Elizabeth Goyder

Impact of self monitoring of blood glucose in the management of patients with non-insulin treated diabetes: open parallel group randomised trial.

Objective To determine whether self monitoring, alone or with instruction in incorporating the results into self care, is more effective than usual care in improving glycaemic control in non-insulin treated patients with type 2 diabetes. Design Three arm, open, parallel group randomised trial. Setting 48 general practices in Oxfordshire and South Yorkshire. Participants 453 patients with non-insulin treated type 2 diabetes (mean age 65.7 years) for a median duration of three years and a mean haemoglobin A1c level of 7.5%. Interventions Standardised usual care with measurements of HbA1c every three months as the control group (n=152), blood glucose self monitoring with advice for patients to contact their doctor for interpretation of results, in addition to usual care (n=150), and blood glucose self monitoring with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle (n=151). Main outcome measure HbA1c level measured at 12 months. Results At 12 months the differences in HbA1c level between the three groups (adjusted for baseline HbA1c level) were not statistically significant (P=0.12). The difference in unadjusted mean change in HbA1c level from baseline to 12 months between the control and less intensive self monitoring groups was −0.14% (95% confidence interval −0.35% to 0.07%) and between the control and more intensive self monitoring groups was −0.17% (−0.37% to 0.03%). Conclusions Evidence is not convincing of an effect of self monitoring blood glucose, with or without instruction in incorporating findings into self care, in improving glycaemic control compared with usual care in reasonably well controlled non-insulin treated patients with type 2 diabetes. Trial registration Current Controlled Trials ISRCTN47464659.

Barriers and facilitators to implementing screening and brief intervention for alcohol misuse: a systematic review of qualitative evidence

BACKGROUND This review aimed to synthesize qualitative evidence for barriers and facilitators to effective implementation of screening and brief intervention for alcohol misuse in adults and children over 10 years. METHODS A search of medical and social science databases was carried out and augmented by hand-searching of reference lists and contents of key journals. Qualitative evidence was synthesized thematically. RESULTS A total of 47 papers varying in design and quality were included in the review. Most evaluated implementation in primary care settings. Implementation was reported to be limited by lack of resources, training and support from management, as well as workload. The appropriateness of context in which discussions take place was reported as an acceptability factor for patients and practitioners. Health professionals require sufficient knowledge about alcohol guidelines and risk in order to implement screening and intervention to those most in need. CONCLUSIONS Whilst brief screening and brief intervention have been shown to be effective in some settings, this review has identified a number of barriers and facilitators to implementation. Adequate resources, training and the identification of those at risk without stereotyping are the main facilitators in primary care. More research is needed to assess implementation in other settings.

Diabetes prevalence in England, 2001—estimates from an epidemiological model

Aims  To estimate the total prevalence of diabetes mellitus (diagnosed and undiagnosed) at national, regional and local level in England to support health‐care planning and delivery.

Behavioural interventions for weight management in pregnancy: A systematic review of quantitative and qualitative data

BackgroundThere is a rising prevalence of excessive weight gain in pregnancy and an increasing number of pregnant women who are overweight or obese at the start of the pregnancy. Excessive weight gain during pregnancy is associated with adverse maternal and neonatal consequences and increases the risk of long-term obesity. Pregnancy therefore may be a key time to prevent excessive weight gain and improve the health of women and their unborn child. This systematic review sought to assess the effectiveness of behavioural interventions to prevent excessive weight gain in pregnancy and explore the factors that influence intervention effectiveness.MethodsWe undertook a systematic review of quantitative and qualitative evidence. This included a meta-analysis of controlled trials of diet and physical activity interventions to prevent excessive weight gain during pregnancy and a thematic synthesis of qualitative studies that investigated the views of women on weight management during pregnancy. A thorough search of eleven electronic bibliographic databases, reference lists of included studies, relevant review articles and experts in the field were contacted to identify potentially relevant studies.Two independent reviewers extracted data. RevMan software was used to perform the meta-analyses. Qualitative data was subject to thematic analysis. Both quantitative and qualitative data were aligned using a matrix framework.ResultsFive controlled trials and eight qualitative studies were included. The overall pooled effect size found no significant difference in gestational weight gain amongst participants in the intervention group compared with the control group (mean difference -0.28 95% CI -0.64 to 0.09). The study designs, participants and interventions all varied markedly and there was significant heterogeneity within this comparison in the meta-analysis (I2 67%). Subgroup and sensitivity analysis did not identify contextual elements that influenced the effectiveness of the intervention.In a thematic analysis of the qualitative studies, three major themes emerged relating to womens views of weight management in pregnancy: pregnancy as a time of transition and change, conflicting and contradictory messages and a perceived lack of control. When the results of both quantitative and qualitative data were aligned it was clear that some of the barriers that women described in achieving healthy weight gain in pregnancy were not addressed by the interventions evaluated. This may have contributed to the limited effectiveness of the interventions.ConclusionsDespite intense and often tailored interventions there was no statistically significant effect on weight gain during pregnancy. Inadequate and often contradictory information regarding healthy weight management was reported by women in qualitative studies and this was addressed in the interventions but this in itself was insufficient to lead to reduced weight gain. Multiple types of interventions, including community based strategies are needed to address this complex health problem.

