Intra-individual variability and longitudinal changes in glycaemic control in patients with Type 1 diabetes mellitus

Association between early glycemic management and diabetes complications in type 1 diabetes mellitus: A retrospective cohort study

AIMS

To investigate the association between early HbA1c levels near diagnosis and future glycemic management, and analyzed risk factors of complications in people with T1DM.

METHODS

This retrospective cohort study included 201 children and adolescents with T1DM. Patient data including sex, age at diagnosis, duration of disease, HbA1c levels, HbA1c variability during the follow-up period, and diabetes complications and comorbidities were collected.

RESULTS

The mean follow-up period of patients was 16.4 years. HbA1c levels in all three examined time points after diagnosis (first year, second year, and first two years) were significantly associated with recent HbA1c level, and second-year HbA1c was most closely correlated with recent HbA1c level. Elevated second-year HbA1c was a risk factor of diabetic ketoacidosis (DKA) and retinopathy, and increased variability of HbA1c was significantly related to various microvascular complications. When HbA1c is stratified into quartiles, the subjects of each quartile trend to stay within that quartile over the follow-up period.

CONCLUSIONS

Early HbA1c levels were closely associated with recent HbA1c levels and diabetes complications in patients with T1DMs. Strict glucose management after diagnosis and reducing variability of HbA1c may prevent future diabetes complications and comorbidities.

Glycaemic trajectory and predictors of suboptimal glycaemic control in people with type 2 diabetes

We aimed to describe the glycaemic trajectory and define characteristics associated with suboptimal glycaemic control in the type 2 diabetes clinic. Higher glycosylated haemoglobin (HbA1c) at 1 year was associated with higher baseline HbA1c, concurrent anti-depressant or antipsychotic medication, higher bodyweight and low treatment adherence. These characteristics may help identify patients unlikely to attain HbA1c treatment targets and be better served by a different model of care.

Clinically meaningful and lasting HbA1c improvement rarely occurs after 5 years of type 1 diabetes: an argument for early, targeted and aggressive intervention following diagnosis

AIMS/HYPOTHESIS

Our objectives were to explore whether the phenomenon of HbA_1c 'tracking' occurs in individuals with type 1 diabetes, how long after diagnosis does tracking take to stabilise, and whether there is an effect of sex and age at diagnosis on tracking.

METHODS

A total of 4525 individuals diagnosed with type 1 diabetes between 1 January 1995 and 1 May 2015 were identified from The Health Improvement Network (THIN) database. Mixed models were applied to assess the variability of HbA_1c levels over time with random effects on general practices (primary care units) and individuals within practices.

RESULTS

4525 individuals diagnosed with type 1 diabetes were identified in THIN over the study period. The greatest difference in mean HbA_1c measurement (-7.0 [95% CI -8.0, -6.1] mmol/mol [0.6%]) was seen when comparing measurements made immediately after diagnosis (0-1 year since diagnosis) with those at 10 or more years (the reference category). The mean difference in HbA_1c for the successive periods compared with 10 or more years after diagnosis declined and was no longer statistically significant after 5 years. In the stratified analysis using sex and age group there was considerable heterogeneity with adult onset type 1 diabetes appearing to track earlier and at a lower mean HbA_1c.

CONCLUSIONS/INTERPRETATION

In individuals with type 1 diabetes, glycaemic control measured by HbA_1c settles onto a long-term 'track' and this occurs on average by 5 years following diagnosis. Age at diagnosis modifies both the rate at which individuals settle into their track and the absolute HbA_1c tracking level for the next 10 years.

Prediction of glycaemic control in young children and adolescents with type 1 diabetes mellitus using mixed-effects logistic regression modelling

OBJECTIVES

Glycaemic control in children and adolescents with type 1 diabetes mellitus can be challenging, complex and influenced by many factors. This study aimed to identify patient characteristics that were predictive of satisfactory glycaemic control in the paediatric population using a logistic regression mixed-effects (population) modelling approach.

