Diabetes Control Measures Research Articles

Achilles Tendinopathy in Diabetes Mellitus

Plantar forefoot ulcers in individuals with diabetes often lead to deep infection and lower extremity amputation. Increasing evidence suggests that the process is initiated by increased passive stiffness within the gastrocnemius-soleus musculotendinous unit. The goal of this investigation was to perform ultrasound examination of the Achilles tendon in a consecutive group of asymptomatic diabetic individuals to identify any inherent structural pathology that might be associated with the increased stiffness that appears to be associated with the development of diabetic forefoot ulcers. Seventy consecutive diabetic individuals with no past history of diabetic foot morbidity underwent ultrasonography of their Achilles tendons. Each patient was also tested for fasting glucose and glycosylated hemoglobin as a measure of diabetes control. Ten similarly aged non-diabetics with no history of Achilles tendinopathy served as controls. The ultrasonography revealed disorganized tendon fibers in 62 of 70 (89%) patients, and calcification within the Achilles tendon in 53 (76%) patients. The Achilles tendon thickness averaged 5.0 (range, 4 to 8) mm. There was no correlation between patient age and Achilles tendon thickness (r = 0.292, p = 0.014); however, there was a trend for duration of disease and Achilles tendon disorganization (p = 0.073). The oldest patients also appeared to demonstrate a trend for more ultrasound-measured Achilles tendinopathy. There was no correlation between fasting glucose or glycosylated hemoglobin and Achilles tendon alterations. This investigation confirms structural abnormalities within the Achilles tendon of diabetic individuals that might represent biologic changes affecting the inherent stiffness that leads to increased forefoot pressure and the development of plantar forefoot ulcers. This process appears to worsen with advanced age and does not appear to be related to diabetes control.

Cystatin C as a surrogate for glomerular filtration rate in the presence of proteinuria.

Sir, All methods for assessing glomerular filtration rate (GFR) have shortcomings. Serum creatinine has a reciprocal relationship to GFR that is related to age, race, sex and muscle mass and is affected by tubular secretion. Creatinine clearance requires a timed urine collection, and radio isotope and inulin clearance methods are expensive. Estimated GFR may only be valid in the steady state of chronic kidney disease (CKD) [1]. There has been much [2] interest in cystatin C, a serine protease inhibitor produced by all nucleated cells, freely filtered at the glomerulus and, although reabsorbed, apparently fully metabolized in tubular cells [3]. Serum cystatin C may be more sensitive to changes in GFR than serum creatinine [4,5]. Renal disease is often accompanied by proteinuria, the severity of which correlates with progression [6], possibly because protein in the tubular fluid injures tubular cells via mechanisms involving reactive oxygen species [7]. We hypothesized that proximal tubular injury by proteinuria might affect cellular handling of cystatin C, leading to an altered relationship to GFR. We measured serum cystatin C in 65 nephrology-clinic patients, with and without proteinuria, using a latex-enhanced immunonephelometric assay based on rabbit polyclonal antibodies (Dade Behring, UK) with a ProSpec analyser (Dade Behring, UK). Urinary creatinine and protein were measured using standard chemistries on Roche Modular systems (Roche/Hitachi, Roche Diagnostics, Gmbh, Germany). GFR was estimated using the modification of diet in renal disease (MDRD) formula [8]. Patients were being treated for stable CKD secondary to primary glomerulonephritis (28%), diabetes (15%), vasculitis or lupus (8%), chronic pyelonephritis (6%), hypertensive nephrosclerosis (3%), miscellaneous conditions (16%) or unknown cause (24%). They were classified as proteinuric if excreting >1 g protein/24 h (range 1–15 g/24 h, n = 24), otherwise non-proteinuric (n = 41). To normalize variance, the reciprocal relationship between serum cystatin C and GFR was analysed as −log(cystatin) versus log(GFR), grouped linear regression (StatsDirect Ltd, Cheshire, UK) being used to assess the common slope and the (statistically significant, P = 0.03) vertical separation of the regression lines in the two groups, and converted back to the linear domain for presentation (Figure ​(Figure1).1). When the regression line for the non-proteinuria group is used to predict cystatin C values for each proteinuric patient, their observed cystatin C is on average 33 ± 8% higher than expected from GFR. Fig. 1 Cystatin C versus GFR, with best-fit lines (see key) converted from a log–log fit derived by grouped linear regression. Although we did not formally measure GFR, these results suggest the need for caution in using cystatin C as a marker for GFR in proteinuria. A similar warning was sounded by anomalies in four patients with sickle cell disease [11] and also by a large study of diabetic patients in which mean cystatin C was ∼50% higher in patients with microalbuminuria than those without, despite no significant difference in mean serum creatinine [12]. The present study extends this by calculating the discrepancy for each proteinuric patient. Although the close reciprocal correlation between cystatin C and radioisotope GFR can be used to predict GFR from cystatin C with high accuracy and precision [9], such formulae may need modification in proteinuria. Longitudinal studies will be needed to determine whether changes in proteinuria in individual patients alter this relationship. More complex interactions between serum cystatin C, markers of tubular dysfunction and measures of diabetic control [13] also merit further investigation. There are two possible explanations for our finding. First, proteinuria might affect the accuracy of the MDRD equation. This significantly underestimates GFR in the presence of microalbuminuria during the hyperfiltration phase of diabetic nephropathy [10], but none of our relatively few diabetic patients were hyperfiltering (GFR > 100 ml/min). Alternatively, proteinuria might raise serum cystatin C. Since proteinuria damages proximal tubular cells cultured in vitro [6,7], we speculate that damaged cells might fail to metabolize all reabsorbed cystatin C, leaving some to re-enter the circulation. If so, a rising serum cystatin C might prove useful in monitoring tubular injury. Conflict of interest statement. None declared.

