Patient Characteristics do not Predict Poor Glycaemic Control in type 2 Diabetes Patients Treated in Primary Care

Many diabetic patients in general practice do not achieve good glycaemic control. The aim of this study was to assess which characteristics of type 2 diabetes patients treated in primary care predict poor glycaemic control (HbA1c > or = 7%). Data were collected from the medical records. 1641 patients were included who had mean HbA1c 7.1(SD 1.7)% , and 42% had HbA1c > or = 7%. On univariate analysis younger age; longer duration of diabetes; higher levels of blood glucose at diagnosis; most recent fasting blood glucose (FBG), total cholesterol, and triglyceride; higher body mass index (BMI); treatment with oral hypoglycaemic agents (OHA); treatment with insulin; more GP-visits for diabetes in the last year; and lower educational level were associated with poor control. Both in multiple linear regression and in multiple logistic regression higher levels of FBG (odds ratio (OR): = 1.6, 95% confidence interval (CI): 1.49, 1.70), treatment with OHA (OR: 2.1, 95% CI: 1.41, 3.04), treatment with insulin (OR: 7.2, 95% CI: 4.18, 12.52), lower educational level (OR: 1.26, 95% CI: 1.01, 1.56) were independently associated with poor levels of HbA1c. When FBG levels were excluded from the model, higher blood glucose at diagnosis, higher values for triglyceride and total cholesterol, and younger age predicted poor glycaemic control, but these variables explained only 15% of the variation in HbA1c. In conclusion prediction of poor glycaemic control from patient characteristics in diabetic patients in general practice is hardly possible. FBG appeared to be a strong predictor of HbA1c, which underlines the usefulness of this simple test in daily diabetes care. The worse metabolic control in those treated with either OHA or insulin suggests that current treatment regimes might be not sufficiently applied to reach the targets of care. Providers of diabetes care should be attentive to patients with lower educational level.     

Social and psychological characteristics of Kuwaiti children and adolescents with type 1 diabetes

Type 1 diabetes mellitus is a chronic disease that may have an impact on children's psychosocial adjustment. This study aimed to investigate the psychosocial characteristics of Kuwaiti children with type 1 diabetes as compared to healthy children without diabetes, and assess the impact of glycaemic control on psychosocial variables. A total of 349 school children aged 6-18 years with type 1 diabetes, and 409 children without diabetes having comparable age, gender, and social class were included in the study. Data were obtained by interviewing children and parents using a questionnaire. Psychological distress was measured by the Hopkins symptoms checklist-25 scale including anxiety and depression. Glycaemic control was assessed by glycosylated haemoglobin, HbA(IC) level. Glycaemic control was considered 'good to excellent' at HbA(IC)<8.0%, 'fair' at HbA(IC) 8.1 to 10.0%, and 'poor' at HbA(IC)>10.0%. Median scores of anxiety, depression, and total distress were significantly higher in children with diabetes indicating worse psychological adjustment. There was also significant difference between children with diabetes and those without diabetes in social aspects and school absence days. There was significant positive correlation between HbA(IC) concentration and scores of the psychological functioning indices. Children with poor glycaemic control had worse psychological adjustment. After controlling the variance accounted by gender and age, stepwise multiple regression analysis showed that girls, older children, children in need of emotional support, and those with higher HbA(IC) were at higher risk for psychological maladjustment. These variables explained 47.9% of the variation in total distress. In conclusion, the study supported our hypotheses. Children with diabetes had worse psychological adjustment, and distress was related to glycaemic control. Since psychological distress increases the risk for future complications due to its relation with glycaemic control, longitudinal studies are recommended to identify children with diabetes having distress at an early stage when preventive interventions are effective.     

