Tests of glycemia in diabetes

Disparities in HbA1c levels between African-American and non-Hispanic white adults with diabetes: a meta-analysis

OBJECTIVE

Among individuals with diabetes, a comparison of HbA(1c) (A1C) levels between African Americans and non-Hispanic whites was evaluated. Data sources included PubMed, Web of Science, the Cumulative Index to Nursing and Allied Health, the Cochrane Library, the Combined Health Information Database, and the Education Resources Information Center.

RESEARCH DESIGN AND METHODS

We executed a search for articles published between 1993 and 2005. Data on sample size, age, sex, A1C, geographical location, and study design were extracted. Cross-sectional data and baseline data from clinical trials and cohort studies for African Americans and non-Hispanic whites with diabetes were included. Diabetic subjects aged <18 years and those with pre-diabetes or gestational diabetes were excluded. We conducted a meta-analysis to estimate the difference in the mean values of A1C for African Americans and non-Hispanic whites.

RESULTS

A total of 391 studies were reviewed, of which 78 contained A1C data. Eleven had data on A1C for African Americans and non-Hispanic whites and met selection criteria. A meta-analysis revealed the standard effect to be 0.31 (95% CI 0.39-0.25). This standard effect correlates to an A1C difference between groups of approximately 0.65%, indicating a higher A1C across studies for African Americans. Grouping studies by study type (cross-sectional or cohort), method of data collection for A1C (chart review or blood draw), and insurance status (managed care or nonmanaged care) showed similar results.

CONCLUSIONS

The higher A1C observed in this meta-analysis among African Americans compared with non-Hispanic whites may contribute to disparity in diabetes morbidity and mortality in this population.

Evidence-Based Protocol for Diabetic Foot Ulcers

BACKGROUND

Diabetic foot ulcers are the single biggest risk factor for nontraumatic foot amputations in persons with diabetes. Foot ulcers occur in 12 to 25 percent of persons with diabetes and precede 84 percent of all nontraumatic amputations in this growing population. Because of the high incidence of foot ulcers, amputations remain a source of morbidity and mortality in persons with diabetes. Strict adherence to evidence-based protocols as described herein will prevent the majority of these amputations.

METHODS

The collective experience of treating patients with neuropathic diabetic foot ulcers in four major diabetic foot programs in the United States and Europe was analyzed.

RESULTS

The following protocol was developed for patients with diabetic foot ulcers: (1) establishment of good communication among the patient, the wound healing team, and the primary medical doctor; (2) comprehensive, protocol-driven care of the entire patient, including hemoglobin A1c, microalbuminuria, and cholesterol as well as early treatment of retinopathy, nephropathy, and cardiac disease; (3) weekly objective measurement of the wound with digital photography, planimetry, and documentation of the wound-healing process using the Wound Electronic Medical Record, if available; (4) objective evaluation of blood flow in the lower extremities (e.g., noninvasive flow studies); (5) débridement of hyperkeratotic, infected, and nonviable tissue; (6) use of systemic antibiotics for deep infection, drainage, and cellulitis; (7) off-loading; (8) maintenance of a moist wound bed; (9) use of growth factor and/or cellular therapy if the wound is not healing after 3 weeks with this protocol; and (10) consideration of the use of vacuum-assisted therapy in complex wounds.

CONCLUSIONS

In diabetic foot ulcers, availability of the above modalities, in combination with early recognition and comprehensive treatment, ensures rapid healing, minimizes morbidity and mortality rates, and eliminates toe and limb amputations in the absence of ischemia and osteomyelitis.

Meeting AHA/ACC secondary prevention goals in a vascular surgery practice: An opportunity we cannot afford to miss

OBJECTIVE

In an effort to reduce cardiovascular mortality, patients with atherosclerotic arterial disease should undergo risk factor modification according to the American Heart Association/American College of Cardiology (AHA/ACC) Secondary Prevention Guidelines (hereafter, Guideline). We assessed compliance with the Guideline in a group of patients seen in a vascular surgery practice.

