Type 2 diabetes (T2DM) is a health epidemic that continues to worsen. A major concern is that treatment adherence rates hover around 50%, despite the introduction of new medications, treatments, and technology. Lack of adherence by patients can lead to complications like blindness, kidney disease, and amputations. While there have been many studies conducted to evaluate patient factors related to adherence, fewer studies have been conducted to evaluate the role of the physician-patient relationship. The purpose of this study was to examine the correlation between the physician-patient relationship and patient treatment adherence, and examine the moderators of age, education, ethnicity, and income. Gender was included as a moderator in a secondary analysis. Two theories formed the theoretical framework of this study: biopsychosocial model and self-efficacy theory. This quantitative nonexperimental study was completed with survey data collected from 92 participants in the United States ages 18 or older who were under treatment for T2DM for at least a year, and who had seen their physician at least once in the previous year. Correlational and regression analyses were conducted using data from the modified Clinician and Group Survey and the Diabetes Management Self-Questionnaire. The physician-patient relationship predicted treatment adherence, and gender moderated the relationship. These findings suggest the importance of the physician-patient relationship as a factor in patient treatment adherence. This has important implications for social change because an understanding of which physician factors lead to treatment adherence may help improve patient outcomes, reduce T2DM complications, improve patient quality of life, and reduce healthcare costs.

Adult Oral Health Programme: The Effect of Periodontal Treatment and the Use of a Triclosan Containing Toothpaste on Glycaemic Control in Diabetics Abstract Aim: The aim of the research study is to establish an adult oral health programme for diabetics in Majuro, Republic of the Marshall Islands in order to determine the impact of non-surgical periodontal treatment followed by the use of a triclosan containing dentifrice on the maintenance of periodontal health and glycaemic control in type 2 diabetic patients. Hypothesis: Non-surgical periodontal treatment results in improved periodontal health and better glycaemic control in diabetics and use of a triclosan containing toothpaste is effective in maintaining this improvement in diabetics. Methods: An adult oral health programme was created, within which was conducted a two-group randomised clinical trial to address the hypothesis that non-surgical periodontal treatment results in improved periodontal health and better glycaemic control in type 2 diabetics and that the use of a triclosan containing toothpaste is effective in maintaining this improvement in diabetics. In this double blind controlled trial, sixty adult patients (aged 35 to 65 years) with type 2 diabetes mellitus having a minimum of 16 teeth received non-surgical periodontal treatment. Half of the patients were randomly assigned to use a triclosan containing toothpaste, Colgate Total, and the other group a non-triclosan toothpaste, Colgate Fluoriguard. The study evaluated the improvement in periodontal health by recording Probing Pocket Depth (PPD) on 6 sites of each tooth, and the number of sites bleeding on probing (BOP) at baseline, and at 6 months and 12 months after treatment. The second part of the study evaluated the impact of improvement of periodontal health on glycaemic control in type 2 diabetics by measuring HbA1c and RBS, and also assessing the levels of C-Peptides and CRP at baseline, and at 6 months and 12 months after treatment. The study also evaluated the effectiveness of a triclosan containing toothpaste in maintaining the improvement in periodontal health after non-surgical periodontal treatment. Results: The results showed that it was feasible to establish an oral health programme for the diabetics and could improve their periodontal health, and that toothpaste containing triclosan is effective in maintaining the improved periodontal heath in type 2 diabetics. Mean PPD dropped from 2.35mm to 1.95mm in the triclosan group and from 2.49mm to 2.24 mm in the non-triclosan group and the mean number of BOP sites dropped from 4.9 to 2.8 in the triclosan group and from 4.7 to 3.2 in the fluoriguard at 12 month visits. However, the results did not show improvement of HbA1c nor RBS levels in either group. C-Peptide levels increased and C-Reactive Protein levels decreased in both groups, however, not to significant levels at 12 month visits. Conclusion: The results of this research study lead to the conclusion that treating periodontal infection has effect of periodontal health of type 2 diabetic patients and following-up with simple personal oral hygiene of regular tooth-brushing helps maintain their periodontal health. This programme also proved that this type of oral health programme is feasible and valuable for diabetics in isolated places like the Marshall Islands, where infrastructure, personnel and resources are limited to treat microvascular and macrovascular complications of diabetes. As for the effectiveness of treating periodontal infections on glycaemic control of diabetics, this study failed to support the hypothesis that non-surgical treatment plus triclosan containing toothpaste would lead to better glycaemic management through improved periodontal health.

