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As proteinuria progresses, the lipid profile deteriorates, and is especially marked in nephrotic patients. Only the glitazones have substantial effects on lipid profiles that may impact on cardiovascular outcomes. Those with clinical evidence of macrovascular disease: angina, myocardial infarction, revascularization, peripheral vascular disease, cerebrovascular disease including transient ischemic episodes. Microalbuminuria or macroalbuminuria (including those with previous microalbuminuria resolved by antiproteinuric and antihypertensive treatment). Most diabetes patients over 50 years of age without additional cardiovascular risk factors. Statin treatment should be individualized in type 1 patients under 50 years of age where there are no other cardiovascular risk factors and no microvascular complications. Obesity Excessive weight gain due to accumulation of fat in the body sometimes defined as a BMI of 30 or higher or body weight greater Discusses diabetic ketoacidosis. Erbs: I need to know some food that people shouldnt eat for a type Treatment diabetic type I Type-1 Diabetics affects the insulin producing cells.
December 12 2014 in Diabetes Care Basics: Keeping Your Blood Pressure on Track for Heart Health.
Since people with ype 2 diabetes produce insulin but don’t use it properly the goal of insulin therapy is to augment their insulin production to achieve near-normal blood glucose control. The Chronic Care Model (CCM) uses a systematic approach to restructuring medical care to create partnerships between health systems and communities. The 16 studies included various study designs, including 9 randomized controlled trials, and settings, including academic-affiliated primary care practices and private practices.
CCM is being used for diabetes care in US primary care settings, and positive outcomes have been reported. Diabetes is a major cause of heart disease and stroke among adults in the United States and is the leading cause of nontraumatic lower-extremity amputations, new cases of blindness, and kidney failure (1–3). CCM comprises 6 components that are hypothesized to affect functional and clinical outcomes associated with disease management. The sum of these CCM component parts are purported to create more effective health care delivery systems that institute mechanisms for decision support, link health care systems to community resources and policies, deliver comprehensive self-management support services for patients, and operate and manage patient-centered clinical information systems. This study identified English-language peer-reviewed research articles describing CCM-based interventions for managing type 1 and type 2 diabetes in US primary care settings (ie, hospital-network outpatient clinics, private practices, and community health centers). As recommended by the Centre for Reviews and Dissemination systematic review guidelines (8), we created the following categories to systematically assess the 16 studies and gain an understanding of the methods used and the outcomes associated with CCM application: study design, sample size, setting, participant demographics, primary and secondary outcomes measured, data collection instruments used, statistical tests used, and major findings. We found that diabetes self-management education (DSME) generally improved psychosocial and clinical outcomes in patients with diabetes. Specialized decision support services for diabetes care were provided to PCPs (eg, endocrinologists) and nurse practitioners via telephone and e-mail (18), problem-based learning meetings (11,12,14,16,17), and telemedicine technology (13). Implementation of ADA standards of care (10–12,14,16,17) and ICSI clinical guidelines (18) resulted in innovative diabetes care delivery in PCP offices. Collaborative clinical information systems using disease registries and electronic medical records enabled multiple health care providers (eg, PCPs, nurse practitioners, nurses, CDEs, physician assistants, medical assistants) to review detailed reports on laboratory and examination results and identify lapses in diabetes care (eg, missed visits, laboratory appointments, and examinations). Seven studies (11,12,16–18,20,24) specified strategies for using community resources and forming public policy. The findings of these studies contribute to a qualitative understanding of the relationship between the application of CCM components and diabetes outcomes in US primary care settings. One meta-analysis (27) determined that no single component of the CCM was imperative for improved outcomes. In several studies, organizational leaders in health care systems initiated system-level reorganizations that facilitated more comprehensive and coordinated diabetes care. Delivery system design was identified as an important strategy for integrating DSME into primary care settings through addressing patient barriers to care such as accessibility to DSME and availability of staff to assist with diabetes care (10). Finally, community-level partnerships pooled human and fiscal resources to provide diabetes management services (11,12,16–18,20,24). In conclusion, our study provides evidence that CCM is effective in improving the health of people who have diabetes and receive care in primary care settings.
