Person-Centered Primary Care and Type 2 Diabetes: Beyond Blood Glucose Control.

With an estimated 9% of persons in the United States diagnosed with diabetes, primary care providers such as midwives and nurse practitioners are increasingly working with persons who have diabetes and are seeking primary care services. This article reviews the current literature with regard to the initial evaluation of individuals who are diagnosed with diabetes, and what is entailed in comprehensive continuing management of care. A person-centered interprofessional approach to care of the person with diabetes is presented. Recommendations are given that address dietary habits, activities of daily living, medication regimens, and potential alternative therapies. Social constructs related to effective care of individuals with diabetes also are addressed. Knowledge of current research that has identified effective care practices for individuals with diabetes is imperative to ensuring their well-being, and promoting a person-centered and interprofessional approach is best for offering optimal care to those diagnosed with diabetes.

Diabetes Risk Assessment in Latinas: Effectiveness of a Brief Diabetes Risk Questionnaire for Detecting Prediabetes in a Community-Based Sample.

OBJECTIVE: Numerous validated questionnaires use self-reported data to quantify individuals' risk of having diabetes or developing it in the future. Evaluations of these tools have primarily used nationally representative data, limiting their application in clinical and community settings. This analysis tested the effectiveness of the American Diabetes Association (ADA) risk questionnaire for identifying prediabetes in a community-based sample of Latinas. METHODS: Data were collected using the ADA risk questionnaire and assessing A1C. Among 204 participants without diabetes, we examined the association between individual characteristics and glycemic status. We then calculated the performance characteristics (sensitivity, specificity, positive predictive value [PPV], and negative predictive value [NPV]) of the ADA risk questionnaire for detecting prediabetes, using A1C results as the gold standard to define the outcome. RESULTS: All participants were women of self-reported Hispanic/Latino ethnicity. Their mean ADA risk score was 5.6 ± 1.6. Latinas who had prediabetes were older, with significantly higher rates of hypertension and a higher ADA risk score than those without prediabetes. At a risk score ≥5-the threshold for high risk set by the ADA-the questionnaire had the following test performance characteristics: sensitivity 77.8%, specificity 41.7%, PPV 76.2%, and NPV 43.9%. CONCLUSION: The ADA risk questionnaire demonstrates reasonable performance for identifying prediabetes in a community-based sample of Latinas. Our data may guide other groups' use of this tool in the same target population. Future research should examine the effectiveness of this questionnaire for recruiting diverse populations into diabetes prevention programs. In addition, unique diabetes risk assessment tools for specific target populations are needed and may outperform questionnaires developed using nationally representative data.

Macronutrient Composition or Social Determinants? Impact on Infant Outcomes With Gestational Diabetes Mellitus.

The purpose of this study was to examine, through a randomized, controlled trial, the effects of a maternal carbohydrate-restricted diet on maternal and infant outcomes in gestational diabetes mellitus (GDM). Women diagnosed with GDM were randomly allocated into one of two groups: an intervention group that was placed on a lower-carbohydrate diet (35-40% of total calories) or a control group that was placed on the usual pregnancy diet (50-55% carbohydrate). A convenience sample of participants diagnosed with GDM (ages 18-45 years) was recruited from two different sites: one urban and low-income and the other suburban and more affluent. Individual face-to-face diet instruction occurred with certified diabetes educators at both sites. Participants tested their blood glucose four times daily. Specific socioeconomic status indicators included enrollment in the Supplemental Nutrition Program for Women, Infants and Children or Medicaid-funded health insurance, as well as cross-sectional census data. All analyses were based on an intention to treat. Although there were no differences found between the lower-carbohydrate and usual-care diets in terms of blood glucose or maternal-infant outcomes, there were significant differences noted between the two sites. There was a lower mean postprandial blood glucose (100.59 ± 7.3 mg/dL) at the suburban site compared to the urban site (116.3 ± 15 mg/dL) (P <0.01), even though there was no difference in carbohydrate intake. There were increased amounts of protein and fat consumed at the suburban site (P <0.01), as well as lower infant complications (P <0.01). Further research is needed to determine whether these disparities in outcomes were the result of macronutrient proportions or environmental conditions.

