Frequent Blood Glucose Monitoring Research Articles

POSTOPERATIVE MANAGEMENT OF THE DIABETIC PATIENT

Diabetic patients are at increased risk for adverse outcomes of surgery. These adverse outcomes are related to pre-existing complications of diabetes, especially atherosclerotic disease, nephropathy (and perhaps increased susceptibility to other renal toxins), and peripheral and autonomic neuropathy. Hyperglycemia is associated with likely risks for poorer wound healing, increased susceptibility to infection, and probable loss of administered nutrients through glycosuria. Insulin use has the flexibility of timing and dose in the postoperative management of most diabetic patients. The combinations of intermediate-acting and long-acting insulins and short-acting insulins usually are related to the experience and preferences of the treating physicians and allied health professionals. Intravenous insulin (always R) may be limited to administration in the ICU because of the need for frequent blood glucose monitoring and rapidity of glucose response to intravenous insulin. The use of short-acting insulin analogues has been shown to work well as premeal insulin or for rapidly treating marked hyperglycemia in the outpatient setting. Meal delivery in the hospitalized patient may not be timed as precisely as in the home situation. Nurses may be responsible for many patients. The rapid-acting analogues may be associated with increased risk for hypoglycemia in the hospitalized patient if insulin cannot be given immediately before a meal. These rapid-acting insulin analogues usually are limited to circumstances in which the patient can determine the dose and self-administer just before ingestion of the meal. The long-acting insulin analogues may not afford enough flexibility in many situations in which daily dosages changes are occurring in intermediate-acting and long-acting insulins. Oral glucose-lowering agent use in the postoperative state usually is limited to selected patients, including patients who have been on such agents before surgery, who have only mild elevations of blood glucose, who are able to ingest oral medications, and who do not have significant comorbid conditions (or significant risk for such conditions) that may be contraindications to use of such agents (see Table 3). Sulfonylureas and other insulin secretagogues (e.g., meglitinide, nateglinide) lower glucoses acutely. The risk for hypoglycemia is slightly less with the nonsulfonylurea agents. Efficacy and side effects limit the use of carbohydrase inhibitors for hospitalized patients. The glucose-lowering effects of biguanides and thiazolidinediones usually are not rapid enough for hospitalized patients who have never taken these medications. For patients who have been on a biguanide or thiazolidinedione before admission, these agents often are restarted in the postoperative period when oral intake of medications is possible and hepatic and renal function are stable. The hospital period affords an opportunity to review long-term management issues related to diabetes and its complications. Instruction on the importance of medical nutrition therapy, glycemic control, management of hypertension, dyslipidemia, and aspirin use as well as basic guidelines for foot care should be carried out during the hospitalization and at the time of discharge. Similarly, appropriate arrangements for medical nutrition therapy, general diabetes education (especially for newly diagnosed diabetic patients), and regular medical follow-up are important to ensure long-term, excellent surgical and medical outcomes.

Searching for glycemic control in pediatric type 1 diabetes: A long way to go

Searching for glycemic control in pediatric type 1 diabetes: A long way to go

Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes

Objectives: To examine predictors of glycemic control and to assess how glycemic control affects the incidence of short-term adverse outcomes in a pediatric population with type 1 diabetes. Study design: Three hundred youth, aged 7 to 16 years, with type 1 diabetes who were receiving diabetes specialty care were followed up prospectively for 1 year. Treatment plans and frequency of adverse outcomes were ascertained by questionnaires and medical record review. Incidence rates of adverse outcomes were compared among 3 strata of the population, representing tertiles of baseline glycosylated hemoglobin (HbA1c). Results: Blood glucose monitoring frequency was the sole modifiable predictor of HbA1c (P <.0001). Overall incidence rate of hospitalization was 13 per 100 person-years, more than 3 times the rate in the general pediatric population and significantly higher in the upper HbA1c tertile compared with the other strata (P =.001). Rate of emergency department use was 29 per 100 person-years and did not differ significantly among tertiles. Incidence of severe hypoglycemia was 62 per 100 person-years and notably high even in those with poorest glycemic control. Conclusion: Despite improvements in diabetes care, the incidence of short-term adverse events in children with type 1 diabetes remains high, particularly in those with poorest glycemic control. (J Pediatr 2001;139:197-203)

