RESUMO
Type 2 diabetes continues to be a serious and highly prevalent public health problem worldwide. In 2019, the highest prevalence of diabetes in the world at 12.2%, with its associated morbidity and mortality, was found in the Middle East and North Africa region. In addition to a genetic predisposition in its population, evidence suggests that obesity, physical inactivity, urbanization, and poor nutritional habits have contributed to the high prevalence of diabetes and prediabetes in the region. These risk factors have also led to an earlier onset of type 2 diabetes among children and adolescents, negatively affecting the productive years of the youth and their quality of life. Furthermore, efforts to control the rising prevalence of diabetes and its complications have been challenged and complicated by the political instability and armed conflict in some countries of the region and the recent coronavirus disease 2019. Broad strategies, coupled with targeted interventions at the regional, national, and community levels are needed to address and curb the spread of this public health crisis.
RESUMO
OBJECTIVE: To review characteristics of an urban (primarily African American) diabetes patient population and discuss experience with treatment strategies, we summarize key retrospective and prospective analyses conducted during 15 years. RESULTS: Severe socioeconomic and personal barriers to diabetes care were often seen in the population. An atypical presentation of diabetic ketoacidosis was observed and extensively studied. A structured diabetes care delivery program was implemented more than three decades ago. A better understanding of how to provide simpler but effective dietary education and factors that affect lipid levels were elucidated. The phenomenon of clinical inertia was described, and methods were developed to facilitate the intensification of diabetes therapy and improve glycemic control. CONCLUSIONS: Structured diabetes care can be successfully introduced into a public health system and effective diabetes management can be provided to an under-served population that can result in improved metabolic outcomes. Lessons learned on diabetes management in this population can be extended to similar clinical settings.
Assuntos
Assistência Ambulatorial/organização & administração , Negro ou Afro-Americano/estatística & dados numéricos , Diabetes Mellitus/etnologia , Diabetes Mellitus/terapia , Hospitais Públicos , Serviços Urbanos de Saúde/organização & administração , Estudos de Coortes , Diabetes Mellitus/diagnóstico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Fatores SocioeconômicosRESUMO
BACKGROUND: Although clinical trials have shown that proper management of diabetes can improve outcomes, and treatment guidelines are widespread, glycated hemoglobin (HbA1c) levels in the United States are rising. Since process measures are improving, poor glycemic control may reflect the failure of health care providers to intensify diabetes therapy when indicated--clinical inertia. We asked whether interventions aimed at health care provider behavior could overcome this barrier and improve glycemic control. METHODS: In a 3-year trial, 345 internal medicine residents were randomized to be controls or to receive computerized reminders providing patient-specific recommendations at each visit and/or feedback on performance every 2 weeks. When glucose levels exceeded 150 mg/dL (8.33 mmol/L) during visits of 4038 patients, health care provider behavior was characterized as did nothing, did anything (any intensification of therapy), or did enough (if intensification met recommendations). RESULTS: At baseline, residents did anything for 35% of visits and did enough for 21% of visits when changes in therapy were indicated, and there were no differences among intervention groups. During the trial, intensification increased most during the first year and then declined. However, intensification increased more in the feedback alone and feedback plus reminders groups than for reminders alone and control groups (P<.001). After 3 years, health care provider behavior in the reminders alone and control groups returned to baseline, whereas improvement with feedback alone and feedback plus reminders groups was sustained: 52% did anything, and 30% did enough (P<.001 for both vs the reminders alone and control groups). Multivariable analysis showed that feedback on performance contributed independently to intensification and that intensification contributed independently to fall in HbA1c (P<.001 for both). CONCLUSIONS: Feedback on performance given to medical resident primary care providers improved provider behavior and lowered HbA1c levels. Similar approaches may aid health care provider behavior and improve diabetes outcomes in other primary care settings.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/etnologia , Diabetes Mellitus Tipo 2/terapia , Atenção Primária à Saúde/métodos , Adulto , Competência Clínica , Feminino , Seguimentos , Pessoal de Saúde/normas , Humanos , Internato e Residência , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/normas , Relações Médico-Paciente , Atenção Primária à Saúde/normas , Garantia da Qualidade dos Cuidados de Saúde , Estudos Retrospectivos , Estados UnidosRESUMO
