Showing papers on "Diabetes management published in 1998"

Diabetes management system and method for controlling blood glucose

Abstract: A diabetes management system for predicting a future blood glucose value of a patient and for recommending a corrective action to the patient when the future blood glucose value lies outside of a target range. The system includes a patient-operated apparatus for measuring blood glucose values and for storing data relating to insulin doses administered to the patient. The apparatus predicts the patient's future blood glucose value based upon the patient's current blood glucose value, the fraction of insulin action remaining from the insulin doses, and the patient's insulin sensitivity. The apparatus also determines the corrective action for the patient when the predicted blood glucose value lies outside of a target range. The system also includes a physician computer in communication with the apparatus for receiving the blood glucose values and insulin dose data and for calculating an adjusted insulin sensitivity for use in subsequent predictions.

1998 clinical practice guidelines for the management of diabetes in Canada. Canadian Diabetes Association.

Abstract: Objective To revise and expand the 1992 edition of the clinical practice guidelines for the management of diabetes in Canada incorporating recent advances in diagnosis and outpatient management of diabetes mellitus and to identify and assess the evidence supporting these recommendations Options All aspects of ambulatory diabetes care, including organization, responsibilities, classification, diagnosis, management of metabolic disorders, and methods for screening, prevention and treatment of complications in all forms of diabetes were reviewed, revised as required and expressed as a set of recommendations Outcomes Reclassification of types of diabetes based on pathogenesis; increased sensitivity of diagnostic criteria; recommendations for screening for diabetes; improved delivery of care; recommendations for tighter metabolic control; and optimal methods for screening, prevention and treatment of complications of diabetes Evidence All recommendations were developed using a justifiable and reproducible process involving an explicit method for the citation and evaluation of the supporting evidence Values All recommendations were reviewed by an expert committee that included people with diabetes, family physicians, dietitians, nurses, diabetologists, as well as other subspecialists and methodologists from across Canada Benefits, harm and costs More aggressive screening strategies and more sensitive testing and diagnostic procedures will allow earlier detection and management of diabetes Cost-effectiveness analyses suggest that this will lead to savings in health care costs relating to diabetes care by reducing the incidence of complications of diabetes Similarly, tighter metabolic control in most people with diabetes, through intensive diabetes management, seeks to reduce the incidence of complications and, hence, their associated social and economic burdens Recommendations This document contains numerous detailed recommendations pertaining to all aspects of ambulatory diabetes care, ranging from service delivery to prevention and treatment of diabetes-related complications The terms "insulin-dependent diabetes mellitus" and "non-insulin-dependent diabetes mellitus" should be replaced by the terms "type 1" and "type 2" diabetes Testing for diabetes using fasting plasma glucose (FPG) level should be performed every 3 years in those over 45 years of age More frequent or earlier testing should be considered for people with additional specific risk factors for diabetes The FPG level at which diabetes is diagnosed should be reduced from 78 to 70 mmol/L to improve the sensitivity of the main diagnostic criterion and reduce the number of missed diagnoses Depending on the type of diabetes and the therapy required to achieve euglycemia, people with diabetes should generally strive for close metabolic control to achieve optimal glucose levels This entails receiving appropriate diabetes education through a diabetes health care team, diligent self-monitoring of blood glucose, attention to lifestyle and adjustments in diet and physical activity, and the appropriate and stepwise use of oral agents and insulin therapies needed to maintain glycemic control Also highlighted is the need for appropriate surveillance programs for complications and management options Validation All recommendations were graded according to the strength of the evidence and consensus of all relevant stakeholders Collateral efforts of the American Diabetes Association and the World Health Organization and the input of international experts were also considered throughout the revision process

Diabetes in America: Epidemiology and Scope of the Problem

Abstract: Epidemiological studies performed over the past 40 years have shown that the prevalence of diagnosed diabetes has increased dramatically in the U.S. and that a substantial proportion of the population has undiagnosed diabetes, impaired fasting glucose, and impaired glucose tolerance. Diabetes is most prevalent in minority populations, such as African-Americans, Native Americans, and Mexican Americans. Increasing prevalence of diabetes has led to increases in microvascular complications such as blindness, end-stage renal disease, and lower limb amputations. Poor glycemic control contributes to the high incidence of these complications, yet community-based studies of diabetic patients show their mean fasting plasma glucose concentration is generally > 180 mg/dl compared with 100 mg/dl for nondiabetic individuals. In people with diabetes, risk factors for cardiovascular disease including elevated fasting plasma glucose, blood pressure, total cholesterol, triglycerides, and obesity partly explain the high proportion of deaths (60-70%) caused by cardiovascular disease in people with diabetes. More intensive diabetes management and improved glycemic control could minimize long-term complications of the disease and would be expected to reduce the morbidity, mortality, and costs associated with diabetes.

