Type 2 diabetes mellitus (T2DM) is a heterogeneous metabolic disease impacting more than 8.3% of adults in the United States. Diabetes-related care accounts for more than 11% of all patient care expenditures. The purpose of this project was to identify the primary concerns of members of the T2DM patient population in an underserved clinic in rural southcentral United States and to make recommendations for a staff diabetes education program to address these concerns. Orem's theory of self care outlined the importance of educating and supporting patients in their efforts to manage their own healthcare. Knowles's assumptions of how adult's learn guided the design and provided guidelines for the planning and implementation of the education program. The practice-focused question explored the major concerns of T2DM patients receiving care at the primary care clinic. Clinic providers completed the Diabetic Care Concern Assessment (DCCA) with all adult patients (n = 45) diagnosed with T2DM during primary care patient visits. DCCA responses were placed on an excel spreadsheet and analyzed for themes. Major themes from qualitative analysis of participant responses included fear of the disease, managing daily diabetes control, having additional education on diabetes, learning more about control strategies for diabetes, and helping with daily diabetes management. Findings will promote positive social change at the clinic as providers target specific concerns of their individual patients. T2DM patients may experience improved quality of life as they become empowered to manage their disease. The education program will also lead to the development and implementation of patient treatment plans that potentially decrease complications associated with diabetes.

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Motivation Hypertension and type 2 diabetes mellitus are common in the black population of South Africa. The literature also shows that elevated blood glucose concentrations can lead to an increase in blood pressure and a blunted decline in nocturnal blood pressure. Therefore, the motivation for this study was to determine if blood glucose may play a role regarding the blunted nocturnal decline in blood pressure in African and Caucasian men. Aim The aim of this study was to investigate the relationship between a blunted nocturnal decline in blood pressure and blood glucose in African and Caucasian men. Methodology A comparative population study was preformed that consisted of 202 school teachers (101 African and 101 Caucasian) between the ages of 25–60 years from the North West Province, South Africa. Subjects were excluded if their body temperature was elevated, had a dependence or abuse of psychotropic substances, were regular blood donors and/or vaccinated in the previous three months. Ambulatory systolic (SBP) and diastolic blood pressure (DBP) were measured. Blood samples from the antebrachial vein were collected in sodium fluoride tubes to determine the serum glucose level and glycosylated hemoglobin A1c (HbA1c) percentage. Estimated average glucose (eAG) was determined from the percentage HbA1c by means of a regression formula. Means and proportions were compared by standard t–test and the chi–square test, respectively. Pearson correlations were used to determine unadjusted associations and multiple regression analysis to determine adjusted associations between variables. Results and Conclusion African men had an elevated HbA1c (p<0.001), eAG (p<0.001), nighttime SBP (p<0.001) and DBP (p<0.001). These results remained similar when non–dipping African and Caucasian men were compared. The Africans also smoked more (p=0.012), consumed more alcohol (p=0.049), had a higher percentage of non–dippers (p=0.054), HIV infected subjects (p<0.001) and a larger number of subjects that used anti–hypertensive medication (p=0.049). The unadjusted analysis showed positive correlations between all the blood pressure measurements and serum glucose, HbA1c and eAG in the African non–dipper men. While in the non–dipper Caucasian men, only daytime SBP and nighttime SBP (22:00–06:00) correlated positively with serum glucose, HbA1c and eAG. Furthermore, when viewing the relationship between carotid intima–media thickness (CIMT) and the blood pressure measurements in the African population, only nighttime (00:00– 04:00) SBP (r=0.581, p<0.001) and DBP (r=0.566, p<0.001) showed positive associations. After adjustments were made for age and body mass index the associations between the various blood pressure measurements and blood glucose disappeared in the non–dipper Caucasian men. However, in the non–dipper African men both nighttime (22:00–06:00) SBP and (00:00– 04:00) SBP showed positive correlations with serum glucose, HbA1c and eAG. After full adjustments (age, BMI, smoking, alcohol intake, physical activity, C–reactive protein and baroreceptor sensitivity) were made, nighttime (00:00–04:00) SBP was the only measure of blood pressure that correlated positively with HbA1c (p=0.069) and eAG (p<0.001) in the nondipper African men. No significant relationships were found for Caucasian men. Furthermore, to determine if the association between nighttime (00:00–04:00) SBP and eAG were independent of CIMT, we adjusted for CIMT. By doing so the positive association between SBP and eAG remained significant in the non–dipper African men (R2=0.617; =0.438; p=0.008) and nonsignificant in the non–dipper Caucasian men (R2=0.423; =0.169; p=0.33). However, the relationship between CIMT and eAG disappeared when we adjusted for SBP, suggesting that the SBP and eAG relationship drives CIMT. In conclusion, the association between the early morning SBP (00:00–04:00) and the blood glucose in non–dipping African men suggests that the blunted decline in nocturnal blood pressure during the early morning hours is associated with chronically elevated blood glucose. / Thesis (M.Sc. (Physiology))--North-West University, Potchefstroom Campus, 2011.

