Lucinda Summers

A Metasynthesis of the Self-Management of Type 2 Diabetes

Type 2 diabetes is a metabolic disorder characterized by chronically elevated blood glucose and high risk of comorbidities. In this article we report a metasynthesis of the 21st-Century qualitative research concerning the self-management of type 2 diabetes. We identified 38 relevant articles (sample size range 6 to 175), which were synthesized through a process of iterative reading and theory development. In this literature, authors argued and assumed that diabetes management is influenced by multiple, complex, competing factors, including interpersonal relations, gender, and sociocultural context. Conversely, self-management was sometimes construed as a facet of individual agency and was accepted uncritically, placing accountability for health with patients themselves. We conclude that a satisfactory account of diabetes care would pay attention to the “inner” world, while acknowledging the social and political conditions in which diabetes-related experiences unfold.

Body mass index has no effect on rate of progression of chronic kidney disease in non-diabetic subjects

BACKGROUND Chronic kidney disease (CKD) is increasingly prevalent worldwide. Furthermore, obesity is now a global problem with major health implications. There is a clear association between obesity and the development of CKD but it is not known whether obesity is a risk factor for the progression of pre-existing kidney disease. We examined the relationship between the body mass index (BMI) and the rate of progression of CKD in non-diabetic adults. METHODS The Chronic Renal Insufficiency Standards Implementation Study (CRISIS) is a prospective observational study in a predominantly white population in Greater Manchester. From the CRISIS database, we assessed rate of progression of CKD in 499 adults attending the hospital. Baseline measurements including BMI were obtained and estimated glomerular filtration rate (eGFR) was monitored. The rate of deterioration of eGFR was derived over time, defined as ΔeGFR (mL/min/1.73 m2/year) and assessed using univariate analysis of variance. RESULTS In the groups as a whole, no relationship between BMI and ΔeGFR was shown. Dividing the subjects into obese (BMI≥30) and non-obese (BMI<30) groups and further breakdown into CKD stages 3, 4 and 5, also showed no relationship between BMI and ΔeGFR. Univariate analysis of variance was used. CONCLUSIONS Neither BMI as a continuous variable nor obesity (BMI≥30) as a categorical variable was associated with an increased rate of progression of existing CKD in this predominantly white population.

Getting one's thoughts straight: A dialogical analysis of women's accounts of poorly controlled type 2 diabetes

Type 2 diabetes is a metabolic disorder characterised by chronically elevated blood glucose and a high risk of cardiovascular and other complications. Self-management is central to diabetes care and includes taking regular exercise, low-fat/sugar diet and blood glucose monitoring. However, little is understood about how people with diabetes make sense of self-management. Our aim, therefore, is to explore the process of ‘getting ones thoughts straight’ in relation to illness self-management for women with poorly controlled type 2 diabetes. Eight women were recruited from two hospitals in the North of England. Each was interviewed using a biographic-narrative method. Narratives were analysed using a dialogical approach. We use Bakhtins concepts of voice, official and unofficial truth, and internally persuasive discourse to explore how participants considered, struggled with, and, sometimes, acted upon self-management. We demonstrate how the truth by which participants lived shifted as they encountered new perspectives and experiences. The accounts revealed tension between official, authoritative voices, typically concerned with optimal illness control and unofficial voices that speak at a lived, embodied level. In conclusion, we suggest moving beyond the notion of self-management towards a conceptualisation of life with chronic illness that includes personal goals, values and embodied experience in context.

Behaviour change among people with impaired glucose tolerance: Comparison of telephone-based and face-to-face advice.

Objectives To develop, implement and compare two lifestyle services for people at risk of developing type 2 diabetes. Methods Two localities were selected to implement two different service delivery models, telephone-based and face-to-face, supporting people at risk of developing type 2 diabetes. Impact was assessed by comparing weight, fasting plasma glucose and oral glucose tolerance test (OGTT) results at baseline and six months later. Results Both services were associated with an improvement in OGTT 2-h plasma glucose and weight. In the telephone intervention, 47.3% of participants who completed the project achieved both normal fasting plasma glucose (≤6.0 mmol/l) and normal plasma glucose levels (≤7.7 mmol/l). Participants had a mean weight loss of 3.3 kg (SD 4.3), equating to 3.4% of body weight (p < 0.001). In the face-to-face intervention, 46.3% of participants achieved normal plasma glucose (≤7.7 mmol/l) and a mean weight loss of 2.9 kg (SD 4.5), equating to 3.1% of bodyweight (p < 0.001). Conclusions Local health providers can adapt existing service provision and tailor it to provide lifestyle programmes for people with impaired glucose tolerance. Both service delivery models offer effective diabetes prevention although each model may cater for different population needs and a choice of services might be the preferred option.

Prioritising prevention: Implementation of IGT Care Call, a telephone based service for people at risk of developing type 2 diabetes

AIM To design, deliver and evaluate IGT Care Call, a telephone service providing a 6 month lifestyle education programme for people with impaired glucose tolerance (IGT). METHODS An observational study of IGT Care Call, a programme providing motivational support and education using electronic scripts. The service was delivered to 55 participants, all of whom completed the course (an information pack and at least five telephone calls over 6 months). Clinical measurements were undertaken in General Practice at baseline, on completion of the programme and one year later. RESULTS Among the 40 participants for whom we have complete data available, one year after discharge, participants showed improvements in fasting plasma glucose (0.29 mmol/l, 95% CI 0.07 to 0.51), weight (2.81 kg, 95% CI 1.20 to 4.42) and BMI (1.06 kg/m(2), 95% CI 0.49 to 1.63). All differences were statistically significant (p < 0.01). CONCLUSION Whilst an uncontrolled observational study with a small sample size, this pilot suggests IGT Care Call may be effective in promoting positive and sustained lifestyle changes to prevent type 2 diabetes, which warrants further investigation. A telephone method of service delivery was acceptable, convenient and may have improved self confidence in how to reduce risk of type 2 diabetes.

