Association of weight loss and weight loss maintenance following diabetes diagnosis by screening and incidence of cardiovascular disease and all-cause mortality: An observational analysis of the ADDITION-Europe trial

AIMS

Short-term weight loss may lead to remission of type 2 diabetes but the effect of maintained weight loss on cardiovascular disease (CVD) is unknown. We quantified the associations between changes in weight 5 years following a diagnosis of diabetes, and incident CVD events and mortality up to 10 years after diagnosis.

MATERIALS AND METHODS

Observational analysis of the ADDITION-Europe trial of 2730 adults with screen-detected type 2 diabetes from the UK, Denmark and the Netherlands. We defined weight change based on the maintenance at 5 years of weight loss achieved during the year after diabetes diagnosis, and as 5-year overall change in weight. Incident CVD events (n = 229) and all-cause mortality (n = 225) from 5 to 10 years follow-up were ascertained from medical records.

RESULTS

Gaining >2% weight during the year after diabetes diagnosis was associated with higher hazard of all-cause mortality versus maintaining weight [hazard ratio (95% confidence interval): 3.18 (1.30-7.82)]. Losing ≥5% weight 1 year after diagnosis was also associated with mortality, whether or not weight loss was maintained at 5 years: 2.47 (0.99-6.21) and 2.72 (1.17-6.30), respectively. Losing ≥10% weight over 5 years was associated with mortality among those with body mass index <30 kg/m² [4.62 (1.87-11.42)]. Associations with CVD incidence were inconclusive.

CONCLUSIONS

Both weight loss and weight gain after screen-detected diabetes diagnosis were associated with higher mortality, but not CVD events, particularly among participants without obesity. The clinical implications of weight loss following a diagnosis of diabetes probably depend on its magnitude and timing, and may differ by body mass index status. Personalization of weight loss advice and support may be warranted.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

Cardiovascular risk factors and incident albuminuria in screen-detected type 2 diabetes

BACKGROUND

It is unclear whether cardiovascular risk factor modification influences the development of renal disease in people with type 2 diabetes identified through screening. We determined predictors of albuminuria 5 years after a diagnosis of screen-detected diabetes within the ADDITION-Europe study, a pragmatic cardiovascular outcome trial of multifactorial cardiovascular risk management.

METHODS

In 1826 participants with newly diagnosed, screen-detected diabetes without albuminuria, we explored associations between risk of new albuminuria (≥2.5 mg mmol-1 for males and ≥3.5 mg mmol-1 for females) and (1) baseline cardio-metabolic risk factors and (2) changes from baseline to 1 year in systolic blood pressure (ΔSBP) and glycated haemoglobin (ΔHbA1c ) using logistic regression.

RESULTS

Albuminuria developed in 268 (15%) participants; baseline body mass index and active smoking were independently associated with new onset albuminuria in 5 years after detection of diabetes. In a model adjusted for age, gender, baseline HbA1c and blood pressure, a 1% decrease in HbA1c and 5-mm Hg decrease in SBP during the first year were independently associated with lower risks of albuminuria (odds ratio), 95% confidence interval: 0.76, 0.62 to 0.91 and 0.94, 0.88 to 1.01, respectively. Further adjustment did not materially change these estimates. There was no interaction between ΔSBP and ΔHbA1c in relation to albuminuria risk, suggesting likely additive effects on renal microvascular disease.

CONCLUSIONS

Baseline measurements and changes in HbA1c and SBP a year after diagnosis of diabetes through screening independently associate with new onset albuminuria 4 years later. Established multifactorial treatment for diabetes applies to cases identified through screening.

Insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control

BACKGROUND

It is unclear whether people with type 2 diabetes mellitus on insulin monotherapy who do not achieve adequate glycaemic control should continue insulin as monotherapy or can benefit from adding oral glucose-lowering agents to the insulin therapy.

OBJECTIVES

To assess the effects of insulin monotherapy compared with the addition of oral glucose-lowering agents to insulin monotherapy for people with type 2 diabetes already on insulin therapy and inadequate glycaemic control.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and reference lists of articles. The date of the last search was November 2015 for all databases.

