Intensive diabetes management in adolescents with type 1 diabetes: the importance of intensive follow-up

A nursing educational intervention helped by One Touch UltraSmart improves monitoring and glycated haemoglobin levels in type I diabetic children

OBJECTIVES

To improve the monitoring and control of glycated haemoglobin in insulin-dependent children. This article describes an educational intervention for this purpose where One Touch UltraSmart Software was used to manage diabetes. The results showed that this intervention helped to reduce the levels of blood glucose and glycated haemoglobin to less than 7%.

BACKGROUND

Various research studies have been performed on the effective control of glycated haemoglobin values in diabetic children by means of technological devices. However, none of this research has evaluated the impact of an educational intervention in conjunction with the use of monitoring instruments such as One Touch UltraSmart.

DESIGN

We present an 18-month longitudinal, analytical and observational study of 37 type 1 diabetic patients, 9-16 years of age. For each patient, initial and final values of glycated haemoglobin and the number of blood glucose controls were recorded.

METHODOLOGY

For the purposes of our study seven educational workshops, attended by diabetic children and their parents, were conducted. In addition, participants were asked to complete a brief questionnaire so that information could be gathered regarding the eating and exercise habits of the patients.

RESULTS

This educational intervention using One Touch UltraSmart led to a statistically significant average reduction of glycated haemoglobin.

CONCLUSIONS

Our research showed that the use of One Touch UltraSmart in the context of an educational intervention raised the awareness of the diabetic children and thus helped them to effectively control their disease and to fully understand the necessity of having good dietary and exercise habits.

RELEVANCE TO CLINICAL PRACTICE

It can be concluded that the educational intervention led to a significant improvement in the dietary habits of these patients and also helped them to exercise regularly, all of which has a positive impact on their health.

Pioglitazone as adjunctive therapy in adolescents with type 1 diabetes

OBJECTIVE

To determine whether the addition of the thiazoladinedione, pioglitazone, to standard therapy improves metabolic control in adolescents with type 1 diabetes (T1D) and clinical evidence of insulin resistance.

STUDY DESIGN

Randomized, placebo-controlled 6-month 2-site trial of pioglitazone therapy in 35 adolescents with T1D, high insulin requirements (>0.9 U/kg/d), and suboptimal metabolic control (A1c 7.5%-11%), with the primary outcome of change in A1c. Secondary outcomes include change in insulin dose, body mass index (BMI), lipids, and waist and hip circumference.

RESULTS

Metabolic control (A1c) was improved at 6 months in all subjects (P = .02). There was no significant difference between the pioglitazone and placebo treatment groups at 6 months in either change in A1c (-0.4% +/- 0.9% and -0.5% +/- 1.2%, respectively) or insulin dose. BMI SDS increased by 0.3 +/- 0.3 (kg/m(2)) in the pioglitazone group and remained unchanged in the placebo group (P = .01). There was no significant difference in change in any lipid parameters between the pioglitazone and placebo groups at 6 months.

CONCLUSIONS

Adjunctive pioglitazone therapy was not effective in improving glycemic control in adolescents with T1D. Pioglitazone was associated with increased BMI.

Psycho-educational interventions for children and young people with Type 1 diabetes

BACKGROUND

A systematic review of the literature in 2000 revealed numerous methodological shortcomings in education research, but in recent years progress has been made in the quantity and quality of psycho-educational intervention studies.

SUMMARY OF CONTENTS

This review focuses on diabetes education programmes developed for children, young people and their families in the past 5 years. A comprehensive review of the literature identified 27 articles describing the evaluation of 24 psycho-educational interventions. Data summary tables compare the key features of these, and comparisons are made between individual, group and family-based interventions. Effect sizes are calculated for nine of the randomized studies. Three research questions are posed: firstly has the recent literature addressed the problems highlighted in the previous review; secondly is there sufficient evidence to recommend adaptation of a particular programme; and, finally, what do we still need to do?

CONCLUSIONS

Progress in the quality and quantity of educational research has not resulted in improved effectiveness of interventions. There is still insufficient evidence to recommend adaptation of a particular educational programme and no programme that has been proven effective in randomized studies for those with poor glycaemic control. To develop a range of effective educational interventions, further research involving larger sample sizes with multicentre collaboration is required.

Glycemic Relapse in Type 2 Diabetes

OBJECTIVE

To characterize the occurrence of glycemic relapse after initial improvement in blood glucose levels and to describe predictors of relapse in patients with type 2 diabetes.

METHODS

Occurrence of glycemic relapse was analyzed in 393 consecutive patients with type 2 diabetes after participation in a 3-month intensive outpatient intervention. All patients had hemoglobin A1c (A1C) values (3)7% before the intervention and had achieved adequate glycemic control (nadir A1C<7%) afterward. The median follow-up time was 26.5 months. Relapse was defined as a subsequent increase in A1C to (3)7%.

RESULTS

The probability of glycemic relapse was 45% at 1 year after the intervention and was 76% at 3 years. The median time to relapse was 15.2 months. Cox multivariate regression analysis indicated that treatment with insulin was associated with a greater risk of relapse-- hazard ratio=1.5 (95% confidence interval, 1.1 to 2.2), after controlling for the patient's age, sex, race, body mass index, duration of diabetes, weight change during the intervention, and nadir A1C value. Among those patients not treated with insulin at the end of the intervention, a shorter duration of diabetes and weight loss during the intervention period were significantly associated with decreased risk of relapse.

