Review: Self-management Support Program on Dietary Behaviors in Patients with Type 2 Diabetes Mellitus

Background: Dietary behaviors are the cornerstone in diabetes management. Diabetes self-management support program in which patients play an active role to determine their health care is an important strategy to improve dietary behaviors in type 2 diabetes mellitus (T2DM) patients. Its elements which contribute to the successfulness of the program need to be identified.Purpose: To review and identify the elements of self-management support program to improve dietary behaviors in T2DM patients.Method: An integrative review was conducted. Relevant studies published in English language during last 10-year, measured dietary behaviors in T2DM patients, and retrieved from CINAHL and PubMed were included.Results: 13 experimental studies and 3 meta-analysis studies were reviewed. Goal setting and action planning combined with other strategies (brief counseling and problem solving) seemed more effective to improve dietary behaviors. Either trained lay people or clinicians could lead the program although clinician-led programs were common. Contents and materials of the education vary across the studies. The effects on dietary behaviors could be detected in short term duration of program (<6 months). Continuing follow-up was essential element which face-to-face follow-up as the most common strategy. The utilization of technology such as telephone-call and internet based follow-up might provide more benefits for patients.Conclusion: Diabetes self-management support program is effective to improve dietary behaviors in T2DM patients. Further research is needed to test the effectiveness of goal setting strategy and technology utilization for follow-up strategy such telephone call in Indonesian T2DM population

The Diabetes Remission Clinical Trial (DiRECT): protocol for a cluster randomised trial

Background: Despite improving evidence-based practice following clinical guidelines to optimise drug therapy, Type 2 diabetes (T2DM) still exerts a devastating toll from vascular complications and premature death. Biochemical remission of T2DM has been demonstrated with weight loss around 15kg following bariatric surgery and in several small studies of non-surgical energy-restriction treatments. The non-surgical Counterweight-Plus programme, running in Primary Care where obesity and T2DM are routinely managed, produces &gt;15 kg weight loss in 33 % of all enrolled patients. The Diabetes UK-funded Counterpoint study suggested that this should be sufficient to reverse T2DM by removing ectopic fat in liver and pancreas, restoring first-phase insulin secretion. The Diabetes Remission Clinical Trial (DiRECT) was designed to determine whether a structured, intensive, weight management programme, delivered in a routine Primary Care setting, is a viable treatment for achieving durable normoglycaemia. Other aims are to understand the mechanistic basis of remission and to identify psychological predictors of response. Methods/Design: Cluster-randomised design with GP practice as the unit of randomisation: 280 participants from around 30 practices in Scotland and England will be allocated either to continue usual guideline-based care or to add the Counterweight-Plus weight management programme, which includes primary care nurse or dietitian delivery of 12-20weeks low calorie diet replacement, food reintroduction, and long-term weight loss maintenance. Main inclusion criteria: men and women aged 20-65years, all ethnicities, T2DM 0-6years duration, BMI 27-45 kg/m2. Tyneside participants will undergo Magnetic Resonance (MR) studies of pancreatic and hepatic fat, and metabolic studies to determine mechanisms underlying T2DM remission. Co-primary endpoints: weight reduction ≥ 15 kg and HbA1c &lt;48 mmol/mol at one year. Further follow-up at 2 years. Discussion: This study will establish whether a structured weight management programme, delivered in Primary Care by practice nurses or dietitians, is a viable treatment to achieve T2DM remission. Results, available from 2018 onwards, will inform future service strategy

Is point of care testing for anaemia (HB) and microalbumin feasible in people with type 2 diabetes attending diabetes outpatient clinics?

Introduction: Diabetes is the major cause of chronic kidney disease (CKD) in Australia. Anaemia of CKD occurs earlier than in non-diabetics and is often insidious and undetected.Aim: A large, prospective, single-centre study was undertaken to determine the feasibility of point of care testing (POCT) haemoglobin (Hb) and microalbumin in people with type 2 diabetes (T2DM) attending routine outpatient clinic appointments (OPC).Method: Clinic nurses measured Hb and microalbumin using the HemoCue Haemoglobin Capillary Analyser and the HemoCue Urine Albumin Analyser (Medipac Scientific), respectively when they tested blood glucose, weight and blood pressure. The nurses were trained to use the analysers before the study commenced. Standard demographic data, duration of diabetes, treatment mode, and presence of complications, comorbidities, and HbA1c were ascertained from patients&rsquo; medical records.Results: Five hundred and fifty-four (80%) patients were screened. The nurses were able to perform the tests competently but testing, especially microalbumin, was time-consuming. Patients&rsquo; mean age was 62 years (11 SD): 230 females, mean blood glucose (BG) 10 (3.9 SD) mmol/L, mean haemoglobin 127.2 (16.3 SD) g/L; mean microalbumin 47.8 (58.7 SD) mg/L: 324 were males, mean BG 10.2 (3.9 SD) mmol/L, mean Hb 138.6 (18.8 SD) gm/L, and mean microalbumin 67.9 (73.9 SD) mg/L. 27% of males and 22% of females were anaemic. Of those with anaemia, 27% of females and 29% of males had microalbuminuria.Conclusions: POCT is feasible in routine outpatient clinics but is time-consuming. One in four T2DM attending OPC were anaemic. POCT Hb testing in OPC is feasible and could identify T2DM who need full haematological assessment.<br /