1998 clinical practice guidelines for the management of diabetes in Canada

Abstract: Objective: To revise and expand the 1992 edition of the clinical practice guidelines for the management of diabetes in Canada incorporating recent advances in diagnosis and outpatient management of diabetes mellitus and to identify and assess the evidence supporting these recommendations. Options: All aspects of ambulatory diabetes care, including organization, responsibilities, classification, diagnosis, management of metabolic disorders, and methods for screening, prevention and treatment of complications in all forms of diabetes were reviewed, revised as required and expressed as a set of recommendations. Outcomes: Reclassification of types of diabetes based on pathogenesis; increased sensitivity of diagnostic criteria; recommendations for screening for diabetes; improved delivery of care; recommendations for tighter metabolic control; and optimal methods for screening, prevention and treatment of complications of diabetes. Evidence: All recommendations were developed using a justifiable and reproducible process involving an explicit method for the citation and evaluation of the supporting evidence. Values: All recommendations were reviewed by an expert committee that included people with diabetes, family physicians, dietitians, nurses, diabetologists, as well as other subspecialists and methodologists from across Canada. Benefits, harm and costs: More aggressive screening strategies and more sensitive testing and diagnostic procedures will allow earlier detection and management of diabetes. Cost-effectiveness analyses suggest that this will lead to savings in health care costs relating to diabetes care by reducing the incidence of complications of diabetes. Similarly, tighter metabolic control in most people with diabetes, through intensive diabetes management, seeks to reduce the incidence of complications and, hence, their associated social and economic burdens. Recommendations: This document contains numerous detailed recommendations pertaining to all aspects of ambulatory diabetes care, ranging from service delivery to prevention and treatment of diabetes-related complications. The terms “insulin-dependent diabetes mellitus” and “non-insulin-dependent diabetes mellitus” should be replaced by the terms “type 1” and “type 2” diabetes. Testing for diabetes using fasting plasma glucose (FPG) level should be performed every 3 years in those over 45 years of age. More frequent or earlier testing should be considered for people with additional specific risk factors for diabetes. The FPG level at which diabetes is diagnosed should be reduced from 7.8 to 7.0 mmol/L to improve the sensitivity of the main diagnostic criterion and reduce the number of missed diagnoses. Depending on the type of diabetes and the therapy required to achieve euglycemia, people with diabetes should generally strive for close metabolic control to achieve optimal glucose levels. This entails receiving appropriate diabetes education through a diabetes health care team, diligent self-monitoring of blood glucose, attention to lifestyle and adjustments in diet and physical activity, and the appropriate and stepwise use of oral agents and insulin therapies needed to maintain glycemic control. Also highlighted is the need for appropriate surveillance programs for complications and management options. Validation: All recommendations were graded according to the strength of the evidence and consensus of all relevant stakeholders. Collateral efforts of the American Diabetes Association and the World Health Organization and the input of international experts were also considered throughout the revision process. Sponsors: These guidelines were developed under the auspices of the Clinical and

Insulin management and metabolic control of Type 1 diabetes mellitus in childhood and adolescence in 18 countries

Abstract: Insulin regimens and metabolic control in children and adolescents with Type 1 diabetes mellitus were evaluated in a cross-sectional, non-population-based investigation, involving 22 paediatric departments, from 18 countries in Europe, Japan, and North America. Blood samples and information were collected from 2873 children from March to August 1995. HbA1c was determined once and analysed centrally (normal range 4.4–6.3 %, mean 5.4 %). Year of birth, sex, duration of diabetes, height, body weight, number of daily insulin injections, types and doses of insulin were recorded. Average HbA1c in children under 11 years was 8.3 ± 1.3 % (mean ± SD) compared with 8.9 ± 1.8 % in those aged 12–18 years. The average insulin dose per kg body weight was almost constant (0.65 U kg−124 h−1) in children aged 2–9 years for both sexes, but there was a sharp increase during the pubertal years, particularly in girls. The increase in BMI of children with diabetes was much faster during adolescence compared to healthy children, especially in females. Sixty per cent of the children (n = 1707) used two daily insulin injections while 37 % (n = 1071) used three or more. Of those on two or three injections daily, 37 % used pre-mixed insulins, either alone or in combination with short- and intermediate-acting insulin. Pre-adolescent children on pre-mixed insulin showed similar HbA1c levels to those on a combination of short- and long-acting insulins, whereas in adolescents significantly better HbA1c values were achieved with individual combinations. Very young children were treated with a higher proportion of long-acting insulin. Among adolescent boys, lower HbA1c was related to use of more short-acting insulin. This association was not found in girls. We conclude that numerous insulin injection regimens are currently used in paediatric diabetes centres around the world, with an increasing tendency towards intensive diabetes management, particularly in older adolescents. Nevertheless, the goal of near normoglycaemia is achieved in only a few. © 1998 John Wiley & Sons, Ltd.

