Improved glycaemic control in type 1 diabetes patients following participation per se in a clinical trial--mechanisms and implications

Analysis of the Glucose-Dependent Transcriptome in Murine Hypothalamic Cells

Glucose provides vital energy for cells and contributes to gene expression. The hypothalamus is key for metabolic homeostasis, but effects of glucose on hypothalamic gene expression have not yet been investigated in detail. Thus, herein, we monitored the glucose-dependent transcriptome in murine hypothalamic mHypoA-2/10 cells by total RNA-seq analysis. A total of 831 genes were up- and 1390 genes were downregulated by at least 50%. Key genes involved in the cholesterol biosynthesis pathway were upregulated, and total cellular cholesterol levels were significantly increased by glucose. Analysis of single genes involved in fundamental cellular signaling processes also suggested a significant impact of glucose. Thus, we chose ≈100 genes involved in signaling and validated the effects of glucose on mRNA levels by qRT-PCR. We identified Gnai1–3, Adyc6, Irs1, Igfr1, Hras, and Elk3 as new glucose-dependent genes. In line with this, cAMP measurements revealed enhanced noradrenalin-induced cAMP levels, and reporter gene assays elevated activity of the insulin-like growth factor at higher glucose levels. Key data of our studies were confirmed in a second hypothalamic cell line. Thus, our findings link extra cellular glucose levels with hypothalamic lipid synthesis and pivotal intracellular signaling processes, which might be of particular interest in situations of continuously increased glucose levels.

Glucose Enhances Basal or Melanocortin-Induced cAMP-Response Element Activity in Hypothalamic Cells

Melanocyte-stimulating hormone (MSH)-induced activation of the cAMP-response element (CRE) via the CRE-binding protein in hypothalamic cells promotes expression of TRH and thereby restricts food intake and increases energy expenditure. Glucose also induces central anorexigenic effects by acting on hypothalamic neurons, but the underlying mechanisms are not completely understood. It has been proposed that glucose activates the CRE-binding protein-regulated transcriptional coactivator 2 (CRTC-2) in hypothalamic neurons by inhibition of AMP-activated protein kinases (AMPKs), but whether glucose directly affects hypothalamic CRE activity has not yet been shown. Hence, we dissected effects of glucose on basal and MSH-induced CRE activation in terms of kinetics, affinity, and desensitization in murine, hypothalamic mHypoA-2/10-CRE cells that stably express a CRE-dependent reporter gene construct. Physiologically relevant increases in extracellular glucose enhanced basal or MSH-induced CRE-dependent gene transcription, whereas prolonged elevated glucose concentrations reduced the sensitivity of mHypoA-2/10-CRE cells towards glucose. Glucose also induced CRCT-2 translocation into the nucleus and the AMPK activator metformin decreased basal and glucose-induced CRE activity, suggesting a role for AMPK/CRTC-2 in glucose-induced CRE activation. Accordingly, small interfering RNA-induced down-regulation of CRTC-2 expression decreased glucose-induced CRE-dependent reporter activation. Of note, glucose also induced expression of TRH, suggesting that glucose might affect the hypothalamic-pituitary-thyroid axis via the regulation of hypothalamic CRE activity. These findings significantly advance our knowledge about the impact of glucose on hypothalamic signaling and suggest that TRH release might account for the central anorexigenic effects of glucose and could represent a new molecular link between hyperglycaemia and thyroid dysfunction.

Performance of an Electronic Diary System for Intensive Insulin Management in Global Diabetes Clinical Trials

BACKGROUND

This report describes the performance of a wireless electronic diary (e-diary) system for data collection and enhanced patient-investigator interactions during intensive insulin management in diabetes clinical trials.

MATERIALS AND METHODS

We implemented a customized electronic communication system featuring an e-diary and a Web portal in three global, randomized, controlled Phase 3 clinical trials testing basal insulin peglispro compared with insulin glargine, both combined with prandial insulin lispro, in patients with type 1 or type 2 diabetes mellitus (T1DM and T2DM, respectively). We collected data during 28 weeks of study e-diary use for the report.

