Blood Rheology in Diabetes Mellitus and Its Complications: Assessment of New Methods

This thesis reviews blood rheology and its known associations with diabetes mellitus and vascular complications in diabetic patients. The relationship between blood viscosity and two conditions which are common in diabetes, namely hypertension and peripheral neuropathy, was examined for the first time. Type 2 (non-insulin dependent) diabetics with hypertension were found to have increased blood viscosity compared with normotensive type 2 diabetics. Blood viscosity and red cell deformability were measured in diabetic patients with peripheral neuropathy. When compared with diabetics who have no evidence of neuropathy but were matched for other microvascular complications, no differences were found. Using the recently-introduced Carri-Med filtrometer, red cell deformabiltiy was assessed by filtration through Nuclepore membranes in a large group of type 1 (insulin-dependent) and type 2 diabetic patients. Compared with healthy control subjects, deformability was impaired in all diabetic patients, but to a greater extent in type 1 patients. In the control population, red cell filterability was related to mean cell volume; while in diabetic patients, it was related to mean cell haemoglobin concentration. Within the diabetics, red cell filtration was not significantly different in patients with microvascular or macrovascular complications. Red cell aggregation was measured in the new Myrenne photometric aggregometer and found to be increased in both type 1 and type 2 diabetic patients, particularly hypertensive type 2 diabetics. Aggregation was found to be related to plasma triglyceride and very low density lipoprotein levels. Deformability of white cell subpopulations was measured by a filtration method in type 2 diabetics, and although non significant differences were found when compared with non-diabetic control subjects, a correlation of both mononuclear and polymorphonuclear cell filtration pressure was demonstrated with glycaemic control. The implications of the findings in these studies are discussed, and suggestions for further rheology studies in diabetic patients are proposed

A Website to Promote Physical Activity in People With Type 2 Diabetes Living in Remote or Rural Locations: Feasibility Pilot Randomized Controlled Trial

Background: Research supports the use of Web-based interventions to promote physical activity in diabetes management. However, previous interventions have found poor levels of engagement or have not included health professionals and people with diabetes in the design of the tool.  Objective: To develop and explore the feasibility and indicative effect of a Web-based physical activity promotion intervention in people diagnosed with type 2 diabetes living in remote or rural locations.  Methods: A qualitative approach using focus groups that included patients with diabetes and health professionals were run to identify key concepts, ideas, and features, which resulted in the design of a physical activity website. This site was tested using a quantitative approach with a qualitative 6-month pilot study that adopted a three-armed approach. Participants were randomized into three groups: a control group who received written diabetes-specific physical activity advice; an information Web group, a Web-based group who received the information online; and an intervention Web group, an interactive Web-based group who received online information plus interactive features, such as an activity log, personalized advice, and goal setting.  Results: A website was designed based on patient and health professional ideas for effective physical activity promotion. This website was tested with 31 participants, 61% (19/31) male, who were randomized into the groups. Website log-ins decreased over time: 4.5 times in month 1, falling to 3 times in month 6. Both the information Web group—mean 134.6 (SD 123.9) to mean 154.9 (SD 144.2) min—and the control group—mean 118.9 (SD 103.8) to mean 126.1 (SD 93.4) min,d=0.07—increased time spent in moderate-to-vigorous physical activity, but this decreased in the intervention Web group—mean 131.9 (SD 126.2) to mean 116.8 (SD 107.4) min.  Conclusions: Access to online diabetes-specific physical information was effective in promoting physical activity in people with type 2 diabetes; access to interactive features was not associated with increases in activity.  Trial Registration: International Standard Randomised Controlled Trial Number (ISRCTN): 96266587; http://www.isrctn.com/ISRCTN96266587 (Archived by WebCite at http://www.webcitation.org/6tzX6YesZ

A systematic and integrated review of mobile-based technology to promote active lifestyles in people with Type 2 diabetes

Background: An active lifestyle is important for good Type 2 diabetes management. Mobile-based technology is increasingly being used to promote active lifestyles. Aim: To review studies examining the effectiveness, acceptability and feasibility of mobile-based technology for promoting active lifestyles in people with Type 2 diabetes. Methods: An integrated, systematic review method was used to allow inclusion of a variety of study designs. A comprehensive search of electronic databases including; PubMed, Medline, ScienceDirect and ACM Digital Library was conducted to retrieve studies promoting active lifestyles in people with Type 2 diabetes using mobile-based technology (apps and wearable technology). Studies had to assess; effectiveness, acceptability or feasibility of mobile based technology. Studies were categorised as 1)informing, 2)monitoring, 3)provoking or 4)sustaining behaviour. Results: A total of 9 papers from the 7662 sourced met inclusion criteria; 5 studies used smartphone or tablet apps, 1 a diabetes personal digital assistant, 1 a combination of continuous glucose monitor and accelerometer, 1 a pedometer and 1 a website delivered by a smartphone. The effectiveness of technology was assessed in 6 studies, feasibility examined in 3 studies and acceptability in 4 studies. Most (n=5) of the studies examined the effectiveness of using mobile-based technology to provoke lifestyle. The effectiveness of mobile-based technology in monitoring active lifestyles and the feasibility and acceptability of using mobile-based technology to sustained lifestyle change has not been investigated. Conclusions: To maintain health benefit from active lifestyles future research should explore the feasibility and acceptability of mobile based technology monitoring in sustaining active lifestyles

Objective, continuous measurement of sedentary behaviour and glucose in people with type 2 diabetes