SELECTION CRITERIA

Randomised controlled clinical trials of at least two months' duration comparing insulin monotherapy with combinations of insulin with one or more oral glucose-lowering agent in people with type 2 diabetes.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed risk of bias, extracted data and evaluated overall quality of the evidence using GRADE. We summarised data statistically if they were available, sufficiently similar and of sufficient quality. We performed statistical analyses according to the statistical guidelines in the Cochrane Handbook for Systematic Reviews of Interventions.

MAIN RESULTS

We included 37 trials with 40 treatment comparisons involving 3227 participants. The duration of the interventions ranged from 2 to 12 months for parallel trials and two to four months for cross-over trials.The majority of trials had an unclear risk of bias in several risk of bias domains. Fourteen trials showed a high risk of bias, mainly for performance and detection bias. Insulin monotherapy, including once-daily long-acting, once-daily intermediate-acting, twice-daily premixed insulin, and basal-bolus regimens (multiple injections), was compared to insulin in combination with sulphonylureas (17 comparisons: glibenclamide = 11, glipizide = 2, tolazamide = 2, gliclazide = 1, glimepiride = 1), metformin (11 comparisons), pioglitazone (four comparisons), alpha-glucosidase inhibitors (four comparisons: acarbose = 3, miglitol = 1), dipeptidyl peptidase-4 inhibitors (DPP-4 inhibitors) (three comparisons: vildagliptin = 1, sitagliptin = 1, saxagliptin = 1) and the combination of metformin and glimepiride (one comparison). No trials assessed all-cause mortality, diabetes-related morbidity or health-related quality of life. Only one trial assessed patients' treatment satisfaction and showed no substantial differences between the addition of either glimepiride or metformin and glimepiride to insulin compared with insulin monotherapy.Insulin-sulphonylurea combination therapy (CT) compared with insulin monotherapy (IM) showed a MD in glycosylated haemoglobin A1c (HbA1c) of -1% (95% confidence interval (CI) -1.6 to -0.5); P < 0.01; 316 participants; 9 trials; low-quality evidence. Insulin-metformin CT compared with IM showed a MD in HbA1c of -0.9% (95% CI -1.2 to -0.5); P < 0.01; 698 participants; 9 trials; low-quality evidence. We could not pool the results of adding pioglitazone to insulin. Insulin combined with alpha-glucosidase inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.2); P < 0.01; 448 participants; 3 trials; low-quality evidence). Insulin combined with DPP-4 inhibitors compared with IM showed a MD in HbA1c of -0.4% (95% CI -0.5 to -0.4); P < 0.01; 265 participants; 2 trials; low quality evidence. In most trials the participants with CT needed less insulin, whereas insulin requirements increased or remained stable in participants with IM.We did not perform a meta-analysis for hypoglycaemic events because the included studies used different definitions.. In most trials the insulin-sulphonylurea combination resulted in a higher number of mild episodes of hypoglycaemia, compared to the IM group (range: 2.2 to 6.1 episodes per participant in CT versus 2.0 to 2.6 episodes per participant in IM; low-quality evidence). Pioglitazone CT also resulted in more mild to moderate hypoglycaemic episodes compared with IM (range 15 to 90 episodes versus 9 to 75 episodes, respectively; low-quality evidence. The trials that reported hypoglycaemic episodes in the other combinations found comparable numbers of mild to moderate hypoglycaemic events (low-quality evidence).The addition of sulphonylureas resulted in an additional weight gain of 0.4 kg to 1.9 kg versus -0.8 kg to 2.1 kg in the IM group (220 participants; 7 trials; low-quality evidence). Pioglitazone CT caused more weight gain compared to IM: MD 3.8 kg (95% CI 3.0 to 4.6); P < 0.01; 288 participants; 2 trials; low-quality evidence. Metformin CT was associated with weight loss: MD -2.1 kg (95% CI -3.2 to -1.1), P < 0.01; 615 participants; 7 trials; low-quality evidence). DPP-4 inhibitors CT showed weight gain of -0.7 to 1.3 kg versus 0.6 to 1.1 kg in the IM group (362 participants; 2 trials; low-quality evidence). Alpha-glucosidase CT compared to IM showed a MD of -0.5 kg (95% CI -1.2 to 0.3); P = 0.26; 241 participants; 2 trials; low-quality evidence.Users of metformin CT (range 7% to 67% versus 5% to 16%), and alpha-glucosidase inhibitors CT (14% to 75% versus 4% to 35%) experienced more gastro-intestinal adverse effects compared to participants on IM. Two trials reported a higher frequency of oedema with the use of pioglitazone CT (range: 16% to 18% versus 4% to 7% IM).

