Incidence, prevalence, and potential risk factors for diabetic foot ulceration: A retrospective review at a multidisciplinary centre in Barbados.

OBJECTIVE: Diabetes and lower extremity amputation rates in Barbados are among some of the highest globally, with peripheral neuropathy and peripheral vascular disease found to be independent risk factors for this population. Despite this, there is currently a lack of research evidence on rates of diabetic foot ulceration, which has amputation as its sequela. We aimed to evaluate the incidence and prevalence rates of active ulceration in a population of people with diabetes in Barbados. Secondly, we explored the risk factors for new/recurrent ulceration. RESEARCH DESIGN AND METHODS: Data were extracted from the electronic medical records for the period January 1, 2019 to December 31, 2020 for a retrospective cross-sectional study for patients of a publicly-funded diabetes management programme. Eligible records included people aged 18 years and above with a diagnosis of type 1 or 2 diabetes. Potential risk factors were explored using univariable logistic regression models. RESULTS: A total of 225 patients were included in the study (96% type 2 diabetes, 70.7% female, 98.7% Black Caribbean). The 1-year period prevalence of diabetic foot ulceration was 14.7% (confidence interval [CI]: 10.5, 20.1). Incidence of ulceration in the same period was 4.4% (CI: 4.4, 4.5). Risk factors associated with diabetic foot ulceration included: retinopathy (OR 3.85, CI: 1.24, 11.93), chronic kidney disease (OR 9.86, CI: 1.31, 74.22), aspirin use (OR 3.326, CI: 1.02, 10.85), and clopidogrel use (OR 3.13, CI: 1.47, 6.68). CONCLUSION: This study provided some insight into potential risk factors for foot ulceration in this population, which previous studies have shown to have higher rates of lower extremity amputations. Further research in this understudied group through a larger prospective cohort would allow more meaningful associations with risk factors and would be useful for the creation of risk prediction models.

Individual, healthcare professional and system-level barriers and facilitators to initiation and adherence to injectable therapies for type 2 diabetes: A systematic review and meta-ethnography.

AIMS: To review and synthesise the contemporary qualitative evidence, relating to the individual, healthcare professional and system-level barriers and facilitators to injectable therapies in people with type 2 diabetes, and evaluate (using an intersectional approach to explore the diverse perspectives of different identities) whether views have changed with treatment and guideline advancements. METHODS: A meta-ethnography approach used. Eight databases searched from the years 2006 (GLP-1 analogues introduced) to February 2021. Study selection (using a pre-defined inclusion criteria), quality appraisal and data extraction, conducted independently by two reviewers. RESULTS: Screened 7143 abstracts, assessed 93 full-text papers for eligibility and included 42 studies-using data from 818 individuals with type 2 diabetes and 160 healthcare professionals. Studies covered a diverse range of views from healthcare professionals and individuals, including those relating to older adults and people from ethnic migrant backgrounds, and 10 studies rated moderate to strong research value. Key themes abstracted: barriers (physical/psychological/social) and facilitators (motivation/capability/opportunity). CONCLUSIONS: The first synthesis of contemporary qualitative data to adopt an intersectionality approach and explore diverse views relating to barriers and facilitators that influence engagement with injectable treatments for type 2 diabetes. A model is presented to help patients, health practitioners and policy makers identify barriers and facilitators and understand the complex interplay of physical, psychological and social factors involved when prescribing injectable therapies. Despite advances in injectable treatments and guidelines, findings highlight the many barriers that still exist and show how strongly held culturally-specific health beliefs of people from diverse socio-economic and ethnic backgrounds can become substantial obstacles to treatment.

