Real-time continuous glucose monitoring versus internet-based blood glucose monitoring in adults with type 2 diabetes: a study of treatment satisfaction

Patient-reported outcomes in studies of diabetes technology: What matters

In recent years, diabetes technologies have revolutionized the care of people with type 1 diabetes (T1D). Emerging evidence suggests that people with type 2 diabetes (T2D) can experience similar benefits from these advances in technology. While glycaemic outcomes are often a primary focus, the lived experience of the person with diabetes is equally important. In this review, we describe the impact of diabetes technologies on patient-reported outcome measures (PROMs). We highlight that most of the published studies investigated PROMs as secondary outcomes. Continuous glucose monitoring systems may have an important role in improving PROMs in individuals with T1D, which may be driven by the prevention or proactive management of hypoglycaemia. In people with T2D, continuous glucose monitoring may also have an important role in improving PROMs, particularly in those treated with insulin therapy. The impact of insulin pumps on PROMs seems positive in T1D, while there is limited evidence in T2D. Studies of hybrid closed-loop therapies suggest increased treatment satisfaction, improved quality of life and decreased diabetes-related distress in T1D, but it is unclear whether these benefits are because of a 'class-effect' or individual systems. We conclude that PROMs deserve a more central role in trials and clinical practice, and we discuss directions for future research.

The use of technology in type 2 diabetes and prediabetes: a narrative review

The increasing incidence of type 2 diabetes, which represents 90% of diabetes cases globally, is a major public health concern. Improved glucose management reduces the risk of vascular complications and mortality; however, only a small proportion of the type 2 diabetes population have blood glucose levels within the recommended treatment targets. In recent years, diabetes technologies have revolutionised the care of people with type 1 diabetes, and it is becoming increasingly evident that people with type 2 diabetes can also benefit from these advances. In this review, we describe the current knowledge regarding the role of technologies for people living with type 2 diabetes and the evidence supporting their use in clinical practice. We conclude that continuous glucose monitoring systems deliver glycaemic benefits for individuals with type 2 diabetes, whether treated with insulin or non-insulin therapy; further data are required to evaluate the role of these systems in those with prediabetes (defined as impaired glucose tolerance and/or impaired fasting glucose and/or HbA1c levels between 39 mmol/mol [5.7%] and 47 mmol/mol [6.4%]). The use of insulin pumps seems to be safe and effective in people with type 2 diabetes, especially in those with an HbA1c significantly above target. Initial results from studies exploring the impact of closed-loop systems in type 2 diabetes are promising. We discuss directions for future research to fully understand the potential benefits of integrating evidence-based technology into care for people living with type 2 diabetes and prediabetes.

Wearable filamentary continuous sensor for interstitial glucose detection in diabetes management

The development of novel diabetes monitoring sensors is important for the diabetes management of millions of diabetic patients. This work reports a flexible filamentary continuous glucose monitoring (CGM) sensor. A multilayer CGM sensor has been constructed on titanium filament with low cost and ease of use. The sensor, made of flexible material, offers better adaptability and comfort than traditional rigid filament CGM sensors, allowing continuous monitoring of subcutaneous blood glucose levels to provide patients with treatment strategies. The performance and reliability of the sensor were verified through rat experiments. The trend of the increase and decrease of the detected current was generally consistent with the actual blood glucose, and the detected values were located in regions A and B of the Clarke error grid. The results show that the sensor has the advantages of high sensitivity, high accuracy and fast response speed, which is suitable for monitoring the blood glucose level for a long time and has a broad application prospect in diabetes monitoring, exercise monitoring, health management and clinical application.

Patient experiences of continuous glucose monitoring and sensor-augmented insulin pump therapy for diabetes: A systematic review of qualitative studies

AIMS

Blood glucose control is central to the management of diabetes, and continuous glucose monitoring (CGM) improves glycemic control. We aimed to describe the perspectives of people with diabetes using CGM.

MATERIALS AND METHODS

We performed a systematic review of qualitative studies.