METHODS

The data were obtained from 288 patients aged between 1 and 22 years old recorded retrospectively over 3 years (1852 HbA1c observations). HbA1c status was categorised as 'satisfactory' or 'unsatisfactory' glycaemic control, using an a priori cut-off value of HbA1c ≥ 9% (75 mmol/mol), as used routinely by the hospital's endocrine paediatricians. Patients' characteristics were tested as covariates in the model as potential predictors of glycaemic control.

RESULTS

There were three patient characteristics identified as having a significant influence on glycaemic control: HbA1c measurement at the beginning of the observation period (Odds Ratio (OR) = 0.30 per 1% HbA1c increase, 95% confidence interval (CI) = 0.20-0.41); Age (OR = 0.88 per year increase, 95% CI = 0.80-0.94), and fractional disease duration (disease duration/age, OR = 0.80 per 0.10 increase, 95% CI = 0.66-0.93) were collectively identified as factors contributing significantly to lower the probability of satisfactory glycaemic control.

CONCLUSIONS

The study outcomes may prove useful for identifying paediatric patients at risk of having unsatisfactory glycaemic control, and who could require more extensive monitoring, support, or targeted interventions.

Longitudinal relationship between diabetes-specific emotional distress and follow-up HbA1c in adults with Type 1 diabetes mellitus

AIM

To examine whether diabetes-specific emotional distress was related to follow-up glycaemic control in adults with Type 1 diabetes mellitus.

METHODS

Adults with Type 1 diabetes mellitus completed the Diabetes Distress Scale and reported sociodemographic information when attending a clinical consultation at a university endocrinology unit. Blood samples to determine baseline HbA1c were taken during consultations. All respondents' HbA1c measurements registered from January 2009 to December 2011 were collected from medical records. The relationship between baseline diabetes-specific emotional distress and HbA1c was examined with linear mixed-effects models in 175 patients with complete data.

RESULTS

After controlling for confounders, baseline diabetes-specific emotional distress and glycaemic control were significantly associated (fixed-effect coefficient 0.40, P < 0.001) and the regimen-related distress subscale had the strongest association with glycaemic control (fixed-effect coefficient 0.47, P < 0.001). The two-item measure of diabetes-specific distress had a weaker but still significant association with glycaemic control (fixed-effect coefficient 0.31, P < 0.001). None of these relationships was significant after adjusting for the baseline HbA1c .

CONCLUSIONS

People with elevated baseline diabetes-specific emotional distress are at risk of prolonged suboptimum glycaemic control; therefore, elevated diabetes-specific emotional distress, especially regimen-related distress, might be an important marker for prolonged suboptimum glycaemic control, and might indicate a need for special attention regarding patient self-management.

Rationale for using data on biological variation

The aims of this study are: 1) to use the data included in the biological variation (BV) database to address the usability of BV estimates; and 2) to use different examples from the authors’ laboratories to illustrate the use and the usefulness of BV data in laboratory medicine. The BV database is an essential tool for laboratory management. Examples of application of data derived from BV are given in this paper, such as analytical performance specifications that have been included in various quality control software designed to optimize operative rules; also they have been incorporated as acceptability limits in external quality assurance reports. BV data from pathological status are of utmost interest for monitoring patients and differences between the intra-individual coefficients of variation (CV

Clinical and demographic risk factors associated with mortality during early adulthood in a population-based cohort of childhood-onset type 1 diabetes

AIMS

To calculate standardized mortality ratios and to assess the association between paediatric clinical factors and higher risk of mortality during early adulthood in a population-based cohort of subjects with Type 1 diabetes.

METHODS

Subjects with Type 1 diabetes were identified through the Western Australian Children's Diabetes Database and clinical data for those who reached 18 years of age (n = 1309) were extracted. An age- and sex-matched (without diabetes) comparison cohort (n = 6451) was obtained from the birth registry. Mortality records were obtained from the death registry. Participants were followed up until 31 January 2012. Associations of clinical factors (from clinic visits before 18 years of age) with mortality were assessed using Cox proportional hazard models.