PURPOSE: The purpose of this study was to determine whether an algorithm that recommended individualized changes in therapy would help providers to change therapy appropriately and improve glycemic control in their patients. METHODS: The algorithm recommended specific doses of oral agents and insulin based on a patient's medications and glucose or A1C levels at the time of the visit. The prospective observational study analyzed the effect of the algorithm on treatment decisions and A1C levels in patients with type 2 diabetes. RESULTS: The study included 1250 patients seen in pairs of initial and follow-up visits during a 7-month baseline and/or a subsequent 7-month algorithm period. The patients had a mean age of 62 years, body mass index of 33 kg/m(2), duration of diabetes of 10 years, were 94% African American and 71% female, and had average initial A1C level of 7.7%. When the algorithm was available, providers were 45% more likely to intensify therapy when indicated (P = .005) and increased therapy by a 20% greater amount (P < .001). A1C level at follow-up was 90% more likelyto be <7% in the algorithm group, even after adjusting for differences in age, sex, body mass index, race, duration of diabetes and therapy, glucose, and A1C level at the initial visit (P < .001). CONCLUSIONS: Use of an algorithm that recommends patient-specific changes in diabetes medications improves both provider behavior and patient A1C levels and should allow quantitative evaluation of provider actions for that provider's patients.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/reabilitação , Hemoglobinas Glicadas/metabolismo , Idoso , Algoritmos , Diabetes Mellitus Tipo 2/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/reabilitação , Educação de Pacientes como AssuntoRESUMO
OBJECTIVE: Management of diabetes is frequently suboptimal in primary care settings, where providers often fail to intensify therapy when glucose levels are high, a problem known as clinical inertia. We asked whether interventions targeting clinical inertia can improve outcomes. RESEARCH DESIGN AND METHODS: A controlled trial over a 3-year period was conducted in a municipal hospital primary care clinic in a large academic medical center. We studied all patients (4,138) with type 2 diabetes who were seen in continuity clinics by 345 internal medicine residents and were randomized to be control subjects or to receive one of three interventions. Instead of consultative advice, the interventions were hard copy computerized reminders that provided patient-specific recommendations for management at the time of each patient's visit, individual face-to-face feedback on performance for 5 min every 2 weeks, or both. RESULTS: Over an average patient follow-up of 15 months within the intervention site, improvements in and final HbA1c (A1C) with feedback + reminders (deltaA1C 0.6%, final A1C 7.46%) were significantly better than control (deltaA1C 0.2%, final A1C 7.84%, P < 0.02); changes were smaller with feedback only and reminders only (P = NS vs. control). Trends were similar but not significant with systolic blood pressure (sBP) and LDL cholesterol. Multivariable analysis showed that the feedback intervention independently facilitated attainment of American Diabetes Association goals for both A1C and sBP. Over a 2-year period, overall glycemic control improved in the intervention site but did not change in other primary care sites (final A1C 7.5 vs. 8.2%, P < 0.001). CONCLUSIONS: Feedback on performance aimed at overcoming clinical inertia and given to internal medicine resident primary care providers improves glycemic control. Partnering generalists with diabetes specialists may be important to enhance diabetes management in other primary care settings.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/terapia , Endocrinologia , Atenção Primária à Saúde/organização & administração , Centros Médicos Acadêmicos/organização & administração , Adulto , Idoso , Endocrinologia/educação , Feminino , Seguimentos , Hemoglobinas Glicadas , Humanos , Hiperglicemia/terapia , Internato e Residência , Masculino , Pessoa de Meia-Idade , Avaliação de Programas e Projetos de Saúde , Estudos ProspectivosRESUMO
PURPOSE: The purpose of this study was to assess the influence of appointment keeping and medication adherence on HbA1c. METHODS: A retrospective evaluation was performed in 1560 patients with type 2 diabetes who presented for a new visit to the Grady Diabetes Clinic between 1991 and 2001 and returned for a follow-up visit and HbA1c after 1 year of care. Appointment keeping was assessed by the number of scheduled intervening visits that were kept, and medication adherence was assessed by the percentage of visits in which self-reported diabetes medication use was as recommended at the preceding visit. RESULTS: The patients had an average age of 55 years, body mass index (BMI) of 32 kg/m2, diabetes duration of 4.6 years, and baseline HbA1c of 9.1%. Ninety percent were African American, and 63% were female. Those who kept more intervening appointments had lower HbA1c levels after 12 months of care (7.6% with 6-7 intervening visits vs 9.7% with 0 intervening visits). Better medication adherence was also associated with lower HbA1c levels after 12 months of care (7.8% with 76%-100% adherence). After adjusting for age, gender, race, BMI, diabetes duration, and diabetes therapy in multivariate linear regression analysis, the benefits of appointment keeping and medication adherence remained significant and contributed independently; the HbA1c was 0.12% lower for every additional intervening appointment that was kept (P = .0001) and 0.34% lower for each quartile of better medication adherence (P = .0009). CONCLUSION: Keeping more appointments and taking diabetes medications as directed were associated with substantial improvements in HbA1c. Efforts to enhance glycemic outcomes should include emphasis on these simple but critically important aspects of patient adherence.
Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Diabetes Mellitus Tipo 2/psicologia , Cooperação do Paciente/psicologia , Negro ou Afro-Americano/educação , Negro ou Afro-Americano/psicologia , Análise de Variância , Agendamento de Consultas , Diabetes Mellitus Tipo 2/etnologia , Diabetes Mellitus Tipo 2/metabolismo , Feminino , Georgia , Hemoglobinas Glicadas/metabolismo , Conhecimentos, Atitudes e Prática em Saúde , Hospitais Municipais , Humanos , Hipoglicemiantes/uso terapêutico , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto/normas , Estudos Retrospectivos , Autocuidado/psicologia , População UrbanaRESUMO
PURPOSE: The purpose of this study was to determine whether "clinical inertia"-inadequate intensification of therapy by the provider-could contribute to high A1C levels in patients with type 2 diabetes managed in a primary care site. METHODS: In a prospective observational study, management was compared in the Medical Clinic, a primary care site supervised by general internal medicine faculty, and the Diabetes Clinic, a specialty site supervised by endocrinologists. These municipal hospital clinics serve a common population that is largely African American, poor, and uninsured. RESULTS: Four hundred thirty-eight African American patients in the Medical Clinic and 2157 in the Diabetes Clinic were similar in average age, diabetes duration, body mass index, and gender, but A1C averaged 8.6% in the Medical Clinic versus 7.7% in the Diabetes Clinic (P < .0001). Use of pharmacotherapy was less intensive in the Medical Clinic (less use of insulin), and when patients had elevated glucose levels during clinic visits, therapy was less than half as likely to be advanced in the Medical Clinic compared to the Diabetes Clinic (P < .0001). Intensification rates were lower in the Medical Clinic regardless of type of therapy (P < .0001), and intensification of therapy was independently associated with improvement in A1C (P < .001). CONCLUSIONS: Medical Clinic patients had worse glycemic control, were less likely to be treated with insulin, and were less likely to have their therapy intensified if glucose levels were elevated. To improve diabetes management and glycemic control nationwide, physicians in training and generalists must learn to overcome clinical inertia, to intensify therapy when appropriate, and to use insulin when clinically indicated.
