Care of people with diabetes : a manual of nursing practice

Contents: Diagnosing and classifying diabetes -- Assessment and nursing diagnosis -- Monitoring diabetes mellitus -- Nutritional aspects of caring for people with diabetes -- Medication commonly used in diabetes management -- Hypoglycaemia -- Hyperglycaemia, diabetic ketoacidosis (DKA), hyperosmolar coma and lactic acidosis -- Long term complications of diabetes -- Management during surgical and investigative procedures -- Special situations and unusual conditions related to diabetes -- Diabetes and sexual health -- Diabetes in the older person -- Diabetes in children and adolescents -- Women, pregnancy, and gestational diabetes -- Psychological and quality of life issues related to having diabetes -- Diabetes education -- Discharge planning -- Community and primary care nursing and home-based care -- Complementary therapies and diabetes -- Managing diabetes in the emergency situations.

Medication knowledge and self-management by people with type 2 diabetes

Objective: To explore medication knowledge and self management practices of people with type 2 diabetes.

Design: A one-shot cross sectional study using in-depth interviews and participant observation.

Setting: Diabetes outpatient education centre of a university teaching hospital.

Subjects: People with type 2 diabetes, n=30, 17 males and 13 females, age range 33-84, from a range of ethnic groups.

Outcome measures: Ability to state name, main actions and when to take medicines. Performance of specific medication-related tasks; opening bottles and packs, breaking tablets in half, administering insulin, and testing blood glucose.

Results: Average medication use > or = 10 years. Respondents were taking 86 different medicines, mean 7 +/- 2.97 SD. Dose frequency included two, three and four times per day. All respondents had > or = 2 diabetic complications +/- other comorbidities. The majority (93%) were informed about how and when to take their medicines, but only 37% were given information about side effects and 17% were given all possible seven items of information. Younger respondents received more information than older respondents. Older respondents had difficulty opening bottles and breaking tablets in half. Twenty per cent regularly forgot to take their medicines. Increasing medication costs was one reason for stopping medicines or reducing the dose or dose interval. The majority tested their blood glucose but did not control test their meters and 33% placed used sharps directly into the rubbish.

Conclusion: Polypharmacy was common. Medication knowledge and self management were inadequate and could lead to adverse events.

Prevention of type 2 diabetes in a primary health care setting interim results from the Greater Green Triangle (GGT) Diabetes Prevention Project

Although clinical trials have shown that lifestyle modifications reduce the risk of type 2 diabetes, translating lessons from trials to primary care remains a challenge. The aim of the study was to evaluate efficacy and feasibility of primary care-based diabetes prevention model with modest resource requirements in rural Australia. Three hundred and eleven subjects with at least a moderate risk of type 2 diabetes participated in a combined dietary and physical activity intervention. Clinical measurements and fasting blood samples were taken at the baseline and after intervention. After 3 months intervention, total (change −3.5%, p < 0.001) and LDL cholesterol (−4.8%, p < 0.001) plasma levels as well as body mass index (−2.5%, p < 0.001), weight (−2.5%, p < 0.001), and waist (−1.6%, p < 0.001) and hip (−2.7%, p < 0.001) circumferences reduced significantly. A borderline reduction was found in triglyceride levels (−4.8%, p = 0.058) while no changes were observed in HDL cholesterol (+0.6%, p = 0.525), glucose (+0.06%, p = 0.386), or systolic (−0.98%, p = 0.095) or diastolic (−1.06%, p = 0.134) blood pressure levels. In conclusion, a lifestyle intervention improved health outcomes – especially obesity and blood lipids – in a population at high risk of developing type 2 diabetes. Our results suggest that the present model is effective and feasible to carry out in primary care settings.

Patient engagement and coaching for health: the PEACH study- a cluster randomised controlled trial using the telephone to coach people with type 2 diabetes to engage with their GPs to improve diabetes care: a study protocol.