AUTHORS' CONCLUSIONS

The addition of all oral glucose-lowering agents in people with type 2 diabetes and inadequate glycaemic control who are on insulin therapy has positive effects on glycaemic control and insulin requirements. The addition of sulphonylureas results in more hypoglycaemic events. Additional weight gain can only be avoided by adding metformin to insulin. Other well-known adverse effects of oral glucose-lowering agents have to be taken into account when prescribing oral glucose-lowering agents in addition to insulin therapy.

Patient-centeredness and quality management in Dutch diabetes care organizations after a 1-year intervention

BACKGROUND

More focus on patient-centeredness in care for patients with type 2 diabetes requests increasing attention to diabetes quality management processes on patient-centeredness by managers in primary care groups and outpatient clinics. Although patient-centered care is ultimately determined by the quality of interactions between patients and clinicians at the practice level, it should be facilitated at organizational level too. This nationwide study aimed to assess the state of diabetes quality management on patient-centeredness at organizational level and its possibilities to improve after a tailored intervention.

METHODS

This before-after study compares the quality management on patient-centeredness within Dutch diabetes care groups and outpatient clinics before and after a 1-year stepwise intervention. At baseline, managers of 51 diabetes primary care groups and 28 outpatient diabetes clinics completed a questionnaire about the organization's quality management program. Patient-centeredness (0%-100%) was operationalized in six subdomains: facilitating self-management support, individualized care plan support, patients' access to medical files, patient education policy, safeguarding patients' interests, and formal patient involvement. The intervention consisted of feedback and benchmark and if requested a telephone call and/or a consultancy visit. After 1 year, the managers completed the questionnaire again. The 1-year changes were examined by dependent (non) parametric tests.

RESULTS

Care groups improved significantly on patient-centeredness (from 47.1% to 53.3%; P=0.002), and on its subdomains "access to medical files" (from 42.0% to 49.4%), and "safeguarding patients' interests" (from 58.1% to 66.2%). Outpatient clinics, which scored higher at baseline (66.7%) than care groups, did not improve on patient-centeredness (65.6%: P=0.54) or its subdomains. "Formal patient involvement" remained low in both care groups (23.2%) and outpatient clinics (33.9%).

CONCLUSION

After a simple intervention, care groups significantly improved their quality management on patient-centeredness, but outpatient clinics did not. Interventions to improve quality management on patient-centeredness in diabetes care organizations should differ between primary and secondary care.

Peer support to decrease diabetes-related distress in patients with type 2 diabetes mellitus: design of a randomised controlled trial

BACKGROUND

Many type 2 diabetes mellitus patients face difficulties self-managing their illness, which can lead to high levels of diabetes-related distress. Diabetes distress may be decreased by peer support, as peers understand and have dealt with similar problems, and can help motivate each other. A recent systematic review concluded that evidence of benefits of peer support in patients with type 2 diabetes mellitus is too inconsistent due to weak theoretical foundation of the interventions. This study describes the design of a trial evaluating the effectiveness of a group-based, peer support programme with a strong theoretical foundation on diabetes-related distress in type 2 diabetes patients.

METHODS

This is a parallel group randomised controlled trial of a six session group-based peer support intervention, delivered by peer leaders and group psychotherapists, compared with one educational meeting on diabetes. At least 152 patients with a type 2 diabetes duration of three years or more and between 50 and 70 years of age, recruited via their general practitioner, will be randomised to receive the peer support intervention or one educational meeting. The intervention is developed in line with three key stages of research development of the Medical Research Council framework. The primary outcome measure for this study is diabetes-related distress. Secondary outcomes include self-management behaviour, well-being and health-related quality of life. Perceived social support is a process measure. Outcomes will be measured one month before, and 6, and 12 months after the intervention by means of self-reported questionnaires. Analysis will be on an intention-to-treat basis.

