上海市2型糖尿病患者血糖控制的影响因素分析

[目的]评价上海市2型糖尿病患者血糖控制情况,了解血糖控制的影响因素。[方法]采用随机抽样方法,在210个社区抽取2型糖尿病患者1710人,开展问卷调查和体格检查,得到有效问卷1624份。分别依据美国糖尿病协会（ADA）和中华医学会糖尿病学分会（CDS）标准评估2型糖尿病患者的血糖、血压和血脂的控制情况。根据ADA的血糖控制目标[糖化血红蛋白（HbA1c）〈7％],将被调查者分为血糖控制组和血糖控制不良组,运用多因素非条件Logistic回归分析,探讨血糖控制的影响因素。[结果]1624例2型糖尿病患者的HbA1c平均值为7．5％。根据CDS的控制目标,27．9％的患者HbAl。达标（〈6．5％）,5．1％的患者HbAlc、血压（Bp）和低密度脂蛋白胆固醇（LDL—C）（HbA1c。〈6．5％,BP〈130／80mmHg,LDL—C〈2．5mmol／L）均达标。根据ADA控制目标,43．6％的患者HbA1c达标（〈7．0％）,9．9％的患者三者（HbA1c〈7．0％,BP〈130／80mmHg,LDL—C〈2．6mmol／L）均达标。多因素Logistic回归分析结果显示,影响血糖控制效果的因素有年龄小、病程长、居住地为郊区、不控制饮食及腰臀比（WHR）大。[结论]目前上海市2型糖尿病血糖控制达标率拧低,血糖控制受多种因素影响．     

Predictors of Deteriorations in Diabetes Management and Control in Adolescents With Type 1 Diabetes

PurposeDeteriorating type 1 diabetes management and control are common among adolescents; however, clinical evidence suggests that individual trajectories can vary. The aim of this study was to examine patterns and predictors of blood glucose monitoring (BGM) frequency and glycemic control (hemoglobin A1c).MethodsProspective data analysis spanning 18–24 months was conducted with 150 adolescent–parent pairs. Latent group-based trajectory modeling identified subgroups and determined medical, demographic, psychological, and family predictors of subgroup membership.ResultsThree subgroups emerged, representing diabetes management and control that are “meeting treatment targets” (40%; A1c at baseline = 7.4%, BGM frequency at baseline = 4.8 checks/day) and two levels “not meeting targets”:“normatively similar” youth (40%; A1c = 9.2%, BGM frequency = 2.8 checks/day), and “high-risk” youth (20%; A1c = 11.2%, BGM frequency = 2.9 checks/day). Subgroup membership was maintained over 18–24 months. There was minimal change across time, although only one-third of adolescents met treatment targets. Older age, longer diabetes duration, ethnic minority status, unmarried caregiver status, insulin delivery via injections versus continuous subcutaneous insulin infusion, greater depressive symptoms, negative affect about BGM, and diabetes-specific family conflict each predicted membership in a subgroup with poorer diabetes management and control.ConclusionsAmong the nearly two-thirds of adolescents with management and control that do not meet treatment targets, modifiable and nonmodifiable factors may signal the need for prevention or intervention. Demographic and medical factors may call for proactive efforts to prevent deterioration, and psychological symptoms and family conflict signal opportunities for clinical intervention to promote improved diabetes management and control in adolescence.     

邢台市社区糖尿病患者糖尿病教育的效果评价

目的观察邢台市社区糖尿病教育前后糖尿病病人对糖尿病的认知及血糖相关指标的改变情况。方法选取3个社区1 630名2型糖尿病患者进行糖尿病教育,比较教育前后对糖尿病的认知程度,以及教育前后空腹血糖（FBG）、餐后2 h血糖（2hPBG）、糖化血红蛋白（HbA1c）、血清甘油三酯（TG）、血清总胆固醇（TC）、血清低密度脂蛋白胆固醇（LDL-C）,测量血压（BP）和体重指数（BMI）指标。结果教育前后患者对糖尿病认知以及血糖相关指标检测结果的差异有统计学意义（P〈0.01）。结论糖尿病教育使糖尿病病人认知程度提高,血糖相关指标明显改善。     