Perceptions of healthcare professionals and people with type 2 diabetes on emotional support: a qualitative study.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a demanding condition that impacts the person living with the condition physically and psychologically. Promoting emotional support is a key strategy to improve diabetes care. AIM: To explore the views and experiences of people with T2DM and healthcare professionals (HCPs) on emotional support in diabetes care, and identify barriers and facilitators to the provision of emotional support in clinical practice. DESIGN & SETTING: A qualitative study in England with data collected from four focus groups. METHOD: Focus group discussions were conducted with people with T2DM (n = 10) and HCPs (n = 10). The analysis was informed by the framework method and principles of the constant comparative approach. RESULTS: Emotional support was lacking in diabetes primary care, and there was a need to normalise the emotional impact of T2DM. Barriers to emotional support included: lack of HCP confidence to discuss emotional issues; lack of counselling training; and time constraints in consultations. Inappropriate use of the word 'depression' creates a sense of taboo for those experiencing emotions other than depression. CONCLUSION: Consensus between the two target groups indicated a strong need to integrate emotional support in diabetes care, and the need to support and train HCPs in addressing psychosocial aspects of T2DM. Shared language is recommended across diabetes services to appropriately refer to wellbeing. Addressing barriers and considering ways to incorporate emotional management in diabetes consultations is recommended, includings introducing HCP training to increase confidence and enhance counselling skills.

Incidence and severity of hypoglycaemia in type 2 diabetes by treatment regimen: A UK multisite 12-month prospective observational study.

AIMS: To determine the incidence and severity of self-reported hypoglycaemia in a primary care population with type 2 diabetes. The study also aimed to compare incidence by treatment regimen. MATERIALS AND METHODS: A prospective observational study in 17 centres throughout the UK was conducted. Recruitment was based on treatment regimen (metformin alone, sulphonylurea-, insulin- or incretin-based therapy). Participants were asked to keep a blood glucose diary and self-report hypoglycaemia episodes [non-severe (self-treated) and severe (requiring external help)] over a 12-month period. RESULTS: Three hundred and twenty-five participants were enrolled, of whom 274 (84%) returned ≥1 monthly diaries. Overall, 39% reported experiencing hypoglycaemia; 32% recorded ≥1 symptomatic, 36% ≥1 non-severe, and 7% ≥1 severe episodes. By treatment, incidence (events per person/year) for any hypoglycaemia type was 4.39 for insulin, 2.34 for sulphonylurea, 0.76 for metformin, and 0.56 for incretin-based therapy. Compared with metformin, risk of non-severe hypoglycaemia was ~3 times higher for participants on sulphonylureas and > 5 times higher for those on insulin [incidence rate ratio (IRR) 3.02 (1.76-5.18), P < 0.001, and IRR 5.96 (3.48-10.2), P < 0.001, respectively]. For severe episodes, the incidence for sulphonylurea (0.09) was similar to metformin (0.07) and incretin-based therapy (0.07); for insulin the risk remained almost 5 times higher than metformin [incidence 0.32; IRR 4.55 (1.28-16.20), P = 0.019]. CONCLUSIONS: Hypoglycaemia represents a substantial burden for people with type 2 diabetes. Sulphonylureas and insulin are both associated with a risk of reported non-severe hypoglycaemia, but only insulin with severe episodes. This suggests the importance of the continued use of sulphonylureas in appropriate patients with type 2 diabetes.

Prevalence and Incidence of Hypoglycaemia in 532,542 People with Type 2 Diabetes on Oral Therapies and Insulin: A Systematic Review and Meta-Analysis of Population Based Studies.

OBJECTIVE: To collate and evaluate the current literature reporting the prevalence and incidence of hypoglycaemia in population based studies of type 2 diabetes. RESEARCH DESIGN AND METHODS: Medline, Embase and Cochrane were searched up to February 2014 to identify population based studies reporting the proportion of people with type 2 diabetes experiencing hypoglycaemia or rate of events experienced. Two reviewers independently screened studies for eligibility and extracted data for included studies. Random effects meta-analyses were carried out to calculate the prevalence and incidence of hypoglycaemia. RESULTS: 46 studies (n = 532,542) met the inclusion criteria. Prevalence of hypoglycaemia was 45% (95%CI 0.34,0.57) for mild/moderate and 6% (95%CI, 0.05,0.07) for severe. Incidence of hypoglycaemic episodes per person-year for mild/moderate and for severe was 19 (95%CI 0.00, 51.08) and 0.80 (95%CI 0.00,2.15), respectively. Hypoglycaemia was prevalent amongst those on insulin; for mild/moderate episodes the prevalence was 50% and incidence 23 events per person-year, and for severe episodes the prevalence was 21% and incidence 1 event per person-year. For treatment regimes that included a sulphonylurea, mild/moderate prevalence was 30% and incidence 2 events per person-year, and severe prevalence was 5% and incidence 0.01 events per person-year. A similar prevalence of 5% was found for treatment regimes that did not include sulphonylureas. CONCLUSIONS: Current evidence shows hypoglycaemia is considerably prevalent amongst people with type 2 diabetes, particularly for those on insulin, yet still fairly common for other treatment regimens. This highlights the subsequent need for educational interventions and individualisation of therapies to reduce the risk of hypoglycaemia.

