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Around 25% of the adult Type 1 diabetes population is in persistent poor glycaemic control and thus at increased risk of developing microvascular complications. We here discuss correlates of long-standing poor glycaemic control and review the efficacy of clinical strategies designed to overcome persistent poor control. Only a few studies have identified determinants and correlates of long-standing poor glycaemic control in Type 1 diabetes. There is some evidence implicating genetic factors, as well as lower economic status, and psychological factors, including lack of motivation, emotional distress, depression and eating disorders. Ways of improving glycaemic control include strategies to enable self-management, e.g. motivational strategies, coping-orientated education, psychosocial therapies, and/or intensifying insulin injection therapy plus continuous subcutaneous insulin infusion. Long-standing poor glycaemic control appears to be a heterogeneous and complex phenomenon, for which there is no simple, single solution. Comprehensive psycho-medical assessment in diabetes care may prove useful in tailoring interventions. Further research is warranted, to increase our understanding how psychosocial and biomedical factors, separately and in interaction, determine poor outcomes in Type 1 diabetes.
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PMID:Persistent poor glycaemic control in adult Type 1 diabetes. A closer look at the problem. 1556 26

We studied the impact of nurse case management (NCM) on blood pressure (BP), hemoglobin A1C, lipids, and diabetes complication screening. A 1-year randomized-controlled trial was conducted in two primary care clinics of the Penn State Hershey Medical Center. Diabetes patients were randomized to control group (CG) (n=182) who received usual care by their primary care provider and intervention group (IG) (n=150) who received additional NCM care, including self-management education, and implementation of diabetes guidelines. Primary outcomes included BP, A1C, lipid, process measures, and secondary outcome was diabetes-related emotional distress as assessed by Problem Areas in Diabetes (PAID). BP significantly decreased from 137/77 to 129/72 in IG as compared to an increase from 136/77 to 138/79 in CG after 1 year. PAID scores improved significantly in IG (from 23 to 10) due to reduced emotional stress. A1C (7.4) and LDL (105) were unaffected. Complications screening significantly improved in IG compared to CG: opthalmologic exam 26 to 68%, foot exam 47 to 64%, and nephropathy screening 34 to 72%. NCM improved BP, diabetes-related emotional distress, and process measures in primary care. Unchanged A1C and lipids might be due to a threshold effect. Intervention based upon initial risk assessment may prove more cost-effective.
Diabetes Res Clin Pract 2006 Jan
PMID:Nurse case management improves blood pressure, emotional distress and diabetes complication screening. 1601 2

Until recently, there was little empirical data regarding the psychological impact of screening for type 2 diabetes. There is now some progress in this area, as evidenced by emerging population based studies reporting on the effects of screening for type 2 diabetes on perceived health status and well-being. Recent studies from our own and other groups show that the diagnosis type 2 diabetes has no substantial adverse or positive effect on the participants' perceived health status and well-being after notification of the test result. Importantly, screening-detected type 2 diabetes patients beforehand perceive their risk for type 2 diabetes to be low, despite the presence of risk factors, such as obesity, hypertension and a family history, and overall report low levels of diabetes-related symptom distress. Yet, screening-detected type 2 diabetes patients were bothered more by symptoms of hyperglycaemia and fatigue in the first year following diagnosis type 2 diabetes than non-diabetics. On the basis of research to date, we conclude that screening for type 2 diabetes in the general population has no serious psychological side effects. Whether lack of emotional response to screening, is because of unawareness or indifference, needs further investigation. Future studies should be aiming towards a better understanding of how to raise the awareness and understanding of type 2 diabetes and its risk factors in high-risk individuals, while avoiding or minimizing negative effects, such as emotional distress and denial. The growing number of younger people developing type 2 diabetes warrants further research into labeling effects of an early diagnosis.
Diabetes Metab Res Rev
PMID:The psychological impact of screening for type 2 diabetes. 1614 14