RESULTS

Fifty-four studies involving 1845 participants were included. Six themes were identified: gaining control and convenience (reducing pain and time, safeguarding against complications, achieving stricter glucose levels, and sharing responsibility with family); motivating self-management (fostering ownership, and increasing awareness of glycemic control); providing reassurance and freedom (attaining peace of mind, and restoring social participation); developing confidence (encouraged by the endorsement of others, gaining operational skills, customizing settings for ease of use, and trust in the device); burdened with device complexities (bewildered by unfamiliar technology, reluctant to rely on algorithms, overwhelmed by data, frustrated with malfunctioning and inaccuracy, distressed by alerts, and bulkiness of machines interfering with lifestyle); and excluded by barriers to access (constrained by cost, lack of suppliers).

CONCLUSIONS

CGM can improve self-management and confidence in patients managing diabetes. However, the technical issues, uncertainty in readings, and cost may limit the uptake. Education and training from the health professionals may help to reduce the practical and psychological burden for better patient outcomes.

A Microtube-Based Wearable Closed-Loop Minisystem for Diabetes Management

Diabetes is a chronic metabolic disease with a high blood glucose level, leading to both seriously acute and chronic complications. The closed-loop system is an ideal system for diabetes management. However, the large size and high cost of the commercial systems restrict their widespread uses. Here, we present for the first time a microtube-based wearable closed-loop minisystem for diabetes management. The closed-loop minisystem includes a biosensing device, an electroosmotic micropump, and a printed circuit board (PCB) with an algorithm. The microtube-based sensing device coated on the outer surface of the microtube is inserted into subcutaneous tissue for detecting interstitial glucose; the current signal for sensing glucose is processed by the PCB to power the electroosmotic micropump intelligently for the delivery of insulin into the subcutaneous tissue via the microtube channel. The closed-loop minisystem worn on a diabetic SD rat can successfully maintain its blood glucose level within a safe level. It is expected that this new closed-loop paradigm could open up new prospects for clinical diabetes management.

Exploring Parental Experiences of Using a Do-It-Yourself Solution for Continuous Glucose Monitoring Among Children and Adolescents With Type 1 Diabetes: A Qualitative Study

BACKGROUND

MiaoMiao (MM) is a Bluetooth transmitter, which when paired with a smart phone/device, converts the Abbott FreeStyle Libre flash glucose monitoring system into a Do-It-Yourself (DIY) continuous glucose monitor (CGM). Families are increasingly adopting DIY CGM solutions, but little is known about parent and child experiences with these add-on technologies. We aimed to explore experiences of families using MM-CGM including challenges faced and their advice to others who may choose to use the technology.

METHODS

Between May and July 2019, we conducted 12 semistructured interviews (in person or via video conference) with parents of children (aged ≤16 years) with type 1 diabetes using MM-CGM. Interviews were audio recorded; professionally transcribed and key themes were identified through thematic analysis.

RESULTS

Overall, parents used MM-CGM to proactively manage their child's blood glucose. In all participants, this led to a perceived decrease in frequency of hypoglycemia. Participants reported that the visibility and easy access to blood glucose readings, glucose trends, and customized alarms on parent's phones decreased their disease burden and improved their sleep quality. Common barriers to using MM-CGM included difficulty of the setting up process, connectivity issues, and lack of support from medical teams.

CONCLUSION

This study highlights the potential feasibility of using a DIY CGM system like MM-CGM, which could be an empowering and cost-effective tool for enabling remote monitoring of blood glucose in real time.

Impact of technology on glycaemic control in type 2 diabetes: A meta-analysis of randomized trials on continuous glucose monitoring and continuous subcutaneous insulin infusion

AIM

To conduct a meta-analysis to assess the effect of continuous subcutaneous insulin infusion (CSII), continuous glucose monitoring (CGM), and the combination of the two, on glycaemic control in type 2 diabetes.

MATERIALS AND METHODS

The analysis included randomized clinical trials comparing CSII with multiple daily injections (MDI) in people with type 2 diabetes, as well as studies comparing CGM or flash glucose monitoring (FGM) with self-monitoring of blood glucose (SMBG), with a duration of at least 12 weeks, identified in Medline or clinicaltrials.gov. The principal endpoint was glycated haemoglobin (HbA1c) at the end of the trial. Mean and 95% confidence intervals (CIs) for HbA1c and Mantel-Haenzel odds ratios for severe hypoglycaemia were calculated, using random-effect models.

