Characterization of Adults With Type 1 Diabetes Not Attending Self-Management Education Courses: The Barriers to Uptake of Type 1 Diabetes Education (BUD1E) Study.

People with type 1 diabetes mellitus (T1DM) are offered attendance at diabetes self-management education courses to provide them with skills for self-management of flexible insulin dose adjustment. Attendance is poor, even when courses are evidence-based and nationally available. To understand barriers to attendance, we sought common characteristics of nonattenders from adults with T1DM living in south London. Twenty-five in person semistructured interviews were carried out until thematic saturation occurred. Thematic framework analysis identified six themes: psychological capability, numerical capability, internal/external judgment, confidence in self, thirst for knowledge, and barriers to attendance. Characterization of response profiles according to the themes identified four different typologies. These identified typologies and themes for barriers to attending diabetes self-management courses suggest strategies to improve attendance and extend the benefit of such courses more widely.

Perceptions of insulin use in type 2 diabetes in primary care: a thematic synthesis.

BACKGROUND: Increasing numbers of patients with type 2 diabetes mellitus are progressing to insulin therapy, and despite its potency many such individuals still have suboptimal glycaemic control. Insulin initiation and intensification is now often conducted by Practice Nurses and General Practitioners in many parts of the UK. Therefore, gaining insight into perspectives of patients and primary care clinicians is important in determining self-management and engagement with insulin. A thematic synthesis of studies was conducted exploring the views and experiences of people with type 2 diabetes and of healthcare professionals on insulin use and management in the context of primary care. METHODS: Protocol based systematic searches of electronic databases (CINAHL, Cochrane Library, EMBASE, MEDLINE, PsycINFO, and Web of Science) were performed on 1 October 2014 and updated on 31 March 2015, to identify studies that identified the views and experiences of adults with type 2 diabetes or primary care clinicians on the use of insulin in the management of type 2 diabetes. Studies meeting the review inclusion criteria were critically appraised using the CASP qualitative research checklist or Barley's checklist for survey designs. A thematic synthesis was then conducted of the collected studies. RESULTS: Thirty-four studies were selected. Of these, 12 used qualitative interviews (nine with patients and three with healthcare professionals) and 22 were survey based (14 with patients, three with healthcare professionals, and five with both). Twelve key themes were identified and formed three domains, patient perceptions, healthcare professional perceptions, and health professional-patient relationships. The patient-centred themes were: insulin-related beliefs, social influences, psychological factors, hypoglycaemia, and therapy barriers. The clinician-related themes were: insulin skills of general practitioners, healthcare integration, healthcare professional-perceived barriers, hypoglycaemia, and explanations for adherence. Healthcare professional-patient relationship themes were drawn from the perspectives of patients and from clinicians. CONCLUSIONS: This review reveals multiple barriers to optimal insulin use in primary care at both the patient and healthcare professional levels. These barriers indicate the need for multimodal interventions to: improve the knowledge and competencies of primary care professionals in insulin use; provide more effective patient education and self-management support; and introduce integrated insulin support systems.

A qualitative approach exploring the experiences of smoking and quitting attempts in type 1 diabetes.

AIMS AND OBJECTIVES: To explore the experiences of smoking and quitting attempts in people with type 1 diabetes, including their perceptions of existing services for smoking cessation. BACKGROUND: In the UK, approximately a fifth of the population with type 1 diabetes smoke and despite the adverse effects of smoking, these individuals continue with their smoking habits. There is limited information on the barriers and facilitators to quitting smoking in people with type 1 diabetes. METHODS: This study adopted a qualitative study design using semi-structured individual interviews guided by PRIME theory. Participants (n = 12) were purposively sampled and recruited from two diabetes outpatient clinics in London (UK). Audio-recorded interviews were transcribed verbatim and analysed using the Framework method. RESULTS: Most smokers with type 1 diabetes reported lack of motivation to stop smoking due to the addictive nature of cigarettes. Further barriers to quitting included self-image and habits associated with smoking, such as social activities. Generally, most reported limited awareness about the risks associated with smoking and diabetes. Moreover, the perceived negative attitude towards nicotine replacement therapy and pharmacotherapy impeded their willingness to alter their smoking habits. Nonetheless, these patients suggested that informative guidance from medical professionals and strategies to tackle cravings related to nicotine as helpful approaches to improve quitting attempts. CONCLUSION: Internal and external factors influence quitting attempts among smokers with type 1 diabetes, with particular emphasis on self-image and societal norms. It is evident that existing strategies for smoking cessation recommended by the National Institute for Health and Care Excellence have either not been implemented or not well received by people with type 1 diabetes. RELEVANCE TO CLINICAL PRACTICE: Strategies and resources, such as staff training, to increase delivery of smoking cessation support to patients with diabetes are needed.

