Showing papers on "Diabetes management published in 2000"

Performance Evaluation of the MiniMed® Continuous Glucose Monitoring System During Patient Home Use

Abstract: Background: The recent availability of a continuous glucose monitor offers the opportunity to match the demands of intensive diabetes management with a period of equally intensive blood glucose monitoring. The present study evaluates the performance of the MiniMed® continuous glucose monitoring system (CGMS) in patients with diabetes during home use. Methods: Performance data and demographic information were obtained from 135 patients who were (mean ± SD) 40.5 ± 14.5 years old, had an average duration of diabetes of 18.0 ± 9.8 years, 50% were female, 90% were Caucasian, and 87% of whom had been diagnosed with type 1 diabetes. Patients were selected by their physician, trained on the use of the CGMS and wore the device at home for 3 days or more. The performance of the CGMS was evaluated against blood glucose measurements obtained using each patient’s home blood glucose meter. Evaluation statistics included correlation, linear regression, mean difference and percent absolute difference scores, and Clarke e...

Efficacy and Reliability of the Continuous Glucose Monitoring System

Abstract: S-19 TIGHT CONTROL OF GLUCOSE has been shown to reduce both microvascular and macrovascular complications of diabetes mellitus,1–3 yet euglycemia is achieved only by a minority of patients.4 Intensive control of blood glucose cannot be achieved without vigilant attention to blood glucose levels.5Consequently, the goal of achieving normoglycemia has stimulated the search for optimal methods of monitoring changes in glucose levels in response to food, exercise, insulin, and antidiabetes medications. When it was first introduced, the technique of self-monitored blood glucose (SMBG) testing of capillary blood via fingerstick represented a major advance in methods of monitoring and improving glycemic control. Now that intensive therapy has become the standard of care for both type 1 and type 2 diabetes, SMBG has been established as a cornerstone of patient management. Current American Diabetes Association (ADA) guidelines recommend SMBG testing at least three to four times each day in patients with type 1 diabetes and at least once a day in patients with type 2 diabetes who cannot be managed with diet and exercise alone.6 Unfortunately, there are many impediments to adequate SMBG practice, including patient education and motivation, as well as improper technique.7,8 But even highly motivated patients who carefully perform frequent fingerstick measurements may miss substantial fluctuations in glucose levels, particularly episodes of nocturnal hypoglycemia. Furthermore, the blood glucose meters that are available today do not consistently achieve either the ADA or the Food and Drug Administration (FDA) goals for meter accuracy.9,10 The recent development of a method for continuously and automatically measuring glucose levels offers a dramatic improvement in the ability to monitor blood glucose—and, thus, intensively manage diabetes. The MiniMed® Continuous Glucose Monitoring System (CGMS, MiniMed Inc., Northridge, CA) is the first commercially available continuous glucose monitor. In this chapter, we summarize the results of a multicenter clinical evaluation of the CGMS, the results of a pilot study demonstrating the efficacy of the CGMS in diabetes management, and the results of a large postmarketing surveillance study confirming the performance of the CGMS during its initial commercial use.

Barriers to appropriate diabetes management among homeless people in Toronto

Abstract: Background: Homeless people are more likely to have chronic medical conditions and to encounter barriers to health care than the general population. In this study we identify barriers to appropriate disease management among homeless adults with diabetes mellitus in Toronto. Methods: People with diabetes were surveyed at homeless shelters in Toronto. Information was obtained on demographic characteristics, diabetes history, access to health care, substance abuse and mental illness. Participants’ descriptions of the difficulties they experienced in managing their diabetes were analysed qualitatively. Hemoglobin A1c levels were used to assess adequacy of glycemic control. Results: Fifty people completed the survey (response rate 83%). Of the respondents 82% were male and 64% were white. Type 2 diabetes had been diagnosed in 86%, with 62% of all participants taking oral agents alone and 28% taking insulin alone. Overall, 72% of the participants reported experiencing difficulties managing their diabetes: the most common were related to diet (type of food at shelters and inability to make dietary choices, reported by 64%) and scheduling and logistics (inability to get insulin and diabetic supplies when needed and inability to coordinate medications with meals, reported by 18%). Although alcohol use, cocaine use and mental health problems were common, few respondents cited these issues as barriers to diabetes management. According to Canadian Diabetes Association guidelines, glycemic control was inadequate in 44% of the people tested. Interpretation: In Toronto, most homeless adults with diabetes report difficulties managing their disease, and poor glycemic control is common.

Behavioral interventions for adolescents with type 1 diabetes: how effective are they?

Abstract: OBJECTIVE: To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature. RESEARCH DESIGN AND METHODS: The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated. RESULTS: The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P<0.05, 1-tailed). CONCLUSIONS: Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention's reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting.