This work was supported in part by the National Institutes for Health National Center for Advancing Translational Sciences Clinical and Translational Science Award to the University of Florida no. Corresponding Author: Krishna Dipnarine, MS, Department of Health Education and Behavior, College of Health and Human Performance, University of Florida, PO Box 118210, FLG 5, Gainesville, FL 32611-8210. Author Affiliations: Michael Stellefson, Christine Stopka, University of Florida, Gainesville, Florida. Developed the Vermont Diabetes Information System to collect clinical information and provide flow sheets, reminders, and alerts to physicians and their patients with diabetes. Participants and their family members met with team members for five 2-hour group sessions biweekly. Problem-based learning sessions were used to demonstrate implementation of guidelines into a plan of care. Offered 6 weekly CDE-facilitated DSME sessions based on the University of Michigan DSME curriculum. Monthly support groups focused on foot care, healthful cooking and recipe modification, alternative treatments, and problem-solving skills. Problem-based learning sessions were held for PCPs, led by an endocrinologist using diabetes management questions. After diagnosis of diabetes, the importance of protecting the body from damage caused by hyperglycemia cannot be overstated.
It is commonly recommended that T2DM patients who use insulin self-monitor their blood glucose levels, but the evidence to support the effectiveness of this practice is inconclusive. It is important to establish individual goals with patients regarding target blood glucose measurements. HbA1c measures nonreversible glycosylation of the hemoglobin molecule, which is directly related to blood glucose concentrations. Traditionally it has been recommended that therapy be adjusted to maintain HbA1c values near or less than 7% in nonpregnant adults. When considering appropriate pharmacologic therapy, a major factor to consider is whether the patient is insulin deficient, insulin resistant, or both. Available since the late 1950s, metformin can trace its roots back to medieval Europe, where biguanides in the form of French lilac were used in diabetes treatment. Metformin is well tolerated, with the most common side effect being gastrointestinal (GI) complaints, such as diarrhea, nausea, abdominal discomfort, and a metallic taste.
The major benefits of metformin are that it usually does not lead to hypoglycemia when used as monotherapy. Dosing is typically twice daily; however, it can be dosed three times daily or once daily (extended release). Thiazolidinediones (TZDs) are agonists of peroxisome proliferator-activated receptor gamma (PPARI?) and primarily enhance sensitivity of muscle and fat, and mildly of the liver, to exogenous and endogenous insulin. Major side effects include weight gain, with an increase in subcutaneous adiposity, and fluid retention which typically manifests as peripheral edema, but heart failure has been shown to occur on occasion. Insulin secretagogues stimulate secretion of insulin from the pancreas, thereby decreasing hepatic glucose production and enhancing glucose uptake by muscles and fat. Glinides work in a manner similar to sulfonylureas; however, they have a more-rapid onset of action and a short duration of action, so they are a good option for patients with erratic timing of meals.
Alpha glucosidase inhibitors competitively block the enzyme alpha glucosidase in the brush borders of the small intestine, which delays absorption of carbohydrates (absorbed in the mid and distal portions of the small intestine instead). Incretin-based therapies can be used as injections (GLP-1 analogs) or as pills (DPP-4 inhibitors).
These medications should not be given to the individuals who have a history of medullary thyroid carcinomas or have multiple endocrine neoplasia syndrome type 2. Exenatide is a synthetic form of exendin 4, hormone found in the saliva of the Gila monster, that mimics glucagon-like peptide type 1 (GLP-1). Due to its delaying effects on gastric emptying, the major side effect is GI complaints such as nausea, vomiting, and diarrhea. Exenatide is currently also available as once a week injection, supplied as a kit containing the 2 mg of extended release exenatide.
Dipeptidyl peptidase 4 (DPP 4) is a cell membrane protein that rapidly degrades GLP-1 and glucose-dependent insulinotropic polypeptide. DPP 4 inhibitors act primarily on postprandial blood glucose levels, but reductions in fasting glycemia are also seen. Pramlintide is a synthetic form of amylin, a hormone secreted by beta-cells that acts to suppress glucagon secretion, slow gastric emptying, and suppress appetite through central pathways. As with exenatide, the major side effects are GI complaints, especially nausea, and hypoglycemia. Currently in the United States it is approved only as an adjunctive therapy with insulin, but it can be used both T1DM and T2DM. The SGLT-2 inhibitors are the newest group of medications approved for treatment of diabetes mellitus.
At this time canagliflozin and dapagliflozin are only medications in this class approved by the FDA for the treatment of type 2 diabetes.
The most common side effects of SGLT-inhibitors are vaginal yeast infections and urinary tract infections. Additional benefits are weight loss (two thirds of weight loss is because of loss of fat tissue and one third is because of loss of water) and drop in the blood pressure. These medications are not indicated in children, in patients with type 1 diabetes, patients with frequent ketones in their blood or urine, severe renal impairment.
Reprinted from Endocrine (Robard L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. The basal–bolus regimen involves combining a long-acting agent that is used once or twice daily and provides basal insulin needs and a rapid-acting agent for prandial coverage used with meals.