Short-term effects of coping skills training as adjunct to intensive therapy in adolescents

Abstract: OBJECTIVE Given the urgent need to develop effective programs that improve the ability for adolescents to achieve metabolic control equivalent to programs studied in the Diabetes. Control and Complications Trial, we have undertaken a clinical trial to determine if a behavioral intervention (coping skills training [CST]) combined with intensive diabetes management can improve metabolic control and quality of life in adolescents implementing intensive therapy regimens. RESEARCH DESIGN AND METHODS A total of 65 youths between the ages of 13 and 20 years, who elected to initiate intensive insulin therapy, were randomly assigned to one of two groups: the intensive management with CST group and the intensive management without CST group. CST consists of a series of small group efforts designed to teach adolescents the coping skills of social problem-solving, social skills training, cognitive behavior modification, and conflict resolution. Data were collected at pre-intervention and at 3 months following the use of the Self-Efficacy for Diabetes scale, Children9s Depression Inventory, Issues in Coping with IDDM scale, and the Diabetes Quality of Life: Youth scale. Clinical data (HbA 1c , adverse effects) were collected monthly. RESULTS The experimental and control groups were comparable on all measures at baseline. Results show that adolescents who received CST had lower HbA 1c and better diabetes self-efficacy and were less upset about coping with diabetes than adolescents receiving intensive management alone. In addition, adolescents who received the CST found it easier to cope with diabetes and experienced less of a negative impact of diabetes on quality of life than those who did not receive CST. CONCLUSIONS CST is useful in improving not only an adolescent9s metabolic control, but also their quality of life. As more pediatric providers aim for improved control, in adolescents with diabetes, the addition of this behavioral intervention may be helpful in achieving metabolic and life goals.

Adapting to and Managing Diabetes

Abstract: Purpose: To advance understanding of the lived experience of diabetes as described in published research and theses. Meta-analysis extends the analysis of individual research studies beyond individual experience to incorporate dominant system beliefs and health system ideologies. Organizing Framework: Curtin and Lubkin's (1990) conceptualization of the experience of chronic illness. Sources: Forty-three qualitative interpretive research reports in six computerized data bases 1980–1996 pertaining to the lived experience of diabetes and published in nursing, in the social sciences, and in allied health journals were used. Methods: Meta-ethnography in which trustworthiness was achieved by using multiple researchers, identifying negative or disconfirming cases, and testing rival hypotheses Findings: Balance is the determinant metaphor of the experience of diabetes. People learn to balance diabetes through their experience and experimentation with strategies for managing their illness. Conclusions: Learning to balance is a developmental process in which one learns to assume control of diabetes management. Support for such development requires that nurses know their clients as individuals and value the expertise they have gained in living with diabetes. Control of blood sugar levels within a prescribed range may be a goal established by professionals, but the goal of healthy balance determines a person's willingness to assume an active role in self-care.

The family and type 2 diabetes: a framework for intervention.

Abstract: Four broad groups of factors have been linked with self-management behavior in type 2 diabetes over time: (1) characteristics of patients, (2) amount and management of stress, (3) characteristics of providers and provider-patient relationships, and (4) characteristics of the social network/context in which disease management takes place. Of these four, social network/context has received the least amount of study and has been described in terms not easily applicable to intervention. In this paper, we identified the social network/context of diabetes management as residing within the family. We defined the family for clinical purposes, reviewed the literature concerning what is known about the link between properties of the family context of care and outcomes in type 2 diabetes and other chronic diseases, and identified areas of family life that are relevant to diabetes management. This information was then used to demonstrate how a family context of care can serve as a clinical framework for integrating all four groups of factors that affect disease management. Implications of this approach for practice and research are described.

A population-based approach to diabetes management in a primary care setting: early results and lessons learned.

Abstract: Objective To determine the effect of a multifaceted program of support on the ability of primary care teams to deliver population-based diabetes care. Design Ongoing evaluation of a population-based intervention. Setting/participants Group Health Cooperative of Puget Sound, a staff model HMO in which more than 200 primary care providers treat approximately 15,000 diabetic patients. Intervention A program of support to improve the ability of primary care teams to deliver population-based diabetes care was implemented. The elements of the program are based on an integrated model of well-validated components of delivery of effective care to chronically ill populations. These elements have been introduced since the beginning of 1995, and some aspects of the program were pilot-tested in a few practice sites before being implemented throughout the organization. The program elements include 1) a continually updated on-line registry of diabetic patients; 2) evidence-based guidelines on retinal screening, foot care, screening for microalbuminuria, and glycemic management; 3) improved support for patient self-management; 4) practice redesign to encourage group visits for diabetic patients in the primary care setting; and 5) decentralized expertise through a diabetes expert care team (a diabetologist and a nurse certified diabetes educator) seeing patients jointly with primary care teams. Main outcome measures Patient and provider satisfaction through existing system-wide measurement processes; process measures, health outcomes, and costs are tracked continuously. Results Patient and provider satisfaction have improved steadily. Interest in and use of the electronic Diabetes Registry have grown considerably. Rates of retinal eye screening, documented foot examinations, and testing for microalbuminuria and hemoglobin A1c have increased substantially. Conclusions Providing support to primary care teams in several key areas has made a population-based approach to diabetes care a practical reality in the setting of a staff model HMO. It may be an important mechanism for improving standards of care for many diabetic patients.