The clinical effectiveness of diabetes education models for Type 2 diabetes: a systematic review

To examine the clinical effectiveness of patient education models for adults with Type 2 diabetes. Electronic databases were searched from 2002 to January 2007. A systematic review of the literature on educational interventions in diabetes was undertaken. This was an update of a previous systematic review. Including studies identified in the previous systematic review, there were 13 published studies. Eight studies of education on multiple aspects of diabetes self-management were identified that provided education that was focused on a particular aspect of self-management. The quality of reporting and methodology of the studies was variable. Studies of multi-component educational interventions yielded mixed results. Some trials reported significant improvements on measures of diabetic control but others did not. Positive effects may be attributable to longer-term interventions with a shorter duration between the end of the intervention and the follow-up evaluation point. There may also be an effect of having a multi-professional team delivering the educational programme. Studies of focused educational interventions did not yield consistent results. Some effects were shown on measures of diabetic control in studies that focused on diet or exercise alone. Although the effects shown were generally small, those that were present did appear to be relatively long-lasting. This update review does not substantially alter the conclusions of the previous systematic review; for each outcome, the proportion of studies that demonstrated significant effects of education was similar. Based on the evidence, it would seem that education delivered by a team of educators, with some degree of reinforcement of that education made at additional points of contact, may provide the best opportunity for improvements in patient outcomes. Educators need to have time and resources to fulfil the needs of any structured educational programme. There is also a need for education to have a clear programme at the outset. From the evidence reported it is unclear what resources would need to be directed at the educators themselves to ensure that they can deliver programmes successfully. Any future research should consider patient education within the context of overall diabetes care and as such follow guidelines for the development and evaluation of complex interventions. Good-quality, longer-term studies would be desirable, but these would require careful consideration around the nature of any control group. Information is needed to clarify the sensitivity of diabetes education programmes to the performance of the diabetes educators, in order to ensure success and cost-effectiveness of education programmes.

Pramlintide Improved Glycemic Control and Reduced Weight in Patients With Type 2 Diabetes Using Basal Insulin

To assess the efficacy and safety of pramlintide in patients with type 2 diabetes suboptimally controlled with basal insulin. In a 16-week, double-blind, placebo-controlled study, 212 patients using insulin glargine with or without oral antidiabetes agents (OAs) were randomized to addition of pramlintide (60 or 120 microg b.i.d./t.i.d.) or placebo. Insulin glargine was adjusted to target a fasting plasma glucose concentration of 70-100 mg/dl. One coprimary end point was the change in A1C at week 16. The other coprimary end point was a composite measure of overall diabetes control comprising A1C < or = 7.0% or reduction > or = 0.5%, mean daily postprandial glucose (PPG) increments < or = 40 mg/dl, no increase in body weight, and no severe hypoglycemia. Patients meeting all four conditions at week 16 achieved this end point. More pramlintide- than placebo-treated patients achieved the composite end point (25 vs. 7%; P < 0.001). Reductions (means +/- SE) in A1C (-0.70 +/- 0.11% vs. -0.36 +/- 0.08%; P < 0.05) and PPG increments (-24.4 +/- 3.6 mg/dl vs. -0.4 +/- 3.0 mg/dl; P < 0.0001) were greater in pramlintide- versus placebo-treated patients, respectively. Glycemic improvements were accompanied by progressive weight loss with pramlintide and weight gain with placebo (-1.6 +/- 0.3 kg vs. +0.7 +/- 0.3 kg; P < 0.0001). No treatment-related severe hypoglycemia occurred. Pramlintide improved multiple glycemic parameters and reduced weight with no increase in hypoglycemia in patients with type 2 diabetes who were not achieving glycemic targets with basal insulin with or without OAs.