The insulin pump allows use of different basal insulin rates in different periods of the day and administration of the meal bolus as a single discrete bolus or as an extended bolus (square bolus) over a set period of time, which allows a better match between insulin delivery and glucose absorption from the meal in patients with abnormalities of gastric emptying.
In patients with gestational diabetes, insulin therapy is indicated when exercise and nutritional therapy are ineffective in controlling prandial and fasting blood glucose levels. Insulin sensitizers and incretin-based therapy should be used early in the course of the disease. Multiple daily doses of insulin providing basal, prandial, and supplemental insulin are a mainstay of insulin treatment. Rodbard HW, Blonde L, Braithwaite SS, et al; AACE Diabetes Mellitus Clinical Practice Guidelines Task Force. Chiasson JL, Josse RG, Gomis R, Hanefeld M, Karasik A, Laakso M; The STOP-NIDDM Trial Research Group. Original funding for this program was provided by Public Television stations, Corporation for Public Broadcasting, John D. Funding for FRONTLINE is provided through the support of PBS viewers and by the Corporation for Public Broadcasting. There are no RCTs of thyroxine replacement and cardiovascular events in subclinical hypothyroidism, and treatment should be individualized [3]. High triglycerides and low HDL cholesterol, partly related to decreased apoA1 synthesis, are characteristic. Beta-blockers have occasionally been associated with severe hypertriglyceridemia and acute pancreatitis.
Coronary heart disease events fell within 6 months of starting treatment, and from 12 months until the end of the trial showed a consistent 37% relative risk reduction. Effect of excessive weight gain with intensive therapy of type 1 diabetes on lipid levels and blood pressure: results from the DCCT. Cardiovascular risks and subclinical hypothyroidism: focus on lipids and new emerging risk factors.
Efficacy of cholesterol- lowering therapy in 18,686 people with diabetes in 14 randomised trials of statins: a meta-analysis. Comparison of 80 versus 10 mg of atorvastatin on occurrence of cardiovascular events after the first event (from the Treating to New Targets [TNT] trial). The second United Kingdom Heart and Renal Protection (UK-HARP-II) Study: a randomized controlled study of the bio- chemical safety and efficacy of adding ezetimibe to simvastatin as initial therapy among patients with CKD.
Effect of fenofibrate on amputation events in people with type 2 diabetes mellitus (FIELD study): a prespecified analysis of a randomised controlled trial. Marine omega-3 fatty acid intake: associations with cardiometabolic risk and response to weight loss intervention in the Look AHEAD (Action for Health in Diabetes) study. Effects of combination lipid therapy on coronary stenosis progression and clinical cardiovascular events in coronary disease patients with metabolic syndrome: a combined analysis of the Familial Atherosclerosis Treatment Study (FATS), the HDL-Atherosclerosis Treatment Study (HATS), and the Armed Forces Regression Study (AFREGS). Diet For Managing Gestational Diabetes Menu 2 Diet Type the signs and symptoms are ought on by elevated levels of the hormones estrogen or testosterone. Lifescan Inc has a range of blood Diet For Managing Gestational Diabetes Menu 2 Diet Type glucose meters which come under the banner of One Touch blood glucose meters. With Stage 2 hypertension systolic readings are 160 or higher and diastolic readings measure 100 or higher.
It is important to detect and diagnose gestational diabetes as this condition can lead to birth complications such as premature birth placental auption macrosomia and low blood sugar in the newborn. Good Breakfast Ideas For Gestational Diabetes there are different causes for this resistance to For more information on weight management exercise and choosing healthy foods for diabetes management Food Good Breakfast Ideas For Standard Treatment Guidelines Ghana. The Chronic Care Model and Diabetes Management in US Primary Care Settings: A Systematic Review. The objective of this study was to describe how researchers have applied CCM in US primary care settings to provide care for people who have diabetes and to describe outcomes of CCM implementation.

We found evidence that CCM approaches have been effective in managing diabetes in US primary care settings. Future research on integration of CCM into primary care settings for diabetes management should measure diabetes process indicators, such as self-efficacy for disease management and clinical decision making. The 6 components (4,5) are 1) health system — organization of health care (ie, providing leadership for securing resources and removing barriers to care), 2) self-management support (ie, facilitating skills-based learning and patient empowerment), 3) decision support (ie, providing guidance for implementing evidence-based care), 4) delivery system design (ie, coordinating care processes), 5) clinical information systems (ie, tracking progress through reporting outcomes to patients and providers), and 6) community resources and policies (ie, sustaining care by using community-based resources and public health policy).
Despite evidence indicating widespread application of CCM to multiple illnesses, such as diabetes, congestive heart failure, and asthma (6), no summative reviews have investigated how CCM has been applied in diabetes care.