Factors Influencing Physician Counseling on Cardiovascular Risk.

BACKGROUND AND IMPORTANCE: A significant reduction in cardiovascular disease (CVD) mortality is related to aggressive management of modifiable CVD risk factors. Therefore, patients at increased risk for CVD should not only benefit from standard pharmacotherapy but also from counseling regarding lifestyle behavioral changes. OBJECTIVE: To determine the patient factors that influence provision of cardiovascular risk reduction counseling from physicians, as well as the frequencies of counseling. DESIGN, SETTING, AND PARTICIPANTS: Secondary analysis of a prospective, randomized trial among an underserved inner-city and rural population (n = 388) with a 10% or greater CVD risk (Framingham 10-year risk score). Subjects were followed for 1 year and were seen for quarterly assessments, which included evaluation of weight, blood pressure, lipid, and glucose status. At each of the 4 quarterly visits, subjects were asked if their physician had discussed or made recommendations regarding lifestyle behaviors, specifically diet, weight loss, and exercise. RESULTS: The average patient age was 61.3 ± 10.1 years, average A1c was 6.7 ± 1.6%, average total cholesterol was 201 ± 44 mg/dL. The average body mass index (BMI) was 31.8 ± 6.4 kg/m2, and the average blood pressure was 146 ± 18/82 ±11 mm Hg. Using binary logistic regression analysis, BMI (P < .025) was the only clinical factor related to physician lifestyle counseling. All other risk factors showed no statistical relationship. CONCLUSION: The data indicate that BMI is the major factor associated with whether or not physicians provide counseling regarding nutrition and weight loss. Physicians may be missing important opportunities to influence behavior in patients at high risk for CVD by limiting their focus to obese patients.

Managing hypertension in urban underserved subjects using telemedicine--a clinical trial.

BACKGROUND: We evaluated an Internet- and telephone-based telemedicine system for reducing blood pressure (BP) in underserved subjects with hypertension. METHODS: A total of 241 patients with systolic BP ≥140 mm Hg were randomized to usual care (C; n = 121) or telemedicine (T; n = 120). The T group reported BP, heart rate, weight, steps/day, and tobacco use twice weekly. The primary outcome was BP control at 6 months. RESULTS: Average age was 59.6 years, average body mass index was 33.7 kg/m(2), 79% were female, 81% were African American, 15% were white, 53% were at or below the federal poverty level, 18% were smokers, and 32% had diabetes. Six-month follow-up was achieved in 206 subjects (C: 107, T: 99). Goal BP was achieved in 52.3% in C and 54.5% in T (P = .43). Systolic BP change (C: -13.9 mm Hg, T: -18.2; P = .118) was similar in both groups. Subjects in the T group reported BP 7.7 ± 6.9 d/mo. Results were not affected by age, sex, ethnicity, education, or income. In nondiabetic T subjects, goal BP was achieved in 58.2% compared with 45.2% of diabetic T subjects (P = .024). Nondiabetic T subjects demonstrated a greater reduction in systolic BP (T: -19 ± 20 mm Hg, C: -12 ± 19 mm Hg; P = .037). No difference in BP response between C and T was noted in patients with diabetes. CONCLUSION: In hypertensive subjects, engagement in a system of care with or without telemedicine resulted in significant BP reduction. Telemedicine for nondiabetic patients resulted in a greater reduction in systolic BP compared with usual care. Telemedicine may be a useful tool for managing hypertension particularly among nondiabetic subjects.

The role of telemedicine in the management of the pregnancy complicated by diabetes.

The use of technology to deliver health care over a distance has drawn considerable attention and shown dramatic growth over the last decade because of the possibility it has to reduce cost and improve access to modern medical care. Diabetes in pregnancy, which requires tight glycemic control in order to reduce perinatal complications, is a prime telemedicine intervention target. A review of the literature suggests that telemedicine, although not perfect, can potentially play a role in reducing patient visits and could improve quality of life without jeopardizing the outcome.