The prevalence of insulin resistance and type 2 diabetes mellitus (T2DM) in obese children and adolescents is growing at an alarming rate, especially in ethnic minorities. It is not clear whether young people of different ethnic backgrounds vary in their metabolic response to excessive adiposity. Differences in lipid partitioning in the abdominal fat compartments have been observed among different ethnic groups. The aim of this study was to evaluate whether there are ethnic differences in intramyocellular lipid (IMCL) levels that are related to differences in insulin sensitivity. Eighty-two obese children and adolescents underwent 1) 1H nuclear magnetic resonance (NMR) spectroscopy to non-invasively quantify IMCL levels in their soleus muscle, 2) an oral glucose tolerance test and (in a subset of subjects) a euglycemic-hyperinsulinemic clamp to assess insulin sensitivity, 3) a dual-energy X-ray absorptiometry (DEXA) scan to measure total percent body fat, and 4) magnetic resonance imaging to measure abdominal fat distribution. IMCL levels in Hispanic children and adolescents (1.50 ± 0.64%) were significantly greater than in their Caucasian (1.19 ± 0.40%) and African-American (1.09 ± 0.49%) peers. Visceral fat was significantly lower in African Americans (42.7 ± 18.8cm2) and were similar in Caucasians (70.9 ± 27.5cm2) and Hispanics (77.3 ± 41.9cm2). The three groups were not different with respect to insulin sensitivity. For the entire cohort, IMCL levels were inversely related to insulin sensitivity. There was a significant correlation between visceral fat and insulin resistance in Hispanics and Caucasians but not in African Americans. In conclusion, these data suggest that there are significant ethnic differences in lipid partitioning in both the muscle and abdominal compartment. These findings may explain ethnic differences in insulin sensitivity and further the understanding of the pathogenesis of insulin resistance and T2DM.

This Doctorate of Nursing Practice (DNP) Project is a program evaluation of a Motivational Interviewing (MI) Training Program provided by Southeast Arizona Health Education Center (SEAHEC). MI is a counseling style that focuses on exploring and resolving ambivalence to elicit behavior change. The purpose of this DNP Project was to: 1) describe the Motivational Interviewing Training Program provided by SEAHEC for ¡Vivir Mejor! healthcare providers; and 2) evaluate the long-term effectiveness of the MI training program by assessing: a) if program participants have retained the MI skills they learned in the training program, and b) if program participants apply these learned MI skills one-year post intervention in their encounters with patients diagnosed with T2DM. The Centers for Disease Control (CDC) Framework for Program Evaluation was used to guide this program evaluation. An online survey was administered to the ¡Vivir Mejor! healthcare providers to evaluate the MI program. Overall, based on the survey results, there was a positive response to the SEAHEC MI Training Program. The results of this program evaluation are limited due to a low response rate. However, these results will be shared with key stakeholders to inform the development of future MI training programs for rural healthcare providers.

The purpose of this research was to evaluate the impact of glycemic measures, and changes in identified risk factors (BMI, waist circumference, lipids, blood pressure) on follow-up glycemia, in Pima children at high risk for type two diabetes (type 2 DM).I computed incidence and cumulative incidence of type 2 DM in Pima children 5-19 years of age between 1983 and 2004. Cox proportional hazards rates for development of type 2 DM were calculated by glycemic measure (HbA1C, 20PG, FPG) controlling for confounding factors (age, sex, BMI, blood pressure, and cholesterol). Diabetes was defined by the presence of at least one of four criteria: 1) 20PG of >200 mg/dl, 2) FPG of >126 mg/dl, 3) HbA1C > 8.0%, or 4) hypoglycemic treatment. Linear regression models were computed to identify the impact of changes in risk factors on changes in HbA1C. Only exams performed in non-diabetic children during childhood were included in the regression models.Among 2658 non-diabetic children, 258 cases of diabetes occurred during mean 9.1 years of follow-up (1.5 - 21.7). The age-sex adjusted incident rate of diabetes was 19.0 cases per 1000 person-years, and cumulative incidence was 54% by age 40. Incidence rates increased with increasing baseline values of 20PG, and FPG, but not for HbA1C. For HbA1C the relationship was u-shaped with the lowest and highest quartiles having the highest DM rates. After adjustment for confounding risk factors using Cox proportional hazards analysis, the risk for diabetes increased 2-fold for every 10 mg/dl increase in FPG. Changes in waist circumference best predicted changes in HbA1C (R2 = 0.48, Ï <0.001). However, the ability of waist circumference to predict change is limited due to the powerful effect of regression to the mean, suggesting that these risk factors contribute very little to changes in HbA1C, at least in childhood.Childhood levels of glycemia predict development of type 2 DM later in life. While changes in waist circumference are associated with only moderate changes in HbA1C, this does not refute the significant contribution of adiposity in childhood to the development of type 2 DM.

