Factors influence self-care behavior and diabetic management in patients with diabetes mellitus

At present, close to 5 million people in the UK (7.7% of the population) have a diagnosis of type-1 or type-2 diabetes mellitus and this number has doubled in the last 10 years; in addition, a further 20% of the UK population is at risk of type-2 diabetes 1, 2. Within the surgical population, it is estimated that 15% of patients have diabetes mellitus 3. Due to the rising prevalence of obesity and ageing of the population, diabetes will affect a growing proportion of the UK population in the future, and an increasing number of surgical patients will be affected by this metabolic state which is associated with significant adverse outcomes. Not only do patients with type-1 and type-2 diabetes see their life expectancy reduced by 20 years and 10 years, respectively 2, but they also have increased postoperative mortality primarily due to an increased incidence of complications, such as infection, acute myocardial infarction and acute renal failure 4. A large retrospective study involving > 44,000 patients scheduled for bariatric surgery showed that the presence of diabetes mellitus was associated with increased 30-day postoperative mortality (OR (95%CI) 2.58 (1.44–4.62) and 4.96 (2.74-8.97) for those treated with oral hypoglycaemic agents and insulin, respectively 5. More specifically, other authors have demonstrated in observational studies that peri-operative hyperglycaemia in non-cardiac surgery was associated with an increased incidence of complications and mortality 4, 6. Interestingly, when hyperglycaemia was recognised and treated with peri-operative insulin administration, complication and mortality rates were equivalent to those seen in non-diabetic patients with normal glycaemia 6. From an economic perspective, diabetes mellitus also affects the use of hospital resources, as diabetic patients often stay longer in hospital and intensive care 4, 6. Indeed, in an observational study of over 3000 non-cardiac surgery patients, Frisch et al. demonstrated that patients who were diabetic had a duration of stay 1.8 days longer than non-diabetic patients 4 (mean (SD) 8.8 (10.6) vs. 7 (10.8) days; p < 0.001). Therefore, in order to improve both patient- and economic-focused outcomes, it is necessary to aim for optimal glycaemic control throughout the peri-operative period in all patients with diabetes. Four years after publication of these recommendations, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) has recently published a report reviewing the quality of care provided to adult patients who had diabetes and underwent a surgical procedure 8. Of note, NCEPOD is an independent organisation, established more than 30 years ago, that uses a peer review and confidential enquiry method to examine the quality of care delivered in the peri-operative period 9. As per previous NCEPOD reviews this comprised an extensive retrospective case-note analysis, with 509 patient records included. Of note, there was an over-representation of emergency cases, and type-1 diabetic patients with a type-1:type-2 ratio of 1:3 (type 1-diabetic patients represent 10% of all those with diabetes 1). In addition, more than a quarter of the hospitals included were based in the independent, as opposed to the public, sector. These biases inherent to the methodology chosen by the authors do not undermine the validity of these results. Several key findings should be highlighted and are worthy of discussion. Less than half of referral letters had information on the management of the patient's diabetes and only 42% of these referral letters provided a HbA1c level within the previous 3 months despite national guidance recommending this. Part of this may be due to the high proportion of emergency referrals (43%) included in the analysis, where the patient may not have been referred by their usual primary care team. The need for the recognition and optimisation of chronic medical conditions by primary care, before the scheduling of surgery and pre-operative clinic attendance, is key in preventing unnecessary cancellations and delays in treatment provision 10. The importance of this has been highlighted in relation to other common comorbid conditions such as anaemia 11 and hypertension 12. With respect to hypertension, only around one-third of patients with diabetes had a blood pressure reading recorded in their referral letter. This report suggests that there is still scope for significant improvements to be made in the referral processes from primary care; however, this is a multifaceted, complex area which will take significant investment (both in terms of finance and personnel) in order to address. Initiatives such as the Royal College of Anaesthetists’ Peri-operative Medicine program will be one element in helping this process to evolve by providing a single point of contact for surgeons and general practitioners co-ordinating the care of complex patients 13. It is hoped that greater liaison with primary care, including provisional of educational programmes, will result in improved coordination between primary and secondary/tertiary care in management of long-term health conditions. Only 65% of patients had an HbA1c within 3 months of surgery and 16% of patients whose HbA1c was checked had a value outside the accepted range for elective surgery (> 69 mmol.mol−1). Again, the high number of non-elective cases may have contributed to these low compliance figures. However, the need for this target to be pre-requisite for elective surgery is worthy of consideration. This figure was first suggested in guidelines commissioned by NHS Diabetes 3 as one factor favouring good peri-operative diabetes control. More recent evidence has examined the association of HbA1c with postoperative mortality when controlling for peri-operative glucose level (the majority of earlier studies have examined hyperglycaemia and HbA1c in isolation) 14. This study showed that when controlling for blood glucose levels, HbA1c was not associated with increased 30-day mortality despite a strong relationship between HbA1c levels and peri-operative glucose levels. Thus, it may be that an elevated pre-operative HbA1c level should be viewed as a trigger for aggressive peri-operative glucose control, as opposed to deferral of surgery. This also applies to non-diabetic