CONCLUSION

The majority of study patients with type 2 diabetes who attained satisfactory glycemic control after intensive outpatient intervention had a relapse after the end of the intervention period. Patients receiving insulin therapy were at particular risk of glycemic relapse. Therefore, such patients should receive high priority for continuation of intensive care or for other relapse prevention measures.

Matrix metalloproteinase 2 may be a marker of microangiopathy in children and adolescents with type 1 diabetes mellitus

Matrix metalloproteinases (MMPs) 2 and 9 are responsible for extracellular matrix breakdown and their abnormal circulating levels may pre-date clinical evidence of diabetic angiopathy. We detected by ELISA, plasma MMP-2 and MMP-9 levels and associated activity in 25 children and adolescents with T1DM. Thirteen male and 12 female patients were evaluated at the clinical diagnosis and onset of T1DM and again at a 5-year follow-up. Twelve patients had developed microangiopathic complications at the follow-up evaluation. MMP-2 and MMP-9 levels and activity were detected in samples obtained at T1DM diagnosis and at the 5-year follow-up. As controls, 19 healthy subjects who were the same age as the patients were also evaluated at baseline and again after 5 years. MMP-2 levels and activity were significantly higher in the patients than in the controls at disease onset. This was particularly evident when patients who developed microangiopathic complications were compared to controls and patients without complications. At the 5-year follow-up, a significant increase in MMP-2 levels and a significant decrease in MMP-2 activity were found only in the control group compared to the baseline levels. MMP-2 levels and activity were higher in patients with microangiopathy. MMP-9 levels and activity were increased in all groups compared to baseline levels. MMP-9 levels were lower in patients with microangiopathy compared to controls, but no difference was found between the two patient groups. It is well known that MMP-9 is an index of the severity and stability of macroangiopathy while our results allow us to postulate that MMP-2 may be a marker of microangiopathy.

A randomized trial of regular standardized telephone contact by a diabetes nurse educator in adolescents with poor diabetes control

OBJECTIVE

The aim of this study was to determine the effect of regular standardized telephone contact by a diabetes nurse educator (DNE) on metabolic control, treatment compliance, and quality of life in adolescents with poorly controlled type 1 diabetes.

METHODS

A single-blinded 6-month randomized controlled trial was used. Participants included 46 of 49 eligible adolescents (13-17 yr) with type 1 diabetes >1-yr duration and hemoglobin A1c (HbA1c) >8.5% for the previous 6 months. Subjects were randomly assigned to 6 months of standard diabetes management or standard care plus weekly telephone contact by a DNE. Telephone conversations included review of events in the adolescents' lives and diabetes education, but the primary focus was on blood glucose results and insulin-dose adjustments. HbA1c, compliance with glucose monitoring, quality of life [Diabetes Quality of Life Scale for Youth (DQOLY)], and family functioning [Family Environment Scale (FES)] were assessed at baseline, and at 3 and 6 months. Posthoc, HbA1c levels were assessed 6 months following study completion.

RESULTS

Six months of regular telephone contact by a DNE had no immediate effect on any of the outcome measures. However, posthoc 6 months, HbA1c levels decreased (1% change compared to baseline) in 6/21 of the study group and 0/18 of the control group, while HbA1c increased in 4/21 of study subjects compared to 8/18 of control subjects (p = 0.015).

CONCLUSIONS

In contrast to adult studies, regular telephone contact did not lead to immediate improvements in metabolic control in adolescents with poorly controlled type 1 diabetes. However, knowledge and skills gained during the intervention may have had a delayed beneficial effect in these high-risk adolescents.

Considerations on blood glucose management in Type 2 diabetes mellitus

In recent years the benefits of more intensive management in preventing or delaying the development and progression of diabetic complications have been well documented. What is not as well documented is how to motivate the person with diabetes to manage the condition, how to set, assess and quantify glucose goals, and the glucose variables that should be routinely measured. This review discusses the importance of setting targets and communicating them in a way that the patient understands. When aiming for a glycaemia target, balance is required (1) between achieving reduction of complications and causing an increased degree of hypoglycaemia, and (2) between what is achievable and what degree of benefit is gained. Target values given in guidelines should be adapted by the clinician to take into account the patient's susceptibility to hypoglycaemia, stage and type of complications, age and life expectancy, co-morbidity, social environment, understanding of the steps required and level of commitment to the treatment. Several suggestions are given regarding possible improvements and amendments to existing guidelines for diabetes management in treating to glucose goal. For example, attention should be drawn to the need to individualize goals and to consider education, long-term support, patient needs and treatment outcome when formulating diabetes management plans. The relative properties of the different glucose variables-fasting plasma glucose (FPG), postprandial plasma glucose (PPG), glycated haemoglobin A(1c) (HbA(1c)), and glycated protein-in terms of their convenience of measurement, usefulness and relevance to the physician and patient are also evaluated. When prioritising the variables to be measured it is suggested that where feasible, HbA(1c) should be the standard measurement by which to gauge risk and treatment efficacy. Serial measurements should be made and, where possible, the use of blood glucose meters encouraged, in order to obtain a blood glucose profile for the patient.