Thesis (M Med (Family Medicine) -- University of Limpopo, 2011. / Introduction The burden of type 2 diabetes mellitus continues to rise and constitutes a real threat especially in the developing world. As for most non-communicable diseases, change of behavior and adoption of healthy lifestyle habits help to prevent and slow down the increase of type 2 diabetes mellitus. Aim of the Study To establish the knowledge, attitudes and practices regarding lifestyle modifications among type 2 diabetic patients attending the diabetic clinic at Mamelodi hospital. Methods: This cross sectional study describes the knowledge, attitudes and practices regarding lifestyle modifications (KAP) among 217 type 2 diabetes mellitus patients attending Mamelodi Hospital, Pretoria, Republic of South Africa. A face-to-face interview using a structured questionnaire was carried out for data collection. Socio-demographic characteristics of the participants and anthropometric measurements were obtained and the body mass index (8MI) of participants were determined. The Knowledge, attitude and practice of participants were assessed. 2 Results: Majority of participants were female 176(81.1 %), while male were 41 (18.9%). This amounted to a female to male ratio of 4:1. Most participants were in the age group 51-60 years 93(42.9%). Majority of them had low level of education 108(49.5%) and low income 206(94.9%). Majority of participants were obese 153(71 %) with more female diabetic patients being obese 120 (78.4%) than male 33 (21.6%). 15 participants (14 females and 1 male) were morbidly obese (BMI~40kg/m2). 108 participants (49.5%) did not have a formal education. No respondent had good knowledge and 92.6% of respondents had poor knowledge of the benefits of exercise, weight loss and healthy diet. Majority of respondents (97.7%) had bad practices in relation to lifestyle modifications. Nevertheless, majority of them (84.3%) had positive attitudes toward lifestyle modifications. Significant positive correlation (r= 0.170, p=0.012) was found between the global knowledge level and attitude level alone, whereas there was no significant correlation found between the global knowledge level and practice level as well as the attitude level and practice level. Conclusion: In conclusion, despite positive attitudes of participants toward healthy lifestyle habits, the knowledge and practices regarding lifestyle modifications among type 2 diabetes mellitus patients attending Mamelodi Hospital were generally low. Nevertheless the positive attitudes of participants should be encouraged and the implementation of a lifestyle intervention program will help improve the knowledge and practices of type 2 diabetes mellitus patients attending Mamelodi Hospital for the better management and control of this current pandemic of type 2 diabetes mellitus.

This report takes an approach of laying the first steps to create an artificial pancreassystem as treatment for type 1 diabetes. This includes a thoroughly performedanalysis of the most intrusive physical factors, such as hormonal activity, time offset,errors of measurement and metabolism. Such factors raise a need forcompensation. A compensation that will enable the development of the link betweena continuous glugose monitoring(CGM)-device and an insulin infusion pump,a system that can be described as an Artificial Pancreas.Through analysis of measured glucose series, a mathematicalapproximation is presented to solve the time offset of CGM.The approximation gives sufficient results but with room for improvementFrom the analysis of affecting factors, a compensation model isdeveloped. The model is designed as a closed loop which is suitable for timecontinuous systems. The output of the compensation model equation presented here is adirective that would be read by an insulin pump.