patients who are found to be hyperglycaemic, as high peri-operative glucose levels in this population are also associated with adverse outcomes 15. Aggressive peri-operative blood glucose control is also associated with a reduction in the risk of surgical-site infection 16; the data from this meta-analysis, however, did not take pre-operative HbA1c levels into account. Avoidance of postoperative nausea and vomiting (PONV) is of particular importance in patients with diabetes in order to get the patient eating and drinking again and, therefore, usual diabetic medication. The report judged that inadequate anti-emetic prophylaxis was given in 15% of cases, although the criteria for this judgement are not detailed. On review of the data provided it seems likely that multimodal anti-emetic prophylaxis was infrequently employed, as only 408 anti-emetic agents were used in 438 patients. This, in part, may be due to the omission of dexamethasone, which was only administered in 24% of cases. Dexamethasone increases glycaemic levels in both diabetic and non-diabetic patients by an average of 1.5 mmol.l−1, with a peak effect 4 h after administration 17. However, this does not appear to increase the risk of postoperative wound or systemic infection 18. Due to its prophylactic effect on PONV after general anaesthesia 19-21 or neuraxial anaesthesia with long-acting opioids 22, and its analgesic effect with either i.v. 23, 24 or perineural administration 24, 25, dexamethasone might be an interesting option. However, the decision as to whether to give it should be balanced between the anti-emetic and analgesic benefits and risk of hyperglycaemia. If dexamethasone is administered, then a low-dose should be chosen (i.e. 4 mg as opposed to ≥ 8 mg) as this is associated with lower postoperative blood glucose levels 26, and should be combined with another anti-emetic agent such as 5-HT3 antagonists, as a multi-modal approach is the key to success for effective anti-emetic prophylaxis. Despite over 90% of hospitals having protocols for the recognition and management of hypo- and hyperglycaemia, almost half the patients reviewed did not have their capillary blood glucose recorded intra-operatively and only 14% of patients had their blood glucose recorded in the recovery area. Significantly, one out of 20 diabetic patients in this report developed intra-operative hypoglycaemia 8. This complication, along with hyperglycaemia, is of great concern for the patient under general anaesthesia or the drowsy patient in the recovery room, due to lack of symptoms. The development and clinical implementation of continuous glucose monitoring devices continues to be disappointingly slow 27, leaving intermittent intra-operative sampling the only option at present. An alternative strategy to prevent occult intra-operative hypo- and hyperglycaemic episodes, would be to provide regional anaesthesia. Not only does the patient remain conscious and able to manifest any symptoms, but pain will be better controlled without opioid adverse-effects, such as PONV, that may worsen the condition. However, we should keep in mind that diabetes is associated with an increased risk of epidural abscess 28 or neuropathy 29, and prolonged block duration 30. The choice between general and regional anaesthesia should be individualised and based on a case-by-case situation, while properly weighing the risk-benefit ratio. Unfortunately, this report does not provide any information on the anaesthetic strategies and this, therefore, precludes further analysis. Based on these findings, the NCEPOD working group made similar recommendations to those in earlier guidelines (e.g. close glucose monitoring, safe and detailed handover of patients, avoidance of cancellation of surgery, prioritisation of patients with diabetes on the operating list) but it is always helpful to be reminded. More importantly, as only 28% of hospitals had a named clinical lead for peri-operative diabetes, the authors pointed out that a clinical lead in each hospital should be appointed to ensure that the pre-, intra- and postoperative management of diabetic patients will be optimal and performed following the state of the art and the latest recommendations. There was no recommendation as to what the base speciality of the clinical lead should be, so conceivably this could as be a physician, surgeon or anaesthetist. However, it may be that this responsibility falls within the remit of anaesthesia, due to its increasing role in pre-operative assessment and optimisation, where discussions with other medical specialities regarding the management of chronic disease conditions are initiated commonly. The need for co-ordinated multidisciplinary care has been a common theme in numerous previous NCEPOD reports, mentioned 15 times since 2001, but it is clear that it continues to be a challenge to implement. Part of the solution may be found in the ongoing work attempting to modernise the patient pathway to surgery 10. There appears to be little doubt that involvement of specialist diabetic teams early in these pathways will be of value in the peri-operative management of this complex disease, without forgetting that patient contribution and involvement in the management of this disease is of paramount importance 31. The NCEPOD group should be commended for leading this retrospective case-note survey, which enlightens the current practice in the UK 4 years after publication of guidelines. It is doubtless that the management of diabetic patients can be improved and that the skills and expertise to achieve this, such as diabetic nurse specialists and endocrinologists, are already in place but underutilised in the peri-operative setting. As such, the most important measure that each surgical department should take in the near future is to appoint a clinical lead to ensure that established recommendations are rigorously applied. Inadequate diabetic control needs to be recognised within the operating theatre environment as a risk factor for adverse outcomes that can be addressed with relatively simple clinical interventions. EA has received grants from the Swiss Academy for Anaesthesia Research (SACAR), Lausanne, Switzerland, from B. Braun Medical and from the Swiss National Science Foundation. EA has also received an honorarium from B. Braun Medical AG. MW is an editor of Anaesthesia.

