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Item
#4
Strict control of blood glucose levels in patients newly diagnosed
with type 2 diabetes can result in a reduction of 25 percent in
microvascular complications. Although data have not yet proved a
reduction in mortality, insulin therapy is recommended for an
increasing number of type 2 diabetic patients because of the
accumulating evidence of benefit from strict glycemic control.
Conversely, many patients are reported to dislike the repeated
injections and blood glucose monitoring required in insulin
therapy and to be particularly afraid of possible hypoglycemic
episodes. These fears, plus the sense of failure felt by many
patients because they require insulin therapy, have led to insulin
treatment being associated with a decrease in quality of life in
diabetic patients and their families. De Grauw and colleagues
studied glycemic complications, hypoglycemic events, and quality
of life in 38 Dutch patients changing from oral to insulin therapy
for poorly controlled type 2 diabetes.
Patients with poor glycemic control despite optimal oral
medication were eligible for the study if average glycosylated
hemoglobin levels were 8 percent or higher, or if blood glucose
levels were persistently elevated. The change to insulin was made
in two different ways to evaluate possible effects of the referral
process and the extra attention provided to patients during the
transition process. Group A patients had a 12- week period of
enhanced care by a primary care physician and a dietitian to
optimize noninsulin therapy in combination with diet and oral
medications. Group B patients were immediately referred to a
subspecialist for institution of insulin therapy. Over a
nine-month period, glycemic control was monitored. Patients were
also formally assessed using standardized protocols for medical
history, cardiovascular risk factors and events, complications of
diabetes, and other morbidities. Blood samples were taken for
lipid and creatinine measurements, as well as to monitor glycemic
control. Quality of life was assessed using two questionnaires of
general functioning plus a validated diabetes symptom checklist.
Of
the 38 patients, seven did not transition to insulin therapy
because of marked improvement in glycemic control after entry in
the study. In addition, four patients withdrew or were removed
from the study. Mean HbA^sub 1c^ and fasting blood glucose levels
fell significantly in the remaining 27 patients, who reported a
statistically significant decrease in symptoms associated with
hyperglycemia. Mean body weight and body mass index increased
significantly, but blood pressure and lipid profiles showed a
trend toward improvement. No increase in hypoglycemic symptoms was
noted. No significant changes were found in any of the
quality-of-life measurements, and there was a trend toward
significant improvement in perceived health. By the end of the
study, patients in groups A and B showed no significant
differences in HbA^sub 1c^ changes and quality- of-life scores.
The
authors conclude that patients with poorly controlled type 2
diabetes can be switched to insulin therapy without an increase in
hypoglycemic episodes or deterioration in quality of life. Insulin
therapy results in significant clinical and statistical
improvements in glycemic control.
NOTE:
Family physicians are in a time of great change in the management
of diabetic patients. Physicians are keenly aware of the guilt and
emotional havoc that can result when overzealous "strict control"
is forced on patients, yet we know only too well the consequences
for them and their families if diabetes is allowed to steadily
work its mischief on their bodies. Part of the problem has been
that patients perceive "having to go on insulin" as a personal
failure. We even sometimes use it as a threat. This study
challenges us to change our attitudes and think about using
insulin earlier and more positively. The patients who transferred
to insulin achieved better glycemic control, had no hypoglycemic
episodes, and reported no decline in quality of life.
Br J Gen
Pract July 2001;51:527-32.
===============================
News
Flash:
ADA
Releases New Dietary Guidelines
The
new guidelines support the view that the total amount of
carbohydrates consumed in meals and snacks is important in
diabetes control, not the source of the carbohydrates. The
guidelines emphasize weight loss and physical activity and focus
on individualized dietary plans based on lifestyle, diabetes
management goals and other lifestyle factors.
Reference:
American Diabetes Association. Evidence-based nutrition principles
and recommendations for the treatment and prevention of diabetes
and related complications. Diabetes Care 2002; 25: 202-12.
To
see how you can provide individualized dietary plans based on
lifestyle for your patients,
Click
Here For More Information!
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