Initiating insulin therapy in patients with diabetes mellitus type 2: in a transmural setting is at least as effective as in an outpatient setting; a retrospective study with a 4-year follow-up

OBJECTIVE: Assessing whether the initiation of insulin therapy in patients with diabetes mellitus type 2 can be delivered as effectively in a structured transmural care model as in the more usual outpatients structure. DESIGN: Retrospective comparative cohort study. METHOD: In 1997 data were collected from 52 patients with diabetes mellitus type 2 all of whom were above 40 years of age and transferred to insulin therapy in 1993: 25 in a transmural care setting and 27 in an outpatients setting, both in Amsterdam, the Netherlands. Both groups were treated according to one protocol concerning the initiation and monitoring of insulin therapy, treatment goals and follow-up. Outcome measures were: percentage of glycated haemoglobin (HbA1c), health status, self-care behaviour and patient satisfaction. In 1993 the mean age was (transmural/outpatients setting): 67.5/65.3 years; percentage of men: 32%/48%; mean duration of diabetes: 7.3/10.6 years; HbA1c: 9.1%/9.3%; mean body mass index: 27.4/29.1 kg/m2. RESULTS: In the period 1993-1997 the mean HbA1c decreased from 9.1% to 7.2% in the transmural care group and from 9.3% to 7.6% in the outpatients care group (both: p = 0.000). The percentage of patients with poor glycaemic control (HbA1c > 8%) decreased from 60 to 8 in the transmural care group and from 59 to 15 in the outpatients care group. The percentage of patients with good glycaemic control (HbA1c < 7%) increased from 4 to 52 in the transmural care group and from 11 to 30 in the outpatients care group. No statistically significant differences were found between the patient groups with respect to health status, self-care behaviour and patient satisfaction. CONCLUSION: The transfer of patients with diabetes mellitus type 2 insulin therapy in a shared care setting was at least as effective as in an outpatients setting.     

Diet and weight gain of elderly diabetic patients

Abstract

Objective: To assess glycaemic control among Estonian patients with type 2 diabetes mellitus (DM2) and to find patient and disease related factors associated with adequate glycaemic control. Methods: A cross-sectional study of 200 randomly selected DM2 patients from a primary care setting. Data on each patient's glycosylated haemoglobin (HbA1c), body mass index, blood pressure, and medications for treatment of DM2 were provided by family doctors. A structured patient questionnaire was administered as a telephone interview (n = 166). The patients’ self-management behaviour, awareness of the HbA1c test and its recent value were inquired. Results: The mean HbA1c of the DM2 patients was 7.5%. The targets of DM2 treatment were achieved as follows: 39% of the patients had HbA1c below 6.5% and half the patients had HbA1c below 7%. More than third of the patients had systolic blood pressure below 140 mmHg and in 51% of the patients diastolic blood pressure was below 85 mmHg. Six per cent of the patients were in normal weight (<25 kg/m²). Fifty-two per cent of the patients were aware of the HbA1c test and 36% of them knew its recent value. In multivariate regression analysis, awareness of the HbA1c test but not the HbA1c value, longer duration of diabetes and not having a self-monitoring device were independently associated with adequate glycaemic control (HbA1c< 6.5%).

Conclusion: The studied DM2 patients often did not reach the clinical targets suggested in the guidelines. Awareness of the HbA1c test was related to better glycaemic control. However, advanced stage of the disease had a negative effect on HbA1c.     

Continuous subcutaneous insulin infusion is sometimes a good choice in case of poorly regulated diabetes mellitus type I

Continuous subcutaneous insulin infusion (CSII) was initiated in 3 patients with diabetes mellitus type I who experienced difficulties with their glucose regulation: a woman aged 26 years and two men aged 56 and 41 years. 2 patients responded very well, while the third, the youngest man, did not benefit. Although interest in CSII has been growing in recent years, considerable uncertainty exists about which patients will benefit from it. In most studies, patients have attained a lower HbA,, and fewer blood glucose fluctuations. Recently, the advantages of CSII have been confirmed in 2 large studies in patients with diabetes mellitus type I. Motivated patients in poor glycaemic control seem to benefit most from CSII. Some questions remain, especially whether these advantages can be confirmed in studies comparing CSII with injection regimens using the new long-acting insulin analogues. Motivated patients in poor control and those with an unpredictable daily life, needing a flexible mode of therapy, should not be denied a trial of CSII.     