RESULTS

The standardized mortality ratio for all-cause mortality was 1.7 (95% CI 0.7-3.3) for male and 10.1 (95% CI 5.2-17.7) for female subjects with Type 1 diabetes (median age at end of study 25.6 years). The adjusted hazard ratio was 1.5 (95% CI 1.1-2.1) for a 1% increase in mean paediatric HbA1c level, 3.8 (95% CI 0.9-15.3) for four episodes of severe hypoglycaemia relative to zero episodes, and 6.21 (95% CI 1.4-28.4) for a low-level socio-economic background relative to a high-level background.

CONCLUSIONS

People with childhood-onset Type 1 diabetes have higher mortality rates in early adulthood. At particularly high risk are women, those with a history of poor HbA1c levels, those with recurrent severe hypoglycaemia during paediatric management, and those from a low socio-economic background. These groups may benefit from intensified management during transition from paediatric to adult care facilities.

Pediatric Diabetes Consortium Type 1 Diabetes New Onset (NeOn) Study: factors associated with HbA1c levels one year after diagnosis

OBJECTIVE

To identify determinants of hemoglobin A1c (HbA1c) levels 1 yr after the diagnosis of type 1 diabetes (T1D) in participants in the Pediatric Diabetes Consortium (PDC) T1D New Onset (NeOn) Study.

RESEARCH DESIGN AND METHODS

Diabetes-specific as well as socioeconomic factors during the first year following diagnosis were analyzed in 857 participants (mean age 9.1 yrs, 51% female, 66% non-Hispanic White) not participating in an intervention study who had an HbA1c value at 12 months.

RESULT

Mean ± SD HbA1c at 1 yr was 62 ± 16 mmol/mol (7.8% ± 1.5). In univariate and multivariate analyses, clinical center, non-Hispanic White race, private health insurance, living with both parents, higher frequency of self-monitoring of blood glucose (SMBG), and lower insulin requirements were associated with lower HbA1c concentrations at 1 yr (p < 0.01). No association was found with gender, age, Tanner stage, body mass index (BMI), diabetic ketoacidosis (DKA) at onset, number of positive autoantibodies or HbA1c at onset, or number of visits to diabetes physician during the first year.

CONCLUSIONS

White race, higher socioeconomic status, two-parent household, more frequent SMBG, and low insulin requirements are associated with lower HbA1c concentration 1 yr after the onset of T1D in children.

An anti-inflammatory sterol decreases obesity-related inflammation-induced insulin resistance and metabolic dysregulation

Obesity-related inflammation-induced insulin resistance and metabolic dysregulation were investigated in retrospective analysis of placebo hematologic and metabolic laboratory data from trials associated with increasing chronic low-grade inflammation and body mass index. Studies included healthy subjects and those with progressive stages of metabolic dysregulation, including type 2 diabetes mellitus with uncontrolled hemoglobin A1c. Intrasubject variances in erythroid and metabolic values increased with metabolic dysregulation. Random effects were demonstrated in treatment-naïve diabetes for erythroid, glucose, and HbA1c fluctuations. The anti-inflammatory insulin sensitizer, HE3286, was tested for its ability to decrease obesity-related inflammation-induced insulin resistance and metabolic dysregulation in diabetes. HE3286 significantly decreased erythroid and metabolic variances and improved 1,5-anhydroglucitol (a surrogate of postprandial glucose) compared to the placebo group. HE3286 HbA1c decrease correlated with weight loss and inversely with baseline monocyte chemoattractant protein-1 (MCP-1) in metformin-treated diabetics. Normalization of HbA1c to the 84-day average hemoglobin revealed that HE3286 HbA1c decrease correlated with high baseline MCP-1 and MCP-1 decrease in treatment-naïve diabetics. HE3286 decreased insulin resistance, increased the frequency of decreased day 84 HbA1c in metformin-treated subjects, and decreased day 112 HbA1c in treatment-naïve diabetics. HE3286 may be useful to restore metabolic homeostasis in type 2 diabetes.

Dose Adjustment for Normal Eating (DAFNE) in routine clinical practice: who benefits?

AIMS

To explore the effectiveness of Dose Adjustment for Normal Eating in routine clinical practice in the UK.