Impact of Celiac Autoimmunity on Children with Type 1 Diabetes

Children with type 1 diabetes (T1DM) are at increased risk for celiac disease (CD); however, the benefits of screening for IgA tissue transglutaminase autoantibodies (TG), a marker for CD, are unclear. We compared 71 screening-identified TG+ with 63 matched TG- children with TIDM. Growth, bone density, and diabetes control measures were obtained. The group was 10 +/- 3 years of age, 46% male, with TIDM for 4 +/- 3 years. Z scores for weight (0.3 +/- 1 vs 0.7 +/- 0.8, P = .024), body mass index (BMI) (0.3 +/- 0.9 vs 0.8 +/- -0.8, P = .005), and midarm circumference (0.3 +/- 1.1 vs 0.6 +/- 0.9, P = .031) were lower in the TG+ group. Bone mineral density and diabetes control measures were similar. When limiting the analysis to the 35 TG+ subjects with biopsy changes of CD, the BMI Z score was lower than the control group (0.4 +/- 0.9 vs 0.7 +/- 0.7, P = .05). In children with TIDM, screening-identified evidence of CD is associated with altered body composition, but not bone mineral density or diabetes control. Further study is needed to determine the benefit of early diagnosis and treatment of CD in TIDM children.

Parapharyngeal and Retropharyngeal Space Infection of Odontogenic Origin

This report is of a 64-year-old woman with insulin-dependent diabetes and hypertension with a parapharyngeal and retropharyngeal space infection of odontogenic origin. The patient presented with submandibular swelling. After treatment with antimicrobial agents and diabetes control measures, she had initial improvement. Progressive dysphagia, increasing neck pain, and mild dyspnoea occurred on day 8, and imaging revealed abscess formation in the parapharyngeal and retropharyngeal spaces requiring transcervical drainage. On day 15, the associated teeth were extracted. She recovered uneventfully and was discharged from hospital after 30 days.

Clinical Use of Hemoglobin A1c to Improve Diabetes Management

F or more than 25 years, the hemoglobin A1c (A1C) test has been the most widely accepted outcome measure for evaluating glycemic control in individuals with diabetes. The test provides an index of a patient's average blood glucose level during the past 2-3 months1 and is considered to be the most objective and reliable measure of long-term metabolic control.2,3 The Diabetes Control and Complications Trial established that maintaining A1C levels as close as possible to the normal range results in considerable reductions in long-term health complications.4 Thus, as the “gold standard” measure of diabetes control, this test provides important feedback to health care professionals and patients. It follows that patients' understanding of this test and its implications for long-term health risk is essential. Research has shown that regular measurement of A1C over the long term can identify patients with poor glycemic control and facilitate their improvement.5 The established relationship between A1C measurements and long-term complications,4 as well as the association between regular A1C testing and improved metabolic control,5 underscore the importance of determining the extent of patients' understanding of this important test and how its results are used in the clinical setting. ### Patient Knowledge of A1C Relatively few studies have examined diabetic patients' knowledge and understanding of A1C testing. Findings from one recent study conducted in Norway6 revealed that the majority (82.6%) of 201 adult patients with type 1 diabetes knew what their last A1C was, and most patients (90%) knew what a satisfactory A1C value would be. But a significant number of patients (42%) reported they had low knowledge of A1C testing in general. Furthermore, 25% of patients did not think that treatment intensification should occur at an A1C value of 10%. A recent cross-sectional study …

Factors Associated with Control of Type I Diabetes in Malaysian Adolescents and Young Adults