An increasing number of researchers of the metabolic syndrome assume that many mechanisms are involved in its complex pathophysiology such as an increased sympathetic activity, disorders of the hypothalamo-pituitary-adrenal axis, the action of chronic subclinical infections, proinflammatory cytokines, and the effect of adipocytokines or psychoemotional stress. An increasing body of scientific research in this field confirms the role of the neurotrophins and mastocytes in the pathogenesis of inflammatory and immune diseases. Recently it has been proved that neurotrophins and mastocytes have metabotrophic effects and take part in the carbohydrate and lipid metabolism. In the early stage of the metabolic syndrome we established a statistically significant increase in the plasma levels of the nerve growth factor. In the generalized stage the plasma levels of the neutrophines were statistically decreased in comparison to those in the healthy controls. We consider that the neurotrophin deficit is likely to play a significant pathogenic role in the development of the metabolic anthropometric and vascular manifestations of the generalized stage of MetSyn. We suggest a hypothesis for the etiopathogenesis of the metabolic syndrome based on the neuro-immuno-endocrine interactions. The specific pathogenic pathways of MetSyn development include: (1) increased tissue and plasma levels of proinflammatory cytokines Interleukin-1(IL-1), Interleukin-6 (IL-6 ) and tumor necrosis factor - alpha (TNF-alpha) caused by inflammatory and/or emotional distress; (2) increased plasma levels of neurotrophin - nerve growth factor (NGF) caused by the high IL-1, IL-6 and TNFalpha levels; (3) high plasma levels of NGF which enhance activation of: the autonomous nerve system--vegetodystonia (disbalance of neurotransmitters); Neuropeptide Y (NPY)--enhanced feeding, obesity and increased leptin plasma levels; hypothalamo-pituitary-adrenal axis--increased corticotropin-releasing hormone (CRH) and cortisol (hormonal disbalance); immune cells--increased number and degranulation of mastocytes (MC)--immunological disbalance; (4) as a result of 1-3 insulin resistance is exhibited leading to diabetes mellitus. The hypothesis is confirmed by results obtained after 6-month nonsteroid anti-inflammatory treatment of patients with MetSyn. These results are reported in a separate publication.
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PMID:Metabolic syndrome--neurotrophic hypothesis. 1654 15

The purpose of this article is to share an educational strategy or tool that is relevant for use in patient and professional diabetes education. The tool offers an opportunity for diabetes educators to screen for psychosocial variables such as depression or emotional distress. A systematic review of the literature was conducted to identify psychological variables that have an impact on individuals living with diabetes and their ability to self-manage their disease. The literature revealed that both depression and emotional distress related to diabetes was experienced by individuals with diabetes along with those individuals who were unable to self-management their disease. The Accu-Check Interview is a computer software program that may assist diabetes educators to provide diabetes education. Use of the Accu-Check Interview software program has been implemented at various sites including the Joslin Clinic (Boston, Mass), Baystate Medical Center (Springfield, Mass), and Emerson Hospital (Concord, Mass). The Diabetes Self Care Profile is a Web-based version of the Accu-Check Interview and can be accessed as a demonstration in English and Spanish. These tools allow diabetes educators to screen for psychosocial variables and address issues with individuals while using a motivational interviewing approach.
Diabetes Educ
PMID:Assessing psychosocial variables: a tool for diabetes educators. 1643 92

This study examines baseline levels and correlates of diabetes-related emotional distress among inner-city African Americans and Hispanics with type 2 diabetes. The Problem Areas in Diabetes (PAID) scale, which measures diabetes-related emotional distress, was administered to 180 African American and Hispanic adults participating in the REACH Detroit Partnership. We examined bivariate and multivariate associations between emotional distress and biological, psychosocial, and quality of health care variables for African Americans and Hispanics. Scores were significantly higher among Hispanics than African Americans. Demographic factors were stronger predictors of emotional distress for Hispanics than for African Americans. Daily hassles, physician support, and perceived seriousness and understanding of diabetes were significant for African Americans. Understanding the personal, family and community context of living with diabetes and conducting interventions that provide support and coping strategies for self-management have important implications for reducing health disparities among disadvantaged racial and ethnic groups.
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PMID:Diabetes-specific emotional distress among African Americans and Hispanics with type 2 diabetes. 1680 77