血脂水平对血压正常高值人群脉搏波传导速度的影响

目的 探讨血脂和脂蛋白比值对血压正常高值人群脉搏波传导速度的影响.方法 选择11 611名血压正常的健康体检者,分为正常血压值组(血压＜ 120/80 mmHg)和血压正常高值组(血压为120 ～ 139/80 ～ 89 mmHg).应用全自动动脉硬化仪测定人选者肱踝脉搏波传导速度(baPWV),同时测量身高、体重、FPG、TC、TG、HDL-C、LDL-C等指标,并计算HDL-C和TC/HDL-C比值、LDL-C/HDL-C比值.分析血脂和脂蛋白比值异常情况对不同血压组脉搏波传导速度的影响.结果 血压正常高值组的baPWV异常率均高于血压正常组.血压正常组中除HDL-C外,TC、TG、LDL-C、TC/HDL-C、LDL-C/HDL-C的升高均使baPWV的异常率显著增加(P＜0.001).血压正常高值组中,TC和LDL-C的升高使baPWV的异常率显著增加(P＜0.001).多元logistic回归分析显示,除年龄、BMI、FPG外,TC/HDL-C异常是血压正常组动脉僵硬度增高的独立危险因子(OR=1.732),TG异常是血压正常高值组的独立危险因素(OR=1.301).结论 在正常血压不同水平下,血脂和脂蛋白比值的异常是动脉僵硬度增高的独立危险因素.     

Determinants of Adherence to Diabetes Screening in Iranian Adults With a Positive Family History of Diabetes

Objectives:Insufficient evidence exists regarding factors that affect screening adherence among people with a family history of diabetes, who comprise roughly half of all patients with diabetes. Therefore, we aimed to identify the determinants of diabetes screening adherence in adults with a family history of diabetes who had not yet been diagnosed with diabetes. Methods:This cross-sectional study was conducted at selected urban primary healthcare facilities in Tehran, Iran. The study population was clinically non-diabetic adults above 20 years of age with a family history of diabetes in at least 1 first-degree relative. All eligible people identified on randomly-selected days of the month were invited to join the study. Results:Among 408 participants, 128 (31.4%) had received a fasting blood glucose check during the last year. Using binary logistic regression, the independent predictors of screening adherence were knowledge of adverse effects of diabetes such as sexual disorders (odds ratio [OR], 3.05) and renal failure (OR, 2.73), the impact of family members’ advice on receiving diabetes screening (OR, 2.03), recommendation from a healthcare provider to have a fasting blood glucose check (OR, 2.61), and intention to have a fasting blood glucose check within the next 6 months (OR, 2.85). Other variables that predicted screening adherence were age (OR, 1.05), job (being a housekeeper; OR, 3.39), and having a college degree (OR, 3.55). Conclusions:Knowledge of the adverse effects of diabetes, physicians’ and healthcare providers’ advice about the benefits of early disease detection, and family members’ advice were independent predictors of screening adherence.     

Facteurs prédictifs du niveau des connaissances,des attitudes et de la qualité de vie des diabétiques tunisiens — À propos de 1007 cas

Aim of the studyTo study the predictors of knowledge level, attitudes and quality of life of type 1(T1D) and type 2 (T2D) Tunisian diabeticsPopulation and methodsWe undertook an analytical cross-sectional study. The questionnaire was administered in Arabic and contained a section collecting socio-demographic, clinical and diabetes-specific data. The following sections contained the Arabic-translated and validated versions of the “Simplified Diabetes Knowledge Scale”, the “Diabetes Attitude Scale-3” and the “Diabetes Health Profile-18” to assess level of diabetes knowledge, attitudes towards the disease and diabetics’ quality of life.ResultsWe collected 186 T1D (18.5%) and 821 T2D (81.5%) completed questionnaires. A good level of knowledge about diabetes was indicated in T1D patients by glycemic self-monitoring and by secondary and university education, urban housing, stable employment, insulin therapy and prior therapeutic education, while regular medical follow-up was of particular importance in T2DM patients. Smoking and diabetes complications were predictors of a negative attitude towards the disease in T1D and T2D respectively. Diabetics’ Impaired quality of life was predicted by age < 40 years and a low level of knowledge about diabetes in T1D and by female sex, insulin therapy and a low level of knowledge about diabetes in T2D.ConclusionPredictors of the level of knowledge, attitudes and quality of life of diabetics may be a basis for establishing a therapeutic education program tailored to the different populations.     

Time Course of Oxidative Stress Status in the Postprandial and Postabsorptive States in Type 1 Diabetes Mellitus: Relationship to Glucose and Lipid Changes

Objective: The aim of this study was to compare oxidative stress status (OSS) with blood glucose and lipid changes during the fasting, postprandial and postabsorptive phases in type 1 diabetes mellitus.

Methods: Twenty-three patients on intensive insulin treatment received a standard fat-rich breakfast and lunch. OSS was monitored at fasting (F), just after the post-breakfast glycemia peak (BP) (identified by continuous subcutaneous glucose monitoring), 3.5-h post-breakfast (B3.5), just after the post-lunch peak (LP), just after the post-lunch dale (LD) and 5 hours after lunch (L5).