Type 2 diabetes is caused by impaired insulin secretion and insulin resistance. Aspects that play an important role in management. This disease is education about self-management of diabetes. Appropriate self-care behaviors are enough Manage diabetes management and prevent complications improve quality of life. The purpose of this study was to determine the effect of self-care behavior models on diabetes self-management education in type 2 Diabetes Mellitus patients. The method used in this study was a quantitative approach using cross-sectional methods. The sample used was 120 patients with type 2 DM in Palopo City. The analytical method used is the structural equation model using Amos 2.0 and SPSS 20 (IBM Corp). The results of the study showed that self-care behavior in patients with type 2 DM was influenced by 87% of knowledge factors, 83% of motivation factors, 85% of family support factors, and 81% of self-efficacy factors. On the other hand, diabetes management in patients with type 2 DM was influenced 76% by the treatment factor, 89% by the glycemic control factor, 75% by the diet factor, 88% by the physical activity factor, and 62% by the foot care factor. The structural model of this study explains variable self-care behavior with a self-care management rate of 48%. Diabetes management therefore needs to be more proactive in educating people with diabetes so that they and their families can increase their knowledge and understand how diabetes care can be properly administered.

Diabetes mellitus type 2 is a disease caused by disruption of insulin secretion and insulin resistance. One aspect that plays an important role in the management of this disease is diabetes self-management education. Good self-care behavior will make diabetes management controlled and prevent complications and make the quality of life better. The purpose of this study is to determine the effect of self-care behavior and the magnitude of the influence of knowledge, patient motivation, family support, and self-efficacy on diabetes self-management education for type 2 diabetes mellitus patients. The method used in this study was a quantitative approach using cross-sectional methods. The sample used was 115 patients with type 2 diabetes mellitus in Palopo Regency. The analytical method used is the Structural Equation Model (SEM) using Amos 2.0 and SPSS 20 (IBM Corp). The findings of the study showed that self-care behavior in patients with diabetes mellitus of type 2 was influenced by knowledge factors by 89%, motivation factors by 82.8%, family support by 84.9%, and self-efficacy factors by 78.4%. Meanwhile, diabetes management of type 2 diabetes mellitus patients was influenced by treatment factors by 75.5%, blood sugar control factors by 88.1%, dietary factors by 60.9%, physical activity factors by 87.3%, and foot care factors 53. , 8%. The structural model of this study explains the variable care cell behavior with self-care management of 47.5%. Therefore, the management of diabetes mellitus must be more active in providing education to sufferers so that their knowledge or family members can increase and understand how to carry out diabetic management properly.

