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[Four] Ways to Save Your Heart. Diabetes Forecast. 61(2): 43-49. February 2008.
People with diabetes have a higher-than-average risk of cardiovascular disease (CVD), including heart attack and stroke. This article presents a set of four important steps that people with diabetes can take to reduce these risks. These steps are: take aspirin, quit smoking, control blood pressure, and control lipids. In each area, the author outlines practical activities that readers can incorporate into their daily lives. The recommended blood levels for lipids and blood pressure measurements are provided, with suggestions for ways to improve lipid levels and how to know when blood pressure medications are needed. Readers are referred to www.smokefree.gov for help in quitting tobacco use. One sidebar discusses blood glucose control in people with type 1 diabetes and in people with type 2 diabetes, considering whether lowering blood glucose levels will directly translate into a reduction in CVD risk. Another sidebar encourages readers to avoid all fast food restaurants. The article concludes with a reminder of the benefits of walking, including lowering blood pressure, reducing stress, and helping one to maintain weight loss. 2 figures. 1 table.
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“It Feels Like Home When You Eat Rice and Beans”: Perspectives of Urban Latinos Living With Diabetes. Diabetes Spectrum. 21(2):120-127. Spring 2008.
This article reports on a qualitative study that explored psychosocial issues that affect diabetes self-management for Hispanic/Latino men and women of primarily Caribbean ancestry. The study included 37 adults with diabetes in Bronx, NY, who were recruited to seven focus groups. The focus groups were conducted in Spanish and English, audiotaped, transcribed, and subjected to qualitative analysis. The authors report on the themes that emerged from these groups: the effect of diabetes on sexual health problems, perceptions about the link between depression and diabetes, intergenerational issues and their impact on participants’ beliefs about diabetes, and perceptions of discrimination and discontinuity in health care. The article includes numerous direct quotes from the focus group participants. The authors conclude that perspectives among Hispanic/Latino populations about living with diabetes are diverse, and more research is needed. 2 tables. 38 references.
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2008 Resource Guide. Diabetes Forecast. 61(1): RG1-RG60. January 2008.
This special section of Diabetes Forecast offers the annual guide to diabetes products and services. The guide lists items in seven categories: new diabetes products, type 2 oral medications, insulin, insulin delivery, blood glucose monitoring and data management systems, products for treating low blood glucose, and urine testing. Specific products include human and analog insulin, syringes, injection aids, insulin pens and pen needles, insulin pumps, aids for people who are visually and physically impaired, blood glucose meters, ways to pair the blood glucose meter with software, blood-sampling supplies, meter supplies, glycohemoglobin tests, microalbuminuria testing kits, and over-the-counter products for meal replacement. Each category includes a section of text, bringing readers up to date on the changes in that area, and charts summarizing the products available. The guide includes a list of manufacturers and distributors, arranged alphabetically. 10 figures. 20 tables.
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30 Things You Should Know About Managing Diabetes. Diabetes Forecast. 61(4): 54-56. April 2008.
This article presents some common issues that are important for managing diabetes by grouping them into brief suggestions or reminders in six sections: insulin; blood glucose monitoring; hypoglycemia and hyperglycemia; medications; kidney complications, or diabetic nephropathy; and eye complications, or diabetic retinopathy. The author presents this information in a brief, easy-to-read format, to bring readers up to date and to prevent being overwhelmed with the mass of information that is available on diabetes. Specific topics covered include the use of insulin in type 2 diabetes, insulin storage, blood glucose meter accuracy, health insurance coverage for test strips, the importance of written records, how to treat hyperglycemia, how to treat hypoglycemia, symptoms, different types of medications available for type 2 diabetes, individual responses to medication, the role of a pharmacist, why kidneys get damaged by diabetes, recommended screening tests for kidney function, blood pressure control, annual screening for eye problems, and the role of cholesterol.
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Abnormal Glomerular Permeability Characteristics in Diabetic Nephropathy: Implications for the Therapeutic Use of Low-Molecular Weight Heparin. Diabetes Care. 31( Suppl 2): S202-S207. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the abnormal glomerular permeability characteristics of kidneys in patients with diabetic nephropathy. These alterations can be an early expression of diabetic kidney disease and are shown clinically by albuminuria, or albumin in the urine. The authors describe the characteristics of the glomerular capillary wall, macromolecular filtration, the decreased heparan sulfate content in the glomerular basement membrane (GBM), and the therapeutic effect of heparin and heparinoids. One of the pharmacologic actions of heparin is to decrease transforming growth factor-beta production. Heparanase inhibition and restoration of intrinsic capillary wall heparan sulfate content may well account for the period of delay before albumin excretion rate decreases after initiation of heparin, as well as the continued decrease in albuminuria for months after the drug is stopped. The article includes full-color illustrations and figures. 4 figures. 61 references.
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Activity and Insulin: The Basics. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 49-51.
This chapter about the interplay between physical activity and insulin is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize the benefits of physical activity, including feelings of health, well-being, and more energy; lower blood pressure and improved heart health; improved strength, endurance, and flexibility; weight loss or easier weight maintenance; and decreased insulin resistance. The authors walk readers through the steps of testing blood glucose levels before physical activities and how to proceed based on the result. One illustration depicts a suggested activity pyramid for good health. 1 figure.
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Adverse Events. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 213-240.
This chapter on adverse events is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. The chapter includes 20 tables and figures: percentage of recipients with an adverse event (AE) or serious adverse event (SAE) in year 1 after first infusion; total number of AEs and SAEs in year 1 after first infusion; IA, incidence of posttransplant AEs related to infusion procedure; IAK, incidence of posttransplant AEs related to infusion procedure; IA, incidence of posttransplant AEs related to immunosuppression therapy follow-up based on completed scheduled visits; incidence of posttransplant AEs related to immunosuppression therapy follow-up based on completed scheduled visits; percentage of recipients with a SAE in year 1 after first infusion by year of first infusion, all allograft recipients; SAE type by relatedness to islet infusion or immunosuppression; outcome of SAEs by relatedness to islet infusion or immunosuppression; most common SAEs MedDRA preferred term, islet-alone recipients; most common SAEs MedDRA preferred term, islet after kidney recipients; most common SAEs reported within 1 year of any infusion MedDRA preferred term, all allograft recipients; most common SAEs reported more than 1 year after any infusion MedDRA preferred term, all allograft recipients; summary of reported neoplasms; listing of reported hemorrhages and portal vein thromboses, all allograft recipients; number of days hospitalized at infusion (from admission to discharge) by infusion sequence, islet-alone recipients; number of days hospitalized at infusion (from admission to discharge) by infusion sequence, islet after kidney recipients; hospitalization experienced after last infusion by total number of infusions received, islet-alone recipients; and hospitalization experienced after last infusion by total number of infusions received, islet after kidney recipients. 3 figures. 26 tables.
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Albuminuria: A Great Risk Marker, But an Underestimated Target in Diabetes. Diabetes Care. 31(Suppl 2): S190-S193. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the role of albuminuria as a useful target measurement in diabetes. The authors note that increased levels of albumin in the urine mark risk in not only advanced stages of diabetic disease but also indicate risk in the very early stages of disease. Newer antihypertensive drug therapies not only lower blood pressure but also reduce albuminuria. The individual response to these treatments seems to be highly variable, which offers opportunities to optimize organ protection by individualizing therapies. A final section discusses future therapies for further albuminuria reduction. The authors conclude that albuminuria is a valuable tool that can be used, in addition to standard risk factors such as hypertension, to further decrease the risk for progressive organ function loss in patients with diabetes, particularly with respect to the kidneys and the cardiovascular system. They stress that albuminuria is underused as a risk marker in diabetes and encourage clinicians to monitor and treat albuminuria. 1 figure. 27 references.
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Alcohol Consumption And Diabetes. Practical Diabetology. 21(1): 27-30. March 2008.
This article reviews the risks and benefits of moderate alcohol intake and recommendations practitioners should make for their patients with diabetes. The author cautions that even moderate alcohol intake can interfere with diabetes self-care judgment and may increase lipid levels in some patients with hypertriglyceridemia. However, alcohol can lower insulin resistance, improve glycosylated hemoglobin (HbA1c) levels, lower triglycerides, raise high-density lipoprotein (HDL), reduce blood pressure, and decrease cardiovascular mortality. The author reviews these benefits of moderate alcohol intake, discusses the definition of moderate intake, considers studies that compare the use of wine to other types of alcohol, and offers simple recommendations for physicians working with a diabetes population. The author concludes that practitioners can recommend chronic moderate consumption of alcohol for adults with diabetes who have no contraindications such as risk for alcoholism or hypertriglyceridemia or liver disease. 1 figure. 1 table. 37 references.
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American Diabetes Association: Clinical Practice Recommendations 2008. Diabetes Care. 31(Suppl 1): S1-S110. January 2008.
This special supplement issue of Diabetes Care journal contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). This special issue presents selected position statements about certain topics not adequately covered in the standards. These topics are the diagnosis and classification of diabetes mellitus, nutrition recommendations and interventions for diabetes, diabetes care in schools and daycare settings, diabetes management in correctional institutions, hypoglycemia and employment or licensure, third-party reimbursement for diabetes care, self-management education, and supplies. A brief summary of the revisions made for the 2008 clinical practice recommendations begins the special supplement, followed by a more detailed executive summary of the changes. The publication includes a list of technical reviews, a list of committee reports and consensus statements, and a list of position statements.
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Appendix IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 103-123.
This appendix is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. This appendix offers a wealth of resource materials, including information about diabetes medications and insulin pumps, how to measure insulin, insulin storage guidelines, a recommended schedule of health care for adults, questions and information to prepare before going to see a health care provider, healthy snacks, restaurant favorites for people following a healthy diabetes diet, using the glycemic index, sample menus for weight loss, and a list of learning resources, including the website addresses of a number of organizations. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 1 figure. 11 tables.
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Appendix A: Islet Transplant Center Contributors. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 247-248.
This appendix listing islet transplant center contributors is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. The appendix lists the contributors in alphabetical order by affiliation, usually a hospital or university. In addition, primary investigators are noted by name. No street addresses or contact information is given.
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Bariatric Surgery in Patients With Morbid Obesity And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S297-S302. February 2008.
This article brings readers up to date on current options of bariatric surgery in patients with morbid obesity and type 2 diabetes. The authors briefly review the various approaches to weight loss, including lifestyle intervention, diet therapy, behavior modification, exercise programs, and drug therapy, noting that these usually result in only modest and transient weight loss, particularly in patients with severe obesity. Recent studies show that surgical treatment was significantly more effective than nonsurgical therapy in reducing weight, resolving the metabolic syndrome, and improving quality of life during a 24-month treatment program. The authors summarize the different types of bariatric surgical procedures that can be used and report the results found with each type. They discuss the reversibility of type 2 diabetes after bariatric surgery, observing that euglycemic and normal insulin levels can occur within days after surgery, long before there is any significant weight loss. Other topics discussed include perioperative risk and care of bariatric surgery; and the complications, failures, and weight gain that can be seen as long-term results after bariatric surgery. The authors conclude that the only effective and enduring therapy for morbid obesity is weight-loss surgery. Certain risks exist for weight-loss surgery that can be reduced by surgical experience and patient selection, education, and lifelong surveillance. 65 references.
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Beating the Lows: What You Need to Know About Hypoglycemia. Diabetes Forecast. 61(2): 29-30. February 2008.
This article helps readers newly diagnosed with diabetes to understand hypoglycemia, the condition of low blood glucose levels. The author reviews the causes, symptoms, treatment, and prevention of hypoglycemia, focusing on practical approaches to everyday activities and diabetes care. Blood glucose levels can drop too low when a person with diabetes exercises longer or harder than usual, eats too little, delays a meal, eats too few carbohydrates, mistakenly takes too much insulin, or drinks alcohol on an empty stomach. Combinations of insulin, sulfonylureas, or meglitinides with other diabetes pills and injectable drugs carry a risk of hypoglycemia. Symptoms of hypoglycemia can include nervousness, shakiness, hunger, lightheadedness, sweating, irritability, impatience, chills, sleepiness, nausea, and confusion or other unusual behavior. The author briefly describes hypoglycemia unawareness, which can happen in a person who experiences repeated episodes of hypoglycemia. This occurs more often in people who practice tight diabetes control. Readers are encouraged to test their blood glucose levels as soon as they feel the symptoms of a potential episode of hypoglycemia. To counter mild-to-moderate hypoglycemia, patients should eat or drink something containing 15 grams of carbohydrate, wait 15 minutes, and test their blood glucose again. This pattern can be repeated if needed. The article concludes with a list of suggestions that can help prevent hypoglycemia. 1 figure.
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Benefits of Family-Based Therapies in Managing Diabetes. Today’s Dietitian. 10(4): 16-18. April 2008.
This article reviews the importance of family-based therapies in the comprehensive care of a child or adolescent with diabetes. The author notes that families that exhibit cohesion and open expression, along with problem-solving and communication skills, seem better equipped to help youths with diabetes cope with and manage the disease than families lacking these traits. The author presents some information from Dr. Tim Wysocki, who wrote a book titled The Ten Keys to Helping Your Child Grow Up with Diabetes, as well as some recent studies that correlate improved glycemic control with reduced family conflict. The author explains the basic premise of Behavioral Family Systems Therapy (BFST), an intervention approach originally designed for use with families of delinquent teens or adolescents with hyperactivity or eating disorders. Other family-based interventions that may be helpful all include the use of various behavior change models, such as motivational interviewing, social cognitive theory, and stages of change.
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Beyond the Basic Food and Activity Plan. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 57-70.
This chapter about healthy eating and nutrition is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors discuss how to get the most nutrition out of a food plan, snack foods, insulin use and weight gain, the use of sweetening agents, eating out at restaurants, estimating portion sizes, diabetes and alcohol, the timing of meals, how to adjust insulin to eating more or eating less, the insulin-to-carbohydrates ratio, and how to make insulin adjustments for activity. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 5 figures. 3 tables.
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Blood Glucose Monitoring: A Practical Guide for Use in the Office and Clinic Setting. Diabetes Spectrum. 21(2):100-111. Spring 2008.
This article describes a method for evaluating and interpreting self-monitoring of blood glucose (SMBG) results in the office and clinic setting. The authors contend that such interpretation in the presence of patients may facilitate improved patient-provider discussion, clinical decisions, and the ability to manage glycemic patterns. They outline key steps that should be included in a systematic review of SMBG data: identifying the degree of blood glucose control using mean and standard deviation or variance, identifying patient safety concerns with regard to hypoglycemia, understanding the factors influencing blood glucose control by noting trends and patterns, suggesting strategies for achieving improved blood glucose control, and providing reinforcement to patients with diabetes that this information is valuable and useful in their care. Specific topics include patient records and logbook reviews, meter memories and computation, meter downloads and analysis, problems with basal glucose control, problems with prandial glucose control, frequency of testing, and continuous glucose monitoring (CGM). The article includes case studies that illustrate the process for using and interpreting electronic SMBG downloads. One chart summarizes selected diabetes management software programs. 5 figures. 4 tables. 17 references.
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Can Your A1C Level Be Too Low?. Diabetes Wellness News. 15(6): 1, 4. June 2008.
This patient education newsletter article considers the use of glycosylated hemoglobin (HbA1c) testing to monitor the effectiveness of any program of diabetes management. The author focuses on the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial, a study that included more than 10,000 middle-aged men and women in the United States who have type 2 diabetes and at least two risk factors for cardiovascular disease: obesity, high blood pressure, or high cholesterol. Half the ACCORD patients were treated with the goal of helping them reach an HbA1c level less than 6 percent, known as intensive treatment; the other half were treated with the goal of keeping their HbA1c levels at less than 8 percent, known as standard treatment. For reference, people without diabetes usually have HbA1c levels of 4 to 5 percent. The author reports that the ACCORD study was halted early, in February 2008, because more patients receiving intensive treatment had died of cardiovascular disease than those receiving standard treatment. The author discusses this study, reminding readers that the death rates in both groups of patients in the study were much lower than would be expected in this population. Further information about the details of the ACCORD study is anticipated. The author concludes by noting that most researchers and clinicians recommend staying with the American Diabetes Association (ADA) guidelines of 7 percent for a target HbA1c level. 1 figure.
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Canned Heat: A Simple Broth Becomes a Delicious Meal. Diabetes Forecast. 61(4):40-42. April 2008.
This article encourages readers to consider the use of broths and soups as part of a healthy approach to meal planning when following a diabetes-healthy diet. The author explains the different types of canned broths available and suggests some innovative ways to incorporate broths into traditional recipes, often as a replacement for oils and fats. One sidebar describes three different olive oils that are available in American supermarkets; another sidebar lists five suggestions for quick soups that can be made from standard pantry ingredients, including canned broths.
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Carbohydrate Foods And Blood Glucose Control. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 39-48.
This chapter about the interplay between carbohydrate foods and blood glucose control is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors describe the role of carbohydrates in nutrition and energy and explain carbohydrate counting as a component of overall diabetes management. Another section outlines a diabetes food plan, which is an individual plan based on what and when the patient likes to eat, lifestyle and activity level, health needs, weight goals, and insulin plan. The chapter concludes with information about accurately reading food labels, a necessary skill for carbohydrate counting. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 7 figures. 3 tables.
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Cardiovascular Complications in Diabetes: Targets and Interventions. Diabetes Care. 31(Suppl 2): S215-S221. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers targets and early interventions for the cardiovascular complications associated with diabetes. Topics include identifying the patient with diabetes in the general practitioner’s office, early recognition of the patient at risk for cardiovascular disease (CVD), the role of advanced glycation end products (AGEs) in diabetes complications, the postprandial state and atherosclerosis, patient screening for cardiovascular abnormalities and vascular changes, and the use of percutaneous coronary intervention or coronary artery bypass grafts (CABG) in people with diabetes and coronary heart disease (CHD). A final section considers the care of the critically ill patient, including those being treated on surgical or medical intensive care units. The authors note that some problems of the primary prevention approach include the choice of the method applied for screening, the criteria used to classify patients at risk, and the choice of therapy. They conclude that, although guidelines provide goals to be achieved and offer alternatives for treatment, the medical decision has to be individualized for each patient. 79 references.
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Case Study: Celiac Disease: An Important Comorbidity Associated With Type 1 Diabetes. Clinical Diabetes. 26(2): 85-87. Spring 2008.
This article presents the case of a 33-year-old caucasian woman with a history of type 1 diabetes, diagnosed when she was 19 years old and complicated by microalbuminuria. Since 2003, she has been treated with insulin pump therapy. She presented with a slow, steady weight loss of 20 pounds during the previous year, with no apparent cause. The authors review the diagnostic tests conducted, the patient’s laboratory results, and the eventual determination that she should undergo a small bowel biopsy, which resulted in a diagnosis of celiac disease. After undertaking a gluten-free diet, the patient experienced less abdominal bloating and a 3-pound weight gain over the next 3 months. Her glycosylated hemoglobin (A1C) decreased from 7.2 to 6.3 percent with the dietary modifications. The authors discuss the common clinical features of celiac disease; the relationships among celiac disease, type 1 diabetes, and Graves’ disease; and the screening recommendations for celiac disease and thyroid autoimmunity in patients with type 1 diabetes. 9 references.
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Case Study: Conception as a Potential Consequence of Diabetes Treatment. Clinical Diabetes. 26(2): 83-84. Spring 2008.
This article presents a case report of a 45-year-old caucasian woman with a medical history of type 2 diabetes, polycystic ovarian syndrome (PCOS), hypertension, and gastroesophageal reflux disease. She had a history of one normal, healthy pregnancy and delivery without complication. The authors describe her clinical care, notably the antihyperglycemic medications, including pioglitazone, which has a potential effect of increasing fertility in women with PCOS. The authors review the patient’s nonadherence to some of the antihyperglycemic agents, her concerns about hypoglycemia, patient education needs, her unexpected pregnancy, and the changes in medications that were required as a result of the pregnancy, notably, weaning off the analgesics that were prescribed for her neuropathic pain. The patient experienced a miscarriage at approximately 8 weeks’ gestation, after which she expressed interest in attempting another pregnancy. She was encouraged to improve her glycemic control and blood pressure before attempting another pregnancy. The authors describe the relationship between PCOS and insulin resistance, the mechanisms by which metformin and thiazolidinediones increase fertility in women with PCOS, and the importance of preconception care in all women with diabetes. Tight glycemic goals should be met before conception to reduce the risks of spontaneous abortions and fetal malformations. Medication alterations to improve safety during pregnancy should include discontinuation of oral hypoglycemic agents, statins, and angiotensin-converting enzyme (ACE) inhibitors. 9 references.
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Case Study: Inpatient Hyperglycemia: Typical Versus Ideal Outpatient Follow-Up Care. Clinical Diabetes. 26(2): 41-42. Winter 2008.
This article presents a case of a 54-year-old Hispanic woman who presented to the emergency room with acute cholecystitis. She is 5 feet, 2 inches tall and weighs 186 pounds; she has had annual medical care but was never told her blood glucose levels were high. Both her parents died from complications of type 2 diabetes. The author describes the health care that the patient received at the time of the emergency, 10 days later at her appointment for outpatient cholecystectomy, and a second emergency visit 6 days postoperatively. The patient was placed on varying diabetes care by the hospital team, an endocrinologist, and her primary care physician. Eventually, the case patient completed 10 hours of diabetes education and lost 45 pounds. One year later, her diabetes was controlled with oral drugs, and her glycosylated hemoglobin was 6.8 percent. The author comments on this case, discussing the initial presentation, the lack of adequate insulin during the first hospital stay, when to call in a diabetes education team, the need to control blood glucose levels before surgery, and how a follow-up visit from the diabetes education team could have improved this patient’s care. 5 references.
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Childhood Diabetes Explosion. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 179-200.
This chapter about the recent explosion in childhood diabetes is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter contend that the rising incidence of type 2 diabetes (T2DM) in children is closely associated with the obesity explosion, which in turn is linked to an increased food supply and decreased physical activity. They call for more research on the complex interaction between genes, the environment, and the immune system that culminates in type 1 diabetes, which is also on the rise. They focus on the emergence of the diabetes explosion, the proposed pathogenic mechanisms, and potential interventions. They conclude by recognizing that this public health problem requires an all-encompassing effort involving greatly increased government, research, community, and individual commitments to prevent these disorders. 4 figures. 2 tables. 111 references.
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Choosing an Insulin Regimen for Patients With Type 2 Diabetes. Clinical Diabetes. 26(2): 63-64. Winter 2008.
This article reports on a randomized, controlled study undertaken to compare three insulin regimens used for patients with type 2 diabetes: biphasic insulin aspart twice daily, prandial insulin aspart three times daily, or basal insulin detemir once daily—with the option of using twice daily if needed. Participants were 708 adult patients (64 percent male), with a mean age of 61.7 years, with type 2 diabetes, glycosylated hemoglobin (A1C) levels between 7 and 10 percent on oral hypoglycemic drugs, and a willingness and ability to inject insulin and perform self-monitoring of blood glucose (SMBG). Patients were recruited from 58 clinical centers in the United Kingdom and Ireland. After 52 weeks, the mean A1C was 7.3 percent for the biphasic insulin group; 7.2 percent for the group on prandial insulin; and 7.6 percent for basal insulin. Few patients achieved an A1C of less than 6.5 percent. Hypoglycemia was experienced more in the biphasic and prandial groups than in the basal insulin group; no severe hypoglycemia occurred. This article summarizes these research results, referring readers to the original publication of the study (Holman et al., New England Journal of Medicine, volume 357, 2007). The author provides a commentary about this study, supporting the work that helps clinicians determine appropriate insulin regimens for their patients with type 2 diabetes. The author cautions that the outcomes obtained in clinical care may differ from those achieved in the research setting, which included more structured patient assessment and follow-up. 2 references.
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Clinical Relevance of Non-HDL Cholesterol in Patients With Diabetes. Clinical Diabetes. 26(1): 3-7. Winter 2008.
This article considers the clinical relevance of non-high-density lipoprotein (non-HDL) cholesterol in patients with diabetes. The author reminds readers that patients with type 2 diabetes have high rates of cardiovascular disease (CVD), much of which may be preventable with treatment of their lipid abnormalities. Dyslipidemia in patients with diabetes usually presents as elevated triglycerides and low levels of HDL cholesterol, with a predominance of small, dense low-density lipoprotein (LDL) particles amid relatively normal LDL cholesterol levels. The author contends that non-HDL cholesterol may be a stronger predictor of CVD than LDL cholesterol or triglycerides because it correlates highly with atherogenic lipoproteins. The author reviews recent research findings on the treatment of non-HDL cholesterol in patients with diabetes. Intensive treatment with statin therapy has provided dramatic cardiovascular risk reduction through lowering of LDL, non-HDL, and other atherogenic lipoproteins in these patients, as well as in other high-risk groups. The target goal for LDL cholesterol in patients with diabetes is less than 100 mg/dl, and the goal for non-HDL cholesterol in these patients is less than 130 mg/dl. 2 tables. 34 references.
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Clinician’s Guide to Diabetes Gadgets And Gizmos. Clinical Diabetes. 26(2): 66-71. Spring 2008.
This article brings physicians and other health care providers up to date on new technology available for people with diabetes. The author briefly describes medication delivery systems, including pen devices and needles, disposable pens, refillable pens, and needles; insulin syringes and accessories, including needles, and accessories and enhancements; insulin pumps; and other helpful devices, including blood glucose meters, glucose sensors, lancing devices, safety devices, pill carrying cases, wearable medical identification tags, carbohydrate-counting and meal-planning aids, and extendable mirrors for foot inspection. The article is illustrated with full-color photographs of most of the items discussed. A patient information page accompanies this article and provides manufacturer websites for additional information about the equipment described. 23 figures.
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Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 249 p.
This fifth annual report (2008) presents data from the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. Funded by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) with supplemental funding from the Juvenile Diabetes Research Foundation (JDRF), CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe and Australia. The report includes data from most of islet transplant programs in North America active since 1999 and two European programs that joined CITR in 2006 and 2007. In addition, the data reflects the collaboration of the United Network for Organ Sharing and the Islet Cell Resource Centers, with whom CITR has ongoing data sharing agreements. The data is presented primarily in tables and charts, in eight chapters: islet transplant activity; recipient and donor characteristics; pancreas procurement, islet processing and infusion characteristics; immunosuppression and other medications; graft function; liver, kidney, lipid, and plasma renin activity (PRA) effects; adverse events; and registry data quality review. One appendix lists the islet transplant center contributors. A list of members on CITR committees is provided. A CD-ROM with pdf files of the entire report and the case report forms, and with PowerPoint slides of the exhibits, is included.
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Combined Therapy with Insulin Plus Oral Agents: Is There Any Advantage? An Argument in Favor. Diabetes Care. 31(Suppl 2): S125-S130. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of combined therapy with insulin plus oral agents for patients with type 2 diabetes. The authors describe an argument in favor of combined therapy in a recent debate examining the advantages and limitations of this approach. They describe the pharmacologic rationale for combining agents, present some new physiologic evidence for combining an oral agent with insulin, and offer a few examples of clinical studies showing advantages of combined therapy over insulin used alone. The authors conclude that, when oral therapy is continued during insulin therapy, enhancing either the availability or effectiveness of endogenous insulin, glycemic stability may improve and may lead to better overall glycemic control with similar hypoglycemic risk, or equal glycemic control with less hypoglycemia. In the case of metformin, combination with insulin limits the risk of weight gain. The authors call for additional, longer term medical outcome studies that compare insulin alone with insulin plus oral therapy. 5 figures. 28 references.
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Coming of Age for the Incretins. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press.2008. pp 269-290.
This chapter about the incretin hormones, glucose-dependent insulinotropic polypeptide (GIP), and glucagon-like peptide-1 (GLP-1), is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider the role of these incretin hormones in postprandial insulin secretion, which is insulin secretion that happens after a meal. They note that, in type 2 diabetes, the incretin effect is severely reduced. Substitution therapy with GLP-1 can result in glucose-induced insulin secretion, up-regulation of insulin and other beta-cell genes, stimulation of beta-cell proliferation, neogenesis and inhibition of beta-cell destruction, inhibition of glucagon secretion, inhibition of gastric emptying, and inhibition of appetite and food intake. However, GLP-1 is rapidly destroyed by an enzyme called dipeptidyl peptidase IV (DPP-IV), so any drug therapy that uses GLP-1 will require orally active DPP-IV inhibitors. The authors describe the animal studies and clinical trials that have focused on these incretins. One GLP-1 receptor activator (Byetta) and one of the DPP-IV inhibitors are already on the market and other compounds are in late phases of development or awaiting approval. 110 references.
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Comorbid Depression and Diabetes: Natural History and Clinical Aspects. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 331-352.
