Bethel , M.A., Alexander, J., Lane, J. , Barkauskas, C.E., Feinglos, M.N. Diabetes on a cardiovascular ward: Adherence to current recommendations. SOUTHERN MEDICAL JOURNAL., 2004, 97 : 1031-1037.
OBJECTIVES: Improving diabetes and blood pressure control decreases the incidence and progression of microvascular disease. Likewise, screening for microvascular complications is beneficial in the early detection and treatment of these disorders. However, adherence to practice guidelines for screening and treatment in patients with diabetes is suboptimal. This study describes a group of patients with diabetes who were admitted to a cardiology service at an academic medical center. METHODS: Patient interview and chart review were used to determine glycemic control and compliance with practice guidelines. RESULTS: The mean hemoglobin A1c was 8.3%. Only 69% of patients received ophthalmologic examinations, and fewer were screened for nephropathy. Thirty-five percent of patients monitored home blood glucoses less than daily. Nearly 17% had no hemoglobin A1c or lipid checks during the 3 months before admission. CONCLUSIONS: For a group of poorly controlled patients with diabetes who are at high risk for cardiovascular disease, adherence to practice guidelines and the level of diabetes control is inadequate.
Surwit, R.S., Van Tilburg, M.A.L., Parekh, P.I., McCaskill, C.C., Lane, J.D. , and Feinglos, M.N. Treatment regimen determines the relationship between depression and glycemic control. DIABETES RESEARCH AND CLINICAL PRACTICE, 2005, 69 : 78-80.
Several recent studies have suggested that depression is related to poorer glycemic control in patients with type 1 diabetes , but not in type 2 diabetes . We hypothesize that complexity of self-care regimen rather than the type of diabetes , is more important in determining this relationship of depression to glycemic control. METHODS: One thousand thirty-four adults with diabetes were recruited for the study. These patients were treated with: diet and exercise, oral medications, oral medications and insulin, 1-2 daily injections of insulin, and > or =3 daily injections. All participants completed the Beck depression inventory (BDI) and had a hemoglobin A(1c) (HbA(1c)) performed as part of routine clinical care. RESULTS: Pearson correlations between BDI scores and HbA(1c) were low and insignificant in all groups (0.015< or =r< or =0.066) except for those administering three or more daily shots of insulin (r=0.284; p=0.034). DISCUSSION: The results of this study clearly show that while depressive symptoms are significantly correlated to glycemic control in patients taking three or more insulin injections per day, there is no relationship in patients who are taking fewer than three injections per day.
Lane, J.D., Barkauskas, C.E., Surwit, R.S., and Feinglos, M.N. Caffeine impairs glucose metabolism in type 2 diabetes. DIABETES CARE, 2004, 27: 2047-2048.
Objective: Caffeine is a widely consumed central stimulant that has recently been shown to decrease insulin sensitivity in healthy, non-diabetic individuals. We hypothesized that caffeine disrupts glucose metabolism in patients with type 2 diabetes and causes both hyperinsulemia and hyperglycemia.
Research Design and Methods. A placebo-controlled cross-over study tested the effects of a moderate dose of caffeine (375 mg) on fasting glucose and insulin and on glucose and insulin responses to a mixed carbohydrate meal in 14 adult men and women diagnosed with type 2 diabetes. Responses to the meal were calculated as incremental areas under the 2-hour glucose and insulin time-curves.
Results. Caffeine had no effect on fasting levels of glucose or insulin, but significantly increased the glucose (21% larger) and insulin (48% larger) responses to the mixed meal.
Conclusions. Caffeine can cause exaggerated hyperglycemia and hyperinsulinemia in patients with type 2 diabetes, when given prior to a meal. The increase in post-prandial glucose could impede clinical efforts at glucose control in patients who consume caffeine on a daily basis. Long term effects on diabetes and its complications remain to be determined.
Williams, P.G., Colder, C.R., Lane, J.D., McCaskill, C.C., Feinglos, M., and Surwit, R. S. Examination of the neuroticism-symptom reporting relationship in patients with type 2 diabetes. PERSONALITY AND SOCIAL PSYCHOLOGY BULLETIN, 2002, 28: 1015-1025.