RESULTS

Patients (n=2,938) in 31 countries used e-diaries to transmit 2,439,087 blood glucose (BG) values, 96% of which were associated by the patient with a protocol time point during the 72-h response window. Of 208,192 hypoglycemia events captured, 96% had a BG value, and 95% had treatments and outcomes entered by patients within the 72-h window. Patients recorded administration of 1,964,477 insulin doses; 93% of basal insulin doses were adherent with the investigator prescription. Investigators adjusted 13 basal and 92 bolus insulin prescriptions per patient-year using the e-diary system. After 26 weeks of treatment and e-diary use in the combined study arms, hemoglobin A1c values decreased by 0.6% or 1.6% and fasting BG decreased by 7.8 or 28 mg/dL in patients with T1DM or T2DM, respectively.

CONCLUSIONS

The e-diary system enabled comprehensive data collection and facilitated communication between investigators and patients for intensive insulin management in three global clinical trials testing basal insulins.

Improving the Quality of Outpatient Diabetes Care Using an Information Management System: Results From the Observational VISION Study

BACKGROUND

This study aimed to evaluate the effects of information management system (IMS) use with individuals with type 1 and type 2 diabetes who were treated in outpatient settings.

METHODS

In this 7-month, prospective, observational study, 965 adults with diabetes, mean (SD) baseline HbA1c 8.61(1.2)% (70.6[13.1] mmol/mol), were recruited from 132 outpatient care centers in Germany and Denmark. HbA1c was measured at baseline, month 4, and month 7. IMS reports were generated from uploaded self-monitored blood glucose data and therapy adjustments were documented at months 1 and 4. Hypoglycemic events were documented.

RESULTS

Mean (SD) HbA1c decreased from baseline in type 1 and type 2 diabetes patients at month 4 (-0.61[1.03]% (-6.7[11.3] mmol/mol), n = 213; -0.88[1.22]% (-9.6[13.3] mmol/mol), n = 589, respectively) and month 7 (-0.64[1.02]% (-7.0[11.1] mmol/mol), n = 219; -0.93[1.27]% (-10.2[13.9] mmol/mol), n = 594, respectively), all P < .0001, with no increase in hypoglycemic events. Therapy was adjusted in 106(42.7)% type 1 and 349(52.4)% type 2 diabetes patients at months 1 and 105(42.3)% type 1 and 282(42.3)% type 2 diabetes patients at month 4. Physicians used IMS reports to make therapy adjustments in 90% of patients at month 1 and 86% of patients at month 4.

CONCLUSIONS

Integration of the IMS into outpatient care facilitates significant improvements in glycemic control.

Can integrated technology improve self-care behavior in youth with type 1 diabetes? A randomized crossover trial of automated pump function

Automated blood glucose (BG) and insulin pump systems allow wireless transmission of all BG readings to a user's pump. This study aimed to assess whether use of such a system, as compared with a manual BG entry insulin pump, resulted in higher mean daily frequency of BGs recorded after 6 months. A 12-month randomized crossover trial, comprising 2 phases, was conducted. All participants used insulin pump devices with automated vs manual BG entry for 6 months each; order of system use was randomly assigned. Device interactions were assessed from pump and glucometer downloads. Thirty-five participants were enrolled; 9 withdrew during the study. Use of the automated insulin pump system resulted in higher mean daily BG recorded over 6 months of use when compared to a manual BG entry system (5.8 ± 1.7 vs 5.0 ± 1.9; P = .02 [95% confidence interval, 0.14 to 1.58]). Bolus frequency was similar between groups. No HbA1c difference was observed between groups at 6 months (8.0% [64 mmol/l] ± 1.3 automated vs 7.7% [61 mmol/l] ± 0.9 manual; P = .38). Post hoc analysis demonstrated improved ΔHbA1c with automated system use in an adolescent subgroup with suboptimal baseline BG frequency (-0.9% vs + 0.5%; P = .003). Use of an automated glucometer/insulin pump resulted in higher number of BGs recorded over 6 months when compared to an insulin pump with manual BG entry. This may be especially beneficial for adolescent manual system users who enter <5 BGs per day into their pump.

