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Effects of an individual intensive educational control program for insulin-dependent diabetic subjects with poor metabolic control
DiabetesResearchand Clinical Practice27 (1995)189-192
Effects of an individual intensive educational control program for insulin-dependent diabetic subjects with poor metabolic control Ignacio Conget*, Margarita Jan@ Merck Vidal, Jodp Vidal, JosCM. Manzanares, Ramh Gomis Endocrinology
Unit, Hospital Clinic, Vniversitar de Barcelona. Villarroel 170, 08036 Barcelona, Spain
Received28 July 1994;revisionreceived26 December1994;accepted14January1995 Abstract The aim of our study was to evaluate the efficiency of an individual intensive educational control program on improving the metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. Fifteen insulindependentdiabetic subjectswith poor metabolic control (hemoglobin Ale > 9%) were included. At entry, their knowledgeof diabetes(DKQZ test), total energy intake and its distribution, insulin schedule,technical skill for insulin administration and self monitoring of blood glucosewere evaluated. According to the initial evaluation, individual goals were stipulated and monitored in weekly visits. Individual life-style was particularly kept in mind. Thereafter, patients were switched to our ambulatory clinic for outpatients. At 1, 6, 12 and 24 months of follow-up, the items analyzed at the beginning were reevaluated. After 1 month, the program produced a significant decreasein hemoglobin Ale and an increasein knowledge of diabetes.The samebeneficial effects were present at 6, 12and 24 months evaluation compared to those values recorded at entry. There were neither major changes in dietary intake nor insulin schedule nor any increasein the frequency of hypoglycemic episodes.In conclusion, our program (5.2 f 0.8 weekly visits) significantly reduced and sustained hemoglobin Ale values close to those levels recommendedby multicenter controlled trials. We consider that our program produced two major changes:a long-lasting improvement in knowledge of diabetes and an increasein self-monitoring blood glucose which provided the key for optimal self-regulation. Our study demonstrates that an individual intensive educational control program is useful as a tool to get a long-lasting improvement in metabolic control in insulin-dependent diabetic patients. Keywords: Diabetes educational program; Poor metabolic control
1. Introduction Recent publications demonstrate that intensive therapy delays the onset and slows the progression of diabetic retinopathy, nephropathy and neurol
Correspondingauthor.
pathy in patients with insulin-dependent diabetes mellitus [1,2]. Although the daily management of insulin-dependent diabetes mellitus might be burdensome, therapeutic programs have to be designed which result in blood glucose values being held as close to the normal range as possible. At the same time, this goal should be achieved
0168-8227/95/$09.50 0 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0168-8227(95)01041-B
190
I. Conget et al. /Diabetes Research and Clinical Practice 27 (1995) 189-192
without the burden of major changes in life-style. Individualization of diabetes educative control programs might facilitate the integration of treatment into daily life, improve compliance with the treatment and improve metabolic control not only in the short-term but also in the long-term. The aim of the present study was to evaluate the efficiency of an individual intensive educational control program for improving the metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. 2. Materials and methods Fifteen ’ Type 1 (insulin-dependent) diabetic patients (four men and 11 women) were studied. All subjects were <50 years old and with a duration of diabetes > 1 year. Patients with diabetic chronic complications were excluded. The hemoglobin Ale in all of them was >9% (normal range 4.3-5.9%) from 6 months before the initiation of the study. At entry, six patients were on conventional therapy (two daily injections of intermediate insulin and rapid-acting insulin) and nine were on intensive therapy consisting of the administration of regular insulin before meals and intermediate insulin plus regular insulin before dinner. Study participants had previously completed (from the beginning of their treatment) our standard group educational program for Type 1 diabetic patients including the following topics: diet, insulin, hypoglycaemia, exercise and illness, ketones and hyperglycemia, diabetic complications, practical problems of self-managementand they had been instructed to adapt their insulin dose. At the beginning of the individual intensive program, their knowledge of diabetes was evaluated by directed interview using a DKQ2 test [3] with a possible maximum score of 35. Total energy intake and its distribution as carbohydrates, protein and lipids, as well as its timing throughout the day were also assessed.Insulin requirements, technical skill for insulin administration and capillary blood glucose control with their own material were also evaluated. According to the initial evaluation, in’ After the approval of the Ethical Committee of our hospital.