CKD and Poverty: A Growing Global Challenge

Approximately 1.2 billion individuals worldwide live in extreme poverty (<

Can diabetes prevention programmes be translated effectively into real-world settings and still deliver improved outcomes? A synthesis of evidence

1/d), and 2.7 billion live in moderate poverty (<

Synthesizing diverse evidence: the use of primary qualitative data analysis methods and logic models in public health reviews

2/d). Poverty is most prevalent in developing countries, but does not spare richer economies, where huge income discrepancies have been reported. Poverty is a major health care marker affecting a number of chronic, communicable, and noncommunicable diseases. Poverty and social deprivation are known to affect the predisposition, diagnosis, and management of chronic diseases; they directly impact on the prevalence of such conditions as obesity, diabetes, and hypertension. Also, growing evidence links poverty to chronic kidney disease (CKD). This may be caused by a direct impact of poverty on CKD or indirectly through the increased health care burden linked to poverty-associated diabetes and hypertension. Furthermore, data have shown that the poor and socially deprived have a greater prevalence of end-stage renal disease. Access to renal care, dialysis, and transplantation may also be affected by social deprivation. Overall, poverty and social deprivation are emerging as major risk markers for CKD in both developing and developed countries. Their impact on CKD warrants careful analysis because it may confound the interpretation of CKD risk factors within communities. This review therefore aims to look at the evidence linking poverty to CKD and its major risk factors, namely, diabetes and hypertension.

The Association of Public Health Observatories (APHO) Diabetes Prevalence Model: estimates of total diabetes prevalence for England, 2010-2030

Randomized trials provide evidence that intensive lifestyle interventions leading to dietary and physical activity change can delay or prevent Type 2 diabetes. Translational studies have assessed the impact of interventions based on, but less intensive than, trial protocols delivered in community settings with high‐risk populations. The aim of this review was to synthesize evidence from translational studies of any design to assess the impact of interventions delivered outside large randomized trials.

Preventing the progression to type 2 diabetes mellitus in adults at high risk: a systematic review and network meta-analysis of lifestyle, pharmacological and surgical interventions.

OBJECTIVES The nature of public health evidence presents challenges for conventional systematic review processes, with increasing recognition of the need to include a broader range of work including observational studies and qualitative research, yet with methods to combine diverse sources remaining underdeveloped. The objective of this paper is to report the application of a new approach for review of evidence in the public health sphere. The method enables a diverse range of evidence types to be synthesized in order to examine potential relationships between a public health environment and outcomes. STUDY DESIGN The study drew on previous work by the National Institute for Health and Clinical Excellence on conceptual frameworks. It applied and further extended this work to the synthesis of evidence relating to one particular public health area: the enhancement of employee mental well-being in the workplace. METHODS The approach utilized thematic analysis techniques from primary research, together with conceptual modelling, to explore potential relationships between factors and outcomes. RESULTS The method enabled a logic framework to be built from a diverse document set that illustrates how elements and associations between elements may impact on the well-being of employees. CONCLUSIONS Whilst recognizing potential criticisms of the approach, it is suggested that logic models can be a useful way of examining the complexity of relationships between factors and outcomes in public health, and of highlighting potential areas for interventions and further research. The use of techniques from primary qualitative research may also be helpful in synthesizing diverse document types.

Factors associated with outcomes for looked-after children and young people: a correlates review of the literature.

Diabet. Med. 28, 575–582 (2011)