Effect of a Pharmacist-Managed Diabetes Care Program in a Free Medical Clinic

Abstract: Diabetes care, morbidity, and mortality are usually worse in poor minority populations compared with non-minority ones. This report evaluates evidence-based process and outcome measures of diabetes care in diabetic patients followed in a free medical clinic and compares them to published results. The following process measures compared favorably with measures of the general population: dilated eye and foot exams and measurements of glycated hemoglobin levels; concentrations of total cholesterol; fasting triglycerides and low density lipoprotein (LDL) cholesterol; and proteinuria (by dipstick). Process and outcome measures in 89 diabetic patients referred to a Diabetes Management Program in which diabetes care was delivered by pharmacists following detailed algorithms (experimental group) were compared with measures in 92 diabetic patients who received diabetes care in the general clinic setting (control group). The patients in the experimental group had a slightly longer duration of diabetes and more microvascular and neuropathic complications, and more diabetic patients were taking insulin than were patients in the control group. All of the process measures listed above were more frequent in the experimental group. Compared with the control group, the initial glycated hemoglobin level (% +/- SE) in the experimental group was significantly (P < .001) higher (8.8 +/- 0.2 versus 7.9 +/- 0.2) but fell significantly (P < .03) more (-0.8 +/- 0.2 versus -0.05 +/- 0.3). The lack of a greater decrease in the glycated hemoglobin levels in the experimental group was not related to the inability of the pharmacists to follow the algorithms, the patients' refusal to follow the recommended medication adjustments, or the lack of appropriate self-monitoring of blood glucose in insulin-requiring patients. It was inversely related (r = -0.36, P < .03) to the number of missed visits, i.e., the greater the number of broken appointments, the less the glycated hemoglobin fell. In conclusion, diabetes care for a poor minority population in a free clinic setting can compare favorably to care in the general population. Pharmacists following detailed algorithms can enhance this care further. Administrative and support system changes that minimize the number of missed visits might further improve diabetes care in this population.

Psychology in diabetes care

Abstract: List of Contributors. Foreword to the First Edition. Foreword to the Second Edition. Preface to the First Edition. Preface to the Second Edition. List of Contributors. 1. Diabetes in Children (Barbara J. Anderson and Julienne Brackett). 1.1 Introduction. 1.2 Diabetes in Infancy. 1.3 Diabetes in toddlers and preschoolers. 1.4 Treatment in issues for children under 6 years of age. 1.5 Diabetes in school-aged children. 1.6 Family factors related to glycaemic control and adherence. 1.7 Family involvement in the diabetes management of a school-aged child. 1.8 Treatment issues for school-aged children. 1.9 Disease course and risk factors: implications for clinical practice. 1.10 Conclusions. References. 2. Diabetes in Adolescents (T. Chas Skinner, H. Murphy and Michelle V. Huws-Thomas). 2.1 Introduction. 2.2 Familial interventions. 2.3 Individual interventions. 2.4 Conclusion. References. 3. Psychological Issues in the Management of Diabetes and Pregnancy (Maurice G. A. J. Wouters and Frank J. Snoek). 3.1 Introduction. 3.2 Prepregnancy. 3.3 Pregnancy. 3.4 Delivery. 3.5 Lactation. 3.6 Childhood. 3.7 Practice implications. References. 4. References 4 Diabetes in Older Adults (Marie Clark and Koula G. Asimakopoulou). 4.1 Introduction. 4.2 The ageing process. 4.3 Symptoms and their representation. 4.4 Clinical features of diabetes. 4.5 Diabetes complications in older adults. 4.6 Mortality and type 2 diabetes. 4.7 Diabetes control and complications. 4.8 Quality of life. 4.9 Management of diabetes in older adults. 4.10 Self-management issues. 4.11 Practice implications. 4.12 Summary and conclusions. References. 5. Patient Empowerment (Martha M. Funnell and Robert M. Anderson). 5.1 Introduction. 5.2 Empowerment defined. 5.3 Patient empowerment and diabetes. 5.4 Implementing the empowerment approach. 5.5 Implementing the empowerment approach in diabetes self-management education (DSME). 5.6 Implementing the empowerment approach in diabetes self-management support (DSMS). 5.7 Implementing the empowerment approach in diabetes care. 5.8 Costs and benefits of the empowerment approach. 5.9 Concluding thoughts. Acknowledgement. References 6. Medical Office-Based Interventions (Russell E. Glasgow). 6.1 Theoretical background. 6.2 Clinical and logistic rationale for office-based interventions. 6.3 Research findings from office-based interventions. 6.4 Target groups for inclusion/exclusion. 6.5 Assessment and clinic flow. 6.6 Links to medical management. 6.7 Unanswered questions, new directions. References 7. Psychological Group Interventions in Diabetes Care (T. Chas Skinner and Nicole van der Ven). 7.1 Psychological group interventions in medical illness. 7.2 Psychological group interventions in diabetes. 7.3 Psychological group interventions aimed at psychological problems complicating diabetes. 7.4 Psychological group interventions dealing with complications of diabetes. 7.5 Psychological group interventions dealing with hypoglycaemia. 7.6 Groups dealing with the daily demands of diabetes. 7.7 Using new technologies for groups. 7.8 Discussion and future directions. References. 8. Counselling and Psychotherapy in Diabetes Mellitus (Richard R. Rubin). 8.1 Introduction. 8.2 Diabetes-related distress. 8.3 Psychopathology. 8.4 Practice implications. References. Index.