dividualized goals were established including the following capillary blood glucose values: preprandial between 5.0 and 7.2 mm01 l-‘, postprandial less than 10.0 mm011-l. Thereafter, patients were individually seen and evaluated weekly by the sameteam composed of a physician and a nurse. Insulin dosage was adjusted according to the results of self-monitoring blood glucose (performed at least three times per day), dietary intake and physical activity. Individual life-style was respected avoiding rigid rules. When the aim of the program was achieved, the patients were visited in the ambulatory clinic for insulin-dependent diabetic patients following an ordinary schedule. Finally, a follow-up was made at 1,6, 12 and 24 months and the end points were reevaluated. All values are presented as mean f S.D. The statistical significance of differences betweenmean values was assessedby use of an analysis of variance (ANOVA). 3. Results The subjects were 23.1 f 9.9 years old, with a mean duration of diabetes of 67.7 * 59.9 months. The mean hemoglobin Ale value at entry was 9.9 * 1.2%.All of the patients who were included in our program completed the entire follow-up. Data on BMI, hemoglobin Ale, insulin dose and DKQ2 test score throughout this follow up are included in Table 1. At entry, the mean total energy intake was 2185 f 1009 calories per day which were distributed as follows: 45 f 8% carbohydrate, 20 f 3% protein and 34 * 6% lipids. Adjustment of energy intake was adapted either to achieve or maintain optimal body weight and distributed throughout the day taking into account individual life-style, physical activity and insulin schedule.Only six patients required major dietary changes in order to distribute energy intake as 50-55% carbohydrate, 20-25% proteins and 25-30% lipids. Nevertheless,in all of them changes in the daily distribution of carbohydrates were made. On average, the total energy intake was slightly decreasedto 1927 f 737 calories per day. According to capillary blood glucose goals, two of the six patients on conventional therapy required a changeto the intensive therapy schedule.Only in
191
I. Conget et al. /Diabetes Researchand Clinical Practice 27 (199s) X89-192 Table 1 Comparison of preprogram and I-, 6-, 12-, and 24-month follow-up scores
BMI (kg/m2) HbAlc (%) Insulin dose (U/kg body wt./day) DKQ2 (over 35 points)
At entry
l-month
dmonths
12-months
24-months
21.3 f 9.9 l 0.87 f 22.0 *
21.2 l 7.6 f 0.79 f 26.1 f
22.0 f 8.3 f 0.79 f 26.4 f
22.1 zt 3.2* 7.5 l 1.3* 0.85 zk 0.24 29.3 ct 3.0*
22.8 f 7.3 f 0.80 f 30.1 f
3.2 1.2 0.33 5.0
4.1 1.3. 0.30 4.0’
4.1* 1.2* 0.24 5.0;
2.3’ 1.1* 0.2 3.2*
All values are expressedas mean * SD. *P < 0.05 compared to the value at entry.
three patients were major technical mistakes detected either in insulin administration or in capillary blood glucose determination and these were corrected. A mean of 5.2 f 0.8 weekly appointments was performed before the initiation of ordinary outpatient control. After 1 month, the program produced a significant decrease in hemoglobin Ale values and DKQ2 scoreswithout any change either in insulin dose or in BMI. The 6-month evaluation reflected similar beneficial effects when compared to values recorded at entry. However, a slight increase in BMI was observed although it was always within normal range. The improvement in metabolic control persistedafter 12and 24 months. Moreover, at 12 and 24 months follow-up, there were no changesin dietary intake and insulin schedule,and program participants tested their blood for glucose and adjusted their insulin doses more frequently than when they entered in the program (P < 0.01). DKQ2 score also remained higher than that recorded at entry. We did not observe any increase in the frequency of hypoglycemic episodesduring the 24 months follow-up, ranging from 0 to 2 episodesper week. None required assistanceand no severehypoglycemic episodes occurred throughout our study. 4. Discussion Diabetes education programs have been associated with improved metabolic control [4,5]. Nevertheless,their benefits are not always lasting not only because they usually include major changes in daily life but also because when the source of extrinsic motivation disappears, the pa-
tient’s intrinsic motivation is not sufftcient to maintain compliance [3]. After 1.5 months, on average, of weekly appointments, our program succeeded in significantly reducing hemoglobin Ale values close to those levels achieved and recommendedby multicenter controlled trials [6]. In addition, this beneficial effect lasted 24 months even when the subjects were followed in the ordinary ambulatory clinic. Our program produced two major changes:(i) a long-lasting improvement in knowledge of diabetes and consequently a reinforcement of the beneficial effects of tight control, and (ii) an increase in self-monitoring blood glucose which allows for an optimal selfregulation. Our findings may have implications relevant for educational program planning in diabetes. Firstly, our results demonstrate that without major modifications in life-style and with a relatively inexpensive short-term outpatient program, it is possible to offer to insulin-dependent diabetic patients an effective and long-lasting tool to improve their metabolic control. Secondly, it should be highlighted that this benefit can be achieved without an increase in hypoglycemic episodes. It must be recognized that our study included a group of young subjectswith diabetesand was performed in a university hospital by trained endocrinologist and diabetes educators who were highly motivated. However, program design can be adapted with a wide implementation to other study groups and health care teams. In this context, further work is presently in progressin order to extend the present study to other patient and health-care groups. In summary, our study demonstratesthat an in-
192
I. Conget et al. /Diabetes Research and Clinical Practice 27 (1995) 189-192
dividual intensive educational control program is useful as a tool to improve metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. Acknowledgements We are indebted to all those who were at any time involved in ‘Club jueves’ program. References [I] The Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. New Engl. J. Med. 329, 977-986.