Clinical and Economic Impact of Implementing a Comprehensive Diabetes Management Program in Managed Care

Abstract: Diabetes mellitus places a significant burden on the U.S. healthcare system. Because of the potential to reduce diabetic complications and costs through intensive management, diabetes has become a primary target for disease management programs. We performed a retrospective analysis of short-term baseline and follow-up clinical, economic, and member and provider satisfaction data from approximately 7,000 people with diabetes being treated through seven managed care plans using Diabetes Treatment Centers of America’s Diabetes NetCareSM, (Nashville, TN), a comprehensive diabetes management program. Our analysis indicates that Diabetes NetCareSM achieved gross economic adjusted savings of $50 per diabetic member per month (12.3%), with gross unadjusted savings of $44 (10.9%) per diabetic member per month. Hospital admissions per 1,000 diabetic member years decreased by 18%, and bed days fell by 21%. Patients with diabetes were more likely to get HbA1c tests, foot exams, eye exams, and cholesterol screenings w...

Reducing lower-extremity amputations due to diabetes. Application of the staged diabetes management approach in a primary care setting

Abstract: BACKGROUND While lower-extremity amputation (LEA) is a frequent complication of diabetes, effective strategies for the prevention of LEA in primary care settings have not been extensively studied. METHODS This prospective study of American Indians with diabetes in a rural primary care clinic was divided into three periods: the standard care period (1986 to 1989), during which patients received foot care at the discretion of the primary care provider; the public health period (1990 to 1993), during which patients were screened for foot problems and high-risk individuals received foot care education and protective footwear; and the Staged Diabetes Management (SDM) period (1994 to 1996), during which comprehensive guidelines for diabetic foot management were adapted by the primary care clinicians to their practices and were systematically implemented. RESULTS A total of 639 individuals contributed 4322 diabetic person-years during the three periods of observation. Patient sex distribution, mean age, and mean duration of diabetes were similar i the three periods. The average annual LEA incidence was 29/1000 diabetic person-years for the standard care period (n = 42), 21/1000 for the public health period (n = 33), and 15/1000 for the SDM period (n = 20), an overall 48% reduction (P = .016). Overall, the incidence of a first amputation declined from 21/1000 to 6/1000 (P < .0001). CONCLUSIONS The customization and systematic implementation of practice guidelines by local primary care providers was associated with improved diabetic foot care outcomes. SDM has relevance to primary care organizations seeking to improve outcomes for patients with diabetes.

Contrasting patient and practitioner perspectives in type 2 diabetes management.

Abstract: Studies of self-care behaviors in the management of type 2 diabetes of ten focus on patient knowledge and montivation, without considering the role of practitioner orientations. Using an exploratory descriptive design, we conducted open-ended interviews with 51 type 2 diabetes patients and 35 practitionersfrom clinics in San Antonio and Laredo, Texas. We found critical differences between patient andpractitioner goals, evaluations, and strategies in diabetes management, especially regarding such key concepts as "control" and "taking care of self:" Practitioners' perspectives are rooted in a clinical context, emphasizing technical considerations, whereas patients'perspectives exist within a life-world context andforeground practical and experiential considerations. These result in very different approaches to treatment. Practitioners, presuming failed treatment indicates uncooperativeness, try to inform and motivate patients. The patients we interviewed, however, understood and were committed to type 2 dia...

Social support among African-American adults with diabetes, Part 2: A review.

Abstract: Diabetes mellitus affects African Americans in disproportionate numbers relative to whites. Proper management of this disease is critical because of the increased morbidity and mortality associated with poor diabetes management. The role of social support in promoting diabetes management and improved glycemic control among African Americans is a little-explored area. This review, the second in a two-part series, examines the relationship between social support and glycemic control among African-American adults with diabetes. The main findings of the study are that African Americans tend to rely more heavily than whites on their informal social networks to meet their disease management needs and that social support is significantly associated with improved diabetes management among members of this population. However, there remains a critical need to systematically include substantial numbers of African-American respondents in studies examining the relationship between social support and glycemic control. Only then can the effects of age, gender, socioeconomic status, and other variables on this relationship in African Americans become clear and interventions incorporating relevant aspects of social support be developed.