A survey of diabetes management in nursing homes: the need for whole systems of care

AbstractA structured questionnaire survey of nurse managers of the 40 nursing homes in the catchment of a district hospital revealed inconsistencies in diabetes care and unsafe capillary blood testing practice. Seven homes had diabetes management policies; in the 33 homes that did not, management was based on information received at admission being incorporated into the care plan. Regarding the management of ill insulin‐dependent residents, nine homes stated that insulin should be withheld although all homes indicated that they would increase the frequency of blood glucose monitoring and seek advice. 18/40 homes had a policy for the management of a hypoglycaemic episode; those without a policy relied on the knowledge of the trained staff present. Sharing of blood sampling equipment within homes, a risk to infection control, was identified as commonplace. A lack of guidance appeared a major cause of inconsistency in patterns of ongoing care for residents with diabetes. Specific guidelines and training are required to assure diabetes care and clinical governance in care homes. Copyright © 2001 John Wiley &amp; Sons, Ltd.

Frequency of blood glucose monitoring in relation to glycemic control in patients with type 2 diabetes.

The aim of the study was to investigate the relationship between blood glucose level, measured as HbA(1c), and frequency of self-monitoring in patients with type 2 diabetes. Daily self-monitoring is believed to be important for patients treated with insulin or oral agents to detect asymptomatic hypoglycemia and to guide patient and provider behavior toward reaching blood glucose goals. A national sample of patients with type 2 diabetes was studied in the third National Health and Nutrition Examination Survey. Data on therapy for diabetes, frequency of self-monitoring of blood glucose, and HbA(1c) values were obtained by structured questionnaires and by clinical and laboratory assessments. According to the data, 29% of patients treated with insulin, 65% treated with oral agents, and 80% treated with diet alone had never monitored their blood glucose or monitored it less than once per month. Self-monitoring at least once per day was practiced by 39% of those taking insulin and 5-6% of those treated with oral agents or diet alone. For all patients combined, the proportion of patients who tested their blood glucose increased with an increasing HbA(1c) value. However, when examined by diabetes therapy category, there was little relationship between HbA(1c) value and the proportion testing at least once per day or the proportion testing at least once per week. In this cross-sectional study of patients with type 2 diabetes, the increase in frequency of self-monitoring of blood glucose with increasing HbA(1c) value was associated with the higher proportion of insulin-treated patients in higher HbA(1c) categories. Within diabetes therapy categories, the frequency of self-monitoring was not related to glycemic control, as measured by HbA(1c) level.

Life with continuous subcutaneous insulin infusion (CSII) therapy: child and parental perspectives and predictors of metabolic control.

The purpose of this study was twofold (i): to evaluate metabolic control in patients receiving CSII therapy in a routine pediatric diabetes clinic by describing reasons for initiating therapy and daily management issues, including needle fear; and (ii) to assess the change in parental involvement and anxiety once their child initiated CSII therapy. The study included 52 subjects (aged 7.6-23.6 yr) from a general pediatric diabetes clinic. Management issues were defined as diet, exercise, home blood glucose monitoring (HBGM) frequency, and self/staff assessment of needle fear. Characteristics were analyzed both according to a 0.5% change in HbA1c status (decreased vs. stable vs. increased) compared with pre-CSII therapy, and final HbA1c achieved (< or = 8.1 vs. > 8.1%). The primary recommendation source for CSII use was most often the physician/diabetes team (48.1%), followed by a combination of the former with a personal referral source (32.7%). The most common reason (71.2%) for CSII initiation was a combination of wanting to achieve better metabolic control, dislike of insulin injections, and/or increased flexibility in daily living. Over one-quarter (26.9%) of subjects were identified as being needle-fearful, and this characteristic was predictive of final metabolic control (3/25 subjects </= 8.1% vs. 11/27 subjects > 8.1%, p = 0.03). On CSII therapy, dietary carbohydrate consistency was highly variable, and most subjects (65.3%) exclusively used an insulin to carbohydrate ratio for insulin bolus dosage calculation. The most common adjustment strategy (63.5%) for exercise was a combination of decreasing the insulin basal rate, disconnecting the pump, and/or eating extra carbohydrates. For the total cohort, the frequency of HBGM significantly increased on CSII therapy (4.31-4.85 tests/day, p = 0.02). Females did not have a significant change in HBGM frequency, while the youngest subjects had the highest HBGM frequency. Parental involvement and anxiety primarily stayed the same or decreased, regardless of the child's age (< or = 18 vs. > 18 yr) or metabolic control. Analyses of the various characteristics identified only needle fearfulness as being predictive of poor metabolic control. Interestingly, poor control with CSII therapy did not result in a significant increase in parental involvement and/or anxiety.