Type 2 Diabetes Mellitus is caused by disruption of insulin secretion and insulin resistance. One aspect that plays an important role in the management of this disease is diabetes self-management education. Good self-care behavior will make diabetes management controlled and prevent complications and make the quality of life better. The purpose of this study is to determine the relationship between self-care behavior and knowledge, patient motivation, family support, and self-efficacy on diabetes self-management education for type 2 Diabetes mellitus patients. The method used in this study was a quantitative approach: cross-sectional. The sample used was 115 patients with type 2 Diabetes mellitus in Sidrap Regency. The analytical method used is the Structural Equation Model (SEM). The findings of the study showed that self-care behavior in patients with diabetes mellitus type 2 was influenced by knowledge factors by 89%, motivation factors by 82.8%, family support by 84.9%, and self-efficacy factors by 78.4%. Meanwhile, diabetes management of type 2 Diabetes mellitus patients was influenced by treatment factors by 75.5%, blood sugar control factors by 88.1%, dietary factors by 60.9%, physical activity factors by 87.3%, and foot care factors by 53,8%. The structural model of this study explains the variable care cell behavior with self-care management of 47.5%, so it can be seen that self-care behavior has a significant effect on DMSE in type 2 Diabetes mellitus patients (p-value= 0.001). Therefore, the management of Diabetes mellitus must be more active in providing education to sufferers so that their knowledge or family members can increase and understand how to carry out diabetic management properly.

Simple SummaryDiabetes mellitus is a common disease in patients with cancer. It is a risk factor for certain cancers such as pancreatic, liver, colon, breast, and endometrial cancer. Furthermore, several new cancer treatments or the use of steroids may unmask underlying diabetes or aggravate preexisting diabetes. Evidence suggests that patients with cancer and diabetes have higher cancer-related mortality. Moreover, concurrent complications associated with diabetes in patients with cancer may influence the choice of cancer therapy. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in patients with cancer.Background: Diabetes mellitus and cancer are commonly coexisting illnesses, and the global incidence and prevalence of both are rising. Cancer patients with diabetes face unique challenges. This review highlights the relationship between diabetes and cancer and various aspects of the management of diabetes in cancer patients. Methods: A literature search using keywords in PubMed was performed. Studies that were published in English prior to July 2021 were assessed and an overview of epidemiology, cancer risk, outcomes, treatment-related hyperglycemia and management of diabetes in cancer patients is provided. Results: Overall, 8–18% of cancer patients have diabetes as a comorbid medical condition. Diabetes is a risk factor for certain solid malignancies, such as pancreatic, liver, colon, breast, and endometrial cancer. Several novel targeted compounds and immunotherapies can cause hyperglycemia. Nevertheless, most patients undergoing cancer therapy can be managed with an appropriate glucose lowering agent without the need for discontinuation of cancer treatment. Evidence suggests that cancer patients with diabetes have higher cancer-related mortality; therefore, a multidisciplinary approach is important in the management of patients with diabetes and cancer for a better outcome. Conclusions: Future studies are required to better understand the underlying mechanism between the risk of cancer and diabetes. Furthermore, high-quality prospective studies evaluating management of diabetes in cancer patients using innovative tools are needed. A patient-centered approach is important in cancer patients with diabetes to avoid adverse outcomes.

BackgroundPatients with heart failure frequently report inadequate self-care behaviours. Physical symptoms can impact patients’ ability to perform self-care behaviours. However, studies investigating the association between physical symptoms and heart failure self-care behaviours have produced inconsistent findings, potentially due to variations in the determinants of self-care behaviours among patients with differing levels of self-care proficiency. Understanding the association between physical symptoms and self-care behaviours in heart failure patients with inadequate self-care behaviours could improve care for this subpopulation. The study aimed to explore the association between physical symptoms and self-care behaviours in Chinese heart failure patients with inadequate self-care behaviours.MethodsThis analysis was based on primary data from a cross-sectional study that aimed to investigate factors associated with self-care in heart failure patients. Physical symptoms were measured using the Heart Failure Somatic Perception Scale. Self-care behaviours (i.e., self-care maintenance and management) of heart failure were measured using the Self-Care of Heart Failure Index (version 6.2). Patients who reported scores < 70 on both self-care maintenance and management behaviours were eligible and included in the analysis. Hierarchical regression analysis was performed to explore the association between physical symptoms and self-care behaviours.ResultsA total of 189 patients were included in the analysis, with a mean age of 65 years and a median duration of living with heart failure of 24 months. Most participants were classified as New York Heart Association class III or IV. Dyspnoea symptoms were the most frequently reported physical symptoms. The results of the hierarchical regression analysis showed that the severity of physical symptoms was positively associated with self-care management behaviours (β = 0.157, 95% CI: 0.010, 0.368, p = 0.039) but not significantly associated with self-care maintenance behaviours (β = -0.133, 95% CI: -0.316, 0.026, p = 0.097).ConclusionsBased on the data collected in Changsha, China, we found that patients with HF with poor self-care experienced more dyspnoea symptoms. Severe HF physical symptoms might serve as drivers for better self-care management in patients with inadequate self-care behaviours. Effective care and support should be provided when physical symptoms worsen to facilitate patients’ engagement in self-care behaviour in this subpopulation.

