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Monitoring blood glucose and obesity in type 2 diabetes in primary care
Linköping University, Department of Medicine and Health Sciences, General Practice. Linköping University, Faculty of Health Sciences.
2009 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Type 2 diabetes is a common chronic disease worldwide. An important part of the treatment is monitoring and treating the elevated levels of blood glucose. But there is also a need for monitoringother risk factors that confer an increased risk for vascular complications. This thesis is based on four studies that explore different aspectsof monitoring blood glucose and obesity in patients with type 2 diabetes in primary care.

Methods: To examine the cost and effect on glycaemic control of patients performing self-monitoring of blood glucose (SMBG) an observationalstudy was performed in the county of Östergötland and Jönköping 2003-2004. The study included all known patients with type 2 diabetes at 18 primary health care centres (PHCC), excluding patients in nursery homes.

A structured observational intervention study of 98 patients with type 2 diabetes living at 17 nursery homes were done with monitoringof hypoglycaemic episodes followed by a controlled withdrawal of diabetes medication in patients with HbA1c ≤ 6.0 %.

Baseline data from the cohort study; Cardiovascularrisk in type 2 diabetes – a prospectivestudy in primary care (CARDIPP), was analysed for correlation analyses between anthropometric status and early cardiovascular organ damage, measured by pulse wave velocity (PWV) and left ventricular mass index (LVMI).

Results: When comparing users of SMBG to non-users, there was no association between improvedglycaemic control and use of SMBG. A plasma glucose profile for three consecutive days of the patients at nursery homes, indentified 31 episodes of plasma glucose levels≤ 4.4 mmol/l. A withdrawal of insulin and oral antiglycaemic medicine was performed, which after 3 months follow up was successful in 24 (75 %) of the patients.

The mean annual cost per PHCC for visits to general practitioner and nurse, insulin, SMBG and oral antiglycaemic agents was586 € (SD 435) per patient. There was no correlationbetween costs and glycaemic control at PHCC level.

In the CARDIPP study, both increased sagittalabdominal diameter and increased waist circumference were, independently of sex, age, blood pressure and HbA1c, associated to increasedPWV and LVMI.

Conclusions: Use of SMBG in primary care confers a substantialpart of the treatment costs, but is not associated with improved glycaemic control. Systematic use of SMBG for patients not treated with insulin should not be recommended. At nursery homes, patients with type 2 diabetes are at risk for harmful hypoglycaemia and may benefit from a more frequent control of plasma glucose and a less strict glycaemic control.

Increased abdominal obesity measured with either sagittal abdominal diameter or waist circumference is associated with early cardiovascularorgan damage. In addition to analyses of blood glucose, blood pressure and lipids, the monitoring of abdominal obesity is a feasible risk factor assessment tool, that provides further information about cardiovascular risk that goes beyond that of traditional risk factors.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press , 2009. , 55 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1140
Keyword [en]
Diabetes, primary care
National Category
Family Medicine
Identifiers
URN: urn:nbn:se:liu:diva-20049ISBN: 978-91-7393-573-9 (print)OAI: oai:DiVA.org:liu-20049DiVA: diva2:232815
Public defence
2009-09-18, Originalet, Qulturumhuset, Länssjukhuset Ryhov, Jönköping, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2009-09-15 Created: 2009-08-26 Last updated: 2010-03-02Bibliographically approved
List of papers
1. Self-monitoring of blood glucose and glycaemic control in type 2 diabetes
Open this publication in new window or tab >>Self-monitoring of blood glucose and glycaemic control in type 2 diabetes
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2007 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 25, no 3, 140-146 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVE: Previous studies have shown inconsistent results with regard to whether or not self-monitoring of blood glucose (SMBG) is related to better glycaemic control in type 2 diabetes. The aim of this study was to explore the use of SMBG and its association with glycaemic control in patients with type 2 diabetes in primary care.

DESIGN: A cross-sectional observational study was conducted in 2003 at 18 primary health care centres in Sweden, in which all known patients with diabetes were surveyed. The study included 6495 patients with type 2 diabetes. A sample of 896 patients was selected for further exploration of data from medical records. A telephone interview was performed with all patients in this group using SMBG (533 patients).

RESULTS: There were no differences in HbA1c levels between users (6.9%) and non-users (6.8%) of SMBG in patients treated with insulin or in patients treated with oral agents (6.3% in both groups). In patients treated with diet only, users of SMBG had higher levels of HbA1c compared with non-users (5.5% vs. 5.4%, p =0.002). Comparing medical records between users and non-users of SMBG showed no differences in diabetes-related complications in any treatment category group.

CONCLUSION: The use of SMBG was not associated with improved glycaemic control in any therapy category of patients with type 2 diabetes in primary care. The absence of difference in glycaemic control between users and non-users of SMBG could not be explained by differences in comorbidity between users and non-users of SMBG.

Keyword
Family practice, glycaemic control, primary care, self-monitoring, type 2 diabetes
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20577 (URN)10.1080/02813430701267413 (DOI)17846931 (PubMedID)
Available from: 2009-09-15 Created: 2009-09-15 Last updated: 2017-12-13Bibliographically approved
2. Can diabetes medication be reduced in elderly patients?: An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control
Open this publication in new window or tab >>Can diabetes medication be reduced in elderly patients?: An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control
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2008 (English)In: Diabetes Research and Clinical Practice, ISSN 0168-8227, E-ISSN 1872-8227, Vol. 82, no 2, 197-202 p.Article in journal (Refereed) Published
Abstract [en]

Aim: To explore the feasibility of withdrawal of diabetes medication in elderly patients with HbA1c £ 6.0%.

