Background Type 2 diabetes is a common disease and the prevalence has increased in large parts of the world. In treatment of diabetes the type of diet is of great importance considering metabolic factors such as glucose level and blood lipids. Which diet that is most beneficial to avoid diabetic complications has been heavily debated in recent decades. This thesis is based on two clinical studies designed to compare the effects of different macronutrients. Methods A clinical trial was designed to compare a low-carbohydrate diet (LCD) to a low-fat diet (LFD) in treatment of patients with type 2 diabetes. Sixty-one patients at two health care centres were included and randomized to get advice to eat a LCD or a LFD. The LCD had an energy content where 50 energy percent (E%) where from fat, 20 E% from carbohydrates and 30 E% from protein. For the LFD the nutrient composition was similar to what is traditionally recommended for treatment of type 2 diabetes in Sweden. Metabolic factors, anthropometrics and questionnaires were analysed. To study postprandial effects a trial was designed to compare three different diets. Twentyone patients with type 2 diabetes were included to in randomized order test the three types of diets on separate test days. On each test day the patients were served breakfast and lunch and blood samples were taken at six times these days. Glucose, lipids and hormones were analysed. Results There were equal weight reduction in the two groups in the first trial during the two-year study period. At six month when compliance was good according to diet-records, the glucose level (HbA1c) was lowered and the HDL-cholesterol was increased in the LCD group. The inflammatory markers IL-6 and IL-1Ra were significantly lower in the LCD group than in the LFD group. At 12 months the physical function, bodily pain and general health  scores improved within the LCD group only. In the second trial the postprandial glucose and insulin levels were lower on the LCD compared to the LFD. However, the LCD resulted in a tendency to higher postprandial triglyceride levels. The Mediterranean type of diet with all energy intake at lunch resulted in a more pronounced insulin response and a glucose level at lunch similar to that of the low-fat diet. The increase-ratio of insulin correlated to the elevation of the incretin glucose-dependent insulinotropic peptide (GIP). Conclusions In the two-year study we found benefits for the LCD group regarding glucose control and insulin doses. Furthermore, only the LCD was found to improve the subclinical inflammatory state and there were some aspects of improved well-being in this group. Aiming for 20% of energy intake from carbohydrates is safe with respect to cardiovascular risk factors  compared with the traditional LFD and this approach could constitute a treatment alternative. In the postprandial state, the LCD induced lower insulin and glucose excursions than the LFD but at the same time a tendency of higher triglycerides. The long-term significance needs to be further examined. The accumulation of caloric intake from breakfast to lunch to a single large Mediterranean-style lunch-meal in type 2 diabetes might be advantageous from a metabolic perspective.

Bakgrund: Diabetes typ-2 är en av Sveriges största folksjukdomar. Orsakerna till sjukdomen är både genetiska och miljörelaterade. De miljörelaterade faktorerna är främst övervikt och fetma. Diabetes typ-2 kan behandlas med kost, motion, tabletter eller insulin. Kosten har en central roll i behandlingen av diabetes typ-2 och kan ge effekter på både blodsocker och vikt. Syfte: Syftet är att belysa vad och hur sjuksköterskor kan göra för att främja en god kosthållning för patienter med diabetes typ-2. Metod: I denna litteraturstudie har tio studier analyserats och sammanställts i resultatet. Resultat: Både sjuksköterskor och patienter har en brist på kunskap om diabetes typ-2. Sjuksköterskor upplevde därför att de hade svårigheter att ge patienter adekvata kostråd. Stöd och patientundervisning från sjuksköterskor är viktigt för att främja en god kosthållning. I resultatet framkom det att en låg-kolhydratkost är en effektiv kost för att gå ned i vikt och sänka HbA1c för personer med diabetes typ-2. Resultatet delades in i två kategorier: hur sjuksköterskor kan främja god kosthållning och vilken kost sjuksköterskor kan använda för att främja en god kosthållning. Slutsats: Stöd och patientundervisning från sjuksköterskor var en viktig del för att främja egenvården av kost för personer med diabetes typ-2. Slutsatsen visar på