[Functional insulin therapy]. / L'insulinothérapie fonctionnelle.

This concept has been developed since 1983 in Germany and Austria. It is of greatest interest with regard to a pedagogical approach of insulin therapy in type 1 diabetic patients. The goal of functional insulin therapy is to separate basal and prandial insulin requirements. The patients perform the following experimental sessions in order to establish their own insulin requirements: 24 h fasting to assess the basic insulin requirement, ingestion of test meals containing different amounts of carbohydrates to determine the individual carbohydrate-intake/insulin requirement relationship, determination of an individual correction algorithm to decrease an elevated blood glucose level (1.60 g/L). It involves patient's therapeutic education, frequent self monitoring blood glucose (6 to 8 daily controls), multiple daily insulin injections. This concept has to be adapted to patient's desire of self responsibility and autonomy. Functional insulin therapy improves metabolic control, decreases the frequency of mild and severe hypoglycaemia, it enhances self-esteem in diabetic patients.

Assessment of patient-led or physician-driven continuous glucose monitoring in patients with poorly controlled type 1 diabetes using basal-bolus insulin regimens: a 1-year multicenter study.

OBJECTIVE: The benefits of real-time continuous glucose monitoring (CGM) have been demonstrated in patients with type 1 diabetes. Our aim was to compare the effect of two modes of use of CGM, patient led or physician driven, for 1 year in subjects with poorly controlled type 1 diabetes. RESEARCH DESIGN AND METHODS: Patients with type 1 diabetes aged 8-60 years with HbA(1c) ≥ 8% were randomly assigned to three groups (1:1:1). Outcomes for glucose control were assessed at 1 year for two modes of CGM (group 1: patient led; group 2: physician driven) versus conventional self-monitoring of blood glucose (group 3: control). RESULTS: A total of 257 subjects with type 1 diabetes underwent screening. Of these, 197 were randomized, with 178 patients completing the study (age: 36 ± 14 years; HbA(1c): 8.9 ± 0.9%). HbA(1c) improved similarly in both CGM groups and was reduced compared with the control group (group 1 vs. group 3: -0.52%, P = 0.0006; group 2 vs. group 3: -0.47%, P = 0.0008; groups 1 + 2 vs. group 3: -0.50%, P < 0.0001). The incidence of hypoglycemia was similar in the three groups. Patient SF-36 questionnaire physical health score improved in both experimental CGM groups (P = 0.004). Sensor consumption was 34% lower in group 2 than in group 1 (median [Q1-Q3] consumption: group 1: 3.42/month [2.20-3.91] vs. group 2: 2.25/month [1.27-2.99], P = 0.001). CONCLUSIONS: Both patient-led and physician-driven CGM provide similar long-term improvement in glucose control in patients with poorly controlled type 1 diabetes, but the physician-driven CGM mode used fewer sensors.

[Thoughts about patient education: the experience of diabetes]. / Réflexion sur l'éducation thérapeutique : l'expérience du diabète.

Patient education is not simply information or teaching or coaching. It is learning that is both practical and specialized, intended to help patients acquire therapeutic skills and to support them in changing their self-care practices to attain personalized objectives. It is therapeutic. An effective strategy to overcome health problems requires that patients not avoid the problem by denying the disease. Health prevention behavior requires that the patient be simultaneously confident in the prescribed treatments and able to project into the future. It is more difficult for asymptomatic patients to have a mental representation of the disease and thus be able to modify their lifestyle. Self-measurement of blood glucose can create anxiety and make the risk of complications more tangible, but it is beneficial only if it induces action or reassurance. Changing behavior is possible only to the extent that it does not challenge the patient's own well-being. It may be unreasonable but it is also rational to refuse what the patient perceives as a threat to his or her own identity. Thus, physicians caring for patients with a chronic disease must be skilled in three different fields: biomedicine, pedagogy, and psychology.

A longitudinal study of coping, anxiety and glycemic control in adults with type 1 diabetes.

Diabetes is a unique disorder in how much it requires a high degree of individual self management strategies. Anxiety and stress can affect glycemic control, and thus management of emotions may be key to good glycemic control. This study is the first to examine how anxiety and coping style, and their interaction, can affect long-term glycemic control. We measured anxiety, coping, and HbA1C, a measure for mean blood glucose levels in the previous 6-8 weeks, in 115 patients with Type 1 diabetes at baseline and roughly 5 years later. We found that coping predicted outcomes, especially for those high in trait anxiety. Trait anxiety predicted limited increases in HbA1C (mean increase = 0.02%). Lower levels of emotion-oriented coping predicted clinically significant increases in HbA1C, but only for those high on baseline trait anxiety (mean increase = 0.92%). Task-oriented coping predicted decreases in state anxiety. Use of task- and emotion-oriented coping appears especially important for highly anxious patients, both for emotional regulation and glycemic control. So, coping styles, basal anxiety and their interactions should be considered in designing follow-up and interventions with diabetic patients.