Impact of a telemedicine system with automated reminders on outcomes in women with gestational diabetes mellitus.

BACKGROUND: Health information technology has been proven to be a successful tool for the management of patients with multiple medical conditions. The purpose of this study was to examine the impact of an enhanced telemedicine system on glucose control and pregnancy outcomes in women with gestational diabetes mellitus (GDM). SUBJECTS AND METHODS: We used an Internet-based telemedicine system to also allow interactive voice response phone communication between patients and providers and to provide automated reminders to transmit data. Women with GDM were randomized to either the telemedicine group (n=40) or the control group (n=40) and asked to monitor their blood glucose levels four times a day. Women in the intervention group transmitted those values via the telemedicine system, whereas women in the control group maintained paper logbooks, which were reviewed at prenatal visits. Primary outcomes were infant birth weight and maternal glucose control. Data collection included blood glucose records, transmission rates for the intervention group, and chart review. RESULTS: There were no significant differences between the two groups (telemedicine vs. controls) in regard to maternal blood glucose values or infant birth weight. However, adding telephone access and reminders increased transmission rates of data in the intervention group compared with the intervention group in our previous study (35.6±32.3 sets of data vs.17.4±16.9 sets of data; P<0.01). CONCLUSIONS: Our enhanced telemedicine monitoring system increased system utilization and contact between women with GDM and their healthcare providers but did not impact upon pregnancy outcomes.

A Single A1C >= 6.5% Accurately Identifies Type 2 Diabetes/Impaired Glucose Tolerance in African Americans.

OBJECTIVE: In 2010, the American Diabetes Association revised its criteria for the diagnosis of diabetes to include A1C ≥ 6.5%; however, this has remained controversial, particularly for African Americans. The objective of this pilot study was to examine the usefulness of a single A1C determination in comparison with a same day 2-hour oral glucose tolerance test to diagnose type 2 diabetes in African Americans. METHODS: In sum, 195 oral glucose tolerance tests and A1Cs were obtained on the same day from 77 overweight and obese African American women and 6 men over a period of 15 months. RESULTS: A1C ≥ 6.5% was present in 31 of 195 patients, with 15 of these having type 2 diabetes by oral glucose tolerance test, another 12 having impaired glucose tolerance, and 4 having normal glucose tolerance. This gives a sensitivity of 50% and a specificity of 90%, with a positive predictive value of 48% and a negative predictive value of 91%. A1C ≤ 5.6%, proposed by the American Diabetes Association to indicate normal glucose tolerance, was present in only 28 patients, 10 (35.7%) of whom had normal glucose tolerance, whereas 18 (64.3%) had either impaired glucose tolerance (15 patients) or type 2 diabetes (3 patients). Fasting plasma glucose ≥ 126 mg/dL was present in 5 of 29 patients with type 2 diabetes (sensitivity, 17.2%; specificity, 100%). CONCLUSIONS: First, A1C ≥ 6.5% was a good "rule in" value to identify impaired glucose tolerance and type 2 diabetes (ie, patients at high risk for micro- and macrovascular complications). Second, A1C ≤ 5.6% did not rule out impaired glucose tolerance or type 2 diabetes. Last, fasting plasma glucose ≥ 126 mg/dL detected less than 1 in 5 cases with type 2 diabetes.

The individual and combined effects of glycemic index and protein on glycemic response, hunger, and energy intake.