PI Reichard, P., Nilson, B.Y. and Rosenquist, V. (1993)The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. New Et@. J. Med. 329, 304-309. [31 Lennon, G.M., Taylor, K.G., Debney, L. and Bailey, C.J. (1990) Knowledge, attitudes, technical competence and blood ghrcose.control of type 1 diabetic patients during and after an education programme. Diabetic Med. 7, 825-832. 141 Larpent, N. and Canivet, J. (1984) Bicentric evaluation of a teaching and treatment programme for type 1 (insulin-dependent) diabetic patients. Diabetologia 27, 62. PI Rubin, R.R, Peyrot, M. and Saudeck, CD. (1991) Differential effect of diabetes education on self-regulation and life-style behaviors. Diabetes Care 14, 335-338. 161American Diabetes Association (1993) Implications of the diabetescontrol and complications trial. Diabetes 42, 1555- 1558.
Effects of an individual intensive educational control program for insulin-dependent diabetic subjects with poor metabolic control Ignacio Conget*, Margarita Jan@ Merck Vidal, Jodp Vidal, JosCM. Manzanares, Ramh Gomis Endocrinology
Unit, Hospital Clinic, Vniversitar de Barcelona. Villarroel 170, 08036 Barcelona, Spain
Received28 July 1994;revisionreceived26 December1994;accepted14January1995 Abstract The aim of our study was to evaluate the efficiency of an individual intensive educational control program on improving the metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. Fifteen insulindependentdiabetic subjectswith poor metabolic control (hemoglobin Ale > 9%) were included. At entry, their knowledgeof diabetes(DKQZ test), total energy intake and its distribution, insulin schedule,technical skill for insulin administration and self monitoring of blood glucosewere evaluated. According to the initial evaluation, individual goals were stipulated and monitored in weekly visits. Individual life-style was particularly kept in mind. Thereafter, patients were switched to our ambulatory clinic for outpatients. At 1, 6, 12 and 24 months of follow-up, the items analyzed at the beginning were reevaluated. After 1 month, the program produced a significant decreasein hemoglobin Ale and an increasein knowledge of diabetes.The samebeneficial effects were present at 6, 12and 24 months evaluation compared to those values recorded at entry. There were neither major changes in dietary intake nor insulin schedule nor any increasein the frequency of hypoglycemic episodes.In conclusion, our program (5.2 f 0.8 weekly visits) significantly reduced and sustained hemoglobin Ale values close to those levels recommendedby multicenter controlled trials. We consider that our program produced two major changes:a long-lasting improvement in knowledge of diabetes and an increasein self-monitoring blood glucose which provided the key for optimal self-regulation. Our study demonstrates that an individual intensive educational control program is useful as a tool to get a long-lasting improvement in metabolic control in insulin-dependent diabetic patients. Keywords: Diabetes educational program; Poor metabolic control
1. Introduction Recent publications demonstrate that intensive therapy delays the onset and slows the progression of diabetic retinopathy, nephropathy and neurol
Correspondingauthor.
