Journal Watch

Prepared for IDDT by Jim Young

September 2013

The cost-effectiveness of the Dose Adjustment for Normal Eating (DAFNE) structured education programme: an update using the Sheffield Type 1 Diabetes Policy Model
J. Kruger et al. Diabetic Medicine. Doi: 10.1111/dme.12270

This study used the Sheffield Type 1 Diabetes Policy Model [a simulation model of type 1 diabetes and its associated complications] to estimate the cost-effectiveness of training in flexible intensive insulin therapy – as provided in the Dose Adjustment for Normal Eating (DAFNE) structured education programme. The study compared this with no training for adults with Type 1 diabetes mellitus. The model simulated the development of long-term microvascular and macrovascular diabetes-related complications and the occurrence of diabetes-related adverse events in 5,000 adults with Type 1 diabetes. Total costs were estimated along with the reduction in HbA1c that is associated with the risk of developing long-term diabetes-related complications. It was found that DAFNE resulted in greater life expectancy and reduced incidence of some diabetes-related complications compared with not using DAFNE, with an average of 0.0294 additional quality-adjusted life years for an additional cost of £426 per patient [quality-adjusted life years is a measure of disease burden, including both the quality and the quantity of life lived It is used in assessing the value for money of a medical intervention]. The authors suggest that this confirms that DAFNE is a cost-effective structured education programme for people with Type 1 diabetes and they support its provision by the National Health Service in the UK.


Feedback of personal retinal images appears to have a motivational impact in people with non-proliferative diabetic retinopathy and suboptimal HbA1c
G. Rees et al. Diabetic Medicine. Doi: 10.1111/dme.12192

This small pilot study recruited twenty-five participants with non-proliferative diabetic retinopathy and suboptimal HbA1c readings. The participants were selected at random to receive either visual feedback of their own retinal images or to a control group that did not. At baseline and at 3-month follow-up, HbA1c, diabetes-related distress and self-care activities were assessed. It was found that the intervention group showed significantly greater improvement in HbA1c at 3-month follow-up, as well as enhanced motivation to improve blood glucose management. The authors posit that this small pilot study provided preliminary evidence that visual feedback of personal retinal images may offer a practical educational strategy for clinicians in eye care services to improve diabetes outcomes in non-target compliant patients.


Do we need continuous glucose monitoring in type 2 diabetes?
Anna Rita Maurizi et al. Diabetes/Metabolism Research and Reviews. Doi: 10.1002/dmrr.2450

Because self-monitoring of blood glucose can provide only intermittent snapshots of blood glucose, and because HbA1c is unable to provide detailed diagnostic information, the authors suggest that continuous glucose monitoring (CGM) could provide information on day-to-day change of blood glucose levels and thereby help in achieving treatment targets without increasing the risk of hypoglycaemia. They also posit that the use of CGM may reduce glucose variability, and the resulting improvement in glycaemic control would result in a decrease in the long-term complications of diabetes. In addition CGM would be a powerful motivational device in changing a patients’ lifestyle and improving their quality of life. Notwithstanding the caveat that studies on the economic feasibility of the use CGM as an educational tool must be carried out, they suggest that it would be a powerful motivational device that would enable patients’ to change their lifestyle and improve glycaemic control in type 2 diabetes.


Medical and psychological outcomes for young adults with Type 1 diabetes: no improvement despite recent advances in diabetes care
B. Johnson et al. Diabetic Medicine. Doi: 10.1111/dme.12305

This observational study conducted in two diabetes clinics for young adults (aged 16–21 years) in Sheffield UK., looked at depressive symptoms, anxiety and disordered eating in young people with Type 1 diabetes. [An observational study draws inferences about the possible effect of a treatment on subjects].  It found that mean HbA1c was considerably higher than recommended. Although screening rates were improved and non-attendance was lower than previously reported, levels of non-proliferative retinopathy had increased. Also microvascular complications were present in 46.9% of those diagnosed for more than 7 years.  [In microvascular complications cells in the retina (diabetic retinopathy) or kidney (diabetic nephropathy) or nerves (diabetic neuropathy) may not get enough blood which may lead to loss of function]. Elevated levels of disordered eating were reported by 35.1%., and those scoring above cut-off levels for clinical anxiety (26.6%) and depression (10.9%), and were comparable with other work with young people with Type 1 diabetes. The conclusions from the study were that despite technological advances and improvements to delivery of care, HbA1c remained above recommended levels in a significant proportion of young people, many of whom already have microvascular complications. The authors assert that we need to learn from European centres who achieve better results, improve transition from paediatric care, integrate mental health support with diabetes care provision and take into account young people’s views about clinic.


Statin use and lower extremity amputation risk in nonelderly diabetic patients
Min-Woong Sohn et al. Journal of Vascular Surgery. Doi:10.1016/j.jvs.2013.06.069

This retrospective study from the USA of a cohort of patients with Type I and Type 2 diabetes mellitus was followed for 5 years between 2004 and 2008. It looked at the use of cholesterol-lowering agents and the major risk factors of lower extremity amputation (LEA) including peripheral neuropathy, peripheral artery disease, and foot ulcers. There were 83,953 patients in the study and it was found that statin users were 35% to 43% less likely to experience a LEA when compared with patients who did not use statins. It was also noted that the use of other cholesterol-lowering medications did not result in significantly different LEA occurrence. This is the first study to report a significant association between statin use and diminished amputation risk among patients with diabetes. The authors suggest that unanswered questions to be explored in future studies include a comparison of statins of moderate vs high potency in those with high risk of coronary heart disease, and an exploration of whether the effects seen in this study are simply effects of cholesterol-lowering or possibly pleiotropic effects [Pleiotropy occurs when one gene influences an organism’s multiple characteristics or traits].


Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study
Stephanie R. Johnson et al. Diabetologia. 10.1007/s00125-013-3007-9

In this study 345 patients on pump therapy were matched to controls on injections on the basis of age, duration of diabetes and HbA1c at the time of pump start. Episodes of severe hypoglycaemia and rates of hospitalisation for diabetic ketoacidosis (DKA) were collected prospectively. [Diabetic Ketoacidosis results from a shortage of insulin; in response the body switches to burning fatty acids and producing acidic ketone bodies that cause most of the symptoms and complications]. It was found that the mean HbA1c in the pump cohort was reduced by 6.6 mmol/mol and this remained significant throughout the 7 years of the follow-up. It was also found that pump therapy reduced severe hypoglycaemia, whereas severe hypoglycaemia increased in the non-pump cohort. The rate of hospitalisation for DKA was also lower in the pump cohort. This longest and largest study of insulin pump use in children and demonstrated that pump therapy provided a sustained improvement in glycaemic control, with reductions of severe hypoglycaemia and hospitalisation for DKA.


Risk of breast cancer by individual insulin use – an international multicenter study
Lamiae Grimaldi-Bensouda et al. Diabetes Care. Doi: 10.2337/dc13-0695

Several studies were published in 2009 that suggested a possible association between insulin glargine and an increased risk of malignancies, including breast cancer. The objective of this study was to assess the relation between the individual insulins (glargine, aspart, lispro and human insulin) and development of breast cancer. The study looked at 775 incident cases of breast cancer occurring in women with diabetes from 92 centers in the U.K., Canada and France and the individual insulin use in the 8 years preceding the study. Taken into consideration were past use of insulin, oral anti-diabetic drugs, reproductive factors, lifestyle, education, hormone replacement therapy and history of contraceptive use, BMI, comorbidities, diabetes duration, and annual number of physician visits. The conclusion was that there was no difference between glargine and the different types of insulins with respect to the risk of developing breast cancer in patients with diabetes.


Patients with Type 1 diabetes consuming alcoholic spirits have an increased risk of microvascular complications
V. Harjutsalo et al. Diabetic Medicine. Doi: 10.1111/dme.12307

Using the Finnish Diabetic Nephropathy Study of 3,608 patients with Type 1 diabetes the investigators assessed the cross-sectional association between alcohol consumption and diabetic nephropathy as well as retinopathy. [Cross-sectional studies are a class of research methods that involve observation of all of a population, or a representative subset, at one specific point in time]. It was found that there was no difference between light consumers and moderate or heavy consumers. Compared with wine drinkers, men consuming mostly alcoholic spirits had a higher risk of nephropathy.  It was also found that alcoholic spirit consumers had a higher risk of severe retinopathy. Overall there was no difference between wine and beer consumers. Interestingly, lifelong abstainers and former users of alcohol have a higher risk of nephropathy and severe retinopathy compared with light consumers.


Chronic fatigue in type 1 diabetes: highly prevalent but not explained by hyperglycaemia or glucose variability
Martine M. Goedendorp et al. Diabetes Care. Doi: 10.2337/dc13-0515

Although fatigue is a symptom of hyperglycemia the relationship between chronic fatigue and diabetes has not been systematically studied. The authors of this cross-sectional observational study looked at the prevalence, impact and potential determinants of chronic fatigue in 214 patients with type 1 Diabetes Mellitus (DM1). [Cross-sectional studies are a class of research methods that involve observation of all of a population, or a representative subset, at one specific point in time]. Chronic fatigue, functional impairments, current health status, comorbidity, diabetes-related factors and fatigue-related cognitions and behaviors were assessed with questionnaires, and HbA1c values and comorbidity were collected from medical records. It was found that DM1 patients were significantly more often chronically fatigued compared to matched controls, and chronically fatigued patients had significantly more functional impairments. [Functional impairment is a health condition in which the normal function of a part of the body is less than full capacity]. The authors suggest that the significant relationship of fatigue with cognitive-behavioral variables and weak association with blood glucose levels suggests that behavioral interventions could be helpful in managing chronic fatigue in DM1. [Cognitive behavioral therapy is a psychotherapeutic approach that addresses dysfunctional emotions, maladaptive behaviors and cognitive processes and contents through a number of goal-oriented, explicit systematic procedures].


Prescribing for Diabetes, England 2005-06 to 2012-13
Health and Social Care Information Centre

This report provided details on prescribing data (April 01, 2005 to March 31, 2013) and covers prescriptions written by general practitioners, nurses, pharmacists and others working in primary care. In the financial year 2012-13 there were 42.5 million items prescribed for diabetes at a net ingredient cost of £764.1 million.  This was a 4.7 per cent (1.9 million) rise in the number of items, from 40.6 million in 2011-12, and a 0.5 per cent (£3.8 million) rise in the net ingredient cost, from £760.3 million in 2011-12. In comparison, overall prescribing costs fell between 2011-12 and 2012-13 by 3.9 per cent. In 2012-13 there were 6.2 million insulin items representing 14.6 per cent of all items prescribed for diabetes.