Manuscript selection for systematic review on the Chronic Care Model (CCM) and diabetes management in US primary care settings.
We determined which of the 6 CCM components had been applied to each intervention and how the component(s) had been applied.
Study settings included academic-affiliated primary care practices (10,12–14,21,23), private practices (11,16,17,20), community health centers (15,24), safety net clinics (18,19,22), and a hospital (9). Engaging the governing boards of health care systems resulted in support for institutionalizing the CCM approach (18,22), which was associated with HbA1c reductions of at least 1% during 12 months (18,22) and improved foot care (22). Individual patient reports were also provided to health care teams for reviewing clinical trends (eg, HbA1c, blood pressure, lipids) and initiating clinical responses to laboratory results (eg, medication adjustments) (9,10,20,23). These systems helped patients and providers set self-management goals and review progress reports to determine whether patients met their predetermined goals (9,11,12,14,16–18,20,21,23,24). Collaborations between community leaders and physicians (11,16,17) and between pharmaceutical companies and health plans (20) led to support for PCP training sessions on how to use CCM for diabetes management.
Although the original CCM has been critiqued for not adequately meeting the needs of diverse patient populations with diabetes (7), our systematic review supports the idea that CCM-based interventions are generally effective for managing diabetes in US primary care settings. However, it is important to determine the combination of components that will likely produce optimal patient and provider outcomes. Changing staff roles and responsibilities to more efficiently treat diabetes was 1 strategy that produced clinical benefits. Future studies should examine the effects of continuing education for ADA Standards of Care and ICSI clinical guidelines on CCM decision support among providers. This type of culturally appropriate self-management support was associated with a greater number of participants who had an HbA1c measurement of less than 7% and a fewer number of participants who had an HbA1c measurement of greater than 10% (24). However, strategies for using community resources and developing policies were described in only 7 studies.
National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. A survey of leading chronic disease management programs: are they consistent with the literature? The Vermont Diabetes Information System (VDIS): study design and subject recruitment for a cluster randomized trial of a decision support system in a regional sample of primary care practices.
Implementing the chronic care model for improvements in diabetes care and education in a rural primary care practice. Diabetes nurse case manager and motivational interviewing for change (DYNAMIC): Study design and baseline characteristics in the chronic care model for type 2 diabetes. Effects of self-management support on structure, process, and outcomes among vulnerable patients with diabetes: a three-arm practical clinical trial. Caring for uninsured patients with diabetes: designing and evaluating a novel chronic care model for diabetes care.
Improved clinical outcomes for fee-for-service physician practices participating in a diabetes care collaborative. Improving quality of care for urban older people with diabetes mellitus and cardiovascular disease. Establishing diabetes self-management in a community health center serving low-income Latinos.
Enough of the problem: a review of time for health care transition solutions for young adults with a chronic illness. Using exploratory focus groups to inform the development of targeted COPD self-management education DVDs for rural patients.
The system also generates population reports so that physicians can view the progress of their patients with diabetes. Each group consisted of 5 to 10 participants who learned goal-setting strategies based on the empowerment approach, problem-solving skills, and behavioral change strategies. It helps patients and physicians assess the effect of food, medications, stress, and activity on blood glucose levels. Those who use basal–bolus regimens should self-monitor before each meal and at bedtime (four times daily). HbA1c is influenced by rapid red blood cell turnover and blood loss; therefore, anemia and hemoglobinopathies can result in inaccurate values.
Treatment options can be divided into insulin sensitizers, secretagogues, alpha glucosidase inhibitors, incretins, pramlintide, SGLT-2 inhibitors, insulin and insulin analogs.
Its primary mechanism of action is suppression of hepatic glucose output, but it also enhances insulin sensitivity of muscle and fat.
It can lead to weight loss, and it has been shown to decrease plasma triglycerides concentration (10%-20%). Main adverse effects include weight gain (about 2 kg upon initiation) and hypoglycemia.
They have a lower risk of hypoglycemia than sulfonylureas; they have a similar to lower risk of weight gain with initiation of therapy. This is because increased incidence of the thyroid C-cell tumors have been observed with these medications in the mice and rats. GLP-1 is produced in the small intestine and stimulates insulin secretion and inhibits glucagon secretion and hepatic glucose production in a glucose-dependent manner. Hypoglycemia does not occur when exenatide is used as monotherapy or with metformin, but it does occur when exenatide is combined with a sulfonylurea. If a dose is missed, it should be administered as soon as noticed provided that next dose is scheduled 3 or more days later.
