The Science of Diabetes Self-Management and Care

This article gives a practical review of the pharmacology, clinical efficacy, safety, dosing, cost, and place in therapy for oral antihyperglycemic agents used in the treatment of type 2 diabetes mellitus. There are 5 classes of oral antihyperglycemic agents available in the United States: sulfonylurea secretagogues, biguanides, α-glucosidase inhibitors, thiazolidinediones, and nonsulfonylurea secretagogues. These agents have distinct characteristics that help in their selection for the treatment of type 2 diabetes.

Purpose

The purposes of this article are to examine the epidemiology of gestational diabetes mellitus (GDM) and subsequent type 2 diabetes, identify risk factors for the development of GDM and subsequent type 2 diabetes, discuss protocols for postpartum screening, and recommend evidence-based interventions to delay or prevent type 2 diabetes after GDM.

Methods

A review of the research literature from 1995 to 2005 concerning gestational diabetes was done using MEDLINE, CINAHL, National Institutes of Health, and American Diabetes Association internet resources. The criteria set for selection included the following: the research explored risk factors for and epidemiology of gestational diabetes, the relationship of gestational diabetes and the subsequent development of type 2 diabetes, and/or the prevention of type 2 diabetes after GDM.

Results

Women with pregnancies complicated by GDM are at increased risk for subsequent development of type 2 diabetes. Research suggests that modification of lifestyle-based risk factors including obesity, poor nutrition, and lack of exercise can delay or prevent the onset of type 2 diabetes in these women. However, there is evidence that recommended postpartum screening protocols for women with GDM are not being followed; hence, those women at high risk for type 2 diabetes are not identified, and no intervention is undertaken to reduce their risks.

Conclusions

Diabetes educators must play an integral role in increasing awareness of the need for postpartum screening and intervention for women with gestational diabetes. Only with early identification and intensive intervention can the devastating toll of diabetes be averted for many of these women.

Purpose

Diabetes self-management education (DSME) is the cornerstone in effective management of diabetes. The continuous quality improvement process was used to identify the problem, collect and analyze data, and develop and implement a DSME program for Medicaid recipients, and subsequently, the program was evaluated to assess its effectiveness.

Methods

A DSME program consisting of a 1-hour initial assessment of individual needs followed by 12 hours of group education on nutrition and self-management was provided to 212 Arkansas Medicaid recipients over 1 year. Key clinical measures were assessed at the end of the period.

Results

Over 1 year, mean HbA1c declined by 0.45% among the DSME participants who completed the full program. Multivariate analyses found that after controlling for age, gender, race, preperiod diabetes drug use, and preperiod costs, DSME participants were found to have fewer hospital admissions, emergency department visits, and outpatient visits. Changes from baseline clinical values for DSME participants were used to project changes in diabetes-related costs using the Gilmer model. An estimated savings in diabetes-related cost over 3 years was $415 per program completer. Over 10 years, completers were estimated to experience 12% fewer coronary heart disease events and 15% fewer microvascular disease events using the United Kingdom Prospective Diabetes Study risk models.

Conclusions

A DSME program for Medicaid recipients can reduce health care use among Medicaid recipients with diabetes within 1 year and over longer periods of time is likely to reduce costs associated with reduced use of health care. Plans are in place to explore the possibility of sustaining the program.

Purpose

The purpose of this study was to use a community-based participatory research (CBPR) approach to identify resources and barriers to implementing a church-based diabetes prevention program (DPP) in a rural African American church community in Georgia.

Methods

In collaboration with community leaders, researchers conducted 4 focus groups with 22 key informants to discuss their understanding of diabetes and identify key resources and barriers to implementing a DPP in the church. Three researchers analyzed and coded transcripts following a content-driven immersion-crystallization approach.