Feasibility of a portable bihormonal closed-loop system to control glucose excursions at home under free-living conditions for 48 hours

BACKGROUND

This study assessed the feasibility of a portable bihormonal closed-loop system at home.

SUBJECTS AND METHODS

Sixteen pump-treated patients with type 1 diabetes received 48 h of closed-loop therapy with a telemonitored insulin- and glucagon-delivering closed-loop system and 48 h of patient-managed open-loop therapy.

RESULTS

Owing to technical problems in five cases, only 11 patients could be analyzed. Whereas median (interquartile range) glucose levels were not significantly different during Day 1 of open-loop control (OL1) from closed-loop control (CL1) (8.27 [0.83] mmol/L vs. 8.84 [1.47] mmol/L; P=0.206), they were significantly lower during Day 2 of closed-loop control (CL2) versus open-loop control (OL2) (7.70 [2.29] mmol/L vs. 8.84 [0.87] mmol/L; P=0.027). Time spent in euglycemia (3.9-10 mmol/L) was comparable with 67.2% (38.5%) in OL1 versus 79.2% (16.9%) in CL1 (P=0.189) and 66.0% (29.8%) in OL2 versus 76.5% (23.9%) in CL2 (P=0.162). Time spent in hypoglycemia (<3.9 mmol/L) was comparable on Day 1 of control (OL1, 0.68% [8.68%]; CL1, 2.08% [7.61%]; P=0.593) but significantly higher during Day 2 of control (OL2, 0.00% [11.07%]; CL2, 2.8% [9.8%]; P=0.0172) (P=0.017).

CONCLUSIONS

Bihormonal closed-loop control is feasible at home, with comparable time in euglycemia to open-loop control and significantly lower median glucose levels on Day 2 of control at the expense of more time in hypoglycemia, albeit still at a very low percentage of time.

Initiation of insulin glargine in patients with Type 2 diabetes in suboptimal glycaemic control positively impacts health-related quality of life. A prospective cohort study in primary care

AIMS

To study prospectively the impact of initiating insulin glargine in suboptimally controlled insulin-naïve patients with Type 2 diabetes on health-related quality of life in relation to glycaemic control.

METHODS

Insulin-naïve Dutch patients with Type 2 diabetes in suboptimal glycaemic control (HbA(1c) > 53 mmol/mol; 7%) on maximum dose of oral glucose-lowering medications were included from 363 primary care practices (n = 911). Patients started insulin glargine and were followed up for 6 months. At baseline (start insulin therapy), 3 and 6 months, HbA(1c) was measured and patients completed self-report health-related quality of life measures, including emotional well-being (World Health Organization-5 well-being index), fear of hypoglycaemia (Hypoglycaemia Fear Survey) and diabetes symptom distress (Diabetes Symptom Checklist-revised). Data were analysed using generalized estimating equations analysis.

RESULTS

HbA(1c) (mmol/mol; %) decreased from 69 ± 16; 8.5 ± 1.7 to 60 ± 11; 7.6 ± 1.0 and 57 ± 11; 7.3 ± 1.0 at 3 and 6 months, respectively (P < 0.001). Pre-insulin BMI (kg/m(2) ) was 30 ± 5.7, which remained stable at 3 months (30 ± 5.8) and increased to 31 ± 5.9 at 6 months (P = 0.004); no significant changes in self-reported symptomatic and severe hypoglycaemia were observed, while nocturnal hypoglycaemia slightly decreased. The Hypoglycaemia Fear Survey score decreased from 14.6 ± 16.2 to 12.1 ± 15.2 and 10.8 ± 14.4 at 3 and 6 months, respectively (P < 0.001). The Diabetes Symptom Checklist-revised score decreased from 15 ± 14 to 10 ± 12 and 10 ± 13 (P < 0.001), with most pronounced reductions in hyperglycaemic symptoms and fatigue. The World Health Organization-5 score increased from 57 ± 25.3 to 65 ± 21.6 at 3-month follow-up and 67 ± 21.8 at 6-month follow-up (P < 0.001).