Design of a Biosensor for Continual, Transdermal Glucose Monitoring

The Diabetes Control and Complications Trial (1) and other trials have shown that frequent monitoring of blood glucose by diabetics is critical to achieving normoglycemic concentrations. The ability to achieve this goal is hampered, however, by the lack of any means of obtaining frequent blood glucose data in a convenient and unobtrusive manner. To address these needs, a continual, noninvasive glucose monitoring system has been developed that utilizes reverse iontophoresis to induce an electroosmotic flux of glucose through intact skin. The electroosmotic glucose flux (measured ex vivo by HPLC) was shown in earlier clinical trials to correlate with the blood glucose concentrations (2). To create a miniaturized and wearable system, an amperometric biosensor has been developed that measures in situ the glucose extracted through the skin into a hydrogel pad to provide periodic measures of blood glucose every 20 min over the course of 12 h. A diagram of this system is shown in Fig. 1⇓ A. Figure 1. Schematic of the GlucoWatch biographer ( A ) and evaluation of stability of glucose extraction and measurement in cadaver skin diffusion cell over 12 h (36 measurements) at 500, 1000, and 4000 mg/L (50, 100, and 400 mg/dL; B ). …

Frequency of blood glucose monitoring in relation to glycaemic control: observational study with diabetes database

Objectives: To investigate patterns of self monitoring of blood glucose concentration in diabetic patients who use insulin and to determine whether frequency of self monitoring is related to glycaemic control.Setting:...

Increasing Self-Monitoring of Blood Glucose: A Pilot Study of the Effect on Corrective Actions and the Impact of Cognitive Behavioral Factors

EARNING OUTCOME: To characterize the actions taken by non-insulin dependent diabetics upon increasing the frequency of blood glucose monitoring and any relationship between these actions and cognitive or affective factors. In an ex-post facto design, non-insulin dependent diabetics (NIDDM) who self-monitor blood glucose (SMBG) were followed in a three week interval for glycemic control (GC) and corrective actions (CA), both in number and type, following a high glucose reading. Subjects were assessed as three groups: those with SMBG ≥ 14 times/week (N=6), 6–13 times/week (N=5), and ≤ 5 times/week (N=5). All subjects were followed for an additional three weeks following random assignment of three subjects from the SMBG ≤ 5 times/week group to the ≥ 14 regimen. The monitoring activity consisted of a demographic and attitudinal survey and a self-report log of glucose levels, CA taken to promote euglycemia, and pertinent health, behavioral, or functional comments. Cognitive behavioral parameters postulated to impact the initiation of behavior change were assessed using Stage of Change, Locus of Control and Health Beliefs scales. Gender distribution, educational level and income were similar among the three baseline groups. Mean age difference among the groups was significant (F=4.17, df=15, p=0.04) with the group monitoring most frequently being the youngest (59.2 years). This group had the heaviest body mass index (40.8), although group differences were not significant. Increasing the frequency of SMBG from ≤ 5 to ≥ 14 times/week was not clearly associated with a pattern of increasing CA, type of CA, or GC for both mean and fasting glucose levels. Sample size and uncontrolled baseline diabetes education were confounders of any SMBG effect. The expected associations between Health Beliefs and Locus of Control with GC or CA were not apparent. However Stage of Change was found to be positively associated with both SMBG frequency and CA taken. Subjects in the precontemplation, contemplation, and preparation (PCP) stages monitored less frequently than those in the action and maintenance (AP) level (32.4 versus 36.4 times/week) and 71 percent of the AP subjects (5 of 7) made at least one CA after a high glucose reading compared to only 44 percent of those in the PCP levels (4 of 9). This pilot study tested and supported the methodology as appropriate for the study of SMBG in NIDDM, but verified the need for larger samples to study this highly individual disorder and its complex behavioral components.

Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus

Objectives: The goal of this study was to identify parental behaviors that relate to adherence and metabolic control in a population of young adolescents with insulin-dependent diabetes mellitus (IDDM), and to understand the interrelationships among the variables of parental involvement, adherence to blood glucose monitoring, and glycemic control. Study design: A cross-sectional design was used to investigate parental involvement in diabetes regimen tasks in 89 youth, aged 10 to l5 years, with IDDM. Levels of parental involvement in blood glucose monitoring (BGM) and insulin administration were evaluated through interviews. Assessment of adherence was made by physicians or nurses, independent of patient or parent reports of adherence. Glycemic control was assessed with glycosylated hemoglobin (HbA lc ) (reference range, 4% to 6%). Results: There were significant differences in the mean HbA lc values between the older (13 to 15 years of age) (HbA lc = 8.9% ± 1.03%) and younger (10 to 12 years) patients (HbA lc = 8.4% ± 1.06%) ( p <0.02). Parental involvement in BGM was significantly related to adherence to BGM (number of blood sugar concentrations checked daily) in both groups of adolescent patients. The younger patients monitored their blood glucose levels more frequently than did the older patients, 39% of the younger patients checked sugar concentrations four or more times daily compared with only 10% of the older group ( p <0.007). In a multivariate model controlling for age, gender, Tanner staging, and duration of diabetes, the frequency of BGM was a significant predictor of glycemic control ( R 2 = 0.19, p <0.02). Increased frequency of BGM was associated with lower HbA 1c levels. When the frequency of BGM was zero or once a day, the mean HbA 1c level was 9.9% ± 0.44 (SE); when the frequency of BGM was two or three times a day, the mean HbA 1c level was 8.7% ± 0.17; and when the frequency of BGM was four or more times daily, the mean HbA 1c level was 8.3% ± 0.22. Conclusions: Parental involvement in BGM supports more frequent BGM in 10- to 15-year-old patients with IDDM. This increased adherence to BGM is associated with better metabolic control (i.e., lower HbA 1c levels). These findings suggest that encouraging parental involvement in BGM with 10- to 15-year-old patients with IDDM may help to prevent the well-documented deterioration in glycemic control and adherence to treatment that often occurs in later adolescence. (J Pediatr 1997;130:257-65)

Subclinical and clinical eating disorders in IDDM negatively affect metabolic control.

To characterize the relationship of subclinical and clinical eating disorders to HbA1c values in women with IDDM. Ninety women with IDDM (18-46 years of age) were recruited from diabetes clinics throughout Connecticut and Massachusetts. Subjects were categorized into one of three groups according to the Diagnostic Statistical Manual of Mental Disorders (DSM-III-R) criteria for eating disorders as follows: the clinical group (n = 14), the subclinical group (partially fulfilling the diagnostic criteria; n = 13), and the control group (n = 63). Group differences in the degree of dietary restraint, binge eating, and bulimic behaviors and weight, shape, and eating concerns were assessed with the Eating Disorder Examination (EDE) and the Bulimia Test Revised (BULIT-R). Women with subclinical and clinical eating disorders had clinically elevated HbA1c results and more diabetes-related complications, compared with the control subjects. The severity of bulimic behaviors, weight concerns, reduced BMI, and decreased frequency of blood glucose monitoring were associated with elevated HbA1c. HbA1c may have clinical utility in the identification of eating disorder behavior in females with IDDM. Health care professionals should be aware of the potent effect of subclinical and clinical eating behaviors including insulin misuse in weight-conscious women with IDDM who have poor glycemic control.

How to Apply the Experience from the Diabetes Control and Complications Trial to Children and Adolescents?

