Diabetes care today: not everyone should have intensive multipharmacological treatment

Type 2 diabetes and quality of life

It is true that a primary goal of diabetes early diagnosis and treatment is quality of life (QoL). The term QoL is still confusing but it is agreed that it composes of four components: The physical component, mental, cogitative component, psychological and social component. Many articles have been written addressing those four components. During the last five years 15500 articles and reviews have been written addressing diabetes and coronary arterial disease, 16100 addressing diabetes and renal function, 28900 addressing diabetes and retinopathy, 16800 addressing diabetic foot ulcers and other 26300 addressing diabetic neuropathy. Moreover 17200 articles are dealing with diabetic sexual dysfunction, 24500 with the correlation of diabetes and depression 17500 about diabetes and dementia, only 1 about diabetes and family functioning and 1950000 about diabetes and QoL, indicating the worldwide interest. In order to confront this metabolic anomaly and its consequences, researchers developed numerous generic and disease specific psychometric tools. With the aid of those psychometric tools the scientific community has started to realize the gruesome effect of diabetes on patients’ lives. Diabetic’s QoL becomes worse when complications start to develop or comorbidities coexist. Dominant amongst complications, in health-related quality of life (HRQoL) lowering, but not related to risk factors (genetic, the weight of birth, or others) is coronary arterial disease followed by renal failure, blindness, and the combination of micro- and macro-vascular complications and in some studies by sexual dysfunction. Moreover many are the comorbidities which deteriorate further the effect of diabetes in a patient life. Among them obesity, hypertension, dyslipidemia, depression, arthritis are the most common. Most intriguing field for research is the interaction of diabetes and depression and in some cases the progression to dementia. Many aspects and combinations of actions are under researchers’ microscope regarding the improvement of HRQoL scores. Until now, the studies performed, have demonstrated little to moderate benefit. More of them are needed to draw safe conclusions on the topic of the best combination of actions to optimize the HRQoL scores.

Adherence to guidelines in people with screen-detected type 2 diabetes, ADDITION, Denmark

OBJECTIVE

In people with screen-detected type 2 diabetes in primary care, (1) to assess adherence to guidelines, recommending consultation with the GP every three months and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist when systolic BP was > 120 mmHg and/or diastolic BP was > 80 mmHg, and (2) to identify predictors for adherence.

DESIGN

Prospective follow-up of a fixed cohort of patients.

SETTING

Fifty-four Danish general practices.

SUBJECTS AND MAIN OUTCOME MEASURES

A total of 361 people with screen-detected type 2 diabetes were followed up for 410 days to assess planned consultations with their GP and recording of BP. Some 226 people, with BP recorded above guideline threshold(s) and where treatment was not already initiated, were followed for up to 410 days to monitor prescription redemption.

RESULTS

At 3, 6, 9 and 12 months 80%, 77%, 74%, and 73% of the cohort attended a consultation. A total of 89% of the cohort attended two of the four planned consultations. The probability of redeemed prescriptions for an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline during the first year following diagnosis was 51%. High initial BP was associated with prescription redemption. No other analysed individual or organisational characteristics were found to be associated with treatment initiation.

CONCLUSION

The consultation attendance was reasonably high, and treatment initiation with an ACE inhibitor or an angiotensin-II receptor antagonist according to the guideline was found in half of the cases. High initial BP increased the probability of treatment initiation.

The dilemma of patient responsibility for lifestyle change: perceptions among primary care physicians and nurses

OBJECTIVE

To explore physicians' and nurses' views on patient and professional roles in the management of lifestyle-related diseases and their risk factors.

DESIGN

A questionnaire study with a focus on adult obesity, dyslipidemia, high blood pressure, type 2 diabetes, and smoking.

SETTING

Healthcare centres in Päijät-Häme hospital district, Finland.

SUBJECTS

Physicians and nurses working in primary healthcare (n =220).

MAIN OUTCOME MEASURES

Perceptions of barriers to treatment of lifestyle-related conditions, perceptions of patients' responsibilities in self-care, experiences of awkwardness in intervening in obesity and smoking, perceptions of rushed schedules, and perceptions of health professionals' roles and own competence in lifestyle counselling.

