Identifying the special needs of children with Type 1 diabetes in the school setting. An overview of parents' perceptions

AIMS

The aims of this observational study were to identify the special needs of children with Type 1 diabetes in schools from the parents' point of view and the difficulties experienced with full integration, and to define a series of interventions which may improve the situation.

METHODS

Parents of children aged 3-18 years with Type 1 diabetes were eligible. Those who agreed to participate completed a self-reporting questionnaire which determined the effects of the disease on children, parents and school personnel, and addressed aspects including children's integration, glycaemic control, insulin administration, meals, sports, trips and attitudes of teachers and school colleagues to their disease.

RESULTS

A total of 499 questionnaires were completed and validated. Median age of children was 11.5 years (95% CI 7.8-15.2). Only 34% of parents believed that teachers could recognize the symptoms of a mild hypoglycaemic episode. Seventeen per cent of parents experienced problems at their schools when they informed staff about their children's disease, 5% were finally not accepted and 8% were forced to change school. In some cases, they had to modify glucose monitoring (9%) and treatment administration (16%) because of a lack of cooperation from the school.

CONCLUSIONS

Training sessions on Type 1 diabetes, an increase in the number of nurses, better availability of resources from diabetic associations to schools and improved communication between school personnel and parents were identified as key factors that may improve the full integration of the diabetic child in this setting.

Comparison of peripheral arterial reconstruction in diabetic and non-diabetic patients: a prospective clinic-based study

To assess the efficacy and safety of lower extremity arterial reconstruction in diabetic and non-diabetic subjects during a 3-year period. A prospective clinic-based study between 1994-1999 in Area 7, Madrid, with a population of 569307 and an estimated diabetic population of 37932 (15505 men and 22427 women). The level of arterial reconstruction and associated risk factors were ascertained.

RESULTS

A total of 588 peripheral revascularization surgical procedures were performed in 481 patients. The diabetic patients (n=174, 36.2%) underwent 222 surgical procedures (including 48 follow-on operations, 21.6%), and 307 non-diabetic subjects underwent 366 surgical procedures (59 follow-on operations, 16.1%). The numbers of surgical procedures per 100000 people at risk and year were 18.8 and 1.8 for non-diabetic men and women, respectively, and 145.1 and 29.0 for men and women with diabetes mellitus (7.7- and 16.2-fold, respectively). Age at reconstruction surgery was 2 and 5 years earlier in non-diabetic than in diabetic men and women, respectively. Diabetic patients had a higher neuropathy score (P<0.05) and were less frequently smokers (P<0.05) than non-diabetic subjects. Diabetic subjects more frequently had distal reconstruction while proximal arterial reconstruction was more often performed in non-diabetic subjects. Between 64.6 and 80.4% of people with diabetes and 82.3 and 88.9% of non-diabetic subjects had no complications during their in-hospital stay. Distal amputation simultaneous to arterial reconstruction was the most frequent morbidity of people with diabetes during the study (P<0.05). Despite a graft occlusion rate after femoropopliteal revascularization significantly higher than in non-diabetic people (P<0.05), diabetic people more often required lower extremity amputations (LEAs) for the same level of bypass (P<0.01). Cumulative limb salvage rates were lower in diabetic patients than in non-diabetic subjects at femoropopliteal (49.2 vs. 89.7%; P<0.001), femorodistal (73.5 vs. 95.2%; P<0.01), and distal reverse (77.9 vs. 87.3%; P<0.05) arterial reconstruction, at the end of the third year, but similar after aorto-iliac reconstruction (93.1 vs. 97.5%). A higher neuropathy score and the presence of foot ulcers were associated to significantly lower limb salvage in diabetic patients (P<0.05), but not in non-diabetic people. Survival rates after 3 years were similar between diabetic and non-diabetic populations after aorto-iliac (93.1 vs. 97.5%), femoropopliteal (97.2 vs. 90.3%), and distal reverse (93.2 vs. 98.1%) revascularization, and slightly lower in diabetic compared to non-diabetic patients after femorodistal revascularization (82.1 vs. 96.3%; P<0.05).

CONCLUSION

Although limb salvage after arterial reconstruction is lower in diabetic than in non-diabetic subjects, particularly in those with a higher neuropathy score, this surgical approach can be applied in both diabetic and non-diabetic subjects with otherwise similar outcome.