This chapter about comorbid depression and diabetes is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author of this chapter stresses that depression is more common in patients with diabetes and that it is associated with negative outcomes in these patients. These negative outcomes include less adherence to treatment recommendations, higher blood glucose levels, higher rates of microvascular and macrovascular complications, lower rates of productivity at work, higher health care costs, and higher mortality rates. The chapter discusses why depression is more common among people with diabetes, how depression could increase one’s risk of developing type 2 diabetes, psychoneurohormonal mechanisms, and how treating depression may improve clinical outcomes. A final section offers suggestions for designing research studies to retrieve better information about the interplay between diabetes and depression. The author emphasizes the potential benefits of screening for depression in those patients at high risk for developing type 2 diabetes and briefly reviews the questionnaires and instruments available for screening. All patients with depression should receive treatment; antidepressants, and counseling, notably cognitive behavior therapy (CBT), are usually effective. 2 tables. 102 references.
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Comparison Between a “Terror” Reaction and a “Nonchalant” Reaction to the Diagnosis of Gestational Diabetes. Clinical Diabetes. 26(4): 177-178. Fall 2008.
This article presents the case of a 30-year-old woman who was diagnosed with gestational diabetes (GDM) in the 27th week of her second pregnancy and had a very frightened reaction to the diagnosis. The authors compare her with another case of a 38-year-old woman who was diagnosed with GDM in the 28th week of her third pregnancy. This woman had a very nonchalant attitude toward the diagnosis. The authors review the usual methods of screening for diabetes in pregnancy in the United States, outline the normal parameters for blood glucose in pregnancy, and make suggestions for counseling women with such widely varying reactions to this diagnosis. Readers are reminded that although there is no cause for unreasonable alarm, GDM requires treatment for the benefit of both woman and fetus. The author emphasizes the importance of referring a patient to a diabetes education program staffed by certified diabetes educators. 6 references.
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Continuous Glucose Monitoring. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 4p.
Glucose monitoring is a technique that helps people with diabetes manage their disease and avoid its associated complications. The most common way to check glucose levels involves pricking a fingertip to obtain a blood sample and using a glucose meter to measure the glucose level in the sample. Continuous glucose monitoring (CGM) systems use a tiny sensor inserted under the skin to check glucose levels in tissue fluid. A transmitter sends glucose measurements to a wireless monitor. This fact sheet describes CGM, including the equipment used, costs, and which patients are most appropriate for this type of glucose monitoring. The fact sheet concludes with a section that describes current research studies in the area of developing an artificial pancreas. Contact information for three organizations is provided: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, and the Juvenile Diabetes Research Foundation International at ww.jdrf.org or 1–800–533–2873. A final section describes the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 3 figures.
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Continuous Glucose Monitoring: The Future of Diabetes Management. Diabetes Spectrum. 21(2):112-119. Spring 2008.
This article brings readers up to date on continuous glucose monitoring (CGM), technology used to provide real-time information about interstitial fluid glucose levels as part of a diabetes management plan. CGM provides short-term feedback about the effectiveness of diabetes interventions such as insulin administration, and it provides warnings when glucose concentrations become dangerously high or low. The authors stress that CGM has made the attainment of near-normal blood glucose concentrations an achievable goal for most patients with diabetes. However, they note that several challenges remain to be addressed, including the high cost of the devices, limitations in approved clinical uses, and insurance coverage for the technology. The article reviews the strengths and weaknesses of current CGM technology and provides information about how these devices can best be used in clinical practice for the care of people with diabetes. The authors conclude that CGM can offer diabetes patients a major advance in improving glycosylated hemoglobin (A1C) values and reducing the occurrence of disruptive hypoglycemia. 3 figures. 2 tables. 20 references.
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Continuous Intravenous Insulin: Ready for Prime Time. Diabetes Spectrum. 21(4): 255-261. Fall 2008.
This article about continuous intravenous insulin (CII) is from a special issue about the inpatient care of hyperglycemia. The author reports evidence that careful management of hyperglycemia in the acute care setting can decrease lengths of stay, morbidity, and mortality. In unstable, critically ill patients, blood glucose excursions are most effectively controlled through the use of continuous intravenous insulin infusion protocols. Topics include the use of CII versus traditional sliding scale insulin, variability and rate of change in blood glucose levels, protocol-driven CII therapy, the importance of institutional support, protocol selection, preventing and managing hypoglycemia, point-of-care (POC) blood glucose testing, the use of CII in the intensive care unit (ICU) and on regular care settings, and staff education issues. The author describes how a multidisciplinary team approach can help overcome staff misconceptions and fears regarding tight glycemic management in hospitalized patients. 5 tables. 43 references.
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Controversies in Evaluation and Management of Lipid Disorders in Diabetes. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 291-316.
This chapter about controversies in evaluation and management of lipid disorders in diabetes is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author of this chapter emphasizes that dyslipidemia is a key factor contributing to the high risk of cardiovascular disease (CVD) in diabetes and that its management is of prime importance. However, there are some controversies in this area, including the extent to which diabetes increases CVD risk, which varies considerably among different patients. A second question addressed deals with the preferred dietary and other weight loss therapies and their benefits in dyslipidemic subjects. The third topic discussed deals with the question of guidelines for LDL-cholesterol lowering. A fourth section discusses the indications and approach to the use of second or third lipid-modifying agent in combination with statin therapy. A final section considers the controversial issue of whether apolipoprotein or lipoprotein subfraction measurements add to the value of the standard lipid profile. 120 references.
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Controversies in Obesity, Diabetes and Hypertension (CODHy) Meeting. What Is It All About?. Diabetes Care. 31( Suppl 2): S111-112. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy), introduces the conference, held in Berlin in October 2006. The conference was designed to provide clinicians with answers to unresolved questions of clinical relevance, to provide a deeper understanding of and ability to integrate new research findings into clinical practice, and to consolidate current knowledge by way of evidence-based research. The diabetes sessions focused on the recent introduction of new treatment modalities, notably insulin analogs and insulin pump therapy, for diabetes management. The relative advantages and risks of analogs and continuous subcutaneous insulin infusion therapy, new glucose monitoring technologies, and inhaled insulin were discussed at the conference. Other topics covered include new treatments for type 2 diabetes; the pathophysiology of type 2 diabetes; the complications of diabetes, including the interplay of oxidative stress, insulin resistance, hypertension and diabetes, as well as cardiovascular complications; the pathophysiology of hypertension and the role of specific drug combinations in the management of patients with both diabetes and hypertension; and obesity-related insulin resistance. The authors of this introductory article stress that, in this special supplement issue, the controversies are presented alongside the reviews of specific topics, leaving the reader to decide which pieces of data are convincing enough to be integrated into their daily practice.
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Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. 367 p.
This book addresses diabetes controversies, specifically in the etiology and management of the disease. The volume covers commonly accepted forms of therapies and complications, as well as new and emerging advances, therapies, and inadequacies in several standard treatments. The book offers 17 chapters, each written by experts in the field. Topics are patient selection for pancreas transplantation; the effectiveness of islet transplantation; appropriate treatment for metabolic syndrome; reducing the complications of diabetes through intensive treatment; when to introduce insulin into the treatment for type 2 diabetes; the prevention of diabetic retinopathy; the evaluation, management, and controversies in treatments for diabetic neuropathies; endpoints in clinical research studies on diabetic neuropathy; intensive insulin therapy for the critically ill patient; the recent explosion in childhood type 1 and type 2 diabetes; weight loss in type 2 diabetes patients; a unifying hypothesis of diabetic complications; the diabetic foot; developments in incretins; controversies in the evaluation and management of lipid disorders in diabetes; polypharmacy for the treatment of type 2 diabetes; and the natural history and clinical aspects of comorbid depression and diabetes. Each chapter includes an outline, a summary, and a list of references. A list of contributors and their affiliations is provided. A subject index concludes the volume.
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Conversation Maps in Canada: The First 2 Years. Diabetes Spectrum. 21(2):139-142. Spring 2008.
This article describes the use of Conversation Maps, a patient education tool that is used to generate discussion and encourage self-reflection and sharing of the experience of living with diabetes. The Conversation Maps are not a game, but they provide a visually pleasing platform that looks like a game that can engage participants and allow them to discover facts about diabetes for themselves. The Conversation Maps are usually used with small groups, led by a facilitator who may be a diabetes educator. The questions used to start a discussion ask participants to relate their understanding of or experiences with different aspects of diabetes management, thus acknowledging their past experiences and defining the base on which the ensuing discussion will build new knowledge. The author reports on the development and implementation of Conversation Maps in Canada in 2004 and their use since then. The author reports on feedback from 15 diabetes educators who are familiar with the Conversation Maps. Topics include training educators, integrating the Conversation Maps into clinical practice, some problems and limitations with using the Conversation Maps, and strategies to encourage use of the Conversation Maps. The author concludes with a brief section describing the launching of the Conversation Maps in the United States in June 2007. 2 references.
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CQI: A Step-by-Step Guide for Quality Improvement in Diabetes Education. 2nd ed. Chicago, IL: American Association of Diabetes Educators. 2008. 103 p.
This handbook provides information about continuous quality improvement (CQI) in diabetes self-management education (DSME). CQI is a process for improving the system of delivering care and services in a healthcare setting. The handbook begins with a review of CQI and the U.S. health care system, including the evolution of the quality improvement processes, the chronic care model, common elements of CQI, customer focus, and the use of objective focus. The remainder of the handbook outlines the differences between health status outcomes and CQI, the program and patient benefits of CQI, selecting the CQI team members, reporting, establishing a timeline, and the details of the seven steps of the CQI process. The seven [a1]steps are: identify the problem or opportunity, collect the data, analyze the data, identify alternative solutions, develop an implementation plan, implement the plan, evaluate the actions, and maintain the improvement. A final chapter offers four detailed case studies that illustrate missing A1C data, measuring behavior change, improving turnaround time, and evaluating behavior change across DSME sites. Appendices include a description of some of the more common analytical and presentation tools used in the CQI process, an expanded glossary, a resource list, and a subject index. This second edition of the handbook includes a CD–ROM with forms that can be used to document and verify the various steps in the CQI process. The forms are in an Adobe PDF and can be completed electronically and printed. 7 figures. 24 tables. 45 references.
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Data Quality Review. IN: Collaborative Islet Transplant Registry Fifth Annual Report. . Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 241-246.
This chapter on registry data quality review is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. The authors note that data quality and assurance is an integral component of the CITR. Real-time quality control and assurance programs and reports are implemented during data entry, and monthly reports are generated and reviewed by the participating islet transplant centers. The chapter includes three tables and figures: expected and submitted forms by infusion sequence; expected and submitted follow-up forms after last infusion, all allograft recipients; and extent of follow-up after last infusion, all allograft recipients. The form submission rate of 100 percent for infusion forms is due to the fact that this was one of the criteria for closing the annual report annual database: the participant had to have at least one infusion form submitted to be included in the analysis database. In addition, a complete review of all local islet transplant protocols and patients was conducted to verify that all patients were approached to join the CITR and that there was not selective registration of participants for CITR. 4 tables.
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Designing a Conventional Insulin Treatment Program. IN: Beaser, R.S. Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. pp 33-74.
This chapter is from a handbook that helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The author walks readers through the design of a conventional insulin treatment program. Topics include the indications for insulin therapy in type 1 diabetes and in type 2 diabetes; the goals of insulin treatment; glucose monitoring programs for patients using insulin; the initiation of insulin therapy for type 1 diabetes, including choosing and designing an appropriate program; the initiation of insulin therapy for type 2 diabetes; the implications of insulin quality; specific insulin regimens; intensified conventional therapy; modifying the insulin treatment program; rebound hyperglycemia; and adjustment guidelines. The chapter concludes with a lengthy table that helps physicians adjust insulin dosages and timing according to the problem being experienced and the insulin regimen the patient is presently following. The chapter is illustrated with line drawings and tables. Readers are referred to the more comprehensive Joslin's Diabetes Deskbook: A Guide for Primary Care Providers for more information. 5 figures. 3 tables.
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Diabetes and Depression. Diabetes Wellness News. 14(4): 1, 6. April 2008.
This patient education newsletter article reviews the relationship between diabetes and depression. The author reports that people with diabetes are 50 percent more likely to be diagnosed with major depressive disorder (MDD) than are people who do not have diabetes. Patients with diabetes are twice as likely to experience symptoms of depression that are not severe enough to qualify for a diagnosis of MDD. The author describes the negative impact that depression can have on diabetes management, primarily because people who are depressed tend not to manage their diabetes as actively as people with diabetes who have no symptoms of depression. Studies have found links between depression and high blood glucose levels and higher diabetes complications rates. These findings are somewhat expected given the association between depression and less active self-care. The author reminds readers that depression is a problem regardless of the presence of diabetes. Seeking treatment for depression is vital. Antidepressant medications and counseling both work to relieve symptoms of depression in people with diabetes. 2 figures.
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Diabetes And Exercise. Diabetes Educator. 34(1): 37-40. January 2008.
This article presents the position statement of the American Association of Diabetes Educators (AADE) on diabetes and exercise. The AADE is a multidisciplinary professional membership organization of health care professionals dedicated to integrating successful self-management as a key outcome in the care of people with diabetes and related conditions. The AADE asserts that diabetes educators play a unique and influential role in advising and motivating individuals with diabetes to integrate physical activity and exercise into a lifestyle that supports optimal diabetes management and health. The position statement covers the health benefits of exercise, the role of exercise in diabetes prevention, potential exercise risks, exercise recommendations and guidelines, and outcomes expectations. The statement concludes that, although exercise carries potential risks for individuals with diabetes, with careful planning, its numerous health benefits far outweigh these risks. By using established, sound exercise guidelines and tailoring exercise recommendations to thorough pre-exercise assessment, diabetes educators can suggest safe and effective physical activity interventions that will enhance the health and well-being of all individuals with diabetes. Physical activity remains an underused treatment modality in diabetes management. 25 references.
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Diabetes and High Blood Pressure: The Two Leading Causes of Kidney Disease. Bethesda, MD: National Kidney Disease Education Program. 2008. 6 p.
This brochure describes the common factors that can cause kidney disease and encourages readers to be tested for the presence of the disease. The authors remind readers that early kidney disease has no signs or symptoms, but the sooner it is diagnosed, the sooner steps can be taken to keep the kidneys healthy longer. The brochure notes that diabetes and hypertension together are responsible for about 70 percent of kidney failure cases. The brochure reviews two tests used to diagnose kidney disease: glomerular filtration rate (GFR), which measures kidney function, and a urine test to measure the amount of protein in the urine, another sign that the kidneys are not working well. Readers are encouraged to keep diabetes and hypertension under control, to undergo blood and urine tests to monitor for kidney disease, and to ask their health care provider about blood pressure medications that can help slow down kidney disease. Readers are referred to the National Kidney Disease Education Program (NKDEP at www.nkdep.nih.gov or 1–866–454–3639), the National Diabetes Education Program (NDEP at www.ndep.nih.gov or 1–800–438–5385), and the National High Blood Pressure Education Program (www.nhlbi.nih.gov/about/nhbpep or 301–592–8573) for more information.
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Diabetes And Nutrition: Carbohydrates. Chevy Chase, MD: Hormone Foundation. 2008. 1 p.
This brief fact sheet reviews the role of carbohydrates in diabetes. The fact sheet answers common questions about the interrelationship between diabetes and nutrition, the major nutrients in food, what foods contain carbohydrates, how much carbohydrate should be included in a healthy diet, how carbohydrates affect blood glucose levels in people with diabetes, and practical strategies for incorporating this information into one’s daily food habits. One figure lists examples of carbohydrates that would count as one choice; another identifies recommended levels of blood glucose before and after meals. Readers are referred to the Hormone Foundation’s website at www.hormone.org and other resources for more information. The fact sheet is also available in Spanish. 2 figures. 4 references.
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Diabetes And Obesity: Part 2. Diabetes Care. 31(1): 176-182. January 2008.
This is the fifth in a series of articles based on presentations given at the American Diabetes Association’s 67th Scientific Sessions in June 2007 in Chicago. This article focuses on presentations on the interrelationship between diabetes and obesity. Topics include obesity prevention and treatment, lifestyle modification for weight loss, prevalence of obesity, the prognosis for long-term survival for people with obesity, multidisciplinary interventions for obesity, minimizing the weight gain often associated with insulin therapy, weight gain in people with type 1 diabetes, analog insulins and weight gain, pramlintide, dyslipidemia, pharmacologic strategies for weight loss in individuals with type 2 diabetes, phentermine, the cannabinoid receptor blocker rimonabant, exenatide, weight loss diet recommendations, comorbidities associated with obesity and insulin resistance, the role of obstructive sleep apnea (OSA), polycystic ovary syndrome (PCOS), risk of cardiovascular disease (CVD), nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH), lipotoxic heart disease, pregnancy and weight gain in women with diabetes, increasing incidence of diabetes diagnoses, insulin sensitivity, and the metabolic syndrome. The author provides the names and locations of the presenting researchers for readers who want to follow up and obtain additional information about the research summarized in this article. 13 references.
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Diabetes and Surgery. Diabetes Wellness News. 14(7): 3, 5. July 2008.
This patient education newsletter article reviews the recent interest in using bariatric surgery to treat type 2 diabetes. The author reminds readers that bariatric surgery commonly involves creating a short circuit of the upper part of the small intestine and shrinking the stomach volume to 25 percent of its original capacity. Diabetes reversal seems to be independent of the weight loss that accompanies the surgery, possibly because of alterations in some hormones from the stomach and small intestine, including ghrelin and glucagon-like peptide-1 (GLP-1). The author explains why he does not support the use of this major surgery to treat a problem that can be as effectively managed with behavioral intervention strategies. Concerns about the surgery include postoperative mortality, the immorality of choosing a “quick fix,” and the lack of enough surgeons to treat all the people with type 2 diabetes that might need this surgery if it were to become the treatment of choice. The author calls for stern re-examination of this treatment and its use in patients with type 2 diabetes.
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Diabetes and Your Kidneys. Rockville, MD: American Kidney Fund. 2008. 24 p.
Diabetic kidney disease, also called diabetic nephropathy, can result when high blood glucose levels damage the filtering structures in the kidney. This large-print booklet helps readers recently diagnosed with diabetes understand the risk factors that diabetes creates for kidney disease. The authors outline diabetes and how the disease can hurt the kidneys, issues that patients ought to discuss with their health care provider, suggestions for ways to stay healthy, and where to find additional sources of information and assistance. Diabetes causes more than 40 percent of all kidney failure in the United States. Monitoring tests for diabetes and kidney disease include blood glucose tests; glycosylated hemoglobin (HbA1c), a measure of blood glucose over time; blood pressure; urine tests; and glomerular filtration rate (GFR), a measure of kidney function. Other topics include the patient health care team, dietary strategies for managing diabetes, the role of medications including angiotensin-converting enzyme (ACE) inhibitors, symptoms of early kidney disease, the importance of self-monitoring of blood glucose (SMBG), and the interaction between blood pressure and the kidneys. The contact information for seven resource organizations is provided. The booklet includes a glossary of related medical terms, highlighted in the text and defined at the end of the booklet. 16 figures. 2 tables.
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Diabetes Care in the School And Day Care Setting. Diabetes Care. 31 (Suppl 1): S79-S96. January 2008.
This position statement on diabetes care in schools and daycare settings is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement describes diabetes and the law, including Federal laws that protect children with diabetes in schools and daycare settings; general guidelines for the care of the child in school and daycare settings, including a diabetes medical management plan, responsibilities of the various care providers, and expectations of the student in diabetes care; monitoring blood glucose in the classroom; and diabetes information for school personnel. The guidelines stress that both parents and the health care team should work together to provide school systems and daycare providers with the information necessary to allow children with diabetes to participate fully and safely in the school experience. 1 figure. 1 table. 35 references.
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Diabetes Education and Public Health. Diabetes Educator. 34(1): 45-48. January 2008.
This article presents the position statement of the American Association of Diabetes Educators (AADE) on diabetes and public health. The AADE is a multidisciplinary professional membership organization of health care professionals dedicated to integrating successful self-management as a key outcome in the care of people with diabetes and related conditions. The position statement emphasizes that diabetes educators are long-standing advocates for people at risk for and with diabetes, striving to create environments in health care systems, homes, schools, and communities that support diabetes care and prevention. Well-positioned in their own communities, diabetes educators promote access to quality diabetes care and diabetes self-management education, ensure healthy nutrition and physical activity choices, and provide social support to help individuals and families initiate and sustain lifestyle adaptations. The statement offers recommendations in two categories: identifying community needs and making connections. The statement concludes that recognizing the many interconnections involved in health promotion and diabetes prevention can open doors to partnerships at all levels. Although policies and practices may need to be changed at various levels to support the delivery of quality care and environments that promote health, communities are in the best position to determine the interventions that are most needed in their individual situation. 19 references.
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Diabetes Education in the Hospital: Establishing Professional Competency. Diabetes Spectrum. 21(4): 268-271. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, considers the role of professional competency in the delivery of quality diabetes care in the hospital. The author maintains that ensuring the professional competency of an entire clinical staff is essential to the successful delivery of evidence-based, safe, effective, respectful, and appropriate care. An interdisciplinary approach to education is described as effective for facilitating the delivery of knowledge and supporting glycemic control efforts in the hospital. Educational programs should be designed to promote and develop critical thinking skills and clinical judgment using a variety of media and resources targeted to adult learners. Specific topics discussed include core competencies, valid tools that can assess knowledge and skills, new employee orientation, the use of relevant diabetes scenarios in assessment and training efforts, the role of a supportive administration, continuing education, the institutional culture, and how to locate and assess resources. The author concludes that these efforts have the potential to improve quality outcome measures and enhance patient satisfaction. 2 tables. 39 references.
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Diabetes Education: Integrating Theory, Cultural Considerations, and Individually Tailored Content. Clinical Diabetes. 26(4): 148-150. Fall 2008.
This article focuses on ways to improve diabetes self-management education (DSME) by emphasizing the need for more attention on cultural issues, theory, and individually tailored content. The authors stress the importance of integrating health behavior change theory and culturally sensitive material in the design and content of patient DSME programs. These programs must be made more accessible by increasing their availability in clinical and community-based settings. The design of DSME programs should begin with elicitation work to identify population-specific barriers and deficits with respect to the performance of each self-management behavior. The resulting information should subsequently be incorporated into the content and design of the program. The authors conclude that tailored messages, with personally relevant content, are more effective in promoting behavior change than generic content that is sometimes delivered in the form of targeted, group-level programs. Successful DSME programs are associated with improved knowledge, reduced weight, and better control of blood glucose levels. 20 references.
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Diabetes Management in Correctional Institutions. Diabetes Care. 31(Suppl 1): S87-S93. January 2008.
This position statement on diabetes management in correctional institutions is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement provides a general set of guidelines for diabetes care in correctional institutions; it is not designed to be a diabetes management manual. Topics include the intake medical assessment, screening for diabetes, a management plan for each individual, nutrition and food services, urgent and emergency issues, medications, routine screening for and management of diabetes complications, monitoring/tests of glycemia, self-management education, staff education, alcohol and drugs, transfer and discharge, sharing of medical information and records, children and adolescents with diabetes, and pregnancy. The guidelines stress that people with diabetes, including those who are incarcerated, should receive care that meets national standards. Patients must have access to medication and nutrition needed to manage their disease. The authors note that early identification and intervention for people with diabetes is likely to reduce short-term risks for acute complications requiring transfer out of the facility, thus improving security. 1 figure. 2 tables. 15 references.
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Diabetes Numbers At-A-Glance. Rev. ed. Bethesda, MD: National Diabetes Education Program. 2008. 2 p.
This brochure, printed as an information card, summarizes many of the monitoring tests and recommended levels for people who have diabetes. Included on the card are the criteria for diagnosis of pre-diabetes; criteria for diagnosis of diabetes; and treatment goals for the ABCs of diabetes, which are A1c or glycosylated hemoglobin, blood pressure, and cholesterol and lipid profiles. The guidelines are recommended for nonpregnant adults, and readers are reminded to individualize treatment goals as necessary. The reverse side of the card lists the recommended diabetes patient management schedule, summarizing recommended care for each regular diabetes visit, for quarterly visits, annual tests, and lifetime recommendations. Readers are referred to the National Diabetes Education Program (NDEP) contact sites at 1–800-438-5383 or www.ndep.nih.gov for more information.
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Diabetes Overview. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.
This fact sheet provides an overview of information about diabetes, defined as a disorder of metabolism. The fact sheet describes the three main types of diabetes: type 1 diabetes, an autoimmune disease in which the pancreas produces little or no insulin; type 2 diabetes, in which the body does not produce enough insulin or uses insulin inefficiently; and gestational diabetes, which is associated with pregnancy and a subsequent increased risk for type 2 diabetes. The fact sheet discusses diagnostic considerations, the condition of pre-diabetes, the complications that may be associated with diabetes, epidemiology of type 1 and type 2 diabetes, and patient care for people with diabetes. The fact sheet describes current research efforts in the diabetes arena, including the Diabetes Prevention Trial–Type 1 (DPT-1), the Environmental Determinants of Diabetes in the Young Consortium (TEDDY), Type 1 Diabetes TrialNet, the Immune Tolerance Network, the Trial to Reduce IDDM in the Genetically at Risk (TRIGR), islet transplantation studies, the Diabetes Prevention Program (DPP), studies on type 2 diabetes in children and teens, and studies focusing on preventing and treating cardiovascular disease in people with type 2 diabetes. Contact information for three resource organizations is listed: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, and the Juvenile Diabetes Research Foundation International at ww.jdrf.org or 1–800–533–2873. A final section provides contact information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 1 figure.
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Diabetes Self-Management in a Community Health Center: Improving Health Behaviors and Clinical Outcomes for Underserved Patients. Clinical Diabetes. 26(1): 22-27. Winter 2008.
This article reports on a program of diabetes self-management that was implemented in the Community Health Center, Inc. (CHC), a large, federally qualified health center in Connecticut. The comprehensive program was developed to provide self-management education to an underserved, largely Hispanic population of patients with diabetes. The authors discuss the development of a low-literacy, culturally appropriate self-management program; how to cope with high rates of depression in this patient population; staff training in the methodology of self-management; the assessment of the program’s achievements; and the results of this program. They report on the use of the program by 488 patients, of whom 277—63 percent—listed Hispanic as their ethnicity, and 140—32 percent—were monolingual Spanish speakers. The authors conclude that this large cohort of mainly Hispanic patients was able to participate in a comprehensive, self-management program, to set and attain specific goals, and to improve their glycemic control, blood pressure, and low-density lipoprotein (LDL) cholesterol. The study found that depression was even more common than expected in patients with diabetes. Training staff in proper self-management education techniques takes time and ongoing monitoring because there is a strong tendency for medical staff to revert to more didactic models of patient education. The article includes a copy of one of the patient education motivational handouts used, presented in both English and Spanish. 3 figures. 26 references.
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Diabetes Skin And Foot Care: In Step. 4th ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program reviews the importance of skin and foot care for people who have diabetes. The program describes practical suggestions for maintaining healthy skin and feet, how to check for problems, appropriate footwear, and how to work in tandem with a health care provider to minimize any complications. The program depicts the use of the monofilament test that is used to detect diabetic neuropathy or nerve disease, particularly in the extremities. Viewers are reminded of the importance of a self-management plan for keeping diabetes under control and preventing or minimizing these complications with good blood glucose control. The video depicts a variety of people who share their experiences with diabetes management and self-care. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Diabetes Technology During the Past 30 Years: A Lot of Changes and Mostly for the Better. Diabetes Spectrum. 21(2): 78-83. Spring 2008.
This article offers a critical review of the changes in technology in the field of diabetes care and management, including those in glucose measurement, insulin administration, and types of insulin. The author describes the technology and equipment but focuses more on issues of patient compliance and quality of life. The author stresses that diabetes is still all-encompassing, needing attention multiple times a day, whether it’s checking blood glucose levels, calculating each meal and snack, or remaining vigilant to symptoms of hypoglycemia. Technological advances have not eased this burden of managing diabetes. Other topics addressed include parent-child relations, the members of the patient care team, attempts to match insulin dosage to food intake, the need for mathematical skills on the part of patients or parents, self-monitoring of blood glucose (SMBG), point-of-care glycosylated hemoglobin (A1C) tests, analog insulins, insulin pumps, patient selection for new technologies, and the use of continuous glucose monitoring (CGM). 5 figures. 35 references.
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Diabetes Technology Update: Practical Information for Clinicians. Diabetes Spectrum. 21(2): 71-72. Spring 2008.
This article serves as an introduction to a special section on diabetes management technology. The author begins with a brief overview of the history of diabetes care, from the first use of insulin in the 1920s through the introduction of home-based data to make changes in diabetes therapy, to the electronic equipment used today. The author outlines some of the reasons for recent technological advances: better, faster, and smaller blood glucose meters and computers; the global use of the Internet; wide acceptance of insulin pump therapy; the introduction of glucose sensors; and competition among companies to be industry leaders in this area. The author concludes with a brief section lamenting that improvements in technology do not always bring concomitant improvements in patient outcomes and considering where resources and provider attention could be focused to help rectify this situation. 1 reference.