The cost-effectiveness of different management strategies for type I diabetes: a Swiss perspective.

Abstract: Aims/hypothesis. A computer model was developed to determine the health outcomes and economic consequences of different combinations of diabetes interventions in newly diagnosed patients with Type I (insulin-dependent) diabetes in Switzerland.¶Methods. We modelled seven complications of diabetes: hypoglycaemia, ketoacidosis, acute myocardial infarction, stroke, lower extremity amputation, nephropathy, and retinopathy. Transition probabilities and costs were taken from published literature. The Swiss health insurance payer perspective was taken. Various combinations of diabetes management strategies, including intensive or conventional insulin therapy and screening and treatment strategies for renal and eye disease were defined. Life expectancy, cumulative incidences of complications, and mean expected total lifetime costs per patient were calculated under six different management strategies. Incremental cost-effectiveness ratios were calculated in terms of costs per life-year gained compared with conventional insulin therapy alone.¶Results. The addition of screening for microalbuminuria and retinopathy followed by appropriate treatment, if detected, were cost saving, with reduction in cumulative incidence of end stage renal disease and blindness respectively, and, in the case of microalbuminuria screening and treatment, an improvement in life expectancy. Intensive therapy improved life expectancy but increased total lifetime costs.¶Conclusion/interpretation. Optimal management of Type I diabetic patients, including secondary and tertiary prevention, leads to reduced complications and improved life expectancy, with the increased costs of prevention offset to varying degrees by cost savings due to complications avoided. [Diabetologia (2000) 43: 13–26]

A diabetes management program for African American women with type 2 diabetes.

Abstract: PURPOSE this paper describes a clinic and community-based diabetes intervention program designed to improve dietary, physical activity, and self-care behaviors of older African American women with type 2 diabetes. It also describes the study to evaluate this program and baseline characteristics of participants. METHODS The New Leaf... Choices for Healthy Living With Diabetes program consists of 4 clinic-based health counselor visits, a community intervention with 12 monthly phone calls from peer counselors, and 3 group sessions. A randomized, controlled trial to evaluate the effectiveness of this intervention is described. RESULTS Seventeen focus groups of African American women were used to assessed the cultural relevance/acceptability of the intervention and measurement instruments. For the randomized trial, 200 African American women with type 2 diabetes were recruited from 7 practices in central North Carolina. Mean age was 59, mean diabetes duration was 10 years, and participants were markedly overweight and physically inactive. CONCLUSIONS Participants found this program to be culturally relevant and acceptable. Its effects on diet, physical activity, and self-care behaviors will be assessed in a randomized trial.

Antioxidants in Diabetes Management

Abstract: The best ebooks about Antioxidants In Diabetes Management that you can get for free here by download this Antioxidants In Diabetes Management and save to your desktop. This ebooks is under topic such as antioxidants in diabetes management pwcgba antioxidants in diabetes management shahz antioxidants in diabetes management sgscc delivery aspects of antioxidants in diabetes management antioxidants in diabetes management oxidative stress and antioxidants in diabetes management kemara antioxidants in diabetes management oxidative stress and antioxidants in diabetes management adduha antioxidants in diabetes management voojoo antioxidants in diabetes management oxidative stress and antioxidants in diabetes management oxidative stress and antioxidants in diabetes management oxidative stress and antioxidants in diabetes management msrint antioxidants in diabetes management daizer antioxidants in diabetes management oxidative stress and antioxidants in diabetes management oxidative stress and antioxidants in diabetes management oxidative stress and phytochemicals for diabetes management bentham open antioxidants in diabetes management oxidative stress and antioxidants in diabetes management oxidative stress and antioxidants in diabetes management bagabl antioxidants in diabetes management oxidative stress and antioxidants in diabetes management saitrh antioxidants in diabetes management oxidative stress and antioxidants in the prevention and treatment of diabetic the role for vitamin and mineral supplements in diabetes oxidative stress in diabetes mellitus oatext how effective are antioxidant supplements in obesity and antioxidants in diabetes management oxidative stress and antioxidants in diabetes management ccsplc 106 2011 106-125 antioxidants in the treatment of diabetes

Using the continuous glucose monitoring system to improve the management of type 1 diabetes.

