Showing papers on "Diabetes management published in 2009"

Low glycaemic index, or low glycaemic load, diets for diabetes mellitus

Abstract: Background The aim of diabetes management is to normalise blood glucose levels, since improved blood glucose control is associated with reduction in development, and progression, of complications. Nutritional factors affect blood glucose levels, however there is currently no universal approach to the optimal dietary treatment for diabetes. There is controversy about how useful the glycaemic index (GI) is in diabetic meal planning. Improved glycaemic control through diet could minimise medications, lessen risk of diabetic complications, improve quality of life and increase life expectancy. Objectives To assess the effects of low glycaemic index, or low glycaemic load, diets on glycaemic control in people with diabetes. Search methods We performed electronic searches of The Cochrane Library, MEDLINE, EMBASE and CINAHL with no language restriction. Selection criteria We assessed randomised controlled trials of four weeks or longer that compared a low glycaemic index, or low glycaemic load, diet with a higher glycaemic index, or load, or other diet for people with either type 1 or 2 diabetes mellitus, whose diabetes was not already optimally controlled. Data collection and analysis Two reviewers independently extracted data on study population, intervention and outcomes for each included study, using standardised data extraction forms. Main results Eleven relevant randomised controlled trials involving 402 participants were identified. There was a significant decrease in the glycated haemoglobin A1c (HbA1c) parallel group of trials, the weighted mean difference (WMD) was -0.5% with a 95% confidence interval (CI) of - 0.9 to -0.1, P = 0.02; and in the cross-over group of trials the WMD was -0.5% with a 95% CI of -1.0 to -0.1, P = 0.03. Episodes of hypoglycaemia were significantly fewer with low compared to high GI diet in one trial (difference of -0.8 episodes per patient per month, P < 0.01), and proportion of participants reporting more than 15 hyperglycaemic episodes per month was lower for low-GI diet compared to measured carbohydrate exchange diet in another study (35% versus 66%, P = 0.006). No study reported on mortality, morbidity or costs. Authors' conclusions A low-GI diet can improve glycaemic control in diabetes without compromising hypoglycaemic events.

Association Between Adherence and Glycemic Control in Pediatric Type 1 Diabetes: A Meta-analysis

Abstract: CONTEXT: Although adherence has been identified in practice guidelines for youth with type 1 diabetes to promote optimal glycemic control, there has been no systematic integration of studies investigating the adherence-glycemic control link. This recommendation partly stemmed from the Diabetes Control and Complications Trial (DCCT); however, this trial did not comprehensively measure adherence and had only 195 adolescents. OBJECTIVE: Our goal was to determine the magnitude of the adherence-glycemic control link in pediatric type 1 diabetes and evaluate its correlates. METHODS: Our data sources were PubMed (1950–2008), Scopus (1950–2008), and references from reviews in pediatric type 1 diabetes. Studies that included youth under age 19 with type 1 diabetes and a reported association between adherence and glycemic control were eligible for inclusion. Articles were not included if they contained youth with type 2 diabetes, had study samples that overlapped with other studies, or the results came from intervention studies. Of the eligible 26 studies, 21 had sufficient statistical data. Two authors independently extracted information by using a standardized protocol. Agreement between coders was high. RESULTS: The mean effect size across 21 studies, including 2492 youth with type 1 diabetes, was −0.28 (95% confidence interval: −0.32 to −0.24). As adherence increases, A1c values decrease. No sample or disease characteristics were correlates of the adherence-glycemic control link. Pre-DCCT studies had a mean effect size of −0.32 (8 studies; 1169 participants) compared with −0.25 in post-DCCT studies (13 studies; 1323 participants). CONCLUSIONS: This meta-analysis supports the adherence-glycemic control link in pediatric type 1 diabetes. The weaker post-DCCT association suggests that the approach to intensive diabetes management has shortcomings. We conclude that this is because of a mismatch between what scientists and clinicians know is the best way to manage pediatric type 1 diabetes and the capabilities of youth and their families.

Predictors of adherence to diabetes medications: the role of disease and medication beliefs.

