Telephone communications between diabetes clients and nurse educators.

The purpose of this study was to describe the use of telephone communications between diabetes nurse educators (DNEs) and their clients with diabetes. A questionnaire was designed to examine the use of the telephone with diabetes clients from the perspective of DNEs. A total of 465 DNEs across the US were selected using a systematic sample from the membership directory of the American Association of Diabetes Educators. A total of 247 were questionnaires completed and returned (55%). Ninety-one percent of DNEs reported using the phone with clients and averaged 15 phone calls per week. Over 90% frequently reported discussing the following topics with clients: home blood glucose monitoring, hyperglycemia, hypoglycemia, insulin use, and diet. Analysis of telephone users showed that DNE experience and diabetes educator certification were significant factors in the differences observed in the reported topics discussed over the telephone. These findings suggest the need for guidelines for telephone contact with diabetes clients.

The impact of an educational program on improving diabetes knowledge and changing behaviors of nurses in long-term care facilities.

Nursing staffs from two long-term care facilities attended a multisession educational program about the care of residents with diabetes (treatment group). A control group consisted of the nursing staffs from two other similar facilities who did not participate in the educational program. Both groups were given a knowledge pretest and posttest. A chart review also was conducted following the educational intervention to determine any changes in the diabetes care provided by the treatment group. Following the educational program, the treatment group had a significant increase in their mean score on the knowledge test compared with the control group. However, a review of the residents' charts revealed no significant increases in specific behaviors related to diabetes care. The findings suggest that, in addition to educational programs, more focused training concerning diabetes care is needed to improve the care of residents with diabetes in long-term care facilities. Implications for diabetes educators are discussed.

Skeletal muscle GLUT4 protein concentration and aging in humans.

The insulin resistance of aging has been attributed to a postreceptor defect in skeletal muscle. The present study examined whether a reduction in the concentration of the insulin-stimulated glucose transporter (GLUT4) in skeletal muscle was associated with advancing age in men (n = 55) and women (n = 29). Insulin sensitivity (minimal model) was negatively associated (P < 0.001) with age (range, 18-80 years) in men (r = -0.44) and women (r = -0.58). GLUT4 protein concentration in the vastus lateralis was also negatively associated (P < 0.05) with age (men, r = -0.28; women, r = -0.51). There was no relation (P > 0.15) between GLUT4 content in the gastrocnemius and age. GLUT4 concentration in the vastus lateralis was positively associated (P < 0.01) with insulin sensitivity in both sexes (r = 0.42); this relationship persisted in the men after adjusting for overall adiposity, regional adiposity, and cardiorespiratory fitness. These findings suggest that a decrement in GLUT4 protein concentration in skeletal muscle may at least partially contribute to the insulin resistance of aging in humans.

Utilizing content analysis of counseling sessions to identify psychosocial stressors among patients with type II diabetes.

This qualitative, descriptive study identified specific individual and family psychosocial stressors that impact on the ability of patients with type II, non-insulin-dependent diabetes mellitus to manage the self-care regimens recommended by healthcare professionals. A series of 2 to 12 counseling sessions was incorporated into a nationally recognized outpatient diabetes education program. Data collection consisted of in-depth interviews in which six patients with type II diabetes and their families discussed current problems associated with their diabetes. Content analysis identified the following themes and problem areas: patients' inner experience with diabetes, family stressors that affect patients with diabetes, coping strategies of type II diabetes patients, and psychopathology. Based on these findings, specific interventions that emphasize family involvement and support were developed for the healthcare team to use with patients with type II diabetes.

Circulating insulin-like growth factor I concentrations in clinically severe obese patients with and without NIDDM in response to weight loss.