Abstract: S-43 CURRENTLY, there are over 800,000 patients with type 1 diabetes mellitus in the United States, with 30,000 new cases each year.1 Type 1 diabetes is characterized by a loss of beta cells, resulting in insulin deficiency. Therefore, longterm management of type 1 diabetes is dependent on the administration of exogenous insulin to maintain meticulous control and to minimize the development of the associated microvascular and macrovascular pathologies of diabetes, including retinopathy, neuropathy, and nephropathy. Important, too, is managing the daily insulin therapy to maintain a balance between hypoglycemia and hyperglycemia. The Diabetes Control and Complications Trial (DCCT) and other studies have clearly demonstrated the importance of self-monitoring of blood glucose (SMBG) as fundamental to maintaining intensive insulin therapy and achieving tight control.2–4 However, SMBG has its limitations. The DCCT demonstrated also that a primary drawback of intensive insulin therapy was a threefold increase in the occurrence of severe hypoglycemia despite performing four or more SMBG tests each day.2 Many patients are concerned about hypoglycemic episodes; others are often unaware of recurrent hypoglycemic events, especially those that occur during sleeping hours. Through-the-night blood glucose measurement is not practical for most patients, and the commitment of patients to daily self-monitoring varies. Further, type 1 diabetes most often emerges in children, who may not readily observe blood glucose testing and insulin administration protocols. Good glycemic control, therefore, may prove elusive, and this lack of control can be unsafe. Clinically, continuous monitoring of a patient’s blood glucose concentration may provide information to refine diabetes management and allow for adjustments in therapy that would benefit patients. Three cases are presented that demonstrate how the continuous glucose monitoring system (CGMS) can be effective in guiding management to improve glycemic control. The outcomes include reducing risk of hypoglycemic events, moderating glycemic responses to meal intake, and encouraging patient understanding of the effect of diet on blood glucose levels.

Predictors of glycemic control in children with Type 1 diabetes: The importance of race

Abstract: Diabetes is a common cause of kidney failure and blindness among young adults, particularly of African-American descent. Since glycemic control is a predictor of diabetes complications, we evaluated the impact of multiple factors including a special multidisciplinary management program on glycosylated hemoglobin in children with Type 1 diabetes. Data was collected from pediatric diabetes clinics in New Orleans, LA and Baltimore, MD. In New Orleans, hemoglobin A(1c) was higher in African-American patients 12. 5+/-3.3% (n=71) vs. 10.7+/-2.1% (n=80) in Caucasian children, p<0. 0001. Longer duration of diabetes was also associated with higher hemoglobin A(1c) in both races. The effect of race on hemoglobin A(1c) was independent of the influence of sex, insurance status, body mass index (BMI) z-score, and number of clinic visits. Covariate analysis with mean blood glucose levels indicated that higher hemoglobin A(1c) was attributable to higher mean blood glucose levels in African-American children. From the Baltimore data, a multidisciplinary intervention program led to improved total glycosylated hemoglobin for Caucasian patients but not for African-American children. Poorer glycemic control of African-American children is likely to predispose them to a higher likelihood of developing microvascular complications as they mature. Standard hospital-based multidisciplinary programming for diabetes management may have limited effectiveness in improving glycemic control of African-American children with diabetes. Innovative intervention programs are needed for these high-risk patients.

Interventions for children with diabetes and their families.

Abstract: The purpose of this review is to examine the research literature on interventions for children with type 1 diabetes and their families, with a specific focus on three types of intervention (educational and psychosocial/behavioral interventions that focus on individuals with diabetes and family interventions for families, usually parents, of individuals with diabetes). The aim of the review is to determine what interventions produce what outcomes in what populations of children and families. The review includes articles that met the following criteria: (a) empirical study reporting the impact of an intervention on such outcomes as knowledge, behavior, self-care, and metabolic control; (b) children with type 1 diabetes and/or their families as primary subjects; (c) publication between 1980 and January 1, 1999; and (d) publication in English. A total of 41 published papers were included. On the basis of this review, conclusions are as follows: (a) Educational interventions are useful in improving diabetes knowledge but not consistently helpful in improving metabolic control; (b) psychosocial interventions, especially coping skills training and peer support, assist primarily adolescents to improve adjustment and sometimes metabolic control; and (c) family interventions may be helpful in reducing parent-child conflict about diabetes management and care.