Characteristics and morphology of lipohypertrophic lesions in adults with type 1 diabetes with ultrasound screening: an exploratory observational study.

INTRODUCTION: Lipohypertrophy is a common complication of exposure to insulin therapy. Despite the prevalence of lipohypertrophy and its potentially hazardous effects on glucose regulation, it remains a relatively understudied problem in diabetes. The objective of this study was to characterize lipohypertrophic tissue using ultrasound in adults with type 1 diabetes. RESEARCH DESIGN AND METHODS: An observational study of 74 people with type 1 diabetes from a diabetes center in South East London. Participants' insulin exposed areas were scanned with ultrasound, with a high-frequency linear probe (6-13 MHz). The observed tissue changes were described, measured and graded according to nodule size and thickness of the dermal layer. RESULTS: Participants mean age and diabetes duration were 40.6 (±14.2) and 18.3 (±10.9) years, respectively, and 60% (n=44) were male. A total of 740 lipohypertrophic nodules were observed, ranging from 1.8 mm to 40 mm in width. The mean (SD/range) number of nodules per participants was 10.4 (±6.2/1-29). Delineation between the dermal layers was disrupted in all current injection sites. In 52 participants (70%), there was a 30% increase in dermal thickness compared with local none injected tissue, and in 36 participants (48%) the increase was 50%. The level of thickness was >3 mm in the abdominal areas of 22 (40%) of these participants and in thighs of eight participants (17.8%). Hypoechogenic areas suggestive of necrotic tissue were observed within the lipohypertrophic nodules of 22 (30%) participants. Needle length and nodule depth were correlated (r=0.69, p<0.001). A conceptual model of the insulin exposed tissue changes observed was constructed. CONCLUSIONS: The study confirms that insulin-exposed tissue changes are heterogenous and has provided conceptual and grading frameworks for classifying these changes. Further studies are required to establish the clinical implications of these classifications, in relation to glucose regulation and other clinical parameters.

Mean HbA1c, HbA1c variability, and mortality in people with diabetes aged 70 years and older: a retrospective cohort study.