Abstract: Despite the effectiveness of drug therapy in diabetes management high rates of poor adherence persist. The purpose of this study was to identify potentially modifiable patient disease and medication beliefs associated with poor medication adherence among people with diabetes. A cohort of patients with diabetes was recruited from an urban primary-care clinic in New York City. Patients were interviewed in English or Spanish about: disease beliefs, medication beliefs, regimen complexity, diabetes knowledge, depression, self-efficacy, and medication adherence (Morisky scale). Logistic regression was used to identify multivariate predictors of poor medication adherence (Morisky > 1). Patients (n = 151) had diabetes for an average of 13 years with a mean HgA1C of 7.6 (SD 1.7). One-in-four (28%) were poor adherers to their diabetes medicines. In multivariate analyses, predictors of poor medication adherence were: believing you have diabetes only when your sugar is high (OR = 7.4;2-27.2), saying there was no need to take medicine when the glucose was normal (OR = 3.5;0.9-13.7), worrying about side-effects of diabetes medicines (OR = 3.3;1.3-8.7), lack of self-confidence in controlling diabetes (OR = 2.8;1.1-7.1), and feeling medicines are hard to take (OR = 14.0;4.4-44.6). Disease and medication beliefs inconsistent with a chronic disease model of diabetes were significant predictors of poor medication adherence. These suboptimal beliefs are potentially modifiable and are logical targets for educational interventions to improve diabetes self-management.

A Tale of Two Compartments: Interstitial Versus Blood Glucose Monitoring

Abstract: Self-monitoring of blood glucose was described as one of the most important advancements in diabetes management since the invention of insulin in 1920. Recent advances in glucose sensor technology for measuring interstitial glucose concentrations have challenged the dominance of glucose meters in diabetes management, while raising questions about the relationships between interstitial and blood glucose levels. This article will review the differences between interstitial and blood glucose and some of the challenges in measuring interstitial glucose levels accurately.

Multifaceted Determinants for Achieving Glycemic Control: The International Diabetes Management Practice Study (IDMPS)

Abstract: OBJECTIVE—The International Diabetes Mellitus Practice Study is a 5-year survey documenting changes in diabetes treatment practice in developing regions. RESEARCH DESIGN AND METHODS—Logistic regression analysis was used to identify factors for achieving A1C <7% in 11,799 patients (1,898 type 1 diabetic and 9,901 type 2 diabetic) recruited by 937 physicians from 17 countries in Eastern Europe (n = 3,519), Asia (n = 5,888), Latin America (n = 2,116), and Africa (n = 276). RESULTS—Twenty-two percent of type 1 diabetic and 36% of type 2 diabetic patients never had A1C measurements. In those with values for A1C, blood pressure, and LDL cholesterol, 7.5% of type 1 diabetic (n = 696) and 3.6% of type 2 diabetic (n = 3,896) patients attained all three recommended targets (blood pressure <130/80 mmHg, LDL cholesterol <100 mg/dl, and A1C <7%). Self-monitoring of blood glucose was the only predictor for achieving the A1C goal in type 1 diabetes (odds ratios: Asia 2.24, Latin America 3.55, and Eastern Europe 2.42). In type 2 diabetes, short disease duration (Asia 0.97, Latin America 0.97, and Eastern Europe 0.82) and treatment with few oral glucose–lowering drugs (Asia 0.64, Latin America 0.76, and Eastern Europe 0.62) were predictors. Other region-specific factors included lack of microvascular complications and old age in Latin America and Asia; health insurance coverage and specialist care in Latin America; lack of obesity and self-adjustment of insulin dosages in Asia; and training by a diabetes educator, self-monitoring of blood glucose in patients who self-adjusted insulin, and lack of macrovascular complications in Eastern Europe. CONCLUSIONS—In developing countries, factors pertinent to patients, doctors, and health care systems all impact on glycemic control.

The importance of health belief models in determining self-care behaviour in diabetes.

Abstract: Patients' self-care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self-care is often suboptimal. The degree to which patients follow advice as regards the various self-care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self-Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self-care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients' contribution to diabetes self-management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self-care behaviour in diabetes.