METHODS

Participants were 124 adults with Type 1 diabetes who had completed a Dose Adjustment for Normal Eating course. Data were collected before the course and again 1 year later on a variety of biological, psychological and social measures.

RESULTS

There were a range of significant benefits consistent with Dose Adjustment for Normal Eating aims, including: better control among those with baseline HbA(1c) ≥ 81 mmol/mol (9.6%) (z = -2.8, P = 0.004); reduced number of participants reporting severe hypoglycaemia (χ² = 4.27, P = 0.039); total eradication of diabetic ketoacidosis (χ² = 4.17, P = 0.041) and lower diabetes-related distress (z = -4.5, P < 0.001). The most deprived of the clinic population were significantly under-represented (χ² = 17.8, P = 0.001) and the levels of clinical depression were unusually low.

CONCLUSIONS

These results indicate that Dose Adjustment for Normal Eating delivered in routine clinical practice is associated with a range of benefits and that certain clinical and psychosocial characteristics are associated with better outcomes.

Within-subject biological variation of glucose and HbA(1c) in healthy persons and in type 1 diabetes patients

BACKGROUND

Several articles describing within-subject biological variation of fasting glucose and HbA(1c) in healthy populations have been published, but information about biological variation of glucose and HbA(1c) in patients with type 1 diabetes is scarce. It is reasonable to assume that type 1 diabetics differ from their healthy counterparts in this matter. The aim of our study was to estimate the biological variation of glucose and HbA(1c) in healthy subjects and in patients with type 1 diabetes.

METHODS

Fifteen healthy individuals and 15 type 1 diabetes patients were included. Biological variations were calculated based on blood samples collected weekly for 10 consecutive weeks from the healthy and the eligible of the type 1 diabetes patients.

RESULTS

The within-subject variations of glucose were approximately 5% in healthy individuals and 30% in diabetes patients, and for HbA(1c) they were 1.2% in healthy individuals and 1.7% in diabetes patients.

CONCLUSIONS

In conclusion, we found a high within-subject biological variation of glucose in diabetes patients as expected compared to healthy individuals (30% vs. 5%). The short-term (2 months) within-subject biological variation of HbA(1c) did not differ significantly between well regulated type 1 diabetes patients and healthy individuals (1.7% vs. 1.2%).

Cataract surgery in a population-based cohort of patients with type 1 diabetes: long-term incidence and risk factors

PURPOSE

To estimate the long-term cumulative incidence of cataract surgery and associated risk factors in a 25-year follow-up of a population-based cohort of patients with type 1 diabetes.

METHODS

Based on insulin prescriptions, a population-based cohort of 727 patients with type 1 diabetes was identified in 1973. In 1981-1982 diabetic retinopathy was graded and other markers of diabetes were measured in 573 patients who participated in a clinical baseline examination. Based on data from the Danish National Patient Registry, patients were followed until November 2006 and cataract surgery was evaluated during follow-up.

RESULTS

The 25-year crude cumulative incidence of cataract surgery was 20.8% (117 of 562 patients at risk), corresponding to a mortality-adjusted incidence of 29.4% [95% confidence interval (CI) 25.6-33.1%]. Median age and duration of diabetes at the time of surgery were 59.3 and 42 years, respectively. Cataract surgery in the cohort took place approximately 20 years earlier compared to non-diabetic persons. In a multivariate regression analysis, baseline age [hazard ratio (HR) 1.89 per 10 years, 95% CI 1.46-2.27] and maculopathy (HR 1.89, 95% CI 1.05-3.40) were the only statistically significant predictors of cataract surgery. Duration of diabetes, gender, glycaemic regulation, proteinuria, smoking, blood pressure and level of retinopathy were not associated with cataract surgery.

CONCLUSION

Type 1 diabetes is associated with a high long-term incidence of cataract surgery. The association between maculopathy and subsequent cataract surgery is a novel finding and should be addressed in future studies.