att deltagarna i studierna som åt en lågkolhydratkost gick ner i vikt och HbA1c sänktes. Klinisk betydelse: I föreliggande studie presenteras hur och vad sjuksköterskor kan göra för att främja egenvården hos patienter med diabetes typ-2 genom stöd, patientundervisning och kost. Studien kan användas som grund för sjuksköterskor som undervisar i egenvård för patienter med diabetes typ-2. / Background: Type-2 diabetes is one of Sweden´s major national diseases. The causes of the disease are both genetically and environmentally related. The environmental factors are primarily overweight and obesity. Type-2 diabetes can be treated with diet, exercise, tablets or insulin. Diet has a key role in the treatment of type-2 diabetes and can affect both blood sugar and weight. Aim: The aim is to highlight what and how nurses can do to promote a good diet for patients with type-2 diabetes. Method: In this literature study ten scientific articles has been analyzed and put together in the results. Results: Both nurses and patients had a lack of knowledge about type-2 diabetes. Nurses felt that they had difficulties to give the patients adequate dietary advices. Support and patient education from nurses is important to promote a good diet. The results showed that a low-carbohydrate diet is an effective diet for losing weight and lower the HbA1c for people with type-2 diabetes. The results were divided into two categories: how nurses can promote a healthy diet and which diet nurses can use to promote a healthy diet. Conclusion: Support and patient education from nurses were an important part of promoting self-care of diet for people with diabetes type-2. The conclusion shows that the participants in the studies who were on a low-carbohydrate diet lost weight and lowered their HbA1c. Clinical significance: This study presents how and what nurses can do to promote self-care in patients with type 2 diabetes through support, patient education and diet. The study can be used as a basis for nurses who teach patients with type-2 diabetes about self-care.

Bakgrund: Typ 2-diabetes är en av världens största folksjukdomar. Det är en kronisk sjukdom som innebär förändringar i en människas liv och kan medföra komplikationer vilket ställer stora krav på egenvård. För att hantera sjukdomen och uppnå en skälig livskvalitet, behövs kunskap om vilka faktorer som inverkar på egenvården. Syfte: Belysa faktorer som påverkar egenvården hos vuxna med typ 2-diabetes. Metod: En litteraturstudie med kvalitativ ansats utifrån 14 vetenskapliga artiklar. Resultat: Fyra huvudkategorier utkristalliserades i analysen: Stöd, utbildning, patientens bakgrund, samt attityder. Patientutbildning, stöd från hälso- och sjukvården, anhöriga, närstående och från andra i samma situation är av stor betydelse för att införliva egenvårdsaktiviteter adekvat. Resultatet påvisade även att patientens kulturella bakgrund, socioekonomiska miljö och attityden gentemot sjukdomen påverkar egenvården. Slutsats: Faktorerna som påverkar egenvården är många gånger sammankopplade med varandra och reflekterar patienternas inre identitet och miljön de lever i. Klinisk betydelse: Resultatet kan ge personal inom hälso- och sjukvården större förståelse för hur patienter med typ 2-diabetes kan stödjas i sin egenvård. / Background: Type 2 diabetes is one of the world’s major national diseases. It is a chronic disease that involves changes in a person's life and can cause complications which places great demands on self-care. To cope with the disease and achieve a reasonable quality of life, knowledge is needed about the factors that affect self-care. Aim: Elucidating factors affecting self-care in adults with type 2 diabetes. Method: A literature study with qualitative approach based on 14 scientific articles. Results: Four main categories emerged in the analysis: support, education, patient’s background, and attitudes. Patient education, support from health services, family members, relatives and others in the same situation are of great importance to incorporate self-care activities adequately. The result also showed that the patient's cultural background, socio-economic environment and the attitude towards the disease affects their own health care. Conclusion: The factors that influence self-care are often interconnected with each other and reflect patients' inner identity and the environment they live in. Clinical significance: The result can provide personnel in the health care system greater understanding of how patients with type 2 diabetes can be supported in their self-care.

