H. Overmann

Validation of a Diabetes-Specific Quality-of-Life Scale for Patients With Type 1 Diabetes

OBJECTIVE To validate a diabetes-specific quality-of-life scale and to assess its psychometric properties in a large sample of patients with type 1 diabetes. RESEARCH DESIGN AND METHODS To assess the quality of diabetes care in a population-based study, a representative sample of 684 patients with type 1 diabetes was examined. A total of 657 patients (42% female; mean age 36 years; mean diabetes duration 18 years) completed the diabetes-specific quality-of-life scale (DSQOLS), which comprised 64 items on individual treatment goals (10 items), satisfaction with treatment success (10 items), and diabetes- related distress (44 items). Statistical examinations covered factor analysis, internal consistency of subscales, and construct and discriminant validity. RESULTS Factor analysis of the 44 items on diabetes-specific burdens revealed six reliable components (Cronbachs α): social relations (0.88), physical complaints (0.84), worries about future (0.84), leisure time flexibility (0.85), diet restrictions (0.71), and daily hassles (0.70). All six subscales were significantly correlated with a validated well-being scale (r = -0.35 to -0.53, P < 0.001) and treatment satisfaction (r = 0.28 to 0.43, P < 0.001). Physical complaints (r = 0.24) and worries about future (r = 0.17) showed the highest correlations with HbA1c (P < 0.001). A flexible insulin therapy, a liberalized diet, the absence of late complications, and a higher social status were significantly associated with more favorable scores in different domains. CONCLUSIONS The DSQOLS is a reliable and valid measure of diabetes-specific quality of life. The scale is able to distinguish between patients with different treatment and dietary regimens and to detect social inequities. Use of the DSQOLS for assessment of individual treatment goals as defined by the patients may be helpful to identify motivational deficits and to tailor individual treatment strategies.

Cigarette Smoking and Progression of Retinopathy and Nephropathy in Type 1 Diabetes

The objective of the present study was to analyse the association between cigarette smoking and progression of retinopathy and nephropathy, respectively, in a prospective multicentre study including 636 people with Type 1 diabetes: 81 % of the original cohort of consecutively referred patients, aged 15 to 40 years and free of severe late diabetic complications. At baseline, all patients had participated in a 5‐day in‐patient group treatment and teaching programme for intensification of insulin therapy. Patients were examined at recruitment, and after 1, 2, 3 and 6 years including assessment of smoking status, blood pressure, metabolic control, and degree of nephropathy. Degree of retinopathy was assessed by ophthalmoscopy or fundus photography at baseline and after 6 years. Several logistic regression analyses were performed by describing the responses retinopathy and nephropathy, respectively, either as progression yes/no or as actual status at the 6‐year follow‐up and by using different measures for smoking. Adjustments for important covariables were made. While significant associations between smoking, and retinopathy and nephropathy respectively, were found, the relations were variable depending on the statistical model used. The results show that the real associations between smoking and retinopathy and nephropathy are complex and that more emphasis should be put on the complete description of the response variables and the statistical models used in clinical and epidemiological research.

Injection-meal interval: recommendations of diabetologists and how patients handle it

Because regular insulin does not lower blood glucose immediately after injection many physicians recommend an injection-meal interval (IMI). By asking patients to inject well before beginning a meal, these physicians hope to compensate for the lag time between the injection of insulin and its onset of action. The aim of our study was to find out what physicians recommend to their patients with respect to the IMI, when prescribing intensive insulin therapy. A total of 58 diabetologists were surveyed by means of a structured questionnaire. A fixed IMI of 15 (0-30) min [median (range)] was recommended by 29% of the 58 diabetologists, and a flexible IMI was recommended by 71%. The minimal interval for the suggested flexible IMI was 0 min and the maximal interval 45 min (median 23 min). We compared these results with findings of 192 patients with Type 1 diabetes from a population based study. In this study patients were asked by questionnaire about their daily life handling of the IMI. Among the group of 134 patients reporting use of a flexible IMI, 62% used an IMI of < or = 15 min, 16% one of 20-25 min, and 21% one of > or = 30 min. There were 12 patients using a flexible IMI who adapted it so frequently that they could not state a typical interval. A total of 58 patients (30%) used a fixed IMI (67% used an IMI of < or = 15 min, 7% one of 20-25 min, 26% one of > or = 30 min). Our surveys show that diabetologists advocating intensive insulin therapy usually recommend an IMI shorter than 30 min. The majority of patients (75%) with Type 1 diabetes use an IMI of < 30 min in daily life.