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Diabetes. Washington, DC: National Women’s Health Information Center. 2008. 6 p.
This fact sheet answers common questions about diabetes, including type 1 diabetes and type 2 diabetes. Topics covered include a definition of diabetes and its complications, the condition of pre-diabetes or metabolic syndrome, the different types of diabetes, who gets diabetes and what causes the disease, risk factors for diabetes, how to know whether testing for diabetes is needed, the signs and symptoms of diabetes, good self-care for people with diabetes, important self-care for pregnant women with gestational diabetes, and how to prevent type 2 diabetes. Most of the suggestions for improved health, regardless of diabetes diagnosis, focus on achieving and maintaining a healthy weight, eating a nutritious diet, and exercising. The fact sheet refers readers to five resource organizations for more information: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, the Juvenile Diabetes Research Foundation International at ww.jdrf.org or 1–800–533–2873, the Centers for Disease Control and Prevention at www.cdc.gov/diabetes or 1–800–232–4636, and the National Diabetes Information Clearinghouse (NDIC) at www.niddk.nih.gov or 1–800–860–8747. One side bar briefly reports the story of two women, one with type 2 diabetes and one with gestational diabetes, and how they took care of themselves and their diabetes. 2 figures. 1 table.
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Diabetes: A Personal History. Diabetes Spectrum. 21(1): 54-56. Winter 2008.
In this article, Dr. Richard Rubin shares his personal diabetes history, which includes having a sister who was diagnosed with diabetes in childhood and a 7-year-old son who was diagnosed. The article was adapted from an address given at the American Diabetes Association 67th Annual Meeting and Scientific Sessions in Chicago, June 2007. The author is the immediate past president, health care and education, of the American Diabetes Association. He shares his family’s experiences and how diabetes care has changed since his son’s diagnosis in 1979. Topics include self-monitoring of blood glucose (SMBG); the role of self-concept and self-esteem; insulin delivery systems; how the author began to focus on diabetes care in his counseling practice, writing and research; advocacy for kids with diabetes; the organization Children with Diabetes (CWD); and improving psychological care for people with diabetes. The author concludes with a few words encouraging his readers and listeners to think about their own experiences with diabetes and the importance of sharing those experiences with others.
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Diabetic Foot. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 251-268.
This chapter about diabetes-related foot problems is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author discusses a number of controversies, starting with the key question of the best screening methods for the foot “at risk” for ulceration. The simple clinical techniques of examination of the feet and lower limbs are probably the most accurate way to assess for further risk of foot lesions. Additional topics covered include the importance and application of offloading to treat a foot ulcer; the differences between infection and colonization; differentiating between osteomyelitis and Charcot neuroarthopathy; expensive adjunctive therapies used to heal the diabetes-related foot wound, including hyperbaric oxygen (HBO); and the role of footwear. The author contends that a foot ulcer will normally heal if the circulation is intact, infection is treated, and pressure is taken off the lesion. Offloading should be used more frequently because it will lead to satisfactory healing in most plantar neuropathic ulcers. 4 figures. 51 references.
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Diabetic Foot. Diabetes Care. 31(2): 372-376. February 2008.
This is the sixth in a series of articles based on presentations given at the American Diabetes Association’s 67th Scientific Sessions in June 2007 in Chicago. This article focuses on presentations on the diabetic foot. Topics include diabetes and wound healing, the medical care of diabetic foot wounds, preventing amputation, the role of osteomyelitis, debridement, growth factor treatment, the use of offloading while an infection or ulcer heals, the interrelationship between stress and wound healing, new approaches to wound healing, evaluating for ischemia, moist wound healing, the treatment of chronic foot ulcers, the role of sensory neuropathy and loss of protective sensation in the feet, the stimulation of angiogenesis to promote wound healing, the prevention of foot wounds, the incidence of foot wounds in people with diabetes, rates of recurrence, the risk factors for amputation, the importance of patient education, measuring surface temperature of the foot as a prevention measure, footwear, and the use of larval debridement for ulcers infected with antibiotic-resistant organisms. The author provides the names and locations of the presenting researchers for readers who want to follow up and obtain additional information about the research summarized in this article. 38 references.
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Diabetic Kidney Disease: Chronic Kidney Disease and Diabetes. Diabetes Spectrum. 21(1):8-10. Winter 2008.
This article serves as an introduction to a special section on chronic kidney disease (CKD) and diabetes, now called diabetic kidney disease (DKD) rather than diabetic nephropathy. The author emphasizes the push in the renal community to recognize the impact of diabetes on the renal parenchyma at much earlier stages of the disease. When microalbuminuria, macroalbuminuria, or intermediate levels of protein excretion are detectable, the glomerular filtration rate (GFR) has usually passed through the stage of hyperfiltration. The author hopes that teamwork among governing bodies within primary care specialties, pathologists, and quality care consortia will demand serum creatinine standardization and mandatory laboratory reporting of the GFR. The author outlines reasons why reliance on the Cockroft-Gault equation, which estimates creatinine clearance as a surrogate for GFR, is inadequate. Other topics covered include the characteristics of DKD that distinguish it from other forms of CKD, risks for kidney stone formation in patients with DKD, problems with glycemic control in the presence of kidney impairment, the complication of a dynamic bone disease (ABD), the negative impact of smoking on the combination of hypertension and diabetes, and the importance of blood pressure control in patients with type 2 diabetes. The author concludes with a brief introduction of the four subsequent articles in this Research-to-Practice section. 12 references.
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Diabetic Neuropathies: Endpoints in Clinical Research Studies. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 135-156.
This chapter about clinical trials for the treatment of diabetic neuropathy (DN) is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter note that clinical trials of agents for the treatment of DN have been troubled by a lack of agreement on appropriate endpoints, as well as a lack of translation from success in animal studies to success in human clinical trials. Much of the controversy surrounds indexes that are used to reliably measure changes in nerve function, which translate into changes in quality of life, activities of daily living, and health of the individual. In addition, there has been a failure to recognize that the relief of the patient’s symptoms does not necessarily equate to change in the underlying biological disorder. The authors focus on the various measures that have been used for the evaluation of symptoms and those that quantify nerve function, and then compare and contrast the reasons for failure of different measures of neurological deficits; the prevention of degeneration of specific small fiber, large fiber, and autonomic nerve deficits; and those treatments that have potential for reversal of these deficits. A final section considers the identification of candidates for participation in research studies. 88 references.
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Diabetic Neuropathies: Evaluation, Management and Controversies in Treatment Options. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 109-134.
This chapter about diabetic neuropathies (DN) is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author of this chapter focuses on the evaluation, management, and controversies in treatment options for DN, a heterogeneous group of disorders that include a wide range of abnormalities. Distal symmetric polyneuropathy, the most common form of DN, usually involves small and large nerve fibers. Small nerve fiber neuropathy often presents with pain without objective signs or electrophysiologic evidence of nerve damage. The greatest risk of small fiber neuropathy is foot ulceration and subsequent gangrene and amputation. Large nerve fiber neuropathies produce numbness, ataxia, and incoordination, which can impair activities of daily living and contribute to falls and fractures. Symptomatic therapy is available for DN, but preventive strategies and patient education are still the key factors in reducing complication rates and mortality. The author reports on some research studies on new agents that target the pathophysiological mechanisms of DN. New drugs have recently been approved in the United States for the treatment of neuropathic pain of diabetes, including duloxetine. The chapter concludes with a description of adjunctive management strategies such as foot protection and ulcer prevention; mechanical measures, including transcutaneous nerve stimulation; and surgery for the treatment of neuropathy, notably for nerve tunnel entrapment syndromes. 3 figures. 2 tables. 96 references.
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Diabetic Neuropathies: the Nerve Damage of Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 11 p.
Diabetic neuropathies are nerve disorders caused by many of the abnormalities common to diabetes, such as high blood glucose. Neuropathy can affect nerves throughout the body, causing numbness and sometimes pain in the hands, arms, feet, or legs, and problems with the digestive tract, heart, sex organs, and other body systems. This fact sheet defines diabetic neuropathy and discusses its causes, symptoms, the different types of diabetic neuropathy, peripheral neuropathy, autonomic neuropathy and its complications, hypoglycemia unawareness, the impact of neuropathy on the cardiovascular and digestive systems, proximal neuropathy, focal neuropathy, diagnostic tests used to confirm the presence of diabetic neuropathy, and treatment strategies, including pain relief. Treatment for diabetic neuropathies first involves bringing blood glucose levels within the normal range. Good blood glucose control may help prevent or delay the onset of further problems. The fact sheet stresses that foot care is an important part of treatment. People with neuropathy need to inspect their feet daily for any injuries. Untreated injuries increase the risk of infected foot sores and amputation. Treatment includes pain relief and other medications as needed, depending on the type of nerve damage. Smoking significantly increases the risk of foot problems and amputation. Readers are encouraged to work closely with their health care providers for helping in quitting smoking. The fact sheet concludes with a list of publications available from the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Contact information for 12 organizations is provided. The back cover of the fact sheet describes the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 2 figures. 1 table.
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Diabetic Retinopathy: Can It Be Prevented?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 95-108.
This chapter about the prevention of diabetic retinopathy is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The two main causes of vision loss associated with diabetes eye disease are diabetic macular edema and proliferative diabetic retinopathy. The author of this chapter covers the role of glycemic control, type 1 diabetes, type 2 diabetes, hypertension, serum lipids, the role of aspirin and antiplatelet treatments, and diabetes and pregnancy. The author stresses that intensive medical management of diabetes has been proven to be highly beneficial in reducing both the development and progression of diabetic retinopathy in both types of diabetes. In addition, aggressive treatment of dyslipidemia in this population may play an important role in the treatment of diabetic retinopathy. The author describes the Actions to Control Cardiovascular Risks in Diabetes (ACCORD) study, which is designed to evaluate the role of treatment of intensive control of glycemia and blood pressure and treatment of dyslipidemia. Pregnancy may increase the risk of progression of diabetic retinopathy secondary to improvement in glycemic control and to the pregnancy itself. Tight glycemic control, especially before conception, may decrease many adverse side effects. 2 figures. 36 references.
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Diagnosing and Managing Latent Autoimmune Diabetes in Adults. Practical Diabetology. 21(1): 32-37. March 2008.
This article reviews the diagnosis and management of latent autoimmune diabetes in adults (LADA), defined as a slowly progressive form of autoimmune diabetes mellitus characterized by mature age at diagnosis, the presence of pancreatic autoantibodies, and the lack of an insulin requirement at diagnosis. The author notes that patients with LADA present with better-preserved beta-cell function than those with classic type 1 diabetes mellitus, but they usually experience a rapid and progressive loss of beta-cell function and tend to become rapidly unresponsive to intervention with oral medications and parenteral agents such as incretin mimetics. The article discusses the importance of the correct diabetes diagnosis, differentiating autoimmune diabetes from diabetes caused by insulin resistance, the prevalence of LADA, the pathogenesis of LADA, screening and testing that can be done for LADA, and treatment strategies for these patients. The author concludes that, although treatment guidelines for LADA have not been published, intensive management with insulin therapy provides a theoretical advantage by preserving any remaining endogenous pancreatic beta-cell function and minimizing long-term complications. 2 tables. 23 references.
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Diagnosis And Classification of Diabetes Mellitus. Diabetes Care. 31(Suppl 1): S55-S60. January 2008.
This position statement on the diagnosis and classification of diabetes mellitus is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement includes a definition and description of diabetes mellitus, notably type 1 diabetes and type 2 diabetes; the classification of diabetes mellitus and other categories of glucose regulation, including impaired glucose tolerance and impaired fasting glucose; and the diagnostic criteria for diabetes mellitus, including gestational diabetes mellitus (GDM). Specific, practical recommendations are provided, particularly in the section about the diagnostic criteria for GDM. 3 tables. 4 references.
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Diagnosis of Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 13 p.
Diabetes is a disease in which blood glucose levels are above normal. People develop diabetes because the pancreas does not make enough insulin or because the cells in the muscles, liver, and fat do not use insulin properly. This fact sheet reviews the different types of diabetes and provides basic information for people who have just received a diagnosis of diabetes. Topics include type 1 diabetes; type 2 diabetes; gestational diabetes; latent autoimmune diabetes in adults (LADA); pre-diabetes or the metabolic syndrome; diagnostic tests used to confirm diabetes, including the fasting plasma glucose (FPG) test, the oral glucose tolerance test (OGTT), and the random plasma glucose test; risk factors for type 2 diabetes; who should consider being tested for diabetes and pre-diabetes; steps that can delay or prevent type 2 diabetes; and management strategies for diabetes, notably meal planning, physical activity, and medications. The fact sheet emphasizes that people with pre-diabetes can delay or prevent type 2 diabetes by losing a modest amount of weight through regular physical activity and a diet low in fat and calories. The fact sheet describes the use of the body mass index (BMI). One chart reprints the BMI tables. The booklet concludes with contact information for related resource organizations, including the American Association of Diabetes Educators, the American Diabetes Association, the Juvenile Diabetes Research Foundation International, and the National Diabetes Education Program. A final section outlines the goals and activities of the National Diabetes Information Clearinghouse (NDIC). 5 tables.
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Diastolic Pressure in Type 2 Diabetes: Can Target Systolic Pressure Be Reached Without “Diastolic Hypotension”?. Diabetes Care. 31(Suppl 2): S249-S254. February 2008.
This article reports on a study of lowering diastolic blood pressure in 257 patients with diabetes. The authors remind readers that, in people with diabetes, there is nearly a fourfold excess in systolic pressure over diastolic pressure with respect to the recommended systolic/diastolic target pressure of less than 130/80 millimeters of mercury (mmHg). In the study, the authors attempted to force systolic and diastolic blood pressure to less then 130/85 mmHg in the setting of a clinical practice. Target systolic pressure was attained in a third of the cohort; in 57 percent of the patients, the attained diastolic pressure was less than 70 mmHg. Patients with final diastolic pressure less than 70 mmHg were older, had a higher prevalence of coronary artery disease, and had higher initial systolic and pulse pressures. The authors note that other studies have had similar results, and they conclude that attempted lowering of blood pressure to the target systolic pressures is associated with inordinate lowering of diastolic pressure in a significant number of patients. It is yet to be determined whether the benefits of tight systolic control outweigh the risks of excessive diastolic reduction, especially in older people with diabetes or in diabetes patients who also have coronary artery disease. 2 figures. 2 tables. 33 references.
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Dipeptidyl Peptidase-IV Inhibitors: Pharmacological Profile And Clinical Use. Clinical Diabetes. 26(2): 53-57. Spring 2008.
This article reviews a new category of medications, the dipeptidyl peptidase-IV (DPP-IV) inhibitors, notably sitagliptin, the first DPP-IV to be approved. Sitagliptin is approved for the management of hyperglycemia in patients with type 2 diabetes; a second agent, vildagliptin, is in the approval process. The DPP-IV agents accentuate the activity of endogenously produced antihyperglycemic incretin hormones, such as GLP-1, and are generally well tolerated. The author reviews the pharmacology and clinical use of these agents. Topics include clinical trials of these drugs; side effects, contraindications, and precautions; pharmacokinetics and drug interactions; and dosage and indications. The author concludes that DPP-IV inhibitors are a safe and effective method for modestly reducing hyperglycemia in patients with type 2 diabetes, without causing weight gain, significant hypoglycemia, or other major side effects. They are given orally and can be taken in a single daily dose. 1 table. 35 references.
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Does Increased Oxidative Stress Cause Hypertension?. Diabetes Care. 31(Suppl 2): S185-S189. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers whether increased oxidative stress causes hypertension. The author notes that there is still a debate whether oxidative stress is a cause or a result of hypertension. Topics include food intake, obesity, blood pressure and oxidative stress; the possible mechanisms by which oxidative stress may cause hypertension; animal studies in this area; and the use of antioxidant supplements to lower blood pressure. The author concludes that, to date, clinical studies investigating antioxidant supplements have failed to show any consistent benefit. However, lowering blood pressure with antihypertensive medications is associated with reduced oxidative stress. The author contends that oxygen stress is not the cause, but rather a consequence, of hypertension. 1 table. 56 references.
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Early Patient and Clinician Experiences with Continuous Glucose Monitoring. Diabetes Spectrum. 21(2):128-133. Spring 2008.
This article reports on a study that evaluated data from a 12-week study of patients using the FreeStyle Navigator continuous glucose monitoring (CGM) system. The authors note that CGM can assist in overcoming some of the limitations of self-monitoring of blood glucose (SMBG) by providing the ability to track glucose levels 24 hours a day, observe glucose trends and patterns, and receive alarms or alerts for actual and impending hypoglycemia and hyperglycemia. In the study, the authors evaluated responses to questionnaires from both clinicians and patients. Topics include initial impression and ease of use, important features and benefits, data management software, patient compliance, overall experience, future purchase and usage of CGM devices, training materials and content, and individual versus group training. Clinicians noted the ability to train easily on the CGM system, and both patients and clinicians felt they were able to make more informed decisions on therapy adjustments based on information from the receiver and the data management reports. Patients liked the ability to make day-to-day decisions based on the 1-minute glucose readings, threshold and projected glucose alarms, and the glucose trend arrows that allowed them to observe the rate and direction of glucose change. The authors conclude that CGM can be a valuable adjunct to diabetes care but improvement in control depends on the willingness and ability of patients to use CGM information to modify their diabetes management. 3 figures. 1 table. 6 references.
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Efficacy And Safety of Rimonabant for Improvements of Multiple Cardiometabolic Risk Factors in Overweight-Obese Patients: Pooled 1-Year Data From the Rimonabant in Obesity (RIO) Program. Diabetes Care. 31(Suppl 2): S229-S240. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on a study undertaken to better define the effectiveness and safety of rimonabant, the first selective cannabinoid type 1 receptor antagonist. The study was conducted in a large population of overweight and obese patients using pooled efficacy data from three Phase III nondiabetes Rimonabant in Obesity and Related Metabolic Disorders (RIO) studies, selected efficacy data from the RIO-Diabetes study, and pooled safety data for all four RIO studies. The RIO studies included patients who were either overweight with at least one comorbidity—e.g., hypertension, dyslipidemia, or type 2 diabetes—or obese. All patients received daily treatment with rimonabant, 5 or 20 milligrams (mg), or placebo for 1 year, plus a hypocaloric diet featuring a 600-calorie-per-day deficit and advice on increased physical activity. The study included data from 3,165 subjects without diabetes and 692 subjects with diabetes. After 1 year of randomized treatment, changes from baseline in those nondiabetic subjects on 20 mg of rimonabant were as follows: body weight, reduction of 6.4 kilograms; waist circumference, reduction of 6.4 centimeters; high-density lipoprotein (HDL) cholesterol, increase of 16.4 percent; triglycerides, decrease of 6.9 percent; and reductions in fasting insulin and assessment for insulin resistance. In the population with diabetes, 20 mg of rimonabant reduced A1C levels by 0.6 percent. Analyses of the data suggested that 45 to 57 percent of the effect of rimonabant could not be explained by the observed weight loss. Serious adverse events were infrequent with rimonabant and almost equivalent to placebo. Overall, discontinuation rates were similar across treatment groups, except discontinuation from adverse events, which occurred more frequently with 20 mg of rimonabant versus placebo and included depressive disorders, nausea, and mood alterations. The authors conclude that in overweight or obese patients, 20 mg per day of rimonabant produced weight loss and significant improvements in multiple cardiometabolic risk factors. 2 figures. 6 tables. 38 references.
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Egg-Cellent News for Most, But Not Those With Diabetes. Harvard Health Letter. 33(9): 6. July 2008.
This health education newsletter article describes recent findings that eggs can be a part of a healthy diet, except for people who have diabetes. Eggs contain a lot of cholesterol, about 200 milligrams in a large egg, all of it in the yolk. The American Heart Association recommends that people limit their daily cholesterol intake to 300 milligrams. The article briefly reviews some of the recent research findings on how eggs affect one’s cholesterol levels and where they might fit as a high-protein option in a healthy, low-carbohydrate diet. The article explains why these findings may not be applicable to people with diabetes, based on epidemiological research. The author notes that, as yet, there is no evidence to explain how eggs may be metabolized differently in people with diabetes. One sidebar compares the nutritional values of whole eggs versus egg whites. 1 figure.
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Executive Summary: Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S5-S11. January 2008.
This executive summary is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The position statement contains all of the ADA’s key recommendations, including national standards for diabetes self-management education (DSME). The executive summary outlines the revisions to the clinical practice recommendations made for 2008, covering the diagnosis of diabetes, testing for pre-diabetes and diabetes, testing for type 2 diabetes in children, the detection and diagnosis of gestational diabetes mellitus, the prevention or delay of type 2 diabetes, self-monitoring of blood glucose (SMBG), glycemic goals, medical nutrition therapy, DSME, physical activity, psychosocial assessment and care, hypoglycemia, immunization, hypertension control, dyslipidemia management, antiplatelet agents, smoking cessation, coronary heart disease (CHD), nephropathy, retinopathy, neuropathy, foot care, children and adolescents, preconception care, older adults, diabetes care in the hospital, diabetes care in schools and daycare settings, diabetes care at diabetes camp, diabetes management in correctional institutions, emergency and disaster preparedness, and third-party reimbursement. The standards are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence.
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Florida Diabetes Master Clinician Program: Facilitating Increased Quality and Significant Cost Savings for Diabetic Patients. Clinical Diabetes. 26(1): 29-33. Winter 2008.
This article describes the Florida Diabetes Master Clinician Program (DMCP), a program created in 2003 to address the performance gap that exists in diabetes care. In this program, practice teams consisting of a clinician and medical assistant (MA) or nurse receive evidence-based training that includes information about current published clinical standards of care, how to enter data in the Internet-based electronic diabetes registry, how to produce and interpret quality assessment reports, and how to conduct group visits. These teams conduct group visits to practices, to which high-risk patients are invited; high-risk patients can include those who are not achieving their blood glucose, low-density lipoprotein (LDL) cholesterol, or blood pressure goals. The article describes and depicts some of the evaluation tools used during the patient education sessions. The Internet registry is described as a tool that can produce reports to facilitate population management of patients, thereby making one-on-one office visits more effective. Practices are able to track their performance in achieving goals over time. The author concludes that the fiscal and psychological burden of diabetes, as well as the risk for complications, can be significantly reduced if evidence-based goals are achieved for blood glucose, LDL cholesterol, and blood pressure. 7 tables. 13 references.
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Food and Insulin: The Basics. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 33-38.
This chapter about the interplay between food and insulin is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors discuss the importance of keeping a food diary, how to determine what foods to choose, and matching eating habits with insulin. The chapter includes a few sample meal plans as well as a blank form for readers to answer questions about a typical day. 2 figures. 2 tables.
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Food Guide Pyramid. Diabetes Wellness News. 14(1): 4-5. January 2008.
This brief patient education newsletter article introduces readers to the Food Guide Pyramid, introduced by the U.S. Department of Agriculture (USDA) and updated in 2005. The USDA Food Guide Pyramid is designed to motivate consumers to make healthier food choices. This article describes four concepts that are represented in the Food Guide Pyramid: the importance of eating a variety of nutrient-dense foods and beverages from each of the basic food groups every day; proportionality; moderation, notably in one’s consumption of saturated and trans fats; and the importance of engaging in physical activity on a daily basis. The pyramid features a single character walking up a set of stairs, to represent that each person is an individual and must consider his or her own unique needs when making healthy food choices. 1 figure.
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Food Safety and Diabetes. Diabetes Wellness News. 14(1): 1-2, 5. January 2008.
This patient education newsletter article reminds readers of the need to prevent foodborne illness with proper attention to safe food handling and preparation. The author cautions that individuals with diabetes may be more susceptible to foodborne illness for a variety of reasons, including an impaired immune system, gastrointestinal tract differences due to their diabetes, and diabetes-related kidney damage. The article outlines four basic steps that can be used to keep food safe, categorized into these activities: clean, separate, cook, and chill. In each category, practical, simple tips are listed to reduce the spread of bacteria in the kitchen. Readers are referred to a U.S. Department of Agriculture (USDA) food safety guide at www.fsis.usda.gov/PDF/Food_Safety_for_Diabetics.pdf for more information.
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For Women With Diabetes: Your Guide to Pregnancy. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 46 p.
This fact sheet offers information for women with type 1 or type 2 diabetes who are pregnant or planning to become pregnant. Readers are cautioned that all pregnancies in diabetes are considered high risk, which means special care and attention from the mother and health care providers will be necessary to ensure a health pregnancy and delivery. Topics include caring for diabetes before and during pregnancy, checking the baby’s health during pregnancy, labor and delivery, and issues after the baby arrives, including breastfeeding and meal planning. Readers are encouraged to work closely with their health care team. Space is provided for readers to record their daily blood glucose, daily food intake, and daily physical activity. Readers are referred to the website of the National Diabetes Information Clearinghouse (NDEP) for more information (www.diabetes.niddk.nih.gov or 800-860-8747). The document is illustrated with black-and-white line drawings. 16 figures. 6 tables.
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From Trays to Tube Feedings: Overcoming the Challenges of Hospital Nutrition and Glycemic Control. Diabetes Spectrum. 21(4): 233-240. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, reminds readers that nutrition is one of the most complex aspects of glycemic control for hospitalized patients. The authors focus on some of the problems involved in trying to achieve the dual goals of individualization of the nutrition care plan to improve nutritional intake and incorporation of glycemic control targets. They describe creative and practical solutions used by clinicians who have faced this challenge and suggest innovative changes that may be considered as part of hospital improvement initiatives to address glycemic control. Specific recommendations include the inclusion of a registered dietitian (RD) in an interdisciplinary team focused on glycemic control; implementation of less restrictive meal-planning systems; integration of blood glucose monitoring results with nutritional care; coordination of the timing of insulin administration, blood glucose monitoring, and meal service; and ensuring adequate nutritional intake coupled with insulin therapy. Another section discusses glycemic control in patients receiving tube feeding or on total parenteral nutrition (TPN). The authors conclude that an intentional plan for matching insulin with carbohydrate intake will contribute to improvement in blood glucose in the hospital. They call for additional studies of different meal delivery systems, their impact on hospital glycemia, patient nutritional status, and the steps needed to improve patient outcomes. 3 tables. 21 references.
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Get in the Game: How to Build Your Winning Diabetes Health Care Team Diabetes Forecast. 61(4): 51-53. April 2008.
This article encourages readers to take an active part in their own diabetes care, including identifying and creating a diabetes health care team. The author notes there is a broad array of people who may be involved in a patient care team for people with diabetes, including a primary care provider, a nurse educator, a registered dietitian (RD), an eye doctor, a dentist, a mental health professional, a pharmacist, a foot doctor, an exercise specialist or physiologist, and other specialists. Patients are advised to check their health insurance details before they start building a health care team, to determine which services are covered. The author concludes by reminding readers that the patient is the captain of his or her own health care team, and as such, must stay educated and aware of the larger picture of his or her own health.
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Getting Active and Exercising With Diabetes. Diabetes Wellness News. 14(5): 1-2, 8. May 2008.
This patient education newsletter article explores the health benefits of exercise as one component of a program of diabetes management. For people with diabetes, exercise can improve the body’s sensitivity to one’s own insulin and the physiology of glucose transport. Exercise reduces the amount of fat in the body, which can improve blood glucose control in people with diabetes. Lower blood glucose levels reduce the risk of complications associated with diabetes. The author emphasizes that the benefits associated with exercise can be permanent and may even result in a need for reduced medications. The remainder of the article focuses on the how to start and maintain a safe exercise program. Readers are encouraged to obtain medical clearance before starting any new exercise program, particularly if they have not been exercising regularly. Other topics include how to determine the correct amount of exercise for maximum benefit, a definition of moderate intensity exercise, different types of exercise, aerobic exercise versus strength exercise, equipment and supplies that might be used, and how to make sure that exercise is safe and effective.
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Glycemic Control and Hemoglobinopathy: When A1C May Not Be Reliable. Diabetes Spectrum. 21(1):46-49. Winter 2008.
This article, from a series that presents patient cases using an evidence-based practice framework, describes a situation in which glycosylated hemoglobin (A1C) measures may not be a reliable marker for glycemic control and hemoglobinopathy. The case patient was an 11-year-old African-American girl newly diagnosed with type 1 diabetes and Hashimoto’s thyroiditis, who was being followed up after her initial hospitalization for diabetic ketoacidosis 2 weeks previously. The author describes her medication compliance, symptoms, concerns about preprandial hypoglycemia, and vital signs. The review of the patient’s laboratory records show that A1C was not measured by the laboratory because of an abnormal hemoglobin peak. The author considers whether hemoglobinopathies affect the clinical reliability of A1C measurement and, if so, what alternate method of assessment should be used for monitoring these patients. The author reports the results of a literature review, discussing hemoglobinopathy in patients with diabetes, variation by laboratory method, assessment of glycemic control using fructosamine, and an evidence grading system for clinical practice recommendations. The author concludes with an overview of the case patient’s present situation and recommendations for improvement of care and ongoing measurement of the child’s blood glucose levels. 33 references.