RESULTS

A majority agreed that a major barrier to the treatment of lifestyle-related conditions is patients' unwillingness to change their habits. Patients' insufficient knowledge was considered as such a barrier less often. Self-care was actively encouraged. Although a majority of both physicians and nurses agreed that providing information, and motivating and supporting patients in lifestyle change are part of their tasks, only slightly more than one half estimated that they have sufficient skills in lifestyle counselling. Among nurses, those with less professional experience more often reported having sufficient skills than those with more experience. Two-thirds of the respondents reported that they had been able to help many patients to change their lifestyles into healthier ones.

CONCLUSIONS

The primary care professionals experienced a dilemma in patients' role in the treatment of lifestyle-related diseases: the patient was recognized as central in disease management but also, if reluctant to change, a major potential barrier to treatment.

Self-monitoring of blood glucose and glycaemic control in type 2 diabetes

OBJECTIVE

Previous studies have shown inconsistent results with regard to whether or not self-monitoring of blood glucose (SMBG) is related to better glycaemic control in type 2 diabetes. The aim of this study was to explore the use of SMBG and its association with glycaemic control in patients with type 2 diabetes in primary care.

DESIGN

A cross-sectional observational study was conducted in 2003 at 18 primary health care centres in Sweden, in which all known patients with diabetes were surveyed. The study included 6495 patients with type 2 diabetes. A sample of 896 patients was selected for further exploration of data from medical records. A telephone interview was performed with all patients in this group using SMBG (533 patients).

RESULTS

There were no differences in HbA1c levels between users (6.9%) and non-users (6.8%) of SMBG in patients treated with insulin or in patients treated with oral agents (6.3% in both groups). In patients treated with diet only, users of SMBG had higher levels of HbA1c compared with non-users (5.5% vs. 5.4%, p =0.002). Comparing medical records between users and non-users of SMBG showed no differences in diabetes-related complications in any treatment category group.

CONCLUSION

The use of SMBG was not associated with improved glycaemic control in any therapy category of patients with type 2 diabetes in primary care. The absence of difference in glycaemic control between users and non-users of SMBG could not be explained by differences in comorbidity between users and non-users of SMBG.

Dietary and physical activity counselling on type 2 diabetes and impaired glucose tolerance by physicians and nurses in primary healthcare in Finland

OBJECTIVE

To investigate the initiation of dietary and physical activity counselling and the arguments used when discussing physical activity and the type and consumption of dietary fats, during nurse-patient and physician-patient diabetic lifestyle counselling.

DESIGN AND SUBJECTS

This study is a part of a larger follow-up research project focusing on diabetes counselling. The data include 129 videotaped counselling sessions between 17 patients and their physicians and nurses. Content analysis was carried out by identifying the verbal comments and reactions of participants concerning both physical activity and the type and consumption of dietary fats.

RESULTS

The physicians and nurses spent little time on dietary and physical activity counselling. The counselling sessions consisted mainly of short questions with minimal feedback from either party. The beginning of the sessions concentrated on blood cholesterol levels and the extent of physical activity. The health professionals failed to emphasize the roles of reduced dietary fats and increased physical activity in substituting for or supplementing diabetes care. Although the patients communicated the factors that encouraged or discouraged physical activity the subject was generally not pursued by the health professionals.

CONCLUSION

Within primary care there is a need for methods that would facilitate the discussion of health behaviour changes. In healthcare settings, education and training are required to develop the communication skills of health professionals in all aspects of preventive medicine.

Smoking cessation in patients with diabetes mellitus: results from a controlled study of an intervention programme in primary healthcare in Sweden

OBJECTIVE

To evaluate an intervention programme on smoking cessation in patients with diabetes mellitus in primary healthcare.

DESIGN

Regional controlled intervention study.

SETTING

Seventeen primary healthcare centres in Sweden.