Background
The PEACH study is based on an innovative 'telephone coaching' program that has been used effectively in a post cardiac event trial. This intervention will be tested in a General Practice setting in a pragmatic trial using existing Practice Nurses (PN) as coaches for people with type 2 diabetes (T2D). Actual clinical care often fails to achieve standards, that are based on evidence that self-management interventions (educational and psychological) and intensive pharmacotherapy improve diabetes control. Telephone coaching in our study focuses on both. This paper describes our study protocol, which aims to test whether goal focused telephone coaching in T2D can improve diabetes control and reduce the treatment gap between guideline based standards and actual clinical practice.
Methods/design
In a cluster randomised controlled trial, general practices employing Practice Nurses (PNs) are randomly allocated to an intervention or control group. We aim to recruit 546 patients with poorly controlled T2D (HbA1c >7.5%) from 42 General Practices that employ PNs in Melbourne, Australia. PNs from General Practices allocated to the intervention group will be trained in diabetes telephone coaching focusing on biochemical targets addressing both patient self-management and engaging patients to work with their General Practitioners (GPs) to intensify pharmacological treatment according to the study clinical protocol. Patients of intervention group practices will receive 8 telephone coaching sessions and one face-to-face coaching session from existing PNs over 18 months plus usual care and outcomes will be compared to the control group, who will only receive only usual care from their GPs. The primary outcome is HbA1c levels and secondary outcomes include cardiovascular disease risk factors, behavioral risk factors and process of care measures.
Discussion
Understanding how to achieve comprehensive treatment of T2D in a General Practice setting is the focus of the PEACH study. This study explores the potential role for PNs to help reduce the treatment and outcomes gap in people with T2D by using telephone coaching. The intervention, if found to be effective, has potential to be sustained and embedded within real world General Practice.

Prevention of type 2 diabetes by lifestyle intervention in an Australian primary health care setting : Greater Green Triangle (GGT) Diabetes Prevention Project

Background
Randomised controlled trials demonstrate a 60% reduction in type 2 diabetes incidence through lifestyle modification programmes. The aim of this study is to determine whether such programmes are feasible in primary health care.

Methods
An intervention study including 237 individuals 40–75 years of age with moderate or high risk of developing type 2 diabetes. A structured group programme with six 90 minute sessions delivered during an eight month period by trained nurses in Australian primary health care in 2004–2006. Main outcome measures taken at baseline, three, and 12 months included weight, height, waist circumference, fasting plasma glucose and lipids, plasma glucose two hours after oral glucose challenge, blood pressure, measures of psychological distress and general health outcomes. To test differences between baseline and follow-up, paired t-tests and Wilcoxon rank sum tests were performed.

Results
At twelve months participants' mean weight reduced by 2.52 kg (95% confidence interval 1.85 to 3.19) and waist circumference by 4.17 cm (3.48 to 4.87). Mean fasting glucose reduced by 0.14 mmol/l (0.07 to 0.20), plasma glucose two hours after oral glucose challenge by 0.58 mmol/l (0.36 to 0.79), total cholesterol by 0.29 mmol/l (0.18 to 0.40), low density lipoprotein cholesterol by 0.25 mmol/l (0.16 to 0.34), triglycerides by 0.15 mmol/l (0.05 to 0.24) and diastolic blood pressure by 2.14 mmHg (0.94 to 3.33). Significant improvements were also found in most psychological measures.

Conclusion
This study provides evidence that a type 2 diabetes prevention programme using lifestyle intervention is feasible in primary health care settings, with reductions in risk factors approaching those observed in clinical trials.

Trial Number
Current Controlled Trials ISRCTN38031372

The rising prevalence of diabetes and impaired glucose tolerance : the Australian diabetes, obesity and lifestyle study

OBJECTIVE—To determine the population-based prevalence of diabetes and other categories of glucose intolerance (impaired glucose tolerance [IGT] and impaired fasting glucose [IFG]) in Australia and to compare the prevalence with previous Australian data.

RESEARCH DESIGN AND METHODS—A national sample involving 11,247 participants aged >=25 years living in 42 randomly selected areas from the six states and the Northern Territory were examined in a cross-sectional survey using the 75-g oral glucose tolerance test to assess fasting and 2-h plasma glucose concentrations. The World Health Organization diagnostic criteria were used to determine the prevalence of abnormal glucose tolerance.

RESULTS—The prevalence of diabetes in Australia was 8.0% in men and 6.8% in women, and an additional 17.4% of men and 15.4% of women had IGT or IFG. Even in the youngest age group (25–34 years), 5.7% of subjects had abnormal glucose tolerance. The overall diabetes prevalence in Australia was 7.4%, and an additional 16.4% had IGT or IFG. Diabetes prevalence has more than doubled since 1981, and this is only partially explained by changes in age profile and obesity.