Results

The participants’ comments on diabetes and prevention covered 5 research domains: illness perceptions, illness concerns, illness prevention, religion and coping, and program recommendations. Program success was deemed contingent on cultural sensitivities, a focus on high-risk persons, use of church resources, and addressing barriers. Barriers identified included individuals’lack of knowledge of risk and prevention programs, lack of interest, and attendance concerns. Solutions and resources for overcoming barriers were testimonials from persons with illness, using local media to advertise the program, involving the food committee of the church, ministering to the healthy and at risk, and acquiring a support buddy.

Conclusions

A CBPR approach engaged church members as partners in developing a church-based DPP. Focus groups generated enthusiasm among church members and provided valuable insights regarding barriers and resources for program implementation. This methodology may prove useful in other church-based chronic disease prevention efforts with at-risk populations.

Purpose

Insulin therapy has been shown to benefit the prognosis in patients with type 2 diabetes, but its initiation and intensification is often delayed through concerns about hypoglycemia and weight gain. In addition, weight gain is linked to the pathophysiology of type 2 diabetes and contributes to the overall risk for adverse cardiovascular outcomes. This article attempts to summarize this issue and examine the options available for weight management.

Methods

A broad range of literature has been reviewed to distil important, consistent facts about insulin and weight gain and the options available for limiting the problem.

Results

Unfortunately, the great benefits of insulin therapy may be potentially undermined by weight gain. Weight gain is physiologically and psychologically undesirable, especially in patients with diabetes who are already overweight. The fear of weight gain with some medications contributes to psychological insulin resistance, which may discourage patients from commencing or following insulin regimens. However, new diabetes treatments and lifestyle interventions can be used to mitigate these problems.

Conclusions

The exact choice of insulin and oral medications and weight loss interventions are important considerations in the overall management of patients with type 2 diabetes. Changes in a patient’s lifestyle, such as modifications to diet and implementing an exercise program, are first-line treatments for type 2 diabetes and can also counteract insulin-induced weight gain.

Purpose

The purpose of this study was to describe the role of diabetes in acute myocardial infarction (MI) symptom interpretation.

Methods

This is a secondary data analysis of a study of treatment-seeking delay in women with acute MI (N = 52). This study included a subsample of those with diabetes (n = 16). Women were interviewed while hospitalized with MI about their actions, thoughts, and feelings from symptom onset to entry into the health care system. Qualitative description was the method of analysis.

Results

Three major themes were identified in the qualitative data: diabetes and decision making, presenting symptoms, and symptom attribution. Not all women included information about diabetes in their story, but those who checked blood sugars generally found it to be elevated. Diabetes was a factor in decision making for more than half of the sample. Presenting symptoms were variable but raised hypotheses about shortness of breath as a common presenting symptom for women with diabetes and MI. The third theme, symptom attribution, revealed confusion as to the cause of symptoms.

Conclusions

These results provide insight into symptom interpretation in women with diabetes and MI. Women with diabetes should consider atypical symptoms such as shortness of breath, gastrointestinal symptoms, and fluctuating blood sugars as reasons to seek care. Education for women with diabetes should include action plans for how to recognize and respond to symptoms. More research on the influence of diabetes on MI symptom attribution and decision making is needed.

Purpose

The purpose of this descriptive study was to describe attainment of glucose and coronary heart disease (CHD) risk factor goals and to identify factors that were associated with successful goal achievement.

Methods

A cross-sectional survey enrolled 110 subjects with type 2 diabetes undergoing screening for asymptomatic myocardial ischemia.

Results

Many participants had HbA1c levels ≥7% (45%), and 46% to 79% were not meeting goals for CHD risk reduction. Individual factors of age, gender, and anxiety; the illness-related factor of lipid-lowering therapy; and the family-related factor of living alone were independently associated with 1 of the 7 outcomes under study. Illness-related factors of a longer duration of diabetes were strongly associated with glucose and blood pressure control, insulin use with glucose control and waist circumference, and antihypertensive use with blood pressure, triglycerides, and body mass index. Family-related factors of higher income were significantly associated with poorer glucose control and higher body mass index, while higher levels of perceived support by family and friends were associated with a lower risk of not meeting lipid goals. However, individual factors, represented by several aspects of personal model beliefs (exercising regularly, testing glucose, and checking one’s feet) and physical activity, were consistently related to lipid and weight control.

