Diabetes and its care--what do patients expect?

A sample of 77% of the non-insulin dependent diabetics aged 30-70 years from two urban practices offering no structured diabetic care were interviewed. The 55 patients (mean age 60 years) were asked about their experiences and expectations of diabetes and the health professionals involved in their care. Twenty-six patients attended the hospital diabetic clinic regularly but 13 patients received no review at all; 46 patients wanted their general practitioner to be involved in future care and only six wanted to continue with hospital review alone. Patients gave hospital doctors and general practitioners similar high ratings for knowledge of diabetes and its management but general practitioners and practice nurses were rated more highly for communication and accessibility. The aspect of care valued most was being given clear information about diabetic management. Twenty two patients thought that diabetes would have a significant impact on their future health and 35 rated regular diabetic review as extremely important in keeping themselves healthy. Most patients felt it likely that they would have a high blood glucose level most of the time and develop diabetic complications. Little difference was found between the views of clinic attenders and non-attenders, and there was no evidence that non-attenders had actively rejected review. These non-insulin dependent diabetics considered diabetes to be a serious disorder warranting regular care and expressed confidence in the primary care team's ability to provide such care.

Doctors' beliefs about diabetes: a comparison of hospital and community doctors

A sample of general practitioners responded to a questionnaire measuring beliefs about diabetes and its management. The results are compared with those of a previous study concerning hospital doctors. GPs had a bleaker outlook on diabetes, perceiving the disease to carry more risks and having less confidence that achieving goals of treatment would reduce these risks. In accord with these beliefs their approach to treatment was far more lax than that of hospital-based doctors. The implications of these results for shared patient care, and interventions to maximize patient-health outcomes are discussed.

British Diabetic Association holidays--what are they worth?

A postal survey among families of 63 children attending two BDA educational holidays studied their expectations before (Questionnaire 1) and experiences 3 months afterwards (Questionnaire 2). Of 47 families replying to both questionnaires (22M, 25F; mean age 8.4 years, range 5-13.8 years), expectations expressed by parents for their children were that they gain in confidence and independence (n = 36), mix with other diabetic children (n = 32), learn to self-inject (n = 27), improve diet (n = 23), and have a good holiday (n = 10). Thirty-five families subsequently reported that their expectations had been met. After the holiday, although there was no change in frequency of blood or urine testing, there was an increase in children doing tests on their own (Q1: 15, Q2: 28, p = 0.003); more parents reported confidence in their child recognizing a hypoglycaemic episode (Q1: 29, Q2: 39, p = 0.001); and there was a sustained increase in independence with insulin injections (Q1: 29, Q2: 35, p = 0.042). This study provides evidence that BDA holidays benefit parents and their children, and do so mainly by increasing the children's confidence and independence in diabetic care.

Who cares for the patient with diabetes? Presentation and follow-up in seven Southampton practices

A notes survey was undertaken by a group of eight general practitioners in seven Southampton practices to study the mode of presentation and follow-up of the diabetic patients on the lists of 24 doctors. The 431 known diabetic patients were classified as non-insulin-dependent (67%), insulin-dependent (20%), or, if they had commenced their insulin more than a month after the diagnosis had been made, 'insulin-treated' (13%). This classification allowed characterization of the truly insulin-dependent and non-insulin-dependent patients.Non-insulin-dependent diabetics were older than insulin-dependent diabetics and had first presented at a greater age. Most patients in each treatment group presented with classical diabetic symptoms, diabetes-related infections, or recognized complications. The majority of these were diagnosed in general practice. However, over half of the asymptomatic non-insulin-dependent diabetic patients had been diagnosed by routine blood or urine testing in hospital. After 1979 fewer non-insulin-dependent diabetic patients were referred to hospital for follow-up at diagnosis than before 1975.Most non-insulin-treated diabetics were followed up in general practice whereas most patients treated with or dependent on insulin were followed up in hospital clinics. Twenty-two per cent of all patients received diabetic care from both their general practitioner and hospital outpatient departments but 20% received no regular diabetic follow-up at all. One year after the initial study, 4% of patients were still without regular review, and 27 more patients had been identified who would have qualified for the original audit.