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Glycemic Index and the Diabetic Diet: An Introduction. Diabetes Wellness News. 14(4): 5, 7. April 2008.
This patient education newsletter article introduces readers to the glycemic index (GI), a ranking of carbohydrate-containing foods according to how quickly they raise blood glucose levels inside the body. A food with a higher glycemic value raises blood glucose faster and is less beneficial to blood glucose control than a food that scores lower. The GI is about the quality of the carbohydrates, not the quantity. The author outlines the structure of the GI, the benefits of choosing low-GI foods in place of conventional or high-GI foods, tips on choosing low-GI foods, how foods are categorized, and the components of a healthy diet, regardless of whether it is designed for a person with diabetes. A good diet is characterized as abundant in fresh vegetables and fruits, whole grains, low-fat proteins, high-fiber foods. A good diet is low in refined and processed foods. The article includes information presented in sidebars and lists. One recipe is provided: chana dal masala with crispy tortilla. Readers are referred to www.glycemicindex.com, a website that accompanies a new book about glycemic load. 2 figures.
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Glycemic Variability: Should We and Can We Prevent it?. Diabetes Care. 31(Suppl 2): S150-S154. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the issue of blood glucose variability in patients with diabetes. The authors note that diabetes is characterized by glycemic disorders that include both sustained chronic hyperglycemia and acute glucose fluctuations. Ample evidence exists regarding the complications associated with chronic hyperglycemia, but there is less documentation about the role of glucose variability. The authors hypothesize that both upward, or postprandial, and downward, or interprandial, acute fluctuations of glucose around a mean value will activate the oxidative stress. They suggest that a comprehensive antidiabetes strategy should be aimed at reducing to a minimum the different components of dysglycemia, which can include A1C , fasting and postprandial glucose, as well as glucose variability. They conclude with a brief discussion of the newer treatment options including the glucagon-like peptide (GLP-1) agonists and the DPP-IV inhibitors that act through the incretin pathway. 2 figures. 36 references.
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Graft Function. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 103-192.
This chapter on graft function is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR‘s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. This lengthy chapter includes 55 tables and figures: graft function; insulin independence, insulin dependence, absence of fasting C-peptide, or reinfusion after first infusion; insulin independence, insulin dependence or absence of fasting C-peptide after last infusion; insulin independence, insulin dependence, or absence of fasting C-peptide after last infusion by total number of infusions received, islet-alone recipients; prevalence of insulin independence after last infusion, islet-alone recipients; prevalence of insulin independence after last infusion by total number of infusions received, islet-alone recipients; C-peptide greater than or equal to 0.5 ng/ml; severe hypoglycemia; hypoglycemia status before first infusion and after last infusion, all allograft recipients; graft loss after last infusion; persistence of islet graft function (IA, IAK); persistence of islet graft function by ever achieving insulin independence, islet-alone recipients not censored at reinfusion; achievement of insulin independence; persistence of insulin independence and persistence of graft function; composite outcome (hypoglycemia and HbA1c) after last infusion; average daily insulin (units) taken by recipients on insulin baseline and after last infusion; average daily insulin (units/kg) taken by recipients on insulin baseline and after last infusion; percentage of baseline insulin used by recipients on insulin follow-up after last infusion; COX modeling of primary outcomes after first infusion (up to reinfusion, complete islet failure, or last follow-up) according to preinfusion recipient, donor, procurement, and islet characteristics (factors), islet-alone recipients with data available on key predictors; achievement and loss of insulin independence after first infusion; complete islet failure after first infusion; reinfusion after first infusion; primary outcomes after last infusion according to preinfusion recipient, donor, procurement, and islet characteristics; achievement of insulin independence after last infusion; loss of insulin independence after last infusion; complete islet failure after last infusion; fasting plasma glucose (mg/dl) before infusion and after last infusion; HbA1c percentage, basal plasma C-peptide (ng/ml), and fasting plasma glucose (mg/dl) before infusion and after last infusion, islet-alone recipients; recipients with fasting blood glucose less than 126 mg/dl after last infusion by insulin status; insulin dependent recipients with basal C-peptide greater than or equal to 0.5 ng/ml after last infusion; recipients with HbA1c less than 6.5 percent after last infusion by insulin status; preinfusion recipient lab summary by infusion sequence, islet-alone recipients; metabolic summary by follow-up after last infusion, islet-alone recipients; metabolic summary after last infusion by insulin status, islet-alone recipients; secondary complications of diabetes before first infusion and after last infusion, all allograft recipients; and ocular complications before first infusion and after last infusion, all allograft recipients. 98 figures. 27 tables.
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Have You Had Your Pill Today?. Clinical Diabetes. 26(1): 20-21. Winter 2008.
This patient education article reminds readers of the importance of following their medication regimens and offers some practical ideas for remembering to take medicines. The fact sheet notes that most people with diabetes take nine different medications and usually must remember to take medications at various times during the day. Patients are reminded that many of the medications are designed to help prevent long-term complications, so they might not notice immediate symptom changes if they miss their drugs. The fact sheet notes some of the reasons why patients may not take their medications and offers some ideas to motivate patients and help them want to be more careful about their drug therapies. Patients are encouraged to work closely with their health care providers to find ways to follow the recommended medication regimens.
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Helping Challenging Clients Achieve Self-Management Goals. Today’s Dietitian. 10(1): 18, 20. January 2008.
This article considers the use of the label “noncompliant” for patients with diabetes. The author’s focus is to increase awareness among dietitians of the harm this label can cause, as well as to offer alternative ideas about how to help these challenging clients in a productive, proactive way that can improve diabetes outcomes. The author reviews the basics of diabetes self-management, notably the seven key self-care behaviors needed for success: healthy eating, being active, monitoring, taking medication, problem solving, healthy coping, and reducing risks. Readers are referred to the American Association of Diabetes Educators’ (AADE) website for more information (www.diabeteseducator.org/ProfessionalResources/AADE7/Background.html). The article discusses diabetes self-management in the hospital setting and common barriers to optimal diabetes self-management. Common barriers for people with diabetes can include lack of social support from family or significant others, financial constraints, comorbidities such as severe obesity, and depression. Clinicians are encouraged to avoid presumptions and judgments, to use their skills to help clients see where positive changes are possible, and to remind patients they will likely feel better overall with better glycemic control. 4 references.
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Helping Patients Make and Sustain Healthy Changes: A Brief Introduction to Motivational Interviewing in Clinical Diabetes Care. Clinical Diabetes. 26(4): 161-165. Fall 2008.
This article describes the use of motivational interviewing techniques in clinical diabetes care, with the goal of helping patients make and sustain healthy changes in their diabetes management plans. Diabetes is a disease that requires a great deal of patient self-management, in which patients care for their illness and promote their own health. The authors describe how collaborative and autonomy-supportive physician communication can result in higher patient satisfaction and adherence to treatment plans; patient-provider agreement on treatment goals and strategies is associated with better self-management. The authors define motivational interviewing (MI) as a directive, client-centered counseling style that helps the patient explore and resolve ambivalence. The role of the provider is to encourage patients to think about and articulate their own reasons for and against making changes, how their behavior supports or conflicts with their own goals and values, and specific short- and long-term steps toward change. The authors provide specific strategies for providers who would like to learn how to incorporate these techniques, noting that typical medical school training does not equip physicians to take on this role. One case interview is provided as an example. 3 tables. 19 references.
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Helping Your Patients Become Active. Diabetes Spectrum. 21(1): 59-62. Winter 2008.
This article reminds readers of the importance of exercise and physical activity in the prevention and management of diabetes. Exercise is prescribed to prevent diabetes, to improve diabetes control, and to promote weight loss. The author focuses on strategies that health care providers, counselors, and educators can use to help their patients become more active. The author reviews the basic physiology and glucose metabolism associated with exercise and summarizes the barriers to becoming physically active, solutions to those barriers, options for exercise with the presence of diabetes complications and/or orthopedic issues, and guidance for blood glucose management related to exercise. Recommendations to attain the maximum health benefit, improve diabetes control, and maximize caloric expenditure are to exercise daily at low to moderate intensity for 60 minutes or more. The activity can be accumulated throughout the day, with a minimum of 10 minutes or more for each exercise bout. Patients should engage in a combination of aerobic and resistance training. Health care professionals can help patients overcome barriers to exercise by providing them with an understanding of glucose management during exercise and helping them create an exercise routine that is unique to their health status, age, current exercise capacity, glycemic control, and personal goals. 2 tables. 20 references.
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How to Keep Your Feet: Avoiding Peripheral Vascular Disease. Diabetes Forecast. 61(2): 50-51. February 2008.
This article reminds readers of the importance of careful foot care in people with diabetes. The author describes peripheral vascular disease (PVD), the cardiovascular complication of diabetes that contributes to foot problems, and diabetic neuropathy, nerve damaged caused by high blood glucose levels. The first warning sign of danger to the feet is usually an ulcer, which can lead to one of the most feared complications of diabetes: amputation of a foot or leg. The author reviews some of the steps to a thorough physical examination that should be performed by the health care provider each time a patient with diabetes comes in for a check-up. The article describes the Ankle-Brachial Index (ABI), a simple test measuring the balance between the blood pressure in the arms and the feet, which can be an important indication of problems associated with vascular disease. One sidebar emphasizes the importance of quitting smoking immediately because the greatest risk of PVD and foot amputation is in people with diabetes who smoke cigarettes. 2 figures.
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Hyperinsulinemic Hypoglycemia Following Roux-en-Y Gastric Bypass Surgery. Practical Diabetology. 27(11): 10-18. March 2008.
This article describes the problem of hyperinsulinemic hypoglycemia following Roux-en-Y gastric bypass (RYGB) surgery for obesity. The RYGB procedure combines a restrictive and malabsorptive approach to reduce caloric intake. The authors briefly review issues of patient selection, the surgery itself, and peri- and postoperative complications. They present two case series of patients who developed hyperinsulinemic hypoglycemia 1 to 2 years after their RYGB procedure. They describe nesidioblastosis, defined as excessive function of pancreatic beta cells, and hypoglycemia, including the pathophysiology of these conditions, their interplay, presentation and differential diagnosis, diagnostic tests, and treatment approaches. The authors caution that symptoms resemble dumping syndrome, so clinicians must remain cognizant of the possibility of hyperinsulinemia in this patient population. Treatment consists of dietary and pharmacologic therapies that aim to blunt the insulin response to meals or inhibit insulin secretion altogether. After dietary strategies, drug therapies are used, notably alpha-glucosidase inhibitors such as acarbose or miglitol. If a patient cannot tolerate or is refractory to medical therapy, surgical intervention in the form of a partial pancreatectomy is the next step. 8 figures. 4 references.
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Hypoglycemia And Employment/Licensure. Diabetes Care. 31(Suppl 1): S94. January 2008.
This brief position statement on hypoglycemia and employment or licensure is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement reprints the 1984 ADA policy on employment, which states that “any person with diabetes, whether insulin dependent or non-insulin dependent, should be eligible for any employment for which he/she is otherwise qualified.” The position statement notes that discrimination in employment and licensure against people with diabetes still occurs. The effects of diabetes, notably hypoglycemia, are unique to each individual. The position statement considers the incidence and impact of hypoglycemia on daily activities, concluding that people with diabetes should be individually considered for employment based on the requirements of the specific job. Factors to be considered in this decision should include the individual’s medical condition, treatment regimen, and medical history. 1 reference.
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Hypoglycemia in Type 1 Diabetes: A Still Unresolved Problem in the Era of Insulin Analogs And Pump Therapy. Diabetes Care. 31(Suppl 2): S121-S124. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the problem of hypoglycemia in patients with type 1 diabetes. The authors remind readers of the benefits of tight blood glucose control, in terms of reducing long-term complications of diabetes, but note that strict control carries an increased risk of severe hypoglycemia. Recurrent episodes of hypoglycemia, especially at young ages, can lead to hypoglycemia unawareness, can exert adverse effects on neurocognitive function, and can cause significant emotional morbidity in the child and parents. The authors discuss hypoglycemia and insulin analog therapy, as well as hypoglycemia in patients using continuous subcutaneous insulin infusion—CSII or insulin pumps—therapy. They note that, unfortunately, the newer modalities have not resulted in the expected drop in rates of hypoglycemic episodes. The authors conclude with a brief discussion of the ideal solution, an “artificial pancreas,” noting that the technology required for such a device is still under development. 42 references.
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Hypoglycemia. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 12 p.
This fact sheet provides an overview of hypoglycemia, defined as below-normal blood glucose, or blood sugar, levels. Hypoglycemia can happen suddenly, but it is usually mild and can be treated quickly and easily by eating or drinking a small amount of glucose-rich food. However, if left untreated, hypoglycemia can get worse and can cause confusion, clumsiness, fainting, seizures, or coma. Hypoglycemia is nearly always a complication of diabetes treatment. The fact sheet covers how the body controls glucose, the symptoms of hypoglycemia, normal blood glucose ranges, the cause of hypoglycemia in people with diabetes, other causes of hypoglycemia, how to prevent hypoglycemia, diagnostic tests used to confirm hypoglycemia, treatment options, the use of glucagon kits for emergency severe hypoglycemia, the interplay of physical activity and blood glucose levels, hypoglycemia when driving, hypoglycemia unawareness, reactive hypoglycemia, fasting hypoglycemia, and hypoglycemia due to other conditions besides diabetes. For each of the different types of hypoglycemia, the fact sheet reviews symptoms, diagnostic tests that may be used to confirm the condition, causes, and treatment strategies. The fact sheet concludes with contact information for related resource organizations, including the American Diabetes Association, the Juvenile Diabetes Research Foundation International, and the National Diabetes Education Program. A final section outlines the goals and activities of the National Diabetes Information Clearinghouse (NDIC). 1 table.
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Hypoglycemia. Clinical Diabetes. 26(4): 170-173. Fall 2008.
This article about hypoglycemia is the eighth in a 12-part series that reviews the fundamentals of diabetes care for physicians in training. The goal of diabetes therapy is to normalize glucose levels without lowering them excessively. The author presents the rationale for identifying, treating, and avoiding mild and severe hypoglycemic complications of diabetes therapy. The author discusses the mechanisms of hypoglycemia, the problem of hypoglycemia unawareness, treatment of hypoglycemia, and hypoglycemia prevention. The use of new long-acting basal insulin analogs and insulin pumps may contribute to reduced risks of hypoglycemia. The author encourages physicians to stay aware of the risks of hypoglycemia and to consider them particularly during initiation or adjustment of diabetes treatment regimens. Patients should be taught the signs, symptoms, and proper treatment of hypoglycemia, as well as how to prevent it. 13 references.
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Iatrogenic Inpatient Hypoglycemia: Risk Factors, Treatment, and Prevention. Diabetes Spectrum. 21(4): 241-247. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, reports on a 130-patient case control study that was undertaken to examine the patient and hospital care risk factors for experiencing a hypoglycemic patient-day. The authors compared these risk factors with those of control patients who were not experiencing a hypoglycemic patient-day. They examined adherence to the hospital’s hypoglycemia management protocols, documentation of the event, and adjustments to medications and nutritional regimens that occurred in response to the hypoglycemic event. They found that the most powerful risk factors for hypoglycemia were unexpected nutritional interruption, prior hypoglycemia during the hospital stay, and asynchrony of meal delivery and insulin administration. In addition, adherence to hypoglycemia management and documentation standards was poor. The authors conclude that iatrogenic hypoglycemia is pervasive and is the major barrier to achieving improved inpatient glycemic control. They outline strategies to focus improvement efforts on adherence to hypoglycemia treatment protocols and proactive management of patients with these key hypoglycemia risk factors. 4 tables. 25 references.
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Immunosuppression and Other Medications. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 85-102.
This chapter on immunosuppression and other medications is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. The chapter includes 14 tables and figures: immunosuppression regimen at time of first infusion; antibodies used near time of first infusion for induction therapy; antibody dosing at time of infusion by infusion sequence; immunosuppression dosing (mg/day) at time of infusion by infusion sequence; immunosuppression therapy use at specified times after last infusion allograft recipients without reported graft failure at the time of follow-up; immunosuppression dosing after last infusion; sirolimus trough level (ng/ml) after last infusion all allograft recipients; tacrolimus trough level (ng/ml) after last infusion all allograft recipients; antihypertensive medications before infusion and after last infusion all allograft recipients; total number of antihypertensive medications before infusion and after last infusion all allograft recipients; lipid-lowering medications before infusion and after last infusion all allograft recipients; total number of lipid-lowering medications before infusion and after last infusion all allograft recipients; adjunctive therapy used at time of first infusion all allograft recipients; and adjunctive therapy after last infusion all allograft recipients. 5 figures. 12 tables.
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Importance of Being Active. Diabetes Wellness News. 14(3): 2-3, 5-6. March 2008.
This patient education newsletter article explores the health benefits of increasing one’s physical activity, including the impact of exercise on long-term health and the successful daily management of diabetes. The author defines increased activity and the benefits it can offer. The author briefly explains how activity can increase stamina, strength, and flexibility, including the physiology of increased activity in diabetes. The author points out some potential barriers and provides ideas to overcome those barriers. Topics include weight reduction; caloric intake versus caloric expenditure; adjusting insulin dosages for increased physical activity; balancing food, insulin, and exercise; risks of hypoglycemia; how to incorporate exercise into one’s daily life; and special suggestions for readers with reduced mobility. Some of the information presented is reiterated in sidebars and charts, including the exercises and calories burned during 20 minutes of different types of exercise. Readers are encouraged to work closely with their health care providers to safely add exercise and other activities to their program of diabetes management. 4 figures.
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Increasing Monofilament Examinations as a Means of Teaching Quality Improvement. Clinical Diabetes. 26(4): 167-169. Fall 2008.
This article reports on a pilot test of a longitudinal, skills-based curriculum that used the topic of diabetes to teach quality improvement (QI) techniques to the North Carolina Area Health Education Centers. The pilot test was conducted in partnership with the South East Area Health Education Centers (SEAHEC), based in Wilmington, NC, and responsible for providing educational programs for residencies in internal medicine, obstetric and gynecology, and surgery. The authors report on the development of the charter for the curriculum series, the development of the curriculum itself, assessment considerations, interventions, data collection, and the results of the pilot study. The intervention chosen for this proposal was the use of monofilament examination. Nurses would identify each patient with a “diabetes” sticker on the chart and a “date of monofilament exam” sticker on the intake sheet. Various other methods were used to improve the incidence of a monofilament examination being used. After a 2-week period of data collection, monofilament exam completion rates did improve. However, adherence rates to the proposed intervention by the residents were low over time. The authors conclude that the pilot project met some of the stated goals, including reviewing core topics in diabetes care and QI topics. The SEAHEC team was able to assess overall performance and collect real-time data after initiating their intervention. However, implementing any refinements in the health care providers’ intervention proved more difficult. Barriers faced by groups undertaking QI included low group buy-in and a shortage of personnel and time devoted to project work. 1 figure. 1 reference.
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Inpatient Care Coordination for Patients With Diabetes. Diabetes Spectrum. 21(4): 272-275. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, describes the use of inpatient care coordination for patients with diabetes. This care coordination, sometimes called case management, includes a focus on transition of care from outpatient to inpatient and back to an outpatient setting. Inpatient care coordinators, along with an interdisciplinary team from varying settings along the care continuum, can be instrumental in ensuring smooth, safe, and quality transitions. Some of the components of this approach include the identification of hyperglycemic and diabetic patients, the creation of a collaborative team, the full assessment of patients, the development of an individualized plan for each patient, patient education, a focus on a safe environment, and the promotion of self-care and the empowerment of patients. Communication between caregivers before, during, and after hospitalization must include medications prescribed, medical records, education offered, assessment findings, health literacy, and patient and family willingness to change lifestyle factors. This approach provides an avenue to ensure that patients are educated, adherent, and involved in their own health along the continuum of diabetes care. 9 references.
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Inpatient Management of Hyperglycemia And Diabetes. Diabetes Spectrum. 21(4): 230-231. Fall 2008.
This article serves as an introduction to a special series about inpatient care of hyperglycemia, also known as high blood glucose. The author briefly reviews the history of hyperglycemia care in the hospital, up to the present, focusing on the current role of diabetes educators, the problem of maintaining good blood glucose control while coping with standard hospital routines and treatments, and difficulties providing patient education while patients are struggling with acute illness. The author briefly summarizes each of the articles in the special issue, which cover the healing powers of food and nutrition, iatrogenic hypoglycemia, the impact of uncontrolled hyperglycemia in hospitalized patients, continuous intravenous insulin, the role of data collection in improving the quality of inpatient hyperglycemia and diabetes management, professional education on these topics, and the coordination of care during the transition from inpatient to outpatient settings. The author concludes with some brief examples from her practice that demonstrate how to implement some practice guidelines that will improve clinical care. 2 references.
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Insulin And Incretins. Clinical Diabetes. 26(1): 35-39. Winter 2008.
This article is part of a 12-part series for physicians in training that reviews the fundamentals of diabetes care; this article summarizes the use of insulin and Incretins. The author notes that insulin has been combined with additives and modified at the molecular level to changes its pharmacokinetic properties. Some insulin preparations accelerate insulin’s effects in the bloodstream, and others prolong the pharmacokinetic profile. The author describes specific drugs, including regular insulin, insulin analogs, inhaled insulin, protamine solutions, zinc solutions, and long-acting insulin analogs, including glargine and detemir. The article outlines standard insulin regimens, newer insulin regimens, the approach to initiating insulin therapy, and the use of incretins, such as exenatide, and the amylin analog, pramlintide. The author emphasizes that good understanding of the pharmacokinetics of insulin action and proper management on insulin regimens allow health care providers and patients to control blood glucose levels and safely avoid hypoglycemia and hyperglycemia. 32 references.
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Insulin as a First-Line Therapy in Type 2 Diabetes: Should the Use of Sulfonylureas be Halted?. Diabetes Care. 31(Suppl 2): S136-S139. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of insulin as a first-line therapy in patients with type 2 diabetes, supplanting the use of sulfonylurea compounds. The authors explore the advantages and drawbacks to each therapy, focusing on the evidence base, the limitations of present information, other treatment options, pathogenesis, and the impact of specific drug regimens on cardiovascular disease (CVD). The authors conclude that it is not easy to recommend a simple treatment regimen for patients with type 2 diabetes, and the complexities are not only based on whether or not insulin should be a first-line therapy. They stress that appropriate therapy of type 2 diabetes needs to be highly individualized, taking contraindications and potential downsides of treatment options into account and trying to define and target the leading pathogenetic defects behind the prevailing metabolic phenotype. Cost considerations must be figured into the decision. A patient care algorithm for the management of hyperglycemia in type 2 diabetes is presented. 1 figure. 23 references.
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Insulin Resistance and Hyperinsulinemia: Is Hyperinsulinemia the Cart or the Horse?. Diabetes Care. 31(Suppl 2): S262-S268. February 2008.
This article reviews insulin resistance, recently recognized as a strong predictor of disease in adults and a condition that, as the leading element of the metabolic syndrome, has become a renewed focus of research. Insulin resistance exists when insulin levels in the blood are higher than expected, relative to the level of blood glucose. The authors note that many causes and consequences of insulin resistance and hyperinsulinemia have been identified, but the direct contributions of insulin itself in causing or sustaining insulin resistance have received little sustained attention. The authors examine situations where insulin itself appears to be a proximate and important contributor to insulin resistance. They discuss hormones that regulate tissue sensitivity to insulin; transgenic hyperinsulinemia, in a mouse study; the disruption of insulin secretion by insulin resistance; primary hyperinsulinemia in vivo, where insulin resistance is associated with continuous exposure to high levels of insulin; the use of pulsatile insulin to minimize desensitization; basal hyperinsulinemia with insulinomas; and mechanisms of insulin-induced resistance to insulin. The authors conclude that hyperinsulinemia in the basal state, due to any cause, produces widespread insulin resistance. All tissues that have insulin receptor pathways will be affected, including the pancreatic beta-cell and possibly the brain. 3 figures. 65 references.
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Insulin Resistance and Pre-diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 8 p.
Insulin resistance is a condition in which the body produces insulin but does not use it properly. Insulin, a hormone made by the pancreas, helps the body use glucose for energy. Glucose is a form of sugar that is the body’s main source of energy. This fact sheet describes insulin resistance and pre-diabetes. When people are insulin resistant, their muscle, fat, and liver cells do not respond properly to insulin. Insulin resistance increases the chance of developing type 2 diabetes and heart disease. Pre-diabetes is defined as a condition in which blood glucose levels are higher than normal but not high enough for a diagnosis of diabetes. The fact sheet describes the causes of insulin resistance, the symptoms of insulin resistance and pre-diabetes, diagnostic approaches to these conditions, risk factors, ways to reverse insulin resistance and pre-diabetes, body mass index (BMI), and the role of medicines in reversing insulin resistance. The fasting glucose test and the glucose tolerance test may be used to identify and diagnose insulin resistance and pre-diabetes. Causes of insulin resistance and pre-diabetes include genetic factors, excess weight, and lack of physical activity. Being physically active, making wise food choices, and reaching and maintaining a healthy weight can help prevent or reverse insulin resistance and pre-diabetes. The fact sheet concludes with a section that describes current research studies in this area. Contact information for three organizations is provided: the American Diabetes Association at www.diabetes.org or 1–800–342–2383, the National Diabetes Education Program at www.ndep.nih.gov or 1–888–693–6337, and the National Heart, Lung, and Blood Institute Information Center at www.nhlbi.nih.gov or 301–592–8573. The back cover of the fact sheet describes the goals and activities of the National Diabetes Information Clearinghouse (NDIC), a Government service that provides information about diabetes to people with diabetes and to their families, health care professionals, and the public. 1 table.
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Intensive Insulin Therapy for the Critically Ill Patient. IN: Vanhorebeek, I.; Van den Berghe, G. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 157-178.
This chapter about intensive insulin therapy for the critically ill patient is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider the clinical complications associated with critical illness (CI), hyperglycemia in CI, blood glucose control with intensive insulin therapy in CI, the risk of hypoglycemia, the mechanism by which intensive insulin therapy achieves blood glucose control, and mechanisms explaining the improved outcome with intensive insulin therapy in these CI patients. The authors conclude that the simple metabolic intervention of maintaining normal blood glucose levels with intensive insulin therapy improves the survival of critically ill patients and reduces morbidity. Both strict glycemic control itself and other metabolic and nonmetabolic effects of the insulin administered contribute to these benefits. 3 figures. 101 references.
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Intensive Treatment and Complications of Diabetes: Can They Be Effectively Reduced?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 51-68.
This chapter about the use of intensive treatment of diabetes to prevent complications of the disease is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter cover the pathophysiology of diabetic vascular disease, the components of intensive therapy, data from clinical trials that demonstrate the advantages of intensive therapy, a multiple risk factor approach to intensive therapy, mechanisms of the benefit of intensive therapy, intensive lifestyle change, and intensive pharmacological therapy with oral agents. A final section describes current clinical trials in this area. The goal of intensive therapy is to reduce blood glucose levels to near normal and to incorporate effective management of other associated risk factors such as lipid abnormalities and blood pressure. The authors emphasize that intensive glycemic control has not been conclusively shown to decrease cardiovascular events, which are a leading cause of death in people with diabetes. Therapeutic agents used in treating glycemia have different effects on cardiovascular risks and therefore may have different effects on outcome. Metformin is the only oral antidiabetes medication shown to decrease cardiovascular events independent of glycemic control. Insulin therapy acutely reduces mortality and morbidity in patients with hyperglycemia when critically ill, but the effect on cardiovascular events is unclear. The authors conclude by calling for additional research to determine whether goals for intensive therapy should be lower than current goals and to test various therapeutic strategies to determine the optimum methods to prevent diabetes complications. 58 references.
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Into the Water. Diabetes Wellness News. 14(7): 1, 6, 8. July 2008.
This patient education newsletter article encourages readers to consider swimming and other water exercise as components of an overall program of diabetes management. The author outlines the benefits of water exercise, including an increase in endurance and muscular strength, as well as having some good, old-fashioned fun. Topics include the reduced impact of performing sports in water, water sports as a part of cross-training regimens, water activities as part of rehabilitation from injuries or postoperatively, aerobic workouts in the pool, increased aerobic endurance and strength training achieved with water exercise, factors that can be varied to increase the intensity level of a water workout, the importance of a warm-up session, and using a flexible water toy or noodle to add to the workout variety. The author defines a few related water terms: buoyancy, drag, viscosity, and turbulence. A list of recommended exercises to do in the water is included. Readers are referred to two websites for more information: the Aquatic Exercise Association at www.aewave.com and www.waterwellnessworkout.com. 5 figures.