Results: Whereas whole blood glutathione and plasma protein thiols increased in the postprandial period (from 6.52 ± 1.20 (F) to 7.08 ± 1.45 μmol/g Hb (BP), p = 0.005), ascorbate decreased gradually from 44 ± 17 (F) to 39 ± 19 μmol/L (LD), p = 0.015. Retinol and α-tocopherol also decreased from 27.1 ± 7.0 (F) to 25.3 ± 5.2 μmol/L (BP), p = 0.005. Uric acid decreased later, from 213 ± 77 (BP) to 204 ± 68 μmol/L (B3.5), p = 0.01, but then increased in LP (231 ± 70 μmol/L) and LD to values higher than F (215 ± 64, μmol/L, p = 0.01). Malondialdehyde increased gradually from 1.02 ± 0.36 (F) to a maximum of 1.14 ± 0.40 μmol/L (LP). In the postabsorptive phase (L5) all parameters except for thiols reverted to fasting concentrations.

Conclusions: In type 1 diabetes lipid peroxidation increases during the postprandial phase in parallel to glucose and triglyceride changes. Blood antioxidants, however, followed diverse patterns of change.     

Evaluation and Management of Diabetes Mellitus

Diabetes mellitus is a major public health problem with tremendous medical and economic burdens. It is the seventh leading cause of death and the number one cause of end-stage renal disease, adult blindness, impotence, and nontraumatic lower-limb amputation in the United States. People with diabetes are 2 to 4 times more likely to suffer from stroke or from cardiovascular disease, and are twice as likely to die compared with age-matched individuals without diabetes. Diabetes cost the United States around $174 billion in 2007, $58 billion of which was related to disability, work loss, and early mortality. Although there is currently no known cure for diabetes, much progress has been made over the past 2 decades to improve the diagnosis and management of diabetes. Evidence has shown that applying aggressive interventions early can prevent or delay progression to microvascular complications that increase the mortality rate in diabetes. The authors review the guidelines for optimal evaluation of diabetes mellitus and discuss the current and emerging therapeutic options available in the United States.Diabetes mellitus is a chronic and devastating disease, affecting 8% of the US population.1 Despite recent advances in diagnostic and therapeutic options, the incidence of diabetes continued to rise in 2007. According to the Centers for Disease Control and Prevention, approximately 24 million Americans are currently diagnosed with diabetes, an increase of 3 million over the past 2 years, and another 57 million are classified as having prediabetes.1 About one third of the people with diabetes remain undiagnosed.Worldwide, the prevalence of diabetes is projected to reach 366 million people by the year 2030.2 Major increases in both macrovascular and microvascular complications can be projected on the basis of this growing prevalence. Indeed, recent studies have reported that life expectancy is reduced in patients with diabetes, with an estimated risk of death about twice that of the general population of similar age.1,3 Men and women who are diagnosed with diabetes before the age of 40 have an average life expectancy reduction of 12 and 19 years, respectively.4The cost of diabetes to the US healthcare system is staggering; it was estimated to be around $174 billion in direct ($116 billion) and indirect ($58 billion) costs in 2007.1Data from the United Kingdom Prospective Diabetes Study Group, the Diabetes Control and Complications Trial, and the Kumamoto study have clearly shown that early and aggressive glycemic interventions can reduce the risk of microvascular complications—retinopathy, nephropathy, and neuropathy—of diabetes.5–7 Despite this knowledge, studies continue to show that most Americans with diabetes are not achieving the recommended treatment goals. Recent data from the National Health and Nutrition Examination Survey reported that only one third of diabetic patients are at goal with regard to glycemic and blood pressure control, and only half are meeting their cholesterol goals.8 It is hopeful that the availability of published guidelines and algorithms will aid physicians to bring more patients to the desired glycemic, blood pressure, and lipid goals.     

Comparative Effectiveness of a Mindful Eating Intervention to a Diabetes Self-Management Intervention among Adults with Type 2 Diabetes: A Pilot Study