Home telehealth for diabetes management: a systematic review and meta-analysis

Abstract: Aim: It is estimated that more than 180 million people worldwide have diabetes. Health-care providers can remotely deliver health services to this patient population using information and communication technology, also known as home telehealth. Home telehealth may be classified into two subtypes: home telemonitoring (HTM) and telephone support (TS). The research objective was to systematically review the literature and perform meta-analyses to assess the potential benefits of home telehealth compared with usual care (UC) for patients with diabetes. Methods: An electronic literature search was conducted to identify studies on home telehealth and patients with diabetes that were published between 1998 and 2008 using Medline, Medline In-Process & Other Non-Indexed Citations, BIOSIS Previews and EMBASE. Results: Twenty-six studies (n = 5069 patients) on home telehealth for diabetes were selected. Twenty-one studies evaluated HTM and 5 randomized controlled trials assessed TS. HTM had a positive effect on glycaemic control [as measured by lower glycated haemoglobin level] compared with UC (weighted mean difference =−0.21; 95% confidence interval −0.35 to −0.08), but the results were mixed for TS. Study results indicated that home telehealth helps to reduce the number of patients hospitalized, hospitalizations and bed days of care. Home telehealth was similar or favourable to UC across studies for quality-of-life and patient satisfaction outcomes. Conclusions: In general, home telehealth had a positive impact on the use of numerous health services and glycaemic control. More studies of higher methodological quality are required to give more precise insights into the potential clinical effectiveness of home telehealth interventions.

Psychological insulin resistance: patient beliefs and implications for diabetes management

Abstract: Purpose To define and understand patient psychological insulin resistance (PIR) and its impact on diabetes management.

Exploration of the Relationship Between Household Food Insecurity and Diabetes in Canada

Abstract: Objective: To determine the household food insecurity (HFI) prevalence in Canadians with diabetes and its relationship with diabetes management, self-care practices and health status. Research Design and Methods: We analyzed data from Canadians with diabetes aged 12 and older (N=6,237) from cycle 3.1 of the Canadian Community Health Survey, a population-based cross-sectional survey conducted in 2005. The HFI prevalence in Canadians with diabetes was compared to those without diabetes. The relationships between HFI and management services, self-care practices, and health status were examined for Ontarians with diabetes (N=2,523). Results: Household food insecurity was more prevalent amongst people with diabetes [9.3% (8.2-10.4)] than amongst those without [6.8% (6.5-7.0)] and was not associated with diabetes management services, but was associated with physical inactivity [OR,1.54 (1.10-2.17)], lower fruit and vegetable consumption [OR,0.52 (0.33-0.81)], current smoking [OR,1.71 (1.09–2.69)], unmet healthcare needs [OR,2.71 (1.74–4.23)], having been an overnight patient [OR,2.08 (1.43–3.04)], having a mood disorder [OR,2.18 (1.54–3.08)], suffered effects of a stroke [OR,2.39 (1.32–4.32)], lower satisfaction with life [OR,0.28 (0.18–0.43)], self-rated general [OR,0.37 (0.21–0.66)], and mental [OR,0.17 (0.10–0.29)] health, and higher self-perceived stress [OR,2.04 (1.30–3.20)]. The odds of HFI were higher for someone diagnosed with diabetes younger than forty years of age [OR, 3.08 (1.96-4.84)]. Conclusions: Household food insecurity prevalence is higher amongst Canadians with diabetes, and is associated with increased likelihood of unhealthy behaviours, psychological distress, and poorer physical health.

Improving Diabetes Care and Health Measures Among Hispanics Using Community Health Workers: Results From a Randomized Controlled Trial

Abstract: The increasing prevalence of diabetes and obesity, growing health disparities, and shortage of bilingual and culturally trained health care professionals underscore the role of trained community health workers (CHWs) to provide economically sustainable and culturally relevant services. This prospective randomized design evaluated the relative effectiveness of a CHW intervention among Hispanic persons with newly diagnosed type 2 diabetes, as compared with usual clinic practice in three inner-city health centers. In sum, 189 Hispanic patients newly diagnosed with type 2 diabetes were randomly assigned to one of three 6-month diabetes management approaches--CHW, case management, and standard provider care--and assessed for diabetes-related health measures and clinical indicators at baseline and postintervention. Participants in the CHW group achieved greater improvements than did the controls in program measures: health status, emergency department utilization, dietary habits, physical activity, and medication adherence. They also had 2.9 times greater odds of decreasing body mass index.