CONCLUSIONS

Results of this observational study demonstrate combined glycaemic and health-related quality of life benefits of initiating insulin glargine in patients with Type 2 diabetes in routine primary care.

Randomized trial of a literacy-sensitive, culturally tailored diabetes self-management intervention for low-income latinos: latinos en control

OBJECTIVE

To test whether a theory-based, literacy, and culturally tailored self-management intervention, Latinos en Control, improves glycemic control among low-income Latinos with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 252 patients recruited from community health centers were randomized to the Latinos en Control intervention or to usual care. The primarily group-based intervention consisted of 12 weekly and 8 monthly sessions and targeted knowledge, attitudes, and self-management behaviors. The primary outcome was HbA(1c). Secondary outcomes included diet, physical activity, blood glucose self-monitoring, diabetes knowledge and self-efficacy, and other physiological factors (e.g., lipids, blood pressure, and weight). Measures were collected at baseline and at 4- and 12-month follow-up. Change in outcomes over time between the groups and the association between HbA(1c) and possible mediators were estimated using mixed-effects models and an intention-to-treat approach.

RESULTS

A significant difference in HbA(1c) change between the groups was observed at 4 months (intervention -0.88 [-1.15 to -0.60] versus control -0.35 [-0.62 to 0.07], P < 0.01), although this difference decreased and lost statistical significance at 12 months (intervention -0.46 [-0.77 to -0.13] versus control -0.20 [-0.53 to 0.13], P = 0.293). The intervention resulted in significant change differences in diabetes knowledge at 12 months (P = 0.001), self-efficacy (P = 0.001), blood glucose self-monitoring (P = 0.02), and diet, including dietary quality (P = 0.01), kilocalories consumed (P < 0.001), percentage of fat (P = 0.003), and percentage of saturated fat (P = 0.04). These changes were in turn significantly associated with HbA(1c) change at 12 months.

CONCLUSIONS

Literacy-sensitive, culturally tailored interventions can improve diabetes control among low-income Latinos; however, strategies to sustain improvements are needed.

Contact frequency determines outcome of basal insulin initiation trials in type 2 diabetes

AIMS/HYPOTHESIS

The aim of the present study was to investigate whether predetermined contact frequency with the study team and endpoint insulin dose are associated with study outcomes in basal insulin initiation trials in type 2 diabetes.

METHODS

A systematic Medline search was performed. Using data from the selected studies, contact frequency was plotted against HbA(1c) reduction and endpoint insulin dose. The importance of face-to-face vs telephone contact was also analysed. Insulin dose was plotted against HbA(1c) reduction, hypoglycaemia rate and weight gain. To investigate non-specific study effects, the relationship between contact frequency and HbA(1c) was also assessed in dipeptidyl peptidase-4 (DPP-4) inhibitor trials.

RESULTS

The reduction in HbA(1c) was highly correlated with contact frequency and endpoint insulin dose (r (2) = 0.751, p < 0.001 and r (2) = 0.433, p = 0.008, respectively). However, after adjusting for contact frequency, the relationship between insulin dose and HbA(1c) reduction was no longer significant (p = 0.270). The frequency of both clinical and telephone contacts were independent predictors of HbA(1c) improvement (p = 0.010 and p < 0.001, respectively). We found no dose-response relationship between end-of-study insulin dose and hypoglycaemia or weight gain. In DPP-4 inhibitor studies, contact frequency was not positively associated with HbA(1c).