ABSTRACT Background: Prediabetes is a precursor condition to type 2 diabetes mellitus. Previous research and clinical trials have shown that the onset of type 2 diabetes could be delayed or prevented through structured life style modifications such as dietary changes, modest weight loss and moderate-intensity exercise. This study examines U.S adults of different ethnicities that include non-Hispanic white, non-Hispanic black and Mexican Americans and whether their awareness of diabetes risk is associated with their participation in diabetes risk reduction behavior, a combination of physical activity, weight control and fat/calories intake. Methods: The 2007-2008 National Health and Nutrition Examination Survey, NHANES, was used to conduct a cross-sectional study of 4083 U.S. adults who were 20 years old and above and were aware of their diabetes risk. The association between the awareness of one’s diabetes risk and the adoption of diabetes risk reduction behavior were examined in present of other risk factors such as age, gender, ethnicity, education, annual family income, BMI, hypertension, mean systolic blood pressure, mean diastolic blood pressure, total cholesterol, LDL, HDL and triglyceride levels. Males and females were examined separately for all analyses performed. Cross tabulation was conducted and p-values were calculated by the Pearson’s chi-square test for the categorical variables which include gender, ethnicity, education, annual family income, adiposity and hypertension. One Way ANOVA and Tukey post hoc tests were conducted for the continuous variables which include age, mean systolic blood pressure, mean diastolic blood pressure, total cholesterol, LDL, HDL and triglyceride levels. Univariate and multivariate analyses were performed to determine the association between the main independent variable, awareness of one’s diabetes risk, and the dependent variable, adoption of diabetes risk reduction behavior, controlling for other risk factors. A p-value of <0.05 and 95% confidence intervals were used to determine statistical significance throughout all analyses performed. Results: After controlling for age, gender, race, education, annual family income, BMI, hypertension, mean systolic blood pressure, mean diastolic blood pressure, total cholesterol, LDL, HDL, and triglycerides, results from the multivariate analysis showed that subjects who were aware of their diabetes risk were more likely to adopt diabetes risk reduction behavior (OR= 1,734, 95 % CI=1.217-2.470). Females and non-Hispanic blacks, who were aware of their diabetes risk, were also more likely to adopt diabetes risk reduction behavior compared to males, non-Hispanic whites and Mexican Americans. An increase in the levels of education, annual family income and BMI was also associated with the adoption of diabetes risk reduction behavior. Stratification according to gender and ethnicity, showed that Mexican American males and females were more likely to engage in diabetes risk reduction behavior compared to non-Hispanic whites and non-Hispanic blacks (Mexican American males: OR: 2.496, CI: 0.792-7.868; Mexican American females: OR: 2.830, CI: 0.917-8.736). Conclusion: This study provides useful insights for health care providers and public health professionals who are developing health promotion and prevention interventions to address pre diabetes before it develops into type 2 diabetes. This study also allows the development of tailored interventions for specific genders and ethnic groups that are at risk. Results of this study indicate that Mexican Americans and females (in general) are more likely to adopt diabetes risk reduction behavior. Therefore, physicians and health care providers should develop culturally, linguistically and gender- specific education materials and programs for this particular gender and ethnic group. This in turn, may reduce the overall increasing prevalence of diabetes, reduce racial and gender disparities and may have a positive impact on the overall health of the U.S. population.