Relation of Glycemic Control to Diabetic Complications and Health Outcomes

Abstract: Data from the Wisconsin Epidemiologic Study of Diabetic Retinopathy (WESDR) demonstrated that the incidence of diabetic complications is directly related to glycemic control. The results of the Diabetes Control and Complications Trial and Stockholm Study showed that intensive insulin therapy and improved glycemic control reduced diabetic complications in people with type 1 diabetes. Results of the U.K. Prospective Diabetes Study Group and the Kumamoto trial also support the relationship between glycemic control and diabetic complications in individuals with type 2 diabetes. Preliminary WESDR health outcomes data suggest that higher levels of glycemia are related to a decreasing quality of life. This study and others showing that higher levels of glycemia are associated with an increased incidence of complications suggest that it is the complications of diabetes that contribute to a decrease in quality of life. Despite evidence of the benefits of improved glycemic control, a large percentage of people with diabetes maintain poor glucose control in part because of the limitations of the therapies available for diabetes management.

Well-Being and Symptoms in Relation to Insulin Therapy in Type 2 Diabetes

Abstract: OBJECTIVE To determine the influence of insulin therapy on physical symptoms, emotional and general well-being, and treatment satisfaction in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS A descriptive prospective 2-year cohort study was performed. The study population consisted of 272 eligible NIDDM patients of Dutch origin ≥ 40 years of age who had a known diabetes duration ≥ 3 months and who were treated with diet and/or oral hypoglycemic agents. Dependent variables in the logistic regression analysis were scores on the Type 2 Diabetes Symptom Checklist, the Profile of Mood States, and questions regarding general well-being and treatment satisfaction. Potential determinants under study were age, sex, known diabetes duration, insulin dose, duration of insulin therapy, comorbidity, baseline and change in metabolic parameters and cardiovascular risk factors. RESULTS A baseline and 2-year questionnaire were available for 157 patients (58%). During follow-up, 39 of them (24.8%) were treated with insulin. Initiation of insulin therapy was significantly associated with improved glycemic control (mean HbA 1c 8.2 ± 1.4 [SD] to 7.4 ± 0.9%, P = 0.001) and weight gain (BMI 27.1 ± 3.9 to 28.6 ± 4.3 kg/m 2 P = 0.000). Of all symptom and well-being scores, only feelings of emotional fatigue worsened significantly, although modestly (0.4–1.7 on a scale of 0.0–10.0, P = 0.02). Although diabetes management with insulin was experienced as more demanding ( P = 0.04), treatment satisfaction scores were not adversely influenced (2.5–1.9, P = 0.39). High insulin doses were significantly and independently associated with high symptom scores (total score, hypoglycemic score) and with low mood (displeasure score, anger, tension, emotional fatigue) and perceived state of health. CONCLUSIONS Initiation of insulin therapy in type 2 diabetes improves glycemic control effectively, has little influence on physical and psychological well-being dimensions, and does not affect treatment satisfaction.

Pregnancy outcomes among women with and without diabetic microvascular disease (White's classes B to FR) versus non-diabetic controls.

Abstract: The objective of this paper is to evaluate the impact of contemporary management on the maternal and neonatal outcomes of pregnancies complicated by diabetes in women with microvascular disease versus women without microvascular disease. The study population consisted of two hundred and eighty-eight (288) pregnant women with pregestational diabetes and one hundred and fifty (150) healthy pregnant controls. Diabetic women were grouped according to the presence (n = 103) or absence of diabetic microvascular disease (n = 185). Data were collected regarding diabetes management, level of glycemic control, and the development of antenatal complications. Maternal and neonatal outcomes were compared among the three groups. Women in the diabetes groups were stratified according to mean blood glucose levels and glycosylated hemoglobin during each trimester. There was no significant difference found between the two diabetes groups in terms of preterm labor, polyhydramnios, pyelonephritis, and growth restriction. The only maternal complications that occurred with increased incidence among women with microvascular disease were acute hypertensive complications (51.6 vs. 32.9%; p<0.05). However, when the diabetes groups were compared to healthy controls, a significant difference was seen in all maternal and neonatal complications. Preterm delivery, polyhydramnios, and large-for-gestational-age (LGA) infants were associated with poor third-trimester metabolic control as compared with others in satisfactory metabolic controls: 30.8 vs. 11.4% for preterm delivery; 17.3 vs. 5.1% for polyhydramnios; 51.9 vs. 33.9% for LGA; p<0.05. Congenital malformations were associated with poor first-trimester glucose control (5.8 vs. 1.3% anomalies in well-controlled women). Furthermore, major congenital malformations were also significantly increased in the offspring of women with diabetic microvascular disease 6.8%, as compared to 1.69% in diabetic women without microvascular disease; p<0.01. The incidence of hypertensive complications did not differ between the two diabetic groups. Pregestational diabetic women with and without microvascular disease can be counseled to anticipate comparably favorable pregnancy outcomes, although maternal and neonatal complications may exceed that experienced by pregnant women without diabetes mellitus.