The impact of hand strength in consideration of sedentary behaviour on diabetes management in patients with type 2 diabetes mellitus (T2DM) is unclear. The purpose of this study was to examine the impact of hand strength on HbA1c, body mass index (BMI) and body composition by group according to the duration of sedentary behaviour in Japanese patients with T2DM. In this retrospective, cross-sectional, single-centre study, hand strength standardised by bodyweight (GS) and sedentary time (ST), were obtained and analysed in a total of 270 Japanese T2DM outpatients in 2021. After dividing the patients into four categories of median values (high and low GS, and long and short ST), odds ratios (ORs) for good control of HbA1c, BMI, waist circumference (WC) and intra-abdominal fat (IAF) were investigated using logistic regression models. The high GS/short ST group was found to have a significantly higher (OR = 2.01; 95% CI: 1.00, 4.03; P = 0.049) for controlled HbA1c compared with that of the low GS/long ST group. The high GS/short ST and the high GS/long ST groups had significantly higher ORs for controlled BMI, WC and IAF compared with the OR of the low GS/long ST group. In addition, the ORs were significantly increased with a positive trend in order from low GS/long ST, low GS/short ST, high GS/long ST, to high GS/short ST in all models (P < 0.001 for trend). Hand strength, with modest effects from sedentary behaviour, could be helpful for diabetes management in T2DM patients.

Most heart failure patients have multiple comorbidities. This study aims to test the moderating effect of comorbidity on the relationship between self-efficacy and self-care in adults with heart failure. Secondary analysis of four mixed methods studies (n = 114) was done. Self-care and self-efficacy were measured using the Self-Care of Heart Failure Index. Comorbidity was measured with the Charlson Comorbidity Index. Parametric statistics were used to examine the relationships among self-efficacy, self-care, and the moderating influence of comorbidity. Qualitative data yielded themes about self-efficacy in self-care and explained the influence of comorbidity on self-care. Most (79%) reported two or more comorbidities. There was a significant relationship between self-care and the number of comorbidities (r = -.25; p = .03). There were significant differences in self-care by comorbidity level (self-care maintenance, F[1, 112], 5.96, p = .019, and self-care management, F[1, 72], 4.66, p = .034). Using moderator analysis of the effect of comorbidity on self-efficacy and self-care, a significant effect was found only in self-care maintenance among those who had moderate levels of comorbidity (b = .620, p = .022, F(change) df[6,48], 5.61, p = .022). In the qualitative data, self-efficacy emerged as an important variable influencing self-care by shaping how individuals prioritized and integrated multiple and often competing self-care instructions. Comorbidity influences the relationship between self-efficacy and self-care maintenance, but only when levels of comorbidity are moderately high. Methods of improving self-efficacy may improve self-care in those with multiple comorbidities.

Management of diabetes in patients with COVID-19

Management of diabetes in patients with COVID-19

Diabetes is one incurable chronic disease, yet may be controlled through the compliance of diabetic management. This condition may distress the patients. Various efforts have already been made to improve the diabetic patients’ compliance through self-care management and diabetic self-management. However, those efforts do not involve family. Thus, efforts involving families in the management of diabetic patients are greatly necessary. The efforts may be conducted by creating a model of family empowerment. The research is conducted with a quasi-experiment pre post-test with control group design on each of 15 respondents. In both intervention and control group are given education on diabetic diet, physical activities for the diabetic patients, drugs and stress management. In the intervention group, the education is then structurally continued involving families every week for a month. In the next three months, the blood glucose and glycated hemoglobin (HbA1c) level are measured. The data are analyzed using paired and independent t-test. The research results show that the majority of respondents in both groups are at the middle of adult age with the gender of female (60.0%) in the intervention group and (53.3%) in the control group, senior high school education level (46.7%)in the intervention group and (33.3%) in the control group, occupation as housewives (40.0%) in the intervention group and (33.3%) in the control group, length of treatment duration in both groups is at the average of 3 years. This research proves that family involvement on diabetes management may lower the blood glucose level (p=0.000) and HbA1c level (p=0.000) of those diabetic patients.

