Diabetes Management Strategies Research Articles

Addressing Obesity and Diabetes Among African American Men: Examination of a Community-Based Model of Prevention

The Save Our Sons study is a community-based, culturally responsive, and gender-specific intervention aimed at reducing obesity and diabetes among a small sample (n = 42) of African American men. The goals of the study were to: (1) test the feasibility of implementing a group health education and intervention model to reduce the incidence of diabetes and obesity among African American men; (2) improve regular access to and utilization of health care services and community supportive resources to promote healthy lifestyles among African American men; and (3) build community networks and capacity for advocacy and addressing some of the health needs of African American men residing in Lorain County, Ohio. Trained community health workers facilitated activities to achieve program aims. Following the 6-week intervention, results indicated that participant's had greater knowledge about strategies for prevention and management of obesity and diabetes; increased engagement in exercise and fitness activities; decreased blood pressure, weight, and body mass index levels; and visited a primary care doctor more frequently. Also, local residents elevated African American men's health and identified it as a priority in their community. This model of prevention appears to be a substantial, robust, and replicable approach for improving the health and wellbeing of African American men.

Diabetes and its impact on health-related quality of life: a life table analysis

To investigate the health burden of diabetes and determine its impact on health-related quality of life (HRQOL) in a population with a high prevalence of chronic conditions. A representative sample of the Canadian province of Newfoundland and Labrador (NL) was used to estimate prevalence of diabetes and mean health utility index (HUI), a utility-based measure of HRQOL. Diabetes-deleted life expectancy (LE) and health-adjusted life expectancy (HALE) were derived to measure HRQOL. Diabetic individuals comprised 6.8% of the sample and accounted for 14% of total deaths from 2001 to 2005. Life Expectancy at age 15 was 61.3 years for men and 66.7 years for women, of which 53.0 and 57.0 years, respectively, were spent with perfect health (86.4 and 85.5%). Eliminating diabetes would extend both the overall LE and HALE for men by 1.3 and 1.4 years, and women by 2.0 and 1.7 years, respectively. People with diabetes had a significantly lower HRQOL than people without diabetes (mean HUI: 0.78 vs. 0.88, P < 0.01). The burden of illness from diabetes in NL is considerable. Using cause-eliminated LE and HALE provides a robust approach for assessing HRQOL that may have important implications for diabetes surveillance, prevention, and management strategies.

Defining the Importance of Daily Glycemic Control and Implications for Type 2 Diabetes Management

Glycemic control remains an elusive goal for most patients with type 2 diabetes. Questions concerning glucose targets that have emerged from recent outcomes studies further complicate glucose control strategies. Navigating through these challenges requires an understanding of the relationship between hyperglycemia, glycemic variability, and risk, as well as how to combine antidiabetic agents safely and effectively to minimize complications. Relevant data were selected from recently published major outcomes studies and peer-reviewed articles discussing glycemic variability, incretins, and dipeptidyl peptidase-4 inhibition. Incretin hormones play a premier role in maintaining normal glucose homeostasis. In type 2 diabetes, however, incretin functioning is impaired and glucose homeostasis is disturbed, contributing to hyperglycemia and both acute and chronic glucose fluctuations. Glycemic control efforts should involve quarterly glycated hemoglobin assessments, routine monitoring of daily blood glucose values, and combination therapy that targets both fasting and postprandial hyperglycemia. Dipeptidyl peptidase-4 inhibitors, which enhance endogenous incretin function, are well suited for combination with other agents to promote daily glycemic control without increasing the risk of hypoglycemia or weight gain. Results of recent outcomes studies suggest that a lifetime strategy for diabetes management might involve aggressive efforts to control glycemia daily and early in type 2 diabetes, with less stringent glucose targets and avoidance of hypoglycemia as patients acquire comorbidities, such as advanced cardiovascular disease. Dipeptidyl peptidase-4 inhibitors have the potential to play a vital role in diabetes management at all stages of the disease.