The Diabetes Control and Complications Trial (DCCT) taught us to set target blood glucose (BG) and glycohaemoglobin (GHb) goals, to ensure safety regarding hypogly-caemia, to be flexible with insulin and meal planning and to offer frequent contact with diabetes educators, dieticians, psychologists and social workers as well as with diabe-tologists skilled in intensified management. Insulin dosage should be individualized based upon frequent BG monitoring results. Co-ordinated multidisciplinary health care teams provide optimum problem-solving rather than disaster control working with children, adolescents and their families. The patient and the family should form the central core of the diabetes team with outpatient follow-up every month and frequent telephone contact between visits. GHb should be obtained at least every 1–2 months to provide feedback as based on the DCCT intensified treatment cohort. Insulin lispro helps minimize hypoglycaemia and makes insulin administration more convenient and timely. Barriers to improvement should be identified: learning problems, concomitant significant illnesses (epilepsy, coeliac and thyroid disease, asthma) and family problems. Ensure age-appropriate transfer of self-care but continue adult supervision. Educate, motivate and re-educate. Meal planning includes not only carbohydrate counting but also maintaining normal lipids and energy needs for growth and development as well as strategies for activity compensation and hypoglycaemia prevention. Consideration of protein restriction may be required in adolescents with microalbuminuria. Individualized multidose insulin algorithms allow reactive (corrective) decisions based upon capillary BG results plus proactive (anticipatory) decisions to compensate for expected BG changes from changes in activity, food and/or illness using a multidose insulin schedule. The number of insulin injections does not define an intensified insulin treatment programme but rather the ability to target and achieve near-normal BG values as often as possible - without severe episodes of hypoglycaemia. Self BG monitoring is a key to success. Long-term monitoring should include not only frequent GHb but also at least annual fasting lipids, thyroid functions and microalbuminuria as well as dilated retinal exams, blood pressure, growth charting and Tanner staging.

Effect of glycemic control on the growth velocity and several metabolic parameters of conventionally treated children with insulin dependent diabetes mellitus.

To determine the effect of glycemic control on the growth velocity and several metabolic parameters of children with insulin-dependent diabetes mellitus (IDDM), 79 patients with IDDM, 45 females and 34 males with a mean chronological age of 8.4 +/- 3.0 years were followed over a 5-year period starting at the onset of diabetes. Glycemic control was assessed by measuring total glycosylated hemoglobin; children were divided into better controlled, GHb < 9%, 30 children (Group A) and worse controlled, GHb > or = 9%, 49 patients (Group B). Growth velocity was significantly lower, in the five years of follow up, in the worse controlled patients when compared to the better controlled subjects (4.8 +/- 1.6 vs 6.7 +/- 2.2 cm/yr after the first year and 5.0 +/- 2.0 vs 6.5 +/- 1.8 cm/yr after the fifth year, in group B and group A, respectively). Higher cholesterol (185.3 +/- 33.7 vs 158.8 +/- 39.5 mg/dl) and triglyceride levels (85.9 +/- 43.5 vs 71.0 +/- 37.4 mg/dl) were apparent in the worse controlled patients, when compared to the better controlled children. Insulin dose was not significantly different in the two groups (0.76 +/- 0.3 vs 0.84 +/- 0.4 U/kg/day in the 1st year and 0.9 +/- 0.3 vs 0.92 +/- 0.4 U/kg/day in the 5th year, in group B and A respectively). Although both groups received the same initial and long term training by our pediatric diabetes team, more frequent blood glucose monitoring, better record keeping and rotation of injection sites and more clinic visits were clearly noted in the better controlled group. Ketoacidotic episodes were more common in the worse controlled patients, while better controlled children had a higher number of hypoglycemic episodes. In conclusion, we have found poor glycemic control, as reflected by higher glycosylated hemoglobin levels, to affect the growth velocity and several metabolic parameters of children with diabetes followed for a five-year period. Other factors besides insulin dose and initial and subsequent diabetic education seem to play a role in their glycemic control.

Diabetes in urban African-Americans. I. Cessation of insulin therapy is the major precipitating cause of diabetic ketoacidosis.