DISCUSSION

This article contains a description of the design of a study that will investigate the effect of a group-based, peer support intervention on diabetes-related distress in type 2 diabetes patients. The intervention was developed in recognition of the limited evidence, and the importance of a theoretical foundation and its implementation. Findings will contribute to knowledge in the field of peer support and patient-important outcomes in type 2 diabetes patients.

TRIAL REGISTRATION

Dutch Trial Registry: NTR3474.

Tailored support for type 2 diabetes patients with an acute coronary event after discharge from hospital - design and development of a randomised controlled trial

BACKGROUND

Type 2 diabetes mellitus patients with an acute coronary event (ACE) experience decreased quality of life and increased distress. According to the American Diabetes Association, discharge from the hospital is a time of increased distress for all patients. Tailored support specific to diabetes is scarce in that period. We developed an intervention based on Bandura's Social Cognitive Theory, Leventhal's Common Sense Model, and results of focus groups. The aim of this study is to evaluate the effectiveness of the intervention to reduce distress in type 2 diabetes patients who experienced a first ACE.

METHODS

Randomised controlled trial. Two hundred patients are recruited in thirteen hospitals. A diabetes nurse visits the patients in the intervention group (n = 100) at home within three weeks after discharge from hospital, and again after two weeks and two months. The control group (n = 100) receives a consultation by telephone. The primary outcome is diabetes-related distress, measured with the Problem Areas in Diabetes (PAID) questionnaire. Secondary outcomes are well-being, health status, anxiety, depression, HbA1c, blood pressure and lipids. Mediating variables are self-management, self-efficacy and illness representations. Outcomes are measured with questionnaires directly after discharge from hospital and five months later. Biomedical variables are obtained from the records from the primary care physician and the hospital. Differences between groups in change over time are analysed according to the intention-to-treat principle. The Holm-Bonferroni correction is used to adjust for multiplicity.

DISCUSSION

Type 2 diabetes patients who experience a first ACE need tailored support after discharge from the hospital. This trial will provide evidence on the effectiveness of a supportive intervention in reducing distress in these patients.

TRIAL REGISTRATION

NCT01801631.

Development of metabolic syndrome components in adults with a healthy obese phenotype: a 3-year follow-up

OBJECTIVE

There is a lack of data on the progression from a healthy obese phenotype toward an unhealthy obese phenotype and the development of metabolic syndrome (MetS). Our aim was to assess the development of MetS 3 years after screening in centrally obese individuals with a healthy obese phenotype and to evaluate the usefulness of repeated screening.

DESIGN AND METHODS

Eighty-eight individuals (mean age 47 years, 88% female) with central obesity as their only MetS component (ATP III criteria) at baseline screening were re-evaluated for MetS status after 3 years.

RESULTS

At follow-up, the cardiometabolic risk profile in centrally obese individuals with a healthy phenotype showed a tendency toward deterioration. Thirty-two percent developed at least one additional MetS component, 7% had developed MetS. Nobody had developed type 2 diabetes. An increased triglyceride level (n = 16) and an increased blood pressure (n = 18) were the components most often present at follow-up. The people developing additional MetS components had a lower education level compared with the group that preserved the healthy centrally obese phenotype (80 vs. 71% lower educated, P = 0.35). They also had slightly worse baseline levels of the risk factors.

CONCLUSION

The number of centrally obese individuals developing an unhealthy phenotype in this relatively short follow-up period emphasizes the need for a regular surveillance of cardiometabolic parameters in centrally obese individuals. However, it is questionable whether a repeated screening for type 2 diabetes every 3 years, as recommended by the American Diabetes Association, in this category of patients is appropriate.