To examine the association between ethnicity, depression, quality of life, and diabetic control in Malaysian adolescents and young adults with type I diabetes mellitus. Fifty-two outpatients with type I diabetes (mean age 15.5 years) who attended a Diabetes Clinic were included. The level of HbA1c was the measure of diabetes control used (better control defined as HbA1c < 10%). Other variables were measured through questionnaires (e.g., depressive symptoms, quality of life), computerized diagnostic interviews (major depression), and medical records (e.g., demographic, family circumstances, compliance with treatment). Ethnic Chinese youth showed better diabetic control than Malays and Indians (mean HbA1c 9.1%, 10.3%, and 11.0% respectively). Young people with better diabetic control (HbA1c < 10%) were more likely to have better quality of life and less likely to live in problematic families. When the cut-off for diabetic control was stricter (HbA1c < or = 8%), the young person's compliance was the main predictor of poor control. Family problems were also associated with poor control but to a lesser extent. The initial association between poorer diabetes control and depression became non-significant when quality of life was taken into account. There are ethnic differences in juvenile diabetic control in this Malaysian sample which need to be understood further. Previous findings of an association between quality of life and glycemic control were verified but different definitions of good control showed different associations with individual and environmental variables. Clinicians' awareness and early intervention for psychosocial problems (for example, inadequate family support) could improve diabetes control.

Depression and diabetes symptom burden

Objective To examine the relationship among patient-reported diabetes symptoms, severity of depressive illness and objective measures of diabetes control and severity among a population-based sample of patients with diabetes. Methods A mailed survey was sent to all patients with diabetes from nine primary care clinics of a Health Maintenance Organization. The Patient Health Questionnaire (PHQ-9) was used to diagnose major depression, the Self-Completion Patient Outcome instrument assessed diabetes symptoms and automated medical record data were used to measure diabetes treatment intensity, HbA 1c levels, diabetes complications and medical comorbidity. Analysis of covariance (ANCOVA) was used to determine if the number of diabetes symptoms was related to having major depression and to number of depressive symptoms. Logistic regression analyses determined the relative strengths of the associations between each individual diabetic symptom and presence of major depression, HbA 1c levels above 8.0% and two or more diabetes complications. Results Among 4168 patients with diabetes, those with major depression ( N=487) reported significantly more diabetes symptoms (mean=4.40) than participants without depression (mean=2.46) after adjusting for demographic characteristics, objective measures of diabetes severity and medical comorbidity [ F(1,4029)=339.31, P<.0001]. The overall number of diabetes symptoms was related to the number of depressive symptoms (from 0 to 9) endorsed by participants [ F(9,4021)=110.05, P<.0001]. Logistic regression analyses found that depression was significantly related to each of the 10 diabetes symptoms (all P<.001). Conclusions The depression-diabetes symptom association is stronger than the association of diabetes symptoms with measures of glycemic control and diabetes complications.

P0408 PREVALENCE OF CELIAC DISEASE IN SAUDI CHILDREN WITH TYPE 1 DIABETES MELLITUS

Introduction: The association between celiac disease (CD) and type 1 diabetes mellitus (DM) was identified in 1969. Subsequently, the prevalence of CD in children with type 1 DM has been established to be about 2–5%. A relationship between the two conditions can in part be explained on the basis of a similar genetic background. Our aim is to study the prevalence of celiac disease in diabetic children from the western region of Saudi Arabia. Methods: A cohort of 110 diabetic children and adolescents attending the diabetic clinic at King Abdulaziz University Hospital were routinely screened for CD. Patients were tested using IgA Antigliadin (AGA-A) and or anti tissue transglutaminase (tTG) antibody. Results: 110 children (mean age 9.7 ± 3.8 years (range 1.12–18) with type-1 DM were screened for celiac disease. 63 (57%) were females. Out of 23 patients (21 %) identified as positive screening on one or more celiac serology tests, 14 (13%) underwent small bowel biopsy, 11 (10%) were found to have villous atrophy compatible with CD. Patients diagnosed as CD have a mean age at diagnosis of 11± 4.3 (range 3.56–18), Majority (82%) were asymptomatic. Comparing patients with positive screening tests (n=23) with those with negative screening (n=87), they tended to have a lower hemoglobin level (mean 11.87 vs 12.5, p < 0.05), however we did not find statistically significant differences between the two groups in either growth parameters (weight for age z-score, height for age z score, and body mass index) or measures of diabetic control (insulin dosage per kg body weight and hemoglobin A1c level). Conclusion: The prevalence of CD in diabetic children in Saudi Arabia is among the highest reported from European countries, therefore routine screening is justifiable.