Utilized a within-subject, experience sampling methodology to examine the relationship between neuroticism (N) and physical symptom reports. 94 individuals (aged 31-82 yrs) with type 2 diabetes monitored diabetes-related symptoms, rated negative and positive affect (NA and PA), estimated their blood glucose (BG) levels, and tested their actual BG levels with a glucometer 4 times per day for 7 days. Multilevel modeling analyses indicated that N, NA, and PA were related to reported symptom frequency. Neuroticism moderated the relation between PA and symptom reports: Lower PA was more strongly related to symptom reports among high-N individuals. In addition, there was evidence that symptoms mediated the relationship between N and state NA. Finally, N was related to overestimation of BG, beyond that accounted for by state NA. Results are discussed with respect to potential effects of N on the processing of negative self-relevant information and on self-regulatory behavior in health contexts.
Surwit, R.S. Williams, R.B. Siegler, I.C., Lane, J.D., Helms, M., Applegate, K.L., Zucker, N., Feinglos, M.N., McCaskill, C.M., and Barefoot, J.C. Hostility, race, and glucose metabolism in non-diabetic individuals. DIABETES CARE, 2002, 25:835-839.
OBJECTIVE: The present study was designed to determine whether hostility is differentially related to measures of glucose metabolism in African-Americans and Caucasians. RESEARCH DESIGN AND METHODS: The relationship of hostility, as measured by a subset of the Cook-Medley hostility scale (CMHOST) inventory items, to various parameters of glucose metabolism were examined in a young, healthy sample of male and female African-American and Caucasian volunteers. Fasting blood samples were collected during an inpatient admission, at which time the CMHOST was also administered. RESULTS: In the entire sample, the CMHOST was found to be significantly correlated with fasting glucose and insulin sensitivity, as measured by the homeostatic model assessment (HOMA). However, the relationship of hostility to these parameters of glucose metabolism was different in African-American and Caucasian subjects. Hostility was significantly related to fasting glucose in African-Americans and to insulin sensitivity and fasting insulin in Caucasian subjects. The relationship of hostility to insulin sensitivity and fasting insulin was partially dependent on BMI in Caucasians, but the relationship of hostility to fasting glucose was unrelated to BMI in African-Americans. CONCLUSIONS: Our data suggest that the relationship of hostility to measures of glucose metabolism is mediated differently in these two ethnic groups. Therefore, hostility seems to be part of a constellation of risk-related behaviors related to BMI in Caucasians but independently related to fasting glucose in African-Americans.
Surwit, R. S., van Tilburg, M. A., Zucker, N., McCaskill, C. C., Parekh, P., Feinglos, M. N., Edwards, C. L., Williams, P. and Lane, J. D. (2002). "Stress management improves long-term glycemic control in type 2 diabetes." Diabetes Care 25(1): 30-4.OBJECTIVE: There is conflicting evidence regarding the utility of stress management training in the treatment of diabetes. The few studies that have shown a therapeutic effect of stress management have used time-intensive individual therapy. Unfortunately, widespread use of such interventions is not practical. The aim of the present investigation is to determine whether a cost-effective, group-based stress management training program can improve glucose metabolism in patients with type 2 diabetes and to determine whether a particular subset of patients is more likely to get positive results. RESEARCH DESIGN AND METHODS: Patients with type 2 diabetes were randomized to undergo a five-session group diabetes education program with or without stress management training. Participants (n = 108) were followed for 1 year, during which HbA(1c) tests and questionnaires assessing perceived stress, anxiety, and psychological health were administered at regular intervals to evaluate treatment effects. RESULTS: Stress management training was associated with a small (0.5%) but significant reduction in HbA(1c). Compliance with the treatment regimen decreased over time but was similar to that seen in patients receiving stress management for other reasons in the clinic. Trait anxiety (a measure of stable individual differences in anxiety proneness) did not predict response to treatment, showing that highly anxious patients did not derive more benefit from training. CONCLUSIONS: The current results indicate that a cost-effective, group stress management program in a "real-world" setting can result in clinically significant benefits for patients with type 2 diabetes.