Risk factors for mortality and ischemic heart disease in patients with long-term type 1 diabetes

AIMS

The purpose of this study is to evaluate the effect of glycemic regulation, dyslipidemia, and renal dysfunction on mortality (all-cause and cardiovascular) and ischemic heart disease (IHD) in a long-term follow-up of a population-based cohort of Danish type 1 diabetic patients with at least 20 years of diabetes.

METHODS

A population-based cohort of type 1 diabetic patients was identified as of July 1, 1973 (n=727). In 1993 to 1996, the cohort was reassessed and baseline data were collected from blood and urine samples in 389 patients. Mean (glycemic regulation and lipids) and highest values (creatinine and albuminuria) of the baseline period were used to predict mortality and IHD between baseline and 2006. Data of mortality and morbidity were provided by the Danish Civil Registration System, the Danish Causes of Death Registry, and the Danish National Patient Registry.

RESULTS

At the follow-up in 2006, 256 patients (65.8%) were still alive. In a statistical model adjusted for age, sex and duration of diabetes, the following parameters were related to all-cause mortality and cardiovascular mortality: glycemic regulation, triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol (inversely), total cholesterol, creatinine, and macroalbuminuria. Furthermore, all markers except macroalbuminuria were associated with IHD. Microalbuminuria at baseline was not related to any of the endpoints.

CONCLUSIONS

Glycemic regulation, dyslipidemia, and renal dysfunction were all related to mortality and IHD in a 13-year follow-up of long-term Danish type 1 diabetic patients. These results underscore the better outcome for tightly regulated type 1 diabetic patients, even in long-term survivors.

Long-term mortality and retinopathy in type 1 diabetes

The incidence of type 1 diabetes is increasing in Denmark as well as the rest of the world. Due to diabetes-related micro- and macrovascular complications, the morbidity and the mortality is higher among type 1 diabetic patients. The aim of this thesis was to examine a population-based cohort of 727 type 1 diabetic patients from Fyn County, Denmark, with an onset of diabetes before 1 July 1973 in order to: (1) Evaluate the all-cause mortality rates and the influence of sex, duration of diabetes and calendar year of diagnosis in a 33-year follow-up (Paper I). (2) Examine glycaemic regulation, lipids and renal dysfunction as risk factors for all-cause mortality, cardiovascular mortality and IHD (Paper II). (3) Estimate the prevalence of DR as well as the 25-year incidence of PDR and associated risk factors in long-time surviving patients (Paper III). (4) To compare the grading of DR between ETDRS seven standard field 30 degrees stereoscopic colour films and nine field 45 degrees monoscopic digital colour images in long-term surviving patients (Paper IV). In the years 1973-2006 an overall MR of 22.3 per 1000 person-years was found. Furthermore a relative mortality of 3.4 was found as compared to the general population in Denmark. The relative mortality was especially high for patients aged 30-39 (SMR 9.8). There was a tendency towards a better survival for patients diagnosed after 1964. This was especially seen for men. Diabetes was the most common cause of death for those who died in the group. In 1993-1996 blood samples were drawn and glycaemic regulation, lipids and renal markers were subsequently used as predictors of all-cause mortality, cardiovascular mortality and ischaemic heart disease. Glycaemic regulation, dyslipidaemia and creatinine were all significantly associated with all three endpoints. Furthermore, variations in glycaemic control were also identified as a risk factor for overall mortality. Two hundred and one patients were examined for diabetic retinopathy in 1981-1982 and 2007-2008. At follow-up, 97.0% had DR and 42.9% of all patients without PDR at baseline developed this during the follow-up period. Patients who had had a poor glycaemic regulation as well as those who had NPDR at baseline were more likely to develop PDR than the remaining patients. On the other hand, other risk factors such as high blood pressure and proteinuria did not predict PDR. In the comparative study between ETDRS seven standard field 30 degrees stereoscopic colour films and nine field 45 degrees monoscopic digital colour images, 43 eyes of 43 patients were examined in 2008. A poor correlation was found between the two methods: only 29.3% were graded alike. In the remaining, the level of DR was graded higher in the digital photos. Among these, PDR was detected in three eyes using digital photos but remained undetected on all films. This suggests that digital photos with wide fields are the best way to detect DR in long-term type 1 diabetic patients. Overall, it is concluded that mortality is still higher among type 1 diabetic patients. This depends, among other things, on glycaemic regulation, lipid status and, partly, renal dysfunction. Diabetic retinopathy is almost universal in long-term type 1 diabetic patients, and almost half of all patients will develop PDR in 25 years. Nine field digital photos provide the best grading of retinopathy in long-term type 1 diabetic patients.

