XI. STRATEGIES FOR IMPROVING DIABETES CARE D iabetes is a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Diabetes care is complex and requires that many issues, beyond glycemic control, be addressed. A large body of evidence exists that supports a range of interventions to improve diabetes outcomes. These standards of care are intended to provide clinicians, patients, researchers, payors, and other interested individuals with the components of diabetes care, treatment goals, and tools to evaluate the quality of care. While individual preferences, comorbidities, and other patient factors may require modification of goals, targets that are desirable for most patients with diabetes are provided. These standards are not intended to preclude more extensive evaluation and management of the patient by other specialists as needed. For more detailed information, refer to Bode (Ed.): Medical Management of Type 1 Diabetes (1), Burant (Ed): Medical Management of Type 2 Diabetes (2), and Klingensmith (Ed): Intensive Diabetes Management (3). The recommendations included are diagnostic and therapeutic actions that are known or believed to favorably affect health outcomes of patients with diabetes. A grading system (Table 1), developed by the American Diabetes Association (ADA) and modeled after existing methods, was utilized to clarify and codify the evidence that forms the basis for the recommendations. The level of evidence that supports each recommendation is listed after each recommendation using the letters A, B, C, or E.

Standards of Medical Care in Diabetes

admission. This proportion could already be greater in some parts of the country and may increase if referrals of cases of self-poisoning increase faster than the facilities for their assessment and management. The provision of social work and psychiatric expertise in casualty departments may be one means of preventing unnecessary medical admissions without risk to the patients. Dr Blake's and Dr Bramble's figures do not demonstrate, however, that any advantage would attach to medical teams taking over assessment from psychiatrists except that, by implication, assessments would be completed sooner by staff working on the ward full time. What the figures actually suggest is that if assessment of overdoses were left to house doctors there would be an increase in admissions to psychiatric units (by 19°U), outpatients (by 5O°'), and referrals to social services (by 140o). So for house doctors to assess overdoses would provide no economy for the psychiatric or social services. The study does not tell us what the consequences would have been for the six patients who the psychiatrists would have admitted but to whom the house doctors would have offered outpatient appointments. E J SALTER

Vitamin D deficiency.

Appetite assessment: simple appetite questionnaire predicts weight loss in community-dwelling adults and nursing home residents

At present, diabetic kidney disease affects about 15-25% of type 1 and 30-40% of type 2 diabetic patients. Several decades of extensive research has elucidated various pathways to be implicated in the development of diabetic kidney disease. This review focuses on the metabolic factors beyond blood glucose that are involved in the pathogenesis of diabetic kidney disease, i.e., advanced glycation end-products and the aldose reductase system. Furthermore, the contribution of hemodynamic factors, the renin-angiotensin system, the endothelin system, and the nitric oxide system, as well as the prominent role of the intracellular signaling molecule protein kinase C are discussed. Finally, the respective roles of TGF-beta, GH and IGFs, vascular endothelial growth factor, and platelet-derived growth factor are covered. The complex interplay between these different pathways will be highlighted. A brief introduction to each system and description of its expression in the normal kidney is followed by in vitro, experimental, and clinical evidence addressing the role of the system in diabetic kidney disease. Finally, well-known and potential therapeutic strategies targeting each system are discussed, ending with an overall conclusion.

From hyperglycemia to diabetic kidney disease: the role of metabolic, hemodynamic, intracellular factors and growth factors/cytokines.

Orlistat, an anti-obesity drug, is a potent and specific inhibitor of intestinal lipases In light of the recent US FDA approval of the over-the-counter sale of orlistat (60 mg three times daily), clinicians need to be aware that its use may be associated with less well known, but sometimes clinically relevant, adverse effects More specifically, the use of orlistat has been associated with several mild-to-moderate gastrointestinal adverse effects, such as oily stools, diarrhoea, abdominal pain and faecal spotting A few cases of serious hepatic adverse effects (cholelithiasis, cholostatic hepatitis and subacute liver failure) have been reported However, the effects of orlistat on non-alcoholic fatty liver disease are beneficial Orlistat-induced weight loss seems to have beneficial effects on blood pressure No effect has been observed on calcium, phosphorus, magnesium, iron, copper or zinc balance or on bone biomarkers Interestingly, the use of orlistat has been associated with rare cases of acute kidney injury, possibly due to the increased fat malabsorption resulting from the inhibition of pancreatic and gastric lipase by orlistat, leading to the formation of soaps with calcium and resulting in increased free oxalate absorption and enteric hyperoxaluria Orlistat has a beneficial effect on carbohydrate metabolism No significant effect on cancer risk has been reported with orlistat Orlistat interferes with the absorption of many drugs (such as warfarin, amiodarone, ciclosporin and thyroxine as well as fat-soluble vitamins), affecting their bioavailability and effectiveness This review considers orlistat-related adverse effects and drug interactions The clinical relevance and pathogenesis of these effects is also discussed

Orlistat-associated adverse effects and drug interactions: a critical review.