Although high protein and low glycemic index (GI) foods are thought to promote satiety, little is known about the effects of GI, protein, and their interaction on hunger and energy intake several hours following a mixed meal. This study investigated the long term effects of GI, protein, and their combined effects on glucose, insulin, hunger, and energy intake in healthy, sedentary, overweight, and obese adults (BMI of 30.9 ± 3.7 kg/m(2)). Sixteen individuals participated separately in four testing sessions after an overnight fast. The majority (75%) were non-Hispanic Blacks. Each consumed one of four breakfast meals (high GI/low protein, high GI/high protein, low GI/low protein, low GI/high protein) in random order. Visual analog scales (VAS) and blood samples were taken at baseline, 15 min, and at 30 min intervals over 4 h following the meal. After 4 h, participants were given the opportunity to consume food ad libitum from a buffet style lunch. Meals containing low GI foods produced a smaller glucose (P < 0.002) and insulin (P = 0.0001) response than meals containing high GI foods. No main effects for protein or interactions between GI and protein were observed in glucose or insulin responses, respectively. The four meals had no differential effect on observed energy intake or self-reported hunger, satiety, and prospective energy intake. Low GI meals produced the smallest postprandial increases in glucose and insulin. There were no effects for GI, protein, or their interaction on appetite or energy intake 4 h after breakfast.

Rural and urban characteristics impact cardiovascular risk reduction.

PURPOSE: Our aim was to provide a descriptive analysis of specific differences between rural and urban residents and the interaction between these differences and those who reduced cardiovascular disease (CVD) risk in response to intervention versus those who did not. METHODS: This study is a descriptive analysis comparing rural groups with urban groups and those who decreased CVD risk with those who did not. Two hundred five rural (median age = 64.0 years [interquartile = 57.0, 71.0], 56% men) and 183 urban (median age = 58.0 years [interquartile = 50.0, 65.0], 53% men) residents were included. RESULTS: Rural and urban groups differed (P < .05) for demographic, anthropometric, physiological, and health-related variables. Those who decreased CVD risk, regardless of rural or urban, had greater blood pressure, greater low-density lipoprotein cholesterol, lower walking distance, greater CVD risk score, greater metabolic syndrome score, and greater internal health locus of control (all P < .05). Interestingly, there were differences between those who decreased risk and those who did not within the rural and urban groups. Triglycerides, C-reactive protein, diabetes knowledge, risk perception, and outcome expectations were greater for the rural group who decreased their CVD risk versus those who did not (all P < .05). For the urban group, there was a greater powerful others locus of control for those who decreased CVD risk (P < .05). CONCLUSIONS: To maximize the likelihood of success, risk reduction intervention and educational strategies for urban and rural groups must be tailored to address unique demographic, physiological, and health-related characteristics.

Gestational diabetes screening after HAPO: has anything changed?

Gestational diabetes mellitus (GDM) is one of the most common complications of pregnancy. It is defined as diabetes that is first recognized during pregnancy. The diagnosis of GDM is important because it impacts maternal health care during and after pregnancy. The American Diabetes Association, American Congress of Obstetrics and Gynecology, the World Health Organization, and the National Diabetes Data Group all have recommendations for screening; however, there is no consensus. The Hyperglycemia and Adverse Pregnancy Outcome Research Cooperative Study Group published their findings that show hyperglycemia has a significant effect on pregnancy outcome. In addition, recent studies showed that treatment of mild hyperglycemia may affect adverse outcomes. However, at this time no new guidelines for screening and diagnosis of gestational diabetes have been published. This article summarizes the current state of screening for gestational diabetes.

Gender differences in cardiovascular risk factors and risk perception among individuals with diabetes.

PURPOSE: The purpose of this study was to examine gender-based differences in cardiovascular risk factors and risk perception among individuals with diabetes. METHODS: The sample consisted of patients with an established history of diabetes who were enrolled in a telemedicine trial to reduce cardiovascular disease (CVD) risk. All subjects had a 10% or greater risk on the Framingham risk index. Assessments included blood pressure, A1C, lipid profile, medication history, and knowledge and risk perception surveys. RESULTS: Data were available for 211 individuals with type 2 diabetes (88 men and 123 women). The women and men did not differ in age, body mass index, or Framingham risk. Only 37.4% of women and 40.9% of men were at an A1C target of <7%. Total cholesterol levels were significantly higher among women, and fewer women were at low-density lipoprotein or blood pressure targets. Knowledge of CVD was similar between the 2 sexes. However, women perceived their risk for CVD to be significantly higher than did men. CONCLUSION: Less favorable cardiovascular risk profiles are observed among women with diabetes as compared with their male counterparts. Multifaceted approaches to both diabetes management and education are needed to target CVD risk reduction among individuals with diabetes.