CONCLUSIONS/INTERPRETATION

The frequency of contact with the study team is highly correlated with the improvement in HbA(1c) achieved in basal insulin initiation trials in type 2 diabetic patients. This has important implications for trial design and interpretation, as well as for clinical care.

Use of a patient linked data warehouse to facilitate diabetes trial recruitment from primary care

Recruitment into clinical trials from primary care may be difficult. Our aim was to use the Secure Anonymised Information Linkage (SAIL) databank to identify potential participants for two factitious trials. We identified 284 and 711 participants for each study (population=250,086). This method appears promising in identifying trial participants.

Effects of insulin pump vs. injection treatment on quality of life and impact of disease in children with type 1 diabetes mellitus in a randomized, prospective comparison

OBJECTIVE

Effects of pump treatment vs. four times daily injections were explored in children with diabetes with regard to quality of life and impact of disease as well as adverse effects and parameters of metabolic control.

METHODS

An open, parallel, randomized controlled prospective comparative study lasting 14 months was completed by 38 type 1 children with diabetes (age 4-16 yr) following a 3.5-months run-in phase. Standardized quality-of-life Pediatric Quality of life Inventory (PedsQL) and impact of disease scores were obtained every 3.5 months as well as regular medical parameters. Parallel treatment group data and longitudinal within-patient data were analysed for each treatment modality.

RESULTS

Within-patient comparisons of the two treatment modalities showed significant improvement in PedsQL and impact scores after pump treatment. Treatment group comparisons did not show significant improvement. Pump treatment resulted in decreased symptomatic hypoglycaemia and lowered haemoglobin A1c by 0.22% after run in.

CONCLUSIONS

Within-patient comparison suggests that metabolic control, frequency of severe hypoglycaemia (a threefold decrease), quality of life and impact of disease scores are improved by pump treatment in comparison to regular treatment with four daily insulin injections.

Recruitment to a clinical trial improves glycemic control in patients with diabetes

OBJECTIVE

We assessed the effect upon A1C of recruitment to a clinical trial in patients with diabetes who had been screened and interviewed to determine eligibility but whose therapy was otherwise unchanged.

RESEARCH DESIGN AND METHODS

Eligible trials were selected from the global program of an insulin manufacturer. Included were studies in which patients were seen on a single screening visit, pharmaceutical therapy was not altered before randomization, and A1C was measured in a central laboratory at both screening and randomization. Three trials involving patients with type 1 diabetes (n = 429) and three trials involving patients with type 2 diabetes (n = 611) were identified for analysis. The main outcome measure was change in A1C. Separate regression equations on the change in A1C were fitted for type 1 and type 2 diabetes and included effects of baseline A1C and the interval between the screening and randomization visits.

RESULTS

A1C changed by -0.13% (range +0.09 to -0.26%) in those with type 1 diabetes at a median of 28 days and by -0.16% (-0.14 to -0.27%) for those with type 2 diabetes at a median of 14 days. The mean change in A1C in those with an interval of >or=28 days was -0.24% for those with type 1 diabetes and -0.23% for those with type 2 diabetes. The reduction was proportional to initial A1C, with large decreases in those with the poorest initial control but no overall change in those at or below the 10th percentile of A1C.

CONCLUSIONS

Recruitment to a clinical trial, independent of any therapeutic intervention, produces improvements in glucose control.

Nocturnal hypoglycaemia in Type 1 diabetic patients, assessed with continuous glucose monitoring: frequency, duration and associations

AIMS

We quantified the occurrence and duration of nocturnal hypoglycaemia in individuals with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) or multiple-injection therapy (MIT) using a continuous subcutaneous glucose sensor.