Mindful eating offers promise as an effective approach for weight management and glycemic control in people with diabetes. Diabetes self-management education (DSME) is an essential component of effective self-care. Yet, little research has compared the effect of mindful eating to DSME–based treatment. This study compared the impact of these two interventions in adults with type 2 diabetes mellitus. A prospective randomized controlled trial with two parallel interventions was used. Participants included adults age 35 to 65 years with type 2 diabetes mellitus for 1 year or more, body mass index (BMI) of 27 or more, and hemoglobin A1c (HbA1c) of 7% or more who were randomly assigned to a 3-month mindful eating (MB-EAT-D; n=27) or Smart Choices (SC) DSME–based (n=25) intervention. Follow-up occurred 3 months after intervention completion. Dietary intake, physical activity, weight, HbA1c and fasting plasma glucose, and fasting insulin were assessed using repeated measures analysis of variance with contrast analysis. There was no significant difference between groups in the change in weight or glycemia at study end. Significant difference occurred between groups in the change in dietary intake/1,000 kcal of trans fats, total fiber, and sugars (all P<0.05). Mean (± standard error) reduction in weight (?2.92±0.54 kg for SC vs ?1.53±0.54 kg for MB-EAT-D) and HbA1c (?0.67±0.24% for SC and ?0.83±0.24% for MB-EAT-D) were significant (P<0.01). Significant reduction in energy intake and glycemic load occurred (all P<0.0001) for both groups. Training in mindful eating and diabetes self-management facilitate improvement in dietary intake, modest weight loss, and glycemic control. The availability of effective treatments gives patients with diabetes choices in meeting their self-care needs.     

Hyperglycemia and Carotenoid Intake Are Associated with Serum Carotenoids in Youth with Type 1 Diabetes

BackgroundSerum carotenoids are commonly used as biomarkers of fruit and vegetable (F/V) intake in the general population. Although hyperglycemia induces oxidative stress, it is unknown whether this pathway is associated with lower serum carotenoid concentrations in individuals with type 1 diabetes. Consequently, the utility of serum carotenoids as markers of F/V intake in individuals with type 1 diabetes is unclear.ObjectiveThe study objectives were: 1) to investigate the relationship of glycemic control, oxidative stress, dietary carotenoid and F/V intake with serum carotenoid concentrations in youth with type 1 diabetes and 2) to determine whether glycemic control or oxidative stress moderates the association of carotenoid and F/V intake with serum carotenoids.DesignThe study was a secondary analysis of baseline data from youth with type 1 diabetes. Blood samples were drawn from youth with type 1 diabetes to assess carotenoids and markers of glycemic control (glycated hemoglobin and 1,5-anhydroglucitol); urine samples were used to assess oxidative stress (8-iso-prostaglandin F_2α); and 3-day diet records completed by families were used to determine F/V and carotenoid intake.Participants/settingThe study participants were youth with type 1 diabetes (n=136; age range: 8 to 16.9 years; diabetes duration ≥1 year; glycated hemoglobin: 5.8% to 11.9%) enrolled in a nutrition intervention trial from 2010 to 2013 at a tertiary diabetes center in Boston, MA.Main outcome measuresSerum carotenoids (total carotenoids and α-carotene, β-carotene, lycopene, β-cryptoxanthin, and lutein+zeaxanthin).Statistical analysisRegression analyses were used to estimate the association of glycemic control, oxidative stress, F/V and carotenoid intake with serum carotenoids, as well as the role of glycemic control and oxidative stress in moderating diet-serum carotenoid associations.ResultsGreater F/V intake (β=0.35, P<0.001) and carotenoid intake (β=0.28, P<0.01) were associated with higher total serum carotenoids, and no moderation by glycemic control or oxidative stress was observed. Greater hyperglycemia, as indicated by lower 1,5-anhydroglucitol (β=0.27, P<0.01), was related to lower serum carotenoids; however, glycated hemoglobin was not associated with serum carotenoids. 8-Iso-prostaglandin F2α was not associated with glycemic control or serum carotenoids.ConclusionsFindings support the validity of serum carotenoids as markers of F/V and carotenoid intake in youth with type 1 diabetes.     

Relationship of diabetes-specific knowledge to self-management activities, ambulatory preventive care, and metabolic outcomes

BACKGROUND: Educational interventions increase diabetes patients' knowledge and self-care activities, but their impact on the use of health services to prevent diabetes complications is unclear. We sought to determine the relationship of patients' diabetes-specific knowledge with self-management behaviors, use of ambulatory preventive care, and metabolic outcomes. METHODS: We surveyed 670 adults with diabetes from three managed care plans to assess diabetes knowledge (using an eight-item scale) and self-management activities. With chart review, we assessed five processes of care--retinal and foot examinations, low-density lipoprotein cholesterol (LDL-C) testing, hemoglobin A1c (HbA1c) testing, and urine microalbumin testing--and three metabolic outcomes--HbA1c < or = 9.5%, LDL-C <130 mg/dL (3.36 mmol/L), and last blood pressure <140/90 mm Hg. RESULTS: In adjusted analyses, a one-point increase on the knowledge scale was associated with following a diabetes diet (OR 1.23, 95% CI 1.10-1.38), blood glucose self-measurement (OR 1.29, 95% CI 1.13-1.48), and regular exercise (OR 1.15, 95% CI 1.03-1.28) but not with processes of care or metabolic outcomes. CONCLUSIONS: Knowledgeable patients were more likely to perform self-management activities but not to receive recommended ambulatory care or reach metabolic outcome goals. Providing patient education about diabetes care processes should be tested as a means of increasing ambulatory care to prevent diabetes complications.     