METHODS

We evaluated 200 consecutive patients with lower-extremity occlusive disease, cerebrovascular disease, or abdominal aortic aneurysm seen by a university-based vascular surgery practice. The subjects were patients who had been seen previously in our clinic (ESTABLISHED) and new referrals (NEW). Data pertinent to each of the nine AHA/ACC Guideline goals were collected from patient interviews, medication histories, and laboratory records. Compliance with each of the Guideline goals was evaluated. Differences in compliance between ESTABLISHED and NEW patient groups were also compared. We also recorded whether a patient had a previous endovascular or open surgical vascular intervention (EVENT or NO EVENT). Differences in compliance between the EVENT and NO EVENT groups were compared.

RESULTS

Most patients did not achieve the secondary prevention goals recommended in the Guideline. Patients who had a prior vascular intervention (EVENT) were significantly more likely to achieve goals for low-density lipoprotein level (43% vs 23%), and for statin (71% vs 39%), beta-blocker (46% vs 27%), angiotensin-converting enzyme inhibitor (53% vs. 35%), and antiplatelet agent (85% vs. 68%) use (P < .05). ESTABLISHED patients were significantly more likely than NEW patients to have a prior EVENT (87% vs 47%, P < .0005). ESTABLISHED patients were significantly more likely than NEW patients to achieve goals for low-density lipoprotein level, beta-blocker, and statin use; however, these differences were likely due to the higher proportion of EVENT patients in the ESTABLISHED group.

CONCLUSION

Compliance with the Guideline is suboptimal in patients with atherosclerotic arterial disease. Secondary prevention goals were more often achieved in the EVENT patient group, suggesting that a vascular intervention may lead to increased patient and physician awareness and compliance with the Guideline. A targeted effort towards risk factor modification in patients with atherosclerotic arterial disease could improve compliance with the Guideline and reduce cardiovascular mortality.

Sick day management using blood 3-hydroxybutyrate (3-OHB) compared with urine ketone monitoring reduces hospital visits in young people with T1DM: a randomized clinical trial

AIMS

Diabetic ketoacidosis (DKA), a life-threatening acute complication of Type 1 diabetes, may be preventable with frequent monitoring of glycaemia and ketosis along with timely supplemental insulin. This prospective, two-centre study assessed sick day management using blood 3-hydroxybutyrate (3-OHB) monitoring compared with traditional urine ketone testing, aimed at averting emergency assessment and hospitalization.

METHODS

One hundred and twenty-three children, adolescents and young adults, aged 3-22 years, and their families received sick day education. Participants were randomized to receive either a blood glucose monitor that also measures blood 3-OHB (blood ketone group, n = 62) or a monitor plus urine ketone strips (urine ketone group, n = 61). All were encouraged to check glucose levels > or = 3 times daily and to check ketones during acute illness or stress, when glucose levels were consistently elevated (> or = 13.9 mmol/l on two consecutive readings), or when symptoms of DKA were present. Frequency of sick days, hyperglycaemia, ketosis, and hospitalization/emergency assessment were ascertained prospectively for 6 months.

RESULTS

There were 578 sick days during 21,548 days of follow-up. Participants in the blood ketone group checked ketones significantly more during sick days (276 of 304 episodes, 90.8%) than participants in the urine ketone group (168 of 274 episodes, 61.3%) (P < 0.001). The incidence of hospitalization/emergency assessment was significantly lower in the blood ketone group (38/100 patient-years) compared with the urine ketone group (75/100 patient-years) (P = 0.05).

CONCLUSIONS

Blood ketone monitoring during sick days appears acceptable to and preferred by young people with Type 1 diabetes. Routine implementation of blood 3-OHB monitoring for the management of sick days and impending DKA can potentially reduce hospitalization/emergency assessment compared with urine ketone testing and offers potential cost savings.