METHODS

A microdialysis sensor was worn at home by 24 patients on CSII (mean HbA(1c) 7.8 +/- 0.9%) and 33 patients on MIT (HbA(1c) 8.7 +/- 1.3%) for 48 h. Occurrence and duration of nocturnal hypoglycaemia were assessed and using multivariate regression analysis, the association between HbA(1c), diabetes duration, treatment type (CSII vs. MIT), fasting and bedtime blood glucose values, total daily insulin dose and mean nocturnal glucose concentrations, and hypoglycaemia occurrence and duration was investigated.

RESULTS

Nocturnal hypoglycaemia < or = 3.9 mmol/l occurred in 33.3% of both the CSII- (8/24) and MIT-treated patients (11/33). Mean (+/- sd; median, interquartile range) duration of hypoglycaemia < or = 3.9 mmol/l was 78 (+/- 76; 57, 23-120) min per night for the CSII- and 98 (+/- 80; 81, 32-158) min per night for the MIT-treated group. Multivariate regression analysis showed that bedtime glucose value had the strongest association with the occurrence (P = 0.026) and duration (P = 0.032) of nocturnal hypoglycaemia.

CONCLUSIONS

Microdialysis continuous glucose monitoring has enabled more precise quantification of nocturnal hypoglycaemia occurrence and duration in Type 1 diabetic patients. Occurrence and duration of nocturnal hypoglycaemia were mainly associated with bedtime glucose value.

Effect of a pocket-size tablet-dispensing device on glycaemic control in Type 2 diabetic patients

AIM

To evaluate whether a pocket-size tablet-dispensing device would improve adherence to therapy as judged by reduction of HbA(1c) levels in a large population of Type 2 diabetic patients.

METHODS

The study design was prospective, randomized, open label with two parallel groups. Patients (2296) were recruited from general practitioners and internists and randomized to either receive a tablet dispenser (TD) or no intervention (control group, CO). Patients' characteristics and current oral therapy (including dosage) were recorded at baseline. HbA(1c) was compared between groups at baseline and after 6 months' intervention.

RESULTS

Data were available in 2081 patients. Baseline characterisitcs, including age, body mass index (BMI), blood pressure and gender distribution were comparable between the two groups, as was HbA(1c)[7.9 (7.9-8.0), TD vs. 8.0 (7.9-8.0)%, CO, means (95% CI)]. After 6 months, HbA(1c) improved in both groups, but improvement was significantly greater in TD than in controls [-0.74 (0.67-0.80) vs. -0.53 (0.47-0.59)%, P < 0.0001]. Possession of a dispenser remained an independent predictor of improved control in a multiple regression model. In the subgroup analysis, the effect was significantly more pronounced (i) in patients receiving more medications and (ii) more diabetes medications per day (iii) in younger patients.

CONCLUSION

In this large study population in a 'realistic' setting, a simple tablet-dispensing device led to a significant and clinically relevant improvement in HbA(1c) levels. Because patients with a more complex therapy regimen benefited more, we suggest that TD might have improved adherence to therapy.

Short-term effects of cognitive behavioural group training (CBGT) in adult Type 1 diabetes patients in prolonged poor glycaemic control. A randomized controlled trial

AIMS

To assess the effects of cognitive behavioural group training (CBGT) on glycaemic control, diabetes self-efficacy and well-being in Type 1 diabetes patients in persistent poor glycaemic control.

METHODS

In a randomized controlled trial, a total of 107 patients with Type 1 diabetes in poor glycaemic control (HbA(1c) > or = 8%) were assigned to a 6-week CBGT or blood glucose awareness training (BGAT) as control condition. The intervention was preceded by a 3-month run-in period. Glycaemic control (HbA(1c)), diabetes-specific self-efficacy (CIDS), diabetes-related distress (PAID) and depressive symptoms (CES-D), were assessed at baseline (T1), directly before (T2) and 3 months after (T3) the intervention.