Assuntos
Atitude do Pessoal de Saúde , Diabetes Mellitus Tipo 2/terapia , Atenção Primária à Saúde/normas , Diabetes Mellitus Tipo 2/sangue , Hemoglobinas Glicadas/análise , Humanos , Cooperação do Paciente , Garantia da Qualidade dos Cuidados de SaúdeRESUMO
BACKGROUND: Type 2 diabetes mellitus is highly prevalent in minority populations in the United States. We studied the relationship of age to glycemic control in a predominantly urban African American population with type 2 diabetes. METHODS: We selected all patients with type 2 diabetes who were enrolled in the Grady Diabetes Clinic, Atlanta, Ga, between April 1, 1991, and December 31, 1998, and had a hemoglobin A(1c) (HbA(1c)) level measured at their initial visit and at follow-up 5 to 12 months later (n = 2539). Patients were divided into 4 age categories: less than 30 years, 30 to 49 years, 50 to 69 years, and more than 69 years old. We also studied the relationship of age to HbA(1c) level in a primary care clinic. RESULTS: At baseline, average HbA(1c) levels were 9.9%, 9.5%, 9.2%, and 8.8% in the 4 groups ranked in increasing age, respectively (P<.001), and body mass indexes (calculated as weight in kilograms divided by the square of height in meters) were 37.8, 33.9, 31.6, and 29.2, respectively (P<.001). On follow-up, HbA( 1c) level improved in all groups (P<.001), but there was still a trend for younger patients to have higher levels of HbA(1c). There was little change in body mass index with time. Younger age, longer diabetes duration, higher body mass index, less frequent interval visits, and treatment with oral agents or insulin were associated with a higher HbA(1c) level at follow-up. Our findings in a primary care clinic showed also that HbA( 1c) level and body mass index were negatively correlated with age (P<.001). CONCLUSION: Our data show a high prevalence of obesity and poor glycemic control in young adult urban African Americans with diabetes.
Assuntos
Negro ou Afro-Americano/estatística & dados numéricos , Diabetes Mellitus Tipo 2/complicações , Hiperglicemia/epidemiologia , Hiperglicemia/etiologia , Obesidade/epidemiologia , Obesidade/etiologia , Adulto , Fatores Etários , Idoso , Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Feminino , Seguimentos , Georgia/epidemiologia , Hemoglobinas Glicadas/metabolismo , Humanos , Hiperglicemia/sangue , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Obesidade/sangue , Prevalência , Fatores de Tempo , População Urbana/estatística & dados numéricosRESUMO
OBJECTIVES: To compare demographics and disease characteristics in a multiethnic diabetes clinic population to identify changes over time. DESIGN: Analysis and comparison of demographics and disease characteristics of diabetes patients, recorded electronically at intake over 10 years. SETTING: An urban outpatient diabetes clinic. PATIENTS: A total of 8,551 African-American (88%), White (7%), or Hispanic (3%) patients (average age, 52 years; mean diabetes duration, 5.1 years; 59% women). MAIN OUTCOME MEASURES: Proportion of patients by ethnic group, age, diabetes duration, initial hemoglobin A1c, and body mass index. RESULTS: Between 1992 and 2001, the percentage of African-American patients was relatively unchanged (from 87.6% to 87.2%; P=.2), White patients decreased (from 9% to 5%; P=.0006), and Hispanic patients increased (from 1.3% to 5.5%; P<.0001). Among African-American patients, average age decreased from 52 to 50 years (P=.015), diabetes duration decreased from 5.6 years to 4.3 years (P=.0003), initial hemoglobin A1c decreased from 9.3% to 8.8% (P<.0001), and body mass index increased from 31 kg/m2 to 32.1 kg/m2 (P=.0001). Compared with African-American and White patients, Hispanic patients were younger (P<.0001) and had a lower body mass index (P<.0001) but had hemoglobin A1c comparable to that of African-American patients (9.3% vs 9.1%; P=.45) and higher than that of White patients (9.3% vs 8.7%; P=.0022). CONCLUSIONS: The demographic and disease profiles of patients in this urban diabetes clinic have shifted, and disparities in glycemic control and obesity exist. Modifications in treatment and education approaches may be necessary to compensate for a changing patient population.
Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Diabetes Mellitus/etnologia , Hispânico ou Latino/estatística & dados numéricos , Serviços Urbanos de Saúde/estatística & dados numéricos , População Branca/estatística & dados numéricos , Adolescente , Adulto , Negro ou Afro-Americano/educação , Fatores Etários , Idoso , Índice de Massa Corporal , Bases de Dados Factuais , Demografia , Diabetes Mellitus/sangue , Diabetes Mellitus/epidemiologia , Feminino , Hemoglobinas Glicadas/análise , Hispânico ou Latino/educação , Humanos , Masculino , Indigência Médica , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Estados Unidos/epidemiologia , Saúde da População Urbana/estatística & dados numéricos , População Branca/educaçãoRESUMO
PURPOSE: Since diabetes is largely a primary care problem but we know little about management by residents in training--the primary care practitioners of the future--we examined surrogate outcomes reflective of their performance. METHODS: A seven-week observational study was conducted in a typical training site- a municipal hospital internal medicine resident "continuity" (primary care) clinic in a large, academic, university-affiliated training program. We evaluated control of glucose, blood pressure, and lipids; screening for proteinuria; and use of aspirin relative to national standards. RESULTS: Five hundred fifty-six (556) patients were 72% female and 97% African-American, with mean age 63 years, duration of diabetes 12 years, and BMI 34 kg/m2. Patients were managed largely with diet alone (22%) or oral agents alone (40%); 7% used oral agents and insulin in combination, and 30% insulin alone. Hemoglobin A1c (mean 8.2%) was above goal (<7.0%) in 61% of patients. Low density lipoprotein cholesterol (mean 128 mg/dL) was above goal (<100) in 76% of patients, but high density lipoprotein (mean 53 mg/dL) was at goal in 46%, and triglycerides (mean 138 mg/dL) were at goal in 85%. Diastolic pressure (mean 75 mm Hg) was at goal (<85) in 77% of patients, but systolic pressure (mean 143) was at goal (<130) in only 25% of patients. An average of only 53% of the patients had urine protein screening per 12 months, and use of aspirin was documented for only 39% of patients. CONCLUSIONS: Patients with type 2 diabetes in a typical internal medicine resident primary care clinic frequently do not achieve national standard of care goals. Since skills and attitudes developed in residency are likely to carry over into later practice, local diabetes educators may need to work with medical faculty to develop new interventions to improve postgraduate medical education in diabetes management.
Assuntos
Diabetes Mellitus/terapia , Hospitais Municipais , Internato e Residência/normas , Atenção Primária à Saúde , Centros Médicos Acadêmicos , Adolescente , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Glicemia/metabolismo , Pressão Sanguínea/fisiologia , HDL-Colesterol/sangue , LDL-Colesterol/sangue , Diabetes Mellitus/sangue , Diabetes Mellitus/etnologia , Feminino , Hemoglobinas Glicadas/metabolismo , Humanos , Hipoglicemiantes/uso terapêutico , Insulina/uso terapêutico , Medicina Interna/educação , Masculino , Pessoa de Meia-Idade , Proteinúria/fisiopatologia , Proteinúria/terapia , Resultado do Tratamento , Triglicerídeos/sangueRESUMO
Limited access to health care is associated with adverse outcomes, but few studies have examined its effect on glycemic control in minority populations. Our observational cross-sectional study examined whether differences in health care access affected hemoglobin A1c (HbA1c) levels in 605 patients with diabetes (56% women; 89% African American; average age, 50 years; 95% with type 2 diabetes) initially treated at a municipal diabetes clinic. Patients who had difficulty obtaining care had higher A1c levels (9.4% vs. 8.7%; p=0.001), as did patients who used acute care facilities (9.5%; p<0.001) or who had no usual source of care (10.3%; p<0.001) compared with those who sought care at doctors' offices or clinics (8.6%). In adjusted analyses, HbA1c was higher in persons who gave a history of trouble obtaining medical care (0.57%; p=0.04), among persons who primarily used an acute care facility to receive their health care (0.49%; p=0.047), and in patients who reported not having a usual source of care (1.08%; p=0.009). Policy decisions for improving diabetes outcomes should target barriers to health care access and focus on developing programs to help high-risk populations maintain a regular place of health care.