Staged diabetes management according to individual patient insulin resistance and β‐cell function ameliorates glycaemic control in type 2 diabetes mellitus

The current consensus algorithm for management of type 2 diabetes is based on the fasting glucose concentration and glycated haemoglobin A(1c) (HbA(1c)) level. We applied a new therapeutic strategy by assessing insulin secretion and insulin resistance, in addition to glucose concentrations in individual patients. We enrolled 193 patients with type 2 diabetes. The patients were assigned to one of six groups according to insulin secretion measured by the serum fasting C-peptide concentration and insulin resistance measured by an insulin tolerance test (ITT). The two groups were treated differently: 108 patients were treated using a new staged diabetes management (SDM) strategy and 85 patients continued with conventional therapy. We compared metabolic variables in the two groups at baseline and 12 months after enrollment. In patients treated with the SDM strategy, fasting glucose concentration decreased from 9.8 +/- 2.1 to 8.2 +/- 1.7 mmol/l (P < 0.001). Postprandial 2-h glucose concentration decreased from 14.19 +/- 3.34 to 12.27 +/- 3.24 mmol/l (P < 0.001). HbA(1c) level decreased from 8.37 +/- 1.42% to 7.72 +/- 1.39% (P < 0.001). About 43% of the new SDM group achieved an HbA(1c) of < 7.0% compared with 25% of patients in the conventional treatment group. The new SDM strategy, based on individual data on insulin resistance and insulin secretion, may provide valuable clinical benefits in non-obese Korean patients with type 2 diabetes.

Factors affecting uptake of an education and physical activity programme for newly diagnosed type 2 diabetes

AbstractBackground: Intensive lifestyle intervention involving weight reduction and moderate physical activity has been shown to help regulate, and even prevent, type 2 diabetes.Aim: This study sought to explore factors affecting uptake of an education and physical activity programme for those diagnosed with type 2 diabetes.Method: Focus group discussions were conducted with individuals who completed the programme and semi-structured interviews were conducted with those who declined the invitation to attend. Data were analysed using a thematic framework approach and key similarities and differences between the groups were identified.Results: The 11 programme participants studied appeared to have received clearer messages about the severity of unmanaged diabetes, whereas the 10 non-attenders studied felt that co-morbidities posed greater risks to their health. There were major concerns among both groups about undertaking exercise, and strategies for diabetes management focused heavily on dietary modificati...

Global nutritional recommendations: a combination of evidence and food availability?

AbstractDiet and exercise are vital diabetes management strategies. Health professionals (HPs) use dietary guidelines to advise their clients but the current macronutrient recommendation in the guidelines varies.The aim of this study was to explore the similarities and differences in macronutrient dietary advice in different parts of the world and suggest some reasons for any differences identified.The study was undertaken in two phases: (1) a one‐shot cross‐sectional survey of HPs and global diabetes organisations using self‐completed, anonymous questionnaires (n=40), and (2) a review of dietary guidelines from relevant diabetes associations (the American Diabetes Association [ADA], the Diabetes and Nutrition Study Group [DNSG] of the European Association for the Study of Diabetes [EASD], the Canadian Diabetes Association [CDA], the Joslin Diabetes Center, Diabetes UK, and the Indian Council of Medical Research [ICMR]).Dietary recommendations differed among countries and from the guidelines, and reflected socioeconomic factors and local food availability. With regard to macronutrient recommendations, carbohydrate ranged from 40–70%, protein 12–20% and fat 15–40% of total energy intake. Nations with higher gross domestic product (GDP) based on purchasing‐power‐parity (PPP) per capita tended to recommend a much lower ratio of carbohydrate than those with lower GDP PPP per capita. However, all guidelines stressed the importance of healthy eating.It was concluded that socioeconomic factors and local food availability appear to influence HPs' dietary recommendations. Copyright © 2008 John Wiley &amp; Sons.

Adoption and Implementation of Strategies for Diabetes Management in Primary Care Practices

Secondary and tertiary prevention of chronic illness is a major challenge for the United States healthcare system. Controlled studies show that interventions can enhance secondary prevention in primary care practices, but they shed little light on implementation of secondary prevention outside the experimental context. This study examines the adoption and implementation of an important set of secondary and tertiary prevention efforts--diabetes management strategies--for type 2 diabetes in the everyday clinical practice of primary care. It explores whether adoption and implementation processes differ by type of strategy or prevalence of diabetes among patients in the practice. Holistic case studies (those used to assess a single analytic unit, in this case, the physician group practice, as opposed to multiple embedded subunits) were conducted in 2001-2002 on six primary care practices in North Carolina identified from a statewide physician survey on strategies for diabetes management. Practices were selected by prevalence of diabetes and type of strategy for diabetes management--patient oriented (focused on self-management) versus biomedical (focused on secondary prevention practices). Results were derived from thematic analysis of interviews and secondary documents. Adoption and implementation did not differ by diabetes prevalence or type of diabetes strategy. All practices had a routine forum for vetting new strategies, and most used traditional channels for identifying them. Implementation often required adaptation of the strategy and the organization. Sustained use of a diabetes strategy depended on favorable organizational policies and procedures (e.g., training, job redesign) and ongoing commitment of resources. Diabetes management strategies are often complex and require adoption and implementation processes different from those described by classic innovation diffusion models. Alternative conceptual models that consider organizational process, structure, and culture are needed.