Dietary advice for treatment of type 2 diabetes mellitus in adults.

While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available. To assess the effect of type and frequency of different types of dietary advice to all adults with type 2 diabetes on weight, measures of diabetic control, morbidity, total mortality and quality of life. We carried out a comprehensive search of The Cochrane Library (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October Week 1, 2003), EMBASE (1980 to Week 40, 2003), CINAHL (1982 to October Week 1, 2003), AMED (1985 to October 2003), bibliographies and contacted relevant experts. All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention in adults with type 2 diabetes mellitus. The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. For continuous outcomes, endpoint data were preferred to change data. Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias. There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.

Dietary advice for treatment of type 2 diabetes mellitus in adults.

While initial dietary management immediately after formal diagnosis is an 'accepted' cornerstone of treatment of type 2 diabetes mellitus, a formal and systematic overview of its efficacy and method of delivery is not currently available. To assess the effect of type and frequency of different types of dietary advice to all adults with type 2 diabetes on weight, measures of diabetic control, morbidity, total mortality and quality of life. We carried out a comprehensive search of The Cochrane Library (The Cochrane Library Issue 3, 2003), MEDLINE (1966 to October Week 1, 2003), EMBASE (1980 to Week 40, 2003), CINAHL (1982 to October Week 1, 2003), AMED (1985 to October 2003), bibliographies and contacted relevant experts. All randomised controlled trials, of six months or longer, in which dietary advice was the main intervention in adults with type 2 diabetes mellitus. The lead investigator performed all data extraction and quality scoring with duplication being carried out by one of the other six investigators independently with discrepancies resolved by discussion and consensus. Authors were contacted for missing data. For continuous outcomes, endpoint data were preferred to change data. Thirty-six articles reporting a total of eighteen trials following 1467 participants were included. Dietary approaches assessed in this review were low-fat/high-carbohydrate diets, high-fat/low-carbohydrate diets, low-calorie (1000 kcal per day) and very-low-calorie (500 kcal per day) diets and modified fat diets. Two trials compared the American Diabetes Association exchange diet with a standard reduced fat diet and five studies assessed low-fat diets versus moderate fat or low-carbohydrate diets. Two studies assessed the effect of a very-low-calorie diet versus a low-calorie diet. Six studies compared dietary advice with dietary advice plus exercise and three other studies assessed dietary advice versus dietary advice plus behavioural approaches. The studies all measured weight and measures of glycaemic control although not all studies reported these in the articles published. Other outcomes which were measured in these studies included mortality, blood pressure, serum cholesterol (including LDL and HDL cholesterol), serum triglycerides, maximal exercise capacity and compliance. The results suggest that adoption of regular exercise is a good way to promote better glycaemic control in type 2 diabetic patients, however all of these studies were at high risk of bias. There are no high quality data on the efficacy of the dietary treatment of type 2 diabetes, however the data available indicate that the adoption of exercise appears to improve glycated haemoglobin at six and twelve months in people with type 2 diabetes. There is an urgent need for well-designed studies which examine a range of interventions, at various points during follow-up, although there is a promising study currently underway.

BEDSIDE SCORING PROCEDURE FOR THE DIAGNOSIS OF DIABETIC PERIPHERAL NEUROPATHY IN YOUNG PATIENTS WITH TYPE 1 DIABETES MELLITUS

Objective: To test the applicability of a bedside scoring method for screening for diabetic peripheral neuropathy (DPN) in patients with type 1 diabetes mellitus (DM) in an ambulatory clinic. The prevalence of DPN was estimated and its risk factors identified. Methods: A total of 217 patients (102 males) with type 1 DM, median age 23.4 years (7.5–49 years) and median duration of DM 13.2 years (1–34 years) were evaluated for DPN using the bedside Neuropathy Disability Score (NDS). A score of 3–5 indicated mild DPN, 6‐8 moderate DPN and 9–10 severe DPN. The presence of DPN was correlated with possible predictive factors. Results: The NDS was reliable and highly reproducible. The overall prevalence of DPN was 17.1%: mild in 14.3%, moderate in 2.3%, and severe in 0.5% of patients. The prevalence and severity of DPN were significantly related to long‐term glycemic control (p&lt;0.001), DM duration (p&lt;0.005), age (p=0.005), and duration of pubertal DM duration (p=0.03). The prevalence of DPN was significantly associated with the presence of retinopathy (p&lt;0.002) and overt proteinuria (p&lt;0.005). Conclusions: The NDS is a simple, reliable and reproducible screening method for use in the ambulatory clinic to identify the early signs of DPN, leading to early institution of intensive diabetes control measures and preventive foot care.