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Is Continuous Glucose Monitoring for Everyone? Consideration of Psychosocial Factors. Diabetes Spectrum. 21(4): 287-289. Fall 2008.
This article considers the psychosocial factors that may be involved in the use of continuous glucose monitoring (CGM). CGM is a real-time sensor through which interstitial glucose values, not blood glucose values, are provided and alarms signal high or low glucose values. CGM offers individual glucose readings every 1 to 5 minutes and tracings of glucose patterns throughout a period of days. The author stresses that because of cost, training time, and possible medical contraindications, health care professionals need to ascertain which patients can most effectively use CGM by better understanding the emotional, cognitive, and behavioral characteristics of patients who want to use this technology. Topics include helping patients set realistic expectations for CGM use, determining how patients will react to and cope with the amount of information that CGM supplies, the lag time between CGM interstitial glucose measurements and fingerstick blood glucose measurements, and fear of hypoglycemia. The article shares three case studies to help elucidate which patients would be most appropriate for CGM, as well as the information that can be gleaned from a trial period with CGM. 7 references.
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Is Pancreatic Diabetes (Type 3c Diabetes) Underdiagnosed and Misdiagnosed?. Diabetes Care. 31(Suppl 2): S165-S169. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, discusses pancreatic diabetes, known as type 3c diabetes. Exocrine pancreatic insufficiency is frequency associated with both type 1 and type 2 diabetes. The incidence of diabetes caused by exocrine pancreatic disease appears to be underestimated and may make up 8 percent or more of the general diabetes patient population. The authors review the multiple mechanisms by which nonendocrine pancreas disease can cause diabetes. Both regulation of beta-cell mass and physiological incretin secretion are directly dependent on normal exocrine function. The authors comment on the presence of genetic mutations that can induce both exocrine and endocrine failure. The authors conclude by calling for the adaptation of diagnostic and screening strategies to detect exocrine diseases at earlier stages and possibly to stop progression to overt exocrine and endocrine pancreas insufficiency. 1 table. 47 references.
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Is Type 2 Diabetes an Operable Intestinal Disease? A Provocative Yet Reasonable Hypothesis. Diabetes Care. 31(Suppl 2): S290-S296. February 2008.
This article presents available evidence in support of the hypothesis that type 2 diabetes may be an operable disease characterized by a component of intestinal dysfunction. The author notes that conventional gastrointestinal operations for morbid obesity have been shown to dramatically improve type 2 diabetes, resulting in normal blood glucose and glycosylated hemoglobin levels, with discontinuation of all diabetes-related medications. Return to normal blood glucose and insulin levels are observed within days after surgery, suggesting that weight loss alone cannot entirely explain why surgery improves diabetes. The author considers recent experimental studies that point toward the rearrangement of gastrointestinal anatomy as a primary mediator of the surgical control of diabetes, suggesting a role of the small bowel in the pathophysiology of the disease. The author concludes by calling for clinical trials of diabetes surgery and by summarizing open questions for future clinical research in this area. 4 figures. 35 references.
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Is Weight Loss Beneficial for Reduction of Morbidity and Mortality? What is the Controversy About?. Diabetes Care. 31(Suppl 2): S278-S283. February 2008.
This article addresses the question of long-term weight loss and its impact on morbidity and mortality. Obesity is a well-established risk factor for many chronic disorders such as cardiovascular disease (CVD), type 2 diabetes, and certain cancers. However, weight loss is paradoxically associated with an increased mortality risk. As more strategies and approaches are brought to bear on managing the obesity epidemic, there is a need for more information about what happens after weight loss. The author explores possible explanations for increased health risks associated with weight loss, the risk of CVD and diabetes in relation to obesity, weight control achievement in type 2 diabetes, lifestyle intervention to decrease risk of diabetes, drug interventions to decrease the risk of diabetes, the effects of rimonabant on weight loss, observational studies on the effects of weight loss in diabetes, and the use of bariatric surgery. The author summarizes some of the ongoing research studies that address this question, including the Swedish Obese Subjects (SOS) surgery study, the Look AHEAD (Action for Health in Diabetes) trial in the United States, and the Comprehensive Rimonabant Evaluation Study of Cardiovascular ENDpoints and Outcomes (CRESCENDO) trial. 1 table. 41 references.
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Islet Cell Transplantation: How Effective Is It?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 11-32.
This chapter about the effectiveness of islet transplantation is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter note that islet transplantation as a treatment for diabetes has shown great promise but has significant limitations. The chapter covers a brief history of islet transplantation, islet isolation, limits of the procedure, clinical islet transplantation, immunosuppression, the Edmonton advance, islet transplantation outcome follow-up, benefits, risk and limitations, new methods of beta-cell replacement and encapsulation, and endogenous beta-cell regeneration. Although islet transplantation can restore insulin independence to the patient with type 1 diabetes, nearly all patients must return to insulin therapy by 5 years after procedure due to loss of islet function. Other problems include the need for immunosuppression, an inadequate islet supply, risks associated with the portal vein cannulation, host sensitization against the donor islets, allogeneic islet effects on the surrounding host liver tissue, and great expense. The authors conclude by encouraging ongoing research in this area. 102 references.
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Islet Inflammation in Type 2 Diabetes: From Metabolic Stress to Therapy. Diabetes Care. 31(Suppl 2): S161-S164. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy, Berlin, 2006), reviews the pathology of islet failure in type 2 diabetes. The authors highlight evidence that this pathology includes an inflammatory process in response to metabolic stress. The histology of islets from patients with type 2 diabetes shows an inflammatory process characterized by the presence of cytokines, apoptotic cells, immune cell infiltration, amyloid deposits, and eventually fibrosis. The authors hypothesize that this inflammatory process is probably the combined consequence of dyslipidemia, hyperglycemia, and increased circulating adipokines. The article briefly considers the interplay between antidiabetes drugs and islet inflammation. The authors conclude that modulation of intra-islet inflammatory mediators, in particular interleukin-1beta, appears to be a promising treatment approach. 2 figures. 55 references.
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Islet Transplant Activity. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 33-44.
This chapter on islet transplant activity is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. This chapter includes eight tables and figures: islet transplant centers reporting data to CITR: participating North American centers, 1999 to 2007; number of islet transplantation centers performing islet allografts per year and number with data entered in CITR database all North American islet transplant centers, 1999 to 2007; total number of islet transplant recipients; recipients at CITR-participating centers; and recipients with detailed data reported to CITR by year of first islet allograft infusion all North American islet transplant centers, 1999 to 2007; total number of islet allograft infusion procedures performed and number with data reported to CITR: CITR-participating North American islet transplant centers, 1999 to 2007; total number (n = 649) of islet allograft infusion procedures conducted and entered in CITR database, by year and infusion procedure number at CITR-participating North American and international centers, 1999 to 2007; total number (n = 649) of islet allograft infusion procedures per recipient at CITR-participating North American and international centers, 1999 to 2007; total number (n = 712) of deceased donors per islet allograft infusion procedure at CITR-participating North American and international centers, 1999 to 2007; islet alone and islet after kidney recipients: CITR-participating North American and international centers, 1999-2007. 9 figures.
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It All Adds Up: Poor Math Skills Can Endanger Health. Diabetes Forecast. 61(1): 70, 72, 76. February 2008.
This article presents a profile of Russell Rothman, M.D., a primary care physician and director of the Vanderbilt Program on Effective Health Communication at Vanderbilt University in Nashville, TN. Rothman is a recipient of an American Diabetes Association (ADA) clinical research grant and one of his areas of interest is improving education and self-management skills for diabetes patients with poor mathematical skills. Rothman’s research included 5 years studying the impact of literacy and numeracy on diabetes treatment, finding that more than two-thirds of his diverse patient population had less than ninth-grade math skills. Almost all of the research participants had some difficulties when trying to apply math to diabetes-related tasks. The study questionnaire tested basic arithmetic skills crucial to diabetes nutrition and included real-world examples such as reading a nutrition label or multiplying to get a prescribed amount of carbohydrates in a certain number of servings. One section describes Rothman’s ongoing interests in how language and cultural barriers can complicate communication between doctors and patients. The article concludes by reminding readers of the importance of doctors, nurses, and educators slowing down and clearly communicating to help patients successfully treat themselves. 1 figure.
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Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. 138 p.
This handbook helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The book contains three key chapters from the larger Joslin's Diabetes Deskbook, which discuss insulin and its use in the clinical arena. The first chapter reviews the general principles of insulin therapy, covering endogenous insulin; insulin for exogenous therapy; insulin purity; insulin types, brands, and modes of delivery; insulin antibodies; insulin allergy; storage considerations; syringes and other injection devices; syringe preparation techniques; injection techniques; common mixtures; insulin pens; automatic injection aids and jet injectors; injection aids for people with low vision; injection sites; syringe reuse; and disposal of syringes. Chapter 2 walks readers through the design of a conventional insulin treatment program. Topics include the indications for insulin therapy in type 1 diabetes and in type 2 diabetes; the goals of insulin treatment; glucose monitoring programs for patients using insulin; the initiation of insulin therapy for type 1 diabetes, including choosing and designing an appropriate program; the initiation of insulin therapy for type 2 diabetes; the implications of insulin quality; specific insulin regimens; intensified conventional therapy; modifying the insulin treatment program; rebound hyperglycemia; and adjustment guidelines. The final chapter addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. Each chapter is illustrated with line drawings and tables.
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Latent Autoimmune Diabetes in Adults and Pregnancy: Foretelling the Future. Clinical Diabetes. 26(1): 44-46. Winter 2008.
This case report presents the case of a 25-year-old woman referred for newly diagnosed gestational diabetes mellitus (GDM). Before the pregnancy, her baseline weight was 205 pounds, and her BMI was 33. Overall, she was feeling well and tolerating her pregnancy well. A previous pregnancy, uncomplicated by GDM, had resulted in a healthy, full-term girl who was subsequently diagnosed with type 1 diabetes at age 4. The authors describe the woman’s care, which included the use of bedtime human insulin NPH and close monitoring of blood glucose levels. Insulin lispro was added for mealtime coverage, and her blood glucose control improved on intensive insulin therapy. At term, she delivered a healthy boy by uncomplicated, spontaneous vaginal delivery. Follow-up therapy noted ongoing impaired glucose tolerance, and 4 weeks later the patient experienced symptoms of polyuria, polydipsia, and blurry vision. Her blood glucose values had been between 200 and 350 mg/dl for 3 days. Because of the family history of type 1 diabetes in her daughter and the acute exacerbation of hyperglycemia, an autoantibody test was ordered and she was diagnosed with latent autoimmune diabetes in adults (LADA). Intensive insulin therapy was started with insulin lispro for prandial coverage and insulin glargine for basal coverage. She used an insulin pump and had excellent glycemic control, including through her third pregnancy. The authors use this case to review LADA, how it is diagnosed, and how treatment for LADA varies from that for type 1 or type 2 diabetes. 2 figures. 8 references.
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LDL Cholesterol Lowering in Type 2 Diabetes: What Is the Optimum Approach? Clinical Diabetes. 26(1): 8-13. Winter 2008.
This article helps clinicians lower cardiovascular risk in their patients with type 2 diabetes. The author focuses on the importance of assessing and treating elevated low-density lipoprotein (LDL) cholesterol. Statins are the preferred treatment, and the author notes that intensive statin therapy may be necessary to meet the current goal of less than 100 mg/dl. The optional goal of less than 70 mg/dl is recommended for high-risk patients and to address other components of diabetic dyslipidemia. The author notes that overall, standard doses of statins are well tolerated and cases of muscle-related toxicity and elevated liver enzymes are low, particularly when standard doses are used in appropriately selected patients. The author concludes by reiterating that intensive treatment of LDL cholesterol, along with aggressive glucose and blood pressure control, is a vital part of cardiovascular risk reduction in these patients. 3 figures. 42 references.
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Lipoprotein Management in Patients With Cardiometabolic Risk: Consensus Statement from the American Diabetes Association and the American College of Cardiology Foundation. Diabetes Care. 31(4): 811-822. April 2008.
This article presents the consensus statement from the American Diabetes Association and the American College of Cardiology Foundation on lipoprotein management in patients with cardiometabolic risk (CMR) factors. The risk factors for type 2 diabetes and cardiovascular disease (CVD) include obesity, insulin resistance, hyperglycemia, dyslipoproteinemia, and hypertension. These conditions can cluster or occur in isolation, and they are exaggerated by physical inactivity and smoking. This article reports on the consensus development conference held in July 2007 that focused on lipoprotein management in patients with CMR. The consensus statement covers five areas: the extent to which lipoproteins contribute to CVD, the clinically important lipoprotein parameters, other factors to be considered in the evaluation and treatment of patients with lipoprotein abnormalities, the principles and objectives of treatment of lipoprotein abnormalities, and new research-based information that would help improve lipoprotein management. Specific treatment strategies discussed include those to reduce low-density lipoprotein (LDL) levels, determining cut points for initiating therapy, the therapeutic options for LDL cholesterol lowering, assessing response to therapy, and treatment goals for adults with CMR and lipoprotein abnormalities. Recommendations include statin therapy for most adult patients with CMR and dyslipoproteinemia; treatment goals that include the high lifetime risk of patients with dyslipoproteinemia and CMR; the use of apoB to help guide therapy; and a focused, multifaceted public health effort, focused on lifestyle modification, to reduce mean population levels of atherogenic lipoproteins. The authors conclude by calling for studies on residual risk for patients on long-term statin therapy, the role of elevated triglycerides, high-density lipoprotein (HDL) cholesterol, combination therapy, the benefits of lipoprotein management in other high-risk subsets, and the utility of biomarkers. 1 figure. 1 table. 93 references.
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Liver, Kidney, Lipid, and PRA Effects. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 193-212.
This chapter on liver, kidney, lipid, and plasma renin activity (PRA) effects is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. The chapter includes 20 tables and figures: incidence of abnormal liver function tests at any CITR scheduled time after first infusion, all allograft recipients; alanine aminotransferase (ALT; IU/L) before infusion and after last infusion; aspartate aminotransferase (AST; IU/L) before infusion and after last infusion; alkaline phosphatase (IU/L) before infusion and after last infusion; total bilirubin (mg/dl) before infusion and after last infusion; incidence of abnormal lipid tests at any CITR scheduled time after first infusion, all allograft recipients; total cholesterol (mg/dl) before infusion and after last infusion; high-density lipoprotein (HDL; mg/dl) before infusion and after last infusion; low-density lipoprotein (LDL; mg/dl) before infusion and after last infusion; triglycerides (mg/dl) before infusion and after last infusion; incidence of increase in serum creatinine (mg/dl) greater than 0.5 from baseline at any CITR scheduled time after first infusion; serum creatinine (mg/dl) before infusion and after last infusion; calculated creatinine clearance (ml/min/1.73m2) before infusion and after last infusion; estimated glomerular filtration rate (GFR; ml/min/1.73m2) before infusion and after last infusion; class I PRA percentage before infusion and after last infusion; change in class I PRA from before first infusion before subsequent infusion and after last infusion; class I PRA after last infusion, islet-alone recipients with complete graft loss; class I PRA after last infusion, islet-alone recipients without complete graft loss; class I PRA after last infusion nonimmunosuppressed, islet-alone recipients; and class I PRA after last infusion immunosuppressed, islet-alone recipients. 31 figures.
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Living With Diabetes IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 3-12.
This chapter about living with diabetes is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors define the different types of diabetes, including type 1, type 2, and gestational diabetes; describe the tests used to diagnose diabetes; explain the glycosylated hemoglobin (HbA1c) test and how it is used to monitor diabetes management; review common diabetes symptoms; explain the stepped progression of diabetes care; and address concerns that readers may have about taking insulin. Readers are reminded that needing to go on insulin does not mean that they have failed in their diabetes care, but merely that their body needs the additional treatment that insulin can provide. Much of the information throughout the chapter is provided in figures, lists, and charts for ease of access and understanding. 4 figures. 3 tables.
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Living Your Best Life: Diabetes And Insulin. Chevy Chase, MD: Hormone Foundation. 2008. (DVD).
Narrated by diabetes educator Michelle Sheldon-Rubio, this video introduces four people with diabetes, including an African American man in his twenties, a white woman in her forties, a white woman in her sixties, and a white man in his seventies. They share their emotions and feelings from when they were first told they had diabetes or first told they needed to use insulin. Throughout the video, they describe their experiences as they learned about insulin. The program offers statistics about the use of insulin, encourages viewers to consider a diabetes diagnosis as a way to embrace living, defines terms, debunks myths, shows how to test blood glucose levels, and teaches about blood glucose management, insulin storage, and insulin administration. Readers are referred to the Hormone Foundation website at www.hormone.org for more information.
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Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 And Type 2 Diabetes. Diabetes Care. 31(Suppl 2): S140-S145. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reports on the use of long-acting insulin analogs versus insulin pump therapy for the treatment of patients with either type 1 or type 2 diabetes. The authors consider whether multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for continuous subcutaneous insulin infusion (CSII). They discuss hypoglycemia, elevated glycosylated hemoglobin (A1C ) levels and glycemic variability, the dawn phenomenon, the problems of poor control in type 2 diabetes, and CSII as a management strategy in type 2 diabetes. They conclude that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current treatment option for some people with type 1 diabetes. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little research on the use of MDI based on long-acting analogs compared with insulin pumps. 4 figures. 2 tables. 47 references.
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Look at System-Wide Data Collection Processes to Improve Patient Outcomes. Diabetes Spectrum. 21(4): 262-267. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, explores how data collection processes can be modified to improve quality and safety for patients. Data collection and analysis can lead to these improved outcomes through practice changes, development of protocols and order sets, and staff education. The authors describe the tools and resources that are available to assist diabetes professionals with their efforts toward continuous quality improvement (CQI). They stress that an important part of the CQI plan is the selection of performance measures that include clinical and financial targets, as well as perceptions of care. Both hypoglycemia and hyperglycemia are important patient safety issues that are appropriate for CQI analysis. Specific data collection suggestions for each are outlined. One section discusses the use of glucometrics, the process associated with the systematic review of hospitalwide glucose data. The authors conclude that the components that separate the best diabetes programs from the rest is their ability to continually collect and evaluate systemwide data, thoroughly analyze the variables, and implement timely and meaningful quality initiatives based on the data. 1 figure. 3 tables. 25 references.
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Low Blood Glucose. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 29-32.
This chapter about low blood glucose, also known as hypoglycemia, is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors discuss the causes of low blood glucose, the symptoms of low blood glucose, strategies to treat low blood glucose, and identifying symptoms that resemble those of hypoglycemia that are not actually due to low blood glucose levels. 1 figure.
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Management of Hyperglycemia in Type 2 Diabetes: A Consensus Algorithm for the Initiation And Adjustment of Therapy. Diabetes Care. 31(1): 173-175. January 2008.
This article presents an evidence-based algorithm developed to guide health care providers as they choose the most appropriate treatment regimens for their patients with type 2 diabetes who need medications for the management of hyperglycemia. The authors endorse the major features of the algorithm, including the need to achieve and maintain blood glucose levels within or as close to the nondiabetic ranges as is safely possible, the initiation of lifestyle interventions and treatment with metformin at the time of diagnosis, the rapid addition of medications and transition to new regiments when target glycemia is not achieved, and the early addition of insulin therapy in patients who do not meet target A1C levels. In this update, changes include an update on the current understanding of the advantages and disadvantages of the thiazolidinediones, and the inclusion of the DPP-4 sitagliptin in the choices of medications for patients with type 2 diabetes. 1 figure. 1 table. 17 references.
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Management of Hypertension in Diabetic Patients With Chronic Kidney Disease. Diabetes Spectrum. 21(1): 30-36. Winter 2008.
Diabetes is associated with markedly increased cardiovascular risk, a risk that is made worse by the presence of chronic kidney disease (CKD), a common complication of diabetes. More than 80 percent of people with diabetes and CKD have hypertension. This review from a special section on managing patients with diabetes and CKD, called diabetic kidney disease (DKD), discusses the evidence regarding one of the most important treatment targets for these patients, namely, control of blood pressure to less than 130/80 millimeters of mercury (mmHg). The author provides detailed information about appropriate blood pressure measurement and treatments to best achieve that target. Careful blood pressure measurement, a multiple risk factor modification strategy, and persistent and judicious renin-angiotensin-aldosterone system (RAAS) blockade in combination with diuretics and add-ons should result in good blood pressure control in a majority of patients. In addition, engaging patients and their families through home-based blood pressure measurement (HBP), lifestyle modification, and collaboration with clinic nurses, pharmacists, and other health care providers will facilitate success. 2 tables. 57 references.
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Management of Inpatient Hyperglycemia in Noncritically Ill Patients. Diabetes Spectrum. 21(4): 248-255. Fall 2008.
This article, from a special issue about the inpatient care of hyperglycemia, focuses on the management of inpatient hyperglycemia in noncritically ill patients with diabetes. The authors note that hyperglycemia in hospitalized patients is associated with increased morbidity, mortality, and length of hospital stay. Insulin counteracts the damaging processes caused by hyperglycemia and is therefore a logical choice in treating inpatient hyperglycemia. The management of inpatient hyperglycemia is undergoing a change from sliding scale insulin (SSI) to a more physiological approach. The authors emphasize the importance of using a physiological, that is, basal-bolus, insulin regimen for noncritically ill hospitalized patients, discuss protocols for initiating and titrating insulin doses and for transitioning from insulin infusion to a subcutaneous regimen, and recommend insulin teaching as part of discharge planning for patients who were not on insulin before admission. They conclude with suggestions for research in this area, including length of stay, lower costs of hospital stays, and benefits of improved glycemic control. 4 tables. 49 references.
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Managing Preexisting Diabetes for Pregnancy: Summary of Evidence And Consensus Recommendations for Care. Diabetes Care. 31(5): 1060-1079. May 2008.
This article presents consensus panel recommendations for the medical care of pregnant women with preexisting diabetes, including type 1 and type 2 diabetes. The document is designed to help clinicians deal with the broad spectrum of problems that arise in the management of diabetes before and during pregnancy, and to prepare women with diabetes for treatment that may reduce complications in the years after pregnancy. Guidelines are presented in two sections. The first section addresses managing preexisting diabetes for pregnancy, including the organization of preconception and pregnancy care, initial evaluation, glycemic control, perinatal outcome and glycemic goals, assessment of metabolic control, medical nutrition therapy, insulin therapy, oral antihyperglycemic agents for type 2 diabetes, physical activity and exercise, and behavioral therapy. The second section covers the management of diabetes complications, including diabetic ketoacidosis (DKA), maternal hypoglycemia, thyroid disorders, management of cardiovascular risk factors, screening for cardiovascular disease (CVD), hypertension, diabetic nephropathy, diabetic retinopathy, and diabetic neuropathies. Practical suggestions, including recommended laboratory values and goals, are highlighted. The recommendations for diagnostic and therapeutic actions are based on a grading system adapted by the American Diabetes Association that was used to clarify and codify the research evidence available.
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Managing Your Diabetes. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 53-56.
This chapter about general strategies for diabetes management is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors review the basics of diabetes care, including testing blood glucose levels, taking insulin, counting carbohydrates, and following one’s individual food and activity plan. They encourage readers to review how they are accomplishing each of these tasks and to consider where they could improve. This chapter provides an opportunity for readers to review and reflect on how their overall diabetes care approach is going. 1 figure.
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Mens Sana in Corpore Sano. Diabetes Wellness News. 14(1): 1, 8. January 2008.
This patient education newsletter article considers the interplay of mind and body and describes how this concept may be particularly appropriate for people with diabetes. The author reminds readers that the mind, or the mens, has a great impact on the corpore, or the body. The article focuses on the concept of self-efficacy, which includes mastery, self-sufficiency, wholeness, and autonomy. The author stresses that although all the advancements in medications and other patient care are wonderful and helpful, addressing the full spectrum of issues that people who have diabetes face in their everyday lives is vital. Other topics discussed include the importance of goal setting, goal setting as a collaborative approach, coping with barriers to one’s goals, supporting behavior change, and how to integrate diabetes self-care into the practical ups and downs of daily living. 1 figure.
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Metabolic Complications of Childhood Obesity: Identifying and Mitigating the Risk. Diabetes Care. 31(Suppl 2): S310-S316. February 2008.
This article reviews the metabolic complications of childhood obesity, focusing on identifying and reducing the risk factors for obesity. The authors discuss the impact of genetic, intrauterine, and childhood factors in obesity; the impact of race and ethnicity; the impact of the degree of obesity; the impact of lipid partitioning; altered glucose metabolism in obese children; nonalcoholic fatty liver disease (NAFLD) in obese children; lifestyle interventions for obese children; and the goals of behavior change programs. The authors recommend that clinicians who see growing numbers of obese children and adolescents should attempt to identify those at greatest risk for the development of early morbidity. Clinical judgment should be used to assess the degree of obesity and to identify greater visceral adiposity, both of which are strongly associated with increased metabolic risk. Screening for clinically silent conditions such as impaired glucose tolerance (IGT) and NAFLD should be based on a high index of suspicion, using information gathered from history taking and anthropometric parameters. The authors stress that focused lifestyle modification interventions are showing promising results in improving the metabolic profile of obese children. 77 references.
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Metabolic Syndrome: Is There Treatment That Works?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 33-50.
This chapter about the metabolic syndrome is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author of this chapter defines metabolic syndrome as a cluster of risk factors including elevated glucose, triglyceride and blood pressure levels, and low HDL cholesterol levels, which typically occur in the setting of obesity and a sedentary lifestyle. The chapter covers risk factor clustering and the criteria for the metabolic syndrome; metabolic syndrome as a risk factor for type 2 diabetes and cardiovascular disease (CVD); the use of therapeutic lifestyle change to prevent metabolic syndrome, type 2 diabetes, and CVD; and drug therapies for the metabolic syndrome. The author notes that there is a good evidence base for therapeutic lifestyle change (TLC) that focuses on changing obesity and physical inactivity to reduce disease risk. In addition, TLC is safe for most people and has other, nonobesity health benefits. There is no specific drug therapy recommended for metabolic syndrome beyond medications that lower levels of its component risk factors, especially hypertension and dyslipidemia. 1 table. 84 references.
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Microalbuminuria in Type 2 Diabetes And Hypertension: A Marker, Treatment Target, or Innocent Bystander? Diabetes Care. 31( Suppl 2): S194-S201. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the role of microalbuminuria in type 2 diabetes. The authors note that albuminuria is a predictor of poor renal and cardiovascular outcomes in these patients. They contend that albuminuria should be measured in all patients with type 2 diabetes and hypertension and that steps should be taken to suppress albuminuria to prevent future renal and cardiovascular adverse events. The authors discuss the definition and measurement of albuminuria, the prevalence of microalbuminuria in essential hypertension, the factors that influence the relationship between arterial pressure and albuminuria, albuminuria and the treatment of hypertension, and renal and cardiovascular outcomes in essential hypertension and in diabetes. They summarize the evidence that reduction of albuminuria leads to improvement in the risk profiles of these patients. Physicians are encouraged to measure urinary albumin excretion in patients with type 2 diabetes and hypertension routinely and be as aggressive in treating this modifiable risk factor as they do blood pressure, cholesterol, and blood glucose. 1 figure. 3 tables. 58 references.
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Microvascular And Macrovascular Complications of Diabetes. Clinical Diabetes. 26(2): 77-82. Spring 2008.
This article is part of a 12-part series for physicians in training that reviews the fundamentals of diabetes care; this article summarizes the microvascular and macrovascular complications of the disease. The author emphasizes the importance of protecting the body from hyperglycemia, the complications of which are the major source of morbidity and mortality from both type 1 and type 2 diabetes. The article discusses the microvascular complications, including diabetic retinopathy, diabetic nephropathy, and diabetic neuropathy. The article outlines the macrovascular complications of diabetes, notably the increased risk of cardiovascular diseases. Readers are reminded of the importance of monitoring their patients for these complications, implementing therapies that counter hyperglycemia, using drug therapies and lifestyle changes to manage hypertension, and regularly measuring blood pressure and blood glucose levels. Recommendations for various monitoring and screening tests are also provided. 39 references.
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Monitoring: How Are We Doing?. Diabetes Wellness News. 14(3): 1, 6. March 2008.
This patient education newsletter article reviews one of the activities that can have an impact on good diabetes management: blood glucose monitoring. The author places this discussion in the context of determining the elements that predict whether a person with diabetes will have a long, healthy, and productive life. The central idea that good blood glucose control predicts positive outcomes is briefly explained. The author emphasizes the need for regular self-monitoring of blood glucose (SMBG) to achieve that good control. The article includes data from 1997 and 2006 from the Centers for Disease Control and Prevention (CDC) on the numbers of patients who are measuring their blood glucose levels at least once daily and having their glycosylated hemoglobin (HbA1c) measured at least annually. These data show that in 1997, only 40.6 percent of respondents reported daily SMBG; by 2006, that number had increased to 63.4 percent. Factors that seemed to predict good outcomes included having at least a high school education, having health insurance coverage, seeing a physician at least once annually, and having taken a diabetes education course.
