Persistent Poor Glycaemic Control Research Articles

Persistent poor glycaemic control in individuals with type 2 diabetes in developing countries: 12\xa0years of real-world evidence of the International Diabetes Management Practices Study (IDMPS)

Aims/hypothesisWe evaluated the secular trend of glycaemic control in individuals with type 2 diabetes in developing countries, where data are limited.MethodsThe International Diabetes Management Practices Study provides real-world evidence of patient profiles and diabetes care practices in developing countries in seven cross-sectional waves (2005–2017). At each wave, each physician collected data from ten consecutive participants with type 2 diabetes during a 2 week period. The primary objective of this analysis was to evaluate trends of glycaemic control over time.ResultsA total of 66,088 individuals with type 2 diabetes were recruited by 6099 physicians from 49 countries. The proportion of participants with HbA1c <53 mmol/mol (<7%) decreased from 36% in wave 1 (2005) to 30.1% in wave 7 (2017) (p < 0.0001). Compared with wave 1, the adjusted ORs of attaining HbA1c ≤64 mmol/mol (≤8%) decreased significantly in waves 2, 5, 6 and 7 (p < 0.05). Over 80% of participants received oral glucose-lowering drugs, with declining use of sulfonylureas. Insulin use increased from 32.8% (wave 1) to 41.2% (wave 7) (p < 0.0001). The corresponding time to insulin initiation (mean ± SD) changed from 8.4 ± 6.9 in wave 1 to 8.3 ± 6.6 years in wave 7, while daily insulin dosage ranged from 0.39 ± 0.21 U/kg (wave 1) to 0.33 ± 0.19 U/kg (wave 7) for basal regimen and 0.70 ± 0.34 U/kg (wave 1) to 0.77 ± 0.33 (wave 7) U/kg for basal–bolus regimen. An increasing proportion of participants had ≥2 HbA1c measurements within 12 months of enrolment (from 61.8% to 92.9%), and the proportion of participants receiving diabetes education (mainly delivered by physicians) also increased from 59.0% to 78.3%.ConclusionsIn developing countries, glycaemic control in individuals with type 2 diabetes remained suboptimal over a 12 year period, indicating a need for system changes and better organisation of care to improve self-management and attainment of treatment goals.

The Role of Occupational Therapy in Secondary Prevention of Diabetes.

Diabetes mellitus is becoming a global health concern due to its prevalence and projected growth. Despite a growing number of interventions for secondary prevention of diabetes, there is a persistent poor glycemic control and poor adherence to the prescribed diabetes management regimen. In light of the tremendous costs of diabetes to both individuals and the society, it is pressing to find effective ways to improve diabetes self-management (DSM) and treatment adherence. Occupational therapists can bring values to the diabetes care team by evaluating multiple levels of influence on DSM, addressing personal and environmental barriers to well-being and DSM, and supporting patients to develop of a highly complex competences and skills to satisfactorily self-manage diabetes. This article summarizes two evidence-based, well-structured occupational therapy (OT) programs that use activity-based treatments and psychosocial strategies, respectively, to improve DSM abilities and to enhance quality of life. As the needs of adolescents with diabetes are quite different from other diabetic populations, this article also provides a summary of pediatric OT interventions that aim to facilitate autonomy and development of DSM ability among adolescents with diabetes. Evidence indicates that OT interventions can improve the quality of life and treatment adherence in patients with diabetes and hence should be continued and built on to address the increasing needs of diabetic populations.

Burden of Cardiovascular Risk Factors Over Time and Arterial Stiffness in Youth With Type 1 Diabetes Mellitus: The SEARCH forDiabetes in Youth Study.

BackgroundThe incidence of type 1 diabetes mellitus (T1DM) in children is increasing, resulting in higher burden of cardiovascular diseases due to diabetes mellitus–related vascular dysfunction.Methods and ResultsWe examined cardiovascular risk factors (CVRFs) and arterial parameters in 1809 youth with T1DM. Demographics, anthropometrics, blood pressure, and laboratory data were collected at T1DM onset and 5 years later. Pulse wave velocity and augmentation index were collected with tonometry. ANOVA or chi‐square tests were used to test for differences in measures of arterial parameters by CVRF. Area under the curve of CVRFs was entered in general linear models to explore determinants of accelerate vascular aging. Participants at the time of arterial measurement were 17.6±4.5 years old, 50% female, 76% non‐Hispanic white, and duration of T1DM was 7.8±1.9 years. Glycemic control was poor (glycated hemoglobin, 9.1±1.8%). All arterial parameters were higher in participants with glycated hemoglobin ≥9% and pulse wave velocity was higher with lower insulin sensitivity or longer duration of diabetes mellitus. Differences in arterial parameters were found by sex, age, and presence of obesity, hypertension, or dyslipidemia. In multivariable models, higher glycated hemoglobin, lower insulin sensitivity, body mass index, blood pressure, and lipid areas under the curve were associated with accelerated vascular aging.ConclusionsIn young people with T1DM, persistent poor glycemic control and higher levels of traditional CVRFs are independently associated with arterial aging. Improving glycemic control and interventions to lower CVRFs may prevent future cardiovascular events in young individuals with T1DM.

