Primary Care Diabetes

Editorial Board

2011-12-01

Destiny in your own hands – Does a positive family history matter in the prevention of type 2 diabetes?

Matti Uusitupa, Jaakko Tuomilehto — 2011-12-01

Type 2 diabetes has become one of the most important chronic non-communicable diseases globally due to unbalanced diet, obesity epidemic and sedentary lifestyle. Therefore, the interest to find new tools to prevent type 2 diabetes has recently been increasing . In addition to lifestyle, also the genetic predisposition significantly contributes to the development of the disease . In this issue of the Primary Care Diabetes, Heideman et al. reviewed the prevention trials in which the prevention has specifically been focused on individuals with a positive family history (FH) of diabetes, who are known to have an increased risk of diabetes even after common risk factors for type 2 diabetes have been taken into account . Therefore, FH as an indicator for the genetic susceptibility is also recognized as one of the markers in screening for increased risk of diabetes, and it has been included in various risk questionnaires such as the Finnish Diabetes Risk Score (FINDRISC) . The main objective of the work by Heineman et al. was to find out what we can learn from the studies specifically aimed at the prevention of type 2 diabetes in people with FH of diabetes. The authors reviewed several hundreds of papers and identified only six publications fulfilling the selected inclusion criteria. Altogether there were 892 participants in these six studies, and only three of them had over a hundred people participating in the intervention. Three studies also fulfilled the criteria of a randomized controlled trial (RCT), two of them lasted 24 months and one 12 months. In all of these three RCT studies different prevention tools were tested against a control. In two of them the effects of diet, diet and exercise or exercise alone were evaluated. In the ProActive study there was a different approach; comparing the effects of a behaviour intervention by telephone or face to face at home with a control group who received only a leaflet. In the long-term there were no significant differences across the different intervention tools, but usually the intervention resulted in beneficial changes in cardiovascular risk factors, serum insulin and weight loss, and the greater the weight loss the smaller was the incidence of diabetes in one study lasting for two years . The authors speculate that people with FH could form a specific target group for lifestyle intervention.

Changing the odds. What do we learn from prevention studies targeted at people with a positive family history of type 2 diabetes?

2011-07-18

Abstract: People with a positive family history of type 2 diabetes (T2DM) are at high risk of developing diabetes. We set out to review the literature reporting on the development and/or evaluation of lifestyle interventions specifically aimed at prevention of T2DM in this group.Targeting people with a positive family history of T2DM seems so far an underutilized prevention strategy. They can and should be approached with the aim to raise risk awareness and promote healthy eating, weight loss and physical activity, thereby reducing their risk of developing diabetes.

Clinical profile of diabetes in the young seen between 1992 and 2009 at a specialist diabetes centre in south India

2011-05-25

Abstract: Aim: To describe the trends and clinical profile of young diabetic patients (YD) attending a tertiary diabetes centre in south India.Methods: We reviewed medical records of 2630 YD patients (age at onset ≤25 years) registered between 1992 and 2009. Patients were classified as type 1 diabetes (T1DM), type 2 diabetes (T2DM) gestational diabetes mellitus (GDM) and other types. Retinopathy was assessed initially by direct and indirect ophthalmoscopy and later by retinal photography, nephropathy if urine protein excretion was >500mg/day, neuropathy if vibration perception threshold on biothesiometry was ≥20V.Results: The percentage of YD patients rose from 0.55% in 1992 to 2.5% in 2009 (trend chi square, 15.1, p<0.001). Of the 2630 YD subjects registered, 1135 (43.2%) had T1DM, 1262 (48.0%) had T2DM, 118 (4.5%) had GDM and 115 (4.4%) other types. T1DM patients were younger, had lower body mass index, waist circumference, systolic and diastolic blood pressures, and less family history of diabetes compared to T2DM (p<0.001 for each). Retinopathy was seen in 71.9% and 77.3% nephropathy in 22.1% and 12.1% and neuropathy in 34.5% and 21.4% of T2DM and T1DM respectively in those with ≥15 years duration of diabetes.Conclusions: The percentage of YD in south India is increasing, predominantly due to early onset T2DM.