BACKGROUND: Glycaemic targets for older people have been revised in recent years because of concern that more stringent targets are associated with increased mortality. We aimed to investigate the association between glycaemic control (mean HbA1c) and variability (variability of HbA1c over time) and mortality in older people with diabetes. METHODS: We did a 5-year retrospective cohort study using The Health Improvement Network database, which includes data from 587 UK primary care practices. We included patients of either sex who were aged 70 years and older with type 1 or type 2 diabetes. The primary outcome was time to all-cause mortality. Our primary exposure variables were mean HbA1c and variability of HbA1c over time. The observation included a 4-year run-in period (from 2003) as a baseline, with a 5-year follow-up (from 2007 to 2012). We assessed mean HbA1c in three models: a baseline mean HbA1c for 2003-06 (model 1), the mean across the whole follow-up period (model 2), and a time-varying yearly updated mean (model 3). A variability score (from 0 [low] to 100 [high]) was calculated on the basis of number of changes in HbA1c of 0·5% (5·5 mmol/mol) or more from 2003 to 2012 or to the point of mortality, based on changes in the annual mean as per each model with a minimum of six readings. FINDINGS: The cohort consisted of 54 803 people, of whom 17 680 (8614 [30·7%] of 28 017 women and 9066 [33·8%] of 26 786 men) died during the observation period. The overall mortality rate was 77 per 1000 person-years (73 per 1000 person-years for women and 80 per 1000 person-years for men). The data showed a J-shaped distribution for mortality risk in both sexes, with significant increases with HbA1c values greater than 8% (64 mmol/mol) and less than 6% (42 mmol/mol), although excess mortality risk was non-significant in model 1 for men at HbA1c values of 8% (64 mmol/mol) to less than 8·5% (<69 mmol/mol) and in models 1 and 3 for both sexes assessed individually at HbA1c values less than 6% (42 mmol/mol). Mortality increased substantially with increasing HbA1c variability in all models (overall and for both sexes). For the model 2 HbA1c measure, the adjusted hazard ratios comparing patients with a glycaemic variability score of more than 80 to 100 with those with a score of 0 to 20 were 2·47 (95% CI 2·08-2·93) for women and 2·21 (1·87-2·61) for men. Fitting the mean HbA1c models with the glycaemic variability score altered the risk distribution; this observation was most marked in the model 2 analysis, in which a significant increased risk was only apparent with HbA1c values greater than 9·5% (80 mmol/mol) in women and 9% (75 mmol/mol) in men. INTERPRETATION: Both low and high levels of glycaemic control were associated with an increased mortality risk, and the level of variability also seems to be an important factor, suggesting that a stable glycaemic level in the middle range is associated with lower risk. Glycaemic variability, as assessed by variability over time in HbA1c, might be an important factor in understanding mortality risk in older people with diabetes. FUNDING: King's College London and Diabetes Frail.

A Systematic Review of Ultrasound-Detected Lipohypertrophy in Insulin-Exposed People with Diabetes.

INTRODUCTION: Lipohypertrophy (LH) is a common complication occurring in diabetes individuals. The most common methods used include palpation, visual examination and/or ultrasound (US). To date, there is limited information on the detection sensitivity among the different techniques used to identify LH. This systematic review aimed to identify studies that examined insulin-related LH using US detection to identify the prevalence, characteristics and morphology of LH, and to compare US and clinical palpation methods for detecting LH. METHODS: Three electronic databases were systematically searched for studies detecting LH using US in insulin users. Articles were screened for eligibility and included studies were appraised using quality assessment tools. The quality of the evidence was evaluated using Grading of Recommendations Assessment, Development and Evaluation, and the extracted data was synthesised narratively. RESULTS: Sixteen articles were included in the review providing data on 1722 patients. The prevalence of LH prevalence varied from 14.5% to 88% (median 56.6%). Identified risk factors for the development of included insulin injection behaviour such as a lack of injection site rotation and social factors such as low education level. Four studies compared LH detection by US to palpation, providing inconsistent results. One study showed that palpation detected 64% more LH, whilst two studies demonstrated that US identified 50% more sites and extended areas of LH (additional ~ 5 cm2). Another study provided comparable estimates between palpation and US in clinicians trained to detect LH (97%). CONCLUSION: The evidence highlights a lack of congruence in results pertaining to the detection sensitivity of US and palpation for LH sites. More research with robust study design is needed to verify whether clinically palpation is sufficient to detect LH, or whether US would increase the precision of LH assessment to help address this common clinically significant problem.

High risk of cardiovascular disease in patients with type 1 diabetes in the U.K.: a cohort study using the general practice research database.