RESULTS

No significant changes in HbA(1c) were found after CBGT, whilst diabetes self-efficacy increased (mean CIDS score 71.6 +/- 14.0 to 74.3 +/- 12.2) and diabetes-related distress (mean PAID score 47.0 +/- 21.6 to 42.6 +/- 20.8) and depressive symptoms decreased (mean CES-D score 16.9 +/- 12.8 to 13.5 +/- 12.6). Changes in psychological outcomes were similar for both treatment groups. Diabetes self-care behaviours improved equally. Drop-out rate, which was higher among CBGT participants, was relatively low overall (total n = 15, 17.05%), and both interventions were well-appreciated by the participants.

CONCLUSIONS

CBGT was successful in improving self-efficacy, diabetes-related distress and mood at 3 months' follow-up, but not in improving glycaemic control.

Self-monitoring of blood glucose in patients with type 2 diabetes mellitus who are not using insulin

BACKGROUND

Self-monitoring of blood glucose (SMBG) has been found to be effective for patients with type 1 diabetes and for patients with type 2 diabetes using insulin. There is much debate on the effectiveness of SMBG as a tool in the self-management for patients with type 2 diabetes who are not using insulin.

OBJECTIVES

The objective of this review was to assess the effects of SMBG in patients with type 2 diabetes mellitus who are not using insulin.

SEARCH STRATEGY

Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references of retrieved articles. Date of last search: September 2004.

SELECTION CRITERIA

We included randomised controlled trails investigating the effects of SMBG compared with usual care and/or with self-monitoring of urine glucose in patients with type 2 diabetes who where not using insulin. Included studies should have used at least one of the following outcome measures: glycaemic control, quality of life, well-being, patient satisfaction, or hypoglycaemic episodes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data from included studies and assessed study quality. Data from the studies were compared to decide whether they were sufficiently homogeneous to pool in a meta-analysis.

MAIN RESULTS

Six randomised controlled trials were included in the review. Four trials compared SMBG with usual care, one trial compared SMBG with self-monitoring of urine glucose and there was one three-armed trial comparing SMBG with self-monitoring of urine glucose and usual care. Because of the differences in patient characteristics, interventions and outcomes between the studies, it was not possible to perform a meta-analysis. The methodological quality of studies was low. Two of the six studies reported a significant lowering effect of self-monitoring of blood glucose on HbA1c. However, one of these studies had a co-intervention with education on diet and lifestyle. There were few data on the effects of other outcomes and these effects were not statistically significant.

AUTHORS' CONCLUSIONS

From this review we concluded that self-monitoring of blood glucose might be effective in improving glycaemic control in patients with type 2 diabetes who are not using insulin. To assess the potential beneficial effects of SMBG in these patients a large and well-designed randomised controlled trial is required. This long-term trial should also investigate patient-related outcomes like quality of life, well-being and patient satisfaction, and provide adequate education to the patient to allow SMBG to be effective.

Cognitive behavioural group training (CBGT) for patients with type 1 diabetes in persistent poor glycaemic control: who do we reach?

Approximately a quarter of adults with type 1 diabetes do not succeed in achieving satisfactory glycaemic control, partly due to problems with the demanding self-management regimen. To improve glycaemic control, interventions with a cognitive behavioural approach, aimed at modifying dysfunctional beliefs, reducing negative emotions and enhancing self-care practices are a potentially successful tool. Little is known about the reach of such an approach. This article describes characteristics of participants in a randomized, controlled trial of cognitive behavioural group training for patients with type 1 diabetes in poor glycaemic control. Results show that outpatients from seven hospitals in the area of Amsterdam, selected on long-standing high HbA1c and volunteering to participate, report high levels of psychological distress and depressive symptoms. Furthermore, self-care behaviours were perceived as important, but burdensome. Diabetes-specific self-efficacy was relatively low. It is concluded that this selected group of adults with type 1 diabetes would potentially benefit from a cognitive-behavioural intervention in order to reduce negative emotions, enhance diabetes self-efficacy, self-care behaviour and glycaemic outcomes.