Background Carbohydrate counting is a method used to calculate insulin doses to meals, in the treatment of diabetes type 1. Few studies are available with a clear consensus on its efficacy and effect on anthropometrics in children and adolescents. Aim To evaluate if carbohydrate counting as treatment method in diabetes type 1 improved glycemic control and anthropometrics compared to conventional treatment, one and two years after onset in children and adolescents at Astrid Lindgren children’s hospital. A secondary aim was to explore patients and caregivers perception of insulin dosage to meals with focus on efficacy, time consumption and adherence. Method A clinical prospective study was performed on data collected from the Swedish pediatric quality registry (Swediabkids). Children with diabetes onset between 2010 and 2014 registered at Astrid Lindgren Children’s hospital (n=371) were included and divided into two groups, carbohydrate counters and non-carbohydrate counters. Normal distribution was assumed and parametric tests were performed. The registry data was complemented with a web-based questionnaire providing information on perception of carbohydrate counting, answered by 78 subjects. Results Carbohydrate counting reduced insulin requirements (p<0.001) and eliminated differences between pump- and pen users (p<0.001) as well as differences between boys and girls. Glycemic control was not improved by carbohydrate counting one and two years after diabetes onset (p=0.233, p=0.295). An adverse effect was increased body mass index standard deviation score (BMI-sds) (p=0.044), especially amongst girls (p=0.038). Conclusion Carbohydrate counting lowers insulin requirements with maintained glycemic control. Contradictory, greater weight gain was found in the carbohydrate counting group, especially among girls. A plausible explanation is that carbohydrates have taken focus off protein- and fat intake in combination with a more liberal approach to energy dense foods, causing excess energy intake. The strength of carbohydrate counting does not lie in its ability to lower HbA1c-values but as a helpful tool, which patients are happy to use. / Bakgrund Kolhydraträkning är en metod som används för att beräkna insulindoser till måltider, i behandlingen av diabetes typ 1. Få studier finns för att ge en samlad konsensus gällande dess effekt på glykemisk kontroll och tillväxt hos barn och ungdomar. Syfte Att utvärdera om införandet av kolhydraträkning som behandlingsmetod vid diabetes typ 1 påverkat metabol kontroll och tillväxt i jämförelse med konventionell metod, ett och två år efter diabetesdebut. Ett andra syfte var att utforska patienters och vårdnadshavares uppfattning om insulindosering till måltider med fokus på effektivitet, tidskonsumtion och följsamhet. Metod En klinisk prospektiv studie utfördes med data inhämtad från Nationellt kvalitetsregister för barn och ungdomar med diabetes (Swediabkids). Barn och ungdomar som debuterade med diabetes typ 1 på Astrid Lindgrens barnsjukhus mellan 2010 och 2014 (n=371) inkluderades i studien och delades in i två grupper baserat på debutdatum; kolhydraträknare och icke-kolhydraträknare. Materialet bedömdes som normalfördelat och parametriska test utfördes. En tvärsnittsenkät administrerades till studiedeltagarna för att införskaffa fördjupad information om patienters och vårdnadshavares uppfattning om insulindosering till måltider. Den webbaserade enkäten besvarades av 78 deltagare. Resultat Kolhydraträkning reducerade insulinbehovet (p<0.001) och jämställde insulinbehovet mellan pump- och pennanvändare (p<0.001) liksom skillnader mellan pojkar och flickor inom gruppen. Glykemisk kontroll förändrades inte av kolhydraträkning ett och två år efter debut (p=0.233, p=0.295). En oönskad effekt av kolhydraträkningen var en ökning i BMI-sds (p=0.044), speciellt hos flickor (p=0.038). Slutsats Kolhydraträkning från diabetesdebut sänker insulinbehov med bibehållen glykemisk kontroll. Motsägelsefullt, så fanns en viktökning i gruppen som använde kolhydraträkning, speciellt hos flickor. En möjlig förklaring är att kolhydrater har tagit fokus från protein- och fettintag tillsammans med en mer frikostig syn på energität mat, vilket har orsakat ökat energiintag. Styrkan i kolhydraträkning ligger inte i dess förmåga att förbättra glykemisk kontroll men som ett användarvänligt verktyg som patienterna är nöjda med.

Class of 2009 Abstract / OBJECTIVES: To evaluate an educational booklet written in Chinese designed for Chinese-Americans with Type 2 diabetes mellitus. METHODS: Healthcare professionals who work with Chinese-American patients with Type 2 diabetes mellitus and proficiency in writing Chinese developed an educational booklet on Type 2 diabetes. An expert panel of Chinese American pharmacists and dietitians evaluated the booklet by rating language appropriateness, ease of reading, ease of locating information, overall presentation of the booklet, and usefulness of the booklet in a practice setting. Topics of the booklet were assessed for accuracy, relevance, and irrelevance. RESULTS: Questionnaires were completed by 8 healthcare professionals. In the expert panel, there were five pharmacists and three dietitians. Of the three dietitians, two were certified diabetes educator. The panel rated the booklet very highly; the mean overall rating was 22.4(±1.2) with 25 being the highest possible score. Overall, 100% of the evaluators would recommend this booklet for patients in their setting. CONCLUSIONS: Healthcare professionals found the booklet to be accurate, culturally relevant, and useful for their Chinese- American patients with type 2 diabetes mellitus.

Diabetes typ 1 är en av de sjukdomar som ständigt ökar. Sjukdomen för med sig stora kostnader för samhället och på individnivå kan komplikationer utgöra stor risk och livshotande tillstånd för patienten. Behandling vid diabetes typ 1 består till största del av insulininjektioner och noggrann kontroll av blodsockret. Vården som ges till de som insjuknat i diabetes typ 1 strävar efter att hjälpa patienten till god egenvård och som i längden kan bidra till bättre hälsa. I samband med att sjukdomen tar plats i den sjukes vardag, i detta fall hos barnet, kommer sjukdomen inte enbart påverka barnet utan även familjen. Författarna valde att belysa ämnet då de båda har erfarenheter och intresse inom ämnet. Syftet med denna studie är att belysa ur ett föräldraperspektiv hur familjen påverkas när ett barn har diabetes typ 1. Författarna valde att göra en litteraturstudie som innebär att redan befintlig kunskap sammanställs. Studien består av 10 artiklar av både kvalitativ och kvantitativ forskning. Resultatet i studien visade att föräldrarna uttryckt familjens upplevelse. Det visade sig att familjen upplevde att deras rutiner i vardagen förändrades i och med att barnet blev sjukt. Familjen är i behov av kunskap och stöd för att få den nya vardagen att fungera samt stöd från vårdpersonal och andra familjer. I diskussionen tar författarna upp de tre teman som framkom i resultatet.