Impact of a Natural Disaster on Diabetes: Exacerbation of disparities and long-term consequences

Abstract: OBJECTIVE To examine the impact of Hurricane Katrina on the health of individuals with diabetes. RESEARCH DESIGN AND METHODS This was an observational study in 1,795 adults with an A1C measurement 6 months before and 6−16 months after Hurricane Katrina in three health care systems: private (Tulane University Hospital and Clinic [TUHC]), state (Medical Center of Louisiana at New Orleans [MCLNO]), and Veterans Affairs (VA). Glycemic control (A1C), blood pressure, and lipids before the hurricane were compared with the patients9 first measurement thereafter. The CORE Diabetes Model was used to project life expectancy and health economic impact. RESULTS Mean predisaster A1C levels differed between MCLNO and VA patients (mean 7.7 vs. 7.3%, P P P P = 0.008). Mean LDL cholesterol increased in the VA (97.1–104.3 mg/dl) and TUHC patients (103.4–115.5; P CONCLUSIONS A major disaster had a significant effect on diabetes management and exacerbated existing disparities. These effects may have a lasting impact on both health and economic implications.

Chronic sorrow in parents of children with type 1 diabetes

Abstract: Title. Chronic sorrow in parents of children with type 1 diabetes. Aim. This paper reports on a study exploring parents’ longer-term experiences of having a child with type 1 diabetes. Background. Parents of children with type 1 diabetes may experience a grief reaction at diagnosis similar to that normally associated with bereavement, but little is known about their long-term emotional adaptation. Chronic sorrow, a sustained but intermittent grief reaction, is identified in adults with diabetes but has not previously been explored in relation to parents. Methodology. In-depth interviews were conducted in 2007 with a convenience sample of 17 parents of children with type 1 diabetes 7–10 years after diagnosis. Data were explored within a theoretical framework of grief, loss, adaptation, and change. Findings. Parents had adapted to the needs of diabetes management but most had not ‘come to terms’ with the diagnosis. They experienced a resurgence of grief at critical times during their child’s development and some, particularly mothers, became upset during their interviews, even though these took place 7–10 years after their child’s diagnosis. Mothers elaborated more on their emotions than fathers, but continuing feelings associated with grief, such as anger and guilt, were expressed by both fathers and mothers. Conclusion. Greater understanding of parents’ long-term emotional responses and recognition that grief may never resolve in these parents may enable healthcare professionals to provide appropriate and timely support at critical times.

Evaluation of a hypertension medication therapy management program in patients with diabetes

Abstract: Objective To evaluate the effect of a 9-month community pharmacy–based medication therapy management (MTM) program on quality of care in patients with diabetes and hypertension. Design Randomized controlled trial. Setting Tulsa, OK, between November 2005 and July 2007. Patients 52 patients with diabetes and hypertension who were enrolled in a managed care organization. Intervention During monthly visits, intervention group participants received MTM services for hypertension and diabetes management. Main outcome measures Systolic blood pressure (SBP), percentage at goal blood pressure ( Results The mean intervention group SBP decreased 17.32mm Hg, whereas the mean control group SBP level increased 2.73mm Hg ( P = 0.003). The percentage of patients at goal blood pressure increased from 16.0% to 48.0% in the intervention group and decreased from 20.0% to 6.67% in the control group. Intervention group participants were 12.92 times more likely than control group participants to achieve goal blood pressure ( P = 0.021). Although the mean adherence rate in the intervention group increased 7.0% while remaining fairly constant in the control group (−0.7%), this group difference was not statistically significant. Conclusion A community pharmacy–based hypertension MTM program was effective in improving blood pressure control among managed care enrollees with diabetes and hypertension. Community pharmacists are strategically positioned to provide MTM services and effectively communicate with providers to improve quality of care for patients.

A low-fat vegan diet elicits greater macronutrient changes, but is comparable in adherence and acceptability, compared with a more conventional diabetes diet among individuals with type 2 diabetes.

