Efficacy of a training programme for the management of diabetes mellitus in the hospital: A randomized study (stage 2 of GOVEPAZ healthcare).

AIMS: To assess the efficacy of a structured educational intervention for health professionals on the appropriateness of inpatient diabetes care and on some clinical outcomes in hospitalised subjects. METHODS: A multicentre (6 regional hospitals) cluster-randomized (2:1) two parallel-group pragmatic intervention trials, as a part of the GOVEPAZ study, was conducted in three clinical settings, that is, Internal Medicine, Surgery and Intensive Care. Intervention consisted of a 2-month structured education of clinical staff to inpatient diabetes care. Twelve wards - 2 for each hospital - and 6 wards - 1 for each hospital - were randomized to usual care and to the intervention arm, respectively. Consecutively hospitalised diabetic subjects (n = 524, age 74 ± 14 years, 57% males, median HbA1C 57 mmol/mol) were included. The clinical appropriateness of inpatient diabetes management was assessed by a previously validated multi-domain performance score (PS). Clinical outcomes included hypoglycemia, glucose control biomarkers, clinical conditions at discharge and inpatient mortality rate. RESULTS: A numerically, but not statistically significant, higher PS (+0.94; 95% C.I.: -0.53 - +2.4) was achieved in the intervention than in the usual care wards. Hypoglycemias (p = 0.32), glucose control (p = 0.89) and survival rates (p = 0.71) were similar in the two experimental arms. Plasma glucose on admission (OR = 1.52 per 1 SD; C.I. 1.07-2.17; p = 0.021) and the number of hypoglycemic events per patient (OR = 1.55 per 1 SD; C.I.:1.11-2.16; p = 0.011) were independently associated with the inpatient mortality rate. CONCLUSIONS: Structured education of the clinical staff failed to improve the inpatient appropriateness of diabetes care or clinical outcomes. In-hospital hypoglycemia was confirmed to be an independent indicator of death risk.

A performance score of the quality of inpatient diabetes care is a marker of clinical outcomes and suggests a cause-effect relationship between hypoglycaemia and the risk of in-hospital mortality.

AIMS: To build a tool to assess the management of inpatients with diabetes mellitus and to investigate its relationship, if any, with clinical outcomes. MATERIALS AND METHODS: A total of 678 patients from different settings, Internal Medicine (IMU, n = 255), General Surgery (GSU, n = 230) and Intensive Care (ICU, n = 193) Units, were enrolled. A work-flow of clinical care of diabetes was created according to guidelines. The workflow was divided into five different domains: (a) initial assessment; (b) glucose monitoring; (c) medical therapy; (d) consultancies; (e) discharge. Each domain was assessed by a performance score (PS), computed as the sum of the scores achieved in a set of indicators of clinical appropriateness, management and patient empowerment. Appropriate glucose goals were included as intermediate phenotypes. Clinical outcomes included: hypoglycaemia, survival rate and clinical conditions at discharge. RESULTS: The total PS and those of initial assessment and glucose monitoring were significantly lower in GSU with respect to IMU and ICU (P < .0001). The glucose monitoring PS was associated with lower risk of hypoglycaemia (OR = 0.55; P < .0001), whereas both the PSs of glucose monitoring and medical therapy resulted associated with higher in-hospital survival only in the IMU ward (OR = 6.67 P = .001 and OR = 2.38 P = .03, respectively). Instrumental variable analysis with the aid of PS of glucose monitoring showed that hypoglycaemia may play a causal role in in-hospital mortality (P = .04). CONCLUSIONS: The quality of in-hospital care of diabetes may affect patient outcomes, including glucose control and the risk of hypoglycaemia, and through the latter it may influence the risk of in-hospital mortality.

Plasma triglycerides predict ten-years all-cause mortality in outpatients with type 2 diabetes mellitus: a longitudinal observational study.

BACKGROUND: Cardiovascular disease (CVD) is the leading cause of death in type 2 diabetes mellitus (T2DM). American Diabetes Association standards of care set a series of targets recommended for the CVD prevention: blood pressure, LDL and HDL cholesterol (LDL-C and HDL-C), triglycerides and HbA1c goals. The aim of this study was to evaluate cardiovascular risk factors in a T2DM outpatient population in order to estimate their specific clinical value in predicting long-term overall mortality. METHODS: Our study population was composed of 1917 T2DM outpatients attending the hospital-based Diabetes Clinic of Ferrara for a mean follow-up period of 10 years; recorded information included personal, clinical and biochemical data, and pharmacological treatment. RESULTS: A Cox proportional hazard analysis was performed, pointing out as age (HR:1.08; IC95%: 1.06-1.11), sex (males: HR:1.97; IC95%: 1.26-3.07), mean triglycerides levels during follow-up (III vs I tertile: HR:1.87; IC95%: 1.12-3.12) and lipid-lowering treatment (HR:0.56; IC95%: 0.35-0.90) were significantly associated with all-cause mortality, independent of confounding factors such as mean values of LDL-C, HDL-C, HbA1c, blood pressure, BMI, fasting glucose, and antihypertensive and antidiabetic treatment. CONCLUSIONS: This finding suggests that more attention should be given to the management of cardiovascular risk in type 2 diabetic patients with high triglycerides levels.