Hypoglycemic effect of Egyptian Morus alba root bark extract: effect on diabetes and lipid peroxidation of streptozotocin-induced diabetic rats

The hypoglycemic activity of the flavonoids rich fraction of 70% alcohol extract of the Egyptian Morus alba root bark (MRBF-3) was evaluated after its oral administration to streptozotocin-induced diabetic rats. Diabetes was induced by injection of 60 mg kg(-1) i.p. The administration of MRBF-3 to streptozotocin (STZ)-diabetic rats for 10 days in a dose of 200 and 400 mg kg(-1)day(-1) was not significant. However, administration of MRBF-3 for 10 days (600 mg kg(-1)day(-1)) significantly reduced the amount of the glucose from control level (379+/-9 mg/dl) to a lower level (155+/-8 mg/dl) and significantly increased the insulin level from control (10.8+/-0.3 microU/ml) to a high level (15.6+/-0.3 microU/ml). The measurement of produced lipid peroxides (expressed as the amount of thiobarbituric acid (TBA) reactive substance, nmol TBARS/ml serum) indicated antiperoxidative activity of MRBF-3. The oral administration of MRBF-3 to STZ-diabetic rats significantly decreased the lipid peroxides from 6.3+/-0.8 to 5.1+/-0.7 nmol TBARS/ml serum. The phytochemical investigation of MRBF-3 resulted in the isolation of four hydrophobic flavonoids with one or two isoprenoid groups (log P=5-9): morusin, cyclomorusin, neocyclomorusin, and kuwanon E, a 2-arylbenzofuran, moracin M, and two triterpenes, betulinic acid and methyl ursolate. The data obtained from this study revealed that MRBF-3 may protect pancreatic beta cells from degeneration and diminish lipid peroxidation. However, this is the first biological screening of the Egyptian Morus alba root bark; further future merit studies including clinical study will be necessary in order to confirm the results obtained from this study.

The role of self-monitoring of blood glucose in the care of people with diabetes: report of a global consensus conference

Self-monitoring of blood glucose (SMBG) is an underutilized but integral part of disease management for patients with both type 1 and type 2 diabetes. Guidelines on the recommended frequency and timing of SMBG vary among international diabetes associations, and patients are often unaware of actions they should take in response to SMBG. results. In response to this, a global consensus conference of recognized diabetes experts convened to clarify the role of SMBG as a tool to help optimize glycemic control (e.g., complementing information provided by hemoglobin A1c, detecting postprandial excursions, identifying glucose patterns, and providing patients feedback on lifestyle and medications) while minimizing hypoglycemia and maintaining quality of life. The consensus panel also sought to reinforce the importance of appropriate and systematic patient and provider response to the collected SMBG data. A set of 16 consensus statements was approved by the panel. This article presents the 16 statements together with some brief rationale for their inclusion.

Monitoring glycemic control: the importance of self-monitoring of blood glucose

Several methods, each with differing utility and limitations, exist for monitoring glycemic control. Hemoglobin A1c (HbA1c) is considered the standard measure of long-term glycemic control, and HbA1c levels are strongly associated with complications of diabetes. However, HbA1c does not provide "real-time" information about individual hyperglycemic or hypoglycemic excursions. Urine glucose testing is noninvasive and inexpensive, but it is dependent on the patient's individual renal threshold and can only detect glucose concentrations above this threshold. As such, urine testing cannot be recommended for diabetes management that aims for near-normoglycemia. Self-monitoring of blood glucose (SMBG) complements HbA1c by providing real-time blood glucose data. It is an educational tool for both patients and their healthcare providers to understand the effects of diet, exercise, and medications on day-to-day glycemic control. However, guidelines from various international diabetes organizations vary in their level of specificity regarding the frequency and timing of self-monitoring. SMBG should be implemented for all patients as part of an overall diabetes management plan that includes specific instruction on how, when, and why to test.

