Predictors of wellness and American Indians

Wellness is an important American Indian (AI) concept, understood as being in balance with one's body, mind, and environment. Wellness predictors are reported in this paper within the context of health. A cross-sectional randomized household survey of 457 AI adults at 13 rural health care sites in California was conducted. Measures included wellness perceptions, barriers, health status/health conditions, spirituality, cultural connectivity, high-risk behaviors and abuse history. Statistical analysis obtained the best predictive model for wellness. Predictors of wellness were general health status perception, participation in AI cultural practices and suicide ideation. Significant differences in wellness status were observed depending on experience of adverse events in childhood and adulthood (neglect, physical abuse, and sexual abuse). Cultural connectivity (speaking tribal language, participating in AI practices, and feeling connected to community) was also associated with perceptions of wellness. Recommendations are for culturally-appropriate education and interventions emphasizing community and cultural connectivity for improving wellness status.

Self-management problem solving for adolescents with type 1 diabetes: intervention processes associated with an Internet program

OBJECTIVE

Describe intervention processes associated with an Internet self-management problem solving program for adolescents with type 1 diabetes, and relate participant characteristics to program use.

METHODS

Forty-one adolescents with type 1 diabetes, aged 13-17, participated in an Internet intervention.

RESULTS

Participants reported psychosocial self-management barriers related to social issues (45%), time pressures (22%), and emotions (25%). Most adolescents (76%) completed the two guided problem solving cycles, and most (97%) problems were appropriate and specific to diabetes. Of the 61 diabetes problems reported, 92% were mostly or completely solved. Baseline hemoglobin A1c, diabetes duration, and age were not related to online activities, however females posted more often to the forum (U=130.0, Z=2.13, p=.033). The majority of parents (87%) interacted with their child about the website.

CONCLUSION

Adolescents experience psychosocial barriers to self-management that can be addressed by teaching problem solving via the Internet.

PRACTICE IMPLICATIONS

An Internet self-management problem solving program with minimal external support provides a viable option for diabetes clinics to improve pediatric diabetes outcomes.

Development and initial validation of the barriers to diabetes adherence measure for adolescents

AIMS

The purpose of this study was to develop a measure of psychosocial barriers to adherence in adolescents with type 1 diabetes (T1D) and examine relationships to patient characteristics, adherence, and hemoglobin A1C (A1C).

METHODS

Barriers to diabetes adherence (BDA) items were generated by researchers, clinicians, and patients. Adolescents aged 12-17 with T1D completed the BDA and an adherence measure. Hemoglobin A1C was obtained through medical chart review.

RESULTS

Factor analysis from 123 adolescents resulted in a 21-item, five-component solution that accounted for 64.5% of the variance. The components were stress and burnout, time pressure and planning, social support, parental autonomy support, and stigma. The BDA total and subscales were internally consistent. The BDA total and some components were associated with adherence and A1C. The BDA was the only predictor of A1C compared to demographic, clinical, and adherence variables (F 6.17, p<.05). Subjects with higher A1C (>8.5) showed a higher level of barriers (F 15.20, p<.001) and a differential profile of barriers (F 5.75, p<.05).

CONCLUSIONS

The BDA may be useful in research and clinical settings as a compliment to adherence measures and to tailor educational programs. Additional research is necessary to establish test-retest reliability and discriminant validity.

Psychosocial problems in patients with newly diagnosed diabetes: number and characteristics

Early in the course of diabetes, it is important to identify and support patients whose psychosocial situations and reactions to the diagnosis may affect their ability to adjust or take adequate responsibility for self-care. We aimed to identify (a) the number and characteristics of patients, 18-65 years, newly diagnosed with diabetes, who needed psychosocial interventions and (b) the type of psychosocial problems they had. A total of 106 patients (72 men) were included in the study. Interviews showed that 41.5% had psychosocial problems. Fifteen dropped out early in the study; 38% of those remaining had psychosocial problems (PSP). More than half had problems with their life situation; most commonly in relationships. About a third had problems related to diabetes, most commonly, work-related. Compared to other participants, PSP patients lived in more strained social situations, especially regarding personal finances and social support. More of the PSP patients were anxious and depressed. They used negative coping strategies more often and more frequently expected that diabetes would negatively affect their future. In conclusion, early in the course of diabetes, screening instruments should be used to identify PSP patients. Treatment by medical social workers skilled in diabetes care should be offered.