Treatment targets in patients with type 2 diabetes set by primary care physicians from Central and Eastern Europe

Background: Primary care physicians have an important role in the care of patients with Type 2 diabetes but little is known about this issue in Central and Eastern European countries.

Objectives: To investigate the treatment goals of patients with type 2 diabetes mellitus (type 2 DM) set by primary care physicians in Central and Eastern European countries and illustrate inter-country variation.

Methods: A cross-sectional survey of primary care physicians randomly chosen in nine countries. A validated questionnaire was used. Physicians reported treatment goals for patients with type 2 DM.

Results: A total of 44.1% of physicians, reported the acceptance of HbA1c < 6.5% (48 mmol/mol) as a treatment goal, whilst 40% chose lower levels (< 6.1%; 43 mmol/mol). In all countries, 62% of physicians set FPG at a level of < 6.0 mmol/l. Most respondents set low BP levels as a goal of therapy (47% of physicians in all countries: BP < 130/80 mmHg and 48% < 120/80 mmHg). A TC level < 4.5 mmol/l and a LDL-C level < 2.5 mmol/l were reported as the targets for patients with diabetes by 51% and 69% of all respondents, respectively. The overall differences between all the countries were statistically significant (P < 0.01).

Conclusion: For patients with diabetes approximately half of physicians set treatment goals at levels that were recommended within the international guidelines. Most of them set treatment goals for HbA1c and BP at very low levels. Educational efforts to raise awareness about new treatment goals are needed.     

Improving Diabetes Care and Patient Outcomes in Skilled-Care Communities: Successes and Lessons From a Quality Improvement Initiative

ObjectiveTo improve the quality of care for residents of long term care (LTC) facilities who have diabetes by (1) improving glycemic control, (2) increasing comprehensive diabetes management, (3) reducing fragmented care, and (4) empowering patient-care teams to educate patients and families regarding this disease.DesignBased on the Plan-Do-Study-Act principles of effective change, a baseline evaluation of contemporary care for residents with diabetes was conducted through focus-group interviews, a confidence survey, and chart review. Three live educational workshops provided guideline-recommended information addressing educational desires and needs of clinical staff, a tool for improving performance in key areas of need, and an opportunity for care teams to engage in dialogue about advances in diabetes with a national diabetes expert. Reassessment was performed via chart review twice at 3 and 5 months post education. Key lessons and tools for improvements were disseminated to other LTC communities through a CME-certified publication activity and follow-up teleconferences.SettingTwo skilled-nursing LTC communities.ParticipantsPhysicians, administrators, nurses, certified nursing assistants, and nutrition staff.InterventionThree live continuing education/continuing medical education-certified workshops attended by 83 health care professionals.MeasurementsTwenty-five comprehensive clinical indicators of diabetes care and overall health were assessed for all residents with a diabetes diagnosis at baseline (n = 35), 3 months (n = 40), and 5 months (n = 27) post education.ResultsThe primary objective of improving glycemic control we reached through a statistically significant 18% reduction in the percentage of residents experiencing hypoglycemia from baseline to 3 months post education (31% at baseline, 13% at 3 months, P = .046). Low levels of hypoglycemia (11%) were maintained at 5 months post education. Positive changes in an additional 3 measures of patient health include improved daily blood glucose levels, reduced ranges of HbA1c, and improved low-density lipoprotein cholesterol concentrations. Improvements in 4 measures of clinician performance were also observed, namely comprehensive foot evaluations, referrals to specialists for foot care and eye exams, and improved use of physical activity.ConclusionDiabetes care, particularly in elder adults, is complex and requires a multidisciplinary approach. Focused quality improvement activities within LTC communities offer care providers the information and tools required to make effective changes that have the ability to promote improved patient care. These efforts must be multidisciplinary and effectively engage all stakeholders.     