Abstract: Background Although therapeutic diets are critical to diabetes management, their acceptability to patients is largely unstudied. Objective To quantify adherence and acceptability for two types of diets for diabetes. Design Controlled trial conducted between 2004 and 2006. Subjects/setting Individuals with type 2 diabetes (n=99) at a community-based research facility. Participants were randomly assigned to a diet following 2003 American Diabetes Association guidelines or a low-fat, vegan diet for 74 weeks. Main outcome measures Attrition, adherence, dietary behavior, diet acceptability, and cravings. Statistical analyses For nutrient intake and questionnaire scores, t tests determined between-group differences. For diet-acceptability measures, the related samples Wilcoxon sum rank test assessed within-group changes; the independent samples Mann-Whitney U test compared the diet groups. Changes in reported symptoms among the groups was compared using χ 2 for independent samples. Results All participants completed the initial 22 weeks; 90% (45/50) of American Diabetes Association guidelines diet group and 86% (42/49) of the vegan diet group participants completed 74 weeks. Fat and cholesterol intake fell more and carbohydrate and fiber intake increased more in the vegan group. At 22 weeks, group-specific diet adherence criteria were met by 44% (22/50) of members of the American Diabetes Association diet group and 67% (33/49) of vegan-group participants ( P =0.019); the American Diabetes Association guidelines diet group reported a greater increase in dietary restraint; this difference was not significant at 74 weeks. Both groups reported reduced hunger and reduced disinhibition. Questionnaire responses rated both diets as satisfactory, with no significant differences between groups, except for ease of preparation, for which the 22-week ratings marginally favored the American Diabetes Association guideline group. Cravings for fatty foods diminished more in the vegan group at 22 weeks, with no significant difference at 74 weeks. Conclusions Despite its greater influence on macronutrient intake, a low-fat, vegan diet has an acceptability similar to that of a more conventional diabetes diet. Acceptability appears to be no barrier to its use in medical nutrition therapy.

Cultural and Family Challenges to Managing Type 2 Diabetes In Immigrant Chinese Americans

Abstract: OBJECTIVE Although Asians demonstrate elevated levels of type 2 diabetes, little attention has been directed to their unique cultural beliefs and practices regarding diabetes. We describe cultural and family challenges to illness management in foreign-born Chinese American patients with type 2 diabetes and their spouses. RESEARCH DESIGN AND METHODS This was an interpretive comparative interview study with 20 foreign-born Chinese American couples ( n = 40) living with type 2 diabetes. Multiple (six to seven) semistructured interviews with each couple in individual, group, and couple settings elicited beliefs about diabetes and narratives of care within the family and community. Interpretive narrative and thematic analysis were completed. A separate respondent group of 19 patients and spouses who met the inclusion criteria reviewed and confirmed the themes developed from the initial couples. RESULTS Cultural and family challenges to diabetes management within foreign-born Chinese American families included how 1 ) diabetes symptoms challenged family harmony, 2 ) dietary prescriptions challenged food beliefs and practices, and 3 ) disease management requirements challenged established family role responsibilities. CONCLUSIONS Culturally nuanced care with immigrant Chinese Americans requires attentiveness to the social context of disease management. Patients' and families' disease management decisions are seldom made independent of their concerns for family well-being, family face, and the reciprocal responsibilities required by varied family roles. Framing disease recommendations to include cultural concerns for balance and significant food rituals are warranted.

Exercise and glucose metabolism in persons with diabetes mellitus: perspectives on the role for continuous glucose monitoring.

Abstract: Exercise causes profound changes in glucose homeostasis. For people with type 1 diabetes, aerobic exercise usually causes blood glucose concentration to drop rapidly, while anaerobic exercise may cause it to rise, thereby making glycemic control challenging. Having the capacity to know their glucose levels and the direction of change during exercise increases self-efficacy in these persons who are prone to hypo- and hyperglycemia. For people with type 2 diabetes, learning first hand that regular exercise improves glucose levels may be a motivating factor in getting them to be more active. Continuous glucose monitoring is a potentially useful adjunct to diabetes management for the active person with either forms of diabetes. This review aims to guide the reader to use this technology to its maximum advantage by providing an overview of technical features, performance characteristics, and clinical utility, all balanced against the limitations that may be more prominent during physical activity.

