Flexible eating and flexible insulin dosing in patients with diabetes: Results of an intensive self-management course

Self-adjustment of phosphate binder dose to meal phosphorus content improves management of hyperphosphataemia in children with chronic kidney disease

BACKGROUND

Hyperphosphataemia in patients with chronic kidney disease (CKD) is associated with mineral and bone disorder and increased cardiovascular mortality. Despite phosphate binders (PB), nutrition counselling and dialysis therapy, the prevalence of hyperphosphataemia remains unacceptably high. It was hypothesized that an inadequate relation of PB dose to meal inorganic phosphorus (iP) content may be an important factor for failure of phosphate management.

METHODS

The innovative 'Phosphate Education Program' (PEP) bases on patient empowerment to eye-estimate meal iP content by newly defined 'Phosphate Units' (PU; 1 PU per 100 mg phosphorus) and self-adjust PB dosage to dietary iP intake by an individually prescribed PB/PU ratio (PB pills per PU). In a prospective study, 16 children (aged 4-17 years) with CKD and their parents were trained with the PEP concept and followed up for 24 weeks for changes in serum electrolyte levels, dietary behaviour and PB dose.

RESULTS

Within 6 weeks after PEP training, the percentage of children with serum phosphate (PO) >1.78 mmol/l dropped from 63% (10/16) to 31% (5/16). Mean serum PO level decreased from 1.94 ± 0.23 at baseline to 1.68 ± 0.30 (SD) mmol/l in Week 7-12 (P = 0.02) and to 1.78 ± 0.36 (SD) mmol/l in Week 19-24 (P = 0.2), whereas serum calcium [2.66 ± 0.3 vs 2.60 ± 0.23 (SD) mmol/l in Weeks 7-12 (P = 0.45) and 2.66 ± 0.23 (SD) mmol/l in Week 19-24 (P = 0.21)] and serum potassium [4.69 ± 0.48 vs 4.58 ± 0.68 (SD) mmol/l in Week 7-12 (P = 0.40) and 4.65 ± 0.49 (SD) mmol/l in Week 19-24 (P = 0.73)] remained unchanged. The mean daily PB dose rose from 6.3 ± 2.9 to 8.2 ± 5.4 (SD) pills during observation period with an increased meal-to-meal variability (P = 0.04). Dietary iP intake was not affected by PEP concept.

CONCLUSION

The empowerment of children with CKD and their parents to self-adjust PB dose to eye-estimated meal iP content significantly improved management of hyperphosphataemia without reducing dietary iP intake.

Does an advanced insulin education programme improve outcomes and health service use for people with Type 2 diabetes? A 5-year follow-up of the Newcastle Empowerment course

OBJECTIVE

To show that an advanced diabetes education programme delivers sustained benefits to people with diabetes prescribed insulin and healthcare providers over and above those provided by basic diabetes education.

METHODS

An historical cohort study of 68 people with Type 1 and 51 people with Type 2 diabetes on insulin who attended the 4-day Newcastle Empowerment programme in 2001 and 2002 compared with 71 people with Type 1 and 312 people with Type 2 diabetes who attended only the basic 4-day insulin education programme over the same period, followed until 2007. Primary outcome was all hospital admissions and emergency visits; secondary outcomes were the composite of first cardiac event or death and readmission for diabetes complications. Cox-proportional hazards regression was used to analyse Type 1 and Type 2 diabetes separately.

RESULTS

The empowerment programme significantly delayed time to first hospital admission/visit for patients with Type 2 diabetes; the hazard ratio (HR) of 0.41 (P = 0.01) translates into a delay of almost 3 years; this was partly driven by a significant reduction in cardiovascular events and mortality (HR = 0.24, P = 0.01). These effects were not seen for people with Type 1 diabetes.

CONCLUSIONS

A one-time, advanced diabetes education programme teaching intensive insulin self-management with an empowerment style can lead to sustained improvement in patient outcomes and reduce use of hospital services for people with Type 2 diabetes on insulin.

The Relationship Between Diabetes Mellitus, Depression, and Missed Appointments in a Low-Income Uninsured Population

Purpose

The purpose of this project is to identify rates of depression and document mental health needs of adults with diabetes who obtained care in free clinics. Data were collected to determine if there is a relationship between diabetes and depression and missed appointments in a sample of patients who were low-income, uninsured, and represented a variety of racial groups.

Methods

A sample of 183 adults with diabetes participated by completing paper and computerized questionnaires. Instruments included the Patient Health Questionnaire 9 (to measure prevalence of depression), the RAND 36 Health Survey (to measure quality of health), the Audit of Diabetes Dependent Quality of Life (to measure diabetes-dependent quality of life), and the Diabetes Empowerment Scale (to measure self-efficacy).

Results

The prevalence of depression at a moderate or greater level in the sample was found to be 30.1%. Levels of quality of health and self-efficacy were found to be reduced among those with the presence of depression. A significant increase in the rate of depression was found among those who had attended the free clinic for a longer period. No significant differences were found in diabetes-dependent quality of life and missed appointments among those with depression compared with those without.

Conclusions

Rates of depression among adults with diabetes in a free clinic setting were found to be comparable with the highest rates reported by other studies of insured populations. Results of this study support the need to develop mental health treatment programs for free clinic settings.

Effect of popular takeaway foods on blood glucose levels in type 1 diabetes mellitus patients on intensive insulin therapy

AIMS

Intensive insulin therapy (IIT) is the preferred treatment for patients with type 1 diabetes, which requires them to calculate the total number of grams of carbohydrate eaten, but little research has been performed on the effect of mixed meals on blood sugar. We examined the effects of popular takeaway foods on glycaemic response in people with type 1 diabetes.

METHODS

Nine participants on IIT each consumed a pasta, Thai, hamburger and sandwich (cheese sandwich and an apple) meal on four different occasions, at least 3 days apart. The meals had the same amount of carbohydrate but different macronutrient quantities and different glycaemic indices (GI). Participants' normal basal insulin was given, but the mealtime bolus insulin was withheld to measure blood glucose level (BGL), every half hour for 3 h postprandially.

RESULTS

The glycaemic response as measured by 2-h BGL, the area under the BGL curve and BGL range (maximum-minimum over 3 h) were consistently lower after ingesting a low-GI high-fat pasta meal in relation to the other meals. There was no difference between the sandwich, Thai and hamburger meals. BGLs rose between 3.91 and 8.44 mmol/l at the conclusion of 3 h, which shows that a single CHO portion (15 g) can raise BGLs by 1-2 mmol/l, depending on the GI of the food.

CONCLUSIONS

People with type 1 diabetes on IIT who are concerned about postprandial glycaemic variability should consider not only overall carbohydrate content but also glycaemic index and fat content when adjusting insulin dosages.