Introduction: Diabetes type 1 is a common chronic disease in children and adolescents. The disease affect, not only the child, but also the parents in their everyday life. The specialist diabetic nurse has a huge responsibility in supporting the parents to feel confident in managing the child’s diabetes. Aims of the study: To investigate how parents of children with diabetes type 1 perceive the care given from the specialist diabetic nurse and what wishes they have concerning the care they receive. Design and methods: Searches for studies in electronic databases were conducted between January 2013 and march 2013. A literature review containing 16 studies was compiled. Both qualitative and quantitative studies were used and analyzed according to Friberg (2006). Findings: Several parents had a positive view of the diabetic care they had received from the specialist diabetic nurse. Great knowledge, expertise in diabetic care and ability to inform the family in a proficient way were considered as important by the parents. To receive knowledge regarding diabetic care the parents preferred to be given practical education from the nurse, but also appreciated to get written information. The parents would have liked to get more emotional support during the time of the diagnosis, especially in forms of counseling and encouragement. They also whished that caregivers would have been more eager to prepare them in managing the disease outside the hospital.  Conclusions: The majority of the parents had an optimistic experience of the care they had received from the specialist nurse in diabetic care. To prepare the family for a life with diabetes it’s necessary with adequate education, encouragement and emotional support from the specialist diabetic nurse.

Aims: to test the hypothesis that peripheral blood neutrophils (PMN) exhibit delayed spontaneous apoptosis in individuals with type 2 Diabetes, and that the delay is further exacerbated in individuals who co-express chronic periodontitis. Materials and methods: 73 individuals were enrolled, including those with type 2 diabetes (T2DM) (n=16), chronic periodontitis (CP) (n=15), diabetics with chronic periodontitis (T2DM+CP) (n=21) and healthy volunteers (n=21). PMN apoptosis was determined by flow cytometry using TUNEL and Annexin V assays. Caspase 3, 8 and 9 activity was measured by colorimetric assay. PMN surface death receptor quantification was performed by flow cytometry staining with fluorescence conjugated anti-CD120a (TNFR1) and anti- CD95 (FasR) antibody. Inflammatory biomarker analyses of serum samples were performed using multiplexed sandwich immunoassays. Results: In healthy volunteers, individuals with T2DM, CP and T2DM+CP, spontaneous PMN apoptosis observed at 12 hours reached 85.3% ± 3.1, 67.3% ± 3.9, 62.9% ± 3.5 and 62.5% ± 5.4, respectively (p<0.05 ). Caspase-3 activity was significantly reduced in individuals with T2DM and T2DM+CP (p<0.05), when compared to healthy volunteers. Caspase-8 activity was also significantly decreased in CP and T2DM+CP (p<0.05), associated with reduced cell surface Fas receptor, TNF receptors and Fas ligand serum levels. Glucose alone was not observed to effect PMN apoptosis; concurrent incubation with the RAGE agonist S-100B induced a significant PMN apoptosis (p<0.05). Conclusion: These data support the premise that the inhibition of PMN apoptosis in individuals with T2DM occurs through an AGE/RAGE ligand/receptor mediated interaction.

Bakgrund: Diabetes typ 2, en globalt ökande folksjukdom, kräver aktiv egenvård och livsstilsförändringar för att minimera komplikationer. Egenvård blir därmed en central aspekt i behandlingen av denna sjukdom. Metod: En Litteraturöversikt av 10 vetenskapliga artiklar med kvalitativ design har genomförts. Dataanalysen har skett i fem steg enligt Friberg. Syfte: Syftet var att beskriva sjuksköterskors erfarenheter av patienter med diabetes typ 2 och egenvård. Resultat: Resultatet redogörs med två teman som är uppdelade i sex subteman: betydelsen av relationen till patienten (Kommunikation, Att skapa relation) samt sjuksköterskans roll i förändringsprocessen (Attityders betydelse, Att överbrygga hinder, Att utbilda patienter). Slutsats: Denna litteraturöversikt belyser viktiga aspekter av sjuksköterskors roll med patienter som har diabetes typ 2 och egenvård. Kommunikation, ehälsa och kontinuerlig kompetensutveckling är centrala faktorer. Utmaningar och hinder för patienters följsamhet, inklusive kulturella och ekonomiska faktorer identifieras. / Background: Type 2 diabetes, a globally increasing health challenge with a rising prevalence, requires active self-care and lifestyle changes to minimize complications. Self-care thus becomes a central aspect in the treatment of this disease. Method: Literature review with a qualitative design and inductive approach analyzed using Friberg's five-step analysis method. Purpose: The purpose was to describe nurses' experiences with type 2 diabetes patients and self-care. Results: The result is presented with two themes divided into six subthemes: the significance of the relationship with the patient (Communication, establishing a relationship) and the nurse's role in the process of change (The importance of attitudes, Overcoming barriers, To educate patients). Conclusion: This literature review highlights important aspects of nurses' roles with patients with type 2 diabetes and self-care. Communication, eHealth, and continuous competence development are central factors. Challenges and barriers to patient adherence, including cultural and economic factors, are identified.