Nontraumatic lower extremity amputations in diabetic and non-diabetic subjects in Madrid, Spain

The purpose of this study was to determine the incidence of non-traumatic lower extremity amputations (LEAs) in diabetic and non-diabetic subjects in Madrid, Spain, and their direct cost. All patients who underwent LEAs between the 1st of January 1994 and the 31st of December 1996, and who had lived in area 7 of the city (569,307 inhabitants) for at least the last 6 months, were identified through operating theatre records cross-checked with Vascular Surgery Department discharge records. In addition, the direct cost of LEAs per year was estimated, taking into account the length of the hospital stay, the period of rehabilitation in the outpatient clinic after discharge, and the use of artificial limbs and their maintenance. The incidence of LEAs was 1.6 (95% CI: 1.1-2.2) per 10(5) non-diabetic subjects and 46.1 (95% CI: 34.5-57.6) per 10(5) diabetic patients. Relative risk was 28. Total direct costs associated with LEAs per year were US$ 56,131 in the diabetic population and US$ 30,765 in the non-diabetic population. Thus, potential cost savings associated with excess amputations in the diabetic population was estimated at US$ 541,353 per year of US$ 94,736 per 10(5) inhabitants. It is concluded that the incidence of LEAs in both diabetic and non-diabetic populations in area 7 is the lowest reported in European countries. The potential cost savings per 10(5) inhabitants and per year is estimated at US$ 94,736.

Changes in nutritional pattern, insulin sensitivity and glucose tolerance during weight loss in obese patients from a Mediterranean area

In order to study the nutritional pattern in obese subjects living in an area with a Mediterranean diet, as well as the modifications in nutritional behaviour, cardiovascular risk factors and insulin sensitivity induced by changes in nutritional pattern, 54 obese patients completed a 20-week behaviour programme. They prospectively fulfilled a food records diary in order to ascertain their nutritional pattern. Weight, body mass index (BMI). waist-to-hip ratio (WHR), blood pressure (BP), cholesterol, HDL-c, LDL-c, triglycerides, fasting and 2 h-post glucose load plasma glucose were determined at the onset and at the end of the study. Insulin sensitivity index (SI), and glucose effectiveness (Sg) were assessed by using the modified FSIVGTT. The usual diet in obese patients living in a Mediterranean country is low in carbohydrates (35%) and high in fats (43%), 55% of the latter being monounsaturated fatty acids (MUFAs), especially olive oil. After the educational programme they decreased the caloric intake to slightly over 700 Kcal/day, with a reduction of 36% in carbohydrates consumption, 18% in proteins and 43% in fats (46% in MUFAs). These modifications resulted in a decrease in weight, BMI, WHR, BP, and fasting and 2 h-post glucose load plasma glucose (all p < 0.05), whereas the lipoprotein profile did not change. In a similar way SI and Kg (glucose disappearance rate) increased, while fasting plasma insulin (FPI) decreased (p < 0.05) and Sg and I1+3 remained unaffected. Our results indicate that weight loss induced by caloric restriction improves insulin sensitivity rather insulin secretory capacity or glucose effectiveness, and all the cardiovascular risk factors but lipoproteic profile, that remains unchanged, probably because of the lower MUFAs consumption. These facts should be taken into account when recommending changes in the diet of obese patients with a Mediterranean-style diet.

Comparison between acarbose, metformin, and insulin treatment in type 2 diabetic patients with secondary failure to sulfonylurea treatment