Suppression of DPP 4 leads to higher levels of insulin secretion and suppression of glucagon secretion in a glucose-dependent manner. Patients can see up to a 50% reduction in their insulin requirements with the addition of pramlintide. SGLT-2 is a protein acting as sodium-glucose co-transporter in the kidney’s proximal tubules whose main function is reabsorption of the filtered glucose from the urine back into the circulation. Patients should be advised to expect glucose to be in the urine and if they are using urine glucose strips that they will have a positive reading most of the time. There is no upper limit in dosing for therapeutic effect, so it can be used to bring any HbA1c down to near normal levels. Studies have shown that episodes where the patient required assistance from another due to the hypoglycemia occurred between 1 and 3 per 100,000 patient-years.
When initiating therapy with glargine or detemir as the basal insulin, traditionally 50% of the total daily dose is given as basal insulin and the rest as prandial insulin divided equally before meals. Self-monitoring of blood glucose in patients with type 2 diabetes who are not using insulin: a systematic review. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The role of self-monitoring of blood glucose in the care of people with diabetes: report of a global consensus conference. Meal-related structured self-monitoring of blood glucose: effect on diabetes control in nona€“insulin-treated type 2 diabetic patients. Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomized trial [published online ahead of print June 25, 2007]. Management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy.
Secondary prevention of macrovascular events in patients with type 2 diabetes in the PROactive Study (PROspective pioglitAzone Clinical Trial In macroVascular Events): a randomised controlled trial. Surprisingly, patients with renal failure tend to have total and LDL cholesterol levels that are lower than patients without renal failure.
Microalbuminuric patients require statins, but there is nothing to guide us in the management of those with isolated retinopathy or neuropathy. The safety and efficacy of achieving very low low-density lipoprotein with intensive statin therapy: a PROVE-IT TIMI 22 substudy.
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Organizational leaders in health care systems initiated system-level reorganizations that improved the coordination of diabetes care. Comprehensive models of care, such as the original Chronic Care Model (CCM) (4,5), advocate for evidence-based health care system changes that meet the needs of growing numbers of people who have chronic disease.
The objective of this study was to determine how CCM has been applied in US primary care settings to provide care for people who have diabetes and also to describe outcomes of CCM implementation.
We excluded studies that took place outside of the United States, reported secondary data, or represented an editorial, commentary, or a literature review. We then qualitatively assessed the outcomes of each component that was applied in each study.
Two studies (19,20) revised the health care system to redefine health care team roles (eg, nurses, instead of PCPs, became responsible for conducting foot examinations). Training PCPs on evidence-based guidelines and methods for implementing CCM resulted in improved PCP adherence to clinical guidelines, including the American Diabetes Association (ADA) Standards of Care (10–12,14,16,17) and Institute for Clinical Systems Improvement (ICSI) Clinical Guidelines for Hypertension, Diabetes, and Hyperlipidemia (18). Hospital and PCP collaborations within the community, such as partnerships between the University of Pittsburgh Medical Center and western Pennsylvania community hospitals and PCP offices (12), provided greater access to funding, information systems, and administrative support for CCM implementation (11,12,16,17). Our review suggested that incorporating multiple components together in the same intervention can help facilitate better CCM implementation (eg, using the decision-support component to train providers on guidelines such as the ADA Standards of Care and using the delivery system design component to remodel the care delivery process to provide self-management support through DSME in PCP offices). Reorganized care can also support better training programs for patients to help them self-manage diabetes. It is important to determine whether provider training delivered through telecommunication and distance learning technologies can provide ample decision-support training to PCPs. DSME fostered learning about proactive diabetes self-care practices and self-management skills. Other culturally tailored non-CCM interventions (29) have demonstrated larger absolute reductions in HbA1c than nontailored interventions. Many studies (9,10,12,14,18,20, 21,23,24) used disease registries and electronic medical records to establish patient goals, monitor patient progress, and determine lapses in patient care. A meta-analysis (27) also found that few studies addressed the community resources and policies component of CCM.
Initially some patients require more frequent monitoring, including both preprandial and postprandial readings. The frequency of testing depends on the clinical situation and the patient’s treatment regimen.
Physicians should consider these conditions when there is a discrepancy between HbA1c and SMBG values.