INTERVENTION

In the intervention centres, nurses with education in diabetes were given one half-day of training in motivational interviewing and smoking cessation. An invitation to participate in a smoking cessation group was mailed to patients from the intervention centres followed by a telephone call from the patient's diabetes nurse. The nurses who intervened were specially educated in smoking cessation. The control group received a letter containing advice to stop smoking and information about a one-year follow-up.

PATIENTS

Daily smokers with diabetes mellitus, 30-75 years of age. In the intervention centres 241 patients fulfilled the criteria and in the control centres 171 patients.

MAIN OUTCOME MEASURES

Self-reported smoking habits after one year.

RESULTS

In total, 21% of the smokers accepted group treatment. After 12 months, 20% (42/211) in the intervention centres reported that they had stopped smoking and 7% (10/140) in the control centres; 40% (19/47) of the smokers who had participated in group treatment reported that they had stopped smoking.

CONCLUSION

A computerized record system for patients in primary healthcare was used to identify diabetic patients who were smokers. The selected group was invited to a stop smoking programme. At a one-year follow-up significantly more patients in the intervention centres had stopped smoking compared with patients in the control centres.

Quality of life of patients with diabetes mellitus. An overview of research in primary health care in the Nordic countries

OBJECTIVE

A review of articles on health-related quality of life (HRQoL) among diabetes patients in primary health care in the Nordic countries.

DESIGN

Search in PubMed and related sources. Used MeSH terms were: "Diabetes Mellitus", "Quality of Life", "Primary Health Care", and "Scandinavia" or "Denmark", "Finland", "Iceland", "Norway", or "Sweden".

RESULTS

In total, 19 relevant articles were found, 9 from Finland and 10 from Sweden. HRQoL questionnaires used were from the Medical Outcomes Study, i.e. the SWED-QUAL in seven, SF-20 in four and SF-36 in one, NHP in two, GQL in two, GHQ in one, and own questionnaires in two. HRQoL was moderately affected in diabetic patients, with macrovascular diseases, especially coronary heart disease, and non-vascular diseases as the most consistently found and strongest predictors. Weaker predictors were microvascular complications, age, sex, metabolic level, and education. Other groups at higher risk of worse HRQoL were diabetes patients with psychiatric disorders, especially depression, and foreign-born patients. Good continuity of care was associated with better HRQoL.

CONCLUSION

Diabetes affects the HRQoL through macrovascular complications and associated non-vascular comorbidity, and also by adding to the total burden of disease. Future research areas include transcultural and ethnic aspects, and effects of lifestyle interventions.

Survival in patients with hypertension treated in primary care. A population-based follow-up study in the Skaraborg Hypertension and Diabetes Project

OBJECTIVE

To explore risk factors for all-cause mortality in patients with hypertension.

DESIGN

Community-based cohort study.

SETTING

Hypertension outpatient clinic in primary health care.

SUBJECTS

Hypertensive men and women who consecutively underwent an annual follow-up during 1992--1993 (n =894).

METHODS

Vital status was ascertained up to December 1999 by record linkage with national registers. Gender-specific predictors for mortality from baseline examination were analysed by Cox regression.

MAIN OUTCOME MEASURE

All-cause mortality.

RESULTS

In both sexes all-cause mortality was predicted by fasting blood glucose (RR by 1 mmol L(-1): 1.2, CI: 1.1-1.3 in men; 1.2, 1.1-1.4 in women), and known type 2 diabetes (RR: 1.9, CI: 1.3-2.9 in men; 2.5, 1.7-3.9 in women). In men, furthermore, mortality was predicted by previous cardiovascular disease, left ventricular hypertrophy and microalbuminuria, whilst in women mortality was predicted by high blood pressure and dyslipidemia. In patients without known diabetes male gender was a strong predictor of mortality (RR: 2.0, CI: 1.4-2.9), whereas in patients with hypertension and type 2 diabetes combined, male gender was not associated with increased mortality (RR: 1.4, CI: 0.9-2.2).

CONCLUSION

Type 2 diabetes in hypertensive patients treated in primary care predicts mortality and dilutes gender difference in survival. For hypertensive patients general practitioners should be observant regarding disturbed glucose metabolism and regarding the associated major risk increase in women.