Earlier studies have demonstrated decreased levels of circulating Insulin-Like Growth Factor-I (IGF-I) in patients with NIDDM and IDDM (Yde 1969; Rieu and Binoux 1985), with a return to normal in those diabetics who achieve improved metabolic control (Rieu and Binoux 1985; Ameil, Sherwin, Hintz, Gertner, Press and Tamborlane 1984) following insulin therapy. One method of improving metabolic control in clinically severe obese NIDDM patients is the gastric bypass procedure (GBP). This study revealed a significant decrease in serum IGF-I concentrations in clinically severe obese patients with NIDDM (obese NIDDM) (105 ng/dl +/- 11; n = 29) as compared with clinically severe obese patients with normal glucose tolerances (obese control) (143 +/- 11; n = 21) and lean controls (177 +/- 14; n = 19) (p < 0.001). Following a GBP, IGF-I levels increased in the NIDDM group (142 ng/dl +/- 13.0; n = 20) to the extent that no significant difference was seen between postoperative NIDDM, obese controls, and lean controls. Postoperative IGF-I levels in the obese controls (151 +/- 14; n = 9) revealed no difference from preoperative levels. Postoperative obese NIDDM and obese control had a 28% and 29% decrease, respectively, in weight, with no difference between the groups in respect to Body Mass Indices. The NIDDM postoperative group revealed reductions in levels of HbA1C, insulin, and glucose concurrent with elevations in IGF-I when compared with controls. We conclude that improvement in glucose control led to the increase in IGF-I levels.

Measuring the diabetes knowledge of nurses in long-term care facilities.

A knowledge test was developed by a local diabetes educators' group to evaluate the diabetes knowledge base of 59 nurses currently employed in four long-term care facilities in eastern North Carolina. The test contained items in the following categories: monitoring, medication, hypoglycemia, hyperglycemia, illness care, diet, exercise, foot care, and patient/family education. The results of the diabetes knowledge test were analyzed according to overall test scores as well as scores in each of the selected categories. The overall scores ranged from 42% to 89%, with a group mean of 67% (passing = 70% or higher). The scores in the individual categories ranged from 18.6% for monitoring and 23.8% for medications to 91.5% for patient/family education.

Weight loss in severely obese subjects prevents the progression of impaired glucose tolerance to type II diabetes. A longitudinal interventional study.

OBJECTIVE: To determine if weight loss may prevent conversion of impaired glucose tolerance (IGT) to diabetes, because weight loss reduces insulin resistance. The prevalence of IGT in the U.S. population is estimated at 11.2%, more than twice that of diabetes. Furthermore, because an oral glucose tolerance test is needed for its detection, most of these patients are undiagnosed. Screening for IGT would be meaningful if progression to diabetes could be delayed or prevented. RESEARCH DESIGN AND METHODS: For an average of 5.8 years (range 2-10 years), 136 individuals with IGT and clinically severe obesity (> 45 kg excess body weight) were followed. The experimental group included 109 patients with IGT who underwent bariatric surgery for weight loss. The control group was made up of 27 subjects with IGT who did not have bariatric surgery. The criteria of the World Health Organization was used to detect IGT and diabetes in this population. The main outcome measure of this nonrandomized control trial is the incidence density, or number of events (development of diabetes) divided by the time of exposure to risk. RESULTS: Of the 27 subjects in the control group, 6 developed diabetes during an average of 4.8 +/- 2.5 years of postdiagnosis follow-up, yielding a rate of conversion to diabetes of 4.72 cases per 100 person-years. The 109 individuals of the experimental group were followed for an average of 6.2 +/- 2.5 years postbariatric surgery. Based on the 95% confidence interval of the comparison group, we would expect to find that between 22 and 36 subjects in the experimental group developed diabetes over the follow-up period. Only 1 of the 109 experimental-group patients developed diabetes, resulting in a conversion rate of the experimental group of only 0.15 cases per 100 person-years, which is significantly lower (P < 0.0001) than the control group. CONCLUSIONS: Weight loss in patients with clinically severe obesity prevents the progression of IGT to diabetes by > 30-fold.

Exercise training increases GLUT-4 protein concentration in previously sedentary middle-aged men.

The purpose of this study was to determine if 14 wk of exercise training would increase insulin-sensitive glucose transporter protein (GLUT-4) concentration in skeletal muscle of previously sedentary middle-aged men (47.2 +/- 1.3 yr; n = 13). Muscle samples (lateral gastrocnemius) and insulin action [insulin sensitivity index (ISI), minimal model] were obtained in the sedentary condition and 48 h after the final training bout. GLUT-4 protein concentration increased (P < 0.001, 2,629 +/- 331 to 4,140 +/- 391 absorbance units/100 micrograms protein) with exercise training by 1.8-fold. ISI increased by twofold (P < 0.05, 2.1 +/- 0.5 to 3.4 +/- 0.7 SI x 10(5) min/pM) with training. The percentage of GLUT-4 rich type IIa muscle fibers increased by approximately 10% (P < 0.01), which may have contributed to the elevation in transporter protein. GLUT-4 concentration and citrate synthase activity (1.7-fold, P < 0.001) also increased by similar increments. These findings indicate that GLUT-4 protein concentration is elevated in middle-aged individuals with exercise training.