Living with type 1 diabetes: perceptions of children and their parents

Abstract: Aim. To explore and describe the experiences of children and their parents living with type 1 diabetes mellitus from diagnosis onwards. Background. Type 1 diabetes mellitus is a psychologically and behaviourally demanding chronic condition that necessitates children and their parents taking extensive responsibility for managing the condition. Diabetes management involves maintaining a highly effective level of treatment to reduce the risks of short- and long-term complications. Treatment is carried out in the context of daily life, but little research evidence is available about this experience. Design. A phenomenological study using conversational interview. Method. A purposive sample of 10 children, (aged 4–17) living with type 1 diabetes mellitus and their parents participated in this study. Participants were from different ethnic backgrounds and at differing lengths of time since diagnosis. Data were generated through conversational interviews and analysed using thematic analysis. Results. The central theme that was identified was ‘normal’. This was underpinned by four subthemes: transition, attachment, loss and meaning. The notion of ‘normal’ is dominant in the lives of these children and their parents because diabetes not only makes these families different, but also makes their pursuit of ‘normal’ more visible. Conclusion. These findings highlight that, despite different cultures, ages and lengths of time since diagnosis, families living with diabetes share very similar experiences. Understanding how children and parents create meaning and how this meaning influences their actual and potential health problems, is important if the provision of healthcare is to be effective in meeting their needs. Relevance to clinical practice. Conducting child- and parent-centred qualitative research allows exploration of the perceptions and understanding of type 1 diabetes mellitus and the meaning ascribed by children and their parents who live with the condition. Diabetes is a lifelong, life-threatening condition that has a significant impact on children’s and parents’ lives. Developing a deeper understanding of their lives and experiences will enable the delivery of nursing care to meet their specific needs.

An Assessment of Attitudes, Behaviors, and Outcomes of Patients with Type 2 Diabetes

Abstract: Objectives: Patient self-care behaviors, including taking medication, following a meal plan, exercising regularly, and testing blood glucose, influence diabetes control. The purpose of this research was to identify (1) which barriers to diabetes management are associated with problem behaviors and (2) which patient behaviors and barriers are associated with diabetes control. Methods: This was a cross-sectional study of linked medical record and self-reported information from patients with type 2 diabetes. A randomly selected sample of 800 clinic patients was mailed an investigator-developed survey. The study sample consisted of 253 (55%) individuals who had measured glycosylated hemoglobin (HbA1c) within 3 months of the survey date. Results: The barriers to each diabetes self-care behavior differed. Cost was the most common barrier to the 4 self-care behaviors. In a multivariable regression model, the belief that type 2 diabetes is a serious problem and depression were strongly associated with higher HbA1c levels. Lower HbA1c levels were significantly associated with being married and greater self-reported adherence-satisfaction with taking medication and testing blood glucose. Conclusion: This study expanded earlier research by focusing on 4 specific self-care behaviors, their barriers, and their association with HbA1c. Barriers that were significantly associated with HbA1c were specific to the behavior and varied across behaviors.

The role of peer support in diabetes care and self-management.

Abstract: In light of the growing prevalence and healthcare costs of diabetes mellitus, it is critically important for healthcare providers to improve the efficiency and effectiveness of their diabetes care. A key element of effective disease management for diabetes is support for patient self-management. Barriers to care exist for both patients and healthcare systems. As a result, many people with diabetes do not get the care and support needed to successfully manage their diabetes. Disease management approaches that incorporate peer support may be a promising way to help provide self-management support to patients with diabetes. Trained peers provide emotional support, instrumental (tangible or material) support, education, and skills training to those they serve, and outreach and care coordination for provider systems. They play a unique role that complements and supports clinical care. To describe how peers are currently supporting diabetes care, a number of databases were searched for studies describing the roles of peers using relevant key words. This paper reviews current literature that describes the roles and duties of peers in interventions to improve diabetes care, with a focus on their contributions to six essential elements of self-management support: (i) access to regular, high-quality clinical care; (ii) an individualized approach to assessment and treatment; (iii) patient-centered collaborative goal setting; (iv) education and skills training; (v) ongoing follow-up and support; and (vi) linkages to community resources. Peers worked under a variety of titles, which did not define their duties. The scope of their work ranged from assisting health professionals to playing a central role in care. Providing education and follow-up support were the two most common roles. In all but one study, these roles were carried out during face-to-face contact, most frequently in community sites. A growing body of literature supports the value of peer models for diabetes management. Additional research can answer remaining questions related to such issues as cost effectiveness, sustainability, integration of peers into health and social service delivery systems, and recruitment, training, and support of peers. Continuing to develop and evaluate innovative models for more effectively mobilizing and integrating peers into diabetes care has great potential for improving diabetes outcomes worldwide.

