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Archive for April, 2013

The real world versus lifestyle change trials in diabetes

23 Apr, 13 | by Dr Dean Jenkins

Unfortunately it seems that in the real world primary care can only stabilise weight and HbA1c in people with Type 2 Diabetes. A study of electronic records in primary care in the Netherlands has shown that the effect of lifestyle interventions was not as great as that seen in published research.

“Despite effective lifestyle interventions in controlled trial settings, we found that real-world primary care is only able to stabilize weight and HbA1c in patients with T2DM over time. Medical registration can be used to monitor the actual effectiveness of interventions in primary care.” [1]

CAPHRI logoThe authors felt that more future research (of effectiveness) should take place in real-world primary care settings and especially those that have electronic records. This would better reflect the feasibility of translating this research into practice.

Another finding from the study was that the authors felt most of the variability of outcomes was explained by differences between patients rather than healthcare staff. This has implications for correct interpretation of variability in apparent performance.

1. Linmans JJ, Viechtbauer W, Koppenaal T, Spigt M, Knottnerus JA. Using electronic medical records analysis to investigate the effectiveness of lifestyle programs in real-world primary care is challenging: a case study in diabetes mellitus. J Clin Epidemiol 2012 Jul;65(7):785–792. Available from: http://www.ncbi.nlm.nih.gov/pubmed/22560776

Type 2 Diabetes in the young

23 Apr, 13 | by Dr Dean Jenkins

There was an excellent update on type 2 diabetes in children and young adults by Professor Melanie Davies at the weekend in Leicester as part of the Postgraduate Diploma in Diabetes lecture series. She outlined the current burden of the disease, its risks and gave an account of the ongoing research at University of Leicester. This is an important area to consider and quite specialised involving poor physical health, poor diet, mental health and family issues let alone the presence of retinopathy, fatty liver and cardiovascular risks at presentation. “It can be a lot more complicated than a Type 1 Diabetes Clinic”, she said.

IPSAD logoThe International Society for Pediatric and Adolescent Diabetes (ISPAD) have published guidelines on Type 2 Diabetes in children and adults which acknowledge the association with obesity and insulin resistance, and the increasing public health burden changing the pattern of presentation of diabetes in the young.

“T2DM is commonly associated with other features of the insulin resistance syndrome [hyperlipidemia, hypertension, acanthosis nigricans, ovarian hyperandrogenism, non-alcoholic fatty liver disease (NAFLD)] … In Hong Kong > 90% of young onset diabetes is T2DM.” [1]

Professor Melanie Davies speaking at BMJ / UoL Diabetes Diploma lecturesProfessor Davies also gave an overview of the EXPEDITION study – Early Detection of Cardiovascular Dysfunction and Health Behaviours in the Young with Type 2 Diabetes – that they are running at Leicester with some examples of the marked cardiovascular changes in these young people detected with cardiac MRI.

 

1. Rosenbloom AL, Silverstein JH, Amemiya S, Zeitler, P, Klingensmith, G. Type 2 diabetes in the child and adolescent. Pediatric Diabetes 2009: 10 (Suppl. 12): 17 – 32

Computer-based Type 2 Diabetes self-management

4 Apr, 13 | by Dr Dean Jenkins

A Cochrane systematic review of computer-based technology to support the self-management of people with Type 2 Diabetes has been published and it raises more questions than it answers. The authors concluded:

Two_Cell_Phones“Computer-based diabetes self-management interventions to manage type 2 diabetes appear to have a small beneficial effect on blood glucose control and the effect was larger in the mobile phone subgroup. There is no evidence to show benefits in other biological outcomes or any cognitive, behavioural or emotional outcomes.” [1]

Whilst there is a great potential for computer-based technologies to support people with diabetes – especially, perhaps, where there is connectivity through wireless internet connections – the authors point out that there remains uncertainty about which active components of these types of interventions actually work.

These computer-based interventions are complex and despite the enthusiasm of a number of mHealth, telemedicine, and telehealth supporters it is clear that technology in itself is not necessarily an effective tool. Aspects of the design around the use of theoretical models of behaviour change need to be explored.

I don’t see this review as negative as the summary reads. A small (albeit expensive) effect on blood glucose is to be welcomed. This is review that points out that the initial enthusiasm for mobile technologies show some promise but more rigorous research needs to be undertaken to see which aspects work. Designers of computer-based applications to support people with diabetes should work more closely across disciplines including human-computer-interface design and theoretical models of behaviour change.

 

1. Pal K, Eastwood SV, Michie S, Farmer AJ, Barnard ML, Peacock R, Wood B, Inniss JD, Murray E. Computer-based diabetes self-management interventions for adults with type 2 diabetes mellitus. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 1996 Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008776.pub2/abstract

Taking diabetes prevention out of the clinic seems to work

1 Apr, 13 | by Dr Dean Jenkins

We know from a number of studies – including the Diabetes Prevention Programme (DPP) [1] and the Finnish Diabetes Prevention Study [2] – that lifestyle advice to people with abnormal glucose metabolism greatly reduces the risk of diabetes. However, the interventions are expensive.

Researchers from the Wake Forest University School of Medicine in the US have therefore looked at the use of community-based programmes to achieve the same results. They report the two year results [3] of their Healthy Living Partnership to Prevent Diabetes (HELP-PD) programme that uses community health workers leading groups in parks and recreation centres rather than clinics. They claim their results are comparable with those at a similar stage in the DPP but at a third of the cost.

help-pd-logo“The lifestyle weight-loss group in HELP PD cost $850 in direct medical costs for 2 years, compared to $2631 in direct medical costs for the first 2 years of DPP.”  [4]

This is a well documented randomised controlled trial that demonstrates efficacy and cost-effectiveness but only in one county in the US. Local policies and culture (strong pre-existing community networks and motivation) could have affected the results. Community prevention strategies if they can be deployed successfully could feasibly be more cost-effective than more traditional, clinic-focussed services.

 

1. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM, Walker EA, Nathan DM. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N. Engl. J. Med 2002 Feb;346(6):393–403. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11832527
2. Lindström J, Eriksson JG, Valle TT, Aunola S, Cepaitis Z, Hakumäki M, Hämäläinen H, Ilanne-Parikka P, Keinänen-Kiukaanniemi S, Laakso M, Louheranta A, Mannelin M, Martikkala V, Moltchanov V, Rastas M, Salminen V, Sundvall J, Uusitupa M, Tuomilehto J. Prevention of diabetes mellitus in subjects with impaired glucose tolerance in the Finnish Diabetes Prevention Study: results from a randomized clinical trial. J. Am. Soc. Nephrol. 2003 Jul;14(7 Suppl 2):S108–113. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12819313
3. Katula JA, Vitolins MZ, Morgan TM, Lawlor MS, Blackwell CS, Isom SP, Pedley CF, Goff DC. The Healthy Living Partnerships to Prevent Diabetes Study: 2-Year Outcomes of a Randomized Controlled Trial. American Journal of Preventive Medicine 2013 Apr;44(4):S324–S332. Available from: http://www.ajpmonline.org/article/S0749-3797(13)00023-8/abstract
4. Lawlor MS, Blackwell CS, Isom SP, Katula JA, Vitolins MZ, Morgan TM, Goff Jr. DC. Cost of a Group Translation of the Diabetes Prevention Program: Healthy Living Partnerships to Prevent Diabetes. American Journal of Preventive Medicine 2013 Apr;44(4, Supplement 4):S381–S389. Available from: http://www.sciencedirect.com/science/article/pii/S074937971300024X

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