The purpose of this study was to determine the most suitable treatment for Type 2 (non-insulin-dependent) diabetic patients with secondary failure to sulfonylureas (SFS). In a four-month comparative study, 36 Type 2 diabetic patients given SFS were allocated to three treatment groups: A (n = 12, M/F 6/6, HbAlc 9.1 +/- 1.6%) received 0.3 IU/Kg body weight (BW) of insulin-Zn between 10 and 11 p.m.; B (n = 12, M/F 6/6, HbAlc 9.2 +/- 1.6%) SFS plus 850 mg/day of metformin; and C (n = 12, M/F 6/6, HbAlc 9.5 +/- 2.4%) SFS plus acarbose 3 x 100 mg daily. Modifications in HbAlc, BW, blood pressure (BP), lipoprotein profile and insulin sensitivity were evaluated. HbAlc decreased in the three groups (A: 17.9 +/- 13.5%; B: 18.2 +/- 4.5%; C: 7.6 +/- 16.8%; all p < 0.05; A and B vs C = p < 0.05). BW increased in group A and decreased in the other groups. BP decreased statistically in group B. HDL-cholesterol increased (1.26 +/- 0.46 vs 1.49 +/- 0.36 mmol/L; p < 0.05) and triglyceride levels decreased (1.68 +/- 0.85 vs 1.16 +/- 0.43 mmol/L; p < 0.05) in group A. There were no significant changes in the other studied parameters. We conclude that, for Type 2 diabetic patients given SFS, both insulin and metformin plus SFS provided better glycaemic control than acarbose plus SFS. Metformin combined with SFS offered further advantages for the control of BW and BP.

Regular physical activity and reduced occurrence of microalbuminuria in type 2 diabetic patients

In order to evaluate the influence of regular non-strenuous physical exercise on the appearance of microalbuminuria in Type 2 (non-insulin-dependent) diabetic patients, we have studied a cohort of 372 Type 2 diabetic patients (152 males and 220 females, mean age: 63.59 +/- 0.70 years, evolution time: 10.31 +/- 0.4 years, M +/- SEM). One hundred and ninety seven (52.9%) presented normo-albuminuria, 124 (33.3%) microalbuminuria and 51 (13.7%) proteinuria. These three groups were different with regard to evolution time, weight, BMI, waist-hip ratio, Hb1Ac value, prevalence of hypertension and physical activity level. 132 (35.4%) patients had a regular exercise-induced caloric expenditure under 500 kcal/wk whereas 122 (32.7%) were between 500 and 1.000 kcal/wk and 118 (31.7%) over 1.000 kcal/wk. Prevalence of normo-albuminuric patients was 40.1%, 52.4% and 67.7% respectively (p < 0.01). Prevalence of normo-albuminuric patients remained significatively higher in the patient with the greater physical activity level when adjusted to systolic blood pressure, diastolic blood pressure, evolution time and HbA1c value. Our results stress the fact that regular non-strenuous physical activity may have a protective effect on the appearance of microalbuminuria in Type 2 (non-insulin-dependent) diabetic patients. Whether the cardiovascular protective influence of exercise in these patients depends on such an effect remains unknown. On the basis of this cross-sectional evidence, a longitudinal study is now under way.

Estimation of the prevalence of diabetes mellitus diagnosed, and incidence of type 1 (insulin-dependent) diabetes mellitus in the Avila Health Care region of Spain

We studied the prevalence of diabetes mellitus diagnosed in the Avila Health Care region, Spain, based on the prescribed daily dosage (PDD) of insulin (corrected in function of insulin loss (PDDc)) and sulphonureas, from a sample representative of prescribing physicians (A, n = 48) and pharmacies (B, n = 25) in our region. The amounts of the PDDcs of insulin sold during 1989 per 1000 inhabitants/day were 6.06 and 6.20, respectively for the two samples (A and B). The figures for PDDs of sulphonurea/1000 inhabitants/day were 16.25 and 19.16, respectively. We determined the proportion that diabetic patients on diet alone represented in relation to non-insulin treated diabetic patients who visited the only specialized clinic for diabetic patients in our province in 1989. These patients accounted for 40.83% of non-insulin treated diabetic patients. The patients being treated with biguanides or with a combination of anti-diabetic drugs accounted for less than 1% of those treated in the specialized clinic. Taking this into account, the prevalence of diabetes mellitus in Avila was 3.35% (C.I. 95%: 3.10-3.59), according to the sample A and 3.85% (C.I. 95%: 3.50-4.31) according to the sample B. In addition, we studied the hospital admission records during three consecutive years in order to find out the incidence of type 1 insulin-dependent diabetes mellitus (IDDM) below 15 years of age in the Avila Health Care region of Spain. All prescribing physicians that did not work in the Hospital (197 in the rural area and 18 in the urban area) were used as the secondary source for validation of case ascertainment.(ABSTRACT TRUNCATED AT 250 WORDS)