Energy Intake and Glycemia in Lactating Women with Type 1 Diabetes

Objective To describe glycemia and insulin administration in lactating women with type 1 diabetes and compare their energy intake, lactation onset, and postpartum weight to lactating women without diabetes.Design A prospective observational study conducted at 2, 3, 6, 14, 42, and 84 days postpartum. Insulin dosage and glucose levels after fasting and at 80 and 110 minutes after eating (by measuring capillary blood glucose concentrations and glycated hemoglobin [HbA_1c] values) are described for women with type 1 diabetes. Dietary intake, weight, and lactation onset for women with type 1 diabetes are compared with those without the disease.Subjects/setting Fourteen lactating women with type 1 diabetes and 25 women without diabetes (control subjects) were recruited from private obstetrician offices and high-risk prenatal clinics at 3 major medical centers.Statistical analyses A repeated-measures 2-factor analysis of variance was used to determine group, time, and interaction effects between women with type 1 diabetes and the control group at 2, 3, 7, 14, 42, and 84 days postpartum.Results Seven women with type 1 diabetes breast-fed through 84 days postpartum, although they perceived later onset of milk and had fasting and postprandial hyperglycemia. Their HbA_1c levels increased by 20%, confirming relative hyperglycemia. After adjustment for prepregnancy weight, women with type 1 diabetes consumed 7 kcal fewer per kilogram per day than control subjects. Average insulin dose was returned to prepregnancy levels of 45.3±3.6 U/d (least square means±standard error of the mean) by 1 week.Application Achieving desired metabolic control during the establishment of lactation is difficult. A better understanding of energy and insulin needs and their relationship to lactation in women with type 1 diabetes is needed. J Am Diet Assoc. 1998; 98: 642–648.     

Racial and Ethnic Disparities in Diabetes Care Quality among Women of Reproductive Age in an Integrated Delivery System

BackgroundDiabetes is increasingly prevalent among women of reproductive age, yet little is known about quality of diabetes care for this population at increased risk of diabetes complications and poor maternal and infant health outcomes. Previous studies have identified racial/ethnic disparities in diabetes care, but patterns among women of reproductive age have not been examined.MethodsThis retrospective cohort study analyzed 2016 data from Kaiser Permanente Northern California, a large integrated delivery system. Outcomes were quality of diabetes care measures—glycemic testing, glycemic control, and medication adherence—among women ages 18 to 44 with type 1 or type 2 diabetes (N = 9,923). Poisson regression was used to estimate the association between patient race/ethnicity and each outcome, adjusting for other patient characteristics and health care use.ResultsIn this cohort, 83% of participants had type 2 diabetes; 31% and 36% of women with type 2 and type 1 diabetes, respectively, had poor glycemic control (hemoglobin A1c of ≥9%), and approximately one-third of women with type 2 diabetes exhibited nonadherence to diabetes medications. Compared with non-Hispanic White women with type 2 diabetes, non-Hispanic Black women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) and Hispanic women (adjusted risk ratio, 1.2; 95% confidence interval, 1.1–1.3) were more likely to have poor control. Findings among women with type 1 diabetes were similar.ConclusionsOur findings indicate opportunities to decrease disparities and improve quality of diabetes care for reproductive-aged women. Elucidating the contributing factors to poor glycemic control and medication adherence in this population, particularly among Black, Hispanic, and Asian women, should be a high research and practice priority.     

Vitamin E Improves Serum Paraoxonase-1 Activity and Some Metabolic Factors in Patients with Type 2 Diabetes: No Effects on Nitrite/Nitrate Levels

Objective: It is known that markers of oxidative stress and nitrite/nitrate anion (NO_x) increase and activity of antioxidative enzyme paraoxonase-1 decline in type 2 diabetes mellitus (DM). The effects of vitamin E on paraoxonase-1 activity and NO_x in patients with type 2 diabetes are not known. The purpose of this study was to examine the hypothesis that vitamin E supplementation would affect paraoxonase-1 activity, metabolic factors, and NO_x in patients with DM.

Methods: This double-blind, randomized, controlled clinical trial was conducted on 83 patients with DM aged 30–60 years. Forty-two of the subjects had taken 400 IU/day vitamin E and 41 were given placebo over 8 weeks. Fasting blood samples, anthropometric measurements, and dietary intake data were collected at the baseline and at the end of the trial.

Results: Vitamin E significantly increased serum vitamin E level, paraoxonase-1 activity, and total antioxidant status (TAS) and decreased fasting blood sugar (FBS) compared to the control group (p < 0.05). Hemoglobin A1c, serum insulin, and insulin resistance significantly decreased in the vitamin E group compared to baseline values (p < 0.05). Alterations in serum levels of malondialdehyde and NO_x were not significant in any of groups (p > 0.05).

Conclusions: Vitamin E improved serum vitamin E level, paraoxonase-1 activity, TAS, and FBS in patients with type 2 diabetes. Longitudinal studies are warranted to assess the outcome of these results in reducing complications of diabetes in patients with type 2 diabetes.     