Conclusions

A variety of factors were associated with control of blood glucose and CHD risk factors, suggesting that a one-size-fits-all approach to multiple risk factor reduction efforts may not result in goal attainment.

Purpose

The objectives of the present study were (1) to discern trends in the prescribing of oral pharmacotherapy for the management of type 2 diabetes mellitus (DM) in the United States during the years 1990 through 2001 and (2) to examine the mediating role of primary health insurance coverage on patients’ access to pharmaceutical innovation for the management of type 2 DM.

Methods

Data from the US National Ambulatory Medical Care Survey (NAMCS) for the years 1990 through 2001 were used for this analysis.

Results

National estimates of the number of office-based visits documenting a diagnosis of type 2 DM and the prescribing of an oral medication for glycemic control increased from 7 871 283 in 1990 to 13 730 886 in 2001 (a 74.4% increase). A significantly higher proportion of patients covered by private health insurance were prescribed a newer agent, either alone or as part of a combination regimen of oral agents, as compared to patients covered by either Medicare or Medicaid (ϰ2 ≤ .001).

Conclusions

Over the time frame of 1995 through 2001, access to pharmaceutical innovation for the management of type 2 DM was mediated by the patient’s primary source of health insurance coverage. Future research will need to discern the effect of observed differences in the prescribing of oral agents for the management of type 2 DM on both clinical and economic outcomes and, in light of ongoing discussion regarding health care reform in the United States, to foster clinically rational and equitable access to pharmaceutical innovation.

The management of inpatient hyperglycemia has received much recent attention because of an expanding literature supporting the benefits of quality improvement and the creation of guidelines in this area. The authors began a process in 2002 to create modern protocols for glycemic control with intravenous insulin in their intensive care units and with subcutaneous basal-prandial insulin in all of their non-intensive care units. In this report, they describe both the process employed and the current protocols they are using. They also describe the process, perpetually ongoing, for educating nurses and residents in a large academic medical center. The annual cycle of senior residents passing on the regular insulin sliding scale to first-year interns and students can be broken. The hospital ward can be a valuable setting in which to teach basal/prandial insulin protocols, which will readily translate into the outpatient clinic. Where better to teach the importance and real-time usefulness of HbA1c than on the inpatient ward of a teaching hospital? Protocols to prevent and treat hypoglycemia can also be taught and widely accepted, hospital insulin formularies can be streamlined, and modern information technology can be used to track and improve multiple metrics of care for inpatients with hyperglycemia. The inpatient encounter with diabetic care can be a golden window of opportunity for patient as well as physician and nurse education.

Purpose

Diabetes self-management education (DSME) is an integral component of diabetes care; however, skilled educators and recognized programs are not uniformly available in rural communities.

Methods

To increase access to quality DSME, the Montana Diabetes Control Program and the Montana chapter of the American Association of Diabetes Educators developed a mentoring program with 3 levels: basic, intermediate, and advanced. All participants were assisted by a volunteer certified diabetes educator (CDE) mentor. In addition, the program provided technical support for recognition through the American Diabetes Association and the Indian Health Service.

Results

From 2000 to 2005, 90 individuals participated; 76% were nurses and 21% dietitians. Twenty-seven of the 90 enrollees (30%) completed their structured option, and 13 achieved CDE certification. Most provided services in frontier counties (66%). Statewide, the number of CDEs in Montana increased 46% from 52 in 2000 to 76 in 2005. Twenty-five of the 30 facilities that received technical assistance achieved recognition. Statewide, the number of recognized education programs increased from 2 in 2000 to 22 in 2005. Twelve (55%) of these programs were located in frontier counties.

Conclusions

Mentoring and technical support is an effective method to increase personnel skills for DSME and to increase access to quality education programs in rural areas.