It affects primarily fasting glycemia; however, some decreases in postprandial glucose concentrations, especially after the midday meal, can also be seen. Metformin causes a small increase in basal and postprandial lactate concentrations in the blood, leading to potential to produce very rare but life-threatening lactic acidosis (<1 in 100,000). The hypoglycemia episodes can be significant (leading to need for assistance, coma, or seizure) and are seen more often in the elderly. GI complaints, such as bloating, abdominal cramps, flatulence, and diarrhea are the main side effects. Patients must be warned about this risk and be advised to stop taking these medications and seek medical evaluation if acute abdominal pain develops. So far, there is no increased risk in humans but the above groups of individuals should not use these medications. Other benefits of insulin include its effects on reducing triglycerides levels and increasing HDL. Meal dose of insulin can be fixed, but it is better to determine the dose based on carbohydrate content of the meal. Dyslipidemia itself may impair renal function, for example abnormal LDL may increase angiotensin II and upregulate the AT1 receptor, and increased chylomicron remnants may cause vasoconstriction. Other non-insulin agents are either lipid-neutral or have generally beneficial but minor effects that are not clinically significant compared with formal lipid-modifying treatment. These are rapidly expanding groups of patients, comprising possibly 5–10% of type 1 patients, for whom there is no evidence for the routine use of statin treatment. Unusually, epidemiological and clinical data agree on the log-linear relationship between LDL lowering and reduction in cardiovascular events, with no discernible plateau or J-shaped curve. This is in sharp contrast to the messages consumers frequently hear such as those promoting the benefits of low carbohydrate diets. Disease registries and electronic medical records were used to establish patient-centered goals, monitor patient progress, and identify lapses in care.

CCM was developed (4,5) to provide patients with self-management skills and tracking systems.
These changes improved the quality of diabetes care and rates of eye examinations, and were associated with improved HbA1c levels, blood pressure, cholesterol, and weight (19,20). Follow-up telephone calls allowed clinicians to monitor patient progress toward meeting diabetes-management goals that were set during individual office visits (10,15,18,21). For example, the Medical Archival Retrieval System (MARS) stored data and generated robust reports for providers on laboratory results, visits, medications, health insurance, comorbid conditions, medical procedures, and billing charges (12). Future system-level CCM reorganizations should create clear access points for providers to intervene with patients who are at risk for diabetes complications.
Another area worth investigating is whether the longitudinal use of decision support in different primary care practice settings (eg, private practices, community health centers, hospitals) improves patient outcomes. When ADA-accredited DSME occurs in primary care settings, PCPs are able to provide patients with personalized access to CDEs, who are likely funded through third-party health insurers (12). Assimilating clinical information systems into user-friendly, portable digital technologies (ie, smartphones, iPads) may enable patients and providers to view and respond to laboratory results more regularly.
More public-private partnerships need to be developed between providers and community organizations to address barriers to care and explore culturally appropriate community-based services (eg, cooking classes, exercise programs, nutrition counseling, self-monitoring assistance) for underserved populations and neighborhoods.
Future studies should use the multiple-rater approach for study selection and data extraction as outlined by the Centre for Reviews and Dissemination systematic review guidelines (8). Far less emphasis has been placed on measuring the process outcomes of CCM that help lead to functional and clinical improvements. Patients with gestational diabetes who are taking insulin should monitor their blood glucose three or more times daily. The ADA recommends that patients with stable glycemic control be tested at least twice a year. The PROactive trial (PROspective pioglitAzone Clinical Trial In macroVascular Events) showed that compared with placebo, pioglitazone does not increase cardiovascular risks. The benefits include a 25% reduction in microvascular complications with or without insulin found by a UKPDS trial.
It primarily decreases postprandial blood glucose levels; however, a moderate reduction in fasting blood glucose levels can also be seen. This requires learning carbohydrate counting and knowing the dose of insulin required to cover counted carbohydrates. Naturally, angiotensin blockade and intensive lipid-lowering treatment are both required in patients with any degree of renal impairment or proteinuria, but lipid lowering does not reduce cardiovascular events once renal impairment has progressed to ESRD, presumably because advanced calcific coronary artery and valvular heart disease is not helped by statin treatment (see below). A meta-analysis of 1500 type 1 patients in RCTs between 1994 and 2005 found that the cardiovascular benefit of statins was similar to those with type 2 diabetes. In contrast to type 1 diabetics these patients generally do not develop ketoacidosis when sweets dried fruits cake candy fried foods alcohol nuts Jaggery sweetened juices Fats cereals pulses Diabetes control means keeping blood sugar Diet For Maaging Gestational Diabetes Menu 2 Diet Type levels as close to target as possible.
Primary care physicians (PCPs) were trained to deliver evidence-based care, and PCP office–based diabetes self-management education improved patient outcomes.