Insulin resistance: the possible link between gestational diabetes mellitus and hypertensive disorders of pregnancy.

Gestational hypertension, preeclampsia, and diabetes are all associated with increased risks of poor maternal and perinatal outcomes. Pregnant women with gestational diabetes have been shown in population studies to have increased risk of pregnancy-associated hypertension compared with nondiabetic women. Moreover, pregnant patients with hypertension are at increased risk for developing gestational diabetes mellitus. It has been hypothesized that this association could be due, at least in part, to insulin resistance. Although insulin resistance is a physiologic phenomenon in normal pregnancy, in predisposed individuals this could lead to hyperinsulinemia with the development of gestational hypertension, gestational diabetes mellitus, or both.

Cardiovascular disease knowledge and risk perception among underserved individuals at increased risk of cardiovascular disease.

BACKGROUND: Cardiovascular disease (CVD) risk factor awareness and knowledge are believed to be prerequisites for adopting healthy lifestyle behaviors. The purpose of this study was to examine knowledge of CVD risk factors and risk perception among individuals with high CVD risk. METHODS: The sample consisted of inner city and rural medically underserved patients at high risk of CVD. To be eligible for the trial, subjects were required to have a 10% or greater CVD risk on the Framingham risk score. Knowledge of CVD was assessed with a 29-item questionnaire created for this study. Subjects also rated their perception of risk as compared with individuals of their own sex and age. RESULTS: Data were collected from 465 subjects (mean [SD] age, 60.5 [10.1] years; mean [SD] Framingham risk score, 17.3% [9.5%]). The mean (SD) CVD knowledge score was 63.7% (14.6%), and mean (SD) level of risk perception was 0.35 (1.4). Men and women had similar Framingham risk scores, but women perceived their risk to be significantly higher than that of their male counterparts. Women were also more knowledgeable than men about CVD. Urban participants had significantly higher actual risks than did their rural counterparts (18.2% [10.7%] vs 16.0% [8.9%], respectively; P = .01) but were significantly less knowledgeable about heart disease and also perceived their risk to be lower. CONCLUSIONS: These results indicate a low perception of risk and cardiovascular knowledge especially among men and inner city residents. Innovative educational strategies are needed to increase risk factor knowledge and awareness among at-risk individuals.

Accuracy of blood pressure measurements transmitted through a telemedicine system in underserved populations.

In underserved populations, inadequate surveillance and treatment allows hypertension to persist until actual cardiovascular events occur. Thus, we developed an Internet-based telemedicine system to address the suboptimal control of hypertension and other modifiable risk factors. To minimize cost, the subjects used home monitors for blood pressure (BP) measurements and entered these values into the telemedicine system. We hypothesized that patients could accurately measure their BP and transmit these values via a telemedicine system. Inner city and rural subjects (N = 464; 42% African-American or Hispanic) with 10% or greater 10-year risk of cardiovascular disease and with treatable risk factors were randomized into two groups, control group (CG) and telemedicine group (TG). Each subject received a home sphygmomanometer with memory. The TG recorded and entered BP at least weekly. During office visits, the BP meters were downloaded and recorded BP compared to BP values transmitted via telemedicine. The telemedicine (T) BP values were similar to the meter recorded (R) values (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and R: systolic/diastolic BP 136.4 +/- 11.9.4/79.7 +/- 7.5 mm Hg). The percent error was <1% for both systolic (-0.02 +/- 0.04%) and diastolic (-0.03 +/- 0.04%) BP. Lastly, the telemedicine BP values were similar to the office (O) BP values for systolic and diastolic BP (T: systolic/diastolic BP 133.4 +/- 11.1/77.5 +/- 6.8 mm Hg, and O: systolic/diastolic BP 136.3 +/- 20.5/78.1 +/- 10.5 mm Hg). In underserved populations, this inexpensive approach of patients using a home monitor and entering these values into a telemedicine system provided accurate BP data.