Major diabetes-related vascular events do not improve glycaemic control in a population-based cohort of type 1 diabetic individuals

OBJECTIVE

It is known that sudden serious events alter life styles related to treatment efficiency, as for example in cancer patients. However, it has not been specifically addressed if a first-time diabetes-related clinical event has impact on glycaemic regulation. We therefore assessed this in a population-based cohort of patients with long-term type 1 diabetes.

METHODS

This study was based on a cohort of type 1 diabetes patients with at least 20 years duration of diabetes. Of the 460 patients from the original cohort still alive at 1 January 1994, all patients with a major first-time diabetes-related clinical event (limb amputation, blindness, stroke, cardiac event, or panretinal photocoagulation) and glycated haemoglobin (HbA(1c)) measurements before, 3 and/or 12 months after the event were included. Differences in HbA(1c) measurements before and after the event were tested with Wilcoxon's test.

RESULTS

A total of 64 patients with a major clinical event between 1994 and 2006 entered the study. Mean HbA(1c) measurements decreased from 8.8% at baseline to 8.6% at 3 months and 8.7% after 12 months, a non-significant decrease. In all event groups, glycaemic regulation was unaltered in the majority of the patients. Only a minority worsened or improved their regulation, and in all groups only non-significant changes were seen.

CONCLUSIONS

Surprisingly, complication-related events did not improve glycaemic regulation in long-term type 1 diabetes patients. This is in contrast with the experience from other patient categories and shows how difficult it can be to alter glycaemic regulation in diabetes patients with stabilized disease.

Can we predict future improvement in glycaemic control?

AIMS

To determine the factors responsible for poor glycaemic control in diabetes and whether any such factors are associated with likely improvement in glycaemic control.

METHODS

A prospective cohort study of 130 diabetic patients with poor glycaemic control (HbA(1c )> or = 10.0%) with 1-year follow-up in a teaching hospital Diabetes Clinic. Changes in HbA(1c) were measured after 1 year.

RESULTS

Poor glycaemic control was attributed to one of 15 possible causes. Those cases due to recent diagnosis of diabetes, inadequate treatment with diet, oral glucose-lowering agents or insulin, exacerbation of co-existent medical problems, recent stressful life-events and missed clinic appointments were all associated with significant improvement in HbA(1c) at 12 months. Patients with low mood or alcohol excess, inadequate blood glucose monitoring, poor exercise/sedentary lifestyle, refusal to take tablets or underdosing and refusal to take insulin at all or to increase the dose were all associated with continuing poor glycaemic control at 12 months. The patients were divided almost equally between the two groups.

CONCLUSIONS

In patients with poor glycaemic control, it is possible by simple features identified at clinic to predict which individuals are likely to show improvement in control and which will not. These findings have not been reported previously and suggest that about half of individuals with poor control will improve within our current diabetes clinic practice. Additional strategies will be required to address those individuals who are not likely to respond.

The influence of dietary intake and meal pattern on blood glucose control in children and adolescents using intensive insulin treatment

AIMS/HYPOTHESIS

We studied dietary factors and their association with blood glucose control in type 1 diabetic children and adolescents using intensive insulin treatment.

MATERIALS AND METHODS

A total of 550 children and adolescents with type 1 diabetes mellitus (age 2-19 years) recorded their diet for 4 days in pre-coded food diaries. Of the study group, 34% used insulin pumps, 43% used four or more injections and 16% three injections per day. HbA(1c) was related to targets of optimal blood glucose control defined by the International Society for Pediatric and Adolescent Diabetes (ISPAD).