Diabetes Mellitus: desafios relacionados ao autocuidado abordados em Grupo de Apoio Psicológico

O objetivo foi identificar os sentimentos dos usuários associados ao diagnóstico do Diabetes Mellitus (DM), as dificuldades inerentes ao controle glicêmico e estratégias de enfrentamento adotadas diante das demandas impostas pela doença. Estudo qualitativo realizado com grupo de pessoas acompanhadas por equipe multiprofissional de um centro de pesquisa e extensão universitária de Ribeirão Preto, SP, Brasil. Quatro sessões grupais que constituíram o corpus da pesquisa, foram audiogravadas e transcritas. A análise temática originou as categorias: sentimentos despertados a partir do diagnóstico do DM; dificuldades no controle da doença e estratégias de enfrentamento. Os resultados evidenciaram diferentes modos de lidar com os desafios suscitados pela doença no cotidiano, que influenciam diretamente na adesão ao tratamento e constituem elementos relevantes para o planejamento de intervenções mais efetivas.

Healthy coping: issues and implications in diabetes education and care

Psychological, emotional, and social factors not only impact quality of life, but also often play a role in chronic illness outcomes. Diabetes care, in particular, is greatly influenced by psychosocial factors when they hinder a person's ability to manage the disease and achieve metabolic control. Healthy coping, defined as responding to a psychological and physical challenge by recruiting available resources to increase the probability of favorable outcomes in the future, is essential to effective self-management by people with diabetes. In June 2009, the American Association of Diabetes Educators convened a multidisciplinary expert panel to discuss healthy coping in diabetes. The panel included diabetes educators and behavioral science and mental health professionals. Drawing on their knowledge and experiences, as well as information presented at the symposium, the panel probed several aspects of healthy coping including what it entails, common barriers, assessment, population diversity, and clinical applications. A team approach to addressing the patient's coping is critical. Team involvement relieves the diabetes educator of the entire burden of supporting the patient in this regard. The team should be broadly defined and include those who are formally and informally involved. Healthy coping is a complex, qualitative behavior that cannot be easily quantified. Future efforts to address the issue of healthy coping should add to the body of literature regarding diabetes self-management at the individual and population-based levels.

Understanding GLP-1 analogs and enhancing patients success

Recent research into the mechanisms of type 2 diabetes reveals intricate interactions among many hormonal processes. Ultimately, these pathways lead to hyperglycemia, pancreatic beta-cell failure, and the emergence of type 2 diabetes. The incretin hormones, glucagon-like peptide-1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP), are now known to play major roles in endogenous glucose control, including regulation of insulin, glucagon, and hepatic glucose metabolism. Investigation of the incretin system has led to development of drugs that mimic or enhance the endogenous hormones, including GLP-1 receptor agonists and dipeptidyl peptidase-4 (DPP-4) inhibitors. This supplement describes the role of incretin hormones in the pathophysiology of type 2 diabetes and their potential as therapeutic targets for disease management. In addition, safety and efficacy profiles of the GLP-1 receptor agonists are reviewed, and the advantages and limitations of these medications are discussed from the perspective of promoting their successful implementation in individualized treatment regimens. As understanding of the underlying pathophysiology and pathogenesis of type 2 diabetes advances, the number of new therapeutic approaches expands. GLP-1 receptor agonists address several aspects of the pathophysiology of type 2 diabetes. A large body of data reveals the efficacy, safety, and tolerability of these drugs. A clear understanding of the evidence base for these drugs will translate into improved education of patients regarding their options to improve glycemic control and, ultimately, to better patient care.