Diabetes prevention in the real world: effectiveness of pragmatic lifestyle interventions for the prevention of type 2 diabetes and of the impact of adherence to guideline recommendations: a systematic review and meta-analysis.

OBJECTIVE To summarize the evidence on effectiveness of translational diabetes prevention programs, based on promoting lifestyle change to prevent type 2 diabetes in real-world settings and to examine whether adherence to international guideline recommendations is associated with effectiveness. RESEARCH DESIGN AND METHODS Bibliographic databases were searched up to July 2012. Included studies had a follow-up of ≥12 months and outcomes comparing change in body composition, glycemic control, or progression to diabetes. Lifestyle interventions aimed to translate evidence from previous efficacy trials of diabetes prevention into real-world intervention programs. Data were combined using random-effects meta-analysis and meta-regression considering the relationship between intervention effectiveness and adherence to guidelines. RESULTS Twenty-five studies met the inclusion criteria. The primary meta-analysis included 22 studies (24 study groups) with outcome data for weight loss at 12 months. The pooled result of the direct pairwise meta-analysis shows that lifestyle interventions resulted in a mean weight loss of 2.12 kg (95% CI -2.61 to -1.63; I(2) = 91.4%). Adherence to guidelines was significantly associated with a greater weight loss (an increase of 0.3 kg per point increase on a 12-point guideline-adherence scale). CONCLUSIONS Evidence suggests that pragmatic diabetes prevention programs are effective. Effectiveness varies substantially between programs but can be improved by maximizing guideline adherence. However, more research is needed to establish optimal strategies for maximizing both cost-effectiveness and longer-term maintenance of weight loss and diabetes prevention effects.

The Reversal Intervention for Metabolic Syndrome (TRIMS) study: rationale, design, and baseline data.

BACKGROUND: Recent attention has focused on strategies to combat the forecast epidemic of type-2 diabetes (T2DM) and its major vascular sequelae. Metabolic syndrome (MetS) comprises a constellation of factors that increase the risk of cardiovascular disease (CVD) and T2DM. Our study aims to develop a structured self-management education programme for people with MetS, which includes management of cardiovascular and diabetes risk factors, and to determine its impact. This paper describes the rationale and design of the TRIMS study, including intervention development, and presents baseline data. METHODS: Subjects recruited from a mixed-ethnic population with MetS were randomised to intervention or control arms. The intervention arm received structured group education based on robust psychological theories and current evidence. The control group received routine care. Follow-up data will be collected at 6 and 12 months. The primary outcome measure will be reversal of metabolic syndrome in the intervention group subjects compared to controls at 12 months follow-up. RESULTS: 82 participants (44% male, 22% South Asian) were recruited between November 2009 and July 2010. Baseline characteristics were similar for both the intervention (n = 42) and control groups (n = 40). Median age was 63 years (IQR 57 - 67), mean waist size 106 cm (SD ± 11), and prescribing of statins and anti-hypertensives was 51% in each case. CONCLUSION: Results will provide information on changes in diabetes and CVD risk factors and help to inform primary prevention strategies in people with MetS from varied ethnic backgrounds who are at high risk of developing T2DM and CVD. Information gathered in relation to the programme's acceptability and effectiveness in a multi-ethnic population would ensure that our results are widely applicable. TRIAL REGISTRATION: The study is registered at ClinicalTrials.gov, study identifier: NCT01043770.