CONCLUSIONS—Australia has a rapidly rising prevalence of diabetes and other categories of abnormal glucose tolerance. The prevalence of abnormal glucose tolerance in Australia is one of the highest yet reported from a developed nation with a predominantly Europid background.

Abbreviations: 2hPG, 2-h plasma glucose • AusDiab, Australian Diabetes, Obesity and Lifestyle Study • CD, Census Collector District • FPG, fasting plasma glucose • IFG, impaired fasting glucose • IGT, impaired glucose tolerance • KDM, known diabetes mellitus • NDM, newly diagnosed diabetes mellitus • OGTT, oral glucose tolerance test • WHO, World Health Organization

Peridontal disease : the overlooked diabetes complication

Periodontal diseases are infectious processes that occur in the presence of bacteria, which trigger an inflammatory response. Periodontal disease is associated with many medical conditions, including diabetes mellitus and its complications (such as kidney disease). It has been described as the "sixth diabetes complication" but is often overlooked in routine diabetes management and complication screening processes. Proactive, preventative dental and diabetes self care, as well as regular dental and diabetes assessment, are important management strategies because periodontal disease contributes to the progression of impaired glucose tolerance to diabetes mellitus and to hyperglycemia in individuals with established diabetes.

Interaction of dietary fibre, carbohydrate metabolism and diabetes in the rat

It is currently accepted that the most appropriate diet in the treatment of non-insulin-dependent diabetes mellitus "e;NIDDM"e; is high in carbohydrates, high in fibre and low in fat. Dietary fibre reduces the rate of carbohydrate absorption, which may have a beneficial effect on insulin action. Furthermore, high fibre diets also increase the amount of carbohydrates which are not absorbed from the small intestine. These malabsorbed carbohydrates are fermented by the bacterial population in the large intestine, producing short chain fatty acids "e;SCFA"e;, including propionate, which has been shown to alter liver carbohydrate metabolism. This thesis investigated the actions of slowed carbohydrate absorption and carbohydrate malabsorption in streptozotocin-induced "e;STZ"e; diabetic rats. High carbohydrate diet supplemented with guar gum, a soluble dietary fibre, fed to STZ diabetic rats improved insulin sensitivity. investigation of the alterations in the stomach and small intestine demonstrated that guar increased the viscosity of the meal in the intestine. The action of increased fermentation, producing more propionate, was investigated by supplementing propionate into the diets of STZ diabetic rats or when perfused into isolated rat livers. No changes in insulin action or liver glucose metabolism were measured. in addition, it was shown that guar gum reduces food intake in STZ diabetic rats. Mild reductions in food intake in STZ diabetic rats were shown to increase insulin action. In summary, STZ diabetic rats fed high carbohydrate, high fibre diets reductions in food consumption and slowed carbohydrate absorption are important factors which may lower blood glucose concentrations and increase insulin action. increased SCFA production is unlikely to contribute significantly to the improvements in insulin action.

Sustained gains from a diabetes prevention program and the role of telephone support

Background
An evaluation of the sustainability of lifestyle changes was undertaken for participants completing a 12 month diabetes prevention program. This second part of the study also tested whether regular structured telephone calls could be effective in maintaining lifestyle changes.

Methods
Originally, 237 participants completed a 12 month group-based lifestyle intervention study. They were aged 40–75 years, with a moderate to high risk of developing type 2 diabetes. Participants were then randomised to telephone support (n = 107) or self-care only (n = 98) for 18 months, and re-assessed using anthropometric, clinical, psychological and general health measures.

Results
A total of 164 participants (85 telephone support and 79 self-care only) completed the follow-up. Changes between 12 and 30 months for the telephone support group were not significantly different from those found in the self-care only group. Beneficial lifestyle changes achieved by participants were generally sustained after the diabetes prevention program, with the exception of fasting plasma glucose and some psychological measures.

Conclusions
Positive outcomes achieved at 12 months were generally maintained after a further 18 months. Telephone support did not appear to produce additional benefits.