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/etnologia , Diabetes Mellitus Tipo 2/prevenção & controle , Hemoglobinas Glicadas/análise , Acessibilidade aos Serviços de Saúde/economia , Pobreza , População Urbana , Diabetes Mellitus Tipo 2/economia , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , Inquéritos e Questionários , Estados Unidos , Saúde da População UrbanaRESUMO
OBJECTIVE: Because readily available glycemic indicators are needed to guide clinical decision-making for intensification of diabetes therapy, our goals were to define the relationship between casual postprandial plasma glucose (cPPG) levels and HbA(1c) in patients with type 2 diabetes and to determine the predictive characteristics of a convenient glucose cutoff. RESEARCH DESIGN AND METHODS: We examined the relationship between cPPG levels (1-4 h post meal) and HbA(1c) levels in 1,827 unique patients who had both determinations during a single office visit. RESULTS: The population studied was predominantly African American and middle-aged, with average cPPG of 201 mg/dl and HbA(1c) of 8.4%. The prevalence of HbA(1c) > or = 7.0% was 67% and HbA(1c) >6.5% was 77%. Overall, cPPG and HbA(1c) were linearly correlated (r = 0.63, P < 0.001). The correlation between cPPG and HbA(1c) was strongest in patients treated with diet alone (n = 348, r = 0.75, P < 0.001) and weaker but still highly significant for patients treated with oral agents (n = 610, r = 0.64, P < 0.001) or insulin (n = 869, r = 0.56, P < 0.001). A cutoff cPPG >150 mg/dl predicted an HbA(1c) level > or = 7.0% in the whole group, with a sensitivity of 78%, a specificity of 62%, and an 80% positive predictive value. The same cPPG cutoff of 150 mg/dl predicted an HbA(1c) level >6.5%, with a sensitivity of 74%, a specificity of 66%, and an 88% positive predictive value. CONCLUSIONS: When rapid-turnaround HbA(1c) determinations are not available, a single cPPG level >150 mg/dl may be used during a clinic visit to identify most inadequately controlled patients and allow timely intensification of therapy.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Hemoglobinas Glicadas/análise , Período Pós-Prandial , População Negra , Dieta para Diabéticos , Feminino , Georgia , Humanos , Hipoglicemiantes/classificação , Hipoglicemiantes/uso terapêutico , Masculino , Pessoa de Meia-Idade , Análise de Regressão , Sensibilidade e EspecificidadeRESUMO
OBJECTIVE: Failure to meet goals for glycemic control in primary care settings may be due in part to lack of information critical to guide intensification of therapy. Our objective is to determine whether rapid-turnaround A1c availability would improve intensification of diabetes therapy and reduce A1c levels in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: In this prospective controlled trial, A1c was determined on capillary glucose samples and made available to providers, either during ("rapid") or after ("routine") the patient visit. Frequency of intensification of pharmacological diabetes therapy in inadequately controlled patients and A1c levels were assessed at baseline and after follow-up. RESULTS: We recruited 597 subjects. Patients were 79% female and 96% African American, with average age of 61 years, duration of diabetes 10 years, BMI 33 kg/m(2), and A1c 8.5%. The rapid and routine groups had similar clinical demographics. Rapid A1c availability resulted in more frequent intensification of therapy when A1c was >/=7.0% at the baseline visit (51 vs. 32% of patients, P = 0.01), particularly when A1c was >8.0% and/or random glucose was in the 8.4-14.4 mmol/l range (151-250 mg/dl). In 275 patients with two follow-up visits, A1c fell significantly in the rapid group (from 8.4 to 8.1%, P = 0.04) but not in the routine group (from 8.1 to 8.0%, P = 0.31). CONCLUSIONS: Availability of rapid A1c measurements increased the frequency of intensification of therapy and lowered A1c levels in patients with type 2 diabetes in an urban neighborhood health center.