Motivation Hypertension and type 2 diabetes mellitus are common in the black population of South Africa. The literature also shows that elevated blood glucose concentrations can lead to an increase in blood pressure and a blunted decline in nocturnal blood pressure. Therefore, the motivation for this study was to determine if blood glucose may play a role regarding the blunted nocturnal decline in blood pressure in African and Caucasian men. Aim The aim of this study was to investigate the relationship between a blunted nocturnal decline in blood pressure and blood glucose in African and Caucasian men. Methodology A comparative population study was preformed that consisted of 202 school teachers (101 African and 101 Caucasian) between the ages of 25–60 years from the North West Province, South Africa. Subjects were excluded if their body temperature was elevated, had a dependence or abuse of psychotropic substances, were regular blood donors and/or vaccinated in the previous three months. Ambulatory systolic (SBP) and diastolic blood pressure (DBP) were measured. Blood samples from the antebrachial vein were collected in sodium fluoride tubes to determine the serum glucose level and glycosylated hemoglobin A1c (HbA1c) percentage. Estimated average glucose (eAG) was determined from the percentage HbA1c by means of a regression formula. Means and proportions were compared by standard t–test and the chi–square test, respectively. Pearson correlations were used to determine unadjusted associations and multiple regression analysis to determine adjusted associations between variables. Results and Conclusion African men had an elevated HbA1c (p<0.001), eAG (p<0.001), nighttime SBP (p<0.001) and DBP (p<0.001). These results remained similar when non–dipping African and Caucasian men were compared. The Africans also smoked more (p=0.012), consumed more alcohol (p=0.049), had a higher percentage of non–dippers (p=0.054), HIV infected subjects (p<0.001) and a larger number of subjects that used anti–hypertensive medication (p=0.049). The unadjusted analysis showed positive correlations between all the blood pressure measurements and serum glucose, HbA1c and eAG in the African non–dipper men. While in the non–dipper Caucasian men, only daytime SBP and nighttime SBP (22:00–06:00) correlated positively with serum glucose, HbA1c and eAG. Furthermore, when viewing the relationship between carotid intima–media thickness (CIMT) and the blood pressure measurements in the African population, only nighttime (00:00– 04:00) SBP (r=0.581, p<0.001) and DBP (r=0.566, p<0.001) showed positive associations. After adjustments were made for age and body mass index the associations between the various blood pressure measurements and blood glucose disappeared in the non–dipper Caucasian men. However, in the non–dipper African men both nighttime (22:00–06:00) SBP and (00:00– 04:00) SBP showed positive correlations with serum glucose, HbA1c and eAG. After full adjustments (age, BMI, smoking, alcohol intake, physical activity, C–reactive protein and baroreceptor sensitivity) were made, nighttime (00:00–04:00) SBP was the only measure of blood pressure that correlated positively with HbA1c (p=0.069) and eAG (p<0.001) in the nondipper African men. No significant relationships were found for Caucasian men. Furthermore, to determine if the association between nighttime (00:00–04:00) SBP and eAG were independent of CIMT, we adjusted for CIMT. By doing so the positive association between SBP and eAG remained significant in the non–dipper African men (R2=0.617; =0.438; p=0.008) and nonsignificant in the non–dipper Caucasian men (R2=0.423; =0.169; p=0.33). However, the relationship between CIMT and eAG disappeared when we adjusted for SBP, suggesting that the SBP and eAG relationship drives CIMT. In conclusion, the association between the early morning SBP (00:00–04:00) and the blood glucose in non–dipping African men suggests that the blunted decline in nocturnal blood pressure during the early morning hours is associated with chronically elevated blood glucose. / Thesis (M.Sc. (Physiology))--North-West University, Potchefstroom Campus, 2011.