Medical Management of Diabetes Mellitus

Abstract: Overview The Burden of Diabetes Mellitus Michael M. Engelgau and Linda S. Geiss Type 1A Diabetes as an Immunological Disorder Elizabeth Stephens and George S. Eisenbarth Type 2 Diabetes: Where Have We Been, Where Are We, and Where Are We Going? Richard Eastman Standards of Care in Diabetes Nathaniel G. Clark Diabetes Self-Management Education and the Diabetes Team Christine T. Tobin Insulin Resistance William T. Cefalu Diabetes in Managed Care Ronald E. Aubert, Rishi Sikka, William H. Herman Signs, Symptoms, Diagnosis, and Diabetes Types Type 1 Diabetes Paul J. Beisswenger Type 2 Diabetes Mellitus Jack. L. Leahy Diabetes in Children Joseph I Wolfsdorf and Daniel J. Nigrin Diabetes Care in the Adolescent Nathaniel G. Clark and Paul B. Madden Diabetes in Pregnancy Karen Hugo and Lois Jovanovic Drug-Induced Disorders of Glucose Metabolism Sri Prakash L. Mokshagundam and Alan N. Peiris Secondary Forms and Genetic Syndromes of Diabetes Mellitus Shirwan A. Mirza and Jack L. Leahy Therapies Medical Nutrition Therapy in Diabetes: Clinical Guidelines for Primary Care Physicians Melinda Downie Maryniuk Exercise Therapy in Diabetes John T. Devlin Oral Pharmacological Agents Andrew J. Ahmann and Matthew C. Riddle Insulin Therapy Frank P. Kennedy Insulin Pump Therapy: A Practical Tool for Treating People with Type 1 and Insulin Requiring Type 2 Diabetes Steven V. Edelman Pancreas Transplantation Elizabeth R. Seaquist and David E.R. Sutherland Complications Benefits of Intensive Diabetes Management Bernard Zinman Diabetic Eye Disease Craig M. Greven Cardiac Disease in Diabetes Mellitus Debasish Chaudhuri and William E. Hopkins Gastrointestinal Complications of Diabetes Mellitus Bernard Coulie and Michael Camilleri Diabetic Kidney Disease Virginia L. Hood Erectile Dysfunction in Diabetes Mellitus Kenneth J. Snow and Andre Guay Peripheral Vascular Disease in Diabetes Gary W. Gibbons Management of the Diabetic Foot Geoffrey M. Habershaw Diabetic Neuropathy Peter D. Donofrio The Diagnosis and Management of Lipoprotein Disorders Ernst J. Schaefer and Leo J. Seman Hypoglycemia Patrick J. Boyle Skin Changes Associated with Diabetes John R. T. Reeves Psychosocial Complications of Diabetes Alan M. Jacobson and Katie Weinger Hypertension and Diabetes James R. Sowers and Bharat Raman Special Settings Diabetes and Aging Caroline S. Blaum and Jeffrey B. Halter Weight Management in Patients with Type 2 Diabetes Mellitus Jorge Calles Escandon Inpatient Management of Diabetes Suzanne S. P. Gebhart Perisurgical Management of the Patient with Diabetes Burrit L. Haag Nutritional Support in the Diabetic Patient M. Molly McMahon Diabetic Ketoacidosis and Hyperosmolar Coma Muriel Helene Nathan Diabetes and Polycystic Ovary Syndrome Carolyn H. Kreinsen and Andrea Dunaif Polyendocrine Syndromes K. Patrick Ober

Optimizing insulin delivery: assessment of three strategies in intensive diabetes management

Abstract: SUMMARY Objective To compare three intensive management strategies with respect to metabolic control (glycated haemoglobin, preprandial blood glucose, lipid profile, body weight, hypoglycaemic episodes) and psycho-social adaptation (quality of life, self-efficacy, stress and perceived complexity). Research Design and Methods: Fifteen adults with type 1 diabetes completed this 1-year, randomized, prospective, cross-over study. The three treatment strategies were categorized according to flexibility with insulin self-adjustments as follows: Simplified (SIMP) = meal plan based on food exchanges with no self-adjustments of insulin for food, exercise and stress; Qualitative (QUAL) = meal plan based on food exchanges with qualitative adjustment of insulin for food, exercise and stress; Quantitative (QUANT) = meal plan using carbohydrate counting with quantitative adjustment of insulin for food and qualitative adjustment for exercise and stress. All three strategies allowed for adjustments of insulin for preprandial blood glucose and the option of adjusting diet for exercise. All subjects followed each strategy for 3.5 months. Subjects kept detailed log sheets where they recorded preprandial blood glucose, insulin dosages, food intake, activity and stress level at least four times/day. The psycho-social aspects were determined with validated questionnaires that were completed before and after each strategy. Results There were no statistically significant differences in metabolic control, quality of life and self-efficacy between the three strategies. The mean (± s.e.) for HbA1 levels (normal < 8.5%) were: Baseline: 10.9 ± 0.06 and End of SIMP = 9.7 ± 0.03; QUAL = 9.5 ± 0.04; QUANT = 10.2 ± 0.04. Body weight and serum lipid levels did not change significantly. The frequency of severe hypoglycaemic episodes for the entire study was 20 episodes/100 patient-years. Perceived complexity of treatment strategy increased (p < 0.0001) from SIMP to QUANT (least to most flexible). Although the majority of subjects (n = 11) were following a strategy similar to SIMP prior to entering the study, 12 subjects chose to continue with QUAL, three with QUANT and none with SIMP at the end of the study. Conclusions These results indicate that a strategy that allows for flexibility of self-adjustments of insulin and is not very complex (such as QUAL) may be the strategy of choice for intensive management programmes.