The mechanism of protracted wound healing on oral mucosa in diabetes. Review

Diabetic patients increase their body's susceptibility to infection and diabetes is a risk factor for periodontal diseases and oral infection. Although many studies showed the mechanism of impaired wound healing in diabetes, there are still arguments to shed light on what kind of factors, including local and systemic factors are involved in the protracted wound healing. This review article summarizes reports on the wound healing in diabetes and discusses the mechanism of the protracted wound healing of the oral mucosa in diabetes. Delayed vascularization, reduction in blood flow, decline in innate immunity, decreases in growth factor production, and psychological stresses may be involved in the protracted wound healing of the oral mucosa in diabetics.

Behavioural research in patients with end-stage renal disease: a review and research agenda

OBJECTIVE

To suggest a behavioural research agenda for patients with end-stage renal disease (ESRD) based on a concise review of seven stages of psychosocial research, a literature review, and current behavioural research in other chronic somatic diseases.

METHODS

Historical behavioural ESRD research was classified. The specialized register of the Cochrane Behavioral Medicine Field was also checked, and additional papers were selected by screening reference lists and related behavioural science journals, to identify promising areas for future research.

RESULTS

The top-five topics identified via the literature search pertain to (1) psychological aspects and interventions, (2) adaptation, coping, and depression, (3) exercise, (4) counseling and education, and (5) compliance. 'Illness and treatment beliefs', 'sexuality', 'suicide', 'family support', and 'self-management interventions', were identified on the basis of research in other chronic illnesses as topics for future research. Regarding theory, the Common-Sense Model (CSM) was judged to offer useful theoretical perspectives; regarding methods, qualitative methods can be a valuable addition to quantitative research methods.

CONCLUSION

Illness beliefs, treatment beliefs, and self-management behaviours are promising concepts in the assessment and clinical care of ESRD-patients. Cognitive-behavioural treatments appear to have potential and should be specified and elaborated for specific categories and problems of ESRD-patients.

PRACTICE IMPLICATIONS

This research agenda is in line with moves towards patient-centred disease-management to improve the quality of medical care for ESRD-patients.

Effect of interventions for major depressive disorder and significant depressive symptoms in patients with diabetes mellitus: a systematic review and meta-analysis

BACKGROUND

Comorbid depression in diabetes is highly prevalent, negatively impacting well-being and diabetes control. How depression in diabetes is best treated is unknown.

OBJECTIVE

This systematic review and meta-analysis aims to establish the effectiveness of existing anti-depressant therapies in diabetes.

DATA SOURCES

PubMed, Psycinfo, Embase and Cochrane library. Study eligibility criteria, participants, interventions: randomized controlled trials (RCTs) evaluating the outcome of treatment by psychotherapy, pharmacotherapy or collaborative care of depression in persons with Type 1 and Type 2 diabetes mellitus.

STUDY APPRAISAL

risk of bias assessment; data extraction. Synthesis methods: data synthesis, random model meta analysis and publication bias analysis.

RESULTS

Meta analysis of 14 RCTs with a total of 1724 patients show that treatment is effective in terms of reduction of depressive symptoms: -0.512; 95% CI -0.633 to -0.390. The combined effect of all interventions on clinical impact is moderate, -0.370; 95% CI -0.470 to -0.271; it is large for psychotherapeutic interventions that are often combined with diabetes self management: -0.581; 95% CI -0.770 to -0.391, n=310 and moderate for pharmacological treatment: -0.467; 95% CI -0.665 to -0.270, n=281. Delivery of collaborative care, which provided a stepped care intervention with a choice of starting with psychotherapy or pharmacotherapy, to a primary care population, yielded an effect size of -0.292; 95% CI -0.429 to -0.155, n=1133; indicating the effect size that can be attained on a population scale. Pharmacotherapy and collaborative care aimed at and succeeded in the reduction of depressive symptoms but, apart from sertraline, had no effect on glycemic control.

LIMITATIONS

amongst others, the number of RCTs is small.

CONCLUSION

The treatment of depression in people with diabetes is a necessary step, but improvement of the general medical condition including glycemic control is likely to require simultaneous attention to both conditions. Further research is needed.

Expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction in insulin-naïve patients with type 2 diabetes

AIM

The aim of this study was to investigate how patients' expectations about and experiences with insulin therapy contribute to diabetes treatment satisfaction.