While previous health research with Aboriginal populations focused almost exclusively on Aboriginal Peoples of First Nations descent living on reserves or in isolated rural communities in Canada, this study focusing on diabetes aimed to engage Aboriginal Peoples of First Nations and Métis descent living in an urban Ontario setting. Type 2 diabetes mellitus is a progressive metabolic disorder that affects Aboriginal Peoples of Métis and First Nations descent disproportionately compared to the rest of the Canadian population. To understand this disparity in diabetes incidence and to address issues with existing diabetes prevention and management strategies, this study: a) explores the perceptions surrounding Type 2 diabetes and its prevention from First Nations and Métis community people and health service providers and policy makers; and b) informs the existing diabetes prevention, management and care strategies in light of these perceived understandings. Primary data was collected through 40 in-depth one-on-one narrative interviews with First Nations and Métis people, health service providers and policy makers. Thematic codes that emerged through the narrative analysis of this data revealed that to fully understand the social determinants of diabetes in an urban First Nations and Métis people’s context required the application of intersectionality theory, since production of First Nations and Métis diabetes is socially determined and deeply intersectional. By combining the concepts of the social determinants of health and intersectional approaches, narrative analysis of the primary data revealed that diversities in socio-economic, cultural, legal and spatial contexts determine First Nations and Métis people’s life choices and have a strong bearing on their health outcomes. First Nations and Métis participants’ narratives revealed that dimensions of marginalization were reflected not only through inadequate material resources, but also through intersections of multiple factors such as colonial legacies, stereotyping, legal statuses, and the pan-Aboriginal nature of government policies and services. First Nations and Métis community members indicated that preventive programming aimed at avoiding or managing diabetes should be grounded in balancing and restoring the positive aspects of physical, mental, spiritual and emotional health and should also balance their diverse needs, lived realities, and social circumstances. The views of health service providers and policy makers captured in this thesis tended to reflect an understanding of diabetes causation grounded in both biomedical and intersecting social determinants of health. At the pragmatic level, however, the solution to this health issue presented by health service providers and policy makers addresses only the measurable individualistic biomedical risk factors of diabetes. Policy makers also discussed the need for developing qualitative indicators of the success of presently implemented health programs. Overall, the results of this study indicated that effective diabetes prevention and management strategies for urban First Nations and Métis people must recognize and address the diversities in their historical, socio-economic, spatial and legal contexts as well as their related entitlement to health services. A comprehensive diabetes prevention strategy should target the social determinants of health that are specific to urban First Nations and Métis people and must build on community strengths.

Objective: To explore the association of insulin resistance (IR) with direct measures of physical activity (PA). Research methods and procedures: A school-based, cross-sectional study was conducted in two remote British Columbia coastal First Nations villages. 74 healthy boys and girls (mean = 11.8yrs ± 2.2; range = 8.8-18.5yrs) volunteered to participate. PA was measured with the ActiGraph accelerometer. IR was determined using the homeostasis model assessment of insulin resistance (HOMA-IR). Body mass index standardized for age and sex (zBMI) and waist circumference were used to assess total and central adiposity. Results: From the 39 participants with complete data sets, moderate to vigorous intensity physical activity (MVPA) was inversely related to HOMA-IR (r = -.45, p<0.01) while total and central adiposity were directly related (r= .44, p<.01 and r=.35, p<.05, respectively). Discussion: These data provide evidence of the important role of PA, particularly MVPA, in improving IR and potentially preventing type 2 diabetes in First Nations youth.