Weight Loss Expectations and Attrition in Treatment-Seeking Obese Women.

OBJECTIVE: The analysis of the relation between weight loss goals and attrition in the treatment of obesity has produced conflicting results. The aim of the present study was to investigate the role of weight loss goals on attrition in a cohort of obese women seeking treatment at 8 Italian medical centres. METHODS: 634 women with obesity, consecutively enrolled in weight loss programmes, were included in the study. Weight loss goals were evaluated with the Goals and Relative Weights Questionnaire (GRWQ), reporting a sequence of unrealistic ('dream' and 'happy') and more realistic ('acceptable' and 'disappointing') weight loss goals. Attrition was assessed at 12 months on the basis of patients' medical records. RESULTS: At 12 months, 205/634 patients (32.3%) had interrupted their programme and were lost to follow-up. After adjustment for age, baseline weight, education and employment status, attrition was significantly associated with higher percent acceptable and disappointing weight loss targets, not with dream and happy weight loss. CONCLUSION: In 'real world' clinical settings, only realistic expectations might favour attrition whenever too challenging, whereas unrealistic weight loss goals have no effect. Future studies should assess the effect of interventions aimed at coping with too challenging weight goals on attrition.

Personality features of obese women in relation to binge eating and night eating.

Personality traits can affect eating behaviors, the development of obesity, and obesity treatment failure. We investigated the personality characteristics and their relation with disordered eating in 586 obese women consecutively seeking treatment at eight Italian medical centers (age, 47.7±9.8 years) and 185 age-matched, normal weight women without symptoms of eating disorders (Eating Attitude Test<20). The assessment included anthropometry, the Temperament and Character Inventory (TCI), the Binge Eating Scale (BES) and the Night Eating Questionnaire (NEQ). Logistic regression analyses were carried out in different models with BES score≥27 and NEQ≥30 as dependent variables and TCI scores as independent factors. Personality traits of obese individuals included significantly lower self-directedness and cooperativeness on TCI. BES and NEQ scores were higher in obese women, and values above the defined cut-offs were present in 77 and 18 cases (14 with high BES), respectively. After controlling for age and BMI, high BES values were associated with high novelty seeking and harm avoidance and low self-directedness, the last two scales being also associated with high NEQ. We conclude that personality traits differ between obese patients seeking treatment and controls, and the presence of disordered eating is associated with specific personality characteristics.

The effect of obesity management on body image in patients seeking treatment at medical centers.

OBJECTIVE: Body image dissatisfaction is common in treatment-seeking patients with obesity. We aimed to investigate the effects of obesity management on body image in patients with obesity attending Italian medical centers for weight loss programs. RESEARCH METHODS AND PROCEDURES: A total of 473 obese patients seeking treatment in 13 Italian medical centers (80% females; age, 45.9 +/- standard deviation 11.0 years; BMI, 36.8 +/- 5.7 kg/m(2)) were evaluated at baseline and after a 6-month weight loss treatment. Body uneasiness, psychiatric distress, and binge eating were tested by Body Uneasiness Test (BUT, Part A), Symptom CheckList-90 (SCL-90), and Binge Eating Scale (BES), respectively. RESULTS: At 6-month follow-up, the percentage weight loss was significantly higher in men (9.0 +/- 6.3%) than in women (6.8 +/- 7.3%; p = 0.010). Both men and women had a significant improvement in BUT Global Severity Index and in all of the BUT subscales with the exception of the Compulsive Self-Monitoring subscale. Linear regression analysis selected baseline psychological and behavioral measures (global score of BUT and SCL-90) and improved psychiatric distress and binge eating as independent predictors of changes in basal body dissatisfaction in females, whereas in males, changes were associated only with baseline BUT-Global Severity Index score, binge eating, and its treatment-associated improvement. Pre-treatment BMI and BMI changes did not enter the regression. DISCUSSION: Obesity treatment, even with a modest degree of weight loss, is associated with a significant improvement of body image, in both females and males. This effect depends mainly on psychological factors, not on the amount of weight loss.