Background Type 2 diabetes mellitus (T2DM) and serious mental illness involves major public health problems in the world. People with severe mental illness have an increased risk of metabolic abnormalities and obesity, leading to an increased incidence for T2DM. District nurses with advanced training in diabetes care will in their profession give support to lifestyle changes and healthy living habits. Aim The purpose of this study was to illuminate district nurses´ experience of how they can support people with T2DM and serious mental illness.Method A qualitative methodology based on individual interviews analyzed with qualitative content analysis was used. Twelve informants were part of the study. Results The individual meeting with mutual relations and respect for individuals was important. During periods of worsening mental health of the patient, the district nurses provide support and monitoring, adjusted to the patients' ability. The district nurses felt inadequacy and frustration when the patients' physical and mental health were deteriorating. The strategy was to acknowledge progress when small improvements were made and extended contacts with nurses in out-patient psychiatry were requested. Conclusion Support was designed as respectful treatments and individual meetings were prioritized. District nurses' strategies were to guide the patient by positive attitudes according to the individual, and by giving support adapted to the needs of the patient. Despite feelings of insufficiency the district nurses never gave up and conveyed the message to never let go. Cooperation and extended contact with open psychiatry were desirable to exchange knowledge, giving accordance in decisions and messages.

Exposure to microorganisms is considered an environmental factor which can contribute to diabetes mellitus via cytotoxicity or autoimmune responses against pancreatic cells. Firstly, the effects on rat insulinoma pancreatic β-cell line of secondary metabolites pyrrolnitrin (Burkholderia spp), phenazine compounds (Pseudomonas aeruginosa and Burkholderia spp) were investigated. Both compounds separately showed significant cytotoxicity after 24 h and at concentrations of 10 & 100 ng/ml potentiated insulin gene transcription, Ca2+ content and glucose-stimulated insulin secretion (GSIS). Furthermore, the outward membrane current was inhibited by phenazine (100 ng/ml) or pyrrolnitrin (10 or 100 ng/ml). Secondly, the capacity of 45 microbial species to bind insulin was screened in order to assess how common insulin binding was amongst microorganisms Burkholderia multivorans, B. cenocepacia and Aeromonas salmonicida bound insulin. A genomic library of B. multivorans was constructed in λ Zap Express and screened successfully for insulin binding recombinants. Recombinant phagemids p1 & p2 were excised, p1, encoded an insulin binding protein (IBP1 30 kDa) with homology to the iron complex siderophore receptor. For p2, two IBPs were detected at 20 & 30 kDa (IBP2 & IBP3), representing an intracellular and outer membrane peptide transporter. Comparison of IBP1 and human insulin receptor (HIR) produced 6 linear epitopes, and for IBP2 & IBP3 produced 3 epitopes. Thirdly, glutamic acid decarboxylase GAD65 is a major pancreatic autoantigen contributing to autoimmune diabetes. To assess the likelihood that microorganisms possess epitopes that mimic regions on GAD, 45 microbial species were tested for homology. This was facilitated by purifying recombinant GAD protein which was used to produce GAD antiserum. Four E. coli cross-reacting proteins were identified using mass spectrometry, outer-membrane protein A, formate dehydrogenase, superoxide dismutase and DNA starvation protein. Epitopes occurred at the C-terminal region of GAD65 (residues 419–565), a region previously reported to be targeted by autoantibodies. This study suggests that pyrrolnitrin and phenazine are cytotoxic to pancreatic β-cells and B. multivorans IBPs linear epitopes may be diabetogenic, particularly in patients with cystic fibrosis related diabetes (CFRD) who suffer a long term infections with Pseudomonas and Burkholderia species. Furthermore, microbial GAD epitopes could potentially induce an autoimmune response leading to diabetes.