Metabolic outcomes 2 years following gastric bypass surgery in people with type 2 diabetes: an observational cohort study

BACKGROUND Gastric bypass surgery induces early remission or significant improvement in type 2 diabetes (T2D). AIM To assess effectiveness of stopping glucose-lowering treatment at the time of surgery. DESIGN Observational cohort analysis. METHODS We identified 101 patients (62 women) with T2D who had undergone gastric bypass surgery at a mean (SD, standard deviation) age of 51.4 (9.0) years. We recorded weight, body mass index (BMI), glycosylated haemoglobin (HbA1c), blood pressure (BP), total and high-density lipoprotein (HDL) cholesterol preoperatively and at a median 4, 12 and 24 months postoperatively, and changes to glucose-lowering therapy. RESULTS Mean (SD) baseline BMI was 50.3 (6.3) kg/m(2), HbA1c 65.3 (18.5) mmol/mol, systolic BP 146.0 (18.0) mmHg, diastolic BP 87.0 (10.8) mmHg and total cholesterol-to-HDL cholesterol ratio 4.0 (1.2). Mean (95% confidence interval) reduction in BMI was 16.4 (14.1-18.7) kg/m(2), HbA1c 23.6 (17.6-29.6) mmol/mol, systolic BP 12.9 (5.9-19.8) mmHg, diastolic BP 6.1 (1.8-10.5) mmHg and total cholesterol-to-HDL cholesterol ratio 1.1 (0.6-1.5) at 24 months (P < 0.001 for all measures). Although 91% of patients were receiving glucose-lowering therapies preoperatively, complete (HbA1c < 42 mmol/mol) and partial (HbA1c 42-48 mmol/mol) remissions of T2D were seen in 62.1% and 5.2% at 2 years postoperatively. CONCLUSIONS Cessation of glucose-lowering therapies in people with T2D at the time of gastric bypass surgery was clinically effective. The majority of patients remained in complete or partial remission of diabetes up to 2 years postoperatively.

Liraglutide therapy in obese people with type 2 diabetes — Experience of a weight management centre

Whilst many antidiabetic therapies aggravate weight gain, glucagon-like peptide-1 receptor (GLP-1R) agonists have been shown to promote weight loss in addition to improving glycaemic control [1]. We assessed the clinical effectiveness of the GLP-1R agonist liraglutide in obese people with type 2 diabetes (T2D) [2], in the clinical practice setting of a National Health Service medical weight management centre in a university teaching hospital in North West England. We studied 79 obese patients with T2D aged 19–80 years, of whom 50 (63%) were women, treated with liraglutide. Baseline mean (standard deviation) body weight was 118.8 (24.5) kg, body mass index (BMI) 42.5 (8.9) kg/m and HbA1c 69.1 (21.8) mmol/mol. Patients were recommended a reduced calorie diet supported by specialist weight management dietetic review. We analysed the data by descriptive statistics, Student t-test, one way analysis of variance (ANOVA) and χ test using SPSS 20.0.0 (IBM SPSS Inc., Chicago, IL) and Prism 4.03 (GraphPad Software Inc., La Jolla, CA, USA). P b 0.05 was considered statistically significant and 95% confidence interval (CI) was reported as a measure of precision. Permission was obtained from the Clinical Audit department of our institution. The 79 patients had median (range) duration of T2D of 10.0 (1–33) years. Major co-morbidities included hypertension in 47 (60%), sleep apnoea in 18 (23%), heart failure in 3 (4%), depression in 22 (28%), chronic back-pain in 14 (18%) and chronic joint pains in 25 (32%) patients. The median dose of liraglutide was 1.2 mg daily; other anti-diabetic therapies included metformin in 66 (84%), sulphonylureas in 18 (23%), glitazones in 10 (13%) and insulin in 22 (28%) patients. There was a significant reduction in BMI with mean (95% CI) difference of 1.9 (1.0–2.7) kg/m (P b 0.001) at 12 months from baseline (Fig. 1a). Reduction in BMI ≥ 5.0% (Group 1) occurred in 38% of patients with a median (range) reduction of 8.0 (5.0–23.8)%. Reduction in BMI of 0.0–4.9% (Group 2) occurred in 43% of patients with a reduction of 2.2 (0.2–4.7)%. Sulphonylureas were in use in 7.7% of patients in Group 1 compared to 31.0% in Group 2 (P = 0.031). There was no reduction in BMI in 19% of patients with a weight gain of 1.0 (0.1–2.5)%. HbA1c reduced from 69.1 to 60.0 mmol/mol (ANOVA, P = 0.046) at 12 months (Fig. 1b). There was a reduction in HbA1c in 65.9% of patients. Sulphonylureas were in use in 25.9% of patients who achieved reduction in HbA1c compared to 6.7% of patients who did not (non-significant). Reductions in systolic and diastolic blood pressures were non-significant (Fig. 1c). There was