Impact of Using a Pedometer on Time Spent Walking in Older Adults With Type 2 Diabetes

The purpose of this study was to investigate the impact of using a pedometer on time spent walking, in sedentary and overweight adults with type 2 diabetes participating in a coaching intervention. It was hypothesized that participants using a pedometer would spend more time walking than would nonpedometer participants. Method A sample of 57 men and women with a mean age of 62 years participated in a randomized controlled trial in a community setting. Participants were allocated to either a pedometer and coaching (intervention) group or a coaching-only (control) group. Coaching for both groups involved education, goal setting, and supportive/motivational strategies to increase time spent walking. The duration of the study was 6 months, with blood pressure, glycosylated hemoglobin, anthropometric, and fitness measurements assessed at baseline and at 3-month intervals. A repeated-measures analysis of variance indicated that the coaching-only group spent significantly more time walking than did the pedometer group. However, when an analysis of covariance with all the other variables as covariates was performed, group membership had no influence on time spent walking. Significant reductions in waist circumference and weight were achieved for both groups from baseline to 6 months. Cardiovascular fitness also increased significantly for both groups. The study demonstrated that previously sedentary older adults with type 2 diabetes, supported with a coaching intervention, were able to achieve the physical activity targets known to be beneficial to health. However, using a pedometer added no further benefit. Further research on the impact of specific coaching strategies in diabetes management is warranted.

Changing the Way Diabetes is Treated With Information and Resources

T he U.S. Department of Health and Human Services' National Diabetes Education Program (NDEP) is the leading federal government public education program that promotes diabetes prevention and control. Based on the scientific results of the Diabetes Control and Complications Trial,1 NDEP was launched in 1997 with a mission to reduce the morbidity and mortality associated with diabetes. To fulfill that mission, NDEP translates the latest science and disseminates the message that type 2 diabetes is serious, common, and costly, yet controllable and preventable. NDEP is jointly sponsored by the National Institutes of Health and the Centers for Disease Control and Prevention, with the support of > 200 partner organizations. Health care professionals need to know about current advances in diabetes management and prevention and require access to the most appropriate and effective tools and materials to assist them in administering the most effective care. NDEP provides a wealth of information and tools through three major campaigns: 1. Control Your Diabetes. For Life. This is a comprehensive information campaign focusing on tips and strategies for effective diabetes management. 2. Be Smart About Your Heart: Control the ABCs of Diabetes. This emphasizes the link between diabetes and cardiovascular disease. 3. Small Steps. Big Rewards. Prevent Type 2 Diabetes. This is the first national diabetes prevention effort. In view of the spiraling epidemic of diabetes in …

Management of Diabetes During Acute Stroke and Inpatient Stroke Rehabilitation

Golden SH, Hill-Briggs F, Williams K, Stolka K, Mayer RS. Management of diabetes during acute stroke and inpatient stroke rehabilitation. Objectives To summarize evidence on the impact of hyperglycemia on stroke outcomes and to present therapy algorithms for inpatient management in diabetic stroke patients. Data Sources Guidelines for inpatient management of diabetes were reviewed and extracted from a technical review and recommendations from 2 national diabetes and endocrine organizations. MEDLINE database searches were conducted using key words: stroke, diabetes, hyperglycemia, hypoglycemia, inpatient, hospitalized, treatment, outcomes, disability, self-management, and education. Study Selection Studies were selected that specifically addressed the impact of the following in stroke patients: hyperglycemia and diabetes on rehabilitation outcomes, management strategies for hyperglycemia and diabetes, and strategies for facilitating diabetes self-management. Data Extraction Two authors independently extracted data and management practices from selected articles and published practice guidelines. Data Synthesis Diabetes is prevalent in stroke patients and results in poorer inpatient hospital and rehabilitation outcomes. Management of diabetes in stroke patients is further complicated by impairments in mobility and vision, necessitating accommodation strategies and tools for self-management. Optimal management of hyperglycemia using insulin or oral hypoglycemic agents results in reduced morbidity and mortality among diabetic inpatients. Conclusions To achieve inpatient glycemic management targets, use of clinical management algorithms, self-management tools, and systems approaches such as diabetes management teams are useful.