Van Tilberg, M.A.L., McCaskill C.C., Lane, J.D.¸ Edwards, C.L., Bethel, A., Feinglos, M.N., and Surwit, R. S. (2001). "Depressed mood is a factor in glycemic control in type 1 diabetes." Psychosomatic Medicine, 63: 551-555.OBJECTIVE: The diabetes literature contains conflicting evidence on the relationship between depression and glycemic control. This may be due, in part, to the fact that past studies failed to distinguish between patients with type 1 and type 2 diabetes. Because these are actually completely different diseases that are often treated differently and consequently make different demands on patients, the relationship between glycemic control and depressed mood in type 1 and type 2 diabetes was examined separately. METHODS: The relationship between Beck Depression Inventory (BDI) scores and HbA1c, as an index of long-term glycemic control, was measured in samples of 30 patients with type 1 and 34 patients with type 2 diabetes. RESULTS:: Groups of patients with type 1 and type 2 diabetes did not differ in mean BDI score or HbA1c level. Correlation analysis revealed a significant positive relationship between BDI scores and HbA1c in the type 1 group (r = .44, p < .02) but not in the type 2 group (r = -0.06, p > .05). This relationship was evident throughout the entire range of BDI scores and was not restricted to scores indicative of clinical depression. Patients with type 1 diabetes who had higher HbA1c and BDI scores reported a lower frequency of home blood glucose monitoring. CONCLUSIONS: Variations in depressive mood, below the level of clinical depression, are associated with meaningful differences in glycemic control in type 1 but not type 2 diabetes. Preliminary data analysis suggests that this effect may be mediated, at least in part, by decreased self-care behaviors in patients with more depressed mood.
Lane, J.D. McCaskill, C.C., Williams, P.G., Parekh, P.I., Feinglos, M.N., and Surwit, R.S. (2000). "Personality Correlates of Glycemic Control in Type 2 Diabetes." Diabetes Care 23: 1321–1325.OBJECTIVE — To determine whether traits of normal personality are associated with variations in glycemic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS — A longitudinal cohort study was conducted using data from 105 type 2 diabetic patients in a clinical trial of a stress management intervention. Before treatment assignment, patients completed the NEO Personality Inventory, Revised, which is a questionnaire inventory measuring 5 major domains of normal personality and 30 important traits that define these domains. Glycemic control was assessed by measures of HbA1c and average blood glucose levels based on 7 days of self-monitoring at baseline and at 6 and 12 months. Relationships between personality traits and measures of glycemic control were examined by correlation and linear regression models that were adjusted for age, sex, race, duration of diabetes, medication status, and experimental treatment. RESULTS — Lower average blood glucose values at baseline were associated with higher scores for the personality domain of neuroticism and several specific traits including anxiety, angry hostility, depression, self-consciousness, and vulnerability but were associated with lower scores for the trait of altruism. Results were similar for HbA1c but were not as strong. Follow-up results were similar but were less consistent. CONCLUSIONS — Personality traits may offer new insights into variations in glycemic control in patients with type 2 diabetes undergoing standard management. The relative tendency to experience fewer negative emotions and to focus on the needs of others instead of oneself could prove to be a risk factor for poor glycemic control.
Feinglos, M. N., Thacker, C. H., English, J., Bethel, M. A. and Lane, J. D. (1997). "Modification of postprandial hyperglycemia with insulin lispro improves glucose control in patients with type 2 diabetes." Diabetes Care 20(10): 1539-42.OBJECTIVE: Insulin lispro is a rapid-acting analog of human insulin that can be used to target the postprandial rise in plasma glucose. We designed an open-label randomized crossover study of type 2 diabetic patients with secondary failure of sulfonylurea therapy to determine whether improvement of postprandial hyperglycemia would affect total daily glucose control. RESEARCH DESIGN AND METHODS: Twenty-five type 2 diabetic patients who were poorly controlled on a maximum dose of sulfonylureas were studied in a university hospital clinical research center. In one arm of the study, patients continued therapy with maximum-dose sulfonylureas. In the other arm, patients used a combination therapy with insulin lispro before meals and sulfonylureas. After 4 months, patients were crossed over to the opposite arm. Fasting plasma glucose (FPG) and 1- and 2-h postprandial glucose (after a standardized meal), HbA1c, total, HDL, and LDL cholesterol, and triglyceride levels were measured at the end of each arm of the study. RESULTS: Insulin lispro in combination with sulfonylurea therapy significantly reduced 2-h postprandial glucose concentrations compared with sulfonylureas alone, from 18.6 to 14.2 mmol/l (P < 0.0001), and incremental postprandial glucose area from 617.8 to 472.9 mmol.min.1-1 (P < 0.0007). FPG levels were decreased from 10.9 to 8.5 mmol/l (P < 0.0001), and HbA1c values were reduced form 9.0 to 7.1% (P < 0.0001). Total cholesterol was significantly decreased in the lispro arm from 5.44 to 5.10 mmol/l (P < 0.02). HDL cholesterol concentrations were increased in the lispro arm from 0.88 to 0.96 mmol/l (P < 0.01). The patients weighed significantly more after lispro therapy than after sulfonylureas alone, but the difference was small in absolute terms (sulfonylurea therapy alone, 90.6 kg; lispro therapy, 93.8 kg; P < 0.0001). Two episodes of hypoglycemia (glucose concentrations, < 2.8 mmol/l) were reported by the patients while using lispro. CONCLUSIONS: Previously, it has not been possible to address the effect of treatment of postprandial hyperglycemia specifically. We have now shown that the treatment of postprandial hyperglycemia with insulin lispro markedly improves overall glucose control and some lipid parameters in patients with type 2 diabetes.