A qualitative assessment of using lay trainers with type 2 diabetes in an intervention programme for people at risk of type 2 diabetes

Objective: More knowledge is needed on the impact of expert patients within health intervention programmes. The University of East Anglia Impaired Fasting Glucose (UEA-IFG) feasibility programme was a structured dietary and exercise intervention to reduce the risk of type 2 diabetes mellitus (T2DM) in susceptible individuals. Lay volunteers with T2DM (T2 trainers) were recruited to support participants in adopting healthier lifestyles. This study aimed to explore the acceptability, perceived effectiveness and sustainability of lay trainers within the programme. Design: A qualitative focus group study. Setting: A clinical research unit in Norwich, United Kingdom (UK). Method: Focus groups were conducted with: (1) T2 trainers (n = 15); (2) programme participants who had received their support (n = 11); and (3) salaried staff facilitators who had worked alongside the T2 trainers (n = 3). Framework analysis was applied to identify the different experiences of the lay trainer role. Results: All groups perceived advantages for peer support, particularly in sharing the day-to-day experiences of living with T2DM. However, staff facilitators raised the importance of role boundaries, emphasizing that T2 trainers should not provide medical advice. Acceptability of T2 trainers was enhanced by contacting participants at a convenient time and before substantial lifestyle changes had been made. Conclusion: Lay trainers were seen as a complementary method to motivate individuals to reduce their risks of T2DM. A less prescriptive approach needs to be adopted to enable full integration of lay trainers, allowing them a greater level of contribution. To sustain effective use of lay trainers, health professionals need to work alongside volunteers and be trained to encourage peer involvement

A cluster randomized controlled trial of the effectiveness and cost-effectiveness of Intermediate Care Clinics for Diabetes (ICCD) : study protocol for a randomized controlled trial

Background World-wide healthcare systems are faced with an epidemic of type 2 diabetes. In the United Kingdom, clinical care is primarily provided by general practitioners (GPs) rather than hospital specialists. Intermediate care clinics for diabetes (ICCD) potentially provide a model for supporting GPs in their care of people with poorly controlled type 2 diabetes and in their management of cardiovascular risk factors. This study aims to (1) compare patients with type 2 diabetes registered with practices that have access to an ICCD service with those that have access only to usual hospital care; (2) assess the cost-effectiveness of the intervention; and (3) explore the views and experiences of patients, health professionals and other stakeholders. Methods/Design This two-arm cluster randomized controlled trial (with integral economic evaluation and qualitative study) is set in general practices in three UK Primary Care Trusts. Practices are randomized to one of two groups with patients referred to either an ICCD (intervention) or to hospital care (control). Intervention group: GP practices in the intervention arm have the opportunity to refer patients to an ICCD - a multidisciplinary team led by a specialist nurse and a diabetologist. Patients are reviewed and managed in the ICCD for a short period with a goal of improving diabetes and cardiovascular risk factor control and are then referred back to practice. or Control group: Standard GP care, with referral to secondary care as required, but no access to ICCD. Participants are adults aged 18 years or older who have type 2 diabetes that is difficult for their GPs to control. The primary outcome is the proportion of participants reaching three risk factor targets: HbA1c (≤7.0%); blood pressure (<140/80); and cholesterol (<4 mmol/l), at the end of the 18-month intervention period. The main secondary outcomes are the proportion of participants reaching individual risk factor targets and the overall 10-year risks for coronary heart disease(CHD) and stroke assessed by the United Kingdom Prospective Diabetes Study (UKPDS) risk engine. Other secondary outcomes include body mass index and waist circumference, use of medication, reported smoking, emotional adjustment, patient satisfaction and views on continuity, costs and health related quality of life. We aimed to randomize 50 practices and recruit 2,555 patients

Sex-specific-differences in cardiovascular risk in type-1-diabetes : a cross sectional study