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Motivational Interviewing: Promoting Reflection as a Cue to Change. Clinical Diabetes. 26(4): 166. Fall 2008.
This one-sheet overview reminds physicians of the benefits of using motivational interviewing (MI) with their patients as a way to assist them in reaching their behavior change goals. Diabetes is a disease that requires a great deal of patient self-management, in which patients care for their illness and promote their own health. Motivational interviewing (MI) is a directive, client-centered counseling style that helps the patient explore and resolve ambivalence. The role of the provider is to encourage patients to think about and articulate their own reasons for and against making changes, how their behavior supports or conflicts with their own goals and values, and specific short- and long-term steps toward change. The author provides specific suggestions for questions to ask the patient during an MI session.
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NADPH Oxidases, Reactive Oxygen Species, And Hypertension: Clinical Implications and Therapeutic Possibilities. Diabetes Care. 31(Suppl 2): S170-S180. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the role of reactive oxygen species (ROS) and hypertension in the development of cardiovascular disease (CVD), including that associated with diabetes. The authors describe how ROS influences many physiological processes including host defense, hormone biosynthesis, fertilization, and cellular signaling. Oxidative stress has been found to contribute to vascular damage by promoting cell growth, extracellular matrix protein deposition, activation of matrix metalloproteinases, inflammation, endothelial dysfunction, and increased vascular tone—all characteristic features of the vascular phenotype in hypertension. A major source for vascular and renal ROS is a family of nonphagocytic NAD(P)H oxidases. The authors discuss the potential role of targeting ROS as a treatment possibility in the management of hypertension and CVD. The authors conclude that current clinical data are not conclusive with regards to the pathophysiological role of oxidative stress in hypertension; more studies in this field are warranted. 2 figures. 1 table. 157 references.
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National Standards for Diabetes Self-Management Education. Diabetes Care. 31(Suppl 1): S97-S104. January 2008.
This section of National Standards for Diabetes Self-Management Education (DSME) is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” The national standards for DSME are designed to define quality diabetes self-management education and to assist diabetes educators in a variety of settings to provide evidence-based education. These standards are reviewed and revised approximately every 5 years by key organizations and Federal agencies within the diabetes education community. The section first summarizes the five guiding principles used to guide the review and revision of the DSME. Ten standards are presented, covering documentation of the DSME organizational structure, mission, and goals; the use of an advisory group; clarification of the target population and assessment of its needs; coordination, including the designation of a coordinator for planning, implementation, and evaluation of DSME; the instructors of DSME; the use of a written curriculum; individual assessment and education plans; personalized follow-up plans for ongoing self management support; measurement of the attainment of patient-defined goals and patient outcomes; and measurement of the effectiveness of the education process, including the determination of opportunities for improvement. Each of these standards is briefly described, with specific suggestions for design, implementation, and evaluation of the DSME program, supported by the literature. 164 references.
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Natural History of Cardiovascular Disease in Patients With Diabetes: Role of Hyperglycemia. Diabetes Care. 31(Suppl 2): S155-S160. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the natural history of cardiovascular disease (CVD) in patients with diabetes. The authors discuss possible reasons for the increased incidence of cardiovascular (CV) events in individuals with diabetes. They contend that although an increased prevalence of standard CV risk factors has been clearly documented in association with diabetes, diabetes-related abnormalities, particularly hyperglycemia, also play a role. Analysis of data from populations that included individuals with impaired glucose tolerance and impaired fasting glucose suggests that the pathogenic role of hyperglycemia on the blood vessel wall already exists in the early stages of glucose intolerance. Epidemiological data demonstrate that the effect of postprandial or postchallenge hyperglycemia on the risk of CVD is greater than the effect of fasting hyperglycemia. The authors conclude that the most appropriate targets in interventional trials would be postprandial hyperglycemia or A1C levels, which measure blood glucose levels over time. 1 figure. 1 table. 45 references.
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Non-Insulin Medications for Diabetes. 5th ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program reviews noninsulin medications that may be used to help manage type 2 diabetes. The program focuses on the causes of type 2 diabetes and the role of different oral medications, including combination medications, in keeping blood glucose levels under control. One section describes the use of exenatide (Byetta), an injectable drug used for type 2 diabetes. Safe medication use is emphasized. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management and oral medications. Simple graphics are used to explain most of the topics covered. Short video segments about the drug classes sulfonylureas, biguanides, alpha-glucosidase inhibitors, thiazolidinediones, meglitinides, DPP-IV, and combinations appear at the end of the full presentation. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Nutrition Recommendations And Interventions for Diabetes. Diabetes Care. 31(Suppl 1): S61-S78. January 2008.
This position statement on nutrition recommendations and interventions for diabetes mellitus is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement describes the goals of medical nutrition therapy (MNT) for the prevention and treatment of diabetes; the effectiveness of MNT; managing energy balance, overweight, and obesity; nutrition recommendations and interventions for the prevention of diabetes––primary prevention; nutrition recommendations for the management of diabetes––secondary prevention; nutrition recommendations for the prevention of complications––tertiary prevention; nutrition interventions for acute complications; and special considerations for patients with comorbidities in acute and chronic care facilities. The goal of these recommendations is to make people with diabetes and health care providers aware of beneficial nutrition interventions. Achieving nutrition-related goals requires a coordinated team effort that includes the person with diabetes and involves him or her in the decision-making process. In addition, the guidelines recommend that a registered dietitian, knowledgeable and skilled in MNT, be the team member who plays the leading role in providing nutrition care. 3 tables. 119 references.
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Nutritional Challenges of a Dual Diagnosis: Chronic Kidney Disease and Diabetes. Diabetes Spectrum. 21(1): 26-29. Winter 2008.
People with diabetes strive to keep blood glucose, blood pressure, and blood lipids within desirable ranges to prevent long-term complications such as chronic kidney disease (CKD). This article, from a special section on managing patients with diabetes and CKD, summarizes some of the nutritional strategies that can be used to prevent or delay progression to kidney failure. The author stresses that once kidney failure has started, nutritional management becomes even more complex. The article reviews the functions of normal kidneys and outlines the goals of treatment for both diabetes and kidney disease, including controlling blood glucose and blood pressure to prevent further kidney damage as well as cardiovascular disease. The article addresses protein intake, the role of carbohydrates and fats, and micronutrient assessment. Six basic goals are outlined for this patient population: intensive glycemic control, antihypertensive therapy, cholesterol-lowering therapy, dietary protein restriction, prevention of malnutrition, and multidisciplinary patient support. A chart summarizes the possible nutrition interventions that would be recommended at each stage of kidney disease. 1 table. 13 references.
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Nuts And Bolts of Achieving End Points with Real-Time Continuous Glucose Monitoring. Diabetes Care. 31(Suppl 2): S146-S149. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the basics of using real-time continuous glucose monitoring (RT-CGM) as a component of comprehensive diabetes management. The author cautions that RT-CGM is most appropriate in patients who are skilled in diabetes self-management. Training issues include the implications of the physiologic lag between interstitial and capillary blood glucose levels, as well as the increased risk among RT-CGM users for hypoglycemia related to blind postprandial bolusing. Patients must understand the importance of calibrating their equipment during steady-state conditions to improve sensor accuracy. In addition, they need to use fingerstick measurements for treatment decision making when the glucose level is changed rapidly. The author notes that consideration of “insulin on board” and the impact of the glycemic index of different foodstuffs on postprandial glucose patterns can help minimize the risk for hypoglycemia from supplemental boluses taken to correct postprandial hyperglycemia. The article includes colorful figures that help readers learn to translate the data received from RT-CGM. 4 figures. 9 references.
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Organized Care for Depression Improves Outcomes and Reduces Costs. Clinical Diabetes. 26(1): 15-16. Winter 2008.
This article summarizes a recent research study of 329 patients with diabetes and a depressive disorder. The randomized, controlled trial and economic analysis featured a nine-item patient health questionnaire (PHQ), baseline visits, and assignment to a nurse-delivered multicomponent depression management program or usual care. The program used a stepped-care approach, with incorporation of patient preferences for treatment, including antidepressant medications, structured psychotherapy, or both. The main outcome was depression-free days. Health service use and costs were estimated. The results showed that intervention patients had a mean of 61 more depression-free days during the 24 months of the study and had outpatient health care costs that were a mean of $314 lower than the patients with usual care. The study was published in the Archives of General Psychiatry (Simon, G.E., et al., volume 64, 2007). In this commentary, the author applauds these findings and contends that organized depression care programs should be a high priority for providers and payers. However, greater attention has been focused on other aspects of care, including macrovascular and microvascular complications. A brief final section considers some of the barriers to providing high-quality care for patients with diabetes and depression. 6 references.
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Pancreas Procurement, Islet Processing, and Infusion Characteristics. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 65-84.
This chapter on pancreas procurement, islet processing, and infusion characteristics is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. The chapter includes 15 tables and figures: pancreas procurement and islet processing; cold ischemia information; islet equivalents and timing of count; islet product characterization; differences in islet characteristics by pancreas preservation method univariate analysis; significant relationships between islet outcomes and categorical predictors univariate analysis; univariate correlation of islet characteristics with donor, recovery, and processing characteristics; islet product and infusion characteristics by infusion sequence; preinfusion portal pressure by infusion sequence; peak portal pressure by infusion sequence; closure portal pressure by infusion sequence; change from before infusion to closure portal pressure by infusion sequence; change from preinfusion to peak portal pressure by infusion sequence; cell volume infused per infusion by infusion year; IEQS infused per infusion by infusion year. 7 figures. 13 tables.
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Pancreas Transplantation: Should They Be Reserved for Simultaneous Renal Transplants?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 1-10.
This chapter about pancreas transplantation is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter consider whether pancreas transplantations should be reserved for simultaneous renal transplants. The chapter begins with their assertion that solitary pancreas transplants, called PTA when they are done alone in nonuremic patients, or PAK, when they are done after a kidney transplant, should be done, as should simultaneous pancreas-kidney transplants (SPK) in uremic diabetics who cannot get a kidney transplant first. The authors maintain that it is regressive to restrict pancreas transplants to just the uremic population and, in this restricted population, to just those who cannot get an early kidney transplant to preempt the dialysis that would otherwise be necessary while waiting for both organs from a deceased donor. For many patients who have both uremia and diabetes, the best option is a living donor kidney followed by a pancreas transplant; a living donor eliminates waiting for a kidney, and the waiting time for a solitary pancreas at present is relatively short. Although pancreas graft survival rates are higher after SPK transplants, the gain in patient survival rates by doing a preemptive kidney transplant more than offsets the lower insulin-independence rates after a PAK. The authors conclude that the outcomes justify the continuance of pancreas transplants in all three categories of recipients. 9 figures. 12 references.
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Patient with Diabetes, Hepatitis C Virus Infection, and Hemochromatosis Gene Mutation. Clinical Diabetes. 26(4): 174-176. Fall 2008.
This article presents the case study of a 51-year-old African American man who presented with fatigue, polyuria, and polydipsia. He had been diagnosed with type 1 diabetes 1 year before and had experienced four different hospitalizations with hyperglycemic crises in that year. His adherence to a diabetes treatment, including basal and premeal insulin, was poor. After his hyperglycemia was stabilized in the hospital, additional testing diagnosed hepatitis C virus (HCV) infection and hereditary hemochromatosis (HH). During the hospital stay, his condition improved, and his blood glucose significantly decreased after volume resuscitation and subcutaneous insulin therapy. The authors comment on this case and the patient’s comorbidities. Because diabetes is highly prevalent in patients with HCV and vice versa, HCV infection should be considered in patients with diabetes who have abnormal serum transaminases. Iron overload manifested by elevated transferrin saturation and ferritin concentration in patients with diabetes may occur because of HFE gene mutation. Therefore, testing for HH may be indicated. Other causes of iron overload may need to be considered. 21 references.
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Physiologic Insulin Treatment Programs. IN: Beaser, R.S. Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. pp 77-134.
This chapter is from a handbook that helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The author addresses physiologic insulin treatment programs, including patient selection, replacement therapy, estimating starting doses, descriptions of basal insulin patterns, preparing patients to start physiologic insulin, the health care providers most appropriate for managing replacement therapy, treatment adjustments, coping with hyperglycemia and hypoglycemia, weight gain and loss on physiologic insulin, insulin pump therapy, complications of insulin therapy, exercise and sick day adjustments, going off the insulin pump, and the role of pramlintide. The author concludes by cautioning that developing a proper routine for, and method of, physiologic insulin replacement therapy takes time and effort. Developing a routine requires a major, long-term commitment on the part of the patient and medical and educational support from a skilled health care team. The chapter is illustrated with line drawings and tables. Readers are referred to the more comprehensive Joslin's Diabetes Deskbook: A Guide for Primary Care Providers for more information. 8 figures. 1 table.
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Picking and Choosing: What Science Says About Food and Your Heart. Diabetes Forecast. 61(2): 32-35. February 2008.
This article helps readers understand current recommendations for eating a low-fat, high-fiber diet to help with cardiovascular health. The author describes the role of soluble fiber, which may help prevent heart disease by lowering harmful LDL cholesterol and may help keep blood glucose levels steady. Readers are encouraged to incorporate high-fiber foods into their diet, such as beans, oats, barley, nuts, flaxseed, carrots, apples, and oranges. The author explains the potential role of omega-3 fatty acids, which are found in fatty fish such as salmon and in plant sources like flaxseed. The article includes one recipe, salmon with garlicky kale, for which the nutrition facts, including exchange lists, are provided. One sidebar briefly describes the product of the month, a marinated and baked tofu product called “soy boy.”
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Point-of-Care Glycosylated Hemoglobin and its Impact on Diabetes Care. Practical Diabetology. 27(1): 20-24. March 2008.
This article helps clinicians understand the appropriate use of the glycosylated hemoglobin test (HbA1c or A1C), a measure of blood glucose levels over time. Even though HbA1c is considered an estimate of the mean blood glucose level over a period of 3 months, the authors note that the most recent 30 days of glycemia is responsible for about 50 percent of the observed HbA1c level. Therefore, although HbA1c is not a perfect test for monitoring a patient’s past glycemic control, it can be useful for assessing treatment effectiveness and helping patients understand the implications of the their blood glucose levels. The article covers the benefits and disadvantages of point-of-care HbA1c measurement and provides specific recommendations for the use of HbA1c in the office-based setting. The authors contend that point-of-care HbA1c can verify the accuracy of home blood glucose readings, provide a more accurate picture of glycemic control, and improve the timeliness of treatment decisions, thereby improving the management of diabetes. 1 figure. 4 tables. 16 references.
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Polypills for Treatment of Type 2 Diabetes: Is the Concept of Polypharmacy Correct?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 317-330.
This chapter about the use of polypharmacy for treatment of type 2 diabetes is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The author of this chapter notes that recently, polypharmacy, consisting of different drugs condensed in a polypill, has been proposed as a tool of primary and secondary prevention of cardiovascular disease and even for primary and secondary prevention of type 2 diabetes (T2DM). However, any antidiabetic polypill would need to be tailored to one of the various stages of T2DM, which differ considerably because metabolic and clinical defects evolve as the disease progresses. The author contends that even though a daily fixed-dose treatment might be helpful, there are obstacles including the size and weight of its formulation and the loss of therapeutic flexibility. Treatment flexibility is required to treat acute metabolic derangements and to cope with intermittent increases in blood pressure. A final section considers some of the other issues that would prevent the use of a polypill, including ineffective or insufficient diabetes care provision, which can be due to many factors from inadequate patient education to unavailable or unaffordable health care. 2 figures. 2 tables. 42 references.
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Possible Role of Oxidative Stress in the Pathogenesis of Hypertension. Diabetes Care. 31(Suppl 2): S181-S184. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the possible role of oxidative stress in the pathogenesis of hypertension. The author describes how an imbalance in superoxide and nitric oxide production may account for reduced vasodilation, which in turn can favor the development of hypertension. The author discusses the use of antioxidants, particularly in the form of fresh fruits and vegetables, and their effects on oxidative stress in hypertension. One final section considers the role of antihypertensive drug therapy, notably beta blockers and angiotensin receptor blockers. 50 references.
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Potential of Group Visits in Diabetes Care. Clinical Diabetes. 26(2): 58-62. Spring 2008.
This article considers the role of group visits for patients with diabetes. The authors stress that, compared with more ambitious redesign of practice delivery, group visits are a relatively straightforward innovation that can improve efficiency and encourage patient self-management. They review practical issues, sharing their experience with the use of group visits in a Midwest academic medical center and a West Coast family medicine residency. Most successful group visit programs include an element of between-visit care coordination and case management, typically provided by a nurse or nurse practitioner. Group visits may be used in place of or in addition to usual one-on-one primary care and offer advantages in length, focus, patient interaction, and added structure. The visit may include group education, shared problem-solving, focused private or semi-private medical evaluations that allow individualized medication adjustment, and ordering of preventive services and referrals. The authors discuss the evidence that supports group diabetes visits; patient selection and retention; educational materials; reimbursement issues; the nurse-practitioner-led, 90-minute model; and the physician-led, 1-hour minigroup visit. The authors conclude that the choice of optimal personnel and structure for group visits will depend on local resources. They call for additional research to define how group visits could best be combined with case management, information feedback to patients and providers, self-management innovation, and connection to community resources. 1 table. 25 references.
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Practice Implications of What Couples Tell Us About Type 2 Diabetes Management. Diabetes Spectrum. 21(1): 39-45. Winter 2008.
Type 2 diabetes requires adults to assume responsibility for many lifestyle and medical surveillance self-care behaviors to achieve and sustain optimal glycemic control. This article discusses the role of social relationships, particularly marriage or cohabitation, in the practical management of type 2 diabetes. The authors note that social relationships have been shown to mediate lifestyle and medical surveillance behaviors, glycemic control, and other health outcomes. The self-care regimen often involves spouses or significant others. The authors report on a study undertaken to listen to and draw conclusions from what couples had to say about managing daily life with type 2 diabetes. The study included 12, 90-minute focus groups, each with 5 to 10 participants, conducted in Pennsylvania. The groups used a structured discussion guide to promote consistency across the groups. Analyses revealed four core themes: educate yourselves, talk about the disease, work together, and be your own health advocate. The authors conclude with a discussion of this unique perspective on couples’ needs for care and the subsequent implications for the health community in acknowledging the role of significant relationships in the management of diabetes. 2 tables. 19 references.
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Pregnancy and Diabetes. JAMA: Journal of the American Medical Association. 299(21): 2590. June 2008.
This patient education fact sheet reviews the interplay of pregnancy and diabetes mellitus. The author briefly describes the differences among type 1 diabetes, type 2 diabetes, and gestational diabetes. The author outlines the risks of pregnancy for women with diabetes. These risks include heavier than average birth weight, low blood glucose in the newborn, higher chance of shoulder dystocia, congenital anomalies or birth defects, higher risk of cesarean delivery, and higher risk of delivering a stillborn infant. The next section outlines the strategies that can be used to manage diabetes before and during a pregnancy. The author emphasizes that optimal blood glucose management reduces risks to both the mother and the fetus. Readers are referred to the websites of the American Diabetes Association at www.diabetes.org, the Women’s Health Information Center at www.womenshealth.org, and the American College of Obstetricians and Gynecologists at www.acog.org for more information. A sidebar reminds readers of related patient education fact sheets published in the Journal of the American Medical Association and available at www.jama.com. 1 figure.
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Prevent Diabetes Problems: Keep Your Diabetes Under Control. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 23 p.
Diabetes is a disease in which blood glucose levels are above normal. People who have diabetes often experience complications of the heart, blood vessels, eyes, and kidneys because of these high blood glucose levels. This booklet, written in nontechnical language, answers common questions about complications that can be caused by diabetes. Topics covered include the risk factors for complications; daily activities that can help a person with diabetes stay healthy; recommended goals for blood glucose; the use of glycosylated hemoglobin testing, or HbA1c, a measure of blood glucose over time; blood pressure goals; cholesterol level goals; and the problems associated with smoking. Three sections list recommended activities for each day, every time the patient sees a health care provider, and at least once per year. Recordkeeping forms are included. The booklet concludes with a list of organizations through which readers can get additional information about diabetes complications and a section that briefly summarizes the activities of the National Diabetes Information Clearinghouse. The booklet is illustrated with black-and-white line drawings. 10 figures. 6 tables.
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Prevent Diabetes Problems: Keep Your Feet And Skin Healthy. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 23 p.
Diabetes is a disease in which blood glucose levels are above normal. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This booklet, written in nontechnical language, answers common questions about foot and skin problems associated with diabetes. Topics include the importance of daily diabetes care to stay as healthy as possible, how diabetes can hurt the feet, the importance of daily foot care and wearing appropriate shoes and socks, the role of the health care team in foot care, common diabetes foot problems, the use of special shoes, how diabetes can affect and damage the skin, and recommended skin care. The booklet concludes with contact information for resource organizations and a brief summary of the activities of the National Diabetes Information Clearinghouse (NDIC). The booklet is illustrated with black-and-white line drawings and includes a brief pronunciation guide for some of the medical terms used. 17 figures.
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Prevent Diabetes Problems: Keep Your Kidneys Healthy. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 18 p.
Diabetes is a disease in which blood glucose levels are above normal. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This booklet, written in nontechnical language, answers common questions about kidney disease associated with diabetes, or diabetic nephropathy. Topics include daily diabetes care to stay as healthy as possible; the anatomy and function of the kidneys; how to prevent diabetes-related kidney problems; the need to protect one’s kidneys during special x-ray tests; how diabetes can damage the kidneys; the symptoms of kidney failure; how kidney problems are diagnosed; and some treatment options, including hemodialysis and peritoneal dialysis. The booklet includes a pronunciation guide for the medical terms used, a brief list of recommended websites to visit, a list of the titles in the patient education series called “Prevent Diabetes Problems,” and the contact details for four resource organizations that can help patients obtain additional information. The booklet concludes with a brief summary of the activities of the National Diabetes Information Clearinghouse (NDIC). The booklet is illustrated with black-and-white line drawings. 12 figures.
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Prevent Diabetes Problems: Keep Your Nervous System Healthy. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 27 p.
Diabetes is a disease in which blood glucose levels are above normal. People who have diabetes often experience complications due to these high blood glucose levels, including in the heart, blood vessels, eyes, and kidneys. This booklet, written in nontechnical language, answers common questions about nerve problems that can be caused by diabetes. Topics covered include daily activities that can help a person with diabetes stay healthy; foot care; the physiology of the nervous system; how diabetes can affect the peripheral, autonomic, and cranial nerves; the symptoms of nerve damage; and where to get additional information about diabetes nerve problems, including the contact information for resource organizations. The booklet concludes with a section that briefly summarizes the activities of the National Diabetes Information Clearinghouse (NDIC). The booklet is illustrated with black-and-white line drawings and includes a brief pronunciation guide for some of the medical terms used. 14 figures.
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Prevent Diabetes Problems: Keep Your Teeth And Gums Healthy. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.
This illustrated booklet, written in nontechnical language, uses a question-and-answer format to provide people who have diabetes with information about preventing tooth and gum problems caused by the disease. Too much glucose in the blood for a long time can cause diabetes problems and can damage many parts of the body, such as the heart, blood vessels, eyes, and kidneys. High blood glucose, also called blood sugar, helps bacteria grow, which can lead to a condition called periodontitis. Symptoms of tooth and gum damage include red, sore, swollen gums; bleeding gums; gums pulling away from teeth; loose or sensitive teeth; bad breath; a bite that feels different; and poor-fitting dentures. The booklet explains how people and their dentists can keep teeth and gums healthy, reviews the symptoms of damage to the teeth and gums, and offers recommendations for daily home oral care. The booklet concludes with sources of information about diabetes and a brief summary of the activities of the National Diabetes Information Clearinghouse (NDIC). The booklet is illustrated with simple line drawings. 8 figures.
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Preventing Long Term Complications of Diabetes. 4th ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program explains the long-term complications of diabetes, including atherosclerosis and other cardiovascular diseases, kidney disease, eye disease, and neuropathy. Viewers are reminded of the importance of a self-management plan for keeping diabetes under control and preventing or minimizing these complications. The management plan outlined includes patient education, healthy eating, physical activity and exercise, medications, self-monitoring of blood glucose (SMBG), and the glycosylated hemoglobin (A1C) test used for longer term monitoring of blood glucose levels. The video depicts a variety of people who share their experiences with complications and diabetes management. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Prevention of Hypoglycemia While Achieving Good Glycemic Control in Type 1 Diabetes: The Role of Insulin Analogs. Diabetes Care. 31(Suppl 2): S113-S120. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the prevention of hypoglycemia while achieving good glycemic control in patients with type 1 diabetes. The authors focus on the role of insulin analogs as a tool to achieve good glycemic control and prevent hypoglycemia. Topics include the physiology of plasma glucose homeostasis, a definition of hypoglycemia, the frequency of hypoglycemia, normal responses to hypoglycemia and their pathophysiology in diabetes, antecedent hypoglycemia as a primary cause of hypoglycemia unawareness, the mechanisms of hypoglycemia unawareness, the benefits of insulin analogs versus human nonmodified insulin, and regimens of multiple daily injections and continuous subcutaneous insulin infusion (CSII). Now that soluble long-acting insulin analogs are available, multiple daily injections are no longer considered inferior to CSII in terms of A1C and frequency of hypoglycemia. The authors conclude that, when combined with appropriate patient education and motivation of the subjects with type 1 diabetes, insulin regimens based on insulin analogs—either multiple daily injections or CSII—can successfully achieve appropriate glycemic targets, thus protecting against the risk of long-term complications; prevent hypoglycemia unawareness; and improve quality of life. 3 figures. 76 references.
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Primary Prevention of Cardiovascular Disease in People with Dysglycemia. Diabetes Care. 31( Suppl 2): S208-S214. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the primary prevention of cardiovascular disease (CVD) in people with dysglycemia. Topics include hyperglycemia as a cardiovascular risk factor in people who do not have diabetes, the mechanisms of vascular damage of hyperglycemia, and cardiovascular risk reduction in dysglycemic subjects. The authors stress that epidemiologic data support the hypothesis of a direct and independent relationship between blood glucose levels and CVD. Prevention or delay in onset of diabetes is of utmost importance because chronic hyperglycemia is associated with CVD, and the risk starts to increase long before the onset of clinical diabetes. The authors conclude that reducing the burden of CVD requires identification of initial alteration of glucose homeostasis, as well as a careful search for any associated CVD risk factor. Lifestyle modification has been shown to be quite effective in preventing conversion of patients with impaired glucose tolerance (IGT) to having overt diabetes; lifestyle changes can also result in effective improvement in many cardiovascular risk factors. 1 table. 64 references.
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Problem Solving Highs And Lows. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 71-79.
This chapter about problem-solving high and low blood glucose levels, also known as hyperglycemia and hypoglycemia, respectively, is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize the importance of accurate recordkeeping, particularly when trying to determine the causes of hyperglycemia and hypoglycemia. They discuss the common causes of these problems, how to deal with sick days, the role of ketone testing, the use of glucagon injections for severe hypoglycemia, and being aware of hypoglycemia in the context of safe vehicle driving. A worksheet is provided to help readers determine the percentage of time their blood glucose levels are in target ranges. 2 figures. 2 tables.
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Quality Improvement in Diabetes Care Using Community Health Workers. Clinical Diabetes. 26(2): 75-82. Spring 2008.
This article describes the experiences of the Holyoke Health Center (HHC) in Holyoke, MA, as it incorporated community health workers (CHWs) into a quality improvement initiative focusing on patients with diabetes. The HHC has two sites and serves approximately 20,000 patients, most of whom are Spanish speaking; more than 1,700 of the center’s adult patients have diabetes. CHWs were added to the diabetes care team in 2003 to engage and support patients who were not succeeding in managing their diabetes. The authors describe the interventions used, the general outcomes, and the implications for practice. Separate results for the CHW program are not available because this effort was only one component of a multifaceted approach to improve services to this patient population. However, results showed an increase in the proportion of active patients who were visiting the clinic regularly and improvements in glycemic control, as measured by glycosylated hemoglobin (A1C). Appended to the article is a brief editorial comment referring readers to research on the topic of incorporating lay health workers into patient care.
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Quandary of Improving Hypertension Control in Diabetes. Clinical Diabetes. 26(4): 158-160. Fall 2008.