Serum Trace Element Levels and Their Correlation with Picky Eating Behavior,Development, and Physical Activity in Early Childhood

Trace elements are vital components for healthy growth, development, and physical activity. The aim of this study was to investigate the relationship between trace element (iron, zinc, copper) deficiencies and picky eating behavior, development level, and physical activity level. This cross-sectional study involved 203 children aged 4–7 years; picky eating behavior, development level, and physical activity level were assessed through questionnaires. Zinc deficiency has the highest prevalence (37.4%); 67.5% of the children were assessed as picky eaters. Children with picky eating behaviors, poor development level, or poor physical activity level have significantly lower zinc levels, and higher prevalence of zinc deficiency. Pearson’s correlation coefficient indicated a positive correlation between serum zinc level and development scores (r = 0.221, p = 0.002) and physical activity scores (r = 0.469, p < 0.001). In multivariate analysis, zinc deficiency independently related to picky eating (OR = 2.124, p = 0.037, CI = 1.042–4.312), developmental level (OR = 0.893, p = 0.022, CI = 0.810–0.984), and physical activity level (OR = 0.785, p < 0.001, CI = 0.700–0.879). In conclusion, the prevalence of zinc deficiency in children aged 4–7 was high, especially in picky eaters. Zinc deficiency was significantly associated with low development and poor physical activity in early childhood.     

Hypoglycaemic and hypolipidaemic effects of low GI and medium GL Indian diets in type 2 diabetics for a period of 4 weeks: A prospective study

This prospective study reports significant hypoglycaemic and hypolipidaemic effects in type 2 diabetic subjects who were provided the complete diet plan to be on low glycaemic index (GI) and low-medium glycaemic load (GL) Indian vegetarian snacks and mixed meals for 4 continuous weeks. Five millilitres of fasting blood sample drawn at weekly intervals for 4 weeks were analysed for blood glucose, HbA1c and lipid profile. Four weeks later mean blood glucose level of 173.6 mg% decreased to 137.8 mg%, HbA1c of 8% also decreased to 7.1% which reflected the blood glucose level during the study period and hence correlated well with the fall in blood glucose level. Triglyceride level of 244.5 mg% decreased to 164.7 mg% (p < 0.0001) and total cholesterol of 173.5 mg% decreased to 134.6 mg% (p < 0.0001). High-density lipoprotein cholesterol of 33 mg% increased to 39.8 mg% (p < 0.003), very low density lipoprotein (VLDL) cholesterol of 48.9 mg% decreased to 32.9 mg% (p < 0.0001) and low-density lipoprotein cholesterol of 90.1 mg% decreased to 64.3 (p < 0.009). This significant outcome can be improved further if compliance to low GI and low-to-medium GL diet is continued. This may achieve desired glycaemic control and that's limit oxidative stress.     

Quality of life and coping behaviour in Type 1 diabetes mellitus: relationship with metabolic control

Uncovering factors possibly leading to insufficient metabolic control in Type 1 diabetes, both on the part of the patient or the treating physician, is of considerable relevance. The present long-term study investigated the relevance of patient-related vs education-related factors for the success in achieving acceptable glycaemic control. Adolescents or young adults with Type 1 diabetes mellitus (n= 26, mean age= 22+/-2 yr, diabetes duration= 11+/-5 yr) were followed during 36+/-5 months. All patients were treated by the same diabetologist. At the beginning of the study coping behaviour, quality of life and evaluation of emotional status were assessed. Changes in HbA1c were used as a parameter of glycaemic control. At follow-up there was a significant decrease in HbA1c of 0.4% (p<0.01). However, this was not in statistically significant correlation with age, gender, aspects of quality of life or coping behaviour. Therefore, glycaemic control and/or improvement of glycaemic control in adolescents or young adults with Type 1 diabetes mellitus seems to be primarily related to other factors, eg continuous education provided in a stable setting.     

Italian multicentre study of intensive therapy with insulin lispro in 1184 patients with Type 1 diabetes

Insulin lispro is absorbed more rapidly and has a shorter duration of action than regular human insulin. It improves glycaemic control but large-scale studies are required to identify regimens that optimise efficacy and safety with local dietary habits. This study involved 1184 Italian patients with Type 1 diabetes, randomised to insulin lispro (n=586) or regular human insulin (n=598) as pre-meal bolus for 3 months. Optimisation of basal NPH insulin was carried out in both groups. The number of administrations of NPH insulin was increased when using insulin lispro but, because basal and bolus insulins were mixed before meals, the total number of injections per day was unchanged. Compliance to administration time was significantly (p<0.001) greater with insulin lispro than with regular human insulin. Post-prandial blood glucose levels were lower with insulin lispro after breakfast (p<0.001), lunch (p<0.005) and dinner (p<0.001). The HbA1c level was decreased from baseline by both insulins, but the percent increase in patients with acceptable (<8%) HbA1c was greater with insulin lispro. While frequency of hypoglycaemia was decreased from baseline by both insulins, the proportion of episodes classified as severe was significantly increased from baseline with regular human insulin, but not with insulin lispro. Thus, compared with regular human insulin, improved glycaemic control was achieved with insulin lispro without an increase in severe hypoglyeaemia.     