PANORAMA: A European study to evaluate quality of life and treatment satisfaction in patients with type-2 diabetes mellitus—Study design

2011-07-15

Abstract: Aim: Type-2 diabetes mellitus (T2DM) is a major cause of disability reaching epidemic proportions worldwide. The disease burden of T2DM is commonly characterised using health status measures, but few European-wide data are available concerning patients’ views of their quality of life (QoL) and other patient-reported outcomes (PROs). Despite evidence supporting benefits of glycaemic control, many patients are currently not treated to recommended HbA1c targets (<7%). Consequently, the prevalence of T2DM-related chronic complications remains high, impacting negatively on patients’ health status. Hypoglycaemia is a side effect associated with some antidiabetes medications that may also diminish QoL and treatment satisfaction. The aim of the PANORAMA study (NCT00916513) is to evaluate QoL and other PROs in patients with T2DM. It will investigate the association between these variables, the different diabetes treatment regimens used and levels of glycaemic control achieved across Europe. This report describes the rationale for conducting the PANORAMA study, and the study design.Methods: PANORAMA is an observational, multicentre, multinational, cross-sectional study. Approximately 5000 patients with T2DM currently treated with diet, oral antidiabetes agents and/or injectables (insulin and/or glucagon-like peptide-1 [GLP-1] analogues), ≥1-year follow up, will be randomly selected from a representative sample of mainly primary care practices across nine countries. Patient demographics; HbA1c level (standardised measurement); PROs, including QoL (ADDQoL), health status (EQ-5D), treatment satisfaction (DTSQ) and fear of hypoglycaemia (HFS-II); disease-related variables; health-economic variables; physician demographics and physician-reported outcomes will be collected.Discussion: The large-scale, European-wide PANORAMA study is designed to evaluate QoL and other PROs in patients with T2DM.

Graves’ disease in subjects with type 1 diabetes mellitus: A prevalence study in western Sicily (Italy)

Domenico Greco, Maria Pisciotta, Francesco Gambina, Filippo Maggio. — 2011-06-27

Abstract: Objective: To assess the prevalence of Graves’ disease in patients with type 1 diabetes mellitus all coming from a defined geographical area (western Sicily—Italy) and to investigate the clinical features of these subjects.Methods: The records of 470 consecutive patients with type 1 diabetes mellitus referred in a 5-year period were analyzed.Results: During the period of the survey, out of 470 patients with type 1 diabetes, 14 (3%) had a previous diagnosis of Graves’ disease. There were 9 female and 5 male; these patients showed a high age at diabetes onset (mean 38 years). Diagnosis of Graves’ disease was often pre-existing or simultaneous to that of diabetes. Vitiligo was coexisting in 4 subjects; none of them presented other autoimmune diseases. Graves’ orbitopathy was present in two cases.Conclusions: Our data confirm the frequent association between Graves’ disease and type 1 diabetes. Graves’ disease often preceded diagnosis of type 1 diabetes, particularly in female subjects with a high age at diabetes onset; therefore, in these subjects, an active search for the presence of pancreatic autoimmunity is warranted for many years after thyroid dysfunction appearance.

Characteristics, complications and management of a large multiethnic cohort of younger adults with type 2 diabetes

2011-07-22

Abstract: Aims: To describe the characteristics and management of a cohort with type 2 diabetes (T2DM) <40 years.Methods: Cross-sectional study of the last visit of 648 adults attending 2 specialist centres in the UK. Differences between the lowest (≤22) vs. highest quintile (≥33) of age of diagnosis were analysed.Results: 57.9% were female; 45.5% Black or Minority Ethnic origin (91.9% of South Asian origin); median age at diagnosis was 28 years (24–31); diabetes duration of 4.0 years (1.9–7.0); BMI of 33.0kg/m2 (28.3–38.7). HbA1c of 8.2% (6.8–9.9) with HbA1c >7% in 70%. 71.8% had cholesterol >4mmol/l, 54.9% triglycerides >1.7mmol/l, 45% had hypertension, 19.8% retinopathy, 16.9% microalbuminuria. Insulin was used in 43.3%. 27.7% received antihypertensives and 31.5% a statin. Compared to the highest quintile of age of diagnosis, the lowest quintile had more often retinopathy (22.1% vs. 16.9%, p=0.021), was less on insulin (45.6% vs. 46.4%, p=0.039) and often managed with diet only (9.6% vs. 6.2%, p=0.005).Conclusions: These younger adults with T2DM often have inadequately treated risk factors. In particular, patients from the lowest quintile of age of diagnosis were less aggressively treated. There is a need for tailored strategies to manage this high-risk group.