Thiazolidinediones—Benefits on microvascular complications of type 2 diabetes

Type 2 diabetes is associated with serious microvascular complications, such as nephropathy, retinopathy, and neuropathy, which have a significant impact on patients' quality of life, morbidity, and mortality. Type 2 diabetes management strategies to reduce the risk of microvascular complications include treatment of hyperglycaemia, hypertension, and other vascular risk factors. The importance of glycaemic control in reducing the risk of microvascular complications of diabetes is well established. However, many antihyperglycaemic therapies fail to provide adequate glycaemic control and do not prevent complications in the long term. The thiazolidinediones (TZDs) are a class of agents that provide sustained glycaemic control, mediated primarily by reductions in insulin resistance. Evidence reviewed suggests that the TZDs may have the potential to reduce microvascular complications through benefits that go beyond glycaemic control. Insulin resistance underlies a range of metabolic abnormalities, collectively known as the metabolic syndrome (MS), which are cardiovascular (CV) risk factors. Components include visceral obesity, hyperglycaemia, hypertension, dyslipidaemia, low-grade inflammation and microalbuminuria (an early manifestation of target organ damage). Reducing insulin resistance, therefore, has the potential to reduce both microvascular and macrovascular complications.

Promoting Lifestyle and Behavior Change in Overweight Children and Adolescents With Type 2 Diabetes

Sixteen-year-old Juana is a high school sophomore who loves movies, the local pizza parlor, and salsa music. She is young but has the health risks of someone three times her age. With a BMI > 95th percentile for age, Juana has many of the features of metabolic syndrome and may be only months from displaying the symptoms of type 2 diabetes. Juana is one of 8.8 million American youth who are overweight or obese.1 The plight of Juana and her agemates has become increasingly visible in the media and in the scientific literature. Genetics has been blamed. Parents have been blamed. Schools have been blamed. Television has been blamed.2 Society has been blamed. Although we are closer to understanding the causes, we lack effective strategies for prevention and management of obesity and diabetes in children and adolescents. The road to obesity and diabetes may begin in utero. Low birth weight and exposure to maternal diabetes have been implicated.3,4 There may be genetic components to the problem.5 Certain genes associated with type 2 diabetes have been identified in Cree-Ojibway aboriginal children in Canada.6 Largely, however, the rise in childhood obesity corresponds to various environmental changes. Children today are less physically active than in the past. They play less outside and have less physical education in school. In high school, enrollment in daily physical education (P.E.) classes dropped from 42% in 1991 to 25% in 1995.7 Only 19% of all high school students are physically active for at least 20 minutes in P.E. classes every day during the school week. What has replaced physical activity is television watching, Internet surfing, and computer gaming. There is a strong correlation between childhood obesity and access to television. Children are more likely to be obese if they …

The CORE Diabetes Model: Projecting Long-term Clinical Outcomes, Costs and Costeffectiveness of Interventions in Diabetes Mellitus (Types 1 and 2) to Support Clinical and Reimbursement Decision-making

SUMMARYObjectives: We have developed an Internet-based, interactive computer model to determine the longterm health outcomes and economic consequences of implementing different treatment policies or interventions in type 1 and type 2 diabetes mellitus. The model projects outcomes for populations, taking into account baseline cohort characteristics and past history of complications, current and future diabetes management and concomitant medications, screening strategies and changes in physiological parameters over time. The development of complications, life expectancy, quality-adjusted life expectancy and total costs within populations can be calculated.Methods: The model is based on a series of sub-models that simulate important complications of diabetes (cardiovascular disease, eye disease, hypoglycaemia, nephropathy, neuropathy, foot ulcer, amputation, stroke, ketoacidosis, lactic acidosis and mortality). Each sub-model is a Markov model using Monte Carlo simulation incorporating time, state, time-in state, and diabetes type-dependent probabilities derived from published sources. Analyses can be performed on cohorts with type 1 or type 2 diabetes. Cohorts, defined in terms of age, gender, baseline risk factors and pre-existing complications, can be modified or new cohorts defined by the user. Economic and clinical data in the model can be edited, thus ensuring adaptability by allowing the inclusion of new data as they become available; creation of country- or provider-specific versions of the model; and allowing the investigation of new hypotheses.Conclusions: The CORE Diabetes Model allows the calculation of long-term outcomes, based on the best data currently available. Diabetes management strategies can be compared in different patient populations in a variety of realistic clinical settings, allowing the identification of efficient diabetes management strategies.