This article reports and comments on a research study that was undertaken to find methods of improving hypertension control in patients with diabetes. The study examined what proportion of diabetic patients (n = 1,169) with a triage blood pressure greater than 140 mmHg systolic or 90 mmHg diastolic received a treatment change during a single routine visit and to what extent certain provider and patient factors influenced the likelihood of change. About 49 percent of the patients with these blood pressure levels had a treatment change, either medication changes or a plan for follow-up blood pressure measurement within 4 weeks. There was no relationship between an increasing number of comorbid conditions and the likelihood of change. Discussion of medication or adherence issues was associated with a lower likelihood of medication change. The authors of the research study conclude that uncertainty about the accuracy of triage blood pressure measurements was a prominent factor in the decision to not intensify antihypertensive therapy. The article’s authors address concerns about inertia and uncertainty that are preventing clinicians from improving hypertension control in their patients. They stress that the use of a multimodal intervention that includes a multidisciplinary care team that includes a clinical pharmacist practitioner, computerized registries, and standardized treatment algorithms can result in successful reduction of blood pressure in patients with diabetes. However, this intervention is only effective when the clinical pharmacist can make direct changes in the patient’s medication; simply alerting the physician was not successful. 10 references.
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Reading and Understanding Food Labels. Diabetes Wellness News. 14(7): 1-2, 4. July 2008.
This patient education newsletter article helps readers understand food labels and how they can be used to make good choices for a healthy diet. The author briefly reviews the history of food labels, which, in their modern design, were required beginning in 1994 on most processed and semi-processed foods. Both the ingredients and nutritional information are required to be provided, along with a food label of a standard size and shape. Labels must provide information about how the food fits into an overall daily diet. Labels must include information about the amount per serving of saturated fat, cholesterol, dietary fiber, and other nutrients. Information must be expressed in common measures. Information must be reasonable in terms of serving sizes that people actually eat. The author describes the components of each part of the food label: the nutrition facts panel, the percent daily values, and the ingredient list. The author offers suggestions for readers with diabetes, discussing serving sizes, calories, and calories from fat. Readers are reminded that some of the healthiest foods, such as fresh produce, do not come with food labels. One sidebar reprints six symbols that are often found on food products to promote certain properties of the foods. The U.S. Food and Drug Administration (FDA) has not issued any regulations concerning food icons.
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Recipient and Donor Characteristics. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 45-64.
This chapter on recipient and donor characteristics is from the 2008 annual report of the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. After a brief textual introduction, most of the information is presented in charts and figures. The chapter includes 15 tables and figures: recipient demographics; transplant recipient primary funding information CITR-participating U.S. centers; recipient characteristics at first infusion; recipient diabetes characteristics at first infusion; recipient infectious disease testing at first infusion; recipient characteristics at first infusion by total number of infusions received; recipient demographics and characteristics at first infusion by total number of infusions received; recipient laboratory values at first infusion; donor demographics all allograft donors; donor characteristics all allograft donors; characteristics of organ procurement and donor cause of death all allograft donors; treatments given to donor during hospitalization all allograft donors; donor serology all allograft donors; donor laboratory data all allograft donors; and organ crossmatch results for all allograft donors. 18 tables.
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Retrospective Review of Incidental Retinal Emboli Found on Diabetic Retinopathy Screening: Is There a Benefit to Referral for Work-Up and Possible Management?. Clinical Diabetes. 26(4): 179-182. Fall 2008.
This article reports on a retrospective chart review that the authors conducted on all patients (n = 7,819) presenting to diabetic retinopathy screening clinics at the Nashville and Murfreesboro, TN, Veterans Administration Hospitals from May 2003 to September 2006. Screening was done with high-resolution digital fundus imaging, telemedicine, and centralized image grading. The authors were particularly interested in screening for retinal arteriolar emboli, which are associated with cerebrovascular and cardiovascular morbidity and mortality, in this patient population with type 2 diabetes. The screening identified 149 patients--1.9 percent of the patients screened--with retinal arteriolar emboli. These patients were referred to their primary care provider for further evaluation and possible treatment. Of these 149 patients, the average age was 67 years, and 73 percent had previously known cardiovascular disease, 54 percent were smokers, and 2.7 percent had symptoms of retinal emboli before the screening. The authors note that the detection of incidental emboli found when screening for diabetic retinopathy provides an important opportunity to initiate further work-up and management. The management of retinal arteriolar emboli includes the identification of risk factors and possible treatment with antiplatelet medication or vascular surgery. 2 tables. 16 references.
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Scientific Summary. IN: Collaborative Islet Transplant Registry Fifth Annual Report. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. pp 9-25.
This scientific summary chapter begins the 2008 annual report that presents data from the Collaborative Islet Transplant Registry (CITR) on islet/beta cell transplantation. Funded by the National Institute of Diabetes, Digestive and Kidney Diseases (NIDDK) with supplemental funding from the Juvenile Diabetes Research Foundation (JDRF), CITR’s mission is to expedite progress and promote safety in islet/beta cell transplantation through the collection, analysis, and communication of comprehensive and current data on all islet/beta cell transplants performed in North America, Europe, and Australia. Islets are clusters of insulin-producing cells located in the pancreas. In patients with type 1 diabetes mellitus (T1DM), all islets are destroyed by an autoimmune attack and patients need to inject insulin every day to stay alive. In patients with T1DM and poor kidney function, a whole pancreas transplant is sometimes performed. T1DM patients with severe hypoglycemia may be eligible for an alternative procedure using insulin-producing cells (islets of Langerhans) extracted from a deceased donor pancreas which, in the United States, is an experimental procedure. A small subset of these allogenic islet recipients have previously received a kidney transplant for end-stage renal disease and were already receiving long-term immunosuppression therapy at the time of their islet transplant. For all types of recipients, islets are implanted typically via the portal vein in the liver, where the islets produce insulin as needed by the recipient. Thirty-one medical institutions in the United States and Canada are currently or were previously active in islet transplantation since 1999. Of the 325 North American and European recipients included in this report, 279 (96 percent) were recipients without a previous kidney transplant who received one or more islet-alone infusions (IA), while 46 recipients (14 percent) had previously received a kidney transplant (IAK). This scientific summary discusses the background and purpose of the report, describes the patients and methods covered, and summarizes the results found in the areas of recipient characteristics, donor information, pancreas procurement, immunosuppression therapy, graft function, metabolic measures, concomitant medications, elevated laboratory tests, adverse events, and reported deaths. The authors stress that islet transplantation continues to show short-term benefits of insulin independence, normal or near normal HbA1c levels, sustained marked decrease in severe hypoglycemic episodes, and a return of hypoglycemia awareness. Long-term primary effectiveness and safety of immunosuppression, as well as the effects on secondary complications, are less well understood and are the focus of ongoing research. Readers are referred to the CITR website for more information and copies of the data collection forms (www.citregistry.org). 16 figures. 3 tables.
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Shock and Awesome. Diabetes Forecast. 61(2): 52-56. February 2008.
This article shares the story of actress Elizabeth Perkins, who was diagnosed with type 1 diabetes at age 44, after more than a decade of feeling constantly run down. In an interview style, Perkins, a mother of four, speaks about handling diabetes in Hollywood, why she is looking forward to getting an insulin pump, and how her diagnosis changed her life for the better. She details some of the frustrations and challenges in dealing with a chronic illness and how she has learned to focus on the consistency required for good diabetes control. 3 figures.
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Should We be More Aggressive in the Therapy Against Cardiovascular Risk Factors? : Should We Prescribe Statin and Aspirin for Every Diabetic Patient, Or is it Time for a Polypill?. Diabetes Care. 31( Suppl 2): S226-S228. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of prevention strategies for cardiovascular disease (CVD) in people with diabetes. The authors focus on the lack of compliance with recommendations for the primary and secondary prevention of cardiovascular complications in people with diabetes, even in developed countries with a well-structured medical system. They discuss financial and structural reasons, insufficient information of physicians and patients, and low compliance of both physicians and patients. The article goes on to discuss the idea of a polypill, an integrated pharmacological agent that could include up to six different compounds meant to prevent CVD. The authors highlight some of the advantages and pitfalls of this concept, focusing on treatment aspects in people with diabetes. They argue against the use of statins indiscriminately in all patients with diabetes, especially against the use of a polypill. 25 references.
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Should We Prescribe Statin and Aspirin for Every Diabetic Patient?: Is it Time for a Polypill?. Diabetes Care. 31(Suppl 2):S222-S225. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the use of prevention strategies for cardiovascular disease (CVD) in people with diabetes. The authors review the use of aspirin administration as secondary prevention in coronary heart disease (CHD), as well as research studies on the use of aspirin as a primary preventive strategy; statin therapy in cardiovascular prevention, notably target levels of lipid-lowering therapy; and the coadministration of aspirin and statins. The authors conclude that aspirin as well as statins are drugs with strong evidence of their beneficial effects, with a significant reduction of cardiovascular events and a low rate of side effects. Thus, a broad use of aspirin and statin treatment in patients with diabetes is recommended. 1 figure. 2 tables. 24 references.
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Soup Can Plan: Getting Fit Without Leaving the House. Diabetes Forecast. 61(2): 37-38. February 2008.
This article encourages readers to incorporate exercise and physical activity into their daily lives, even when they do not think they have the time or inclination to do so. The author reviews the benefits that even moderate amounts of activity can confer on diabetes control, noting particularly the positive aspects of both aerobic activity and resistance training. The article includes an illustration of a simple set of resistance training exercises that can be done with light pounds or household items like soup cans or water bottles. Readers may find it easier to start a program of resistance training because it can feel less taxing on the body than aerobic activities like running, biking, or walking. Aerobic activity can use up some stored glycogen in the muscles, which can help increase insulin action for a period afterwards. Resistance training can result in more muscle mass, which means a greater storage deposit for carbohydrates and a higher metabolism, which can help with weight loss. Readers are reminded to check with their health care provider before starting any new program of exercise.
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Sprinkles and Sprigs. Diabetes Forecast. 61(4):62-68. April 2008.
This article encourages readers to learn more about the use of spices and herbs to help replace sugar, fat, and salt in a healthy, diabetes-friendly diet. The author suggests that learning to prepare dry rubs for seafood, poultry, or meat is a good way to get started. The article offers four recipes: spicy barbecue chicken, herb-roasted salmon, penne with fresh tomato herb sauce, and apple cake with lemon thyme, each of which is illustrated with a full-color photograph. The recipes include ingredients, preparation instructions, and nutritional facts, including exchange list values.
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Standards of Medical Care in Diabetes: 2008. Diabetes Care. 31(Suppl 1): S12-S54. January 2008.
This section is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. Targets that are desirable for most patients with diabetes are provided. The recommendations included are screening, diagnostic, and therapeutic actions known or believed to favorably affect health outcomes of patients with diabetes. For each recommendation, the ADA has assigned a letter grade that represents the level of supporting evidence. Standards of care are categorized into 11 sections: classification and diagnosis; testing for pre-diabetes and diabetes in asymptomatic patients; detection and diagnosis of gestational diabetes mellitus (GDM); the prevention or delay of type 2 diabetes; diabetes care, including medical nutrition therapy (MNT) and diabetes self-management education (DSME); the prevention and management of diabetes complications, including hypertension, cardiovascular disease, dyslipidemia, nephropathy, retinopathy, neuropathy, and foot care; diabetes care in specific populations, including children, adolescents, and older adults; diabetes care in specific settings, such as hospitals, schools, daycare settings, diabetes camps, and correctional institutions; hypoglycemia and employment/licensure; third-party reimbursement for diabetes care, self-management education, and supplies; and strategies for improving diabetes care. 15 tables. 332 references.
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Staying Healthy For a Lifetime. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 87-102.
This chapter about staying healthy with diabetes is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize that complications associated with diabetes are not inevitable but that readers must be aware of them and implement treatment plans when they do occur. Topics include balancing stress, how to manage diabetes and a busy lifestyle, the psychosocial impact of dealing with a chronic disease, the different types of diabetes complications, cardiovascular diseases and how to prevent them, high blood pressure or hypertension, cholesterol management strategies, smoking and diabetes, steps to good foot care, sensory nerves and blood circulation, planning for pregnancy, and other diabetes complications. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 6 figures. 1 table.
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Staying Healthy with Diabetes: Nutrition and Meal Planning. Boston, MA: Joslin Diabetes Center. 2008. 134 p.
This book is designed to help readers newly diagnosed with diabetes understand how to adapt their food habits to help keep blood glucose levels as close to target ranges as possible. The authors encourage readers to learn more about how to make healthy choices to help manage their diabetes. The book offers 16 chapters covering meal planning, how different types of foods affect blood glucose levels, three types of meal plans, exchange lists, carbohydrate counting, a starter meal plan, the role of the dietitian, meal planning tools and recordkeeping, nutrition labels, caloric and noncaloric sweeteners, dietary fiber, glycemic index and glycemic load, hearty-healthy eating, blood fats, dietary fats, sodium, tips for cooking and baking, shopping tips, eating at restaurants, alcohol, holidays and special occasions, meal replacements, coping with sick days, vitamins and minerals, and herbal and other dietary supplements. A final chapter encourages readers to keep their meal planning approach simple and enjoyable. The book concludes with eight lists of food items, serving sizes, and their carbohydrate and calorie content: carbohydrates, protein, fat, free foods, combination foods, fast foods, and vegetarian items. The book includes numerous charts and tables that summarize the data in the text. The inside back cover presents a brief description of the Joslin Diabetes Center in Boston, MA.
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Sweet Stuff. Diabetes Forecast. 61(4): 58-61. April 2008.
This article reminds readers with diabetes of the role of carbohydrates in meal planning. Carbohydrate is the general term for starches and sugar in foods and is the component of one’s diet that has the biggest and most direct effect on blood glucose levels. The author helps readers identify those foods that have carbohydrates, including sugary foods, grains and bread, milk, beans, and some vegetables. Readers are encouraged to choose foods whose carbohydrates come in tandem with other benefits, primarily dietary fiber, vitamins, or minerals, and to avoid so-called “empty” calories. A final section describes the use of the glycemic index, a system that ranks carbohydrate foods based on their effect on blood glucose levels. One sidebar walks readers through reading a nutrition label, with an emphasis on identifying and understanding carbohydrate contents. 4 figures.
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Taking Insulin. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 13-22.
This chapter about taking insulin is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors review the different types of insulin, outline the most common insulin plans used, explain how to measure insulin and inject it, discuss insulin storage, and help readers understand the emotions they might experience as they adjust to using insulin. Readers are referred to three resource organizations for help in locating a mental health care provider. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 4 figures. 1 table.
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Taking Insulin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program reviews the steps involved in taking insulin. With step-by-step demonstrations, viewers are taken through the process of injecting insulin with a single dose syringe, a mixed dose syringe, and an insulin pen. Other topics include the preparation steps, the importance of rotating insulin injection sites, and monitoring for problems at injection sites. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management and insulin injection. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Targets for Intervention in Dyslipidemia in Diabetes. Diabetes Care. 31(Suppl 2): S241-S248. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, reviews the targets used for intervention in dyslipidemia in people with diabetes. Topics include atherosclerosis and blood glucose control, atherosclerosis and diabetic dyslipidemia, diabetes and hypertriglyceridemia, low-density lipoprotein (LDL) in diabetes, high-density lipoprotein (HDL) activity, fatty acids and insulin secretion, the lipoprotein cascade, regulation of the chylomicron, and plant sterols and diabetes. The author notes that the abnormalities in fatty acid metabolism caused by diabetes result in an abnormal lipoprotein cascade from the large chylomicron particle to the small HDL particle. Thus, drugs that alter formation of the chylomicron particle might have a very important role in diabetic dyslipidemia. The author reviews some of the newer treatment options, including drug therapy and dietary recommendations, for patients with dyslipidemia and diabetes. 2 figures. 79 references.
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Teaching Families to Keep Their Children S.A.F.E. From Obesity. Diabetes Spectrum. 21(1): 50-53. Fall 2008.
This article outlines strategies that can be used to help families and children learn healthy approaches to eating that can prevent obesity. The strategy uses the acronym S.A.F.E. to remind readers of the steps to consider: Skip or Stop High Calorie Drinks; Alter Snack Habits; Forget Unhealthy Fast Foods; and Exercise Daily. The authors contend that these steps represent four major nutritional blind spots related to obesity. They encourage dietitians and other health care providers to use this acronym to prompt discussion with their patients regarding common reasons for excess weight gain in children and adolescents. Other topics discussed include behavioral contracts, the need for positive feedback, after-meal snacks, marketing of fast foods, the use of visual tools to help patient education, limiting television and computer time, family exercise options, and clinical reimbursement. The authors conclude that the S.A.F.E. acronym is a simple message for practitioners to use in the busy clinic setting to focus on major contributors to childhood obesity. Implementing just one of these interventions into a family’s lifestyle can result in a positive outcome regarding a child’s health. Encouraging families to make and maintain small, simple changes can yield great success. 2 figures. 10 references.
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Testing Your Blood Glucose. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 23-28.
This chapter about testing blood glucose levels is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors emphasize the importance of good recordkeeping and discuss when to test, glucose targets, the steps for accurate blood glucose testing, how to achieve accurate results, and the safe disposal of used needles and lancets. Space is provided for readers to record their blood glucose goals. 2 figures. 2 tables.
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Third-Party Reimbursement for Diabetes Care, Self-Management Education, and Supplies. Diabetes Care. 31(Suppl 1): S95-S96. January 2008.
This brief position statement on third-party reimbursement for diabetes care, self-management education, and supplies is from the special supplement issue of Diabetes Care journal that contains the latest update of the American Diabetes Association’s (ADA) major position statement, “Standards of Medical Care in Diabetes.” Selected position statements are provided about certain topics not adequately covered in the standards. This position statement stresses that an integral component of diabetes care is diabetes self-management education (DSME) delivered by an interdisciplinary team. DSME teaches individuals with diabetes to assess the interplay among medical nutrition therapy (MNT), physical activity, emotional and physical stress, and medications and respond appropriately and continually to those factors to achieve and maintain optimal glucose control. Because no single diabetes treatment regimen is appropriate for all people with diabetes, providers and patients should have access to a broad array of medications and supplies to develop an effective treatment modality. The position statement addresses the importance of maintaining this access, particularly in the care of a chronic disease such as diabetes. Third-party reimbursement should not implement controls that limit equipment and supplies, including newly developed products. 9 references.
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Treatment Modalities of Obesity: What Fits Whom?. Diabetes Care. 31(Suppl 2): S269-S277. February 2008.
This article focuses on treatment modalities for obesity. The authors review the currently used approaches, noting that not every method will be appropriate for every patient. Obesity treatment should be individually tailored and the age, sex, degree of obesity, individual health risks, metabolic and psychobehavioral characteristics, and outcome of previous weight loss attempts should be taken into account. The authors discuss the types of low-energy diets that can be recommended, the role of physical activity, psychological factors and the behavioral modification of lifestyle, drug treatment of obesity, bariatric surgery, hormonal and hereditary factors affecting weight loss, hormonal determinants of weight loss, hereditary determinants of weight loss, weight loss in monogenic forms of obesity, and the genetic component of weight loss in common forms of obesity. The authors emphasize that obesity needs to be treated within the health care system as any other complex disease—with empathy and without prejudice. Regular physical activity, cognitive behavioral modification of lifestyle, and administration of antiobesity drugs improve weight loss maintenance. The article concludes with a description of a comprehensive multilevel obesity management network, an approach that includes the direct involvement of the health and general insurance industries as well as governments, obesity management centers, obesity specialists, primary care physicians, weight loss clubs, and the media. 79 references.
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Treatment of Diabetes in Long-Term Care Facilities: A Primary Care Approach. Clinical Diabetes. 26(4): 152-156. Fall 2008.
This article presents a primary care approach for managing type 2 diabetes in patients who are residents of long-term care (LTC) facilities. The authors note that there are guidelines for younger patients, but nursing home residents have different characteristics that may affect their diabetes care. Treatment goals for residents of LTC facilities should account for life expectancy, cognition, established complications, polypharmacy, and other issues. The authors stress the importance of individualized treatment plans, based on these issues as well as patient preferences. They examine appropriate guidelines and medication use in this population, including general glucose management, metformin, sulfonylureas, thiazolidinediones, DPP-IV inhibitors, costs factors, residual pancreatic beta cell function, the role of basal insulin injections, management of hypertension, treatment of cholesterol disorders, and aspirin therapy. In short-term management—that is, for patients with 3 to 4 years of life expectancy—avoiding hyperglycemia may be more important in terms of comfort care than in reducing complications. Avoiding hyperglycemia can reduce incontinence, improve fatigue levels and cognition, and improve overall well being. The authors note that avoidance of hypoglycemia is important, particularly in those patients with dementia or other factors that may limit their ability to detect or report symptoms. 2 tables. 36 references.
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Treatment of Diabetic Neuropathy and Neuropathic Pain: How Far Have We Come?. Diabetes Care. 31(Suppl 2): S255-S261. February 2008.
This article explores the current and proposed treatment of diabetic neuropathy and neuropathic pain, common complications in people with diabetes. Treatment is based on four components: causal treatment aimed at achieving normal blood glucose levels; treatment based on pathogenetic mechanisms; symptomatic treatment; and avoidance of risk factors and complications. Because the pathogenesis of diabetic neuropathy is multifactorial, treatments must use different approaches. The authors review some of the new treatments being evaluated in clinical trials, including alpha-lipoic acid and epalrestat, which are already available in some countries. Some new analgesic drugs have been recently approved in the United States, including duloxetine and pregabalin, but the pharmacologic treatment of chronic painful diabetic neuropathy remains a challenge for the physician and patient. Risk factors that can contribute to painful diabetic neuropathy including alcohol consumption, as well as traditional cardiovascular risk factors such as hypertension, smoking, and cholesterol; these factors need to be prevented or treated to help patients coping with diabetic neuropathy. 3 tables. 43 references.
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Treatment of Type 2 Diabetes with Combined Therapy: What Are the Pros and Cons?. Diabetes Care. 31(Suppl 2): S131-S135. February 2008.
This article, from a special supplement of Diabetes Care magazine that reports the proceedings of the 1st World Congress on Controversies in Diabetes, Obesity, and Hypertension (CODHy) held in Berlin in 2006, considers the advantages and limitations of the treatment of type 2 diabetes with combination therapy. The authors recommend a stepwise approach for the treatment of type 2 diabetes, tailored according to the natural course of the disease, including adding insulin when hypoglycemic oral agents fail. They stress that treatment with insulin alone should eventually be considered in a relevant number of cases. Insulin can result in protective effects on beta-cell survival and function, resulting in more stable metabolic control. In comparison, treatment with most insulin secretagogues has been associated with increased beta-cell apoptosis, reduced responsiveness to high glucose, and impairment of myocardial function during ischemic conditions. Insulin treatment, particularly with rapid-acting analogs, has been demonstrated to successfully control postprandial hyperglycemia. The authors voice a final concern about combination regimens in the evidence that polypharmacy can reduce patient compliance to the treatment regimen. 56 references.
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Treatment of Type 2 Using Insulin: When to Introduce?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 51-68.
This chapter about the treatment of type 2 diabetes with insulin is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter stress that insulin therapy is increasingly seen as a key intervention in type 2 diabetes mellitus (T2DM). This is because of the overwhelming evidence in support of glycemic control and an awareness of the long-term consequences of hyperglycemia, in particular the onset and progression of microvascular and macrovascular complications. They focus on issues of implementation and overcoming barriers to the use of insulin. The current treatment debate in T2DM is not about insulin per se, but when and how to introduce simple insulin regimens, dictated by clear algorithms and driven by blood glucose monitoring to achieve long-term near-normoglycemia with minimal effort. These regimens must be managed by the patient in partnership with the diabetes care team. The authors conclude that patients must not be left with excess glycemic burden for extended periods; thus an aggressive strategy to maintain glycemic control with early insulin introduction to ensure target levels of glycemia will bring well-being to the patient and counter the long-term complications of diabetes. 6 figures. 1 table. 65 references.
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Understanding Insulin And Amylin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program reviews how insulin works in the body and how it can be used to help people with diabetes keep their blood glucose levels in a healthy range. The program introduces amylin, another pancreatic hormone, and explains how taking the drug pramlintide (Symlin) can help people who use insulin maintain greater control of their blood glucose levels. Other topics include insulin and amylin safety, storage, recordkeeping, hypoglycemia, and how to handle sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management, insulin use, and pramlintide use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Understanding Insulin. 3rd ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program describes insulin and how it is used by people with diabetes to help keep their blood glucose levels in a healthy range. The program discusses insulin’s mechanism of action and the onset, peak, and duration of different types of insulin. Other topics include insulin safety, storage recommendations, hypoglycemia, and coping with sick days. Viewers are reminded of the importance of a comprehensive self-management plan for keeping diabetes under control. The video depicts a variety of people who share their experiences with diabetes management and insulin use. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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Unifying Hypothesis of Diabetic Complications. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. Totowa, NJ: Humana Press. 2008. pp 233-250.
This chapter about the causes of diabetes complications is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter present a unifying hypothesis that considers several molecular mechanisms that have been implicated in glucose-mediated vascular damage. These mechanisms include increased flux through the polyol pathway, accumulation of advanced glycation end-product precursors, activation of protein kinase C isoforms, and increased hexosamine pathway activity. The authors contend that all of these seemingly unrelated mechanisms arise from a single, hyperglycemia-induced process: the overproduction of reactive oxygen species by the mitochondrial electron transport chain. The chapter concludes with a description of some new treatment approaches that could be used, including transketolase activators, PARP inhibitors, and catalytic antioxidants. 7 figures. 57 references.
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Use of Continuous Glucose Monitoring to Evaluate the Glycemic Response to Food. Diabetes Spectrum. 21(2): 134-137. Spring 2008.
This article considers the use of continuoug glucose monitoring (CGM) to evaluate the glycemic response to food in patients with diabetes. CGM can be used to track glucose levels 24 hours a day, observe glucose trends and patterns, and send alarms or alerts for actual and impending hypoglycemia and hyperglycemia. Glucose values, trend arrows, line graphs, and alarms viewed on the device screen provide real-time perspective. The authors discuss factors affecting postprandial glycemia (PPG), how to evaluate personal glycemic responses to food, PPG response to mixed meals, prandial insulin dosing, timing of the meal bolus, different types of boluses, and insulin sensitivity determined with CGM. The authors conclude by supporting the use of CGM for clinicians and patients to more effectively and easily evaluate the patient’s glycemic response to various types of foods and meals. This information gives patients the ability to more effectively adjust prandial insulin and lifestyle therapy based on their food choices. However, clinicians must take the responsibility for training patients in how to interpret the data and make appropriate decisions. 3 figures. 11 references.
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Use of Internet Technology to Support Nutrition and Diabetes Self-Management Care. Diabetes Spectrum. 21(2): 91-99. Spring 2008.
This article provides an overview of how Internet websites can be used in diabetes care, providing evaluation criteria and a review of selected sites. The authors describe the use of Internet information to support medical nutrition therapy (MNT), which focuses on making behavioral decisions to support an individual’s specific nutritional needs. MNT must take into consideration the variety of situations in which food decisions are made and must determine whether patients are confident and comfortable implementing the nutrition recommendations. The authors discuss access to websites, the categories of nutrition websites, content information sites, behavioral and motivational support sites, data tracking sites, and decision points that can help one evaluate a specific website. One lengthy chart summarizes information about selected nutrition websites, including both free and subscription sites for weight management, nutrition and diabetes management, and Spanish-language sites. Another chart lists five recommended nutrition databases that offer diabetes handouts available on the Internet: Nutritiondata.com at www.nutritiondata.com; Calorie King at www.calorieking.com; American Dietetic Association at www.dce.org/publications/slicks.htm; National Diabetes Education Program at www.ndep.nih.gov; BD Diabetes at www.bddiabetes.com/us/hcp; and Humalog Insulin at www.humalog.com/patient/insulin_educational_materials.jsp. 5 tables.
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Use of Real-Time Continuous Glucose Monitoring Technology in Children and Adolescents. Diabetes Spectrum. 21(2): 84-90. Spring 2008.
This article considers the use of real-time continuous glucose monitoring (CGM) in children and adolescents as part of a comprehensive program of diabetes care. The authors combine research findings and clinical experience to describe the importance of realistic expectations of CGM, wearability considerations, and the potential benefits of glucose alarm features for pediatric patients. CGM systems measure glucose in the interstitial fluid, rather than blood glucose, providing interstitial glucose readings every 1 to 5 minutes. CGM systems are approved for adjunctive use and should be used in addition to blood glucose testing. The authors stress that real-time CGM alarms for actual or projected high glucose can help alert children and adolescents to missed meal boluses and facilitate correction actions earlier than conventional blood glucose testing alone. This is one of the benefits cited as a reason for interest in CGM in this population. In addition, retrospective glucose trends can be used to make medication or lifestyle modifications. 2 figures. 2 tables. 15 references.
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Using Blood Glucose Patterns to Improve Control. IN: Rickheim, P., et al. Insulin Basics. Minneapolis, MN: International Diabetes Center. 2008. pp 81-86.