Polycystic ovary syndrome: a new direction in treatment

Abstract: Polycystic ovary syndrome is a diagnosis made in 5%-10% of women between late adolescence and the menopause. Patients may present with oligomenorrhoea or amenorrhoea, anovulation or infertility, hirsutism or acne. Women with the syndrome have at least seven times the risk of myocardial infarction and ischaemic heart disease of other women, and by the age of 40 years up to 40% will have type 2 diabetes or impaired glucose tolerance. Polycystic ovary syndrome is associated with insulin resistance, with consequent hyperinsulinaemia and (frequently) hyperlipidaemia and obesity. Recent research has shown that the application of diabetes management techniques aimed at reducing insulin resistance and hyperinsulinaemia (such as weight reduction and the administration of oral hypoglycaemic agents) can not only reverse testosterone and luteinising hormone abnormalities and infertility, but can also improve glucose, insulin and lipid profiles. The management of polycystic ovary syndrome should now include patient education and attention to diabetes and cardiovascular risk factors such as hyperlipidaemia, obesity, physical exercise, glucose intolerance, hypertension and cigarette smoking.

Current therapy of diabetes mellitus

Abstract: Introduction. Classificationand Diagnosis of Diabetes Mellitus. Goals of Diabetes Management. Type I Diabetes Mellitus. Psychosocial Problems in Children. Diabetic Ketoacidosis in Children. Diabetic Ketoacidosis in Adults. Hyperglycemic Hyperosmolar Nonketotic Coma. Therapeutic Considerations for Lactic Acidosis. Insulin Therapy in Type I Diabetes Mellitus. Monitoring of Type I Diabetes Mellitus. Hypoglycemia in Type I Diabetic Patients. Hypersensitivity Reactions to Insulin and Insulin Resistance. Exercise in the Management of Type I Diabetes Mellitus. Medical Nutrition Therapy in Type I Diabetes Mellitus. The Diabetes Nurse Educator. Type II Diabetes Mellitus. Diet Therapy of Type II Diabetes Mellitus. Behavioral Weight Control. Exercise in the Management of Type II Diabetes Mellitus. Sulfonylurea. Metformin. Alpha-Glucosidase Inhibitors. Insulin Therapy in Type II Diabetes Mellitus. Combination Therapy: Insulin Sulfonylurea and Insulin-Metformin. Troglitazone (Rezulin). Dyslipidemia. Diabetic Complications. Diabetic Nephropathy: Diagnostic and Therapeutic Approach. Diabetic Nephropathy: End Stage. Cataract in the Diabetic Patient. Diabetic Retinopathy. Diabetic Peripheral Neuropathy. Autonomic Neuropathy. Atherosclerotic Cardiovascular Disease. Heart Failure. Peripheral Vascular Disease. The Diabetic Foot. Hypertension in Patients with Diabetes. Skin and Subcutaneous Tissues. Infections and Diabetes Mellitus. Special Problems. Gestational Diabetes. Type I Diabetes Mellitus in Pregnancy. Infant of the Diabetic Mother. Genetic Counseling. Surgery and Diabetes Mellitus. Geriatrics and Diabetes Mellitus.

Social support among African-American adults with diabetes. Part 1: Theoretical framework.

Abstract: Diabetes mellitus affects African Americans in disproportionate numbers relative to whites. Proper management of this disease is critical because of the increased morbidity and mortality associated with poor diabetes management. The role of social support in promoting diabetes management and improved glycemic control among African Americans is a little-explored area. This article, the first in a two-part series, provides a theoretical framework for examining the relationship between social support and glycemic control among African-American adults.

Incorporation of Quality-of-Life Considerations Into Intensive Diabetes Management Protocols in Adolescents