RESULTS

The retrieved trials showed a significant heterogeneity (I² = 90%). The difference in HbA1c between CSII and MDI was not statistically significant (-0.26% [95% CI -0.74;0.22]; P = .29). The difference in endpoint HbA1c between CGM and SMBG was marginally significant (-0.24 [95% CI -0.49;0.00]; P = .05), and CGM was possibly associated with a lower hypoglycaemic risk. Only one trial explored the effect of FGM, as compared with SMBG, on HbA1c in type 2 diabetes, finding no difference across groups (at study end: 8.4% ± 0.8% vs 8.3% ± 1.1% with FGM and SMBG, respectively). Conversely, FGM was associated with an improvement in quality of life and with a lower incidence of hypoglycaemic events. The small number of retrieved trials indicates that the results should be interpreted with caution.

CONCLUSIONS

The analysis showed that CSII, CGM and FGM provide only small benefits compared with MDI (on either HbA1c, hypoglycaemic risk or quality of life) in insulin-treated people with type 2 diabetes.

Continuous Glucose Monitoring Versus Self-monitoring of Blood Glucose in Type 2 Diabetes Mellitus: A Systematic Review with Meta-analysis

Every eleventh adult has diabetes, and every third has prediabetes. Over 95% of diabetics are of type 2. It is well established that diabetes doubles the risk of heart disease and stroke apart from increasing the risk of microvascular complications. Hence, strict glycemic control is necessary. However, it increases the risk of hypoglycemia, especially in patients with longstanding diabetes. Continuous glucose monitors (CGM) use a sensor to continuously measure the glucose levels in the interstitial fluid every 10 seconds and gives out mean values every five minutes. CGMs are emerging tools in the management of type 2 diabetes. The prime objective of this review is to find out if there is enough supporting evidence, suggesting that continuous glucose monitoring is more effective than self-monitoring of blood glucose (SMBG) in type 2 diabetes. We conducted a systematic literature search in Medline (PubMed) looking for any studies addressing our objective. It is observed that there is a varying level of evidence supporting that employing a CGM can reduce glycated hemoglobin (HbA1c), hypoglycemic events, and increase patient satisfaction. However, some studies reported no significant benefits. This systematic review with meta-analysis concludes that the use of CGM in type 2 diabetes mellitus (T2DM) is beneficial, as it significantly reduces HbA1c compared to the usual method of SMBG. The pooled mean difference in HbA1c was -0.25 (-0.45, -0.06) and statistically significant (at p = 0.01) when comparing CGM to SMBG.

Tolerability and acceptability of real-time continuous glucose monitoring and its impact on diabetes management behaviours in individuals with Type 2 Diabetes - A pilot study

INTRODUCTION

Emerging evidence suggests us of real-time continuous glucose monitoring systems (RT-CGM), can assist to improve glucose control in Type 2 Diabetes (T2D) treatment, however the impact of these devices on patients' stress levels and behaviour is poorly understood. This study aimed to examine the effects of RT-CGM on tolerance and acceptability of device wear, stress and diabetes management and motivation to change.

METHODS

Twenty adults (10 men, 10 women) with T2D (aged 60.6 ± 8.4 years, BMI 34.2 ± 4.7 kg/m²), were randomised to a low-carbohydrate lifestyle plan whilst wearing a RT-CGM or an 'offline-blinded' (Blinded-CGM) monitoring system continuously for 12 weeks. Outcomes were glycaemic control (HbA1c), weight (kg) perceived stress scale (PSS), CGM device intolerance, acceptability, motivation to change and diabetes management behaviour questionnaires.

RESULTS

Both groups experienced significant reductions in body weight (RT-CGM -7.4 ± 4.5 kg vs. Blinded-CGM -5.5 ± 4.0 kg) and HbA1c (-0.67 ± 0.82% vs. -0.68 ± 0.74%). There were no differences between groups for perceived stress (P = 0.47) or device intolerance at week 6 or 12 (both P > 0.30). However, there was evidence of greater acceptance of CGM in the RT-CGM group at week 12 (P = 0.03), improved blood glucose monitoring behaviour in the RT-CGM group at week 6 and week 12 (P ≤ 0.01), and a significant time x group interaction (P = 0.03) demonstrating improved diabetes self-management behaviours in RT-CGM.

CONCLUSION

This study provides preliminary evidence of improved behaviours that accompany RT-CGM in the context of diabetes management and glucose self-monitoring. RT-CGM may provide an alternative approach to glucose management in individuals with T2D without resulting in increased disease distress.

