Foot complications in diabetes are common, complex and costly. Following development of neuropathy, people with diabetes may, secondary to repetitive stress develop a wound much in the way someone would normally develop a hole in a shoe or stocking. It is this wound (diabetic foot ulcer) that frequently becomes infected, leading to loss of limb.

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Diabetes mellitus is an increasingly common, chronic, incurable disease requiring careful monitoring and treatment so as to minimise the risk of serious long-term complications. It has been suggested that computers used by healthcare professionals and/or patients themselves may playa useful role in the diabetes care process. Seven key systems (AIDA, ADICOL, DIABETES, DIAS, IIumaLink, T-IDDM, POIRO) in the area of diabetes decision support, and their underlying techniques and approaches are summarised and compared. The development of the Patient-Oriented Insulin Regimen Optimiser (POIRO) for insulindependent (Type-I) diabetes, and its hybrid statistical and rule-based expert system is then taken forward. The re-implementation and updating of the system for the Palm OS family of modern Personal Digital Assistants (PDAs) is described. The evaluation of this new version in a seven week, randomised, open, cross-over clinical pilot study involving eight patients on short-acting plus long-acting insulin basalbolus regimens showed it to be easy-to-operate, reliable, not time consuming and well liked by patients. Following this, the characteristics and use of all currently available insulin formulations, and the corresponding insulin regimens are summarised. Algorithms to provide dose advice and decision support for patients taking the new rapid-acting, intermediate-acting and premixed insulin formulations are then developed. The user interface is improved and extended, amongst others through the development and use of a model describing individual user's meal time habits. Implementation-related issues encountered are discussed, and further work and future directions are identified and outlined. Motivated by the complex and safety-critical nature of systems such as POIRO, we also report on the use of the B abstract machine notation for the formal specification of the original POIRO system, and focusing on projects and published case studies. review the use of formal methods in the development of medical computer systems.

Diabetes is a chronic disease characterised by high blood glucose levels. Monitoring of blood glucose plays an important role in the management of diabetes. Although, several different glycaemic measures are used in clinical practice, glycated haemoglobin (HbA1c) is increasingly accepted as the standard on which many clinical decisions are based. In this thesis, the relationship between HbA1c and different blood glucose measures will be examined and their relevance to diabetic complications will be investigated. This work is for people at increased risk of type 2 diabetes and for those with newly diagnosed type 2 diabetes. Using the blood glucose profiles available from continuous glucose monitoring, the relationships between HbA1c and derived blood glucose measures were studied. Mean blood glucose and blood glucose peaks equally predicted HbA1c. The correlation of FPG to HbA1c was weaker than that of mean blood glucose. The haemoglobin glycation index (HGI) is defined as the difference between a subject's HbA1c and that expected from regression of HbA1c on FPG and captures the variation in HbA1c not attributable to FPG. I used Early Diabetes Intervention Trial (EDIT) and UK prospective diabetes study (UKPDS) data to determine whether HGI is reproducible and whether differences relate to potential confounders. In both studies, HGI was reproducible and not explained by the potential confounders examined. I examined whether there were additive effects of FPG, HbA1c or HGI on diabetic complications using UKPDS data since it was found previously that either HbAlc or FPG was related to diabetic complications in UKPDS. For microvascular complications, both FPG and HbA1c were independent risk factors. When HGI was related to microvascular complications, HGI made an independent contribution adjusting for either FPG or HbA1c. For macrovascular complications, HbA1c but not FPG was an independent risk factor. HGI did not make an independent contribution to macrovascular complications adjusting for HbA1c. My work showed that the same HbA1c level does not necessarily have the same clinical meaning in two different subjects. There can be marked differences in individual levels of HbA1c relative to FPG values in people with type 2 diabetes. Thus, HbA1c levels should be interpreted with caution and treatment decisions need to be made considering individual glycaemic control. HGI may be useful, informing healthcare professionals of the likely magnitude and direction of difference between observed HbA1c levels and those expected in the light of prevailing blood glucose levels.

This study aims to evaluate a different approach to diabetes patient education. It begins with an overview of the epidemiology of Type 2 diabetes in recognition that although there have been major developments over the years in identifying and treating diabetes, people with diabetes are still dying prematurely and their quality of their life is still poor when compared to those without the condition. Chapter 2 reviews definitions of health, health behaviour models, relevant international literature and its impact on national policy. Most countries are currently at the experimental stage of developing therapeutic and self-management education programmes. However, routine patient education in Europe and the United States is still based largely on biomedical models. A systematic review of group-based, therapeutic and self-management education programmes for adults with Type 2 diabetes is presented in Chapter 3. This reveals that these approaches to diabetes education improve diabetes control, enhance patient knowledge of diabetes and reduce the requirement for diabetes medication. There is also some evidence to suggest there is increased self-management skills, self-empowerment, quality of life and treatment satisfaction, although further research is recommended to confirm those findings. The tutor's manual for the expert patient programme "X-PERT" is presented in Chapter 4. This was written to encourage the delivery of the X-PERT programme to adults living with Type 2 diabetes. It is designed to illustrate the theories of empowerment and patient activation. Delivery and content of this six-session, group-based, health professional-led diabetes expert patient programme is described in detail. The research proposal for the randomised controlled trial is presented in Chapter 5. A brief background summary is followed by a full description of development of the X-PERT trial, demographic aspects of Burnley, Pendle and Rossendale and the research design. The intervention group was invited to attend the X-PERT programme whilst the control group received routine diabetes treatment. The X-PERT trial tests the hypothesis that delivery of a professional-led, community based, diabetes-specific expert patient programme for adults with Type 2 diabetes based on the theories of patient empowerment and patient activation would: (1) develop the skills and confidence needed for patients to be able to make informed decisions regarding their diabetes self-management; (2) improve biomedical, lifestyle and psychosocial outcomes both in the short term (four months) and longer-term (14 months); (3) meet the International Diabetes Federation (IDF) structure and process standards regarding diabetes education. The results, presented in Chapter 6, support each of the three aspects of the hypothesis stated above. The expert patients, compared with the control group, improved their diabetes control, became more knowledgeable about their diabetes, had a greater sense of empowerment, increased their self-management skills and food related quality of life. Many of the IDF diabetes education standards were also addressed. Chapter 7 considers the strengths and limitations of the trial. It then concludes that a structured, group-based approach to patient education, using models of patient empowerment and activation, offers an improved approach to the treatment of Type 2 diabetes, a serious, expensive and increasing international problem. Pressures on NHS resources from diabetes and its complications are large. Offering people living with diabetes the skills and confidence to self-manage their condition could bring immense benefits, both to those with the condition and to the NHS.

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Euclea undulata Thunb. var myrtina is a widely distributed shrub in South Africa. The roots are used by traditional healers for the treatment of diabetes. Research indicates that roots contain epicatechin, lupeol as well α-amyrin-3O-β-(5-hydroxy) ferulic acid. It was found that α-amyrin-3O-β-(5-hydroxy) ferulic acid inhibits α-glucosidase while epicatechin lowers glucose levels in the blood. Existing literature also indicates the presence of the naphthoquinone 7-methyl-juglone in the roots, although it was not detected in all cases. Due to its cytotoxic nature, 7-methyl-juglone poses a potential threat when E. undulata is used as medicinal treatment. In order to assist the effective and safe use of this plant as a treatment for diabetes, this project aims to determine whether the presence of these metabolites is seasonal. It further aims to contribute to more sustainable harvesting methods by investigating stems and leaves in addition to the roots for the presence of these metabolites. / Environmental Sciences / M. Sc. (Environmental Science)