Diabetes mellitus (DM) is a syndrome of multiple etiologies resulting from lack of insulin and / or the inability of insulin properly exercise its effects. It is considered the world, a public health problem by the position it occupies with high epidemiological incidence and prevalence, besides causing macrovascular and microvascular complications. The DM has two main forms, type 1 (DM1), which appears mostly in childhood or adolescence and type 2 (DM2), the most frequent, accounting for 85% to 90% of cases, usually of insidious onset, especially after 40 years of age, affecting obese individuals in 90% of the time. Cardiovascular diseases (CVD) are responsible for approximately 52% of deaths of patients with DM. The strategy of prevention of these chronic complications essentially depend on the adequate control of blood glucose and other comorbidities, including dyslipidemia and hypertension (SAH). This ivestigação was conducted to evaluate the effect of pharmaceutical intervention on glycemic control in outpatients suffering from DM2.Trata is a longitudinal study with intervention, using 100 subjects during query consecutively diagnosed with DM2 in private clinic endocrinology from May 2011 to February 2012. All patients answered a questionnaire and underwent pharmaceutical intervention, conducted by the researcher. After this intervention, there was a significant reduction of 45% CI 95% in A1C levels. Thus, there was still improvement in outcomes among women (69%) (p = 0.01) and the following parameters: fasting glucose (p = 0.000), frequency of exercise (p = 0.0001), adoption of low-calorie diet (p = 0.0001), adherence to drug therapy (p = 0.024) and BMI (p = 0.012). / O diabetes mellitus (DM) é uma síndrome de etiologia múltipla decorrente da falta de insulina e/ou da incapacidade da insulina exercer adequadamente seus efeitos. É considerado, mundialmente, um problema de saúde pública pela posição epidemiológica que ocupa com altas taxas de incidência e prevalência, além de acarretar complicações macrovasculares e microvasculares. O DM apresenta duas formas principais, o tipo 1 (DM1), que aparece principalmente na infância ou na adolescência e o tipo 2 (DM2), a mais freqüente, responsável por 85% a 90% dos casos, geralmente de instalação insidiosa, principalmente após os 40 anos de idade, acometendo indivíduos obesos em 90% das vezes. As doenças cardiovasculares (DCV) são responsáveis por aproximadamente 52% das mortes dos portadores de DM. A estratégia de prevenção destas complicações crônicas dependem, fundamentalmente, do adequado controle da glicemia e de outras comorbidades, entre elas a dislipidemia e a hipertensão arterial sistêmica (HAS). A presente ivestigação foi conduzida visando avaliar o efeito da intervenção farmacêutica no controle da glicemia de pacientes ambulatoriais portadores de DM2.Trata-se de um estudo longitudinal com intervenção, utilizando-se 100 sujeitos durante consulta, consecutivamente, com diagnóstico de DM2 em ambulatório privado de endocrinologia no período de maio de 2011 a fevereiro de 2012. Todos os voluntários responderam a um questionário e sofreram intervenção farmacêutica, realizada pelo pesquisador. Após esta intervenção, ocorreu uma redução significativa de 45% IC 95% nos níveis de A1C. Diante disso, observou-se ainda melhora nos resultados entre as mulheres (69%) (p=0,01) e nos seguintes parâmetros: glicemia de jejum (p=0,000), frequência de exercícios físicos (p=0,0001), adoção da dieta hipocalórica (p= 0,0001), adesão à terapia medicamentosa (p= 0,024) e IMC (p= 0,012).