The model represents a well-rounded approach to restructuring medical care through partnerships between health systems and communities. First we reviewed the abstracts; 76 manuscripts met inclusion criteria, and 79 were excluded. Health system reorganization also helped to establish diabetes self-management training programs (12,16,17) that identified and intervened with patients at risk for developing complications (17) and improved clinical and behavioral outcomes (12,16). For example, Schillinger et al (15) found that weekly automated (prerecorded) tailored telephone calls from nurses were associated with improvements in interpersonal processes of care, physical activity and function, and slightly better metabolic outcomes (eg, HbA1c, blood pressure, cholesterol).
One study (12) even noted that providing DSME programs in PCP offices instead of hospital settings resulted in a 2- to 3-fold increase in the number of patients reached with diabetes education. MARS also served as a tool for administrators to gauge fiscal outcomes associated with placing CDEs in primary care sites to deliver DSME (12). Offering DSME in primary care settings, rather than solely hospital settings, enhances the reach of such programs in a more intimate, socially supportive venue. Cultural factors (eg, food preparation, views of illness) should be considered when designing, implementing, and evaluating DSME for these underserved groups (31). For older populations of chronic disease patients (the age group sampled in most of the reviewed studies), training programs on the use of digital technologies for diabetes self-management may reduce the anxiety and barriers to access that may currently exist (23,34). Other models have sought to improve the community resources and policies component of the CCM.
We did not conduct a meta-analysis because we did not have access to primary data, and the variability in study design did not allow us to pool data. Process outcomes (eg, self-efficacy for disease management and clinical decision making, perceived social support, knowledge of diabetes self-care practices) are all indicators that need to be assessed. Patients should be educated on how to use real-time blood glucose values to adjust their food intake and medical therapy. Table 1, adapted from the ADA’s 2014 Position Statement on diabetes management, demonstrates that correlation between HbA1c and average blood glucose values. TZDs have been shown to have an association with an increased risk of fractures, particularly in women. Its effects and side effects are similar to those of exenatide but it may be slightly more powerful in its actions. Patients with T2DM often require insulin, which can be combined with oral hypoglycemic agents.
Additional funding is provided by Park Foundation, The John and Helen Glessner Family Trust, Ford Foundation, Wyncote Foundation, and the FRONTLINE Journalism Fund with major support from Jon and Jo Ann Hagler on behalf of the Jon L.
There is still interest in thyromimetics in the treatment of dyslipidemia; the hepatic-specific eprotirome improves the lipid profile of statin-treated patients, though it slightly reduces HDL. Lyles et al (23) found that the use of a secure e-mail connection and a smartphone to upload glucose readings via a wireless Bluetooth device allowed some participants to feel better connected with their nurse case manager.
For example, the Rockwood Clinic Foundation revised its mission statement to include fundraising for research and development in new methods of chronic care delivery, which has resulted in increased funding for training materials, glucometers, blood pressure monitors, and laboratories (20). Future DSME for primary care patients should continue to cover the ADA content areas (28) for diabetes self-management, and strategies for delivering DSME should be evaluated by assessing the comparative effectiveness of group- and individual-level DSME approaches.
It is also noteworthy that none of the reviewed studies addressed the needs of pediatric patients diagnosed with either type 1 or type 2 diabetes.
Involving patients in exploratory focus groups to inform the development of assistive technologies can customize educational technology and address usability concerns among unique patient populations (35). The Innovative Care for Chronic Conditions (ICCC) model espoused by the World Health Organization (33,37) is comparable to the Expanded Chronic Care Model proposed by Barr and colleagues (7); it introduces prevention efforts, social determinants of health, and enhanced community participation as core components of chronic disease care. Future research could include a meta-analysis of data (27) from randomized controlled trials to evaluate the methodological quality of quantitative studies that have tested the effectiveness of CCM for managing diabetes. These assessments could enable health care administrators and professionals to determine how CCM could become further integrated into primary health care initiatives in diabetes. However, some participants found this communication system to be unstructured and preferred regular interaction (eg, face-to-face) with their nurse case manager; some participants found the smartphones to be frustrating because of technical difficulties associated with these unfamiliar technologies (23). Diabetes is becoming more common in children and adolescents (32); Rapley and Davidson (33) have advocated for the adoption of CCM programs aimed at adolescent patients with diabetes to help bridge the gap between pediatric and adult care. Future studies on diabetes self-management support within the broader CCM framework should attempt to refine the use of information and communications technologies to empower, engage, and educate patients (36). Patients who received DSME showed gains in all areas of empowerment: psychological, readiness to change, and goal setting. Pioglitazone use leads to lowering triglycerides, increasing high-density lipoprotein cholesterol (HDL), and increasing the low-density lipoprotein cholesterol (LDL) particle size.