Aims: To explore the relationship between daily levels of sitting/lying and glucose in people with Type 2 diabetes (T2D) using objective and continuous measurements. Methods: Ten participants with T2D managed with diet, Metformin or DPP4 inhibitors were recruited (mean age 63.5±9.4 years & BMI 30.8±6.9 kg/cm2). Participants completed a demographic questionnaire and wore an activPAL accelerometer and FreeStyle Libre continuous glucose monitor for 3-14 days whilst documenting sleep, food and medication. Average proportion of time spent sitting/lying, and daily mean glucose during the waking day were calculated. A multiple linear regression was calculated to explore the relationship between time spent sitting/lying, age, BMI, and daily mean glucose. Results: On average, participants spent 67.5% of their day sitting/lying and mean daily glucose was 7.7 (±1.8) mmol/l. Regression analysis suggested a significant effect (F(3,105) = 16.52, p <0.01) for sitting/lying time, age and BMI on daily mean glucose (R2 = 0.30). Participants’ predicted daily mean glucose is equal to -12.23 + 5.14(sitting/lying) + 0.16(age) + 0.21(BMI), with daily mean glucose increasing by 5.14mmol/l for each percent of daily sitting/lying, 0.16mmol/l for each increasing year of age and 0.21mmol/l for each increasing BMI unit. Conclusions: Average sitting/lying time was higher than has previously been reported and percentage sitting/lying time, age and BMI were identified as significant predictors of higher daily mean glucose in people with T2D. Results suggest that increased sedentariness is associated with increased daily mean glucose in those with T2D

The relationship between sedentary bout duration and glucose in adults with type 2 diabetes

Physical activity is important for blood glucose management in people with Type 2 diabetes (T2D). Little research has explored the relationship between sedentary behaviour and mean glucose and glucose variability in people with T2D using objective and continuous measurements. Aims: To explore the relationship between sedentary bout duration and mean glucose and glucose variability in people with T2D using objective continuous measurement. Methods: 16 participants with T2D managed with diet, Metformin or DPP4 inhibitors were recruited (mean age 64.1±10.9 yr & BMI 29.4±6.9 kg/m2). Participants completed a demographic questionnaire and wore an activPAL accelerometer and FreeStyle Libre continuous glucose monitor for 3-14 days whilst documenting sleep, food and medication. Average proportion of time spent sitting/lying, during the waking day were calculated. Bouts of wake time sedentary behaviour were identified and defined as a period of at least 30 minutes continuous, uninterrupted sitting/lying during the waking day. Correlation analysis was conducted to investigate the relationships between sedentary bout duration and mean glucose, glucose range and glucose coefficient of variation. Results: On average, participants spent 65% of their day sitting/lying, 76% of sedentary bouts were ≥30minutes and 29% of bouts were ≥60minutes. Mean glucose was negatively (r = -0.08, p <0.01) associated with sedentary bout duration. Glucose range (r =0.47, p <0.001) and glucose coefficient of variation (r = 0.26, p <0.001) both positively correlated with sedentary bout duration. Participant characteristics such as age, gender and BMI appear to influence the relationship between sedentary bout duration and glucose response. Conclusions: Results indicate increased sedentary time leads to improved mean glucose and increased glucose variability

Evaluation of technology-enhanced learning programs for health care professionals: systematic review

Background: Technology-enhanced learning (TEL) programs are increasingly seen as the way in which education for health care professionals can be transformed, giving access to effective ongoing learning and training even where time or geographical barriers exist. Given the increasing emphasis on this mode of educational support for health care practitioners, it is vital that we can effectively evaluate and measure impact to ensure that TEL programs are effective and fit for purpose. This paper examines the current evidence base for the first time, in relation to the evaluation of TEL programs for health care professionals. Objective: We conducted a systematic review of the current literature relating to the evaluation of TEL programs for health care professionals and critically appraised the quality of the studies. Methods: This review employed specific search criteria to identify research studies that included evaluation of TEL for health care professionals. The databases searched included Medline Ovid, Cumulative Index of Nursing and Allied Health Literature Plus Advanced, Applied Social Sciences Index and Abstracts, ZETOC, Institute of Electrical and Electronics Engineers Explore Digital Library, Allied and Complementary Medicine, and Education Resources Information Center between January 2006 and January 2017. An additional hand search for relevant articles from reference lists was undertaken. Each of the studies identified was critically appraised for quality using the Crowe Critical Appraisal Tool. This approach produced a percentage total score for each study across specified categories. A proportion of the studies were independently assessed by an additional two reviewers. Results: The review identified 21 studies that met the inclusion criteria. The studies included scored totals across eight categories within a range of 37%-95% and an average score of 68%. Studies that measured TEL using learner satisfaction surveys, or combined pretest and posttest knowledge score testing with learner satisfaction surveys, were found to be the most common types of TEL evaluations evident in the literature. The studies reviewed had low scores across reporting on ethical matters, design, and data collection categories. Conclusions: There continues to be a need to develop effective and standard TEL evaluation tools, and good quality studies that describe effective evaluation of TEL education for health care professionals. Studies often fail to provide sufficient detail to support transferability or direct future TEL health care education programs

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

Background: People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden. Aim: To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions. Design & setting: Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8). Method: Factors precipitating admissions were examined using framework analysis. Results: Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services — in time and proximity — and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions. Conclusion: Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care

Oat-enriched diet reduces inflammatory status assessed by circulating cell-derived microparticle concentrations in type 2 diabetes

This work was funded by the Chief Scientists Office of the Scottish Government by a joint grant to the University of the Highland and Islands, Grampian Health Board, Biomathematics and Statistics Scotland and the Rowett Institute of Nutrition and Health, University of Aberdeen. Additional support was provided by Provexis plc.Peer reviewedPublisher PD