RESULTS

Adolescents with optimal glucose control (HbA(1c) < or = 7.5%) had a lower intake of added sugar (7.7 vs 9.1% of energy intake, p = 0.004), a higher intake of fibre (19.3 vs 17.0 g/day, p = 0.01) and a higher intake of fruits and vegetables (257 vs 227 g/day, p = 0.04) than those with suboptimal metabolic control (HbA(1c) > 7.5%). Multiple regression analysis in adolescents showed that fibre and meal pattern were significantly associated with blood glucose control (effect fibre intake = -0.02, p = 0.04, effect having breakfast regularly = -0.89, p = 0.009). In children meal pattern was associated with blood glucose control (effect having dinner regularly = -0.66, p = 0.02, effect having supper regularly = -0.78, p = 0.03).

CONCLUSIONS/INTERPRETATION

In diabetic adolescents both intake of fibre and having a regular meal pattern are associated with blood glucose control. Lower intake of added sugar and sugar-sweetened soft drinks and higher intake of fruits and vegetables are observed among those with optimal compared with those with suboptimal blood glucose control. Dietary guidance should be intensified during adolescence to improve dietary intake and blood glucose control.

Twelve weeks' treatment with diazoxide without insulin supplementation in Type 2 diabetes is feasible but does not improve insulin secretion

AIMS

Treatment with K-ATP channel openers, such as diazoxide, can have beneficial effects on insulin secretion in both Type 1 and Type 2 diabetes. However, the precise conditions for obtaining beneficial effects without untoward events have not been determined. We tested the hypothesis that intermittent administration of diazoxide at bedtime for 12 weeks could produce beneficial effects in the absence of side-effects in Type 2 diabetic patients who were not taking insulin.

METHODS

After an 8-week run-in period, during which treatment with repaglinide and metformin was optimized, we randomized 26 patients to either diazoxide, 100 mg at bedtime, or placebo.

RESULTS

Side-effects were absent or minimal. HbA(1c) did not change. However day-time glucose concentrations by home glucose monitoring were approximately 1.5 mmol/l higher with diazoxide vs. placebo. Stimulation tests (C-peptide-glucagon and breakfast) did not indicate improved pancreatic B-cell function, except by posthoc analysis, in a subgroup of younger age.

CONCLUSION

Compared with previous results with diazoxide together with bedtime insulin, the present results are less favourable and indicate that concomitant insulin treatment is needed during intervention with K-ATP channel openers.

The implementation of managed care for diabetes using medical informatics in a large Preferred Provider Organization

BACKGROUND

It has been demonstrated by meta analysis that if a regular review of patients is guaranteed, the standard of primary care can be as good or better than hospital outpatient care, however, empirical data suggests that compliance with diabetes clinical practice recommendations is inadequate in primary care. This study describes the reorganization of diabetes care using disease management principles in a Preferred Provider Organization (PPO) operating on a country-wide basis in which each diabetes clinic became responsible for the overall care of all patients with diabetes.

METHODS

This descriptive pre and post change study was undertaken in a large public-funded PPO insuring over one and half million individuals. The study was possible due the use of a centralized electronic disease registry which enabled the collection of all patient data. Several markers, such as HbA1C and LDC-cholesterol levels, were used to assess the quality of care for the diabetic patients.

RESULTS

Mean HbA1C results of the cohort showed a continuous reduction from 8.1% (S.D. = 1.55) in 1999 to 7.68% (S.D. = 1.47) in 2002 and to 7.79 (S.D. = 1.54) in 2004. Improved results were also recorded for LDL-C 126.37 (S.D. = 35.16) in 1999 to 114.74 (S.D. = 34.49) in 2002, and to 113.39 (S.D. = 33.8) in 2004. The number of diabetic patients seen by the diabetologist increased by 62% over this period, despite an increase in diabetologist work hours of only 23%.

CONCLUSION

The reorganization of health delivery for diabetic patients within a country-wide PPO, based on the principles of disease management and supported by medical informatics improves quality of care.