Comparison of pregnancy mood profiles in gestational diabetes and preexisting diabetes.

Abstract: PURPOSEThis study sought to answer the following questions: How does intensified diabetes management affect the patient's mood profile? Is there a relationship between levels of glycemic control and emotional profile? Which factors distinguish the emotional profile of women with pregestational diabetes from women with newly diagnosed gestational diabetes?METHODSA secondary analysis was conducted of women with newly diagnosed gestational diabetes (GDM), pregestational diabetes (PGDM), and nondiabetic controls. Those with diabetes were treated with an intensified approach. All participants responded to a questionnaire measuring bipolar subjective mood states. The relation between diabetes types, glucose characteristics during pregnancy, and mood were analyzed.RESULTSThe mood profile was significantly associated with level of glycemic control in GDM women (comparable to controls). PGDM women were not affected by either level of glycemic control or diabetes class categories. The number of glucose determinatio...

Health outcomes in type 2 diabetes.

Abstract: Outcome evaluation is of great interest throughout the healthcare field, but which outcomes are important depends on the viewpoint one holds. For the healthcare organisation costs and resource utilisation are paramount, whereas patients may be interested in being able to work and lead a productive life without long-term complications. Healthcare policy decisions are influenced by varying degrees of social forces, existing regulations and outcome research findings. Ideally, all three are in agreement but often they may be competitive or may not even be included in policy decision making. With respect to improving outcomes, much energy has been spent on developing diabetes care guidelines. However, these have had minimal impact on physician behaviour. Soon after onset or diagnosis of diabetes, we are most concerned with process measures such as micro-albumin levels, blood pressure monitoring, routine eye and foot examinations and lipid profiles. These process measures are related to the development of intermediate outcomes--proteinuria, retinopathy, foot ulcers and dyslipidaemia. Diabetes is an expensive disease but there is accumulating evidence that improved care can lead to better quality of life and reduction in health care resource utilisation. The UKPDS demonstrated that for one percentage point decrease in HbA1c there was a 35% reduction in the risk of complications. Preliminary data from various diabetes management programmes indicate that instituting standardised care may lead to cost savings and improved health. Rationing health care resources wisely requires consideration of multiple factors including quality of life years (QALYs) and healthy year equivalents (HYEs). Formal quantitative methods are used to measure overall desirability of a medical intervention. Questions to be answered include predictability of responsiveness or adverse events to drug therapy. Outcomes research will have a key role in future development of models of diabetes care.

Exercise and diabetes control: a winning combination.

Abstract: IN BRIEF: It is becoming evident that in many individuals, diabetes of all types can be precipitated or exacerbated by inactivity. Exercise is a cornerstone in diabetes management and conveys many health benefits. Different forms of exercise can have varying effects on the blood sugar response, especially in individuals using insulin. Appropriate exercise for effective management of blood sugar levels and published clinical exercise recommendations for individuals with type 1 and type 2 diabetes include additional blood glucose monitoring, modified insulin doses, and supplemental carbohydrate intake. Physicians who treat exercising patients with diabetes should tailor programs to meet individual requirements.

Early detection of high cholesterol levels in young adults.

Abstract: With Diabetes Mellitus, Final Report. Bethesda, Md: National Institute of Diabetes and Digestive and Kidney Diseases; 1990. 20. Weiner JP, Parente ST, Garnick DW, et al. Variation in office-based quality: a claims-based profile of care provided to Medicare patients with diabetes. JAMA. 1995;273:1503-1508. 21. Beckels GL, Engelgau MM, Narayan KM, et al. Population-based assessment of the level of care among adults with diabetes in the U.S. Diabetes Care. 1998; 21:1432-1438. 22. American Diabetes Association. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care. 2000;23(suppl 1): S4-S19. 23. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2000;23(suppl 1):S32-S42. 24. National Diabetes Education Program. National Diabetes Education Program: Guiding Principles for Diabetes Care for Health Care Providers and People With Diabetes. Bethesda, Md: National Institutes of Health; 1998. NIH publication 98-4343. 25. Peterson KA, Vinicor F. Strategies to improve diabetes care delivery. J Fam Pract. 1998;47(5 suppl):S55-S62. 26. Von Korff M, Gruman J, Schaefer J, et al. Collaborative management of chronic illness. Ann Intern Med. 1997;127:1097-1102. 27. Etzwiler DD. Chronic care: a need in search of a system. Diabetes Educ. 1997; 23:569-573. 28. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed Care Q. 1996;4:12-25. 29. Marshall CL, Bluestein M, Briere E, et al. Improving outpatient diabetes management through a collaboration of six competing, capitated Medicare managed care plans. Am J Med Qual. 2000;15:65-71. 30. Aubert RE, Herman WM, Waters J, et al. Nurse case management to improve glycemic control in diabetic patients in a health maintenance organization: a randomized control trial. Ann Intern Med. 1998;129:605-612. 31. MundingerMO,KaneRL,LenzER,etal.Primarycareoutcomes inpatients treated by nurse practitioners or physicians: a randomized trial. JAMA. 2000;283:59-68. 32. Shaffer J, Wexler LF. Reducing low-density lipoprotein cholesterol levels in an ambulatory care system. Arch Intern Med. 1995;155:2330-2335.