Social and emotional complications in a clinical trial among adolescents with diabetes mellitus

Observations are reported on the social and emotional events occurring among children with diabetes mellitus and their families while taking part in a demanding clinical trial. Participants were selected on the basis of: (1) age over 10 years, (2) "informed consent," (3) cooperation with diabetic care, and (4) family stability. Despite endeavours to apply these criteria, it subsequently emerged that one father had doubts about his daughter participating; one family was suffering from severe marital discord; a girl (11 years) and a boy (10 years) were unexpectedly distressed by the venepunctures required; and another girl (13 years) was falsifying the results of her urine tests. All the families wished to complete the trial, and only one did not because of recurrent hypoglycaemia. The psychosocial problems encountered during the trial were unpredictable and occurred despite selection. Documentation of these problems allowed appropriate emotional support to be offered to the children and their families and provided for a fuller and more reliable interpretation of the trial results than would have been possible from the numerical data alone.

Whole foods and increased dietary fibre improve blood glucose control in diabetic children

In prescribing a diabetic diet more attention has traditionally been paid to the amount of dietary carbohydrate than to its type or structure. We have compared the effect on blood glucose of substituting unrefined, whole foods for refined, processed foods in liberal carbohydrate diets (50-55% of dietary energy) eaten by 10 diabetic children in a randomised crossover study. All measurements were made at home. The unrefined diet used whole foods (including) dried beans) supplying 60 g/day of dietary fibre. The refined diet used processed foods supplying 20 g/day of dietary fibre. Diets were isocaloric for carbohydrate, fat, and protein. Glycaemic control was assessed by daily urine analysis for glucose, home blood glucose measurements, glycosylated haemoglobin, and by a 24-hour profile of blood and urinary glucose carried out at home after 6 weeks on each diet. Glycaemic control was significantly better on the unrefined diet. On profile days mean blood glucose levels on the unrefined and refined diets respectively were: preprandial: 5.5 and 8.4 mmol/l; postprandial 8.5 and 12.2 mmol/l. The mean 24-hour urinary glucose excretion on the unrefined diet was 9.3 g and on the refined diet was 38.0 g. Six months after the study the children were eating appreciably more dietary fibre than before (mean increase 13.6 g/day). Attention to food type and structure can improve blood glucose control in diabetic children and should provide an acceptable and more rational basis for dietary prescription than one based on carbohydrate quantity alone.

Timing of pre-breakfast insulin injection and postprandial metabolic control in diabetic children

A peak period of hyperglycaemia in insulin-dependent diabetics occurs after breakfast. A randomised crossover study was performed on nine diabetic children at home to study the effect of varying the time of their morning mixed injection of Monotard and Actrapid insulin on this hyperglycaemic peak. Performing the study at home minimised the children's stress.After diabetic control had been improved children injected their insulin 30 minutes (early injection) or five minutes (late injection) before breakfast on two consecutive Saturday mornings. Blood samples were taken at 30-minute intervals over 3(1/2) hours and analysed for concentrations of glucose, insulin, C-peptide, pyruvate, lactate, alanine, and ketones. Diet, insulin dose, and exercise were kept the same on both test days.The mean blood glucose concentration at breakfast (0 minutes) was 11 mmol/l after the early injection and 10 mmol/l after the late injection. Subsequent concentrations were consistently lower with the early injection regimen than the late regimen. The greatest difference between values in the two groups was 3.7 mmol/l at 150 minutes. Mean plasma insulin concentrations were lower in the children on the early regimen than in those on the late regimen at 30 minutes before breakfast but higher at 0 minutes and thereafter. There were no significant differences in mean concentration of intermediary metabolites between the two injection regimens. These were mainly within the normal range for healthy young adults except for the ketone concentrations, which were raised with both injection regimens until 180 minutes after breakfast.These results suggest that the timing of the morning injection of insulin is important in the control of postprandial hyperglycaemia in diabetic children.