Impact of New Technologies for Middle-Aged and Older Patients: In-Depth Interviews With Type 2 Diabetes Patients Using Continuous Glucose Monitoring

Background

Continuous glucose monitoring (CGM) uses subcutaneous sensors and records the average interstitial sensor current every 5 min in the recorder; data are subsequently exported to a computer 4 to 7 days later when calibration with self-measured blood glucose is made retrospectively. How middle-aged and older patients perceive the added technology intervention is not clear.

Objective

The study aimed to understand the factors associated with the adoption of new technology in diabetes care, to understand the feelings and behaviors while using it, and to determine the changes in attitudes and behavior after completing the use of the new technology at the 3-month follow-up.

Methods

Middle-aged and older type 2 diabetes patients who had received professional continuous glucose monitoring (iPro 2 [Medtronic]) were invited for semistructured in-depth interviews on the day of the CGM sensor removal and at 3 months after CGM-based counseling. A phenomenography approach was used to analyze the interview data.

Results

A total of 20 type 2 diabetes patients (aged 53 to 72 years, 13 males and 7 females, 4 to 40 years duration of diabetes, mean glycated hemoglobin 8.54% [SD 0.71%]) completed 2 sections of semistructured in-depth interviews. Physician guidance and participant motivation toward problem solving were found to be factors associated with adoption of the device. Participants indicated that technology can be a reminder, a supervisor, and a visualizer of blood glucose, all of which are helpful for disease management. However, CGM is somewhat inconvenient, and some participants also reported that the provision of this new technology might be a hint of disease progression. There was a higher percentage of women compared with men who reported that CGM can be a reminder or a supervisor to help them with diet control.

Conclusions

Physician guidance and participants’ degree of motivation are keys to adopting new technology in the case of middle-aged and older adults. Although the CGM sensor may cause inconvenience to patients on their limited body movement when wearing the device, it is helpful for diet control and is an effective behavioral modification tool that offers support, especially in the case of women.

Effectiveness and acceptability of continuous glucose monitoring for type 2 diabetes management: A narrative review

The present narrative review discusses the role of continuous glucose monitoring (CGM) in glycemic and weight control, and lifestyle behavior adherence in adults with type 2 diabetes. A literature search from January 2001 to November 2017 was carried out (MEDLINE, CINAHL, Web of Science and Scopus). Eligible studies were trials evaluating the use of CGM with the aim of achieving glucose control or lifestyle-related treatment adherence over a period of ≥8 weeks in adults with type 2 diabetes compared with usual care or another comparison intervention, or observational trials reporting CGM user experience. A total of 5,542 participants were recruited into 11 studies (eight randomized controlled trials [n = 5,346] and three observational studies [n = 196]). The sample size ranged 6-4,678 participants, the mean age was 51.7-60.0 years and diabetes duration was 2.1-19.2 years, with high heterogeneity between studies. Overall, the available evidence showed, compared with traditional self-monitoring of blood glucose levels, CGM promoted greater reductions in glycated hemoglobin, bodyweight and caloric intake; higher adherence rating to a personal eating plan; and increases in physical activity. High compliance to CGM wear-time and device calibration was reported (>90%). The addition of lifestyle and/or behavioral counseling to CGM appeared to further potentiate these improvements. Preliminary evidence suggests that CGM use promotes glycemic and weight control, and lifestyle behavior adherence in adults with type 2 diabetes. These benefits might be further enhanced with integration of diet, exercise, and glucose excursion education and counseling. However, specific attributes of effective interventions and the application of CGM information for promoting improved outcomes and healthier choices remain unclear.

Characterizing Active Ingredients of eHealth Interventions Targeting Persons With Poorly Controlled Type 2 Diabetes Mellitus Using the Behavior Change Techniques Taxonomy: Scoping Review

BACKGROUND

The behavior change technique taxonomy v1 (BCTTv1; Michie and colleagues, 2013) is a comprehensive tool to characterize active ingredients of interventions and includes 93 labels that are hierarchically clustered into 16 hierarchical clusters.

OBJECTIVE

The aim of this study was to identify the active ingredients in electronic health (eHealth) interventions targeting patients with poorly controlled type 2 diabetes mellitus (T2DM) and relevant outcomes.