The purpose of this study was to validate the Brazilian version of the Problem Areas in Diabetes Scale (B-PAID) in a sample of outpatients with type 2 diabetes (DM2) and to identify the characteristics of individuals at high risk for emotional distress. A cross-sectional study was conducted in a sample of 146 patients randomly selected among those attending outpatient clinics at a University Hospital in Porto Alegre, Brazil. Information was collected regarding age, gender, known duration of diabetes, type of treatment and level of schooling, and a blood sample was taken to measure HbA1c. B-PAID was compared with the already validated Brazilian versions of Satisfaction with Life (SWL) and WHO Quality of Life-Brief (WHOQOL) Scales. One-hundred forty-six DM2 patients (48% males, 59.7+/-9 years, BMI: 29.7+/-5.2kg/m(2), mean duration: 8.63+/-8 years, HbA(1c): 7.2+/-1.7%) were included. There were significant correlations between B-PAID and SWL (r(p)=0.55, p<0.001) and WHOQOL (r(p)=-0.33, p<0.05) Scales. In a multiple regression analysis the B-PAID Scale was associated with younger age (p=0.006) and lower education level (p=0.05). In conclusion, B-PAID is a reliable, valid outcome measure for Brazilian DM2 patients and identifies patients at increased risk for emotional distress who should be prioritized in psychosocial intervention.
Diabetes Res Clin Pract 2007 Jun
PMID:Brazilian version of the Problem Areas in Diabetes Scale (B-PAID): validation and identification of individuals at high risk for emotional distress. 1708 45

Diabetes mellitus affects not only life expectancy but also quality of life. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial's health-related quality of life (HRQOL) and cost-effectiveness components will enable the assessment of the relative importance of the various outcomes from the point of view of patients, provide an understanding of the balance between the burdens and benefits of the intervention strategies, and offer valuable insights into adherence. The HRQOL measures used include the Diabetes Symptoms Distress Checklist; the 36-Item Short Form Health Survey, Version 2 (SF-36) (RAND Corporation, Santa Monica, CA); the Patient Health Questionnaire (PHQ) depression measure (Pfizer Inc, New York, NY); the World Health Organization (WHO) Diabetes Treatment Satisfaction Questionnaire (DTSQ); and the EuroQol Feeling Thermometer (EuroQol Group, Rotterdam, Netherlands). The cost-effectiveness analysis (CEA) in ACCORD will provide information about the relative economic efficiency of the different interventions being compared in the trial. Effectiveness will be measured in terms of cardiovascular event-free years gained and quality-adjusted life-years gained (using the Health Utilities Index Mark 3 [HUI-3] [Health Utilities Inc., Dundas, Ontario, Canada] to measure health-state utility). Costs will be direct medical costs assessed from the perspective of a single-payer health system collected by means of patient and clinic cost forms and hospital discharge summaries. The primary HRQOL and CEA hypotheses mirror those in the main ACCORD trial, addressing the effects of the 3 main ACCORD interventions considered separately. There are also secondary (pairwise reference case) comparisons that do not assume independence of treatment effects on HRQOL. CEA will be done on a subsample of 4,311 ACCORD participants and HRQOL on a subsample of 2,053 nested within the CEA subsample. Most assessments will occur through questionnaires at baseline and at 12, 36, and 48 months.
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PMID:Health-related quality of life and cost-effectiveness components of the Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial: rationale and design. 1759 29

Optimal acne therapy must take into account not only acne type and severity, but also the impact of this skin disorder on the patients quality of life. Several validated instruments have been used to measure quality of life in acne patients. By using these instruments, acne patients have been shown to experience levels of social, psychological and emotional distress similar to those reported in patients with asthma, epilepsy and diabetes. Several studies have demonstrated that the disability caused by acne can be mitigated by effective therapy.
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PMID:The impact of acne on quality of life. 1822 54

The body's ability to keep a steady homeostatic state is crucial to health and life. This involves providing an adequate response to a variety of challenges both physical and mental, such as microbial invasion and emotional distress. Interplay between the neuroendocrine and immune systems is essential in either case. Studies have demonstrated that toll-like receptors, or TLRs, play a regulatory role in both systems, and have been proposed as a possible link between the immune, hormonal and metabolic systems. As part of the innate immune system, these receptors control the identification by the body of microbial invaders and its immediate reaction in immune and inflammatory response. What are referred to as pattern recognition receptors are mostly expressed by cells involved in hematopoietic linkage, but an increasing number of studies have demonstrated their expression in other cell types such as neurons and endocrine cells on the hypothalamic-pituitary-adrenal (HPA) axis, thyrocytes, adipocytes and islets of Langerhans. Together with endocrine and metabolic dysregulation, immune system overreaction is often associated with infection and autoimmunity, clearly indicating TLR involvement at organ level which affects organ function. Several diseases such as autoimmune thyroid and pancreatic diseases, septic dysregulation of the HPA axis, diabetes and the metabolic syndrome have been linked to TLR activation and polymorphism. To gain insight into stress response and adaptation, we need to know more about TLRs and the specific physiological role they play in the endocrine and metabolic system and its processes.
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PMID:Toll-like receptors in endocrine disease and diabetes. 1866


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