Syed Bokhari

Factors affecting diabetes knowledge in Type 2 diabetic veterans

Aims/hypothesisTo describe the clinical, psychological and social factors affecting diabetes knowledge of veterans with established Type 2 diabetes.MethodsWe conducted an observational study of 284 insulin-treated veterans with stable Type 2 diabetes. All subjects completed the University of Michigan Diabetes Research and Training Centre Knowledge Test, the Diabetes Care Profile, the Mini-Mental State Examination, the Geriatric Depression Scale, and the Diabetes Family Behaviour Checklist. Stepwise multiple linear regression was used to develop a model for the diabetes knowledge score based upon clinical and psychosocial variables.ResultsOne hundred eighty subjects were evaluated in a derivation set. The mean age ± SD was 65.4±9.6 years, 94% were men, and 36% were members of a minority group. Performance on the diabetes knowledge test was poor (64.9±15.3% correct). Self-perceived understanding of all management objectives explained only 6% of the variance in the knowledge scores. Multivariate analysis showed that age, years of schooling, duration of treatment, cognitive function, sex, and level of depression were independent determinants of the knowledge score. When the model was applied to 104 subjects in a validation set, there was a strong correlation between observed and predicted scores (r=0.537; p<0.001).Conclusions/interpretationStable, insulin-treated veterans have major deficiencies in diabetes knowledge that could impair their ability to provide self-care. A multivariate model comprised of demographic variables and psychosocial profiling can identify patients who have limited diabetes knowledge and be used to assess individual barriers to ongoing diabetes education.

Risk factor management in stable, insulin-treated patients with Type 2 diabetes: The Diabetes Outcomes in Veterans Study

OBJECTIVES Describe the methodologies and study population of the Diabetes Outcomes in Veterans Study (DOVES). RESEARCH DESIGN AND METHODS Prospective, multicenter, observational study of Southwestern veterans with stable, insulin-treated Type 2 diabetes. Subjects were randomly selected from pharmacy records and were required to be using at least one long-acting insulin preparation daily. Baseline psychosocial evaluations included psychological status, social and cultural barriers to care, self-care behaviors, and vascular disease risk factors. Clinical measurements included self-reported vascular disease, hemoglobin A1c (HbA1c), blood pressure, blood lipids, and body mass index (BMI). A subset of subjects completed a protocol of four times daily self-monitored blood glucose testing for 8 weeks. Subjects were followed for 12 months. Principal endpoints included glycemic control, the occurrence of hypoglycemia, and control of vascular disease risk factors. RESULTS We enrolled 338 subjects. The mean (+/-S.D.) age was 65.1+/-9.7 years and 3.8% were women. At baseline, over two-thirds of subjects reported vascular disease complications. Nearly three-quarters had limited physical activity. Among subjects younger than 65 years, 53% considered themselves disabled for work. Despite the high prevalence of vascular disease, 43.8% had an HbA1c >/=8.0%. Many subjects were sedentary, 62.1% had a BMI of 30 kg/m(2) or above, and 22.2% were still smoking. CONCLUSIONS Detailed measurements of psychological status, self-care behaviors, and risk factor control are feasible in this elderly, debilitated population. Although the prevalence of complications and self-rated disability was high, vascular disease risk factors were poorly controlled in a substantial proportion of subjects.

Beneficial Effects of a Glyburide/Metformin Combination Preparation in Type 2 Diabetes Mellitus

BackgroundType 2 diabetes mellitus is characterized by both insulin deficiency and insulin resistance. Effective treatment often requires therapy directed at both abnormalities. Patients on monotherapy might benefit from a combination agent such as glyburide/metformin, which increases insulin secretion and reduces insulin resistance. MethodsAll patients taking a glyburide/metformin preparation at the Carl T. Hayden VAMC were identified from pharmacy records. Patients with documented hemoglobin A1c values within 31 weeks prior and between 3 and 33 weeks after initiation of therapy (92 subjects) were examined. ResultsGlyburide/metformin combination therapy reduced hemoglobin A1c levels from 0.087 to 0.083 (P < 0.06). Significant reductions were seen in those patients with initial levels higher than 0.08 (0.094 to 0.087;P < 0.01). No significant reductions were seen in those patients with initial levels lower than 0.08. ConclusionsIn patients on monotherapy or on dual oral therapy with inadequate control, changing to a glyburide/metformin combination preparation may improve glucose control.