pathy in patients with insulin-dependent diabetes mellitus [1,2]. Although the daily management of insulin-dependent diabetes mellitus might be burdensome, therapeutic programs have to be designed which result in blood glucose values being held as close to the normal range as possible. At the same time, this goal should be achieved
0168-8227/95/$09.50 0 1995ElsevierScienceIreland Ltd. All rights reserved SSDI 0168-8227(95)01041-B
190
I. Conget et al. /Diabetes Research and Clinical Practice 27 (1995) 189-192
without the burden of major changes in life-style. Individualization of diabetes educative control programs might facilitate the integration of treatment into daily life, improve compliance with the treatment and improve metabolic control not only in the short-term but also in the long-term. The aim of the present study was to evaluate the efficiency of an individual intensive educational control program for improving the metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. 2. Materials and methods Fifteen ’ Type 1 (insulin-dependent) diabetic patients (four men and 11 women) were studied. All subjects were <50 years old and with a duration of diabetes > 1 year. Patients with diabetic chronic complications were excluded. The hemoglobin Ale in all of them was >9% (normal range 4.3-5.9%) from 6 months before the initiation of the study. At entry, six patients were on conventional therapy (two daily injections of intermediate insulin and rapid-acting insulin) and nine were on intensive therapy consisting of the administration of regular insulin before meals and intermediate insulin plus regular insulin before dinner. Study participants had previously completed (from the beginning of their treatment) our standard group educational program for Type 1 diabetic patients including the following topics: diet, insulin, hypoglycaemia, exercise and illness, ketones and hyperglycemia, diabetic complications, practical problems of self-managementand they had been instructed to adapt their insulin dose. At the beginning of the individual intensive program, their knowledge of diabetes was evaluated by directed interview using a DKQ2 test [3] with a possible maximum score of 35. Total energy intake and its distribution as carbohydrates, protein and lipids, as well as its timing throughout the day were also assessed.Insulin requirements, technical skill for insulin administration and capillary blood glucose control with their own material were also evaluated. According to the initial evaluation, in’ After the approval of the Ethical Committee of our hospital.
dividualized goals were established including the following capillary blood glucose values: preprandial between 5.0 and 7.2 mm01 l-‘, postprandial less than 10.0 mm011-l. Thereafter, patients were individually seen and evaluated weekly by the sameteam composed of a physician and a nurse. Insulin dosage was adjusted according to the results of self-monitoring blood glucose (performed at least three times per day), dietary intake and physical activity. Individual life-style was respected avoiding rigid rules. When the aim of the program was achieved, the patients were visited in the ambulatory clinic for insulin-dependent diabetic patients following an ordinary schedule. Finally, a follow-up was made at 1,6, 12 and 24 months and the end points were reevaluated. All values are presented as mean f S.D. The statistical significance of differences betweenmean values was assessedby use of an analysis of variance (ANOVA). 3. Results The subjects were 23.1 f 9.9 years old, with a mean duration of diabetes of 67.7 * 59.9 months. The mean hemoglobin Ale value at entry was 9.9 * 1.2%.All of the patients who were included in our program completed the entire follow-up. Data on BMI, hemoglobin Ale, insulin dose and DKQ2 test score throughout this follow up are included in Table 1. At entry, the mean total energy intake was 2185 f 1009 calories per day which were distributed as follows: 45 f 8% carbohydrate, 20 f 3% protein and 34 * 6% lipids. Adjustment of energy intake was adapted either to achieve or maintain optimal body weight and distributed throughout the day taking into account individual life-style, physical activity and insulin schedule.Only six patients required major dietary changes in order to distribute energy intake as 50-55% carbohydrate, 20-25% proteins and 25-30% lipids. Nevertheless,in all of them changes in the daily distribution of carbohydrates were made. On average, the total energy intake was slightly decreasedto 1927 f 737 calories per day. According to capillary blood glucose goals, two of the six patients on conventional therapy required a changeto the intensive therapy schedule.Only in
191
I. Conget et al. /Diabetes Researchand Clinical Practice 27 (199s) X89-192 Table 1 Comparison of preprogram and I-, 6-, 12-, and 24-month follow-up scores
BMI (kg/m2) HbAlc (%) Insulin dose (U/kg body wt./day) DKQ2 (over 35 points)
At entry
l-month
dmonths
12-months
24-months
21.3 f 9.9 l 0.87 f 22.0 *
21.2 l 7.6 f 0.79 f 26.1 f
22.0 f 8.3 f 0.79 f 26.4 f
22.1 zt 3.2* 7.5 l 1.3* 0.85 zk 0.24 29.3 ct 3.0*
22.8 f 7.3 f 0.80 f 30.1 f
3.2 1.2 0.33 5.0
4.1 1.3. 0.30 4.0’
4.1* 1.2* 0.24 5.0;
2.3’ 1.1* 0.2 3.2*
All values are expressedas mean * SD. *P < 0.05 compared to the value at entry.