Methods: HbA1c was measured in 98 patients with known diabetes in 17 nursing homes in Sweden. 32 subjects with HbA1c £ 6.0% participated in the drug withdrawal study. After measuring plasma glucose on three consecutive days, diabetes drugs were reduced, i.e. complete withdrawal of oral anti-diabetic drugs (OADs), complete insulin withdrawal when doses were £ 20 units/day and reduced by half in patients on more than 20 units/day.

Results: We identified 31 episodes of plasma glucose £ 4.4 mmol/l, most of them nocturnal (n=17). Mean HbA1c was 5.2 % ± 0.4 compared to 7.1 % ± 1.6 in the non-intervention group. Three months after the diabetes drug discontinuation, 24 patients (75%) remained in the intervention group and mean HbA1c was then 5.8 %. ± 0.9. Six months after baseline investigation mean HbA1c in the intervention group was 5.8 % ± 1.1 compared with 6.6 % ± 1.4 in the non-intervention group.

Conclusions: Hypoglycaemic events are common among elderly patients with type 2 diabetes. The withdrawal of diabetes medication in elderly with tight glycaemic control is safe and may decrease the risk for hypoglycaemia.

Keyword
Diabetes, Drug therapy, Hypoglycaemia
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-16312 (URN)10.1016/j.diabres.2008.08.014 (DOI)
Note

Original Publication: Peter Sjöblom, Anders Tengblad, Ulla-Britt Löfgren, Christina Lannering, Niklas Anderberg, Ulf Rosenqvist, Sigvard Mölstad and Carl J Östgren, Can diabetes medication be reduced in elderly patients?: An observational study of diabetes drug withdrawal in nursing home patients with tight glycaemic control, 2008, Diabetes Research and Clinical Practice, (82), 2, 197-202. http://dx.doi.org/10.1016/j.diabres.2008.08.014 Copyright: Elsevier Science B.V., Amsterdam. http://www.elsevier.com/

Available from: 2009-01-14 Created: 2009-01-14 Last updated: 2017-12-14Bibliographically approved
3. Health care costs and glycaemic control in type 2 diabetesin Swedish primary care
Open this publication in new window or tab >>Health care costs and glycaemic control in type 2 diabetesin Swedish primary care
(English)Manuscript (preprint) (Other academic)
Abstract [en]

Aims: The aim of this study was to explore the annual health care cost for patients with type 2diabetes and its association with glycaemic control in primary care.

Methods: All patients with diabetes at 18 primary health care centres (PHCC) in Swedenwere surveyed in this cross sectional observational study. From a total population of 208 490,we identified 6495 patients with type 2 diabetes and information were retrieved from medicalrecords on resource utilisation, clinical data, treatment category and use of self monitoring ofblood glucose (SMBG). Data on costs for pharmaceuticals and test strips for SMBG wereimported from the general ledger.

Results: The mean annual health care cost per patient with type 2 diabetes, was 586 Euro (SD435). Factors associated with high costs at individual level were; type of treatment (r=0.67),number of GP visits (r=0.61), use of SMBG (r=0.46), number of visits to nurse (r=0.34), andlevel of HbA1c (r=0.33). No association was found between costs per health care centre andmean HbA1c per PHCC (r=0.17). Use of SMBG was associated with high total cost evenwhen adjusted for duration of diabetes and treatment type (p<0.01).

Conclusions: Health care costs for type 2 diabetes varied substantially in primary care,primarily explained by differences in costs for SMBG and insulin.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20578 (URN)
Available from: 2009-09-15 Created: 2009-09-15 Last updated: 2010-01-14Bibliographically approved
4. Sagittal abdominal diameter and waist circumference as markers of early organ damage in patients with Type 2 diabetes
Open this publication in new window or tab >>Sagittal abdominal diameter and waist circumference as markers of early organ damage in patients with Type 2 diabetes
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2011 (English)In: Journal of Clinical Metabolism & Diabetes, Vol. 2, no 1Article in journal (Refereed) Published
Abstract [en]

Aims: In a cohort of 465 patients with Type 2 diabetes aged 55-66 years the associationbetween the anthropometric measures: Waist circumference (WC) and Sagittal abdominaldiameter (SAD) versus subclinical cardiovascular organ damage by measuring Pulse wavevelocity (PWV) and Left ventricular mass index (LVMI) was studied.

Methods: Blood pressure, weight, height and WC were measured within primary care. SADwas measured by using standardized calliper equipment. Blood samples were taken foranalysis of HbA1c and serum lipids. LVMI was measured by M-mode echocardiography.Aortic PWV was measured by applanation tonometry (Sphygmocor®) over the carotid andfemoral arteries.

Results: There were significant correlations between aortic PWV and WC (r=0.23; p<0.01)and SAD (r=0.25; p<0.01). LVMI was also correlated to WC (r=0.26; p<0.01) and SAD(r=0.25; p<0.01). When analysed in a multiple regression model, SAD and WC were bothassociated with PWV and LVMI, independently of age, sex, systolic blood pressure, serumlipids and HbA1c.

Conclusion: This study shows that abdominal obesity, measured either with WC or SAD, is afeasible risk assessment tool for early subclinical organ damage in patients who have alreadydeveloped Type 2 diabetes.

Place, publisher, year, edition, pages
San Lucas Medical, 2011
Keyword
type 2 diabetes, obesity, pulse wave velocity, left ventricular mass
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-20579 (URN)
Available from: 2009-09-15 Created: 2009-09-15 Last updated: 2017-03-27Bibliographically approved

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