Studies have found that diabetes and thyroid disorders tend to coexist in patients. Both conditions involve a dysfunction of the endocrine system. Thyroid disorders can have a major impact on glucose control, and untreated thyroid disorders affect the management of diabetes in patients. Consequently, a systematic approach to thyroid testing in patients with diabetes is recommended.

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Thyroid disorders and diabetes mellitus.

Gestational diabetes mellitus (GDM) is a complication of pregnancy that is characterized by impaired glucose tolerance with onset or first recognition during pregnancy. The reported prevalence of GDM varies between 0.6% and 20% of pregnancies depending on screening method, gestational age and the population studied. GDM is characterized by pancreatic β-cell function that is insufficient to meet the body’s insulin needs. Available evidence suggests that β-cell defects in GDM result from the same spectrum of causes that underline hyperglycemia in general, including autoimmune disease, monogenic causes and insulin resistance. Adipokines are proteins secreted from the adipocytes and are believed to have a metabolic influence. Our review suggests that, in GDM, various adipokines, mainly leptin and adiponectin, are dysregulated. These two adipokines might have both prognostic and pathophysiological significance in this disease.

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The role of adipokines in gestational diabetes mellitus.

Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month of Ramadan

Patients with Type 1 diabetes (T1D) are normally exempt from the Ramadan fast; however, some patients insist on following the fast, often without the approval of their physicians. The aim of this study is to provide patients with T1D, who insist on fasting, with the most appropriate insulin regimen during the month of Ramadan. Seventeen patients with T1D who insisted on fasting were studied. Prior to Ramadan, the intermediate insulin was changed to ultralente in all patients. The total dose of insulin given to fasting patients by the end of Ramadan (45.7 +/- 14.4 U/day) was less than the total dose of insulin given before fasting (52.8 +/- 13.1 U/day) p<0.05. The ultralente and regular insulin constituted 70 and 30%, respectively, of the total insulin dose by the end of Ramadan, divided equally between Suhur (before sunrise) and Iftar (after sunset). There was no change in the glycosylated hemoglobin before and after fasting. Patients were instructed to break their fast after any episode of hypoglycemia. There were no severe daytime hypoglycemia episodes. We recommend that patients with T1D wishing to fast be switched to long acting insulin such as ultralente. The total insulin dose should consist of around 85% of their initial insulin dose and it should be composed of around 70% ultralente and 30% rapid insulin, divided equally between Suhur and Iftar.

Insulin therapy during Ramadan fast for Type 1 diabetes patients.

Transforming growth factor ss (TGF-ss) is an immunosuppressor. It plays a role in regulating cell proliferation, and deletion of its gene in transgenic mice leads to an autoimmune-like disorder. A role of this cytokine has been proposed in the pathogenesis of type 1 diabetes and probably type 2 diabetes. Previous studies had shown an elevated serum level in type 2 diabetes and a reduced serum level in type 1 diabetes; however, these studies did not address the onset of the alterations of TGF-ss with regard to the duration of diabetes. In this study, we compared the levels of TGF-ss in the serum of groups of patients with type 1 and type 2 diabetes mellitus divided according to the duration of their disease. Twenty-six normoalbuminuric patients with type 1 diabetes and 25 normoalbuminuric patients with type 2 diabetes were divided into three groups according to the onset of their diabetes and were compared with 27 and 15 age-matched normal subjects, respectively. We conclude that in normoalbuminuric patients serum TGF-ss levels increased at the onset of type 2 diabetes and remained elevated throughout the disease; they did not change at the onset of type1 diabetes, however, they started to decrease around 2 yr after the onset of the disease.

/pdf/alterations-in-plasma-transforming-growth-factor-b-in-2wppdoms1p.pdf

Mira S. Zantout

Papers

Thyroid disorders and diabetes mellitus.

The role of adipokines in gestational diabetes mellitus.

Suggested insulin regimens for patients with type 1 diabetes mellitus who wish to fast during the month of Ramadan

Insulin therapy during Ramadan fast for Type 1 diabetes patients.

Alterations in Plasma Transforming Growth Factor β in Normoalbuminuric Type 1 and Type 2 Diabetic Patients