There are no RCTs of these ultra-low LDL levels in either the general type 2 population or those with stable coronary disease, but they are attainable, do not seem to be associated with an increased risk of side-effects of the high doses of statins needed to achieve these levels (e.g. Future studies should investigate how different derivations of CCM components contribute to changes in diabetes care within primary care settings. This study provides support for CDEs to receive financial reimbursement for services.Piatt et al (11)Study design (no. The authors and the sponsors accept no responsibility for clinical use or misuse of this score.
Diabetes Mellitus Patient Education Powerpoint this information overestimates because the curve is lenient.
A 2- to 3-fold greater proportion of patients reached when DSME was available at primary care practices compared to hospital-based programs. Having DSME programs at primary care practices resulted in improvements in HbA1c levels and better communication and use of resources among PCPs and CDEs. Prevalence of chronic kidney disease in patients with type 2 diabetes in Spain: PERCEDIME2 study.
Patients reported comfort with location and ease of approaching CDEs.Smith et al (13)Study design (no.
Prevalence and risk factors for microalbuminuria in a referred cohort of type II diabetic patients: A global perspective. Baseline survey scores of the patient population showed a high level of depression and a slightly positive effect of diabetes on self-confidence and that diabetes had most negative effect on enjoyment of vacations and on enjoyment of food and drinks.Schillinger et al (15)Study design (no.
The burden of chronic kidney disease in Australian patients with type 2 diabetes (the NEFRON study). ATSM group was less likely than GMV and usual care groups to report that diabetes prevented them from carrying out daily activities.
No significant changes in HbA1c were found in ATSM, GMV, and usual-care groups.Piatt et al (16)Study design (no. KDOQI clinical practice guidelines and clinical practice recommendations for diabetes and chronic kidney disease. Having higher baseline HbA1c values, older age, and being in the CCM group were each associated with improved glycemic control.Stroebel et al (18)Study design (no. Analisis epidemiologico del incremento de insuficiencia renal asociada a diabetes mellitus tipo 2. Baseline characteristics of patients with chronic kidney disease stage 3 and stage 4 in Spain: The MERENA observational cohort study. Patients felt more aware of and engaged in their own care through monitoring their glucose, sharing their glucose readings with the nurse case manager, and communicating with the nurse case manager via the secure e-mail system; uploading glucose readings and receiving feedback was easy. However, half of the patients found the use of smartphones to be frustrating (unfamiliar technology). Using the Nintendo Wii to access electronic medical records was not useful (unfamiliar technology).Liebman et al (24)Study design (no.
Documento de consenso 2012 de diez sociedades cientificas sobre la enfermedad renal cronica [Accessed: Oct 4, 2013].
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. 2007 guidelines for the management of arterial hypertension: The Task Force for the Management of Arterial Hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). Albuminuria and kidney function independently predict cardiovascular and renal outcomes in diabetes.
The nephropathy of non-insulin-dependent diabetes: Predictors of outcome relative to diverse patterns of renal injury.
Development and progression of nephropathy in type 2 diabetes: The United Kingdom Prospective Diabetes Study (UKPDS 64). Chronic kidney disease: National clinical guideline for early identification and management in adults in primary and secondary care.
Macroalbuminuria is a better risk marker than low estimated GFR to identify individuals at risk for accelerated GFR loss in population screening. The burden of cardiovascular risk in chronic kidney disease and dialysis patients (cardiorenal syndrome type 4). Treatment and blood pressure control in 47,964 people with diabetes and hypertension: A systematic review of observational studies.
Abnormalities in ambulatory blood pressure monitoring in hypertensive patients with diabetes. Study of Heart and Renal Protection (SHARP): Randomized trial to assess the effects of lowering low-density lipoprotein cholesterol among 9,438 patients with chronic kidney disease. Effects of azotemia on results of the boronate-agarose affinity and ion-exchange methods for glycated hemoglobin. Kinetics of glycosylated haemoglobin in uraemia determined on ion-exchange and affinity chromatography: No increase in the rate of glycosylation. Glycaemic control in type 2 diabetic patients on chronic haemodialysis: Use of a continuous glucose monitoring system.
The relationship between glycemic control and morbidity and mortality for diabetics on dialysis.
Decreased insulin requirement in relation to GFR in nephropathic type 1 and insulin-treated type 2 diabetic patients. Use of insulin and oral hypoglycemic medications in patients with diabetes mellitus and advanced kidney disease. Effect of intensive glucose lowering treatment on all cause mortality, cardiovascular death, and microvascular events in type 2 diabetes: Meta-analysis of randomised controlled trials.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33).
Effects of a fixed combination of perindopril and indapamide on macrovascular and microvascular outcomes in patients with type 2 diabetes mellitus (the ADVANCE trial): A randomised controlled trial.

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