Can we really close the loop and how soon? Accelerating the availability of an artificial pancreas: a roadmap to better diabetes outcomes.

Abstract: Development of a closed-loop artificial pancreas has been a long-time goal that could transform diabetes management. The primary limitation until recent years was the lack of a robust and portable continuous glucose sensor. There has been significant progress over the past 5 years in the development and commercialization of continuous glucose monitoring (CGM) devices. Used adjunctively, CGM has been demonstrated to add significant value in improving diabetes management by increasing time spent in glycemic targets and improving overall glycemic control. However, these benefits are limited by the human user's finite capacity to respond to the data provided by the device. By automating even a portion of the insulin delivery functionality of combined sensor/pump systems via computer algorithm, impending excursions could be handled more quickly and effectively. This review will describe very promising preliminary closed-loop studies, describe a potential roadmap to an artificial pancreas that will be safe and effective, and propose a solution-a hypo- and hyperglycemia minimizing control-to-range approach-that may allow for near-term delivery of a semiautomated system to people with diabetes.

The Impact of Weight Gain on Motivation, Compliance, and Metabolic Control in Patients with Type 2 Diabetes Mellitus

Abstract: Patients with type 2 diabetes, approximately 85% of whom are overweight or obese, often have an increased incidence of cardiovascular disease (CVD) risk factors such as hypertension and dyslipidemia Both type 2 diabetes and obesity are independent risk factors for CVD Unfortunately, many therapies aimed at maintaining and improving glucose control are associated with weight gain Among the older antidiabetes agents, most, including the insulin secretagogues and sensitizers, can lead to weight gain, except for metformin, which is weight-neutral Among the newer agents, the dipeptidyl peptidase-4 inhibitors generally are weight-neutral in addition to lowering glucose, while the glucagon-like peptide-1 receptor agonists lead to weight reduction Patients with type 2 diabetes are at an increased risk for both diabetes- and CV-related outcomes, and weight reduction is an important component of diabetes management Weight gain in patients with type 2 diabetes can contribute to patient frustration and may negatively impact their compliance to therapeutic regimens The selection of antidiabetes agents that not only improve glucose control but reduce or have a neutral effect on weight with beneficial effects on lipids are ideal options for managing patients with type 2 diabetes

Challenges in diabetes management with particular reference to India

Abstract: Diabetes was estimated to be responsible for 109 thousand deaths, 1157 thousand years of life lost and for 2263 thousand disability adjusted life years (DALYs) in India during 2004. However, health systems have not matured to manage diabetes effectively. The limited studies available on diabetes care in India indicate that 50 to 60% of diabetic patients do not achieve the glycemic target of HbA1c below 7%. Awareness about and understanding of the disease is less than satisfactory among patients, leading to delayed recognition of complications. The cost of treatment, need for lifelong medication, coupled with limited availability of anti-diabetic medications in the public sector and cost in the private sector are important issues for treatment compliance. This article attempts to highlight the current constraints in the health system to effectively manage diabetes and the need for developing workable strategies for ensuring timely and appropriate management with extensive linkage and support for enhancing the availability of trained manpower, investigational facilities and drugs.

Are Current Psychometric Tools suitable for Measuring Outcomes of Diabetes Education