METHODS

We conducted a scoping review using the BCTTv1. Randomized controlled trials (RCTs), studies with or pre-post-test designs, and quasi-experimental studies examining efficacy and effectiveness of eHealth interventions for disease management or the promotion of relevant health behaviors were identified by searching PubMed, Web of Science, and PsycINFO. Reviewers independently screened titles and abstracts for eligibility using predetermined eligibility criteria. Data were extracted following a data extraction sheet. The BCTTv1 was used to characterize active ingredients of the interventions reported in the included studies.

RESULTS

Of the 1404 unique records screened, 32 studies fulfilled the inclusion criteria and reported results on the efficacy and or or effectiveness of interventions. Of the included 32 studies, 18 (56%) were Web-based interventions delivered via personal digital assistant (PDA), tablet, computer, and/or mobile phones; 7 (22%) were telehealth interventions delivered via landline; 6 (19%) made use of text messaging (short service message, SMS); and 1 employed videoconferencing (3%). Of the 16 hierarchical clusters of the BCTTv1, 11 were identified in interventions included in this review. Of the 93 individual behavior change techniques (BCTs), 31 were identified as active ingredients of the interventions. The most common BCTs identified were instruction on how to perform behavior, adding objects to the environment, information about health consequences, self-monitoring of the outcomes and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided of a certain behavior Author: Please note that the journal discourages the use of parenthesis to denote either and/or and prefers to be explicit to avoid ambiguity. Response: Checked and avoided "and/or" and prefers to be explicit to avoid ambiguity. Response: Checked and avoided, and feedback on outcomes of behavior.

CONCLUSIONS

Our results suggest that the majority of BCTs employed in interventions targeting persons with T2DM revolve around the promotion of self-regulatory behavior to manage the disease or to assist patients in performing health behaviors necessary to prevent further complications of the disease. Detailed reporting of the BCTs included in interventions targeting this population may facilitate the replication and further investigation of such interventions.

Remote Monitoring Systems for Chronic Patients on Home Hemodialysis: Field Test of a Copresence-Enhanced Design

Background

Patients undertaking long-term and chronic home hemodialysis (HHD) are subject to feelings of isolation and anxiety due to the absence of physical contact with their health care professionals and lack of feedback in regards to their dialysis treatments. Therefore, it is important for these patients to feel the “presence” of the health care professionals remotely while on hemodialysis at home for better compliance with the dialysis regime and to feel connected with health care professionals.

Objective

This study presents an HHD system design for hemodialysis patients with features to enhance patient’s perceived “copresence” with their health care professionals. Various mechanisms to enhance this perception were designed and implemented, including digital logbooks, emotion sharing, and feedback tools. The mechanism in our HHD system aims to address the limitations associated with existing self-monitoring tools for HHD patients.

Methods

A field trial involving 3 nurses and 74 patients was conducted to test the pilot implementation of the copresence design in our HHD system. Mixed method research was conducted to evaluate the system, including surveys, interviews, and analysis of system data.

Results

Patients created 2757 entries of dialysis cases during the period of study. Altogether there were 492 entries submitted with “Very Happy” as the emotional status, 2167 entries with a “Happy” status, 56 entries with a “Neutral” status, 18 entries with an “Unhappy” status, and 24 entries with a “Very unhappy” status. Patients felt assured to share their emotions with health care professionals. Health care professionals were able to prioritize the review of the entries based on the emotional status and also felt assured to see patients’ change in mood. There were 989 entries sent with short notes. Entries with negative emotions had a higher percentage of supplementary notes entered compared to the entries with positive and neutral emotions. The qualitative data further showed that the HHD system was able to improve patients’ feelings of being connected with their health care professionals and thus enhance their self-care on HHD. The health care professionals felt better assured with patients’ status with the use of the system and reported improved productivity and satisfaction with the copresence enhancement mechanism. The survey on the system usability indicated a high level of satisfaction among patients and nurses.

Conclusions

The copresence enhancement design complements the conventional use of a digitized HHD logbook and will further benefit the design of future telehealth systems.