Evaluation and comparison of guidelines for the management of people with type 2 diabetes from eight European countries

METHODS

The most recent nationally recognised guidelines for type 2 diabetes from eight European countries (Belgium, England/Wales, France, Germany, Ireland, Italy, the Netherlands and Sweden) were compared. The Appraisal of Guidelines for Research and Evaluation (AGREE) instrument was used for quality assessment. Details of recommendations for key process and outcome indicators were also extracted. Appraisal and data extraction were conducted independently by two researchers.

RESULTS

AGREE domain scores varied between guidelines, including a range of 31-95% for rigour of development. The highest mean domain scores were for Scope and Purpose (81%) and Clarity and Presentation (85%); the lowest was for Stakeholder Involvement (49%). Specific recommendations, including targets relating to intermediate outcomes, were broadly similar. However, at detailed level, there were variations, particularly in terms of the level of information provided, for example, only two countries' guidelines provided cut-off points in relation to risk associated with waist circumference.

IMPLICATIONS

Our findings suggest that there are some areas of good practice relating to guideline development where more attention is needed. Despite a substantial degree of consensus for specified targets, observed differences at detailed level suggest a lack of consistency in relation to some aspects of the information provided to clinicians across Europe.

[Improvement of glycemic regulation without exogenous insulin in 40% of poorly regulated patients with type 2 diabetes mellitus; a study in 18 family practices]

OBJECTIVE

To determine the possibility of improving glycaemic control in poorly regulated patients with type 2 diabetes mellitus (DM 2) through maximization of oral medication by the general practitioner followed by education and instruction in self-regulation by the diabetes nurse, as required.

DESIGN

Explorative, descriptive, prospective cohort study.

METHOD

24 general practitioners selected all known patients with DM 2 and poor glycaemic control (HbA1c value > or = 8% and/or fasting blood glucose > 8 mmol/l), and maximized oral blood glucose lowering drugs if possible. When the HbA1c level remained > or = 8%, patients were referred to the diabetes nurse.

RESULTS

In a population of 735 patients with DM 2 treated by the general practitioner, 146 patients were poorly regulated. Out of 112 patients with sub-maximal therapy, 50 achieved an HbA1c < 8% after adjustment of oral therapy. Of the 60 poorly regulated patients on maximum therapy, 39 were referred to the diabetes nurse. Nine of these patients subsequently achieved an HbA1c level < 8%.

CONCLUSION

In 40% (50 + 9/146) of the poorly regulated patients with DM 2, improvement of glycaemic control could be achieved through optimization of oral therapy by the general practitioner and diabetes nurse, without exogen administered insulin.

[Repaglinide, potentially a therapeutic improvement for diabetes mellitus type 2]

In about 25% of type 2 diabetes patients, good diabetes control is not attainable with oral blood-glucose lowering drugs. Furthermore, in many people with diabetes the disease deteriorates, despite the use of blood-glucose lowering medication, due to the decline of the pancreatic beta cells. The development of new drugs, such as repaglinide, is therefore important. Repaglinide is an insulin secretion enhancer with a different mechanism of action to the sulphonylureas, which means it does not continuously stimulate insulin secretion. The tablets should be taken with each meal. After oral ingestion repaglinide is resorbed quickly, with a half-life of between 30 minutes to an hour. In clinical trials repaglinide has been found to be equally effective as glibenclamide. Repaglinide has been found to be particularly effective in sulphonylurea-naïve patients. Skipping the meal plus tablet combination results in less frequent hypoglycaemic symptoms compared to glibenclamide. Repaglinide results in greater reductions in postprandial glucose levels than glibenclamide. It does not affect insulin resistance. Long-term data are lacking, both with regard to efficacy and side effects. Repaglinide deserves a place in the diabetes treatment of newly-diagnosed type 2 diabetes patients who are well-informed about their disease, as well as in patients with renal failure. It should also be considered for patients whose diabetes is poorly controlled on metformin monotherapy.

Experts' opinions on the profile of optimal care for patients with diabetes mellitus type 2 in the Netherlands

BACKGROUND

The St. Vincent Declaration has resulted in discussions and initiatives on optimal diabetes care during recent years. Both are based on two sources of knowledge: evidence and experience. We wanted to reveal the experience based knowledge in the Netherlands to identify essential elements or prerequisites for high quality type 2 diabetes care.