Exploring reasons for very poor glycaemic control in patients with Type 2 diabetes

Hamida Khan, Shawarna S. Lasker, Tahseen A. Chowdhury — 2011-07-22

Abstract: Aim: The aim was to determine prevalence and reasons for very poor glycaemic control (HbA1c≥10% [86mmol/mol]) amongst people with Type 2 diabetes in an ethnically diverse urban population.Methods: Databases of three primary health centres were searched for patients with Type 2 diabetes ≥1 year, most recent HbA1c≥10% [86mmol/mol]. Patients were invited to explore reasons for poor glycaemic control and develop an individualised management plan. Review of glycaemic control was undertaken at 6 months.Results: Of a total population of 28,677, 1261 had Type 2 diabetes (4.4%). 143 (11.3%) had last recorded HbA1c≥10% [86mmol/mol]; 128 were reviewed (46.9% South Asian). People with poorer control had longer duration of diabetes and more South Asian ethnicity. Reasons for poor glycaemic control were: Therapy: lack of titration of tablets (7.8%) or insulin (12.5%), poor concordance with medication (14.0%), insulin refusal (11.7%), side effects (16.4%); Engagement: poor concordance with lifestyle (26.5%), lack of knowledge of diabetes (14.0%), infrequent attendance at clinic (16.4%); Psychosocial/mental health: denial that diabetes was a problem (7.0%), mental health problem (9.4%), social issues (10.9%); Occupation: refusal of insulin due to occupation (1.6%); difficulty in attending reviews (5.5%). At six month review, 54.5% of patients had improved HbA1c≥1%.Conclusions: Poor control affects 1 in 10 of our population. We have determined a number of factors which may explain most causes. Individualised management using care planning can significantly improve control.

Quality evaluation of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool

2011-09-15

Abstract: Context: Many medical journals provide patient information leaflets on the correct use of medicines and/or appropriate lifestyles. Only a few studies have assessed the quality of this patient-specific literature.Objective: The purpose of this study was to evaluate the quality of JAMA Patient Pages on diabetes using the Ensuring Quality Information for Patient (EQIP) tool.Method: A multidisciplinary group of 10 medical doctors analyzed all diabetes-related Patient Pages published by JAMA from 1998 to 2010 using the EQIP tool. Inter-rater reliability was assessed using the percentage of observed total agreement (po). A quality score between 0 and 1 (the higher score indicating higher quality) was calculated for each item on every page as a function of raters’ answers to the EQIP checklist. A mean score per item and a mean score per page were then calculated.Data summary: We found 8 Patient Pages on diabetes on the JAMA web site. The overall quality score of the documents ranged between 0.55 (Managing Diabetes and Diabetes) and 0.67 (weight and diabetes). po was at least moderate (>50%) for 15 of the 20 EQIP items. Despite generally favorable quality scores, some items received low scores. The worst scores were for the item assessing provision of an empty space to customize information for individual patients (score=0.01, po=95%) and patients involvement in document drafting (score=0.11, po=79%).Conclusions: The Patient Pages on diabetes published by JAMA were found to present weak points that limit their overall quality and may jeopardize their efficacy. We therefore recommend that authors and publishers of written patient information comply with published quality criteria. Further research is needed to evaluate the quality and efficacy of existing written health care information.

Record-based, stepwise screening for type 2 diabetes integrated into an annual cardiovascular care review system: Findings from a UK general practice

Benjamin G. Fisher, Yvonne L.E. Ang, Clare Goodhart, Rebecca K. Simmons — 2011-10-04

Abstract: Aims: Screening high-risk individuals for type 2 diabetes (T2DM) is recommended by many organisations. We report results from a pragmatic stepwise T2DM screening programme integrated into an annual review system in a UK general practice.Methods: Patients with hypertension, cardiovascular disease or chronic kidney disease attending an annual review were screened for dysglycaemia by random blood glucose (RBG) measurement. At the discretion of the usual doctor, individuals with an RBG≥6.1mmol/l were invited to return for fasting blood glucose (FBG) or HbA1C measurement, allowing diagnosis of T2DM.Results: 786 eligible patients were invited for T2DM screening as part of their annual review. 544 attended screening, of whom 120 had an RBG≥6.1mmol/l. 40 individuals attended FBG measurement and 8 individuals attended HbA1C measurement, leading to 9 T2DM diagnoses. The positive predictive value of the test for T2DM was 19% and the laboratory cost was £91 per patient diagnosed with T2DM.Conclusions: It is feasible to integrate a simple T2DM screening programme within an annual review system in a UK general practice. Different strategies may be required to increase initial attendance and ensure completion of the screening programme.

Society News

2011-10-31