three patients were major technical mistakes detected either in insulin administration or in capillary blood glucose determination and these were corrected. A mean of 5.2 f 0.8 weekly appointments was performed before the initiation of ordinary outpatient control. After 1 month, the program produced a significant decrease in hemoglobin Ale values and DKQ2 scoreswithout any change either in insulin dose or in BMI. The 6-month evaluation reflected similar beneficial effects when compared to values recorded at entry. However, a slight increase in BMI was observed although it was always within normal range. The improvement in metabolic control persistedafter 12and 24 months. Moreover, at 12 and 24 months follow-up, there were no changesin dietary intake and insulin schedule,and program participants tested their blood for glucose and adjusted their insulin doses more frequently than when they entered in the program (P < 0.01). DKQ2 score also remained higher than that recorded at entry. We did not observe any increase in the frequency of hypoglycemic episodesduring the 24 months follow-up, ranging from 0 to 2 episodesper week. None required assistanceand no severehypoglycemic episodes occurred throughout our study. 4. Discussion Diabetes education programs have been associated with improved metabolic control [4,5]. Nevertheless,their benefits are not always lasting not only because they usually include major changes in daily life but also because when the source of extrinsic motivation disappears, the pa-
tient’s intrinsic motivation is not sufftcient to maintain compliance [3]. After 1.5 months, on average, of weekly appointments, our program succeeded in significantly reducing hemoglobin Ale values close to those levels achieved and recommendedby multicenter controlled trials [6]. In addition, this beneficial effect lasted 24 months even when the subjects were followed in the ordinary ambulatory clinic. Our program produced two major changes:(i) a long-lasting improvement in knowledge of diabetes and consequently a reinforcement of the beneficial effects of tight control, and (ii) an increase in self-monitoring blood glucose which allows for an optimal selfregulation. Our findings may have implications relevant for educational program planning in diabetes. Firstly, our results demonstrate that without major modifications in life-style and with a relatively inexpensive short-term outpatient program, it is possible to offer to insulin-dependent diabetic patients an effective and long-lasting tool to improve their metabolic control. Secondly, it should be highlighted that this benefit can be achieved without an increase in hypoglycemic episodes. It must be recognized that our study included a group of young subjectswith diabetesand was performed in a university hospital by trained endocrinologist and diabetes educators who were highly motivated. However, program design can be adapted with a wide implementation to other study groups and health care teams. In this context, further work is presently in progressin order to extend the present study to other patient and health-care groups. In summary, our study demonstratesthat an in-
192
I. Conget et al. /Diabetes Research and Clinical Practice 27 (1995) 189-192
dividual intensive educational control program is useful as a tool to improve metabolic control of insulin-dependent diabetic patients at short- and long-term follow-up. Acknowledgements We are indebted to all those who were at any time involved in ‘Club jueves’ program. References [I] The Diabetes Control and Complications Trial Research Group (1993) The effect of intensive treatment of diabetes on the development and progression of longterm complications in insulin-dependent diabetes mellitus. New Engl. J. Med. 329, 977-986.
PI Reichard, P., Nilson, B.Y. and Rosenquist, V. (1993)The effect of long-term intensified insulin treatment on the development of microvascular complications of diabetes mellitus. New Et@. J. Med. 329, 304-309. [31 Lennon, G.M., Taylor, K.G., Debney, L. and Bailey, C.J. (1990) Knowledge, attitudes, technical competence and blood ghrcose.control of type 1 diabetic patients during and after an education programme. Diabetic Med. 7, 825-832. 141 Larpent, N. and Canivet, J. (1984) Bicentric evaluation of a teaching and treatment programme for type 1 (insulin-dependent) diabetic patients. Diabetologia 27, 62. PI Rubin, R.R, Peyrot, M. and Saudeck, CD. (1991) Differential effect of diabetes education on self-regulation and life-style behaviors. Diabetes Care 14, 335-338. 161American Diabetes Association (1993) Implications of the diabetescontrol and complications trial. Diabetes 42, 1555- 1558.