Abstract: Aims To critically appraise the suitability, validity, reliability, feasibility and sensitivity to change of available psychometric tools for measuring the education outcomes identified in the (Australian) National Consensus on Outcomes and Indicators for Diabetes Patient Education. Methods Potentially suitable psychometric measurement tools were identified through a two-step process. Step 1: a structured semi-systematic literature review and consultation with experts; step 2: development of inclusion criteria and a formal, purpose designed, systematically derived Appraisal Checklist—from the literature and with expert psychometric advice—to critically appraise the identified tools for relevance, validity, reliability, responsiveness to change, burden, feasibility and acceptability. Results Searching Medline, PubMed, PsycINFO and Cinhal yielded 37 diabetes-specific and generic measurement tools. Eleven of these did not address the research questions, leaving 26 tools. Of these, 11 assessed indicators of psychological adjustment; seven assessed various domains of self-determination; five measured self-management behaviours, for example, foot care, blood glucose testing and lifestyle domains; and three measured diabetes knowledge und understanding, respectively. When the Appraisal Checklist was applied, only three tools met all criteria, namely the Problem Areas in Diabetes (PAID) scale, the Summary of Diabetes Self-Care Activities (SDSCA) scale and the Appraisal of Diabetes Scale (ADS). However, a number of other suitable tools [i.e. the Diabetes Integration Scale (ATT19), the Diabetes Health Profile (DHP-1⁄18), the Self-Care Inventory-Revised (SCI-R), the Diabetes Management Self Efficacy Scale Australian/English version (DMSES-A⁄E), the Diabetes Empowerment Scale–Short Form (DES-SF)] met all except one criteria, that is, either no formal test–retest or no responsiveness to change data. Conclusions Although numerous tools were identified, few met rigorous psychometric appraisal criteria. Issues of suitability, adequate psychometric testing for the intended purpose, burden and feasibility need to be considered before adopting tools for measuring diabetes education outcomes.

Factors related to patient adherence to antidiabetic drug therapy

Abstract: The objective of the present study was to assess patient adherence to antidiabetic drug therapy and its association with factors related to the patient, patient-provider relationship, therapeutic regimen and the disease itself. The study comprised 46 diabetic patients enrolled in a research and extension education center in the State of Sao Paulo, southeastern Brazil, in 2007. Data was collected through interviews using a questionnaire and the Treatment Adherence Measure (TAM). The patient adherence level to antidiabetic drug therapy was 78.3%. In conclusion, since prevalence of adherence is below that recommended in the literature, and in the light of poor blood glucose control and alleged failure of therapeutic regimen, health providers are urged to measure diabetic patient treatment adherence, because it is key to adequate diabetes management with drugs.

Stress among fathers of young children with type 1 diabetes.

Abstract: Although fathers’ stress has been shown to have important implications for children’s health and well-being, few studies of children with type 1 diabetes have considered paternal parenting stress. The current study contributes to the literature by exploring correlates of fathers’ pediatric parenting stress in a sample of young children with type 1 diabetes. Forty-three fathers of children 2–6 years old with type 1 diabetes completed self-report questionnaires examining pediatric parenting stress, child behavior, participation in diabetes management tasks, and parental psychological resources. Results of multiple regression show that fathers’ pediatric parenting stress is positively associated with state anxiety and mother-reported difficult child behavior. These findings suggest that fathers may experience parenting stress differently than mothers, and that their experiences may have implications not only for their own level of anxiety, but also for their children’s behavior.

Effectiveness of IT-based diabetes management interventions: a review of the literature.

Abstract: Information technology (IT) is increasingly being used in general practice to manage health care including type 2 diabetes. However, there is conflicting evidence about whether IT improves diabetes outcomes. This review of the literature about IT-based diabetes management interventions explores whether methodological issues such as sample characteristics, outcome measures, and mechanisms causing change in the outcome measures could explain some of the inconsistent findings evident in IT-based diabetes management studies. Databases were searched using terms related to IT and diabetes management. Articles eligible for review evaluated an IT-based diabetes management intervention in general practice and were published between 1999 and 2009 inclusive in English. Studies that did not include outcome measures were excluded. Four hundred and twenty-five articles were identified, sixteen met the inclusion criteria: eleven GP focussed and five patient focused interventions were evaluated. Nine were RCTs, five non-randomised control trials, and two single-sample before and after designs. Important sample characteristics such as diabetes type, familiarity with IT, and baseline diabetes knowledge were not addressed in any of the studies reviewed. All studies used HbA1c as a primary outcome measure, and nine reported a significant improvement in mean HbA1c over the study period; only two studies reported the HbA1c assay method. Five studies measured diabetes medications and two measured psychological outcomes. Patient lifestyle variables were not included in any of the studies reviewed. IT was the intervention method considered to effect changes in the outcome measures. Only two studies mentioned alternative possible causal mechanisms. Several limitations could affect the outcomes of IT-based diabetes management interventions to an unknown degree. These limitations make it difficult to attribute changes solely to such interventions.