This chapter about using blood glucose patterns to improve diabetes control and management is from a book that provides detailed information about the use of insulin in treating diabetes. The book is designed for people who have been using insulin for a long time, as well as those who may have recently been diagnosed with diabetes. The book encourages readers to learn about diabetes and be an active member of their health care team. The authors describe pattern control as the process of recognizing blood glucose patterns, analyzing what is causing readings that are out of target range, and taking steps to bring the blood glucose levels back into target ranges. They guide readers through the steps of knowing which insulin to adjust, as well as how to safely and accurately make changes to insulin dosages. Information is provided for patients on premixed insulin, background insulin with diabetes pills, and background and mealtime insulin. Much of the information is provided in figures, lists, and charts for ease of access and understanding. 1 figure. 4 tables.
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Using Insulin to Treat Diabetes: General Principles. IN: Beaser, R.S. Joslin's Insulin Deskbook: Designing And Initiating Insulin Treatment Programs. Boston, MA: Joslin Diabetes Center. pp 1-32.
This chapter is from a handbook that helps health care providers understand the complexities of insulin therapy for their patients with diabetes. The chapter reviews the general principles of insulin therapy, covering endogenous insulin; insulin for exogenous therapy; insulin purity; insulin types, brands, and modes of delivery; insulin antibodies; insulin allergy; storage considerations; syringes and other injection devices; syringe preparation techniques; injection techniques; common mixtures; insulin pens; automatic injection aids and jet injectors; injection aids for people with low vision; injection sites; syringe reuse; and disposal of syringes. The chapter is illustrated with line drawings and tables. Readers are referred to the more comprehensive Joslin's Diabetes Deskbook: A Guide for Primary Care Providers for more information. 3 figures. 2 tables.
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Walking 101: Putting One Foot in Front of the Other Can Put You Ahead of the Game. Diabetes Forecast. 61(4): 31-34. April 2008.
This article encourages readers with diabetes to incorporate walking into their every day activities. Walking is extolled as a low-impact aerobic activity that burns substantial calories and has a low risk of injury. The author reviews the health benefits of walking, explains easy strategies to make the most of one’s exercise time, outlines a 4-week beginner’s walking program, and explains the importance of wearing good shoes and socks for walking. One figure demonstrates four steps that can be used to walk faster and more efficiently: stand tall, focus on taking quicker steps not longer ones, bend the arms, and push off of the toes to generate boost at the end of each step. 2 figures.
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Warm-Up Time. Diabetes Forecast. 61(1): 23-30. January 2008.
This article reminds readers of the benefits of soups and stews as part of a healthy meal plan program for managing diabetes. The author emphasizes that thick, creamy soups and hearty, chunky stews do not have to mean a pot full of fat and calories. The article includes three recipes: creamy spinach and leek soup; vegetarian butternut squash and parsnip soup; and Italian sausage and white bean stew. Each recipe includes ingredients, preparation instructions, and full nutritional information, including exchange list values. A final section offers some quick tips for developing better flavors in soup recipes.
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We Have the Power to Prevent Diabetes. Bethesda, MD: National Diabetes Education Program. 2008. 2 p.
This brochure encourages American Indians and Alaska Natives to take the power to prevent diabetes by making simple lifestyle changes such as losing 10 pounds, walking 30 minutes a day, and making healthy food choices. Readers are reminded that even if diabetes runs in their family, these simple steps can help them prevent getting diabetes. The brochure outlines seven steps: move more, make healthy food choices, take off some weight, set realistic goals, record progress, seek help and support, and keep at it. In each section, the brochure includes quotations from people who share how they have incorporated these steps into their lives; their first names and tribal affiliations are noted. The brochure is illustrated with full-color photographs of a variety of American Indians and Alaska Native people. Information about how to contact the National Diabetes Education Program (NDEP) is provided (www.YourDiabetesInfo.org or 1–888–693–6337).
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Weight and Diabetes. JAMA: Journal of the American Medical Association. 299(23): 2814. June 2008.
This patient education fact sheet reviews the interplay of body weight and diabetes mellitus. The author briefly describes the differences between type 1 and type 2 diabetes. The author explains how losing weight greatly reduces one’s chances of developing type 2 diabetes and can be helpful in bringing blood glucose levels under control in people who already have the disease. The fact sheet lists recommended activities and dietary approaches to lose or control weight. Readers are referred to the websites of the American Diabetes Association at www.diabetes.org and the National Institute of Diabetes and Digestive and Kidney Diseases at www.niddk.nih.gov for more information. A sidebar reminds readers of related patient education fact sheets published in the Journal of the American Medical Association and available at www.jama.com. 1 figure.
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Weight Loss in Type 2 Diabetic Patients: Is It Worth the Effort?. IN: LeRoith, D.; Vinik, A., eds. Controversies in Treating Diabetes: Clinical and Research Aspects. . Totowa, NJ: Humana Press. 2008. pp 201-232.
This chapter about weight loss in patients with type 2 diabetes is from a book that addresses diabetes controversies, specifically in the etiology and management of the disease. The authors of this chapter focus on the evidence regarding the role of weight loss in the prevention and treatment of type 2 diabetes. They review strategies that have been shown to be effective in improving adherence to diet and physical activity interventions for individuals with type 2 diabetes. Topics include whether weight loss is worth the effort, the adverse psychological effects of weight loss, the factors that contribute to successful long-term weight loss, diet strategies that optimize weight loss and weight loss maintenance, physical activity strategies that optimize weight loss and maintenance, and how to disseminate effective strategies to more people. The authors conclude that physical activity plays an important role in long-term weight management and has additional health benefits for diabetes patients, including improved insulin sensitivity and glycemic control. Successful weight loss is indeed possible for individuals with diabetes and will result in significant health benefits for this population. 107 references.
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What I Need to Know About Diabetes Medicines. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 16 p.
This booklet helps readers with diabetes understand how diabetes medicines help keep their blood glucose levels in healthy target ranges. Written in nontechnical language, the booklet describes how these medications work; recommended targets for blood glucose levels, including for before and after meals; how blood glucose levels are affected by the presence of diabetes; medicines that may be used for each of the types of diabetes, including type 1, type 2, and gestational diabetes; and the types of diabetes medications and their forms, including insulin injections and insulin pumps, the side effects of insulin, the different types of insulin, oral medications, and injections other than insulin. Inside the back cover of the booklet is a folder with numerous inserts that provide information about specific drugs. The first insert is a form on which readers and their health care providers can record the medications currently prescribed. A second insert offers a list of questions patients might want to ask about their diabetes medications, and a third insert summarizes the different types of insulin. The remaining inserts provide specific information about the following drugs: the alpha-glucosidase inhibitors Glyset (miglitol) and Precose (acarbose); the biguanides Glucophage (metformin), Glucophage XR (long-acting metformin), and Riomet (liquid metformin); Starlix (nateglinide); the DPP-4 inhibitor Januvia (sitagliptin); a meglitinide called Prandin (repaglinide); sulfonylurea compounds including Amaryl (glimepiride), DiaBeta (glyburide), Diabinese (chlorpropamide), Glucotrol (glipizide), Glucotrol XL (long-acting glipizide), Glynase (glyburide), Micronase (glyburide), and the generics tolazamide and tolbutamide; thiazolidinediones Actos (pioglitazone) and Avandia (rosiglitazone); the combination pill Actoplus Met (pioglitazone and metformin); and the amylin mimetic Symlin (pramlintide). Each drug insert explains what the drug is supposed to do, who should and should not take the drug, and possible side effects. A final insert discusses low blood glucose levels. Blank spaces in different sections of the booklet allow readers to note their own individual prescriptions. The booklet concludes with a list of resources from which readers can get more information and a brief description of the goals and activities of the National Diabetes Information Clearinghouse.
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What I Need to Know About Physical Activity and Diabetes. Bethesda, MD: National Diabetes Information Clearinghouse. 2008. 15 p.
Diabetes is a disease in which blood glucose levels are above normal. Over time, high blood glucose damages nerves and blood vessels, leading to complications such as heart disease, stroke, blindness, kidney disease, nerve problems, gum infections, and amputation. This booklet, written in nontechnical language, answers common questions about the role of physical activity and exercise in a complete diabetes management program. Topics include the benefits of a physically active lifestyle, the kinds of physical activity that may be appropriate, cautions for some types of physical activity, the interrelationship between exercise and low blood glucose levels, how to get started on an exercise program, and how to stay motivated to maintain a physically active lifestyle. Suggestions are provided for incorporating exercise into everyday activities, for making sure that aerobic exercise is included, and for stretching and strength training. A sidebar lists tips for treating low blood glucose episodes. The booklet includes contact details for resource organizations where readers can get more information. A final section summarizes the activities of the National Diabetes Information Clearinghouse. The booklet is illustrated with black-and-white line drawings. 6 figures.
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What is Diabetes? (Type 2) 4th ed. Timonium, MD: Milner-Fenwick. 2008. (DVD).
This DVD program explains the differences between type 1 and type 2 diabetes. The program focuses on type 2 diabetes, covering the symptoms, risk factors, long-term complications, and treatment approaches. Viewers are reminded of the impact of excess weight on the development of diabetes. The program discusses insulin resistance, target ranges of blood glucose, healthy food choices, the diabetes food guide pyramid, carbohydrate counting, fats, portion sizes, the role of physical activity, blood glucose monitoring, and the use of medications to help keep diabetes under control. The video depicts a variety of people with type 2 diabetes and shares their experiences with diagnosis and diabetes management. Simple graphics are used to explain most of the topics covered. Viewers are referred to the American Association of Diabetes Educators website for more information and to find a local diabetes educator.
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What Is Diabetes? A Brief Introduction to Its Inner Workings. Diabetes Forecast. 61(4): 48-50. April 2008.
This article briefly reviews the physiology of diabetes and its impact on the health of the body. Topics include how food gets converted into the energy source glucose, the role of insulin, liver cells, beta cells in the pancreas, insulin receptors, and the differences among type 1 diabetes, type 2 diabetes, and gestational diabetes. Insulin regulates metabolism, the body’s processing of energy, and is released in reaction to the torrent of glucose that is in the blood after a meal. Insulin receptors protrude from most cells in the body and transmit the availability of glucose to cells. In type 1 diabetes, the pancreas no longer makes insulin. In type 2 diabetes, the pancreas usually still makes at least some insulin, but the cells are no longer responsive to glucose transport. In gestational diabetes, insulin is still produced, but the body has become resistant due to the hormonal changes of pregnancy. 2 figures.
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Winter Wonders. Diabetes Forecast. 61(1): 58-62. February 2008.
This article helps readers incorporate winter fruits such as apples, pears, and citrus into their regular diet. The article includes recipes and full-color photographs for three items: maple apples, pear-walnut crumble, and winter salad with citrus. The recipes include the ingredients, preparation instructions and nutrition facts, including exchange list values.
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Woman’s Disease. Diabetes Forecast. 61(2): 48-49. February 2008.
This article, from a magazine for people with diabetes, reminds women of their risks for heart attack and other cardiovascular diseases (CVDs). The author notes that, until recently, heart disease was viewed predominantly as a problem for men and much of the research focused on men. However, more women than men die each year of heart and blood vessel disease and about one-third of all adult women have some form of CVD. The article focuses on the ways heart disease differs between men and women, including symptoms, types of heart disease or blood flow blockages, problems in diagnosis, and risk factors. Nine risk factors play major roles in heart attacks in both men and women: cigarette smoking, unhealthy blood lipid levels, high blood pressure, diabetes, obesity in the abdomen, lack of exercise, low intake of fruits and vegetables, high intake of alcohol, and psychosocial factors. Readers are encouraged to learn what to do in an emergency if they think they might be having a heart attack. Suggestions include taking a regular aspirin right away, calling 911 rather than driving or asking a friend or loved one to drive to the hospital, and not delaying; heart attacks are best treated immediately. One sidebar lists the symptoms of heart attack; readers are reminded that women are more likely than men to have symptoms other than chest pain. 1 figure.
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Working With Patients to Enhance Medication Adherence. Clinical Diabetes. 26(1): 17-19. Winter 2008.
This article provides practical suggestions for physicians and nurses who want to help their patients follow their medications regimens effectively. The authors stress that optimal medication adherence improves clinical outcomes and can even lower health care costs by reducing morbidity and decreasing health care use. There are many reasons for patient nonadherence, including depression, side effects, poor provider-patient communication, inadequate knowledge on the part of both patients and providers about a drug and its use, psychological insulin resistance, complicated dosing schedule, costs, and other access issues. The authors outline a number of strategies, introduce a collaborative approach by clarifying the patient-physician/team partnership, explain key information when prescribing a medicine, assess adherence, simplify medication-taking, identify difficulties and barriers related to medication-taking, provide behavioral support, and schedule follow-up contacts specifically for medications. A patient education handout on this topic follows this article in the journal. 2 figures. 17 references.
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10 Steps to Better Living With Diabetes. Alexandria, VA: American Diabetes Association. 2007. 263 p.
This book offers practical strategies that people with diabetes can implement in their daily lives to make diabetes care easier and more satisfying. The author focuses on 10 of the most discussed topics in diabetes self-care: adjusting to a diagnosis of diabetes; medications; meal planning; monitoring and blood testing, including the equipment needed; movement, exercise, and activity; one's social life, including eating, drinking, traveling, and playing; the financial side of diabetes, including organizing and filling out insurance forms; managing diabetes problems such as complications, sick days, and other problem-solving needs; keeping oneself motivated; and finding resources and references. The book includes practical diabetes tips in sidebars labeled DT and is illustrated with numerous figures, charts, restaurant menus, and food labels. A detailed subject index concludes the text.
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16 Myths of a Diabetic Diet. 2nd ed. Alexandria, VA: American Diabetes Association. 2007. 259 p.
This book describes the most common myths about diabetes meal plans, where the myths originate, and how to overcome them. The authors emphasize that having diabetes does not sentence one to a life of boring meals. The book offers 16 chapters that cover medical nutrition therapy (MNT) versus the diabetic diet; the incorporation of foods that contain sugar; the role of starch and fiber; protein; dietary fats; sugar substitutes; carbohydrate counting and the glycemic index; nutrition labels on food items; diabetes and body weight; diabetes and the use of dietary supplements; the role of sodium in a healthy diet; snacks and snacking; how to incorporate exercise in a diabetes management plan; dining out with diabetes; diabetes and food cravings; and how to make favorite recipes healthier. At the end of each chapter is a short quiz for readers to test themselves on their understanding of the material being presented; the answers are in an appendix at the end of the book. A second appendix provides a description of the roles of registered dietitians and certified diabetes educators (CDEs), along with suggestions about how to locate these health care professionals. The book is illustrated with charts and figures. A subject index concludes the volume.
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2006 American Diabetes Association Nutrition Recommendations and Interventions for the Prevention and Treatment of Diabetes. Diabetes Spectrum. 20(1): 49-54. Winter 2007.
This article summarizes the guidelines as presented in the 2006 American Diabetes Association Nutrition Recommendations and Interventions for the Prevention and Treatment of Diabetes. These recommendations reaffirm the importance of medical nutrition therapy (MNT) in the prevention of diabetes, treatment of existing diabetes, and prevention and treatment of the complications of diabetes in which MNT plays a role. The authors highlight major points of emphasis in the 2006 recommendations and note changes from previous recommendations—notably, the 2002 recommendations. Topics include overweight and obesity, pre-diabetes, diabetes treatment, nutrition interventions, type 2 diabetes, pregnancy, older adults, and complications of diabetes. The authors conclude by stressing the importance of monitoring individual outcomes from MNT so that appropriate changes in the overall management plan for diabetes can be implemented. 1 table. 12 references.
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4 Buoc de Kiem Soat Benh Tieu Duong. Suot Doi [4 Steps to Control Your Diabetes for Life]. Bethesda, MD: National Kidney Disease Education Program (NKDEP). 2007. 29 p.
This bilingual booklet helps readers with diabetes understand the everyday activities they can undertake to help control their disease and improve their health. The four steps described are to learn about diabetes, which includes the different types of diabetes, the concept that diabetes is a serious disease, and the problems with diabetes complications; to know the diabetes ABCs, which are the A1C test used to measure blood glucose over time, blood pressure monitoring and treatment as needed, and cholesterol monitoring and treatment as needed; to manage diabetes, with a focus on healthy eating, exercise, maintaining a healthy weight, stress reduction, foot care, oral health, stopping smoking, and taking medications as prescribed; and to get routine health care to avoid problems. Each page presents the information in English on the left side and in Vietnamese on the right side. The booklet is available in other languages, including Tongan, Thai, traditional Chinese, Filipino or Tagalog, Samoan, Korean, and Cambodian (Khmer). The booklet concludes with space for patient notes and questions and a list of resource organizations where readers can get more information. The cover of the booklet is illustrated with full-color photographs of members of the ethnic community whose language is used.
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4 na Hakbang upang Pigilin ang Iyong Diyabetis. Habang Buhay [4 Steps to Control Your Diabetes for Life]. Bethesda, MD: National Kidney Disease Education Program (NKDEP). 2007. 29 p.
This bilingual booklet helps readers with diabetes understand the everyday activities they can undertake to help control their disease and improve their health. The four steps described are to learn about diabetes, which includes the different types of diabetes, the concept that diabetes is a serious disease, and the problems with diabetes complications; to know the diabetes ABCs, which are the A1C test used to measure blood glucose over time, blood pressure monitoring and treatment as needed, and cholesterol monitoring and treatment as needed; to manage diabetes, with a focus on healthy eating, exercise, maintaining a healthy weight, stress reduction, foot care, oral health, stopping smoking, and taking medications as prescribed; and to get routine health care to avoid problems. Each page presents the information in English on the left side and in Tagalog on the right side. The booklet is available in other languages, including Tongan, Thai, traditional Chinese, Vietnamese, Samoan, Korean, and Cambodian (Khmer). The booklet concludes with space for notes and questions and a list of resource organizations where readers can get more information. The cover of the booklet is illustrated with full-color photographs of members of the ethnic community whose language is used.
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4 Sitepu E Pulea ai Lou Ma'i Suka Mo Le Soifuaga [4 Steps to Control Your Diabetes for Life]. Bethesda, MD: National Kidney Disease Education Program (NKDEP). 2007. 29 p.
This bilingual booklet helps readers with diabetes understand the everyday activities they can undertake to help control their disease and improve their health. The four steps described are to learn about diabetes, which includes the different types of diabetes, the concept that diabetes is a serious disease, and the problems with diabetes complications; to know the diabetes ABCs, which are the A1C test used to measure blood glucose over time, blood pressure monitoring and treatment as needed, and cholesterol monitoring and treatment as needed; to manage diabetes, with a focus on healthy eating, exercise, maintaining a healthy weight, stress reduction, foot care, oral health, stopping smoking, and taking medications as prescribed; and to get routine health care to avoid problems. Each page presents the information in English on the left side and in Samoan on the right side. The booklet is available in other languages, including Tongan, Thai, traditional Chinese, Filipino or Tagalog, Vietnamese, Korean, and Cambodian (Khmer). The booklet concludes with space for notes and questions and a list of resource organizations where readers can get more information. The cover of the booklet is illustrated with full-color photographs of members of the ethnic community whose language is used.
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4 Steps to Control Your Diabetes for Life. Bethesda, MD: National Kidney Disease Education Program (NKDEP). 2007. 29 p.
This bilingual booklet helps readers with diabetes understand the everyday activities they can undertake to help control their disease and improve their health. The four steps described are to learn about diabetes, which includes the different types of diabetes, the concept that diabetes is a serious disease, and the problems with diabetes complications; to know the diabetes ABCs, which are the A1C test used to measure blood glucose over time, blood pressure monitoring and treatment as needed, and cholesterol monitoring and treatment as needed; to manage diabetes, with a focus on healthy eating, exercise, maintaining a healthy weight, stress reduction, foot care, oral health, stopping smoking, and taking medications as prescribed; and to get routine health care to avoid problems. Each page presents the information in English on the left side and in Korean on the right side. The booklet is available in other languages, including Tongan, Thai, traditional Chinese, Filipino or Tagalog, Samoan, Vietnamese, and Cambodian (Khmer). The booklet concludes with space for notes and questions and a list of resource organizations where readers can get more information. The cover of the booklet is illustrated with full-color photographs of members of the ethnic community whose language is used.
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4 Steps to Control Your Diabetes for Life. Bethesda, MD: National Kidney Disease Education Program (NKDEP). 2007. 29 p.
This bilingual booklet helps readers with diabetes understand the everyday activities they can undertake to help control their disease and improve their health. The four steps described are to learn about diabetes, which includes the different types of diabetes, the concept that diabetes is a serious disease, and the problems with diabetes complications; to know the diabetes ABCs, which are the A1C test used to measure blood glucose over time, blood pressure monitoring and treatment as needed, and cholesterol monitoring and treatment as needed; to manage diabetes, with a focus on healthy eating, exercise, maintaining a healthy weight, stress reduction, foot care, oral health, stopping smoking, and taking medications as prescribed; and to get routine health care to avoid problems. Each page presents the information in English on the left side and in Thai on the right side. The booklet is available in other languages, including Tongan, Vietnamese, traditional Chinese, Filipino or Tagalog, Samoan, Korean, and Cambodian (Khmer). The booklet concludes with space for notes and questions and a list of resource organizations where readers can get more information. The cover of the booklet is illustrated with full-color photographs of members of the ethnic community whose language is used.
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7-Day Recipe Selector. IN: Denby, N.; Michelucci, T.; Pyner, D. GL Cookbook And Diet Plan: A Glycemic Load Weight-Loss Program With Over 150 Delicious Recipes. Berkeley, CA: Ulysses Press. 2007. pp 93-94.
The glycemic load (GL) system can simplify and improve glycemic index (GI) diet plans by converting GI scores to reflect actual portions. This brief chapter on selecting recipes is from a cookbook that combines an easy-to-follow plan with recipes to create a dietary approach for healthy weight loss and reduced risk of diabetes. The authors describe how the recipes in the subsequent chapters are arranged, emphasizing that each person will have individual preferences and needs. They note that some of the recipes are fast and friendly, requiring no more than 20 minutes of preparation time, whereas others are designed for readers who enjoy cooking as a relaxing activity––those recipes may require more preparation work and time. Readers are referred to the authors' website, www.dietfreedom.co.uk, for more information and help with recipes and the GL diet.
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A Trial in Progress: Gestational Diabetes: Treatment with Metformin Compared with Insulin (the Metformin in Gestational Diabetes [MiG] Trial). Diabetes Care. 30(Suppl 2): S214-S219. July 2007.
This article presents a preliminary report on the Metformin in Gestational Diabetes (MiG) trial, a prospective randomized multicenter trial in women with gestational diabetes mellitus (GDM). This study is testing the hypothesis that metformin treatment, compared with insulin, is associated with similar perinatal outcomes, improved markers of insulin sensitivity in the mother and baby, and improved treatment acceptability. The author reports on the recruitment to the study, the study design and methods, statistical procedures that will be undertaken, a safety analysis of 200 women recruited to the study, and a preliminary analysis of 450 recruits, including their demographic information. The author concludes that the MiG is a key trial in assessing the potential role of metformin treatment during pregnancy. Outcomes will provide detailed information about the effects of treatment on the fetus and the mother. Long-term follow-up will examine whether metformin has independent effects on later health of the offspring. 1 figure. 1 table. 42 references.
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A-Z of Low-GL Foods. IN: Denby, N.; Michelucci, T.; Pyner, D. GL Cookbook And Diet Plan: A Glycemic Load Weight-Loss Program With Over 150 Delicious Recipes. Berkeley, CA: Ulysses Press. 2007. pp 264-281.
The glycemic load (GL) system can simplify and improve glycemic index (GI) diet plans by converting GI scores to reflect actual portions. This appendix is from a cookbook that combines an easy-to-follow plan with recipes to create a dietary approach for healthy weight loss and reduced risk of diabetes. In this appendix, the authors list their recommended low-GL foods, alphabetically, with average portion sizes and GL values noted. Readers are encouraged to visit the authors' website for additional, newly tested low-GL foods and products at www.dietfreedom.co.uk.
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Achieving Glycemic Goals in Type 2 Diabetes. Diabetes Care. 30(1): 174-180. January 2007.
This is the fourth in a series of articles reporting on presentations given at the American Diabetes Association's 66th Scientific Sessions in Washington, DC, June 2006); these papers focus on achieving glycemic goals in type 2 diabetes. Topics include problems achieving recommended glycemic goals in patients with type 2 diabetes, considerations for the use of insulin in this population, aspects of insulin resistance, type 2 diabetes treatment by cytokine modulation, the use of insulin sensitizers, thiazolidinedione (TZD) treatments, new type 2 diabetes treatment approaches, nonalcoholic steatohepatitis, and PROactive analyses. For each topic, the report summarizes the research study and its findings; references are included for readers who want additional information about the findings. 22 references.
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ACP Diabetes Care Guide: A Team-Based Practice Manual and Self- Assessment Program. Philadelphia, PA: American College of Physicians. 2007. (CD-ROM).
This CD–ROM accompanies a guidebook, authored by a multidisciplinary team of physicians, nurses, and diabetes educators, that presents innovative ways to incorporate collaborative care into a variety of clinical settings. The guide includes specific strategies for office redesign; tips on actively involving patients in treatment decisions and self-management; important topics to discuss with patients; up-to-date clinical guidelines for diabetes care; flow sheets, standing orders worksheets, and other tools for better practice; and handouts that can be distributed to patients to support their goal-setting and self-management. The CD–ROM allows readers to test their knowledge in these areas by answering 81 multiple-choice questions modeled after the questions used for internal medicine’s certifying examination. Readers can use this test to qualify for continuing medical education credits. In addition to the self-assessment test, the CD–ROM includes downloadable, printable versions of all the tools contained in the Diabetes Care Guide Toolkit at the back of the resource book. Readers are also referred to the ACP Diabetes Portal website (http://diabetes.acponline.org) for links to additional resources and a wide array of information on diabetes for patients, clinicians, and other members of the health care team.
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ACP Diabetes Care Guide: A Team-Based Practice Manual and Self-Assessment Program. Philadelphia, PA: American College of Physicians. 2007. 184 p.
This guide, authored by a multidisciplinary team of physicians, nurses, and diabetes educators, presents innovative ways to incorporate collaborative care into a variety of clinical settings. The guide includes specific strategies for office redesign; tips on actively involving patients in treatment decisions and self-management; important topics to discuss with patients; up-to-date clinical guidelines for diabetes care; flow sheets, standing orders worksheets, and other tools for better practice; and handouts that can be distributed to patients to support their goal-setting and self-management. A companion CD–ROM allows readers to test their knowledge by answering 81 multiple-choice questions modeled after the questions used for internal medicine’s certifying examination. Readers can use this test to qualify for continuing medical education credits. In addition to the self-assessment test, the CD–ROM includes downloadable, printable versions of all the tools contained in the Diabetes Care Guide Toolkit at the back of the book. Readers are also referred to the ACP Diabetes Portal website (http://diabetes.acponline.org) for links to additional resources and a wide array of information on diabetes for patients, clinicians, and other members of the health care team. A detailed subject index concludes the resource guide. 9 appendices. 4 figures. 35 tables. 135 references.
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Acute Complications of Diabetes. IN: Scobie, I.N. Atlas of Diabetes Mellitus. 3rd ed. New York, NY: Informa Healthcare USA. 2007. pp 63-68.
This chapter about the acute complications of diabetes is from an atlas of diabetes mellitus that offers text and pictures to familiarize clinicians with the most current information about diabetes and its diagnosis and treatment. The volume portrays the wide and varied expressions of diabetes and its complications as an aid to their more ready recognition in clinical practice. This chapter discusses hypoglycemia, diabetic ketoacidosis, and hyperosmolar nonketoacidotic coma. The chapter offers full-color photographs and figures representing these same topics, including the symptoms of hypoglycemia in diabetes, brain activation in patients with hypoglycemia, the biochemical features of diabetic ketoacidosis, the causes of death in diabetic ketoacidosis, and the biochemical features of diabetic hyperosmolar nonketotic coma. 5 figures. 5 references.
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Acute Complications. IN: Beaser, R.S., ed. Joslin’s Diabetes Deskbook: A Guide For Primary Care Providers. 2nd ed. Boston, MA: Joslin Diabetes Center. 2007. pp 403-428.
This chapter on acute diabetes complications is from a book that gives primary care providers a comprehensive overview of diabetes care. The authors categorize the acute complications of diabetes, which can be categorized as relating to either very high glucose levels, called hyperglycemia, or very low glucose levels, called hypoglycemia. The chapter begins with a discussion of diabetic ketoacidosis (DKA), including the usual setting for DKA, pathogenesis, clinical presentation, DKA in patients with alcoholism, diagnostic tests used to confirm the presence of and monitor DKA, patient m |