Assuntos
Glicemia/metabolismo , Diabetes Mellitus Tipo 2/sangue , Hemoglobinas Glicadas/análise , Idade de Início , Instituições de Assistência Ambulatorial , Biomarcadores/sangue , Índice de Massa Corporal , Etnicidade , Feminino , Seguimentos , Georgia , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde , Fatores de Tempo , População UrbanaRESUMO
OBJECTIVE: To compare a simple meal plan emphasizing healthy food choices with a traditional exchange-based meal plan in reducing HbA(1c) levels in urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: A total of 648 patients with type 2 diabetes were randomized to receive instruction in either a healthy food choices meal plan (HFC) or an exchange-based meal plan (EXCH) to compare the impact on glycemic control, weight loss, serum lipids, and blood pressure at 6 months of follow-up. Dietary practices were assessed with food frequency questionnaires. RESULTS: At presentation, the HFC and EXCH groups were comparable in age (52 years), sex (65% women), weight (94 kg), BMI (33.5), duration of diabetes (4.8 years), fasting plasma glucose (10.5 mmol/l), and HbA(1c) (9.4%). Improvements in glycemic control over 6 months were significant (P < 0.0001) but similar in both groups: HbA(1c) decreased from 9.7 to 7.8% with the HFC and from 9.6 to 7.7% with the EXCH. Improvements in HDL cholesterol and triglycerides were comparable in both groups, whereas other lipids and blood pressure were not altered. The HFC and EXCH groups exhibited similar improvement in dietary practices with respect to intake of fats and sugar sweetened foods. Among obese patients, average weight change, the percentage of patients losing weight, and the distribution of weight lost were comparable with the two approaches. CONCLUSIONS: Medical nutrition therapy is effective in urban African Americans with type 2 diabetes. Either a meal plan emphasizing guidelines for healthy food choices or a low literacy exchange method is equally effective as a meal planning approach. Because the HFC meal plan may be easier to teach and easier for patients to understand, it may be preferable for low-literacy patient populations.
Assuntos
Negro ou Afro-Americano , Diabetes Mellitus Tipo 2/dietoterapia , Diabetes Mellitus Tipo 2/reabilitação , Diabetes Mellitus/dietoterapia , Diabetes Mellitus/reabilitação , Dieta para Diabéticos , Comportamento Alimentar , Obesidade , Educação de Pacientes como Assunto/métodos , Biomarcadores/sangue , Peso Corporal , Comportamento de Escolha , Feminino , Georgia , Hemoglobinas Glicadas/metabolismo , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , População UrbanaRESUMO
PURPOSE: The purpose of this study was to determine physical activity preferences and barriers to exercise in an urban diabetes clinic population. METHODS: A survey was conducted of all patients attending the clinic for the first time. Evaluation measures were type and frequency of favorite leisure-time physical activity, prevalence and types of reported barriers to exercise, and analysis of patient characteristics associated with reporting an obstacle to exercise. RESULTS: For 605 patients (44% male, 89% African American, mean age = 50 years, mean duration of diabetes = 5.6 years), the average frequency of leisure activity was 3.5 days per week (mean time = 45 minutes per session). Walking outdoors was preferred, but 52% reported an exercise barrier (predominantly pain). Patients who cited an impediment to physical activity exercised fewer days per week and less time each session compared with persons without a barrier. Increasing age, body mass index, college education, and being a smoker increased the odds of reporting a barrier; being male decreased the chances. Men reported more leisure-time physical activity than women. Exercise preferences and types of barriers changed with age. CONCLUSIONS: Recognition of patient exercise preferences and barriers should help in developing exercise strategies for improving glycemic control.
Assuntos
População Negra , Diabetes Mellitus Tipo 2/reabilitação , Exercício Físico , Satisfação do Paciente , Diabetes Mellitus Tipo 2/psicologia , Feminino , Humanos , Atividades de Lazer , Masculino , Pessoa de Meia-Idade , População UrbanaRESUMO
African Americans have an increased burden of both diabetes and diabetes complications. Since many patients have high glucose levels novel interventions are needed, especially for urban patients with limited resources. In the Grady Diabetes Clinic in Atlanta, a stepped care strategy improves metabolic control. However, most diabetes patients do not receive specialized care. We will attempt to translate diabetes clinic approaches to the primary care setting by implementing a novel partnership between specialists and generalists. We hypothesize that endocrinologist-supported strategies aimed at providers will result in effective diabetes management in primary care sites, and the Improving Primary Care of African Americans with Diabetes project will test this hypothesis in a major randomized, controlled trial involving over 2000 patients. Physicians in Grady Medical Clinic units will receive (1) usual care, (2) computerized reminders that recommend individualized changes in therapy and/or (3) directed discussion by endocrinologists providing feedback on performance. We will measure outcomes related to both microvascular disease (HbA1c, which reflects average glucose levels over an approximately 2-month period) and macrovascular disease (blood pressure and lipids) and assess provider performance as well. We will compare two readily generalizable program interventions that should delineate approaches effective in a primary care setting as needed to improve care and prevent complications in urban African Americans with type 2 diabetes.