Effects of gemfibrozil on insulin resistance to fat metabolism in subjects with type 2 diabetes and hypertriglyceridaemia

To examine whether lowering of plasma triglyceride concentrations using the fibrate peroxisome proliferator-activated receptor (PPAR)alpha agonist gemfibrozil would influence insulin sensitivity to various aspects of intermediary metabolism among subjects with type 2 diabetes mellitus. A randomized placebo-controlled double-blind study in 12 subjects with type 2 diabetes were treated for 12 weeks after a 12-week dietary run-in. Insulin sensitivity was assessed using a low-dose incremental intravenous insulin infusion. Gemfibrozil significantly reduced fasting serum triglyceride concentrations (p < 0.001) but had no effect on measures of diabetic control. Neither gemfibrozil nor placebo treatment altered insulin sensitivity of glucose or glycerol metabolism during low-dose insulin infusion, but significant falls in both non-esterified fatty acid (NEFA) (p = 0.003) and ketone concentrations (p = 0.002) were observed after treatment with gemfibrozil. Gemfibrozil does not affect insulin sensitivity to glucose or fat metabolism in type 2 diabetes but enhances the lowering of plasma NEFA concentrations by insulin, probably by reducing hepatic fatty acid synthesis.

Bedside scoring procedure for the diagnosis of diabetic peripheral neuropathy in young patients with type 1 diabetes mellitus.

To test the applicability of a bedside scoring method for screening for diabetic peripheral neuropathy (DPN) in patients with type 1 diabetes mellitus (DM) in an ambulatory clinic. The prevalence of DPN was estimated and its risk factors identified. A total of 217 patients (102 males) with type 1 DM, median age 23.4 years (7.5-49 years) and median duration of DM 13.2 years (1-34 years) were evaluated for DPN using the bedside Neuropathy Disability Score (NDS). A score of 3-5 indicated mild DPN, 6-8 moderate DPN and 9-10 severe DPN. The presence of DPN was correlated with possible predictive factors. The NDS was reliable and highly reproducible. The overall prevalence of DPN was 17.1%: mild in 14.3%, moderate in 2.3%, and severe in 0.5% of patients. The prevalence and severity of DPN were significantly related to long-term glycemic control (p < 0.001), DM duration (p < 0.005), age (p = 0.005), and duration of pubertal DM duration (p = 0.03). The prevalence of DPN was significantly associated with the presence of retinopathy (p < 0.002) and overt proteinuria (p < 0.005). The NDS is a simple, reliable and reproducible screening method for use in the ambulatory clinic to identify the early signs of DPN, leading to early institution of intensive diabetes control measures and preventive foot care.

Relation of diabetic patients' health-related control appraisals and physician-patient interpersonal impacts to patients' metabolic control and satisfaction with treatment.

Desire for healthcare control, health locus of control, perceived control over diabetes, satisfaction with diabetes treatment, and general personality traits were assessed in 54 Type 1 and Type 2 diabetic patients of the same male endocrinologist during a regularly scheduled office visit. At the end of the consultation, both patients and the physician completed a measure describing the interpersonal impacts produced in each by the other's control and affiliation behaviors. Patient success at diabetes control was assessed via glycosylated hemoglobin A1C (HA1C) level on the day of the visit and variability in HA1C levels across several visits. Patients' satisfaction with treatment was unrelated to diabetes control measures. Patients' desire for behavioral involvement in their own healthcare and NEO Agreeableness scores were positively associated with diabetes control. Better diabetes control also resulted when the physician perceived patients to be more controlling and less submissive, and when there was more reciprocity in patient and physician's perceptions of the other's controlling interpersonal behavior. Findings support the conclusion that both a patient's self-reported desire for involvement in his or her healthcare and the transactional fit of patient-physician interpersonal behaviors are potentially important contributors to better diabetes outcomes.

Deteriorating diabetic control through adolescence-do the origins lie in childhood?