Short-term effects of cognitive behavioural group training (CBGT) in adult Type 1 diabetes patients in prolonged poor glycaemic control. A randomized controlled trial

AIMS

To assess the effects of cognitive behavioural group training (CBGT) on glycaemic control, diabetes self-efficacy and well-being in Type 1 diabetes patients in persistent poor glycaemic control.

METHODS

In a randomized controlled trial, a total of 107 patients with Type 1 diabetes in poor glycaemic control (HbA(1c) > or = 8%) were assigned to a 6-week CBGT or blood glucose awareness training (BGAT) as control condition. The intervention was preceded by a 3-month run-in period. Glycaemic control (HbA(1c)), diabetes-specific self-efficacy (CIDS), diabetes-related distress (PAID) and depressive symptoms (CES-D), were assessed at baseline (T1), directly before (T2) and 3 months after (T3) the intervention.

RESULTS

No significant changes in HbA(1c) were found after CBGT, whilst diabetes self-efficacy increased (mean CIDS score 71.6 +/- 14.0 to 74.3 +/- 12.2) and diabetes-related distress (mean PAID score 47.0 +/- 21.6 to 42.6 +/- 20.8) and depressive symptoms decreased (mean CES-D score 16.9 +/- 12.8 to 13.5 +/- 12.6). Changes in psychological outcomes were similar for both treatment groups. Diabetes self-care behaviours improved equally. Drop-out rate, which was higher among CBGT participants, was relatively low overall (total n = 15, 17.05%), and both interventions were well-appreciated by the participants.

CONCLUSIONS

CBGT was successful in improving self-efficacy, diabetes-related distress and mood at 3 months' follow-up, but not in improving glycaemic control.

High cumulative insulin exposure: a risk factor of atherosclerosis in type 1 diabetes?

BACKGROUND

Since insulin therapy might have an atherogenic effect, we studied the relationship between cumulative insulin dose and atherosclerosis in type 1 diabetes. We have focused on patients with type 1 diabetes instead of type 2 diabetes to minimise the effect of insulin resistance as a potential confounder.

METHODS

An observational study was performed in 215 subjects with type 1 diabetes treated with multiple insulin injection therapy. Atherosclerosis was assessed by measurement of carotid intima-media thickness (CIMT).

RESULTS

The cumulative dose of regular insulin showed a positive and significant relation with CIMT: increase of 21 microm in CIMT per S.D. of insulin use (95% CI: 8-35 adjusted for gender and age), which remained unchanged after adjustment for duration of diabetes, HbA1c, BMI, pulse pressure, physical activity and carotid lumen diameter. A similar relation was found for intermediate-acting insulin: 15.5 microm per S.D. (2-29), which was no longer present after further adjustment.

CONCLUSIONS

These findings provide evidence that a high cumulative dose of regular insulin is a risk factor for atherosclerosis.

Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem

Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes.

Improved glycaemic control in type 1 diabetes patients following participation per se in a clinical trial--mechanisms and implications

The phenomenon of improved diabetes self-management following participation in a clinical trial, with subsequent improvement of glycaemic control, has been acknowledged in literature but has received little attention. Also, the potential implications of such a 'study effect' for clinical research are poorly explored. We review the literature and describe the effects on glycaemic and psychological outcomes in long-term poorly controlled type 1 diabetes patients participating in a qualification phase of a Good Clinical Practice (GCP) trial. Improved glycaemic control following participation in a clinical trial is best understood as the result of improved patients' instrumental coping behaviours, including increased self-monitoring of blood glucose (SMBG). Such improvement in self-care with ensuing improved glycaemic control has important consequences for trial design. Firstly, benefits seen in uncontrolled trials should be interpreted with extreme caution. Secondly, unspecific study effects and the effect of a given intervention may not simply be additive. Therefore, it is wise to include a run-in or qualification phase of adequate length before randomization in a clinical trial. A stable baseline HbA1c can thus be reached, upon which the specific effect of an intervention can be properly judged. Also, in a multi-centre trial, a qualification phase of sufficient length will help diminish differences in terms of intensity of care provided in participating centres.