Diabetes mellitus is a group of metabolic disorders caused by a relative or absolute lack of insulin. Currently, 23.6 million Americans have diabetes. Diabetes can lead to serious microvascular and macrovascular complications, such as cardiovascular disease, blindness, kidney disease, lower-limb amputations, and premature death. Due to the potential cardiovascular complications and the high prevalence of co-morbid hypertension and/or hyperlipidemia in patients with diabetes, diabetes management should include close monitoring of blood glucose, blood pressure, and cholesterol levels. Medical management of diabetic patients is costly; approximately 1 in every 10 health care dollars is currently spent treating diabetes. Studies have shown that in chronic conditions such as diabetes, increased medication use results in demonstrable improvements in health outcomes, reduced hospitalization rates, and decreased direct health care costs. To date no studies have evaluated the impact of a pharmacist-led intervention on diabetic medication adherence. The purpose of this investigation was to analyze the impact of a pharmacist-led medication management program on medication adherence and pharmacy costs and to evaluate clinical measures of diabetes, hypertension, and hyperlipidemia. This study was a quasi-experimental, longitudinal, pre-post study, with a control group. Scott & White Health Plan (SWHP) patients with diabetes (type 1 or type 2), poor glycemic control (most recent A1C >7.5%), and living within 30 miles of participating pharmacies were invited to participate in the intervention which consisted of monthly appointments with a clinical pharmacist and a co-payment waiver for all diabetes medications and testing supplies. A total of 118 patients met study inclusion criteria and were enrolled in the intervention between August 2006 and July 2008. Intervention patients were matched on sex and age to SWHP patients with poor diabetes control living more than 30 miles from a participating pharmacy. To measure the impact of the intervention, medical and pharmacy data were evaluated for one year before and after the study enrollment date. A significant difference was seen in the percentage of patients with type 1 diabetes in the intervention group (14) and the control group (3). The medication management program significantly improved A1C levels in intervention patients relative to controls (-1.1% vs. 0.6%) and was more effective in lowering A1Cs in type 2 diabetics than type 1 patients. Although the generalized linear model did not show that the intervention significantly improved the percentage of patients achieving the ADA goal A1C of <7% compared to controls, the multivariate logistic regression, which controlled for factors such as diabetes type, showed that patients participating in the intervention were 8.7 times more likely to achieve the A1C goal. Persistence with diabetic medications and the number of medications taken significantly increased in the intervention group; however, adherence rates, as measured by medication possession ratio (MPR), did not significantly improve relative to controls. The expenditure on diabetic medications and testing supplies increased substantially more in the intervention group than in the control group. The percentage of patients adherent with antihypertensive medications (MPR ≥80%) increased from 76% to 91% in the intervention group and decreased from 68% to 63% in the control group (P<0.05); no significant difference in blood pressure control was observed. For hyperlipidemia medications, adherence and persistence increased and pharmacy costs decreased in both groups, likely due to the introduction of the first generic HMG-CoA reductase inhibitor into the market during the study period. Future research is needed on the impact of the intervention on medical resource utilization and costs. / text

Type 1 diabetes (T1D) is characterised by an absolute insulin deficiency resulting from the chronic and progressive destruction of pancreatic β-cells by the immune system cells. Continuous subcutaneous insulin infusion (CSII) is becoming a popular technique for insulin delivery among T1D patients. Exercise is known to exert anti-inflammatory effects and metabolic control. Therefore it was of interest to study this in T1D using CSII. The objectives of this thesis were to further understanding of the effect of exercise on blood glucose, hemoglobin A1c, lipids, insulin and inflammatory markers in healthy and T1D volunteers. Three studies have been investigated where the diabetic volunteers used multi daily injections (MDI) or CSII. Firstly a survey was conducted aimed to investigate the effect of exercise on T1D patients using CSII therapy. The second study examined the acute and chronic effects of resistance and cardio exercise at moderate intensity on inflammatory markers such as IL-6, IL-1β, TNF-α and IFN-γ in healthy and T1D using MDI or CSII. Finally, a study was undertaken to find out the effects of chronic moderate intensity exercise on lipids profile and glycaemic control in healthy and T1D using MDI or CSII. The statistical analysis of the survey showed that CSII therapy for T1D had a significant reduction on A1c, insulin requirement and improvement of lipids profile compared to MDI. Moreover, majority of CSII users (63%) rarely suffered from hypoglycemia during exercise. The second study demonstrated that acute and chronic exercises have a positive impact on the inflammatory markers among CSII users e.g. in CSII users statistically significant increase in IL-6 and TNF-α levels were observed (P=0.014 and P=0.001 respectively). The last study showed that lipids profile, total daily insulin units were improved and A1c levels were significantly reduced in CSII as well as MDI groups after 6 weeks of exercise. T1D affects major organs e.g. heart, kidneys, blood vessels etc. However, good glycaemic control can reduce the risk of diabetes complications. This study suggested that CSII therapy along with exercise can maintain the BG level close to normal, as all 5 participants of the study showed an improvement in their BG levels after exercise.