The Potential for Glycemic Control Monitoring and Screening for Diabetes at Dental Visits Using Oral Blood

Objectives. We examined the potential for glycemic control monitoring and screening for diabetes in a dental setting among adults (n = 408) with or at risk for diabetes.Methods. In 2013 and 2014, we performed hemoglobin A1c (HbA1c) tests on dried blood samples of gingival crevicular blood and compared these with paired “gold-standard” HbA1c tests with dried finger-stick blood samples in New York City dental clinic patients. We examined differences in sociodemographics and diabetes-related risk and health care characteristics for 3 groups of at-risk patients.Results. About half of the study sample had elevated HbA1c values in the combined prediabetes and diabetes ranges, with approximately one fourth of those in the diabetes range. With a correlation of 0.991 between gingival crevicular and finger-stick blood HbA1c, measures of concurrence between the tests were extremely high for both elevated HbA1c and diabetes-range HbA1c levels. Persons already diagnosed with diabetes and undiagnosed persons aged 45 years or older could especially benefit from HbA1c testing at dental visits.Conclusions. Gingival crevicular blood collected at the dental visit can be used to screen for diabetes and monitor glycemic control for many at-risk patients.Although diabetes has reached epidemic proportions in the United States,1 many diabetes complications could be mitigated by early detection coupled with lifestyle modification and therapeutic interventions to optimize glycemic control.2 Unfortunately, 8.1 million of the 29.1 million persons in the United States who have diabetes are undiagnosed,3 and among those diagnosed with diabetes, many are not likely to have received regular testing to monitor their glycemic control.4 An additional 86 million US adults have prediabetes, a condition that often progresses to diabetes, but only 11.1% of these persons have been told of their condition.3 Importantly, early identification and treatment of prediabetes can interrupt its progression.5,6 Thus, more opportunities are needed to screen for prediabetes and diabetes and to monitor glycemic control in those already diagnosed.Because many persons in the United States visit a dental provider but not a primary care provider (PCP) each year,7 the dental visit may serve as an opportune site for diabetes screening and monitoring blood glucose.8–10 However, both dental patients and dental providers are accustomed to having dental providers only administer care in the mouth. In an earlier pilot study, we therefore investigated and demonstrated the acceptability and feasibility of using oral blood to screen for diabetes in persons with bleeding on dental probing.11,12 Many patients appreciated the use of oral blood for this screening, indicating that its collection felt like a routine dental cleaning, and most dental providers felt that the oral blood collection was fast and easy.12In the current study, we refined our examination of the use of oral blood to screen for diabetes by implementing a laboratory-based approach to diabetes testing that enabled definitive and accurate analysis of all of the samples for which sufficient blood was collected. We included a large sample of patients (n = 408) at risk for diabetes or its complications who presented for regular dental visits at a dental college’s comprehensive care clinics. We analyzed the sociodemographic and diabetes risk–related characteristics of the sample, and compared the results of diabetes screening and glycemic control monitoring with dried blood samples of gingival crevicular blood (GCB) and gold-standard finger-stick blood (FSB) to determine the validity of using GCB for this purpose. This screening and monitoring was performed by testing the samples for hemoglobin A1c (HbA1c), a test promoted by the American Diabetes Association for diabetes diagnostic purposes and glycemic control monitoring.2 By providing an average measure of glycemic control over a 3-month period, this test is especially advantageous because fasting is not needed for HbA1c assessment, and no acute perturbations (e.g., stress, diet, exercise) affect HbA1c.2 Finally, we examined the potential benefits of this approach to diabetes screening and glycemic control monitoring according to whether study participants had previous-year tests for blood glucose and previous-year visits to PCPs and dental providers.     

Glycemic Control and Insulin Improve Muscle Mass and Gait Speed in Type 2 Diabetes: The MUSCLES-DM Study

ObjectivesType 2 diabetes is a risk factor for sarcopenia. Evidence on the prevention of sarcopenia using blood glucose–lowering therapy is limited. We aimed to examine the relationship between changes in glycemic control and sarcopenia and the effect of antidiabetic agents against sarcopenia in patients with type 2 diabetes.DesignWe conducted an observational longitudinal study.Setting and ParticipantsIn total, 588 Japanese patients with diabetes of an ongoing multicenter study completed 1-year follow-up measurements for sarcopenia and clinical data.MethodsThe data set of the Multicenter Study for Clarifying Evidence for Sarcopenia in patients with Diabetes Mellitus (the MUSCLES-DM study) was analyzed.ResultsDuring the follow-up period, the frequency of sarcopenia marginally increased, and the means of skeletal muscle mass index (SMI), handgrip strength, and gait speed did not show any changes. However, on dividing into 5 groups depending on the degree of changes in glycated hemoglobin (HbA_1c) value, the patients with a decrease of ≥1% in HbA_1c exhibited a significant increase in SMI. Our analysis revealed similar results for gait speed but not handgrip strength. Using the multiple linear regression model, we identified that a ≥1% decrease in HbA_1c value was an independent determinant of the changes in SMI and gait speed. We also determined that insulin use at baseline was an independent factor for the changes in SMI.Conclusions and ImplicationsCorrection of poor glycemic control and use of insulin were significantly associated with the increase in skeletal muscle mass or gait speed in Japanese patients with type 2 diabetes. The current finding increases our understanding of the importance of glycemic control for the prevention of cardiovascular diseases and sarcopenia.     

