Sensor and insulin pump results in better blood-sugar control in all age groups with diabetes, study finds

ScienceDaily (Sep. 26, 2010) ? Adding a continuous blood sugar level sensor to an insulin pump helps patients with type 1 diabetes achieve better blood sugar control compared to the common standard of care, multiple daily insulin injections, concludes a study published online in the New England Journal of Medicine.

The paper is entitled, Effectiveness of Sensor-Augmented Insulin-Pump therapy in Type 1 Diabetes.

"Combining the best technologies for insulin delivery and blood sugar monitoring really pays off for diabetes control," says Dr. Bruce Perkins, one of the co-authors of the study, endocrinologist at Toronto General Hospital and Assistant Professor at the University of Toronto. "Being aware of continuous blood sugar trends and having the tools to do something about them can help committed patients of all ages self-manage their diabetes very well."

Research conducted at 30 centres across North America, including Toronto General Hospital, found a significant decrease in average blood sugar levels (or A1c levels, which measure the average blood sugar levels over the past two or three months) from a baseline of 8.3% to 7.5% in the group using sensors and insulin pumps, compared to 8.3% to 8.1% in the multiple daily injection group, at one year. The decrease in A1c levels in both adults and children occurred without an increase in the rate of severe hypoglycemia, or low blood sugar, a common problem among patients who are trying to achieve better control of their blood sugar. Symptoms include shakiness, rapid heart beat, confusion and even unconsciousness.

Moreover, the proportion of participants who reached the A1c target of 7% or less was greater in the pump-therapy group than in the injection-therapy group. Adults with diabetes try and maintain A1c levels of seven percent or below in order to reduce the risk of complications from diabetes, such as kidney failure, heart disease and blindness.

The 485 study participants with inadequately controlled type 1 diabetes ranged in ages from seven to 70, and were treated for at least one year, in a randomized, controlled trial.

In the study, patients in the sensor-augmented pump therapy arm used an integrated system which incorporates an insulin pump, continuous glucose monitor and self-management software. A glucose (sugar) sensor reveals fluctuations in glucose levels in real-time, and transmits electric signals wirelessly to the insulin pump, which is about the size and shape of a small cell phone. The pump displays the blood sugar levels, allowing patients to react to either high or low levels before they become dangerous.

The study was sponsored by Medtronic, Inc.; and supported by Novo Nordisk; Lifescan; Bayer Heathcare; and Becton Dickinson.

Editor's Note: This article is not intended to provide medical advice, diagnosis or treatment.

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Patient-provider language barriers linked to worse diabetes control

ScienceDaily (Oct. 6, 2010) ? Patients who cannot discuss their diabetes with a doctor in their own language may have poorer health outcomes, even when interpreter services are available, according to a new study by researchers at UCSF and the Kaiser Permanente Division of Research.

The study found that, among Latino diabetes patients with limited English skills, those seen by non-Spanish speaking doctors were nearly twice as likely to have poor control of their blood sugar than those whose doctors spoke Spanish.

Findings will appear in the January 2011 issue of the Journal of General Internal Medicine.

The study, conducted among patients with access to interpreters, is the first to link language barriers with worse diabetes-related health outcomes. It examined only Spanish speakers.

"Diabetes is a complex disease that requires a high level of patient understanding and engagement for successful management," said Alicia Fernandez, MD, a UCSF professor of medicine and lead author of the study. "These patients may need direct communication with Spanish-speaking physicians to manage their disease appropriately."

The team surveyed adults with diabetes who are part of the Diabetes Study of Northern California (DISTANCE), involving patients from the Kaiser Permanente Northern California Diabetes Registry, and compared rates of blood sugar control among Latino patients.

Overall, the study found that Latino patients had worse control of their disease than English-speaking Caucasian patients: even English-speaking Latinos have almost double the rates of poor blood sugar control compared to Caucasians.

However, researchers found no difference in blood sugar control between English-speaking Latinos and non-English speaking Latinos if they had access to a doctor who spoke their language. When Latinos with limited English had a doctor who did not speak Spanish, though, 28 percent of the patients had poor diabetes control, compared to 16 percent of those with Spanish-speaking physicians. Only 10 percent of the Caucasian patients had poor blood sugar control.

More than 8 percent of the U.S. population, or 18 million adults, reported speaking English less than very well in 2000 U.S. Census, and the majority (14 million) spoke Spanish as their first language. The U.S. Latino population is growing rapidly and has one of the highest rates of diabetes, the authors noted.

"The study adds to evidence that the conversation between physician and patient is of critical importance to the success of diabetes care," said senior author Andrew Karter, PhD, principal investigator of the DISTANCE Study and research scientist at the Kaiser Permanente Division of Research.

"Our studies point out the need for quality improvement efforts in diabetes care to reduce health disparities associated with language, in addition to ethnicity," Karter said. "As the U.S. becomes linguistically more diverse, and as the prevalence of diabetes continues to rise, it is increasingly important to understand how language barriers may prevent patients from getting the best possible care."