Waist circumference measurement: knowledge, attitudes and barriers in patients and practitioners in a multi-ethnic population.

BACKGROUND: Currently, body mass index (BMI) is widely used to identify health risk due to overweight or obesity. However, waist circumference is considered by many to be a better indicator of health risk than BMI. The primary health care team are ideally suited to screen for people at high risk of glucose intolerance and increased cardiovascular risk using waist circumference measurement (WCM). OBJECTIVES: To determine the knowledge and attitudes of patients and primary care practitioners concerning WCM, with particular reference to exploring barriers in a multi-ethnic setting. METHODS: A qualitative study using purposive sampling, semi-structured interviews and thematic analysis was conducted. Nine general practices were selected from Leicestershire, UK. The participants were 10 practitioners (four practice nurses, six general practitioners) and 18 patients (six south Asians). RESULTS: Two overarching themes were identified from patient and practitioner interviews: understanding of waist size measurement to assess or monitor risk and attitudes related to perceived barriers and facilitators to waist measurement. A few practitioners felt uncomfortable about carrying out WCM and some perceived that patients might feel embarrassed. Practical barriers raised by professionals included lack of time, extra workload and financial implications. In contrast, patients generally raised few barriers to WCM. Being given an explanation appeared to be what was most important to them. No clear differences emerged when comparing views of patients from different ethnic groups or general practitioners and practice nurses. CONCLUSIONS: This study adds to our understanding of views on WCM in a multi-ethnic setting, highlighting factors for consideration if WCM is to be facilitated in routine practice.

Is having a family history of type 2 diabetes or cardiovascular disease a predictive factor for metabolic syndrome?

AIMS: To determine whether a first degree family history (FH) of diabetes and/or a first degree FH of cardiovascular disease (CVD), can predict prevalent cases of metabolic syndrome (MetS). Also, to establish if the association is different for South Asians compared to White Europeans, and for obese compared to non-obese individuals. METHODS: Cross-sectional data were analysed for a mixed-ethnic cohort of 3094 at-risk individuals, aged 40-75 years (29% South Asian), who were screened in Leicestershire (UK) for undiagnosed type 2 diabetes using an oral glucose tolerance test. Logistic regression was used to assess the relationship between FH and prevalent MetS, including adjustment for potential confounders. RESULTS: Prevalence of MetS was 39%. Adjusted odds ratios (OR) showed that only a FH of CVD (OR 1.41, 95%CI: 1.18-1.68, p<0.001) was significantly associated with prevalent MetS. Interaction analysis showed no effect modification for obesity and ethnicity. We did not find any association for a FH of diabetes. CONCLUSIONS: These findings suggest that a first degree FH of CVD predicts prevalent cases of MetS in a mixed-ethnic population. Evidence of an association may help to identify individuals who should be targeted for screening and early prevention of type 2 diabetes and CVD.

A cross sectional survey of secondary prevention measures in patients with peripheral arterial disease in primary care.

BACKGROUND: The National Service Framework for coronary heart disease (CHD) defines standards for the secondary prevention of cardiovascular disease in at risk individuals, including those with peripheral arterial disease (PAD). AIM: To assess current standards of secondary prevention and health monitoring in patients with PAD following a vascular procedure, and additionally compare care in patients with and without diagnosed CHD. METHODS: Indicators for this cross sectional survey were identified from national recommendations and evidence. A retrospective review was conducted of general practitioner records, for patients who were treated in hospital for PAD. RESULTS: Data were collected for 103 patients from 42 practices. Overall, prescribing was well achieved for antiplatelets but poor for statins. Standards of assessment of blood pressure, smoking status, and smoking cessation advice were high. However, approximately only half of the patients received advice about exercise or had their body mass index checked. Furthermore, for all indicators, standards of care for patients who additionally had a diagnosis of CHD were better than for patients without CHD. CONCLUSION: The cross sectional survey suggested the treatment received by some patients with established PAD is substandard. There is considerable potential to increase secondary prevention of CHD in patients with PAD disease in primary care.