Background: Little is known about the impact of sex-specific differences in the management of type 1 diabetes (T1DM). Thus, we evaluated the influence of gender on risk factors, complications, clinical care and adherence in patients with T1DM. Methods: In a cross-sectional study, sex-specific disparities in glycaemic control, cardiovascular risk factors, diabetic complications, concomitant medication use and adherence to treatment recommendations were evaluated in 225 consecutive patients (45.3% women) who were comparable with respect to age, diabetes duration, and body mass index. Results: Although women with T1DM had a higher total cholesterol than men, triglycerides were higher in obese men and males with HbA1c>7% than in their female counterparts. No sex differences were observed in glycaemic control and in micro- or macrovascular complications. However, the subgroup analysis showed that nephropathy was more common in obese men, hyperlipidaemic women and all hypertensive patients, whereas peripheral neuropathy was more common in hyperlipidaemic women. Retinopathy was found more frequently in women with HbA1c>7%, obese men and in both sexes with a long duration of diabetes. The multivariate analysis revealed that microvascular complications were associated with the duration of disease and BMI in both sexes and with hyperlipidaemia in males. The overall adherence to interventions according to the guidelines was higher in men than in women. This adherence was concerned particularly with co-medication in patients diagnosed with hypertension, aspirin prescription in elderly patients and the achievement of target lipid levels following the prescription of statins. Conclusions: Our data showed sex differences in lipids and overweight in patients with T1DM. Although glycaemic control and the frequency of diabetic complications were comparable between the sexes, the overall adherence to guidelines, particularly with respect to the prescription of statins and aspirin, was lower in women than in men

Diet and diabetes

Provides current evidence regarding the differing diets in diabetes prevention and management once type 2 diabetes mellitus (T2DM) arises, including the role in management of complications such as = hypoglycaemia. Background Guidelines for the prevention and management of type 2 diabetes mellitus (T2DM) reinforce lifestyle management, yet advice to guide general practitioners on principles around dietary choices is needed. Objective This article provides current evidence regarding the differing diets in diabetes prevention and management once T2DM arises, including the role in management of complications such as hypoglycaemia. Discussion Diets should incorporate weight maintenance or loss, while complementing changes in physical activity to optimise the metabolic effects of dietary advice. Using a structured, team-care approach supports pragmatic and sustainable individualised plans, while incorporating current evidence-based dietary approaches

Effective diabetes complication management is a step toward a carbon-efficient planet: an economic modeling study

Background The management of diabetes-related complications accounts for a large share of total carbon dioxide equivalent (CO2e) emissions. We assessed whether improving diabetes control in people with type 2 diabetes reduces CO2e emissions, compared with those with unchanging glycemic control. Methods Using the IQVIA Core Diabetes Model, we estimated the impact of maintaining glycated hemoglobin (HbA1c) at 7% (53 mmol/mol) or reducing it by 1% (11 mmol/mol) on total CO2e/patient and CO2e/life-year (LY). Two different cohorts were investigated: those on first-line medical therapy (cohort 1) and those on third-line therapy (cohort 2). CO2e was estimated using cost inputs converted to carbon inputs using the UK National Health Service’s carbon intensity factor. The model was run over a 50-year time horizon, discounting total costs and quality adjusted life years (QALYs) up to 5% and CO2e at 0%. Results Maintaining HbA1c at 7% (53 mmol/mol) reduced total CO2e/patient by 18% (1546 kgCO2e/patient) vs 13% (937 kgCO2e/patient) in cohorts 1 and 2, respectively, and led to a reduction in CO2e/LY gain of 15%–20%. Reducing HbA1c by 1% (11 mmol/mol) caused a 12% (cohort 1) and 9% (cohort 2) reduction in CO2e/patient with a CO2e/LY gain reduction of 11%–14%. Conclusions When comparing people with untreated diabetes, maintaining glycemic control at 7% (53 mmol/mol) on a single agent or improving HbA1c by 1% (11 mmol/mol) by the addition of more glucose-lowering treatment was associated with a reduction in carbon emissions

Management of type 2 diabetes: the current situation and key opportunities to improve care in the UK

In common with global trends, the number of individuals with type 2 diabetes in the UK is rising, driven largely by obesity. The increasing prevalence of younger individuals with type 2 diabetes is of particular concern because of the accelerated course of diabetes-related complications that is observed in this population. The importance of good glycaemic control in the prevention of microvascular complications of diabetes is widely accepted, and there is a growing body of evidence to support a benefit in the reduction of cardiovascular events in the long term. Despite the importance of maintaining a healthy weight for the prevention of type 2 diabetes, the results from trials of lifestyle intervention strategies to reduce body weight have been disappointing. New glucose-lowering agents offer some promise in this regard, offering an opportunity to combat the dual burden of hyperglycaemia and obesity simultaneously. The timing and appropriate choice of glucose-lowering therapy has never been more complex as a result of rising prevalence of obesity in the young, concomitant obesity in some 90% of adults with type 2 diabetes and an ever-increasing range of therapeutic options. The present review evaluates performance measures specific to weight and glycaemic control in type 2 diabetes in the UK using data from the Quality and Outcomes Framework in England and Wales, and the Scottish Diabetes Survey. Potential barriers to improvement in standards of care for people with type 2 diabetes are considered, including patient factors, clinical inertia and the difficulties in translating therapeutic guidelines into everyday clinical practice