Hypertension management in outpatient visits by diabetic patients

Regardless of the type of diabetes, lifestyle modifications is an essential component of diabetes management in patients with diabetes. Maintenance of self-care behavior, including dietary habits, physical activity frequency, and self-monitoring of blood glucose (SMBG), should be started with structured diabetes education. Diabetes Self Management Education (DSME) improves metabolic control, prevents and manages complications, and maximises quality of life in a cost-effective manner [1,2]. For this reason, clinical practice guidelines on diabetes recommend that DSME must be delivered by a certified educator who has received professional training or a multidisciplinary care team [3,4]. In addition, diabetes is typically a progressive chronic metabolic disease, and chronic illnesses are usually emotionally stressful, leading to both physical and psychological fatigue [5]. Also, changing the patients' daily routines or modifying their lifestyles are not so easy, especially due to the adherence to their current habits that have lasted for a longtime. Even those that generally have self-caring behaviors are under the constant threat of severe and devastating diabetic complications or bothersome symptoms throughout their lives [5,6]. Therefore, to maintain the patients' self-care behavior, the diabetes educators need to take into account various social, emotional, and psychological factors in addition to the patients' clinical situation. Consequently, close monitoring of their adherence to previous habits, emotional support, and regular reinforcement is essential to help patients change their lifestyle and maintain it during their lifetime. To do this, a web-based telemedicine system is a good alternative strategy to guide patients with diabetes. Undoubtedly, telemedicine delivered by health care professionals is cost-effective, time-saving, convenient, and easily accessible. Especially in Korea, more than 40 million people use internet access, corresponding to about 82.5% of the Korean population [7]. Also, telemedicine has a substantial benefit for patients in the sense that it provides more individualized recommendations in real-time. Suh et al. [8] have recently reported a 12-week internet-based mentoring program for patients with type 1 diabetes whose glycemic control status were inadequate. Using the web-based mentoring protocol, 5 volunteer mentors guided 26 patients regarding appropriate insulin dosing, physical activity, and food intake within 48 hours of mentees' request. Mentors were either patients themselves or a parent of one who already had experiences in diabetes management, not professional health care providers or doctors. Unfortunately, in contrast to our expectation, their glycemic control status (HbA1c) with glucose fluctuation (Average daily risk range), number of hypoglycemic episodes, and quality of life measured by Audit of Diabetes Dependent Quality of Life and Diabetes Treatment Satisfaction Questionnaire score were not improved after the mentoring program. However, they found that the mentoring program increased the frequency of SMBG. Considering their study conditions, such as long diabetes duration (about 6 years), young-aged adult (about 32 year-old) subjects, small study number, and short observation period, we believe that emotional or psychosocial support with positive feedback were helpful in motivating patients to familiarize with SMBG. We think that the ideal role and personal qualification of the mentors were the most important factors of this mentoring program for clinical application. Because the mentors had direct influence on patients' life and glycemic control, and they were not healthcare professionals, we suggest that the role of mentors to be confined to encouraging the patients to maintain their healthcare behaviors and provide correct information and skills that will change the patients' lifestyle. In addition, the mentors should take structured diabetes educations, especially regarding insulin dosage adjustment schedule. We also believe that increased frequency of SBMG could lead to clinical benefits. It has been proven that a higher frequency of SMBG was associated with better metabolic control among subjects who were able to adjust insulin doses. At the same time, a SMBG frequency over 1 time per day was significantly related to higher levels of distress, worries, and depressive symptoms in non-insulin-treated patients [9]. Therefore, we must consider the appropriate frequency of SMBG suggested by mentors according to individual clinical circumstances, such as stable glycemic status, sick day, and so forth. A recent study has shown that diabetes-related stress is significantly correlated with a longer diabetic duration and uncontrolled glycemic status [6,10]. Therefore, we think that the internet-based mentoring program would be beneficial for patients with type 1 diabetes, especially for those with longer diabetes duration or diabetic complications, in maximising the effectiveness of diabetes education. In conclusion, well-qualified, experienced, and trained mentors seem to be helpful for both the healthcare of patients with diabetes and healthcare providers.