To determine whether intra-individual measures of diabetes control deteriorated through adolescence and whether HbA1c in late childhood was predictive of HbA1c after adolescence. Retrospective analysis of sequential 3-6 monthly data including HbA1c, height, weight, and total daily insulin dosage in 118 patients with Type 1 diabetes aged between 8.00 and 17.99 years between 1983 and 1999. In females mean body mass index (BMI) increased sharply during adolescence but there was no significant increase in males. The mean total daily dose of insulin/weight (TDDI/W) increased sharply for females through puberty. Males exhibited a constant rate of increase in mean TDDI/W from pre- to post-puberty. There was a constant increase in mean HbA1c for females, with an estimated increase from pre- to post-puberty of 0.92%. In males there was only a slight increase from pre- to peri-puberty and no change subsequently. Comparing pre-puberty (8-9.99 years) and post-puberty (15-17.99 years) in the total group, 47% of patients remained in the same mean HbA1c grouping, 37% had worsened control and 16% had improved control. Analysis of change in the absolute value of mean HbA1c showed that the majority of patients had mean HbA1c values that remained within +/- 1% (54%) or +/- 2% (82%) from pre- to post-puberty. A significant proportion showed significantly worsening control with only a minority showing improved metabolic control from pre- to post-puberty. The likelihood of a significant improvement in HbA1c from late childhood to adolescence is remote, with the majority of patients having either constant or deteriorating metabolic control.

PDB15: DOES PATIENT EXPERIENCE MATTER? TYPE II DIABETES PATIENTS' STATED PREFERENCES FOR INSULIN THERAPIES

OBJECTIVES: Patient preferences for alternative treatments may be affected by health status and experience with the treatment. Randomized Clinical Trials (RCTs) offer a unique opportunity to collect preference data while controlling for patient experience. METHODS: Patients with Type II diabetes in a large US RCT answered a series of stated preference (conjoint format) questions regarding attributes of alternative insulin therapies. All patients are insulin-naive and take insulin as part of the trial. Preference data is collected before the patient begins insulin, after 3 months, and after 6 months of insulin therapy. Insulin attributes include the frequency of insulin injections, method of injection (syringe or pen), glucose control and frequency of hypoglycemia. Personal health data such as glucose control are collected at each administration of the stated preference survey. RESULTS: Preferences are analyzed in an ordered probit panel model that controls for individual health status. Insulin administration attributes have the largest importance scores. The importance score of the insulin injection frequency attribute decreases during the later observation points. While few patients experience nighttime hypoglycemia, this attribute is significant and has a larger importance score than glucose control. CONCLUSIONS: Patient experience significantly affects patient preferences and the derived pharmacoeconomic measures and should be controlled in preference experiments. Results suggest that some insulin-naive patients are more averse to insulin injections before they begin insulin therapy. Results also suggest that increased experience with diabetes control measures during the trial affects treatment preferences.

Fructosamine, hemoglobin A1c, and measures of diabetic control.

Fructosamine, hemoglobin A1c, and measures of diabetic control.

Evaluation of a Food Label Nutrition Intervention for Women with Type 2 Diabetes Mellitus

Objective To evaluate an educational intervention about the food label designed specifically for women with type 2 diabetes mellitus. Design A pretest-posttest control group design. Participants received random group assignment. Subjects/setting Forty-three women aged 40 to 60 years with type 2 diabetes living in a rural community in Pennsylvania participated. Forty participants (93%) completed the program. Intervention Nine weekly group sessions were developed on the basis of findings from previous research among this sample. Principles from Ausubel's learning theory were also incorporated into program design and evaluation. Main outcome measures The effectiveness of the food label education program on participants' knowledge was determined using a multiple-choice test designed to measure declarative and procedural knowledge. A skills inventory assessed participants' perceived confidence in using the food label. The validity and reliability of the instruments had been established previously. Statistical analyses Analysis of variance was performed to compare groups. Paired t tests compared pretest and posttest results. Results The experimental group showed a greater gain than the control group in total knowledge ( P<.001), declarative knowledge ( P<.001), and procedural knowledge ( P<.01) at posttest. Posttest data showed a significant increase ( P<.01) in experimental participants' perceived confidence in using the food label. Conclusions Women with diabetes need more education about the food label. This intervention is an effective outpatient education program. Participant knowledge and perceived confidence in using the food label improved significantly as a result of the intervention. Future research should assess retention of knowledge gained and the impact of the intervention on metabolic measures of diabetes management and control. J Am Diet Assoc. 1999;99: 323–328.