To identify the causes of diabetic ketoacidosis (DKA) in a large urban hospital. Consecutive patients admitted during a 3-month period with a primary diagnosis of DKA and who had moderate-to-severe illness as shown by serum glucose > 13.9 mmol/l ( > 250 mg/dl), bicarbonate < 15 mmol/l, and pH < 7.35 were studied. Diabetes nurse educators interviewed patients and reviewed their medical records for the following: precipitating causes of DKA; content of previous diabetes education; frequency of blood glucose monitoring; recognition of symptoms of metabolic decompensation; and types of medical assistance obtained once patients were ill. There were 56 episodes of DKA, and 75% of the episodes were in patients with known diabetes. In the known diabetic patients, the most common cause of DKA was stopping insulin therapy, which occurred in 67% of episodes. Half of the patients (50%) stopped insulin because of reported lack of money to buy insulin from an outside pharmacy or get transportation to the hospital; 21% stopped insulin because of lack of appetite; 14% stopped insulin because of behavioral or psychological reasons; and 14% did so because they did not know how to manage diabetes on sick days. Of the known diabetic patients, > 80% recalled having been instructed as to blood glucose testing and acute and chronic complications, but fewer patients recalled having been instructed as to insulin dose adjustment (28%) or sick day management (35%). Symptoms of decompensated diabetes were recognized in 55% of the 42 episodes of DKA in patients with known diabetes. However, only 5% of patients contacted the Diabetes Unit when they became ill; the majority (95%) went directly to the emergency room. DKA occurred most often in patients with known diabetes who stopped insulin therapy because of reported lack of money for purchasing insulin or for transportation to the hospital and limited self-care skills in diabetes management. In urban African-American populations, up to two-thirds of the episodes of DKA may be preventable by improving patient education and access to care.

Predictors of Glycaemic Control in Type 1 Diabetic Patients after Participation in an Intensified Treatment and Teaching Programme

The aim of the study was to identify predictors of long-term glycaemic control in Type 1 diabetic patients after participation in an intensified insulin treatment and teaching programme. The study population consisted of 697 Type 1 diabetic patients (mean age 26 +/- 7 (SD) years, duration of diabetes 8 +/- 7 years) who participated in the same structured intensified insulin treatment and teaching programme in 10 hospitals and who were re-examined after 1, 2, and 3 years. Multiple and logistic regression analyses were performed including a set of demographic, disease-related, social, and psychosocial variables as potential predictors. As dependent variables the average HbA1 values during the 3-year follow-up period and a composite variable (average HbA1 values/frequency of severe hypoglycaemia)--dividing patients into three groups with good, moderate or poor metabolic control--were considered. Regression analysis of average HbA1 values revealed significance (p < 0.05) for seven independent predictors in descending order: smoking, age at onset of diabetes, frequency of home blood glucose monitoring, socioeconomic status, diabetes-related knowledge, perceived coping abilities, and sex (R2 (percentage of variation explained by the model) = 17%). In a second regression model, HbA1 values before the intervention programme were added to the model and achieved the highest standardized regression coefficient (0.38), increasing R2 to 29%. In the logistic regression models considering both HbA1 and severe hypoglycaemia as a composite dependent variable, diabetes-related knowledge, HbA1 values before the intervention, smoking, perceived coping abilities, age at onset of diabetes, and C-peptide levels were the strongest predictors of glycaemic control. In conclusion, the relationship between demographic, disease-related, psychosocial, and social variables and metabolic control is complex. Therefore, simplistic concepts of linear causality should be abandoned. In addition to HbA1 values before the intervention, smoking, diabetes-related knowledge, home blood glucose monitoring, age at onset of diabetes, perceived coping abilities and C-peptide levels were the most significant and consistent predictors of glycaemic control.

Factors influencing the clinical outcome of continuous subcutaneous insulin infusion in routine practice

Possible factors that might influence the outcome of continuous subcutaneous insulin infusion (CSII) treatment were investigated in forty-nine, type 1, diabetic patients with median treatment of 3.25 years in routine diabetes care. In nine patients pump treatment was discontinued largely within the first 6 months. Patients characterized as blue-collar workers discontinued pump treatment at a significantly higher rate. Of the remaining forty patients those with the longest treatment experience were of attracted interest. Among twenty patients who had used CSII three years or more improvement of metabolic control was most evident in patients with high haemoglobin A 1c (HbA 1c) values before CSII ( R-square 0.673, P = 0.0001) and in subjects with low insulin requirements on injection therapy ( R-square 0.334, P = 0.0076). This improvement was not explained by more frequent monitoring of blood glucose only. It was found that those who had the lowest body mass index (BMI) before pump treatment had the more pronounced increase of BMI, while those in the upper normal range had an unchanged or reduced body mass ( R-square 0.271, P = 0.0115). We conclude that high HbA 1c values, low insulin requirements and low body mass in conventional injection therapy are the most important factors when trying to achieve and maintain metabolic improvement in CSII treated type 1 diabetic patients.