METHODS

A group of 56 experts on diabetes care were invited to fill in a questionnaire. This included a ranking of 18 elements on the organization of diabetes care and 9 on patient education.

RESULTS

The response rate was 87.5%. With regard to the organization of care 'active patient participation', 'protocolized care' and 'patient education' were evaluated as the most important. The integration in daily diabetes care was seen as the most important aspect of patient education. Optimal diabetes patient education would include five sessions (range: 1-10) of 1 h (range: 0.25-3) with active follow-up. The most appropriate disciplines for patient education are the diabetes nurse (chosen by 93% of the experts) and the dietician (77%).

CONCLUSIONS

Optimal care for diabetes mellitus type 2 consists of structured care with integrated patient education. The majority of the experts indicated that this is not optimally organized within the Netherlands.

The Utrecht Diabetes Project: telemedicine support improves GP care in Type 2 diabetes

The Utrecht Diabetes Project (UDP) is a shared-care project providing remote diabetologist support for 85 GPs. In the UDP all examinations, performed by the GP, follow standardized procedures, results being sent to the diabetologist. Laboratory results are sent automatically to both GP and diabetologist.

AIMS

To study the composition of the UDP population; completeness of data recording; changes in biochemical variables of UDP patients; and GPs' motives for enrolling them.

METHODS

Data were extracted from the records of 19 GPs and a questionnaire was sent to all UDP GPs.

RESULTS

Of 770 patients with Type 2 diabetes, 44% were treated with UDP support, 29% by their GPs alone, and 27% at out-patient clinics. The 336 UDP patients were representative of all UDP patients. Patients older than 75 years were the greater part of those treated by GPs alone; out-patient clinics had more patients with diabetes > 10 years or with complications. UDP patients' records were the most complete. Diabetes regulation, lipid levels and diastolic blood pressure in the UDP patients improved significantly after inclusion in the UDP. GPs tend to seek UDP aid especially for patients who are young, or of recent onset, at risk of macrovascular complications, or needing insulin.

CONCLUSIONS

Standardized data transfer between GP, diabetologist and laboratory might establish an effective infrastructure for shared diabetes care. Diabet. Med. 18, 459-463 (2001)

Education integrated into structured general practice care for Type 2 diabetic patients results in sustained improvement of disease knowledge and self-care

AIMS

The objective of this study was to study the effectiveness of structured care with and without integrated education with regard to patients' knowledge, self-care behaviour and disease perception.

METHODS

Four diabetes care programmes implemented in a daily primary care setting were compared, two based on structured care and two on education integrated into structured care. Measurements were taken at baseline and after 6 and 12 months.

RESULTS

The study included 243 patients with Type 2 diabetes mellitus treated by a general practitioner (mean age 64.0 years; diabetes duration 7.1 years). The level of patients' disease knowledge increased in all programmes, was preserved at follow-up and differed between programmes with a specific educational component (37%) on one hand and the non-educational programmes (11%) on the other (P < 0.001). The percentage of patients performing self-care behaviour increased in all programmes, but more so in the programmes with an educational component. In addition, an increase in the frequency of self-care behaviour was observed, whereas no change in disease perception was found. In cross sectional analyses disease knowledge and self-care behaviour were positively related (partial correlation coefficient: 0.35; P < 0.001 adjusted for age, sex, level of education and duration of diabetes).

CONCLUSIONS

The results indicate that primary care programmes which integrated education into structured care are able to improve both Type 2 diabetic patients' disease knowledge and their self-care behaviour. These improvements endured after the completion of the programmes, which suggests that they initiate lasting changes in the way patients handle their disease.

[Summary of the practice guideline 'Diabetes mellitus type 2' (first revision) of the Dutch College of General Practitioners]

The main changes of the first revision of the guideline of the Dutch College of General Practitioners on the diagnosis and treatment of diabetes mellitus type 2 compared with the first edition concern the following aspects: more attention is given to organisation and management of diabetes care; new diagnostic criteria for diabetes are introduced; guidelines are given for the early detection of diabetes in high risk groups; the distinction between sulfonylureas of the first and the second generation has been dropped; in the treatment of patients with diabetes and a body mass index > 27 metformin is the drug of first choice; optional guidelines are given for the treatment with insulin; guidelines are given for the treatment of hypertension and hypercholesterolaemia in patients with diabetes.