Metabolic fate of plasma glucose during hyperglycemia in impaired glucose tolerance: evidence for further early defects in the pathogenesis of type 2 diabetes

We examined the intracellular metabolic fate of plasma glucose during a hyperglycemic clamp in impaired glucose-tolerant (IGT; n = 21) and normal glucose-tolerant subjects (n = 10) using a combination of [3-(3)H]glucose infusion with measurement of [(3)H]water formation and indirect calorimetry. IGT was associated with approximately 35% reduced first-phase insulin responses, normal second-phase insulin response, and 25-30% reduced insulin sensitivity, resulting in approximately 35% reduced plasma glucose disposal. This was coupled with approximately 55% reduced storage of plasma glucose (P < 0.01) and approximately 15-20% reduced glycolysis of plasma glucose (P < 0.03), accounting for approximately 75 and 25% of the reduction in glucose disposal, respectively. Decreased glucose oxidation accounted for virtually all the decrease in glycolysis. Therefore, nonoxidative glycolysis of plasma glucose in IGT was similar to that in NGT (P > 0.9) and accounted for an increased proportion of systemic glucose disposal (P < 0.05). We conclude that, in IGT, decreased disposal of plasma glucose involves mainly decreased glycogen synthesis and to a lesser extent decreased glycolysis, which is accounted for by decreased glucose oxidation. An increased proportion of plasma glucose hence undergoes nonoxidative glycolysis, representing a novel early abnormality in the pathogenesis of T2DM.

Glucose Counterregulation in Advanced Type 2 Diabetes: Effect of β-Adrenergic Blockade

OBJECTIVE To examine counterregulatory glucose kinetics and test the hypothesis that β-adrenergic blockade impairs these in patients with type 2 diabetes mellitus (T2DM) and advanced β-failure. RESEARCH DESIGN AND METHODS Nine insulin-requiring T2DM subjects and six matched nondiabetic control subjects were studied. β-Cell function was assessed by the C-peptide response to arginine stimulation. Counterregulatory hormonal responses and glucose kinetics were assessed by hyperinsulinemic euglycemic-hypoglycemic clamps with [3-3H]glucose infusion. T2DM subjects underwent two clamp experiments in a randomized crossover fashion: once with infusion of the β-adrenergic antagonist propranolol and once with infusion of normal saline. RESULTS Compared with the control subjects, T2DM subjects had threefold reduced C-peptide responses to arginine stimulation. During the hypoglycemic clamp, glucagon responses were markedly diminished (16.0 ± 4.2 vs. 48.6 ± 6.0 ng/L, P < 0.05), but other hormonal responses and the decrement in the required exogenous glucose infusion rate (GIR) from the euglycemic clamp were normal (−10.4 ± 1.1 vs. −7.8 ± 1.9 µmol · kg−1 · min−1 in control subjects); however, endogenous glucose production (EGP) did not increase (−0.8 ± 1.0 vs. 2.2 ± 0.7 µmol · kg−1 · min−1 in control subjects, P < 0.05), whereas systemic glucose disposal decreased normally. β-Adrenergic blockade in the T2DM subjects increased GIR ∼20% during the euglycemic clamp (P < 0.01), but neither increased GIR during the hypoglycemic clamp or decreased its decrement from the euglycemic clamp to the hypoglycemic clamp. CONCLUSIONS Overall glucose counterregulation is preserved in advanced T2DM, but the contribution of EGP is diminished. β-Adrenergic blockade may increase insulin sensitivity at normoglycemia but does not impair glucose counterregulation in T2DM patients, even those with advanced β-cell failure.