Social status and the quality of care for adult people with type I (insulin-dependent) diabetes mellitus--a population-based study.

Summary The objective of this study was to assess the degree of diabetes care and education achieved for Type I (insulin-dependent) diabetes mellitus at the community level in relation to social status and to elucidate potential pathways that mediate any social class gradient. A population-based sample of 684 adults with Type I diabetes (41 % women, mean ± SD age 36 ± 11, diabetes duration 18 ± 11 years) in the district of North-Rhine (9.5 million inhabitants), Germany, were examined in their homes using a mobile ambulance. Results: HbA1c (normal 4.3–6.1 %) 8.0 ± 1.5 %, incidence of severe hypoglycaemia (injection of glucose or glucagon) 0.21 cases per patient-year; 62 % of patients had participated in a structured group treatment and teaching programme for intensification of insulin therapy; 70 % used 3 or more insulin injections per day, 9 % were on continuous subcutaneous insulin infusion; 91 % reported to have had measurements of HbA1c during the preceding year, and 80 % to have had an examination of the retina by an ophthalmologist. Care was insufficient with respect to the quality of blood pressure control (70 % of patients on antihypertensive drugs had blood pressure values ≥ 160/95 mmHg), patient awareness of proteinuria/albuminuria (27 % of patients had not heard about it) and prevention of foot complications (only 42 % with a diabetes duration over 10 years had remembered to have a foot examination during the preceding 12 months). There was a pronounced social gradient with respect to micro- and macrovascular complications (prevalence of overt nephropathy 7 vs 20 % for highest vs lowest quintiles of social class [OR 3.5, 95 % CI 1.6–7.5, p = 0.002]) and diabetes-specific quality of life. HbA1c, blood pressure and smoking accounted for part of the association between social class and microvascular complications. The social class gradient was not due to inequality to access to health services, but to lower acceptance among low social class patients of preventive and health maintaining behaviour. In conclusion, achieved standards of care are high with respect to the implementation of intensified treatment regimens, the level of patient education achieved, treatment control and eye care, whereas areas for improvement are blood pressure control and preventive measures for foot care. A substantial social gradient in diabetes care persists despite equal access of patients to health services. [Diabetologia (1998) 41: 1139–1150]

Predictors of mortality and end‐stage diabetic complications in patients with Type 1 diabetes mellitus on intensified insulin therapy

SUMMARY

Liberalized diet in patients with type 1 diabetes

Abstract. Objective. To document that strict dietary regimen are not necessary in the context of intensified insulin therapy.

Prognosis of persons with type 1 diabetes on intensified insulin therapy in relation to nephropathy

Abstract. Mühlhauser I, Sawicki PT, Blank M, Overmann H, Bender R, Berger M (University of Düsseldorf, Düsseldorf; University of Hamburg, Hamburg; and University of Bielefeld, Bielefeld, Germany). Prognosis of persons with type 1 diabetes on intensified insulin therapy in relation to nephropathy. J Intern Med 2000; 248: 333–341.

How well do patients with type 1 diabetes measure their blood glucose in daily life.

Chun et al. (1) reported an increased risk of death among patients with first myocardial infarction in a population-based study of coronary disease morbidity and mortality. They comment that some misclassification bias was possible for patients who died, which may have led to an underestimation of the impact of diabetes on subject fatality. Further, they lightly dismissed the phenomenon of stress hyperglycemia because they classified all hyperglycemic patients diagnosed for the first time during hospitalization for myocardial infarction as undiagnosed diabetes. Such misclassification would lead to further distortion of the study results. We have shown that hyperglycemia after acute myocardial infarction is common, and that in most patients it is a temporary phenomenon (2) and is associated with activation of the pituitary adrenal axis (3). However, stress hyperglycemia is likely to have been underreported in the study of Chun et al. because it was population based. The diagnosis of preexisting diabetes when associated with acute myocardial infarction, especially when transient, should be based on additional evidence of hyperglycemia, such as a diabetic glucose tolerance test response or raised HbAlc level.