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Recent papers on diabetes

GP Dr Roger Gadsby reviews newly published research with important implications for primary care

GP Dr Roger Gadsby reviews newly published research with important implications for primary care

What is the best way to prevent someone with impaired glucose tolerance developing diabetes?

The paper

Lindstom J, Ilanne-Parikka P, Peltonen M et al. Sustained reduction in the incidence of type 2 diabetes by lifestyle intervention: follow-up of the Finnish Diabetes Prevention Study. Lancet 2006; 368:1673-9

Method

The Finnish Diabetes Prevention Study showed that an intensive diet and exercise regimen resulted in a 58% reduction in the development of diabetes in a group of people with impaired glucose tolerance. This paper reports the results of a three-year follow-up of those who hadn't developed diabetes at the end of the four-year intervention period of the original study.

Results

There was an incidence of diabetes of 4.3 and 7.4 per 100 person years in what were the intervention and control groups, a 43% reduction in the relative risk.

Conclusion

Beneficial lifestyle changes achieved by participants in the intervention group were maintained when the intervention came to an end.

What I am going to do now

Continue to treat people with impaired glucose tolerance with intensive diet and exercise advice.

Should a glitazone be preferred to a sulphonylurea as the second therapy to be added to metformin?

The paper

Kahn S, Haffner S, Heise M et al. Glycaemic durability of Rosiglitazone, Metformin or Glyburide monotherapy N. Engl J Med 2006; 335:2427-43 (ADOPT study)

Method

Some 4,360 people with type 2 diabetes were randomised to monotherapy with either rosiglitazone titrated up to 8mg daily, metformin titrated up to 2g daily or glyburide (glibenclamide) titrated up to 15mg daily. The patients were treated for four years and the primary outcome was the time after which monotherapy failed.

Results

Cumulative monotherapy failure rate at four years was 15% for rosiglitazone, 21% for metformin and 34% for glibenclamide. Conclusion The result suggests people stay controlled for longer on rosiglitazone.

What I am going to do now

No one study can answer this question, but the results from ADOPT can be interpreted as giving support for the use of a glitazone rather than a sulphonylurea, which is my usual practice.

Should people with type 2 diabetes be referred for group education?

The paper

Deakin TA, Cade JE, Williams R et al. Structured patient education: the Diabetes X-PERT programme makes a difference. Diabetic Medicine 2006 23: 944-54

Method

Adults with type 2 diabetes from Lancashire were randomised to either the control group of individual appointments (n=157), or the X-PERT intervention, a two hours a week structured group education programme delivered by a diabetes research dietician for six weeks (n=157). The theoretical models underpinning the programme are empowerment and discovery learning.

Results

Some 82% in the intervention group attended four or more sessions. By 14 months the intervention group showed a drop of 0.6% in HbA1c compared with controls. The intervention group showed statistically significant improvements in weight, BMI, activity levels, knowledge of diabetes, self-empowerment, and treatment satisfaction.

Conclusion

The results provide compelling evidence that when enthusiastic and motivated healthcare professionals invest more time in patients with diabetes in a structured way there are improved outcomes.

What am I going to do now

Continue to provide education to people with type 2 diabetes in the practice, both one-to-one and in group sessions.

What are the benefits of reporting estimated glomerular filtration rate (eGFR) over serum creatinine alone?

The paper

Basker V, Venugopal H, Holland MR et al. Clinical Utility of estimated glomerular filtration rates in predicting renal disease in a district diabetes population. Diabetic Medicine 2006; 23: 1057-60

Method

A cross-sectional study of 4,548 patients with diabetes attending the diabetes centre in Wolverhampton. They compared the numbers diagnosed as having significant renal impairment found by using eGFR measurements compared with serum creatinine measurement and microalbuminuria estimation using an albumin:creatinine ratio (ACR).

Results

Of those with clinically meaningful renal disease with eGFR below 60ml/min only 42% and 45% were identified by serum creatinine and ACR individually, and 38% of those with eGFR below 60 would have been missed by using both together.

Conclusion

They conclude that eGFR with ACR, creatinine and blood pressure are all needed to assess renal function in adults with diabetes.What am I going to do now I will accept that eGFR is here to stay and that it adds benefit.

Is there reliable evidence that exercise improves glycaemic control in people with diabetes?

The paper

Snowling NJ, Hopkins WG. Effects of different modes of exercise training on glucose control and risk factors for complications in type 2 diabetic patients. Diabetes Care 2007; 29: 2518-27

Method

A review of 27 trials including 1,003 people with type 2 diabetes of average age 55 years for between five and104 weeks.

Results

Differences in the effects of aerobic, resistance and combined training on HbA1c were trivial for training lasting 12 weeks. The overall effect was a small beneficial reduction in HBA1c of 0.8% ± 0.3%. There were generally small to moderate benefits for other measures of glucose control. For other risk factors there were either small benefits or the effects were trivial and unclear, although combined training was generally superior to aerobic and resistance training.

Conclusion

All forms of exercise training produce small benefits in HBA1c, the main measure of glucose control. The effects are similar to those of dietary, drug and insulin treatments. The clinical importance of combining these treatments needs further research.

What am I going to do now?

Continue to recommend increased physical activity to patients with type 2 diabetes, confident that there is a reasonably strong evidence base behind it.

Dr Roger Gadsby is a GP in Warwickshire and a GPSI in diabetes

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