Lifestyle factors associated with glycaemic control and body mass index in older adults with diabetes

OBJECTIVE: To investigate the relations between lifestyle factors (diet and exercise), glycated haemoglobin (HbA(1c)) and body mass index (BMI) in older adults with diabetes. DESIGN AND SETTING: A community hospital-based cross-sectional study of 150 noninstitutionalized, ambulatory adults (>/=65 y) with diabetes, residing within New Zealand's Kapiti region. SUBJECTS: Patients were recruited from all general practices; two diabetes clinics; local diabetes society and through advertisements in community newspapers. A total of 211 eligible people were identified, but 60 refused to participate and one withdrew. In all, 150 people completed the study (71% participation rate). METHODS: Nutrient intakes were calculated by a food-frequency questionnaire. Physical activity was assessed by interview using a validated questionnaire. Medical history and demographic data were obtained by interview or self-completed questionnaires; height, weight and HbA(1c) were measured. Multivariate models using bootstrapping and stepwise linear regression were used to select factors associated with HbA(1c) and BMI. RESULTS: Each five-unit increase in energy from dietary saturated fat and five-unit increase in BMI were associated with 6% (95% confidence interval=2-10%; P=0.004) and 4% (0.3-7%; P=0.031) increases in HbA(1c), respectively. For females with moderate, compared with low overall activity, there was a 14% (7-20%; P=0.000) reduction in BMI while for males the reduction was only 5% (-1-11%; P=0.116). BMI decreased 5% (2-9%; P=0.004) with each 10-y increase in age, while a five-unit increment in energy from dietary sucrose was associated with a 6% (1-11%; P=0.025) increase in BMI. CONCLUSIONS: Reducing dietary saturated fat and excess body weight may be useful means of improving glycaemic control in older adults with diabetes. Increasing physical activity and reducing energy from dietary sucrose may assist weight control, the former particularly in women.     

Sex and ethnic differentials in physical activity levels of adolescents in kuantan

A cross-sectional study was conducted to determine the physical activity levels of 400 adolescents (13 years old) in Kuantan, Pahang using the Physical Activity Questionnaire for Older Children (PAQ-C). The associations of physical activity levels with sex, ethnicity and body mass index were also determined. About one third (35.3%) of the adolescents were in the low physical activity level category, 61.5% in the moderate physical activity level and only 3.0% of the adolescents were in the high physical activity level category. More males (77.9%) were physically active than females (54.9%). Twice as many female adolescents (45.1%) were in the low physical activity level category compared to the male adolescents (22.1%). The associations between physical activity with ethnicity and body mass index were not significant. However, there was a significant interaction effect of sex and ethnicity in mean physical activity score (F = 2.36, p<0.01). Malay males had a significantly higher mean physical activity score as compared to Chinese males (t=2.13; p<0.05). Although Chinese females had a higher mean physical activity score than Malay females, the difference was not statistically significant. Conversely, there was no interaction effect of sex and BMI status in mean physical activity score. This study suggests that physical activity intervention to promote regular physical activity is needed since a high proportion of the adolescents fall within the low physical activity level category.     

Effects of physical activity on cognitive functioning in middle age: evidence from the Whitehall II prospective cohort study

OBJECTIVES: We examined the association between physical activity and cognitive functioning in middle age. METHODS: Data were derived from a prospective occupational cohort study of 10308 civil servants aged 35-55 years at baseline (phase 1; 1985-1988). Physical activity level, categorized as low, medium, or high, was assessed at phases 1, 3 (1991-1994), and 5 (1997-1999). Cognitive functioning was tested at phase 5, when respondents were 46-68 years old. RESULTS: In both prospective (odds ratio [OR] = 1.65; 95% confidence interval [CI]=1.30, 2.10) and cross-sectional (OR=1.79; 95% CI=1.38, 2.32) analyses, low levels of physical activity were a risk factor for poor performance on a measure of fluid intelligence. Analyses aimed at assessing cumulative effects (summary of physical activity levels at the 3 time points) showed a graded linear relationship with fluid intelligence, with persistently low levels of physical activity being particularly harmful (OR=2.21; 95% CI=1.37, 3.57). CONCLUSIONS: Low levels of physical activity are a risk factor for cognitive functioning in middle age, fluid intelligence in particular.     