Long‐term glycaemic control achieved in young insulin‐dependent diabetics

AbstractThe long‐term glycaemic control, assessed by the mean of three successive levels of glycosylated haemoglobin (HbA1c) achieved in a special clinic for insulindependent diabetics aged 12–40, was audited in 1984 and 1987. Clinic policy involved a twice‐daily insulin regimen with infrequent blood glucose monitoring and little emphasis on dietary compliance or formal education. Overall levels of diabetic control were identical in 1984 and 1987; 34% of patients had HbA levels within three standard deviations of the mean and 60% within five standard deviations. There was no correlation between control and age or duration of diabetes. Diabetic control deteriorated in 24% of patients and improved in 20% between 1984 and 1987. There was no significant difference in the overall levels of control compared with other centres. It is concluded that frequent blood glucose monitoring, strict dietary compliance and formal education are not important factors in glycaemic control in insulin‐dependent diabetes.

Perioperative Management of the Diabetic Patient

The diabetic patient has major surgery more frequently than nondiabetic patients. Although many of these operations are done on an elective basis, desirable perioperative control of blood glucose (ranging from 120-180 mg/dL) remains a therapeutic challenge. In planning the management, the type of diabetes, current treatment, the degree of recent control, the presence of complications, and the type of surgical procedure must all be considered. All insulin-dependent patients and many non-insulin-dependent patients need insulin therapy perioperatively. The variable stress associated with major procedures makes a flexible insulin regimen desirable. This can be provided using a continuous insulin (regular) infusion system and frequent bedside blood glucose monitoring.

Intensive versus standard blood glucose awareness training (BGAT) with insulin-dependent diabetes: mechanisms and ancillary effects.

Insulin-dependent diabetes mellitus (IDDM) patients make critical daily self-care decisions on the basis of what they estimate their blood glucose (BG) levels to be. This study: a) replicated efficacy of Standard Blood Glucose Awareness Training (BGAT), b) evaluated the relative efficacy of an Intensive Blood Glucose Awareness Training (BGAT) to enhance patient accuracy of BG estimation, and c) evaluated the mechanisms and ancillary effects of BGAT. Thirty-nine subjects were randomly assigned to one of three groups. Compared with Control, both Standard and Intensive BGAT improved accuracy (p less than 0.001). Intensive BGAT post-treatment accuracy relative to Standard BGAT did not reach statistical significance (p = 0.177). Greater improvement in accuracy was associated with poorer pretreatment accuracy. Only Intensive BGAT improved metabolic control (glycosylated hemoglobin), and this improvement was associated with poorer pretreatment control. The effects of BGAT were highly specific, affecting only accuracy and metabolic control, and not affecting fear of hypoglycemia, diabetes knowledge, of frequency of blood glucose monitoring.

Self-Care Predictors of Metabolic Control in NIDDM Patients

The objective of this study was to evaluate whether the relationship between self-care behavior and metabolic control is comparable in patients with non-insulin-dependent diabetes mellitus (NIDDM) on insulin and not on insulin. We studied 84 NIDDM patients hospitalized for an elective admission in Washington University's Model Demonstration Unit. At admission, patients reported the frequency of exercise, blood glucose monitoring, and meal skipping for the previous 2 wk. Metabolic control over the previous 8-12 wk was determined from glycosylated hemoglobin assays. In cross-sectional analysis controlling for patient sociodemographic and health characteristics, glycosylated hemoglobin levels were positively related to meal skipping (P = 0.0008) and negatively related to the frequency of blood glucose monitoring (P = 0.0025). Self-care behaviors explained 26% of the variance in glycosylated hemoglobin levels in NIDDM patients. Multivariate modeling demonstrated no significant interaction effects between insulin treatment and self-care on metabolic control. In conclusion, these findings support the clinical significance of self-care activities for metabolic control in NIDDM patients, particularly meal skipping and blood glucose monitoring.