OBJECTIVE: To estimate the absolute and relative risk of cardiovascular disease (CVD) in patients with type 1 diabetes in the U.K. RESEARCH DESIGN AND METHODS: Subjects with type 1 diabetes (n = 7,479) and five age- and sex-matched subjects without diabetes (n = 38,116) and free of CVD at baseline were selected from the General Practice Research Database (GPRD), a large primary care database representative of the U.K. population. Incident major CVD events, comprising myocardial infarction, acute coronary heart disease death, coronary revascularizations, or stroke, were captured for the period 1992-1999. RESULTS: The hazard ratio (HR) for major CVD was 3.6 (95% CI 2.9-4.5) in type 1 diabetic men compared with those without diabetes and 7.7 (5.5-10.7) in women. Increased HRs were found for acute coronary events (3.0 and 7.6 in type 1 diabetic men and women, respectively, versus nondiabetic subjects), coronary revascularizations (5.0 in men, 16.8 in women), and for stroke (3.7 in men, 4.8 in women). Type 1 diabetic men aged 45-55 years had an absolute CVD risk similar to that of men in the general population 10-15 years older, with an even greater difference in women. CONCLUSIONS: Despite advances in care, these data show that absolute and relative risks of CVD remain extremely high in patients with type 1 diabetes. Women with type 1 diabetes continue to experience greater relative risks of CVD than men compared with those without diabetes.

Delayed metabolic and thermogenic response to a mixed meal in normoglycemic European women with previous gestational diabetes.

We assessed postprandial thermogenesis (PPT) for 3 h following a mixed meal in 29 normoglycemic European women with previous gestational diabetes (GDM), compared with 37 control women. Given the potential role of catecholamines and insulin in the regulation of PPT, we assessed insulin and catecholamine responses to the meal. There was no significant difference between the two groups in resting energy expenditure, PPT (although lower in the GDM group), or catecholamine levels. However, we observed a difference in the shape of the PPT curve between groups, and by applying a mathematical model, there was a consistent delay in PPT, insulin, and noradrenaline responses to the meal in the GDM group (T: fitted time constant, geometric mean (95% confidence interval), T(PPT) 58 (47-72) vs. 42 (37-48) min, P = 0.006; T(ins) 32 (28-37) vs. 22 (19-27) min, P = 0.002; T(NA) 30 (23-38) vs. 18 (14-23) min, P = 0.01, respectively). Fidgeting activity during the study was assessed by a novel technique and was lower in the GDM group, resting [427 (381-477) vs. 511 (466-560) kJ/min, P = 0.02] but not postprandially. These delayed PPT, insulin, and noradrenaline responses to the meal in post-GDM women represent early metabolic changes. The decrease in fidgeting activity while resting, observed in the post-GDM group, may have physiological significance for energy balance.

Use of hormonal contraceptive methods by women with diabetes.

BACKGROUND AND METHODOLOGY: This study sought to establish use of hormonal contraception in UK women aged between 15 and 44 years with type 1 or type 2 diabetes compared with comparison groups with no diabetes. A cross sectional study design was used to compare 947 cases of type 1 diabetes and 365 cases of type 2 diabetes with comparison groups matched for age. Subjects were selected from the General Practice Research Database (GPRD). RESULTS: Women with diabetes were less likely to use hormonal contraception than women without diabetes--type 1 RR 0.83 (95% CI 0.59-0.93), type 2 RR 0.60 (95% CI 0.42-0.83). Women with type 1 diabetes were more likely to be prescribed a combined pill than a progestogen only pill (POP), but were significantly more likely to be prescribed the POP than were women without diabetes RR 1.65 (95% CI 1.26-2.13). Women with type 2 diabetes were less likely to be prescribed a combined oral contraceptive RR 0.39 (95% CI 0.24-0.62). The injectable contraceptive Depo Provera was significantly more likely to be given to women with diabetes than the comparison group--type 1 RR 1.56 (95% CI 1.12-2.11), type 2 RR 3.57 (95% CI 2.15-5.60). DISCUSSION AND CONCLUSIONS: The study highlighted significant variation in prescribing of hormonal contraception to women with type 1 and type 2 diabetes in comparison to those without diabetes. It is now recognised that hormonal contraception is a safe and effective option for women with uncomplicated diabetes. Possibly there are significant numbers of young women with poorly controlled diabetes or other risk factors for cardiovascular disease that have influenced clinicians in avoiding the use of hormonal contraception. Paradoxically it is these women who are at most risk from unplanned pregnancy.