The 2016 International Society for Heart Lung Transplantation listing criteria for heart transplantation: A 10-year update

Mandeep R. Mehra, MD (Chair), Charles E. Canter, MD, Margaret M. Hannan, MD, Marc J. Semigran, MD, Patricia A. Uber, PharmD, David A. Baran, MD, Lara Danziger-Isakov, MD, MPH, James K. Kirklin, MD, Richard Kirk, MD, Sudhir S. Kushwaha, MD, Lars H. Lund, MD, PhD, Luciano Potena, MD, PhD, Heather J. Ross, MD, David O. Taylor, MD, Erik A.M. Verschuuren, MD, PhD, Andreas Zuckermann, MD and on behalf of the International Society for Heart Lung Transplantation (ISHLT) Infectious Diseases, Pediatric and Heart Failure and Transplantation Councils

Experience of short-term continuous glucose monitoring in people with Type 1 diabetes with persistent poor glycemic control

SUMMARY Aim: This study assessed the effect of short/intermittent use of continuous glucose monitoring in poorly controlled Type 1 diabetes. Methods: A 6-month, multicenter, single-arm, pilot study, enrolling 32 people on multiple daily injections who had completed a structured education program. The primary end point was to evaluate HbA1c change from baseline to 6 months. Results: Median HbA1c change from baseline was -0.4% at day 21, -0.3% at day 95 and -0.3% at 6 months. At 6 months, 44% of participants had a ≥0.5% HbA1c reduction from baseline. Hypoglycemia frequency and time spent in hypoglycemia did not change. Conclusion: Short/intermittent use of continuous glucose monitoring with real-time glucose values, in conjunction with a healthcare professional diabetes management review, resulted in significant HbA1c improvements.

Characteristics of Children with Type 1 Diabetes and Persistent Suboptimal Glycemic Control

Objective: This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.Methods: A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children’s National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39).Results: Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in >25% of patients.Conclusion This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention. Conflict of interest:None declared.

Guided self-determination improves life skills with Type 1 diabetes and A1C in randomized controlled trial

Objective To report 1-year results of newly developed method, guided self-determination (GSD), applied in group training (GSD-GT) for Type 1 diabetes patients with persistent poor glycaemic control. Methods GSD was designed on the basis of qualitative research to help patients develop life skills with diabetes using worksheets filled in at home and coached by nurses in mutual reflection. We randomized 18–49-year-old adults at a Danish university hospital to either 16 h GSD-GT in 2001 or to similar training 1 year later. Inclusion criteria: mean A1C ≥ 8.0% for at least 2 years, disease onset ≤40 years and insulin treatment from onset. Results Thirty GSD-GT patients and 20 controls completed the study. GSD-GT patients did better than control patients in terms of (a) increased autonomy support perceived from health professionals ( p < 0.01); (b) higher frequency of self-monitored blood glucoses ( p < 0.001); (c) increased perceived competence in managing diabetes ( p < 0.01); (d) fewer diabetes-related problems ( p < 0.05); and (e) improved glycaemic control ( p < 0.01). Conclusion GSD was effective in improving life skills with diabetes, including A1C, over a period of 1 year. Practice implications GSD is a worthy candidate for further research. We consider it adjustable to people with type 2 diabetes and other chronic conditions.

Short‐term effects of cognitive behavioural group training (CBGT) in adult Type 1 diabetes patients in prolonged poor glycaemic control. A randomized controlled trial

To assess the effects of cognitive behavioural group training (CBGT) on glycaemic control, diabetes self-efficacy and well-being in Type 1 diabetes patients in persistent poor glycaemic control. In a randomized controlled trial, a total of 107 patients with Type 1 diabetes in poor glycaemic control (HbA(1c) > or = 8%) were assigned to a 6-week CBGT or blood glucose awareness training (BGAT) as control condition. The intervention was preceded by a 3-month run-in period. Glycaemic control (HbA(1c)), diabetes-specific self-efficacy (CIDS), diabetes-related distress (PAID) and depressive symptoms (CES-D), were assessed at baseline (T1), directly before (T2) and 3 months after (T3) the intervention. No significant changes in HbA(1c) were found after CBGT, whilst diabetes self-efficacy increased (mean CIDS score 71.6 +/- 14.0 to 74.3 +/- 12.2) and diabetes-related distress (mean PAID score 47.0 +/- 21.6 to 42.6 +/- 20.8) and depressive symptoms decreased (mean CES-D score 16.9 +/- 12.8 to 13.5 +/- 12.6). Changes in psychological outcomes were similar for both treatment groups. Diabetes self-care behaviours improved equally. Drop-out rate, which was higher among CBGT participants, was relatively low overall (total n = 15, 17.05%), and both interventions were well-appreciated by the participants. CBGT was successful in improving self-efficacy, diabetes-related distress and mood at 3 months' follow-up, but not in improving glycaemic control.