Ecological approaches to self-management: the case of diabetes

In the Diabetes Initiative of The Robert Wood Johnson Foundation, an ecological perspective helped identify the following key resources and supports for self-management (RSSM): individualized assessment, collaborative goal setting, skills enhancement, follow-up and support, access to resources, and continuity of quality clinical care. These RSSM reflect the grounding of diabetes self-management in the context of social and environmental influences. Research supports the value of each of these key resources and supports. Differences among self-management interventions may be seen as complementary, rather than conflicting, ways of providing RSSM. This way of understanding differences among interventions may aid development of varied programs to reach diverse audiences. In contrast to the "5 A's" model of key provider services (Assess, Advise, Agree, Assist, and Arrange), RSSM articulate self-management from the perspective of individuals' needs. Both approaches emphasize identification of goals, teaching of skills, and facilitation and reinforcement of the use of those skills.

Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control

AIMS

In the framework of a nationwide outcomes research programme, we assessed the impact of self-monitoring of blood glucose (SMBG) on metabolic control over 3 years in patients with Type 2 diabetes mellitus (DM2) not treated with insulin.

METHODS

The study involved 1896 patients who completed, at 6-month intervals for 3 years, a questionnaire investigating SMBG practice. Clinical information was collected by participating clinicians at the same time intervals. The predictive value of SMBG frequency on long-term metabolic control was estimated using multilevel analysis. The impact of SMBG on metabolic control was also evaluated in distinct and homogeneous subgroups of patients showing different likelihood of performing SMBG, identified using a tree-growing technique (RECPAM).

RESULTS

Overall, 22% of the patients were on diet alone and 78% were treated with oral agents; 41% practiced SMBG > or = 1/week (10.3% > or = 1/day). The analysis of metabolic control according to the frequency of SMBG failed to show any significant impact of this practice on HbA1c levels over 3 years. Similarly, changes in SMBG frequency during the study were not related to significant changes in HbA1c levels. RECPAM analysis led to the identification of eight classes, characterized by substantial differences in the likelihood of performing SMBG with a frequency of at least 1/week. Nevertheless, in none of the RECPAM classes identified, did SMBG predict a better metabolic control over 3 years of follow-up. In those RECPAM classes indicating that SMBG was mainly performed to avoid hypoglycaemic episodes, SMBG was associated with a decrease in the frequency of hypoglycaemic episodes during the study.

CONCLUSIONS

In a large sample of non-insulin-treated Type 2 diabetic patients, the performance and frequency of SMBG did not predict better metabolic control over 3 years. We could not identify any specific subgroups of patients for whom SMBG practice was associated with lower HbA1c levels during the study.

Depression and glycemic control in Hispanic primary care patients with diabetes

CONTEXT

Maintaining optimal glycemic control is an important goal of therapy in patients with diabetes mellitus. Patients of Hispanic ancestry have been shown to have high rates of diabetes and poor glycemic control (PGC). Although depression is common in adults with diabetes, its relationship to glycemic control remains unclear, especially among Hispanics.

OBJECTIVE

To assess the association of depression with PGC in Hispanics.

DESIGN

Data from a cross-sectional mental health survey in primary care were crosslinked to the hospital's computerized laboratory database.

SETTING

Urban general medicine practice at a teaching hospital.

PATIENTS

Two hundred and nine patients (mean [standard deviation] age, 57.1 [10.3] years; 68% females) with recent International Classification of Diseases, Ninth Revision (ICD-9) codes for diabetes mellitus, and 1 or more hemoglobin A(1c) (HbA(1c)) tests.

MAIN OUTCOME MEASURE

Probability of PGC (HbA(1c)>or=8%).

RESULTS

Probability for PGC steadily increased with severity of depression. Thirty-nine (55.7%) of the 70 patients with major depression had HbA(1c)>or=8%, compared with 39/92 (42.4%) in the minimal to mild depression group, and 15/47 (31.9%) in the no depression group (P(trend)=.01; adjusted odds ratio, 3.27; 95% confidence interval, 1.23 to 8.64, for moderate or severe depression vs no depression). Only 29 (41.4%) of the patients with major depression received mental health treatment in the previous year.

CONCLUSIONS

In this primary care sample of Hispanic patients with diabetes, we found a significant association between increasing depression severity and PGC. Yet, less than one half of the patients with moderate or severe depression received mental health treatment in the previous year. Improving identification and treatment of depression in this high-risk population might have favorable effects on diabetic outcomes.