METHODS

The Expectations about Insulin Therapy (EAITQ) and the Experience with Insulin Therapy Questionnaires (EWITQ) were administered at baseline and end-point, respectively to insulin-naïve patients with type 2 diabetes in a randomised trial comparing treatment algorithms for inhaled insulin. Pearson correlation coefficients were calculated between EAITQ and EWITQ scores, patient characteristics and patient-reported outcomes measures. Wilcoxon Signed Rank test compared EAITQ and EWITQ item score distributions. Differences between EAITQ and EWITQ scores were calculated to categorize patients according to the extent to which their expectations were met by experiences (i.e. unmet, met, exceeded).

RESULTS

EAITQ and EWITQ data were available for 240 patients (61% male, mean age 58 years, mean diabetes duration 10 years, mean baseline HbA(1c) 8.4%). Increasingly positive expectations were significantly associated with greater self-efficacy; greater levels of positive experiences were significantly associated with greater positive expectations, shorter diabetes duration, less symptom distress, greater well-being, self-efficacy and diabetes treatment satisfaction. Overall, patients' experiences with inhaled insulin therapy were significantly more positive than their expectations: 58% patients' experiences exceeded expectations, 29% patients' experiences met expectations and 13% patients' experiences did not meet expectations. Post hoc tests indicated that treatment satisfaction scores differed among these groups (all p < 0.01).

CONCLUSION

Expectations may not independently impact treatment satisfaction, but the relationship with experiences significantly contributes to it. The EAITQ and EWITQ may be useful tools for clinicians to better understand patients' expectations about and experiences with insulin therapy.

Cross-cultural and international adaptation of peer support for diabetes management

Peer support may improve self-management among the millions of people with diabetes around the world. A major challenge to international promotion of peer support is allowing for tailoring to population, cultural, health system and other features of specific settings, while also ensuring congruence with standards for what peer support entails. One strategy to address this challenge was used in the Robert Wood Johnson Foundation Diabetes Initiative. Key functions of self-management-Resources and Supports for Self-Management-were identified. Individual programmes were then encouraged to implement these resources and support in ways that were feasible in their settings and responsive to the needs and perspectives of those they serve. Extending this to peer support, three Key functions are (i) assistance in managing and living with diabetes in daily life; (ii) social and emotional support and (iii) linkage to clinical care. International promotion may be advanced by emphasizing these key functions and then encouraging local variation in the specific ways they are addressed. Similarly, evaluation of the general benefits of peer support across several individual programmes may rest on measurement of implementation of the key functions, participants' reports of receipt of them and common end points. Challenges to promoting peer support include integrating peers amidst others in the health care system, harmonizing peers with family and other social networks, maintaining the engagement of peer supporters and those they assist and preventing training, quality improvement and professionalism from distorting the fundamental benefits of support from a peer.

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.

Behavioral medicine interventions in diabetes

PURPOSE OF REVIEW

Poor glycemic control is prevalent in the majority of patients with diabetes and has a strong impact on medical as well as psychological outcomes. Psychological and behavioral variables are of particular interest, as the patients themselves are the most determining factor of treatment success. Consequently, a wide range of behavioral medicine interventions are aimed at improvement in diabetes self-management, coping strategies, blood glucose awareness, and stress reduction. This review provides an overview of randomized controlled trials (RCTs) published in the past 18 months (from March 2008 to September 2009) that evaluated behavioral medicine interventions in patients with diabetes. The review summarizes the interventions' effects on metabolic control and other medical variables, as well as diabetes self-management and psychological outcomes.

RECENT FINDINGS

Behavioral medicine interventions in the diabetes field encompass a number of different approaches with the goal of improving medical outcomes such as glycemic control as well as psychological outcomes. There is evidence for beneficial effects of recent behavioral medicine treatments in terms of improvement of metabolic control as indicated by decreased glycated hemoglobin (HbA1c). Furthermore, positive effects were observed regarding diabetes-related self-efficacy, self-management, proactive coping, and the reduction of psychological burdens and symptoms.

SUMMARY

Behavioral medicine interventions are effective in diabetes treatment, especially in patients with a high level of diabetes-related distress, difficulty in coping, or insufficient blood glucose awareness.