Enablers and barriers to using two-way information technology in the management of adults with diabetes: A descriptive systematic review

Background This systematic review aimed to explore the enablers and barriers faced by adults with diabetes using two-way information communication technologies to support diabetes self-management. Methods Relevant literature was obtained from five databases using search strategies combining four major constructs: adults with diabetes, biomedical technology, communication technology and patient utilisation. Results Of 8430 unique articles identified, 48 were included for review. Risk of bias was assessed using either the Newcastle-Ottowa or Cochrane risk of bias assessment tools. Seventy-one percent of studies were of cohort design with the majority of studies assessed at high or unclear risk of bias. Consistently identified barriers included poorly designed interfaces requiring manual data entry and systems that lacked functionalities valued by patients. Commonly cited enablers included access to reliable technology, highly automated data entry and transmission, graphical display of data with immediate feedback, and supportive health care professionals and family members. Conclusions People with diabetes face a number of potentially modifiable barriers in using technology to support their diabetes management. In order to address these barriers, end users should be consulted in the design process and consideration given to theories of technology adoption to inform design and implementation. Systems should be designed to solve clinical or behavioural problems that are identified by patients as priorities. Technology should be as automated, streamlined, mobile, low cost and integrated as possible in order to limit the burden of usage for the patient and maximise clinical usefulness.

The Inclusion of Ethnic Minority Patients and the Role of Language in Telehealth Trials for Type 2 Diabetes: A Systematic Review

BACKGROUND

Type 2 diabetes is a serious, pervasive metabolic condition that disproportionately affects ethnic minority patients. Telehealth interventions can facilitate type 2 diabetes monitoring and prevent secondary complications. However, trials designed to test the effectiveness of telehealth interventions may underrecruit or exclude ethnic minority patients, with language a potential barrier to recruitment. The underrepresentation of minorities in trials limits the external validity of the findings for this key patient demographic.

OBJECTIVE

This systematic review examines (1) the research reporting practices and prevalence of ethnic minority patients included in telehealth randomized controlled trials (RCTs) targeting type 2 diabetes and the trial characteristics associated with recruiting a high proportion of minority patients, and (2) the proportion of included RCTs that report using English language proficiency as a patient screening criterion and how and why they do so.

METHODS

Telehealth RCTs published in refereed journals targeting type 2 diabetes as a primary condition for adults in Western majority English-speaking countries were included. Ethnically targeted RCTs were excluded from the main review, but were included in a post hoc subgroup analysis. Abstract and full-text screening, risk of bias assessment, and data extraction were independently conducted by two reviewers.

RESULTS

Of 3358 records identified in the search, 79 articles comprising 58 RCTs were included. Nearly two-thirds of the RCTs (38/58) reported on the ethnic composition of participants, with a median proportion of 23.5% patients (range 0%-97.7%). Fourteen studies (24%) that included at least 30% minority patients were all US-based, predominantly recruited from urban areas, and described the target population as underserved, financially deprived, or uninsured. Eight of these 14 studies (57%) offered intervention materials in a language other than English or employed bilingual staff. Half of all identified RCTs (29/58) included language proficiency as a participant-screening criterion. Language proficiency was operationalized using nonstandardized measures (eg, having sufficient "verbal fluency"), with only three studies providing reasons for excluding patients on language grounds.

CONCLUSIONS

There was considerable variability across studies in the inclusion of ethnic minority patients in RCTs, with higher participation rates in countries with legislation to mandate their inclusion (eg, United States) than in those without such legislation (eg, United Kingdom). Less than 25% of the RCTs recruited a sizeable proportion of ethnic minorities, which raises concerns about external validity. The lack of objective measures or common procedures for assessing language proficiency across trials implies that language-related eligibility decisions are often based on trial recruiters' impressionistic judgments, which could be subject to bias. The variability and inconsistent reporting on ethnicity and other socioeconomic factors in descriptions of research participants could be more specifically emphasized in trial reporting guidelines to promote best practice.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews: CRD42015024899; http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42015024899 (Archived by WebCite at http://www.webcitation.org/6kQmI2bdF).

Conceptualizing type 2 diabetes and its management

Type 2 diabetes is growing worldwide due to population growth, increased rates of obesity, unhealthy diet, and physical inactivity. Risk assessment methods can effectively evaluate the risk of diabetes, and a healthy lifestyle can significantly reduce risk or prevent complications of type 2 diabetes. However, risk assessment alone has not significantly improved poor adherence to recommended medical interventions and lifestyle changes. This paper focuses on the challenge of nonadherence and posits that improving adherence requires tailoring interventions that explicitly consider the social determinants of health.