[The contribution of general practice medicine to undergraduate medical education]

The Blueprint 1994. Objectives of undergraduate medical education, was issued in 1994 and has since been used as a guideline by the eight medical faculties in the Netherlands. This prompted a team of representatives of all eight Institutes for General Practice Medicine of the country to describe the contribution of general practice medicine to undergraduate medical education. The team was guided by two basic principles of general practice medicine, viz. general accessibility for all health problems at all stages and the continuous nature of the care. Out of the 180 general objectives of the Blueprint, 12 were selected of which the teaching should preferably be provided or coordinated by general practice medicine. Out of the approximately 250 problems from the general problem list of the Blueprint, 134 were assigned to general practice medicine: 89 in view of their high incidence in general practice, 15 because of the emergency nature, since GPs are easily accessible, 12 in which a major disease has to be excluded and 18 regarding chronic conditions. In this way, insight is provided into the matters regarding which medical faculties can address departments of general practice medicine about the curriculum to be drawn up. It appears advisable that other specialisms as well should define their potential contributions to undergraduate medical education and the relevant priorities.

Infections in patients with type 2 diabetes in general practice

BACKGROUND

The association between diabetes, glycaemic control and the prevalence of infections seems obvious to most general practitioners. However, this association is still not very clear.

AIM

The aim of this study in general practice was to investigate which infections patients with treated type 2 diabetes present to their general practitioner, and to study whether a relationship exists between glycaemic status and these infections.

METHOD

Over a period of 2 years eight fasting glucose and glycosylated haemoglobin values were related to the presented infections in 328 patients.

RESULTS

193 patients presented with one or more infections (a total of 458 infections, with a mean of 2.4 (+/- 1.9) infections). Patients with and without infections did not differ in mean glycosylated haemoglobin and fasting glucose levels. There was no difference in presentation of infections between well controlled and less controlled patients. However, patients who presented with an infection showed significantly higher mean glycosylated haemoglobin levels in that period compared to the mean levels in periods without any infection.

CONCLUSION

Considering the limitations of this study, hyperglycaemia is more likely a result of than a cause of common infections.

Effects of systematic patient education about cough on the consulting behaviour of a general practice population

In four general practices the effects of systematic patient education on cough were compared with four control practices. Intended and unintended contacts for cough were defined. In two successive autumn-winter periods, in 62% of 5890 contacts for cough the intervention could be applied. In spite of the better baseline situation in the experimental practices, the percentage of intended contacts with the GP increased from 47 to 65% (control group: 28 and 30%, respectively, P < 0.01). There was a considerable interpractice variance. For methodological reasons a leaflet was sent to all the patients in the experimental practices. This possibly also led to a shift in the consulting pattern.

Diabetes and its long-term complications in general practice: a survey in a well-defined population

The aim of this study was to assess the prevalence of long-term complications in all patients with non-insulin-dependent diabetes mellitus, who were known to their general practitioners (GPs). During one year 19 GPs in the area of Hoogeveen in the Netherlands examined their non-insulin-dependent (NIDDM) patients, including those under specialist's care. A detailed protocol was used; the GPs were trained in the diagnostic procedures. Complications were either already known from the records or newly discovered during screening. In a population of 41,940 14.5/1000 patients with diabetes were identified: 12/1000 NIDDM and 2.5/1000 insulin-dependent diabetes mellitus (IDDM). Of the 509 NIDDM patients, 387 (76%) could be screened for late complications. Signs and symptoms of late complications were found in many patients: retinopathy (14%), nephropathy (57%), neuropathy (68%) and macroangiopathy (53%). The prevalence of serious complications was: proliferative retino- and maculopathy (3.3%); diabetic foot (2.6%); renal failure (2.5%). The systemic screening revealed a high number of previously unknown cases. It is concluded that many patients with NIDDM develop signs and symptoms of late complications. Most cases are identified by systemic screening only. More long-term studies of the prognosis of late complications in NIDDM are needed.