Validation of the CORE Diabetes Model Against Epidemiological and Clinical Studies

The aim of this study was to assess the validity of the CORE Diabetes Model by comparing results from model simulations with observed outcomes from published epidemiological and clinical studies in type 1 and type 2 diabetes. A total of 66 second- (internal) and third- (external) order validation analyses were performed across a range of complications and outcomes simulated by the CORE Diabetes Model (amputation, cataract, hypoglycaemia, ketoacidosis, macular oedema, myocardial infarction, nephropathy, neuropathy, retinopathy, stroke and mortality). Published studies were reproduced in the model by recreating cohorts in terms of demographics, baseline risk factors and complications, treatment patterns and patient management strategies, and simulating the progress of the cohort to an equivalent time horizon. Correlation analysis on results from 66 validation simulations produced an R2 value of 0.9224 (perfect fit = 1). A correlation plot of published study data versus values simulated by the CORE Diabetes Model had a trend line with a gradient of 1.0187 (perfect fit = 1). Validation analyses in type 1 and type 2 diabetes were associated with R2 values of 0.9778 and 0.8861 respectively. Correlation of second-order validation analyses (model predictions versus observed outcomes in studies used to construct the model) produced an R2 value of 0.9574, and the value for third-order analyses (model predictions versus observed outcomes in studies not used to construct the model) was 0.9023. The CORE Diabetes Model provides an accurate representation of patient outcomes when compared to 66 studies of diabetes and its complications. Model flexibility ensures it can be used to compare diabetes management strategies in different cohorts across a variety of clinical settings.

Supporting Lifestyle Change With a Computerized Psychosocial Assessment Tool

There are now more than 12,400 certified diabetes educators practicing in the United States.1 Their primary role is to provide diabetes education, diabetes self-management training, and lifestyle change support. The prevalence of type 2 diabetes, which comprises 90–95% of diabetes cases, is increasing at an alarming rate, reflecting recent cultural changes in our eating and exercise habits and a sharp increase in the prevalence of obesity and its associated insulin resistance.2 The need is becoming more urgent for innovative and effective behavior change strategies in diabetes management. Further, as Glasgow and Eakin3, p.144 have noted, “to impact diabetes management, behavioral assessments, interventions, and models should be practical and efficient, be readily understood by non-psychologists, and address issues that diabetes patients and providers (rather than psychologists) perceive as important.” Historically, we have not done a good job in conducting behavioral research that translates behavior change theories and concepts into brief educational interventions that can work in busy clinical settings. Instead, we have focused almost exclusively on academic behavioral research studies that do not get down into the clinical “trenches.” Rollnick et al.,4, p. vii for example, noted that, “despite the abundance of research on treatment adherence [in chronic illness], there is a paucity of teachable methods that have emerged from this body of work.” Harnessing the power of computerization to gather patient questionnaire data, create user-friendly summary reports, and free educators to spend more time counseling patients also makes sense as a behavioral intervention support strategy given the time constraints and logistical challenges diabetes educators typically face. The Accu-Chek Interview,5 a patient assessment tool, was developed to meet the need to translate a promising behavior change theory into practical strategies for diabetes educators and to utilize computerization in the patient assessment process. The tool …

Lipids and psychosocial status in aboriginal persons with and at risk for Type 2 diabetes: implications for tertiary prevention

This study assessed psychosocial correlates of dyslipidemia, towards enabling improved tertiary prevention of macrovascular complications of diabetes mellitus (DM). We tested the hypothesis that psychosocial measures are related to high-density lipoprotein cholesterol (HDL-C) and triglyceride concentrations in a rural aboriginal population in British Columbia, Canada. Persons sampled were on-reserve registered Indians (n=198) with and at risk for Type 2 DM. Relationships between HDL-C and psychosocial variables were associated with glycemic status. For persons with diabetes and impaired glucose tolerance (n=44), quality of life and mastery were positively related (P<0.001), and depression inversely related (P<0.001), to HDL-C. An apparent lack of effect of behavior suggests the influence of emotional pathways involving autonomic-neuroendocrine axes. We recommend assessing mental health, and promoting mastery and diabetes quality of life through empowerment oriented diabetes management strategies, in negotiating culturally acceptable treatment of diabetic dyslipidemia for aboriginal people.

