelines listed for type-I diabetes. Whether the intravenous or the subcutaneous route is used for insulin, repeated glucose determinations are mandatory. If ketoacidosis develops the volume depletion is treated with normal saline. For hyperglycaemia and acidosis insulin (3 – 6 U⋅h−1) with 10 – 20 mmol⋅h−1 potassium phosphate is given. Bicarbonate is only indicated when the serum pH is lower than 7.1. It must be borne in mind that perioperative management of diabetes does not end with postanaesthesia care.

Diabetes and Lipids

Abstract: 1. Introduction 2. Coronary Heart Disease and Diabetes 3. Lipids and Lipoproteins 4. Lipoprotein Abnormalities 5. Diabetes 6. Investigations 7. Diet, Lifestyle and Diabetes Management 8. Hypo-lipidaemic Agents 9. Multiple Risk Factors 10. Severe Hypertriglyceridaemia

Hemorheological effects of intensive diabetes management in the dcct

Abstract: The Diabetes Control and Complications Trial (DCCT), an NIH-sponsored study at 29 institutions in the US. and Canada, began in 1983 to examine the effects of intensive blood glucose management on the complications of type I diabetes. About half of the 1441 patients studied were randomized into a conventional treat­ ment group and half into an intensive management group. About half of each treatment group had diabetes of 1-5 years duration and no retinopathy at random­ ization (primary) and half had diabetes of 1-15 years duration and minimal retinopathy at randomization (secondary). Hemoglobin Ale levels were regularly measured. Information about complications collected systematically included retinal photographs, nerve conduction velocity assessment and evaluation of albu­ minuria and renal function. Differences in mean Hemoglobin Ale level between the intensively-treated group and the group continuing their usual treatment were sustained and substantial. Mean hemoglobin Al c levels were 1 % compared to 3% above the normal range. We measured fibrinogen, haptoglobin, albumin and total protein levels of 1347 patients from April to August of 1991. Mean fibrinogen (measured both by coagulation quantification and clotting time after dilution) and haptoglobin were elevated and albumin level modestly depressed in the overall DCCT group and gender-based differences were also noted. Despite past reports linking diabetes control to plasma protein levels, no trend to normalization was found in the intensively treated group. In fact, mean haptoglobin level was modestly higher in the intensively treated compared to the conventional group. The primary and secondary prevention components had a well-defined difference in total plasma globulin, linked to marginal differences in albumin and total protein level. The globulin was higher in the secondary prevention group, who by study design manifested more microvascular changes. Intensive management of diabetes has no direct favorable effect on the levels of the major blood proteins that influence blood's flow properties.

Computers in Diabetes Management

Abstract: In health, the islet cells of the endocrine pancreas continuously monitor the blood levels of all metabolic substrates and respond immediately to any glucose disturbance by secreting an appropriate amount of insulin into the bloodstream. Glucose—insulin interaction is a classic example of control exerted by an effective feedback control loop, which is shown as a hydraulic analogue in Fig. 9.1.

The role of the national diabetes advisory board in diabetes management

Abstract: The history of the National Diabetes Advisory Board is reviewed, particularly from the perspective of the role of the board in advancing diabetes care. In addition, its potential future activities in the arena of translating research advances, for example, the results of the Diabetes Control and Complications Trial (DCCT), are delineated.