Darbo objektas: Fizinis aktyvumas, mityba ir antrojo tipo cukrinis diabetas. Darbo tikslas: Įvertinti fizinio aktyvumo, mitybos ir antrojo tipo cukrinio diabeto sąsają. Darbo uždaviniai: 1. Įvertinti vyresnio amžiaus sveikų žmonių ir sergančių 2 tipo cukriniu diabetu kūno masės indeksą, išsilavinimą ir rūpinimąsi savo sveikata. 2. Įvertinti vyresnio amžiaus sveikų žmonių ir sergančių 2 tipo cukriniu diabetu fizinio aktyvumo ypatumus. 3. Įvertinti vyresnio amžiaus sveikų žmonių ir sergančių 2 tipo cukriniu diabetu mitybos ypatumus. Hipotezė: 2 tipo cukriniu diabetu sergantys asmenys yra fiziškai pasyvesni ir vartoja daržovių bei vaisių mažiau nei asmenys nesergantys 2 tipo cukriniu diabetu. Asmenys sergantys 2 tipo cukriniu diabetu yra fiziškai pasyvūs, bet vartoja mažiau saldumynų, bei dažniau valgo pusryčius. Išvados: 1. Tarp sergančių, 2 tipo cukriniu diabetu, asmenų vyrauja nutukimas. Didžioji dalis tiriamųjų savo sveikatą vertina petenkinamai. 2. 2 tipo cukriniu diabetu sergantys asmenys nėra pakankamai aktyvūs, jie lyginant su nesergančiais juda dvigubai mažiau. 3. Sergantys asmenys dažniau valgo pusryčius, nei nesergantys 2 tipo cukriniu diabetu. Sergantieji vartoja mažiau alkoholio ir saldumynų. / Object of study: Lifestyle, physical activity, nutrition and type 2 diabetes mellitus. Aim of study: To evaluate link between the physical activity, nutrition and the second type of diabetes mellitus. Goals of study: 1. Rate of older people with type 2 diabetes body mass index, education and carrying their health. 2. Rate of older people with type 2 diabetes physical activity characteristics. 3. Rate of older people with type 2 diabetes nutrition features. Hypothesis: Persons with type 2 diabetes mellitus are moving and eating vegetables less than persons without type 2 diabetes mellitus. Persons with type 2 diabetes are physically passive, but consume less sweets and more frequent eating breakfast. Conclusion of study: 1. Among the persons with type 2 diabetes mellitus dominating obesity. Most of the patients their health valuating by average. 2. Persons with type 2 diabetes mellitus are not active enough. 3. The patients with type 2 diabetes mellitus eating more often than persons without type 2 diabetes mellitus. It is also less using alcohol.

Type 2 diabetes mellitus is a metabolic disease that affects one in ten people in the United States. It is caused by a combination of genetics and lifestyle factors. Disease progression begins with insulin resistance in peripheral tissues followed by pancreatic beta-cell failure. The mechanisms behind disease progression are not completely understood. PH domain leucine rich repeat protein phosphatase 1 (PHLPP1) is a known regulator of Akt and other members of the AGC kinase family. Akt has been established to play a role in numerous metabolic signaling pathways, including insulin action. It is hypothesized that as a regulator of Akt, PHLPP1 would have an important function in glucose homeostasis. Glucose tolerance tests performed on 8-week old Phlpp1-/- mice revealed no significant difference in glucose tolerance compared to wild type, however these mice did exhibit increased fasting blood glucose levels. Glucose tolerance tests were repeated at 20 weeks on the same mice and, interestingly, they displayed impaired glucose tolerance compared to wild type. Insulin tolerance tests showed that 8-week old mice have increased insulin sensitivity, however, the 20-week old mice were insulin-resistant compared to control animals. The 20-week old knockout mice also had significantly higher fasting blood glucose levels compared to 8-week old mice. To determine if the increased fasting blood glucose levels are due to increased hepatic glucose output, pyruvate tolerance tests were performed on both the 8 & 20 week old mice. Old mice displayed significantly increased hepatic glucose production compared to wild type. EchoMRI done on 24-week old mice showed significantly increased fat mass and decreased lean mass in the Phlpp1-/- mice compared to wild type littermates. Western blot analysis of liver samples from 32 week old Phlpp1-/- mice indicates loss of Akt signaling accompanied by a decrease in IRS2 protein levels, a common indicator of insulin resistance. These data suggest that Phlpp1-/- mice mimic the development of type 2 diabetes in humans, and provide a unique animal model to study the progression of type 2 diabetes and diabetes-associated complications.