Type 2 DIABETES MELLITUS AND EXERCISE

Abstract: Several epidemiologic and clinical studies have clearly shown that regular physical activity and exercise are important therapeutic modalities for patients with, or at risk for, diabetes. Despite our lack of understanding of the mechanisms by which exercise exerts its effects, potential benefits of a physically active lifestyle include better glycemic control via improved glucose disposal and insulin sensitivity, which leads to reduced hyperinsulinemia, and lowered need for pharmacological treatment. Exercise may also result in the prevention or control of cardiovascular disease through its effects on some of the factors associated with the metabolic syndrome, including central obesity, hypertension, low HDL, high LDL, hypertriglyceridemia and elevated free-fatty acids, and fibrinogen levels. Regular exercise will also improve functional capacity and quality of life among this patient population. Most people with diabetes, like their counterparts without diabetes, fail to meet national physical activity goals. Sedentary lifestyles have been linked to 23% of deaths from the leading chronic diseases, including heart disease and diabetes. Given the epidemic nature of diabetes in the world during the 21st century, diabetes management through physical activity should be a major therapeutic goal and public health priority. Understanding the beneficial effects of exercise, as well as the mechanisms for adopting a physically active lifestyle, is important for the management of diabetes mellitus. Despite the well-known benefits of exercise, patient education, paired with the implementation and promotion of safe habits of physical activity for individuals with diabetes, is still inadequate.

New concepts in diabetes and its treatment

Abstract: Aetiological classification, pathophysiology and diagnosis, F. Belfiore and S. Iannello insulin secretion and its pharmacological stimulation, F. Belfiore and S. Iannello insulin resistance and its relevance to treatment, F. Belfiore and S. Iannello diet and modification of nutrient absorption, S. Iannello insulin treatment in type 1 and type 2 diabetes - practical goals and algorithms, F. Belfiore and S. Iannello overview of diabetes management - "combined" treatment and therapeutic additions, F. Belfiore and S. Iannello clinical emergencies in diabetes 1 - diabetic ketoacidosis and hyperosmolar nonketotic syndrome, F. Belfiore and S. Iannello clinical emergencies in diabetes 2 - hypoglycemia, F. Belfiore and S. Iannello mechanisms of diabetic complications (nephropathy) as related to perspectives of treatment, M.E. Cooper diabetic retinopathy, T. Bek nephropathy and hypertension in diabetic patients, C.E. Mogensen lipid abnormalities and lipid lowering in diabetes, F. Belfiore and S. Iannello cardiovascular disease and diabetes, G. Zuanetti diabetic neuropathy, A.J.M. Boulton and R.A. Malik foot problems in diabetes, J.E. Shaw and A.J.M. Boulton erectile dysfunction in diabetes and its treatment, M. Tagliabue and G.M. Molinatti multifactorial intervention in type 2 diabetes mellitus, P. Gaede and O. Pedersen managing diabetes and pregnancy, J.L. Kitzmiller.

New Developments in Type 1 (Insulin-Dependent) Diabetes

Abstract: The Diabetes Control and Complications Trial has conclusively demonstrated that improved metabolic control leads to reduction in the rate of microvascular complications of diabetes. In order to allow patients to achieve improved metabolic control, much research has focused on improved methods of glucose monitoring and more physiologic ways of insulin delivery. The 2 most promising methods of minimally invasive blood glucose monitoring are the Glucowatch, using the technique of reverse iontophoresis to measure interstitial fluid glucose levels every twenty minutes and an implantable sensor, in which a catheter resembling that used for insulin delivery through a pump is impregnated with glucose oxidase at the tip. This device monitors blood sugars every few minutes, but like a holter monitor, must be downloaded in the physician's office. Still under development are (1) implantable subcutaneous sensors with a high and low blood glucose alarm and (2) sensors in which the patient will be able to download the data using a home PC. Advances in insulin delivery have included the availability of new insulin analogs which more closely simulate endogenous insulin release, with rapid acting analogs simulating the increase in insulin production that normally occurs after meals. Phase III clinical trials are in progress of a long-acting basal insulin without peak actions to simulate the low dose continuous production of the insulin which normally inhibits hepatic glucose production. In addition, use of the insulin pump has increased markedly since publication of the DCCT with the greatest increase being among adolescents. In addition to advances in treatment of diabetes, research has continued on curing the disease using islet cell transplantation and preventing the disease with agents such as insulin (DPT-1 Trial) and nicotinamide (ENDIT). This article provides an overview of recent advances in diabetes management and prevention.