While this study does not definitively prove that language barriers cause the disparity in diabetes control, it suggests the importance of direct communication with a doctor who speaks the patient's language, the authors said. They recommended that health plans offer diabetes patients a health care provider who speaks the patient's language whenever possible.

Data collection and analyses for this study was conducted by the DISTANCE study, which enrolled 20,000 patients from the Kaiser Permanente Northern California Diabetes Registry. The overarching aim of DISTANCE is to investigate ethnic and educational disparities in diabetes-related behaviors, processes of care and health outcomes.

Co-authors include Dean Schillinger, MD, of the UCSF Center for Vulnerable Populations; Yaell Schenker, MD, and Victoria Salgado, MD, from the UCSF Division of General Internal Medicine at San Francisco General Hospital; Nancy E. Adler, PhD from the UCSF Center for Health and Community; and Margaret Warton, MPH, Howard H. Moffet, MPH, and Ameena Ahmed, MD, from the Division of Research, Kaiser Permanente Northern California.

The DISTANCE study and research team were funded by the National Institute of Diabetes and Digestive and Kidney Diseases, and the National Institute of Child Health and Human Development. Fernandez is supported by the NIH and a professorship award from the Arnold P. Gold Foundation. Schillinger is supported by an NIH Clinical and Translational Science Award. Funders had no role in any aspect of the study.

Editor's Note: This article is not intended to provide medical advice, diagnosis or treatment.

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The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by University of California -- San Francisco.

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Tight blood pressure control for patients with diabetes and coronary artery disease not associated with improved cardiovascular outcomes, study finds

ScienceDaily (Sep. 26, 2010) ? Patients with hypertension, diabetes and coronary artery disease who maintained their systolic blood pressure at less than 130 mm Hg did not have improved cardiovascular outcomes compared to patients with usual blood pressure control, according to a study in the July 7 issue of JAMA.

"Hypertension guidelines advocate treating systolic blood pressure (BP) to less than 130 mm Hg for patients with diabetes mellitus; however, data are lacking for the growing population who also have coronary artery disease (CAD)," according to background information in the article.

Rhonda M. Cooper-DeHoff, Pharm.D., M.S., of the University of Florida, Gainesville, and colleagues examined whether patients with hypertension, diabetes and CAD who achieved systolic BP of less than 130 mm Hg would have a reduced risk of cardiovascular events compared with those who managed to keep their systolic BP within the range of at least 130 mm Hg to less than 140 mm Hg. The analysis included 6,400 of the 22,576 participants in the International Verapamil SR-Trandolapril Study (INVEST). For this analysis, participants were at least 50 years old and had diabetes and CAD. Participants were recruited between September 1997 and December 2000 from 862 sites in 14 countries and were followed up through March 2003, with an extended follow-up through August 2008 through the National Death index for U.S. participants.

Patients received treatment with either a calcium antagonist or beta-blocker followed by angiotensin-converting enzyme inhibitor, a diuretic, or both to achieve systolic BP of less than 130 and diastolic BP of less than 85 mm Hg. Patients were categorized as having tight control if they could maintain their systolic BP at less than 130 mm Hg; usual control if systolic BP ranged from 130 mm Hg to less than 140 mm Hg; and uncontrolled if systolic BP was 140 mm Hg or higher. The primary outcome included the occurrence of all-cause death, nonfatal myocardial infarction (heart attack), or nonfatal stroke.

The primary outcome occurred in 12.7 percent (286 patients) of those in the tight-control group, 12.6 percent (249 patients) of the usual-control group, and 19.8 percent (431 patients) of the uncontrolled groups. When evaluating all-cause mortality for the entire follow-up period, after adjustment, risk of all-cause mortality was significantly greater in the tight-control group (22.8 percent) than in the usual-control group (21.8 percent).

"In this observational study, we have shown for the first time, to our knowledge, that decreasing systolic BP to lower than 130 mm Hg in patients with diabetes and CAD was not associated with further reduction in morbidity beyond that associated with systolic BP lower than 140 mm Hg, and, in fact, was associated with an increase in risk of all-cause mortality. Moreover, the increased mortality risk persisted over the long term," the authors write.

"At this time, there is no compelling evidence to indicate that lowering systolic BP below 130 mm Hg is beneficial for patients with diabetes; thus, emphasis should be placed on maintaining systolic BP between 130 and 139 mm Hg while focusing on weight loss, healthful eating, and other manifestations of cardiovascular morbidity to further reduce long-term cardiovascular risk."

Editor's Note: This article is not intended to provide medical advice, diagnosis or treatment.

Story Source:

The above story is reprinted (with editorial adaptations by ScienceDaily staff) from materials provided by JAMA and Archives Journals.

Journal Reference:

Rhonda M. Cooper-DeHoff; Yan Gong; Eileen M. Handberg; Anthony A. Bavry; Scott J. Denardo; George L. Bakris; Carl J. Pepine. Tight Blood Pressure Control and Cardiovascular Outcomes Among Hypertensive Patients With Diabetes and Coronary Artery Disease. JAMA, 2010; 304 (1): 61-68 [link]

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