An internet-based program to improve self-management in adolescents with type 1 diabetes

OBJECTIVE To report results from YourWay, an Internet-based self-management intervention for adolescents with type 1 diabetes. RESEARCH DESIGN AND METHODS A total of 72 adolescents with type 1 diabetes, ages 13-17 years, were randomized to a usual-care-plus-Internet support or a usual-care group. The intervention was designed to enhance problem-solving barriers to self-management. A1C was obtained from medical records, and problem-solving and self-management were obtained via adolescent report. RESULTS Group differences were not statistically significant using intent-to-treat analyses. Using as-treated analyses, adolescents in the treatment condition showed statistically significant improvement in self-management (d = 0.64; P = 0.02) and important improvements in problem-solving (d = 0.30; P = 0.23) and A1C (d = -0.28; P = 0.27). Mean A1C for the intervention group remained constant (-0.01%), while the control group increased (0.33%). CONCLUSIONS This brief trial suggests that self-management support delivered through a secure website may improve self-management and offset typical decreases in adolescent glycemic control.

Depression and advanced complications of diabetes: a prospective cohort study

OBJECTIVE

To prospectively examine the association of depression with risks for advanced macrovascular and microvascular complications among patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A longitudinal cohort of 4,623 primary care patients with type 2 diabetes was enrolled in 2000-2002 and followed through 2005-2007. Advanced microvascular complications included blindness, end-stage renal disease, amputations, and renal failure deaths. Advanced macrovascular complications included myocardial infarction, stroke, cardiovascular procedures, and deaths. Medical record review, ICD-9 diagnostic and procedural codes, and death certificate data were used to ascertain outcomes in the 5-year follow-up. Proportional hazard models analyzed the association between baseline depression and risks of adverse outcomes.

RESULTS

After adjustment for prior complications and demographic, clinical, and diabetes self-care variables, major depression was associated with significantly higher risks of adverse microvascular outcomes (hazard ratio 1.36 [95% CI 1.05-1.75]) and adverse macrovascular outcomes (1.24 [1.0-1.54]).

CONCLUSIONS

Among people with type 2 diabetes, major depression is associated with an increased risk of clinically significant microvascular and macrovascular complications over the ensuing 5 years, even after adjusting for diabetes severity and self-care activities. Clinical and public health significance of these findings rises as the incidence of type 2 diabetes soars. Further research is needed to clarify the underlying mechanisms for this association and to test interventions to reduce the risk of diabetes complications among patients with comorbid depression.

A cognitive behavior therapy-based intervention among poorly controlled adult type 1 diabetes patients--a randomized controlled trial

OBJECTIVE

To examine the impact of a Cognitive Behavior Therapy (CBT)-based intervention on HbA(1c), self-care behaviors and psychosocial factors among poorly controlled adult type 1 diabetes patients.

METHODS

Ninety-four type 1 diabetes patients were randomly assigned to either an intervention group or a control group. The intervention was based on CBT and was mainly delivered in group format, but individual sessions were also included. All subjects were provided with a continuous glucose monitoring system (CGMS) during two 3-day periods. HbA(1c), self-care behaviors and psychosocial factors were measured up to 48 weeks.

RESULTS

Significant differences were observed with respect to HbA(1c) (P<0.05), well-being (P<0.05), diabetes-related distress (P<0.01), frequency of blood glucose testing (P<0.05), avoidance of hypoglycemia (P<0.01), perceived stress (P<0.05), anxiety (P<0.05) and depression (P<0.05), all of which showed greater improvement in the intervention group compared with the control group. A significant difference (P<0.05) was registered with respect to non-severe hypoglycemia, which yielded a higher score in the intervention group.

CONCLUSION

This CBT-based intervention appears to be a promising approach to diabetes self-management.

PRACTICE IMPLICATIONS

Diabetes care may benefit from applying tools commonly used in CBT. For further scientific evaluation in clinical practice, there is a need for specially educated diabetes care teams, trained in the current approach, as well as cooperation between diabetes care teams and psychologists trained in CBT.