Evaluating the format and effectiveness of a disease state management training program for diabetes

Abstract: The objective of this project was to determine whether a continuing educational approach to disease state management training in diabetes mellitus is an effective means of improving both cognitive knowledge and confidence levels of participants. The continuing education program utilized both lecture format and small group exercises in which participants obtained “hands-on” information related to the pharmacist’s role in the treatment of diabetes. Participants were asked to take a pre- and posttest examination which consisted of a 30-question multiple choice examination and a 15-item attitudinal questionnaire. This test-set evaluated two areas: (i) participants’ cognitive knowledge related to diabetes and diabetes-specific services; and (ii) their attitudes/confidence in providing these services. Cognitive posttest scores (68.6 percent) improved significantly (P < 0.001) over the pretest scores (49.6 percent). Likewise, the posttest scores on all 15 attitudinal items significantly improved over their pretest scores (P ≤ 0.012). This project demonstrates that a modified continuing educational format, providing small group hands-on experience, is an effective means of training pharmacists in diabetes management.

Survey of dietetic provision for patients with diabetes

Abstract: SUMMARY Aims To survey dietitians involved in diabetes care regarding the provisions for patients with diabetes. Methods A national survey of 512 dietitians known to be engaged in provision of diabetes care was conducted in 1997 and 391 (76%) responded. Results Nationally the median provision of dietetic care for diabetes reported was 10.7 h per 100 000 general population per week, but the provision was uneven ranging from 2.0 to 27.6 h per 100 000. Eighty-five per cent of dietitians worked in areas where the provision was less than 22 h per 100 000 general population per week (the current recommended minimum standard). Dietetic provision was greater in secondary care (median 9.1 h per 100 000 general population per week) than in general practice, residential homes and other locations (median 4.4 h per 100 000 general population per week). Provision was greater in those areas in which a designated dietitian had responsibility for co-ordinating the dietetic service for diabetes than in areas where the co-ordinator was not a dietitian or where there was no co-ordinator. Over 90% of dietitians reported following British Diabetic Association (BDA) recommendations regarding advice on carbohydrate, sugar, fat and fibre consumption, but only one-third routinely advised on salt restriction. Of the 17% of dietitians who continue to use carbohydrate exchanges, all combine this method with other approaches. Of the recommendations made by the Clinical Standards Group, only 69% of dietitians reported seeing more than half of newly diagnosd adult patients within four weeks, and less than 50% reported offering half or more of their patients an annual review. Amongst the literature in current use, 98% of dietitians use BDA literature for teaching patients and 90% use BDA publications in their own education. Seventy-six per cent of dietitians believed that there was a role for commercial slimming organizations in weight management of people with diabetes Conclusions Given the proven value of dietetic input in diabetes management, there would be advantages to correcting the regional inequalities in dietetic provision for diabetes care in the UK.

Reemergence of insulin pump therapy in the 1990s.

Abstract: The publication of the landmark Diabetes Control and Complications Trial results in 1993 provided a strong impetus to achieve near-normalization of blood glucose levels in type I diabetic patients using intensive insulin therapy programs. Recent studies show less hypoglycemia with this form of intensive therapy and equivalent or improved glycemic control. Insulin pump therapy is achieving wider acceptance and application in diabetes management. This commentary reviews the current status of insulin pump therapy, including indications and future directions.

An integrative literature review of cardiac risk factor management in diabetes education interventions.

Abstract: PURPOSEthe purposes of this paper are to (1) review the literature on educational interventions for adults with type 2 diabetes; (2) determine what kinds of interventions have been studied; (3) identify which interventions have included cardiac risk factor management; (4) determine how effective these interventions have been on metabolic control, diabetes-related outcomes, and cardiovascular-related outcomes; and (5) make recommendations for further research on combined interventions designed to promote optimal diabetes and cardiac risk factor management in adults with type 2 diabetes.METHODSUsing an integrative literature review approach, 64 studies on diabetes education interventions for adults with diabetes published between 1987 and 1998 were reviewed; 44 met these criteria.RESULTSFew studies included cardiac risk factor management, which should be an integral part of diabetes management. Most studies demonstrated a beneficial effect of education on the management of type 2 diabetes but not cardiovasc...