Assessing Insulin Delivery Device Satisfaction in Patients with Type 1 and Type 2 Diabetes

Over the past several decades, insulin treatment has changed drastically, not only with the development of further insulin analogs but also with the introduction of novel insulin delivery devices such as pumps and pens. In addition, adjunct devices such as continuous glucose monitors and sensor-augmented pumps have become increasingly used in clinical care, increasing the volume of information available to patients and providers. However, with the development of new devices it has become clear that along with the many benefits of these advances, the use of these devices can also present a burden to people with diabetes. For example, some patients report being overwhelmed by too much data when using continuous glucose monitors. Furthermore, there are concerns regarding the accuracy of some of these new devices, particularly for glucose monitoring. As a result, some patients may choose not to use available devices, despite the recognized benefits. Therefore, it is critical to understand how the various insulin delivery devices available currently and in the future affect patients in terms of their diabetes management and perceived burdens and to understand which patient characteristics may predict a lack of satisfaction with these devices. This critical gap in our knowledge is addressed in an article in this issue of the journal through the development of a questionnaire that allows for a better understanding of the impact of insulin delivery devices on quality of life and diabetes management among both type 1 diabetes and insulin-dependent type 2 diabetes patients. The novelty, as well as limitations, of this new instrument for the assessment of insulin delivery device satisfaction are discussed.

Association between adherence, treatment satisfaction and illness perception in hypertensive patients

The relationship between adherence to antihypertension medications, treatment satisfaction and illness perception has not been studied so far. The primary objective of this study was to examine the association between adherence to medication, treatment satisfaction and illness perception in Lebanese hypertensive patients. The relation between medication adherence and blood pressure (BP) control was also assessed. In this cross-sectional study, patients were recruited from the physician's practice offices and community pharmacies in Beirut. Patients who had been treated for hypertension for at least 3 months were invited to participate in the study; they completed three questionnaires: the 8-item Morisky Medication Adherence Scale (MMAS-8), the Treatment Satisfaction Questionnaire for Medication (TSQM-4) and the Brief Illness Perception Questionnaire (BIPQ). BP was also measured and recorded. A total of 117 subjects were included, of whom 29.1% had poor adherence to their antihypertension treatment (MMAS-8 scores<6). The odds of having well-controlled hypertension was 3.5 times higher in patients with high adherence compared with patients with poor adherence (P=0.010). Treatment satisfaction was significantly greater in patients with good adherence (P<0.001). Neither socio-demographic, disease- nor drug-related characteristics of the participants were significantly associated with medication adherence. As for illness perception, even though the mean BIPQ score of adherent participants was lower than the mean score of non-adherent participants, this difference did not reach statistical significance. In conclusion, treatment satisfaction was found to be a predictor of adherence. Studies are needed to determine whether interventions to increase satisfaction can improve adherence and BP control.

Intensive Versus Conventional Glycemic Control in Patients with Diabetes During Enteral Nutrition After Gastrectomy

BACKGROUND

This study compared intensive and conventional glycemic management strategies in diabetic patients receiving enteral nutrition after gastrectomy.

METHODS

Diabetic patients (n = 212) who underwent gastrectomy between September 2006 and March 2014 were randomized to intensive glycemic (IG) management with continuous insulin infusion (target glucose 4.4-6.1 mmol/l (80-110 mg/dl)) or conventional glycemic (CG) management with intermittent bolus insulin (target glucose <11.1 mmol/l (<200 mg/dl)). Outcomes included blood glucose concentrations, insulin administration, and postoperative morbidity and mortality.

RESULTS

Blood glucose levels were lower (5.4 ± 1.2 vs. 9.5 ± 1.8 mmol/l, P < 0.001) and mean insulin dose was higher (55 ± 15 vs.32 ± 16 units/day, P < 0.001) in the IG than in the CG group. Rates of severe hypoglycemia (7.5 vs. 0.9%, P = 0.035) and achievement of target blood glucose (86.3 vs. 72.6%, P = 0.023) were higher, while severe hyperglycemia rate was lower (1.9 vs. 11.3%, P = 0.010), in the IG group. Surgical site infection rate was lower in the IG group (4.7 vs. 13.2%, P < 0.030). Rates of other infective complications, bleeding, delayed gastric emptying, obstruction, hepatic dysfunction, renal dysfunction, and circulatory insufficiency were similar in the two groups.

CONCLUSIONS

Intensive glycemic control in diabetic patients receiving enteral nutrition after gastrectomy was associated with a lower surgical site infection rate but a higher hypoglycemia rate.