Perceptions and attitudes are primary contributors to insulin delivery system satisfaction in people with type 2 diabetes

BACKGROUND

This study identifies factors that influence satisfaction with an insulin delivery system (IDS). Knowledge of such factors could help identify individuals who would benefit from innovative IDS.

METHODS

Individuals with type 2 diabetes who use insulin, recruited from a general and chronic illness panel, participated in a web-based survey that included questions about demographics, self-reported diagnoses and hemoglobin A1c (HbA1c), current IDS used, insulin therapy attitudes, current IDS features, and satisfaction with IDS. Univariate analyses identified variables associated with IDS satisfaction (P < 0.05); those variables were entered into stepwise linear regression analyses with IDS satisfaction as the dependent variable.

RESULTS

Six hundred sixty-seven individuals with type 2 diabetes participated (mean age, 57 years; 52% female; 88% Caucasian; 73% vial/syringe users, 27% insulin pen users). IDS satisfaction was associated (P < 0.05) with gender, health status, HbA1c, self-reported comorbidity, insulin therapy attitudes, IDS type, and evaluation of IDS features. Among individuals who reported their HbA1c (n = 438), the best predictors of IDS satisfaction were perceived effectiveness and value of insulin therapy, evaluation of IDS activity interference, and commitment to insulin therapy (R2 = 0.49, P < 0.001). Among all participants (n = 667), a second regression analysis that employed a variable representing report of HbA1c found the best predictors of IDS satisfaction included those in the first analysis with the addition of gender, report of HbA1c, and evaluation of IDS ease of use. These variables provided additional variance (R2 = 0.56, P < 0.001).

CONCLUSIONS

In people with type 2 diabetes, positive perceptions and attitudes about insulin therapy have greater influence than the type of IDS used on IDS satisfaction.

Perceived diabetes task competence mediates the relationship of both negative and positive affect with blood glucose in adolescents with type 1 diabetes

BACKGROUND

Adolescents dealing with type 1 diabetes experience disruptions in affect and diabetes management that may influence their blood glucose.

PURPOSE

A daily diary format examined whether daily fluctuations in both negative and positive affect were associated with adolescents' perceived diabetes task competence (DTC) and blood glucose, and whether perceived DTC mediated the relationship between daily affect and blood glucose.

METHODS

Sixty-two adolescents with type 1 diabetes completed a 2-week daily diary, which included daily measures of affect and perceived DTC, then recorded their blood glucose readings at the end of the day. We utilized hierarchical linear modeling to examine whether daily perceived DTC mediated the relationship between daily emotion and blood glucose.

RESULTS

Daily perceived DTC mediated the relationship of both negative and positive affect with daily blood glucose.

CONCLUSIONS

This study suggests that within the ongoing process of self-regulation, daily affect may be associated with blood glucose by influencing adolescents' perception of competence on daily diabetes tasks.

Recent research in stress, coping and women's health

PURPOSE OF REVIEW

To highlight recent publications in the area of stress and coping, with specific reference to women's physical health status.

RECENT FINDINGS

The transactional model of stress and coping continues to be the mainstay of research in this area. Several longitudinal studies have demonstrated that stress appraisal and resultant coping responses affect health outcome and health-related quality of life in women. In addition to problem-focused coping, women often use distraction methods, seeking social support and faith or religious coping. Psychological interventions in chronic medical conditions need to move beyond education and incorporate more cognitive behavioral components, at the same time addressing women's specific needs.

SUMMARY

Coping behaviors in response to the negative threat appraisal of a chronic or severe medical illness serve to reduce psychological distress. However, it is still not clear how they impact at the physiological level. In addition, coping responses, which enhance positive effects and promote health-related quality of life, merit greater attention from researchers. There is a need for more gender comparative research to improve health outcomes in men and women.