Obesity is a major public health problem. Bariatric surgery is currently the only available treatment that offers sufficient weight-loss and metabolic benefits over time. Although bariatric surgery is considered safe now, serious complications still occur. The aim of this thesis was to identify factors associated with an increased risk for postoperative complication after laparoscopic gastric bypass surgery. Study I included patients operated with laparoscopic gastric bypass surgery in Sweden from May 2007 until September 2012. The risk for serious complication was low (3.4%). Suffering an intraoperative adverse event or conversion of the operation to open surgery were the strongest risk factors for postoperative complication. The annual operative volume and experience of the procedure at the institution were also important risk factors. Patient-specific risk factors appeared to be less important although age was associated with an increased risk. In Study II, a raised glycated haemoglobin A1c (HbA1c) was evaluated as a risk factor for serious postoperative complications in non-diabetics. A higher incidence of serious postoperative complications was seen with elevated HbA1c values, even at levels classified as ‘‘pre-diabetic’’. Study III was a multicentre, randomised clinical trial (RCT). 2507 patients planned for laparoscopic gastric bypass surgery were randomised to either mesenteric defects closure or non-closure. Closure of the mesenteric defects reduced the rate of reoperation for small bowel obstruction from 10.2% to 5.5% at 3 years after surgery. A small increase in the rate of serious postoperative complication within the first 30 days was seen with mesenteric defects closure. This relatively small increase in risk was however outweighed by the marked reduction of later reoperations for small bowel obstruction. Study IV was a comparison between study III and an observational study on the same population under the same period of time. Although the observational study reached the same conlusion as the RCT, the efficacy of mesenteric defects closure was less pronounced. Observational studies may thus be an alternative to RCTs under situations when RCTs are not feasible. The efficacy may however be underestimated.

Obesity has been recognized as an increasing issue within our country. Obesity contributes to many health related issues, including type 2 diabetes mellitus. Portion size is a factor that has generated clinical research interest. The aim of this study was to determine if there was a relationship between management of diabetes measured by hemoglobin A1c and portion size selection for type 2 diabetics. In this study, subjects selected portion sizes of four different foods. Data were compared to recent A1c levels. Due to the small sample size, nonparametric statistical analysis was used. The relationship of grain portion weight selection and A1c was significant (Spearman R = .900, p = .037). This finding has potential for future investigation and patient education.

The study investigated the association between body mass index (BMI) and depression based upon glycated hemoglobin levels (HBA1C) among United States veterans. Based on Bandura's social cognitive theory, a cross-sectional analysis examined the association between BMI and depression on HBA1C regulation, and if the interaction between BMI and depression affects HBAIC regulation among veterans. Multiple regression analysis was used to test the multivariate associations between depression and BMI on the outcome variable of HBA1C. Linearity, normality, and homoscedasticity were assessed using normal probability plots and residual analysis. Durbin-Watson statistics were used to test for autocorrelations, and variance inflation factor was used to check for multicollinearity. There was not a statistically significant difference between those who were depressed (Mdn = 32.76, IQR = 7.8) and those who were not depressed (Mdn = 33.27, IQR = 5.0) in terms of BMI (U = 774.0, p = 0.47). When depression, BMI, an interaction term for depression*BMI, and other predictor variables were entered into the regression model, these variables did not account for a significant increase in shared variance in HBA1C (Î?R2 = 0.17, F (14, 74) = 0.17, p = 0.37). Social change implications generated from this study include better resource utilization, improved quality of care, increased veteran satisfaction and improved veteran experience across the healthcare system. The findings from the study can be used to expand access to specialized services for chronically ill veterans, coordinate resources, better outcomes and facilitate seamless care coordination between mental health and primary care providers