Reproductive health services for populations at high risk of HIV: Performance of a night clinic in Tete province,Mozambique

Background

In recent decades immigration to Norway from Asia, Africa and Eastern Europe has increased rapidly. The aim of this study was to assess the quality of care for type 2 diabetes mellitus (T2DM) patients from these ethnic minority groups compared with the care received by Norwegians.

Methods

In 2006, electronic medical record data were screened at 11 practices (49 GPs; 58857 patients). 1653 T2DM patients cared for in general practice were identified. Ethnicity was defined as self-reported country of birth. Chi-squared tests, one-way ANOVAs, multiple regression, linear mixed effect models and generalized linear mixed models were used.

Results

Diabetes was diagnosed at a younger age in patients from the ethnic minority groups (South Asians (SA): mean age 44.9 years, Middle East/North Africa (MENA): 47.2 years, East Asians (EA): 52.0 years, others: 49.0 years) compared with Norwegians (59.7 years, p < 0.001). HbA1c, systolic blood pressure (SBP) and s-cholesterol were measured in >85% of patients in all groups with minor differences between minority groups and Norwegians. A greater proportion of the minority groups were prescribed hypoglycaemic medications compared with Norwegians (≥79% vs. 72%, p < 0.001). After adjusting for age, gender, diabetes duration, practice and physician unit, HbA1c (geometric mean) for Norwegians was 6.9% compared to 7.3-7.5% in the minority groups (p < 0.05). The proportion with poor glycaemic control (HbA1c > 9%) was higher in minority groups (SA: 19.6%, MENA: 18.9% vs. Norwegians: 5.6%, p < 0.001. No significant ethnic differences were found in the proportions reaching the combined target: HbA1c ≤ 7.5%, SBP ≤ 140 mmHg, diastolic blood pressure (DBP) ≤ 85 mmHg and total s-cholesterol ≤5.0 mmol/L (Norwegians: 25.5%, SA: 24.9%, MENA: 26.9%, EA: 26.1%, others:17.5%).

Conclusions

Mean age at the time of diagnosis of T2DM was 8-15 years younger in minority groups compared with Norwegians. Recording of important processes of care measures is high in all groups. Only one in four of most patient groups achieved all four treatment targets and prescribing habits may be sub-optimal. Patients from minority groups have worse glycaemic control than Norwegians which implies that it might be necessary to improve the guidelines to meet the needs of specific ethnic groups.     

50岁及以上人群生活质量与体力活动的关联研究

目的 探讨上海市≥50岁人群体力活动水平和生活质量之间的关系。方法 2009年10月至2010年6月使用多阶段随机整群抽样方法抽取上海市5个区8 872名≥50岁的中老年人,使用全球体力活动问卷和WHO生活质量量表8项版（WHOQoL-8）评估体力活动水平和生活质量,并获取社会人口学及健康、社会参与等信息,采用两水平（个体层面和社区层面）线性模型分析不同年龄段的中老年人群其体力活动水平与幸福感的关系。结果 共纳入有效样本8 454份,年龄为（63.16±9.74）岁,体力活动水平较低的人群占59.95%,中等体力活动水平的人群比例为28.00%,高体力活动水平者仅占12.05%。WHOQoL-8生活质量得分为43.91±0.69,体力活动水平越高,WHOQoL-8得分越低,生活质量越好（P=0.00）。在控制社会经济因素和健康状况、社会参与等混杂因素后,对<80岁各个年龄段的中老年人群而言,体力活动水平的增高对提高生活质量具有显著作用（P<0.05）,然而对≥80岁的高龄人群,和低水平体力活动相比,中水平和高水平的体力活动对提升生活质量不具备有意义的影响,P值分别为0.06及0.47。结论 上海市≥50岁且<80岁的人群中,较高的体力活动水平与较好的生活质量相关。     