Darbo tikslas Įvertinti antro tipo cukrinio diabeto (2 tipo CD) chirurginio gydymo klinikinį ir ekonominį efektyvumą. Uždaviniai : 1. Ištirti visus pacientus operuotus dėl nutukimo ir 2 tipo CD LSMUL KK Chirurgijos klinikoje 2005-2010 metais. 2. Palyginti šių pacientų klinikinę būseną ir gyvenimo kokybę prieš ir praėjus daugiau kaip 1 metams po operacijos. 3. Palyginti 2 tipo CD gydymo išlaidas operuojant ir neoperuojant bei įvertinti skrandžio apylankos operacijos ekonominį efektyvumą. Tyrimo metodika Tyrimui atlikti buvo išduotas Kauno regioninio bioetikos komiteto leidimas Nr. BE-2-59. Atlikta pacientų, kuriems dėl nutukimo ir 2 tipo CD 2005-2010m. Kauno Klinikose buvo atlikta skrandžio apylankos operacija, duomenų retrospektyvinė analizė. Praėjus daugiau kaip 1 metams po operacijos detaliai ištirta pacientų klinikinė būsena. Gyvenimo kokybės ir operacinio gydymo naudingumo įvertinimui taikyti SF-36 klausimynas ir SF-6D konversijos modelis. Ekonominio naudingumo analizės modelis naudotas apskaičiuojant ir lyginant operacinio ir konservatyvaus 2 tipo CD tiesiogines gydymo išlaidas. Duomenys apdoroti ir analizuoti naudojant statistinį duomenų analizės paketą SPSS 15. Rezultatai 2005-2010 metais Kauno klinikų chirurginiame skyriuje dėl nutukimo ir 2 tipo CD operuoti 76 pacientai (52 moterys ir 24 vyrai). 67 pacientams buvo atlikta skrandžio apylankos operacija, 8 skrandžio apjuosimo reguliuojama juosta operacija ir 1 pacientui marginalinė skrandžio rezekcija (sleeve... [toliau žr. visą tekstą] / Aim To evaluate the clinical and cost-effectiveness of the laparoscopic Roux-en-Y gastric-bypass (LRYGB) in obese patients with type 2 diabetes. Tasks: 1. To investigate all the patients underwent the LRYGB on obesity and type 2 diabetes in LUHS Kaunas Hospital in 2005-2010. 2. To compare the clinical outcomes and quality of life (QoL) in operated patients before and 1 year or later after the surgery. 3. To evaluate the cost-effectiveness of LRYGB and to compare it with the conventional treatment cost. Methodology of the research The retrospective study of 51 patient underwent LRYGB on obesity and type 2 diabetes in LUHS Kaunas Hospital in 2005-2010. The clinical evaluation of operated patients 1 year or later after the laparoscopic gastric-bypass. SF-36 questionnaire and SF-6D conversion model were used to evaluate the QoL and health benefits after the surgery. To evaluate and to compare the surgical and conventional treatment costs in obese type 2 diabetes patients, the cost utility analysis model was used. Kaunas regional committee of bioethics approved the project (permission Nr BE-2-59). The data was processed and analysed using the package SPSS 15,0 of statistical data analysis. Results 76 patients (52 women and 24 men) were operated on obesity and type 2 diabetes in LUHS Kaunas Hospital in 2005-2010. 67 patients underwent LRYGB, in 8 patients the laparoscopic adjustable gastric banding and sleeve resection in 1 patient were performed. One year or later after the... [to full text]

Background Type 2 diabetes demands self-management over time, to maintain health and reduce the risk for diabetes complications. However, despite efforts, many persons with type 2 diabetes are not reaching the treatment targets. In diabetes, person-centred care and group education are recommended. Diabetes specialist nurses (DSNs) working in primary healthcare have an important role in supporting patients with type 2 diabetes in their self-management to adapt to the demands of the disease in everyday life. Therefore, it is important to explore the DSNs’ professional role and their experiences of practising person-centred care. The overall aim of the thesis was to explore the professional role of DSNs in primary healthcare, and to describe their experiences of person-centred diabetes care. Methods The thesis includes three studies with qualitative, and one with a quantitative, approach. Data collection consisted of focus group interviews, individual interviews, observations, and questionnaires. Qualitative content analysis and statistics were used in the analysis. In studies I and II, 29 and 31 DSNs participated, respectively. In study III, 10 DSNs and 44 persons with type 2 diabetes participated. Lastly, in study IV, 10 DSNs participated. Results The results in the thesis showed that DSNs have a complex and multifaceted professional role that entails striving to be an expert, a fosterer, a leader, an executive, and a role model, which they found challenging. The DSNs perceived high job demands, such as decision-making and learning. The thesis also showed that the interaction between DSNs and persons with type 2 diabetes shifted from empowerment to authority struggles during group support sessions based on person-centred care. The experience of person-centred care was described as enriching, but DSNs also expressed ambivalence, related to an altered professional role. Conclusion There is a desire by DSNs to be close to persons with type 2 diabetes, although they have several challenges to fulfil, which makes it difficult to uphold a relation with proximity; thus, distance is also present. Even though person-centred care is recommended in healthcare, and despite DSNs’ efforts to practise PCC, the result of this thesis shows that it also implies an altered professional role for DSNs that has to be addressed. / Diabetes intervention in Västerbotten, DIVA 2