Restoration of insulin responsiveness in skeletal muscle of morbidly obese patients after weight loss. Effect on muscle glucose transport and glucose transporter GLUT4.

A major defect contributing to impaired insulin action in human obesity is reduced glucose transport activity in skeletal muscle. This study was designed to determine whether the improvement in whole body glucose disposal associated with weight reduction is related to a change in skeletal muscle glucose transport activity and levels of the glucose transporter protein GLUT4. Seven morbidly obese (body mass index = 45.8 +/- 2.5, mean +/- SE) patients, including four with non-insulin-dependent diabetes mellitus (NIDDM), underwent gastric bypass surgery for treatment of their obesity. In vivo glucose disposal during a euglycemic clamp at an insulin infusion rate of 40 mU/m2 per min was reduced to 27% of nonobese controls (P less than 0.01) and improved to 78% of normal after weight loss of 43.1 +/- 3.1 kg (P less than 0.01). Maximal insulin-stimulated glucose transport activity in incubated muscle fibers was reduced by approximately 50% in obese patients at the time of gastric bypass surgery but increased twofold (P less than 0.01) to 88% of normal in five separate patients after similar weight reduction. Muscle biopsies obtained from vastus lateralis before and after weight loss revealed no significant change in levels of GLUT4 glucose transporter protein. These data demonstrate conclusively that insulin resistance in skeletal muscle of mobidly obese patients with and without NIDDM cannot be causally related to the cellular content of GLUT4 protein. The results further suggest that morbid obesity contributes to whole body insulin resistance through a reversible defect in skeletal muscle glucose transport activity. The mechanism for this improvement may involve enhanced transporter translocation and/or activation.

Surgical treatment of obesity and its effect on diabetes: 10-y follow-up.

Since 1980 we have performed the identical Greenville gastric bypass (GGB) procedure on 479 morbidly obese patients with an acceptable morbidity and a mortality rate of 1.2%. The weight loss in the series was well maintained over the follow-up period of 10 y. The GGB can control non-insulin-dependent diabetes mellitus (NIDDM) in most patients. The group of 479 patients included 101 (21%) with NIDDM and another 62 (13%) who were glucose impaired. Of these 163 individuals, 141 reverted to normal and only 22 (5%) remained with inadequate control of their carbohydrate metabolism. Those patients who were older or whose diabetes was of longer duration were less likely to revert to normal values. The gastric bypass operation is an effective approach for the treatment of morbid obesity. Along with its control of weight, the operation also controls the hyperglycemia, hyperinsulinemia, and insulin resistance of the majority of patients with either glucose impairment or frank NIDDM.

Muscle insulin resistance in uremic humans: glucose transport, glucose transporters, and insulin receptors.

To determine the cellular basis for insulin resistance observed in patients with uremia, we investigated insulin action in vivo and in vitro using skeletal muscle obtained from patients with chronic renal failure. Uremic subjects had significantly reduced rates of insulin-stimulated glucose disposal, as determined by a 3-h intravenous glucose tolerance test and using the hyperinsulinemic euglycemic clamp technique. Hepatic glucose production was similar before (control, 76.2 +/- 6.3 vs. uremic, 74.2 +/- 6.9 mg.kg-1.min-1) and during insulin infusion at 40 mU.m-2.min-1 (control, -60.9 +/- 6.6 vs. uremic, -53.9 +/- 6.3 mg.kg-1.min-1). In incubated human skeletal muscle fiber strips, basal 2-deoxy-D-glucose transport was unchanged in uremic subjects compared with controls. However, the increase in insulin-stimulated glucose transport was significantly reduced by 50% in muscles from uremic patients (P = 0.012). In partially purified insulin receptors prepared from skeletal muscle, 125I-labeled insulin binding, beta-subunit receptor autophosphorylation, and tyrosine kinase activity were all unchanged in uremic subjects. The abundance of insulin-sensitive (muscle/fat, GLUT-4) glucose transporter protein measured by Western blot using Mab 1F8 or polyclonal antisera was similar in muscles of control and uremic patients. These findings suggest that the insulin resistance observed in skeletal muscle of uremic patients cannot be attributed to defects in insulin receptor function or depletion of the GLUT-4 glucose transporter protein. An alternative step in insulin-dependent activation of the glucose transport process may be involved.