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes.

Cognitive behavioural group training (CBGT) for patients with type 1 diabetes in persistent poor glycaemic control: who do we reach?

Approximately a quarter of adults with type 1 diabetes do not succeed in achieving satisfactory glycaemic control, partly due to problems with the demanding self-management regimen. To improve glycaemic control, interventions with a cognitive behavioural approach, aimed at modifying dysfunctional beliefs, reducing negative emotions and enhancing self-care practices are a potentially successful tool. Little is known about the reach of such an approach. This article describes characteristics of participants in a randomized, controlled trial of cognitive behavioural group training for patients with type 1 diabetes in poor glycaemic control. Results show that outpatients from seven hospitals in the area of Amsterdam, selected on long-standing high HbA1c and volunteering to participate, report high levels of psychological distress and depressive symptoms. Furthermore, self-care behaviours were perceived as important, but burdensome. Diabetes-specific self-efficacy was relatively low. It is concluded that this selected group of adults with type 1 diabetes would potentially benefit from a cognitive-behavioural intervention in order to reduce negative emotions, enhance diabetes self-efficacy, self-care behaviour and glycaemic outcomes.

Effects of cognitive behavioural group training (CBGT) in adult patients with poorly controlled insulin-dependent (type 1) diabetes: a pilot study

A substantial group of patients with type 1 diabetes has difficulty adhering to the treatment regimen, and as a consequence is at increased risk of developing microvascular complications. Cognitive behavioural interventions may help these patients to cope more effectively with their diabetes. We developed a 4 weeks cognitive behavioural group training (CBGT) for patients with type 1 (insulin-dependent) diabetes in persistent poor glycaemic control, to help them overcome negative beliefs and attitudes towards diabetes and improve their self-care behaviours. Feasibility and efficacy of CBGT were tested in a non-randomised prospective study in 24 poorly-controlled type 1 diabetes patients (mean age 35.2±11.1years; 15 female; mean HbA 1c 9.3% (±1.2)), with assessments at 3 and 6 months follow-up. The programme was delivered in small groups ( n=6–8), by a team of a diabetes nurse specialist and a psychologist. Primary outcome measures were glycosylated haemoglobin (HbA 1c), diabetes-related emotional distress (PAID) and psychological well-being (WBQ-12). Changes in diabetes self-care activities (DSCI) were documented, along with perceived barriers in diabetes questionniare (BDQ) and fear of hypoglycaemia survey (HFS). Data were analysed using repeated measures analysis of variance. The CBGT proved to be feasible in this selected group of patients and was well appreciated. Following CBGT, mean HbA 1c dropped by 0.8% at 6 months from baseline, while emotional well-being was preserved. It is concluded that CBGT is a promising intervention that deserves further evaluation in randomised controlled trials.

Evaluation of a holistic treatment and teaching programme for patients with Type 1 diabetes who failed to achieve their therapeutic goals under intensified insulin therapy.

To evaluate a treatment and teaching programme including psychosocial modules for patients with Type 1 diabetes mellitus on intensified insulin therapy who failed to achieve their treatment goals despite participation in standard programmes. The 5-day inpatient programme comprises small groups of 4-6 patients, focusing on individual needs and problems. Beyond the teaching lessons (most topics are deliberately chosen by the patients), the programme provides intensive group discussions and offers individual counselling concerning motivational aspects, psychosocial problems and coping strategies. Of the first consecutive 83 participants, 76 were re-examined after 17.5 +/- 5.5 months (range 9-31 months). At follow-up, HbA1c was not improved compared to baseline (8.0 +/- 1.3% vs. 8.1 +/- 1.5%). However, the incidence of severe hypoglycaemia per patient/year (glucose i.v., glucagon injection) was substantially decreased: 0.62 +/- 1.5 episodes at baseline compared to 0.16 +/- 0.9 at follow-up (P < 0.001). Twenty-six per cent of the patients at baseline, and 4% at re-examination had experienced at least one episode of severe hypoglycaemia during the preceding year (P < 0.001). Sick leave days per patient/year decreased from 17.0 +/- 38.5-7.7 +/- 13.6 days (P < 0.05). Patients improved their perceptions of self-efficacy, their relationship to doctors and felt less externally controlled (P < 0.001). The majority of patients perceived an improved competence regarding diet (80.6%) and adaptation of insulin dosage (82.4%), an improved knowledge (82.2%), and a renewed motivation for the treatment (84.5%). Treatment success was significantly associated with baseline HbA1c, stability of motivation, frequency of blood glucose self-monitoring, control beliefs and change in subsequent outpatient care. The programme improved glycaemic control mainly as a result of a substantial reduction in the incidence of severe hypoglycaemia. Patients with persistent poor glycaemic control may benefit from structured follow-up care focusing on motivational aspects of self-management and psychosocial support.