Pancreatic beta-cells are responsible for secreting insulin into the circulation to maintain whole body glucose homeostasis. While pancreatic beta-cells have a large capacity to secrete insulin, their function progressively deteriorates during the pathogenesis of type 2 diabetes as a result of both genetic predisposition and environmental factors. Obesity is the largest risk factor for developing type 2 diabetes and is associated with various conditions that can impair normal beta-cell function, including excess free fatty acids, inflammation and insulin resistance. Accumulating evidence in the literature suggests that endoplasmic reticulum (ER) stress contributes to the molecular mechanism of pancreatic beta-cell failure during the progression of type 2 diabetes. In this thesis, I have examined the role of the ER stress sensor ATF6-alpha and also the ER-resident chaperone GRP78 in pancreatic beta-cell homeostasis and function. Work presented in Chapter 2 examined the function of naturally occurring ATF6-alpha protein variants associated with type 2 diabetes. I also examined the role of endogenous ATF6-alpha in pancreatic beta-cells, which is described in Chapter 3. Results from these analyses suggest that the ATF6-alpha gene is not a type 2 diabetes susceptibility gene; however, ATF6-alpha protein expression is important to beta-cell function and survival. Finally, ER stress markers have been detected in pancreatic beta-cells and insulin sensitive tissues (such as adipose and liver), which promote beta-cell dysfunction and insulin resistance, respectively. In Chapter 4, I examined the contribution of ER stress in beta-cell dysfunction specifically by generating transgenic mice over-expressing GRP78. The mice were subsequently challenged by high fat diet to determine their susceptibility to developing symptoms of type 2 diabetes. Indeed increased chaperone capacity in pancreatic beta-cells protected against obesity-induced glucose intolerance and insulin resistance. Overall, these data support the hypothesis that ER stress contributes to beta-cell dysfunction in type 2 diabetes progression.

Background: There are innumerable diabetes studies that have investigated associations between risk factors, protective factors, and health outcomes; however, these individual predictors are part of a complex network of interacting forces. Moreover, there is little awareness about resilience or its importance in chronic disease in adulthood, especially diabetes. Thus, this is the first study to: (1) extensively investigate the relationships among a host of predictors and multiple adaptive outcomes; and (2) conceptualise a resilience model among people with diabetes. Methods: This cross-sectional study was divided into two research studies. Study One was to translate two diabetes-specific instruments (Problem Areas In Diabetes, PAID; Diabetes Coping Measure, DCM) into a Chinese version and to examine their psychometric properties for use in Study Two in a convenience sample of 205 outpatients with type 2 diabetes. In Study Two, an integrated theoretical model is developed and evaluated using the structural equation modelling (SEM) technique. A self-administered questionnaire was completed by 345 people with type 2 diabetes from the endocrine outpatient departments of three hospitals in Taiwan. Results: Confirmatory factor analyses confirmed a one-factor structure of the PAID-C which was similar to the original version of the PAID. Strong content validity of the PAID-C was demonstrated. The PAID-C was associated with HbA1c and diabetes self-care behaviours, confirming satisfactory criterion validity. There was a moderate relationship between the PAID-C and the Perceived Stress Scale, supporting satisfactory convergent validity. The PAID-C also demonstrated satisfactory stability and high internal consistency. A four-factor structure and strong content validity of the DCM-C was confirmed. Criterion validity demonstrated that the DCM-C was significantly associated with HbA1c and diabetes self-care behaviours. There was a statistical correlation between the DCM-C and the Revised Ways of Coping Checklist, suggesting satisfactory convergent validity. Test-retest reliability demonstrated satisfactory stability of the DCM-C. The total scale of the DCM-C showed adequate internal consistency. Age, duration of diabetes, diabetes symptoms, diabetes distress, physical activity, coping strategies, and social support were the most consistent factors associated with adaptive outcomes in adults with diabetes. Resilience was positively associated with coping strategies, social support, health-related quality of life, and diabetes self-care behaviours. Results of the structural equation modelling revealed protective factors had a significant direct effect on adaptive outcomes; however, the construct of risk factors was not significantly related to adaptive outcomes. Moreover, resilience can moderate the relationships among protective factors and adaptive outcomes, but there were no interaction effects of risk factors and resilience on adaptive outcomes. Conclusion: This study contributes to an understanding of how risk factors and protective factors work together to influence adaptive outcomes in blood sugar control, health-related quality of life, and diabetes self-care behaviours. Additionally, resilience is a positive personality characteristic and may be importantly involved in the adjustment process among people living with type 2 diabetes.