Delivering Diabetes Self-Management Education (DSME) in Primary Care

Background

Diabetes self-management education (DSME) is a critical component of the clinical management of diabetes mellitus. Although DSME is recognized as important, the number of patients with diabetes who receive education is disproportionately small. Several barriers to receiving diabetes education exist, including access and DSME delivery approaches.

Objective

The purpose of this project was to explore opportunities to meet the Healthy People 2010 goal of increasing the proportion of people with diabetes mellitus who receive diabetes education from 40% (as it was in 1998) to 60% (in 2010). Our objectives were to examine the provision of DSME in primary care, to determine if DSME delivery in primary care increases the number of people who receive DSME, and to evaluate the effect of DSME on glycosylated hemoglobin (HbA_1c) and low-density lipoprotein-cholesterol (LDL-C) levels. DSME was delivered in primary care practices as part of the Pittsburgh Regional Initiative for Diabetes Education (PRIDE).

Research design and methods

A nurse who was a certified diabetes educator (CDE) was deployed to provide Point-Of-Service diabetes Education (POSE) to four University of Pittsburgh Medical Center (UPMC) Community Medicine Practices (CMI) primary care practices. The group of patients who received POSE was compared with patients from the same practices who were identified as having diabetes and who received usual care. The number of patients was computed and a percentage calculated for comparison against Healthy People 2010 goals. The HbA_1c values of patients were tracked from January 2003 through December 2006, during the timeframe that POSE was provided.

Results

Of the 5344 diabetes patients in the four practices, 784 received POSE. Mean HbA_1c values were higher at baseline in those patients who received POSE than those who received usual care. There was a significant decrease in HbA^1c and LDL-C levels in both groups. Although there was not a significant between-group difference in HbA^1c, those who received POSE had significant improvement in LDL-C levels compared with the usual care group.

Conclusions

Providing DSME in primary care is feasible and offers the opportunity to reach patients who may not be receiving DSME services. However, further research is needed to evaluate other methodologies to increase access to DSME and other factors that may influence improvement in clinical outcomes.

     

Biophysiologic outcomes of the Enhancing Adherence in Type 2 Diabetes (ENHANCE) trial

BackgroundBehavioral research to improve lifestyle in broadly defined populations of patients with type 2 diabetes is limited.ObjectiveWe evaluated a behavioral intervention featuring technology-based self-monitoring on biophysiologic outcomes of glycemic control and markers of cardiovascular risk.DesignIn this single-site, randomized clinical trial, participants were stratified by good and poor glycemic control (glycated hemoglobin <8% or ≥8%) and absence or presence of kidney disease, (estimated glomerular filtration rate ≥60 or <60 mL/min) and randomized within strata. Measurements were obtained at 0, 3, and 6 months.Participants/settingSelf-referred, community-dwelling adults with type 2 diabetes mellitus.InterventionThe intervention group received Social Cognitive Theory-based counseling paired with technology-based self-monitoring, and results were compared with an attention control group.Main outcome measuresGlycated hemoglobin, fasting serum glucose, lipid levels, blood pressure, weight, body mass index, and waist circumference were evaluated.Statistical analyses performedMean differences within and between randomization groups were compared over time. Intervention effects over time were estimated using random intercept models.ResultsTwo hundred ninety-six subjects were randomized, 256 (86.5%) completed 3-month and 246 (83.1%) completed 6-month assessments. Glycated hemoglobin was reduced in the intervention group by 0.5% at 3 months and 0.6% at 6 months (P<0.001 for each), and the control group by 0.3% (P<0.001) at 3 months and 0.2% (P<0.05) at 6 months; but between-group differences were not significant. In those with baseline glycated hemoglobin ≥8% and estimated glomerular filtration rate ≥60 mL/min, glycated hemoglobin was reduced in the intervention group by 1.5% at 3 months and 1.8% at 6 months (P<0.001 for each), and the control group by 0.9% (P<0.001) at 3 months and 0.8% (P<0.05) at 6 months; but between-group differences were not significant. In random intercept models, the estimated reduction in glycated hemoglobin of 0.29% was not significant.ConclusionsTwo behavioral approaches to improving general lifestyle management in individuals with type 2 diabetes mellitus were effective in improving glycemic control, but no significant between-group differences were observed.