Diabetes mellitus: the major risk factor in unstable coronary artery disease even after consideration of the extent of coronary artery disease and benefits of revascularization

Introduction Diabetes and cancer are prevalent diseases whose incidence is globally increasing. Type 2 diabetes mellitus is an independent risk factor for the development of several different types of cancer, including that of the colon and pancreas both in men and women, breast cancer in women and cancer of the liver and bladder in men. Nutritional assessment is an essential step in the global management of diabetic cancer patients. Malnutrition occurs due to a variety of mechanisms, involving the tumour, the host response to the tumour and anticancer therapies (surgery, radiotherapy and chemotherapy). In diabetic patients with cancer, malnutrition is a significant cause of morbidity, with high rate of toxicities during chemotherapy and radiotherapy, increased hospital length of stay, increased treatment costs and altered quality of life. Further, in diabetic cancer people, anorexia and cachexia can co-exist to determine the anorexia–cachexia syndrome, which acts synergistically to impact patients’ morbidity and mortality. Indeed, the concurrence of diabetes and cancer results in profound changes in the protein, lipid and glucose metabolism, in turn causing inefficient use of the energy and plastic substrates. The aim of this paper was to discuss nutrition in diabetic people with cancer. Conclusion The best way to treat cancer cachexia is to cure the cancer, although unfortunately this remains an infrequent achievement among adults with advanced solid tumours. Introduction Diabetes and cancer are prevalent diseases whose incidence is globally increasing1. Epidemiologic evidence suggests that type 2 diabetes mellitus (T2DM) is an independent risk factor for the development of several different types of cancer including that of the colon and pancreas both in men and women, breast cancer in women and cancer of the liver and bladder in men. The link between T2DM and certain types of cancer was first postulated many years ago and it was believed that the relationship could be entirely attributable to the direct effects of diabetes, such as hyperglycemia1,2. Current thinking suggests that diabetes is a possible marker of altered cancer risk due to changes in underlying metabolic conditions, including insulin resistance, hyperinsulinaemia and hyperglycaemia, via their influence on neoplastic processes2. Nutritional assessment is an essential step in the global management of diabetic cancer patients, in order to distinguish malnourished and non-malnourished patients3. The American Society for Parenteral and Enteral Nutrition guidelines defined malnutrition as an involuntary loss or gain of > 10% of usual body weight in 6 months or > 5% in one month4. Malnutrition occurs due to a variety of mechanisms, involving the tumour, the host response to the tumour and anticancer therapies (surgery, radiotherapy, chemotherapy)5. In diabetic patients with cancer, malnutrition is a significant cause of morbidity, with high rate toxicities during chemotherapy and radiotherapy, increased hospital length of stay, increased treatment costs, decreased performance status and altered quality of life6. Cachexia is more common in elderly patients and becomes more pronounced as the disease progresses. The prevalence of cachexia increases from 50% to more than 80% before death and in more than 20% of patients, cachexia is the main cause of death7. In diabetic cancer patients, anorexia and cachexia can co-exist to determine the ‘anorexia–cachexia syndrome’8 that acts synergistically to impact patients’ morbidity, mortality and quality of life9. The presence and severity of anorexia–cachexia syndrome reduce overall survival, contribute to the occurrence of postoperative complications, increase the toxicity induced by radio-chemotherapy, while reducing the sensitivity of tumour cells to antineoplastic treatment. In addition, it lowers the immune response and ultimately becomes the source of psychological stress for the patient and family. This paper discusses the management of diabetic cancer patients including the attempt to address and possibly solve typical diabetes and tumour metabolic changes, reduced caloric intake secondary to the presence of cancer anorexia and specific nutritional requirements by the tumour itself. Discussion The ‘anorexia–cachexia syndrome’ in diabetic cancer patients For a long time, the nutritional problems of diabetic cancer patients * Corresponding author Email: ottavio.giampietro@med.unipi.it Clinical Nutrition Unit, Department of Clinical and Experimental Medicine, University of Pisa