Predictive factors of glycemic control in patients with type 2 diabetes mellitus in primary health care

PURPOSE: To determine the factors associated with poor glycemic control in type 2 diabetic patients followed in primary care units in Sousse, Tunisia. METHODS: A cross-sectional study was conducted on a representative sample of type 2 diabetic patients followed at least two years in primary health care units in Sousse, Tunisia. Data were gathered from three sources: a self-administrated questionnaire, analysis of patient files and HbA1c level. HbA1c level was measured with turbidimetric immunoinhibition assay. Patients were considered well-controlled if glycated hemoglobin (HbA1c) was less than 7%, according to the American Diabetics Association (ADA) recommendations. RESULTS: The study enrolled 404 type 2 diabetic patients. The mean age was 60.5+/-10.89 years, sex-ratio was 0.5, and mean disease duration 8.7+/-6.1 years. ADA recommendations were met by 16.7% of patients. Multivariate analysis using variables in relation with the patient, his/her family, the disease, the treatment and the health care unit, showed that only poor geographic access to the care center (adjusted OR: 1.89, p=0.009) and Body Mass Index (BMI) less than 30 kg/m2 (adjusted OR: 2.21, p=0.034) were significantly and independently associated with poor glycemic control. CONCLUSION: Glycemic control in type 2 diabetic patients is poor. It depends strongly on geographic access to health care. Type 2 diabetic patients should be referred, as much as possible, to the nearest health care unit.     

Assessment of carotenoid status and the relation to glycaemic control in type I diabetics: a follow-up study

OBJECTIVE: To assess the carotenoid status in young type I diabetic patients and its relationship to the glycaemic control of the disease. DESIGN: A follow-up study. SETTING: Hospital Universitario Puerta de Hierro, Health Area VI of Madrid (Spain). SUBJECTS: Forty-seven type I diabetic patients, followed for 2.5 years. INTERVENTIONS: Coinciding with physical examination and laboratory tests, serum levels of carotenoids were analysed by HPLC, and dietary intake of carotenoids was evaluated by a semiquantitative food frequency questionnaire and 3-day prospective dietary records. RESULTS: In type I diabetic patients, average intake, serum levels and correlations between diet and serum levels of carotenoids were comparable to those in reference non-diabetic groups. Between-subjects seasonal variations were observed for beta-cryptoxanthin intake and serum levels (higher in winter) and serum lycopene (higher in summer). Significant within-subjects seasonal changes were shown for dietary and serum beta-cryptoxanthin and serum beta-carotene. Serum carotenoids were unrelated to glycaemic control markers. Subjects with clinically acceptable glycaemic control showed lower lycopene intake than those with unacceptable control. Intake of carotenoids did not explain variance in insulin dose, fasting glycaemia, fructosamine or HbA1c. With the exception of lycopene, serum carotenoids were predicted by dietary intake, but in no case by fasting glycaemia, HbA1c or fructosamine. CONCLUSION: In type I diabetic patients, serum carotenoid concentrations and their variance are determined by dietary intake patterns, and are unrelated to the glycaemic control of the disease, as assessed by biochemical markers.     

Health Status Assessed by the SF-36 Along the Diabetes Continuum in an Australian Population

Objective: To examine the association of health status with stage along the diabetes continuum. Design, setting and participants: Self-reported health status (SF-36) was assessed in the North West Adelaide Health Study, a representative population cohort (n = 4060) aged 18 years and over in metropolitan South Australia. Impaired fasting glucose (IFG), undiagnosed diabetes, diagnosed diabetes, glycaemic control and cardiovascular disease were determined from fasting blood and self-reported data. Results: The prevalence of diagnosed diabetes was 5.6% (95% CI: 4.9–6.3), with an additional 1.0% (95% CI: 0.7–1.4) previously undiagnosed. When compared to those with normal glucose, those with diabetes were significantly impaired on all SF-36 dimensions except Mental Health, and those with IFG (4.3%) were significantly impaired in terms of Physical Functioning and Bodily Pain when controlling for the effects of age, sex and cardiovascular disease. Poor glycaemic control (HbA1c ≥ 7.0%) was also associated with impaired health status. Conclusions: Health status is impaired not only among those with diagnosed diabetes but also those with IFG and undiagnosed diabetes.