Social stigma in diabetes : a framework to understand a growing problem for an increasing epidemic

A comprehensive understanding of the social and psychological impact of diabetes mellitus is important for informing policy and practice. One potentially significant, yet under-researched, issue is the social stigma surrounding diabetes. This narrative review draws on literature about health-related stigma in diabetes and other chronic conditions in order to develop a framework for understanding diabetes-related stigma. Our review of the literature found that people who do not have diabetes assume that diabetes is not a stigmatized condition. In contrast, people with diabetes report that stigma is a significant concern to them, experienced across many life domains, e.g., in the workplace, in relationships. The experience of diabetes-related stigma has a significant negative impact on many aspects of psychological well-being and may also result in sub-optimal clinical outcomes for people with diabetes. We propose a framework that highlights the causes (attitudes of blame, feelings of fear and disgust, and the felt need to enforce social norms and avoid disease), experiences (being judged, rejected, and discriminated against), and consequences (e.g., distress, poorer psychological well-being, and sub-optimal self-care) of diabetes-related stigma and also identifies potential mitigating strategies to reduce diabetes-related stigma and/or enhance coping and resilience amongst people with diabetes. The systematic investigation of the experiences, causes, and consequences of diabetes-related stigma is an urgent research priority.

The use of complementary and alternative medicine among people living with diabetes in Sydney

Background: Complementary and alternative medicine (CAM) is common in patients with chronic disease such as diabetes mellitus. The primary objective of the study was to determine the overall prevalence and type of CAM use in individuals with diabetes mellitus (DM) in Western Sydney and to compare the prevalence and factors associated with CAM use with the literature.

Methods: A multicenter cross-sectional study was undertaken using a self-completed questionnaire distributed to patients with DM attending a public hospital and specialist endocrinology clinics in the region. The type of DM and pattern of CAM utilisation were analyzed.

Results: Sixty nine people responded to the questionnaire: age range of 18-75 years during a twelve week collection period. Overall, 32 respondents with diabetes were using some form of CAM, resulting in a utilisation rate of 46.3%. Twenty of the 32 CAM users used CAM specifically to treat their diabetes accounting for 28.9% of the respondent sample population. Multivitamins (40%), cinnamon, Co-enzyme q10 and prayer were the most frequently used CAM modalities. There was no significant difference between males and females, age range, income or diabetes complications between CAM and non-CAM users. (p values each > 0.05) The factor most significantly associated with CAM usage was being born overseas (p = 0.044).

Conclusions: Almost half the respondents (46.3%) used CAM: 28% used CAM specifically to treat their diabetes. Individuals born overseas were significantly more likely to use CAM than those born in Australia. Other factors such as age, gender, wealth and duration of living with diabetes were not associated with higher rate of CAM usage.

Serum 25-Hydroxyvitamin D, calcium intake and risk of type 2 diabetes after 5 years : results from a national, population-based prospective study (the Australian Diabetes, Obesity and Lifestyle study)

OBJECTIVE To examine whether serum 25-hydroxyvitamin D (25OHD) and dietary calcium predict incident type 2 diabetes and insulin sensitivity.

RESEARCH DESIGN AND METHODS A total of 6,537 of the 11,247 adults evaluated in 1999–2000 in the Australian Diabetes, Obesity and Lifestyle (AusDiab) study, returned for oral glucose tolerance test (OGTT) in 2004–2005. We studied those without diabetes who had complete data at baseline (n = 5,200; mean age 51 years; 55% were women; 92% were Europids). Serum 25OHD and energy-adjusted calcium intake (food frequency questionnaire) were assessed at baseline. Logistic regression was used to evaluate associations between serum 25OHD and dietary calcium on 5-year incidence of diabetes (diagnosed by OGTT) and insulin sensitivity (homeostasis model assessment of insulin sensitivity [HOMA-S]), adjusted for multiple potential confounders, including fasting plasma glucose (FPG).

RESULTS During the 5-year follow-up, 199 incident cases of diabetes were diagnosed. Those who developed diabetes had lower serum 25OHD (mean 58 vs. 65 nmol/L; P < 0.001) and calcium intake (mean 881 vs. 923 mg/day; P = 0.03) compared with those who remained free of diabetes. Each 25 nmol/L increment in serum 25OHD was associated with a 24% reduced risk of diabetes (odds ratio 0.76 [95% CI 0.63–0.92]) after adjusting for age, waist circumference, ethnicity, season, latitude, smoking, physical activity, family history of diabetes, dietary magnesium, hypertension, serum triglycerides, and FPG. Dietary calcium intake was not associated with reduced diabetes risk. Only serum 25OHD was positively and independently associated with HOMA-S at 5 years.

CONCLUSIONS Higher serum 25OHD levels, but not higher dietary calcium, were associated with a significantly reduced risk of diabetes in Australian adult men and women.