Outline of a diabetes disease management model: principles and applications

A complex interactive computer model was developed to determine the health outcomes and economic consequences of different diabetes interventions for user-defined observation periods. The interventions include intensive or conventional insulin therapy, different oral hypoglycaemic medications, different screening and treatment strategies for micro-vascular complications, different treatment strategies for end-stage complications, or multi-factorial interventions. The analyses can be performed on different sub-groups of type 1 and 2 diabetic patients, defined in terms of age, gender, baseline risk factors and pre-existing complications. The model performs real-time simulations. Full on-screen documentation of the model structure, logic, calculations and data sources is available to maximize the model's transparency. Economic and clinical data used in the disease management model are editable by the user, allowing the input of new data as they become available, the creation of country-specific, HMO-specific, or provider-specific versions of the model, and the exploration of new hypotheses (‘what-if’ analyses). The approach used allows maximum flexibility, adaptability, and transparency within the model structure. For the user-defined patient cohorts and intervention strategies the diabetes disease management model compares life expectancy, expected incidence and prevalence of complications as well as expected life-time (or shorter) treatment cost. Diabetes and complication management strategies can be compared in different patient populations in a variety of realistic clinical settings. The model allows extrapolation of results obtained from relatively short-term clinical trials to longer-term medical outcomes, and from trial populations to real-life populations providing a tangible yardstick to judge the quality of diabetes care. The model was used to evaluate diabetes care options in Germany, France, Switzerland, UK and US.

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

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

The Wisconsin Epidemiologic Study of Diabetic Retinopathy: XIII. Relationship of Serum Cholesterol to Retinopathy and Hard Exudate

Serum total and high-density lipoprotein (HDL) cholesterol were measured in a sample of individuals examined between 1984 and 1986 for the Wisconsin Epidemiologic Study of Diabetic Retinopathy. There was a significant trend for increasing severity of diabetic retinopathy and of retinal hard exudate with increasing cholesterol in insulin-using persons. Cholesterol levels were not related to the severity of either ocular condition in older-onset patients. Highdensity lipoprotein-cholesterol was unrelated to the severity of either lesion. In multiple logistic regression analyses, cholesterol was not a significant factor in describing the severity of retinopathy in any group but was a significant factor in describing the severity of retinal hard exudate. Glycosylated hemoglobin and diastolic blood pressure were significant descriptors of the severity of retinopathy in younger-onset patients in these multivariate analyses. Diastolic blood pressure added significantly to explaining the severity of hard exudate in older-onset insulin users. These data support the current management strategies for diabetes, which include control of level of glycemia, blood pressure, and blood lipids.

The role of physicians' knowledge and attitudes in effective diabetes management.

We examined the role of physicians' knowledge and attitudes in effective diabetes management among internal medicine house staff. We examined the extent to which (1) knowledge of common diabetes management strategies and (2) beliefs about the efficacy of, and intentions to engage in, such strategies predict success in their management of patients with diabetes. Successful managers are those house staff whose ambulatory diabetes patients' fasting blood sugar levels were lower than the clinic median. Knowledge was assessed with a written case simulation of an obese noninsulin-dependent woman; beliefs and intentions were surveyed through a self-administered questionnaire. The data suggest that knowledge was unable to discriminate physicians who are relatively successful in controlling their patient's blood sugar levels from those who are less successful. However using intentions related to initial and follow-up management strategies and beliefs about the benefits of achieving euglycemia, there was discrimination between the two physician groups (P less than 0.001). These findings suggest that beliefs are important in understanding why some physicians are successful managers. Further, if beliefs are mutable, continuing medical education courses could be more effective by fostering critical beliefs rather than depending solely upon the transfer of new medical information.