Behaviour modification in obese subjects with type 2 diabetes mellitus

We have followed prospectively, 46 obese, type 2 diabetic patients for a 55-week period, in order to evaluate the efficiency of an educational programme based on behaviour modification to enhance weight loss and changes of other cardiovascular risk factors. No patient received pharmacological treatment during the study. At the end of the follow-up the patients obtained an average weight loss of 9.250 kg (range: 0.500-17.500 kg); the BMI was reduced from 34.2 +/- 0.8 kg/m2 to 30.6 +/- 1.1 kg/m2 (P less than 0.01); fasting serum glucose descended from 7.9 +/- 0.4 to 6.1 +/- 0.5 mM (P less than 0.05); SBP (systolic blood pressure) decreased from 145.7 +/- 3 to 126.4 +/- 5.1 mmHg (P less than 0.01); DBP (diastolic blood pressure) decreased from 83.5 +/- 2.5 to 65 +/- 2.6 mmHg (P less than 0.01); triglyceride levels were lowered from 164.5 +/- 12 to 109.7 +/- 10 mg/dl (P less than 0.01); HDL-cholesterol levels increased from 1.27 +/- 0.05 to 1.53 +/- 0.12 mM (P less than 0.01). Serum glucose 2 h after a 75 g glucose oral load decreased from 14.9 +/- 0.6 to 12.7 +/- 0.9 mM (P less than 0.05) on week 35 of follow-up. Twelve patients no longer presented a diabetic curve (8 normal oral glucose tolerance test (OGTT) curves, and 4 impaired glucose tolerance (IGT) curves). No significant changes in the parameters studied were obtained in the group of patients on conventional treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Effect of weight loss on insulin sensitivity and cardiovascular risk factors in glucose tolerant and intolerant obese subjects

We observed 170 obese patients during 55 weeks in order to study the influence of insulin resistance and insulin sensitivity on cardiovascular risk factors in such patients as well as the changes occurring on these subjects as a result of weight loss. At the beginning of the study, the patients were divided into two groups, according to the results of an oral glucose tolerance test (OGTT) performed with 75 g of glucose: Group A, glucose tolerant subjects (n = 81), Group B, glucose intolerant subjects (n = 89). Initially Group B patients showed higher values for fasting blood glucose, 2 h after OGTT, systolic and diastolic blood pressure, cholesterol, triglycerides and cholesterol/HDL-cholesterol ratio when compared to Group A patients (p less than 0.05). Fasting and 1 h-post glucose load serum insulin levels in both Group A and Group B patients were higher than those found out in non over-weight tolerant subjects, but there were no differences between both groups. The serum glucose descent slope after an insulin tolerance test (ITT) was lower for group B than for group A (p less than 0.05), whereas both groups demonstrated lower descent slopes than non overweight tolerant subjects (p less than 0.05). After a 55 weeks follow-up period, the patients in Group A had lost 4.6 +/- 0.7 kg and those in Group B 6.2 +/- 1.1 kg. In both groups, the values for SBP, DBP, FBG, triglycerides and cholesterol/HDL-cholesterol ratio had dropped significantly, with a rise in the HDL-cholesterol level.(ABSTRACT TRUNCATED AT 250 WORDS)

D-Trp6-luteinizing hormone-releasing hormone inhibits sulpiride-induced hyperprolactinemia in normal men

The effect of a potent agonistic analog of LHRH, D-Trp6-LHRH, on hyperprolactinemia induced by sulpiride was studied in normal men. Six men received sulpiride (100 mg, twice daily, orally) for 44 days. D-Trp6-LHRH was given sc during the last 2 weeks of sulpiride administration; the dose was 500 micrograms on the first day and 100 micrograms daily for the subsequent 14 days. All men had high serum PRL levels before D-Trp6-LHRH administration (mean +/- SEM, 56 +/- 9 ng/mL), which decreased significantly after the first dose of the analog (45 +/- 5 ng/mL; P = 0.031) and also after 15 days of analog administration (41 +/- 6 ng/mL; P = 0.016). These data demonstrate that administration of LHRH agonist can inhibit the hyperprolactinemic effect of sulpiride, suggesting a direct action of the analog on the pituitary gland to modulate PRL secretion.