Coronary heart disease is the single greatest contributor to mortality within developed countries in our time. Type 2 diabetes mellitus and obesity, both of which are potent risk factors for coronary heart disease, are common conditions with rapidly rising rates of prevalence both globally and in Australia. Within Australia, Indigenous Australians suffer from disproportionately high rates of diabetes, obesity and coronary heart disease, the reason for which lies, in part, with changes in dietary intake and decreased levels of physical activity over the past 200 years. These disease trends have led to a substantially reduced life expectancy from an increase in excess cardiovascular deaths in Indigenous Australians. Assessment of cardiovascular risk in Indigenous Australians is complicated by ethnic differences in cardiovascular risk factors and their prevalence. There is also evidence that Indigenous Australians are genetically predisposed to diabetes. Current cardiovascular risk stratification algorithms are suboptimal, significantly underestimating risk in Indigenous Australians. This thesis aimed to address these issues. Firstly, to evaluate the efficacy of a lifestyle intervention programme to sustainably improve markers of health outcome in a cohort of Indigenous Australians who were overweight or had type 2 diabetes mellitus by improving diet and physical activity levels. Secondly, to evaluate the utility of anthropometric markers of obesity, ultrasound markers of atherosclerotic burden and serum C-reactive protein as additional cardiovascular risk stratification tools. The Healthy Lifestyle Programme (HELP) was a two year prospective intervention study designed and implemented with substantial input from the Indigenous community. The primary intervention consisted of a series of educational workshops delivered predominantly by Indigenous health workers advocating improving diet and increasing physical activity. To complement these workshops, facilities were established within the community to support dietary improvement and increased physical activity. Sustainable changes to markers of cardiovascular outcome, including significant reductions in central obesity and blood pressure were demonstrated over time. A slowing in the deterioration of renal function as marked by albuminuria was also detected. These beneficial changes were accompanied by increased physical activity and improved dietary intake. In a substudy, individuals with the apolipoprotein E4 genotype, who were dyslipidaemic at baseline, benefited from lipid profiles that improved significantly during the course of the study. Changes in blood pressure and central obesity detected during the course of the project are likely to have significant clinical impact on health outcomes considering their sustained nature. Evaluating ultrasound imaging based markers of cardiovascular risk, carotid artery intimal medial thickness was a more reliable measure of risk based on its firm correlation with established cardiovascular risk factors compared to brachial artery flow mediated vasodilatation. Carotid artery intimal medial thickness may be the better surrogate marker to improve cardiovascular risk stratification in the Indigenous population. Examining anthropometric markers of obesity, body mass index and waist circumference but not waist hip ratio correlated well with traditional cardiovascular risk factors. Furthermore, both body mass index and waist circumference predicted insulin resistance fairly well using threshold values derived from receiver operating characteristics curve analyses. Both body mass index and waist circumference were simple to perform with a high degree of reproducibility between observers and will likely be valuable additional cardiovascular risk stratification tools. Raised inflammatory stress, as marked by elevated serum C-reactive protein levels, was found in individuals with diabetes or obesity. C-reactive protein levels did not correlate with carotid artery intimal medial thickness, suggesting that C-reactive protein raises cardiovascular risk by means other than increasing atherosclerotic burden. Genotyping a small random sample of our the C-reactive protein gene promoter region. This SNP was found to independently increase serum C-reactive protein in the Framingham cohort. A genetic basis for increased inflammatory stress may contribute to coronary heart disease in Indigenous Australians. In summary, a community centred lifestyle intervention programme was efficacious in producing sustainable improvement in markers of health outcome. Examination of additional cardiovascular risk markers in the Indigenous community have provided evidence for using carotid artery intimal medial thickness, waist circumference, body mass index and serum C-reactive protein levels to improve cardiovascular risk stratification. These additional tools would allow for more specific resource allocation to target individuals at highest cardiovascular risk for preventative management. C-reactive protein gene polymorphisms, their contribution to circulating C-reactive protein levels and cardiovascular outcomes warrants further investigation in the Indigenous population. A more proactive risk management plan, which includes a lifestyle intervention component, may yield the greatest improvement in long term health outcomes if targeted at younger members of the Indigenous community.