Lane, J. D., McCaskill, C. C., Ross, S. L., Feinglos, M. N. and Surwit, R. S. (1993). "Relaxation training for NIDDM. Predicting who may benefit." Diabetes Care 16(8): 1087-94.OBJECTIVE--To examine the benefits of relaxation training for patients with NIDDM and to investigate individual differences that could predict a positive response to relaxation training. RESEARCH DESIGN AND METHODS--Thirty-eight subjects with NIDDM were treated with intensive conventional diabetes therapy after an initial metabolic evaluation and psychological and pharmacological testing. Half were assigned to also receive biofeedback-assisted relaxation training. Treatment effects on GHb levels and glucose tolerance were evaluated after 8 wk. RESULTS--Subjects demonstrated significant improvements in GHb level, but not in glucose tolerance, after 8 wk of intensive conventional treatment. These improvements persisted throughout the follow-up period. However, the group provided with relaxation training did not experience greater improvements on either measure than the group given conventional diabetes treatment only. Within the group that received relaxation training, correlations occurred between the improvements in glucose tolerance after treatment and individual differences in trait anxiety and in the effect of alprazolam on glucose tolerance. Differences in the effects of EPI on glucose tolerance and personality measures of neuroticism and perceived locus of control also appeared to be related to improvements in glucose tolerance after training. CONCLUSIONS--Relaxation training did not confer added benefit over and above that provided by conventional diabetes treatment for patients with NIDDM. Additional research is needed to determine whether the administration of relaxation training to selected patients, especially those who are most responsive to stress, would provide benefits for glucose control that are not achieved by conventional treatment.
Surwit, R. S. and Lane, J. D. (1991). "Physical activity and non-insulin dependent diabetes mellitus [letter; comment]." New England Journal of Medicine 325(26): 1887.
Lane, J. D., Stabler, B., Ross, S. L., Morris, M. A., Litton, J. C. and Surwit, R. S. (1988). "Psychological predictors of glucose control in patients with IDDM." Diabetes Care 11(10): 798-800.
Stabler, B., Lane, J. D., Ross, S. L., Morris, M. A., Litton, J. and Surwit, R. S. (1988). "Type A behavior pattern and chronic glycemic control in individuals with IDDM." Diabetes Care 11(4): 361-2.
Stabler, B., Surwit, R. S., Lane, J. D., Morris, M. A., Litton, J. and Feinglos, M. N. (1987). "Type A behavior pattern and blood glucose control in diabetic children." Psychosomatic Medicine 49(3): 313-6.We studied the relationship between presence of Type A behavior pattern and glycemic response to stress in children with insulin dependent diabetes mellitus (IDDM). Twelve male (six Type A and six Type B) and nine female (four Type A and five Type B) insulin-dependent diabetic patients between the ages of 8 and 16 years received a standard meal and blood glucose values were assessed two hours later. All subjects then played a competitive videogame for 10 minutes following which blood glucose was assessed again. Preprandial and postprandial blood glucose values did not differ between the groups. However, only Type A subjects showed a hyperglycemic response to the videogame stress. Type A subjects also demonstrated significantly higher glycohemoglobin values. In order to assure that this effect was due to a differential response to stress and not simply a difference in metabolic response to a meal, a second study was conducted in which blood glucose values were assessed at one, two and three hours following a standard meal. No significant differences in postprandial blood glucose values were observed between Type A and Type B subjects. These data support previous research which has suggested that some but not all patients with IDDM show a hyperglycemic response to stress.
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