Abstract: Two articles in this issue of Diabetes Care address the relationship between metabolic control and adolescents' perceptions of the impact of diabetes on their quality of life (1,2). A third describes the beneficial effect of a specific psychosocial intervention on both metabolic control and self-perceived quality of life (3). Publication of these studies emphasizes the importance the Diabetes Care editorial board gives to research that addresses the effects of treatment on not only the physical but also the psychological health of adolescent patients. It is, therefore, an opportune time to perform an overview of some of what is known and what needs to be known about these topics. A major increase in interest in and research into psychosocial aspects of diabetes began about 20 years ago. This change was concurrent with the increasing sense that controlling glucose levels might do more than prevent acute life-threatening episodes and with the development of measures of glucose control more sensitive and reliable than glycosuria. It also became clear that newer therapeutic approaches would require increasing involvement by patients and their social supports, including health care teams. Whereas former treatment consisted of one, or occasionally two, injections per day, and the unpleasant but nonpainful use of urine dipsticks, treatment that meets the Diabetes Control and Complications Trial (DCCT) recommendations usually consists of three or more daily injections, multiple finger punctures, constant awareness of what one eats and how one exercises, and an increased risk for hypoglycemia (4). Much research, therefore, has focused on how to minimize the potential negative psychosocial effects of intrusive treatment while recognizing the increasing importance and hope associated with it. These problems are particularly important and vexing for adolescents. The DCCT has shown that the link between excellent metabolic control and reduced risk for complications applies to this age-group. However, daily activities during adolescence are typically less structured than during childhood or adulthood, making adherence to a complex regimen much more difficult. Furthermore, adolescents are still maturing cognitively and emotionally, and there is justifiable concern that long-term psychological health not be compromised by treatment. Formal assessment of how intensive treatment of diabetes affects the emotional state of patients was initiated by the DCCT investigators, who incorporated a diabetesspecific measure of quality of life (DQOL) into their trial (5). This measure was subsequently modified by Ingersoll and Marrero (6) to reflect specific adolescent concerns, and this instrument was used in the three current studies. What is its value? Primarily it provides a reliable assessment of how adolescents see themselves as being affected by the presence and treatment of diabetes. This outcome is as important as metabolic control in comprehensively evaluating new treatment approaches. Quality-of-life measures are increasingly incorporated into analyses of therapeutic trials in a variety of illnesses (7), and it cannot be too controversial to say that the potential negative (or positive) effects of treatment on quality of life should be known and minimized. For adolescents with diabetes, the goal is to minimize the effects of both the disease itself and of therapeutic interventions on both physical and psychological health and development. Unfortunately, to date, we know relatively little about the relationship between DQOL and diabetes treatment in adolescents. In this issue of Diabetes Care, Guttman-Bauman et al. (1) report that DQOL correlates positively with metabolic control as determined by both mean HbAlc and a single measurement. Grey et al. (2) (and earlier, Ingersoll and Marrero [6]) found no correlation with single measurements. The conflicting results, therefore, do not allow us to answer the most important question: What is the effect of a DCCT-type intervention on quality of life? What really needs to be known is whether we can use currently available technology to achieve a level of control that minimizes complications and is tolerable to the patient. Along these lines, the study by Grey et al. (3) is particularly interesting. It reports results from a randomized 3-month trial of intensive therapy (external pumps or three or more daily injections, self-monitoring of blood glucose at least four times daily, monthly outpatient visits, and intermittent telephone contacts) with and without a structured psychosocial intervention of six to eight weekly sessions. The specific intervention, coping skills training (CST), incorporates social problem-solving, social skills training, and conflict resolution. Patients role-played diabetes-specific social situations with demonstration and feedback of positive coping behaviors. Important preliminary findings show that at 3 months, intensive therapy alone improved metabolic control in a relatively unselected population to DCCT levels while DQOL and other psychosocial measures did not deteriorate. Addition of CST resulted in even lower HbAlc levels and improvement in some indexes of DQOL and diabetes self-efficacy. Although this study is limited by the 3month follow-up period and by a potential selection bias toward more socioeconomically advantaged patients, it allows several important preliminary conclusions. First, attempts to reach excellent levels of metabolic control using an intensive regimen in adolescents are not a priori doomed to failure and, in fact, can succeed. Second, they do not necessarily increase psychological distress. Third, addition of at least one type of diabetes-specific psychoeducational (N.B.—not just educational) curriculum can further improve metabolic control and improve aspects of psychosocial functioning. Finally for purposes of health policy planning, treatment by primary care physicians, even in conjunction with initial diabetes education, continues to be shown to be insufficient. There are at least two direct extensions of this line of research. The first is to evaluate ways to extend the ability to success-

Improving diabetes preventive care in a family practice residency program: a case study in continuous quality improvement.

Abstract: BACKGROUND AND OBJECTIVES The paradigm of continuous quality improvement (CQI) holds promise for application in clinical settings. This paper highlights results of a CQI project developed and implemented in a residency-based, ambulatory family medicine center for management of non-insulin-dependent diabetes mellitus. METHODS We developed a CQI program that used several indicators of diabetes management as measures of quality care. These included dietary counseling, exercise counseling, foot care counseling, ophthalmology referral, and measurement of hemoglobin AIC and renal function. RESULTS Overall, compliance with recommendations for diabetes management increased from a baseline proportion of 40% to a level of 70% at the end of 1 year. During the second year, overall compliance was maintained at this level despite the inclusion of additional performance indicators. CONCLUSIONS The CQI process can improve physician performance in managing patients with diabetes.