Oxidative stress and diabetic retinopathy: pathophysiological mechanisms and treatment perspectives

Retinopathy is one of the most severe ocular complications of diabetes and is a leading cause of acquired blindness in young adults. The cellular components of the retina are highly coordinated but very susceptible to the hyperglycemic environment. The microvasculature of the retina responds to hyperglycemic milieu through a number of biochemical changes, including increased oxidative stress and polyol pathway, PKC activation and advanced glycation end product formation. Oxidative stress is considered as one of the crucial contributors in the pathogenesis of diabetic retinopathy, but oxidative stress appears to be highly interrelated with other biochemical imbalances that lead to structural and functional changes and accelerated loss of capillary cells in the retinal microvasculature and, ultimately, pathological evidence of the disease. One such potential connection that links oxidative stress to metabolic alterations is gyceraldehyde-3-phosphate dehydrogenase whose activity is impaired in diabetes, and that results in activation of other major pathways implicated in the pathogenesis of diabetic retinopathy. Alterations associated with oxidative stress offer many potential therapeutic targets making this an area of great interest to the development of safe and effective treatments for diabetic retinopathy. Animal models of diabetic retinopathy have shown beneficial effects of antioxidants on the development of retinopathy, but clinical trials (though very limited in numbers) have provided somewhat ambiguous results. Although antioxidants are being used for other chronic diseases, controlled clinical trials are warranted to investigate potential beneficial effects of antioxidants in the development of retinopathy in diabetic patients.

Self-Monitoring of Blood Glucose (SMBG) in insulin- and non-insulin-using adults with diabetes: consensus recommendations for improving SMBG accuracy, utilization, and research

Current clinical guidelines for diabetes care encourage self-monitoring of blood glucose (SMBG) to improve glycemic control. Specific protocols remain variable, however, particularly among non-insulin-using patients. This is due in part to efficacy studies that neglect to consider (1) the performance of monitoring equipment under real-world conditions, (2) whether or how patients have been taught to take action on test results, and (3) the physiological, behavioral, and social circumstances in which SMBG is carried out. As such, a multidisciplinary group of specialists, including several endocrinologists, a health psychologist, a diabetes nurse practitioner, and a patient advocate (the Panel), discuss within this review article how the potential of SMBG might be fully realized in today's healthcare environment. The resulting recommendations cover technological, clinical, behavioral, and research considerations with the aim of achieving short- and long-term benefits, ranging from fewer hypoglycemic episodes to lower complication-related costs. The panel also made suggestions for designing future studies that increase the ability to discern optimal models of SMBG utilization for individuals with diabetes who may, or may not, use insulin.

A randomised controlled clinical trial of nurse-, dietitian- and pedagogist-led Group Care for the management of Type 2 diabetes

AIM

To verify if Group Care, a model to manage Type 2 diabetes (T2DM) by systemic continuing group education, can be administered by nurses and dieticians under pedagogic guidance, and improve metabolic control, quality of life, Locus of Control, and insulin resistance.

MATERIAL AND SUBJECTS

Twenty-five patients with non-insulin-treated T2DM were randomized to Group Care and 24 to continued habitual individual care and education delivered by a diabetes specialist and pedagogist, respectively. Six nurses and 1 dietician received training by an accredited programme, a detailed operating manual and pedagogical supervision throughout the study. Follow-up was for 2 yr and included measurements of fasting blood glucose, glycated hemoglobin (HbA1c), body mass index, waist circumference, lipids, creatinine, blood pressure, serum insulin, homeostasis model assessment (HOMA) index of insulin resistance, health behaviors, quality of life, state and trait anxiety, and Locus of Control.

RESULTS

One patient on Group Care and 3 controls dropped out. At the end of study, the patients on Group Care had lower HbA1c (7.6+/-0.8 vs 8.4+/-1.3, p<0.05), insulin (18.0+/-9.6 vs 24.3+/-13.7, p<0.001), HOMA index (6.9+/-5.4 vs 9.2+/-6.6, p<0.05), and fatalistic attitude (17.2+/-5.9 vs 24.9+/-4.2, p<0.001) and better quality of life (65.0+/-11.0 vs 78.4+/-19.6, p<0.001) than controls.

CONCLUSIONS

Group Care delivered by trained nurses and dietitian is associated with better outcomes than those obtained by a medically and pedagogically qualified team. It may offer a model for health operators to re-organize clinical practice and for patients to improve lifestyle and strengthen the therapeutic alliance with their carers.