Prevention and treatment of type 2 diabetes mellitus (T2DM), relies heavily on self-care behaviours such as dietary modification, physical activity, and medication adherence. Ability to perform these self-care behaviours depends, at least in part, on executive function (EF). Recent evidence suggests a correlation between T2DM and impaired cognitive function, including EF. Given the importance of EF for regulation of behaviours, and the importance of self-care in diabetes management, attenuated EF would represent a potential barrier to proper disease management. Thus the objective of Study 1 was to examine the association between T2DM and EF through meta-analytic techniques. Medline, PsychoInfo, and Scopus, as well as article references, were used to identify studies comparing individuals with T2DM to a control population. Effect size was calculated using cohen’s d and random effects modeling, and the potential impact of moderators (age, sex, and T2DM duration) were examined. Review of 60 studies (59 articles), revealed a significant, small-to-moderate effect size (d=-0.249, p<0.001) such that those with T2DM have lower EF. This finding was consistent across all aspects of EF examined (verbal fluency, mental flexibility, inhibition, working memory, and attention), and the association was stronger for those with shorter disease duration. The findings of study 1 illustrate that although individuals with T2DM have a great need for EF, as evidenced by the reliance of self-care behaviours on EF, this population has lower EF upon which to draw to perform these behaviours. Thus, strategies that improve EF, such as aerobic exercise, may be particularly relevant to this population. Acute aerobic exercise has been shown to improve EF in young and older adults; however this effect had not yet been examined in individuals with T2DM. Thus the objective of Study 2 was to examine the effects of acute aerobic exercise on EF in adults with T2DM. A within-subject design was used to compare the change in EF task performance following moderate and minimal intensity aerobic exercise, using Stroop and GNG to measure EF. Analysis revealed a significant effect of moderate exercise in women (but not men) and recently active (but not inactive) individuals, such that moderate exercise mitigated the self-regulatory fatigue effect observed following exercise. This study provides preliminary evidence of a significant beneficial effect of moderate aerobic exercise on EF in female and recently active adults with T2DM.

Background Due to population growth, aging, urbanisation, increasing prevalence of obesity and physical inactivity, diabetes mellitus (DM) has become one of the most important and prevalent chronic diseases. Glycated haemoglobin A1c (HbA1c) assessment is currently being used all over to monitor glycaemic control as a cornerstone of diabetes care. It might also be a useful screening tool for non–insulin dependent DM, also known as type 2 DM (T2DM). Elevated HbA1c can be linked with long–term risk of cardiovascular complications. Aim The aim of the study was to determine whether HbA1c can be used as reliable screening tool for early detection of T2DM in an African population. Methods This study was a cross–sectional study and was part of the South African, North–West Province (SANWP) leg of the 12–year Prospective Urban and Rural Epidemiological (PURE) study. Baseline data was collected from March to December 2005. A total of 2010 volunteers were recruited from randomly selected households. Data was collected on socio–demographic characteristics, physical activity, dietary intakes, blood pressure and anthropometry. HbA1c, fasting plasma glucose (FPG), liver enzymes and HIV status were determined. Ethical approval for the PURE study was obtained in July 2004. Oral glucose tolerance tests (OGTT) were also done for a sub–group of 465 subjects. The Statistical Consultation Services of the North–West University were consulted to analyse data with SPSS 17.0 and STATISTICA 9.0. Results The HbA1c values within the diabetic FPG groups were 7.46% for men and 8.08% for women. HbA1c values increased significantly progressively from the normal FPG groups to the groups with impaired FPG and the diabetic FPG groups for both men and women. No significant increases were found in HbA1c between the OGTT groups (normal 2 hour plasma glucose (PG), impaired 2–hour PG and diabetic 2–hour PG). Total cholesterol, triglycerides, body mass index and FPG increased significantly and high–density lipoprotein cholesterol decreased significantly with an increase in HbA1c values in men and women. In addition, systolic blood pressure increased significantly in women with increased HbA1c. Thus, with an increase in HbA1c, an increase in the number of risk factors was observed. When using HbA1c and FPG in combination, 43 subjects of the whole population were detected with having a risk of developing T2DM. However, when considering the commonality of subjects identified to be diabetic or at risk by the OGTT, FPG and HbA1c individually, only one subject was identified by all the methods as having diabetes or being at risk to develop diabetes. Discussion and conclusions An increase in HbA1c and FPG was associated with an increase in risk factors and therefore with metabolic syndrome (MS). MS is associated with an increased risk of developing T2DM and therefore it can be concluded that HbA1c was useful for detecting in this population individuals at increased risk of developing T2DM. The use of FPG and HbA1c in combination was considered a better screening tool when compared to HbA1c alone. Factors other than what were measured in this study might be the cause of the unexpected results obtained in the participants with impaired OGTT. / Thesis (M.Sc. (Nutrition))--North-West University, Potchefstroom Campus, 2011.