Staged Diabetes Management: Computerizing a Disease State Management Program

Abstract: Recently, the Diabetes Control and Complications Trial (DCCT) and other similar studies have demonstrated that near-normalization of blood glucose in diabetes will reduce complications up to 75% but translation of these results into practice has been difficult. In an attempt to help provide the best possible control of patients with diabetes, we have produced a new disease state management system for diabetes, called “Staged Diabetes Management” (SDM), implemented it in over 100 sites worldwide, and developed a computer program to simplify its use. SDM, designed to change the way we deal with patients with diabetes, is based upon five principles: (1) community involvement in setting care guideliness (2) negotiation of goals with patientss (3) appropriate timelines for therapeutic successs (4) use of flowcharts for medical decisionss and (5) evaluation of the program. SDM is designed to be altered by a community to meet its needs and resources. It encourages primary care physicians to deliver better diabetes care using a team approach and to refer patients with diabetes to specialists when appropriate. It has a complete set of materials for communities, individual health care providers and patients. SDM has been tested for changes in structure, process and outcomes. A meta-analysis of seven clinical trials with over 500 patients has shown a time-weighted average fall in hemoglobin Alc of 1.7 points (equivalent to a drop in mean blood glucose of about 3.5 mM or 60 mg/dL). Preliminary pharmacoeconomic analysis demonstrates a lifetime cost saving of over d27,000 per patient. A computer program has been developed for the Microsoft Windows® environment that contains a client-server database, based upon DiabCare, for the data file structure.

It's "all in the family": responsibility for diabetes care.

Abstract: Despite its importance, diabetes management it is an area of great difficulty for children and adolescents. As children reach the teenage years, satisfactory levels of treatment adherence and glycemic control become increasingly difficult to obtain. In order to promote better diabetes care, the present paper emphasizes the need for families to remain actively involved in their youngster's diabetes care, regardless of the child's age. Recent studies of children and adolescents with diabetes are described that support the view that, even as responsibility for diabetes care shifts from a parent-managed to an adolescent-managed system, family members should remain actively involved in day to day management. Based on current research efforts, the specific ways that family members can remain active and involved are discussed.

Approaches to quality of control in diabetes care.

Abstract: Management methods for quality of diabetes care need new approaches because of the poor metabolic control of most of these patients. Poor quality of care generally results from poor instruction and tr

The Significance of Identity in the Adjustment to Diabetes Among Insulin Users

Abstract: In this study, the social theory of identity was used to gain a better understanding of the complex process of how individuals adjust to having insulin-requiring diabetes Semistructured interviews were conducted with 30 individuals to explore issues related to their personal experience with diabetes Narrative methods were used to analyze the data An exploration of participants' stories revealed significant identity issues underlying their interpretation and management of diabetes The diagnosis of diabetes was conceptualized as an assault on personal identity This initial disruption was followed by a process of negotiation whereby individuals grappled with identity issues to adapt to the condition and integrate it into their lives This process was socially shaped and influenced individuals' perceptions of their diabetes management The main concepts examined in this paper are diagnosis and identity, identity and treatment management, and identity and the ongoing nature of adjustment The implications for diabetes education are presented

Health status and practices of urban Caribbean Latinos with diabetes mellitus.

Abstract: Although Caribbean Latinos are more likely than non-Hispanic whites to develop diabetes, their health status has been poorly characterized. Information on diabetes management, metabolic control, dietary habits, and diabetes knowledge was gathered from a group of urban Caribbean Latinos with diabetes in order to characterize the nutritional behaviors, diabetes attitudes, health perceptions, and metabolic control of this high risk group. Interviews and medical record reviews were conducted among seventy low-income urban Caribbean Latinos with type 2 diabetes mellitus. Patients attending outpatient clinics were interviewed by bilingual interviewers. Medical records were reviewed to ascertain prevalence of diabetes-related complications, medications, and metabolic parameters. Participants were primarily Spanish-speaking and of Puerto Rican origin. Eighty-one percent were unemployed, and only 27% had completed high school or higher educational levels. Average hemoglobin A1c was 10.6%. Among those with hypertension and hyperlipidemia, many were not receiving treatment. Participants' estimation of their own degree of metabolic control was poor, as was their understanding of desirable blood glucose and weight goals. A second evening meal was common. Diets were higher in fat and sugar content than currently recommended. More effective treatment strategies for both patients and providers are needed to improve glycemic control and cardiovascular risk factors among indigent urban Caribbean Latinos. Essential features of such strategies for patient programs include culturally appropriate dietary counseling and low literacy materials to better communicate glycemic and weight goals and dietary guidelines. Provider education is needed regarding established guidelines and cultural influences on diabetes-related practices.

The management of diabetes at primary level in South Africa: the results of a facility-based assessment.

Abstract: Diabetes is a widespread condition in South Africa and is often managed at primary level health facilities. This study aimed to assess the quality of diabetes management using a rapid assessment ap...