Predicting Glycemic Control and Hypoglycemia in Type II Diabetic Veterans
Glen H. Murata MD
New Mexico VA Health Care System
Albuquerque, NM
Funding Period: October 1999 - September 2002

BACKGROUND/RATIONALE:
Randomized trials have shown that aggressively managing hyperglycemia reduces the frequency and severity of microvascular complications in type II diabetes mellitus. A substantial proportion of diabetic veterans continue to have poor glycemic control and suffer preventable complications.

OBJECTIVE(S):
The principal objectives are to conduct a comprehensive analysis of self-care behaviors affecting glycemic control in stable, insulin-treated, type II diabetic veterans and to develop multivariate models predictive of poor control and hypoglycemia.

METHODS:
Prospective subjects were randomly selected from pharmacy files at the Albuquerque, Tucson and Phoenix VAMCs. Consenting patients were given a battery of 8 standardized questionnaires on all aspects of diabetes self-care. At the beginning, a subset measured their blood sugars before meals and at bedtime for 8 weeks. Multivariate analysis was used to examine the relationship between questionnaire and monitoring data and HbA1c at 0, 6 and 12 months.

FINDINGS/RESULTS:
From 400+ enrolled subjects, 150 completed the monitoring protocol. Optimal testing times identified for once- and twice-daily monitoring differed from those used in conventional practice. Intensified monitoring resulted in a sustained reduction of HbA1c that was attributed to a decrease in late postprandial glucose levels. Innovative multivariate methods were developed to quantify the contribution of each reading to glucose load; the fasting glucose elevation was shown to be the greatest contributor to an elevated HbA1c. Poor compliance with intensified monitoring was related to perceived inability to perform self-care and barriers to self-monitoring but not to lack of motivation, cognitive dysfunction, depression, or lack of diabetes knowledge. Among the entire cohort, we found that age, education level, preferred language, depression score, mini-mental status score and diabetes duration were independent predictors of diabetes knowledge. Analysis of racial differences in glycemic control showed that Black subjects had significantly higher baseline HbA1c and received lower doses of insulin than non-Hispanic Whites. These findings could not be attributed to ethnic differences in attitudes, BMI, diet, exercise, or other treatment modalities. No discrepancies were found in the control of macrovascular risk factors. Obese patients scored lower on scales on adherence to self-care and self-care abilities, were more highly educated and depressed, and more likely to perceive physical disabilities and barriers to exercise. Quantifying lifestyle factors showed that obesity was more closely associated with excessive caloric and fat intake than lack of exercise. The Diabetes Care Profile was found to be an exceptional instrument for rating attitudes; 8 of 14 subscales were correlated with HbA1c or scores on other psychological instruments. Individual scores were also correlated with HbA1c after adjusting for BMI, dietary compliance, exercise, and treatment intensity, suggesting that certain attitudes drive other important self-care behaviors. Measurements of routine physical activities showed that many subjects were sedentary and that limitations were mostly due to irreversible disabilities and diabetes complications. Adherence to ADA dietary recommendations was poor and attributable to social and occupational factors but not to poor attitudes, lack of knowledge, or disabilities related to shopping or cooking.

IMPACT:
Current methods for blood glucose monitoring and intensification of insulin treatment may have to be completely revised. Psychosocial profiling should be incorporated into the standard evaluation of diabetic veterans. Diabetes care programs should be restructured to include periodic reassessment of knowledge, level of depression, and cognitive functioning. Insulin management should accommodate the special needs of minorities because of their vulnerability to poor glycemic control. Quantification of dietary intake should be done in obese patients because of the strong association between BMI and dietary indiscretion. Dietary modifications must accommodate social and occupational factors and cannot rely only upon educational or motivational strategies. Together, these findings suggest that fundamental revisions should take place in microvascular risk management programs for veterans.

PUBLICATIONS:

Journal Articles

1. Murata GH, Duckworth WC, Shah JH, Wendel CS, Mohler MJ, Hoffman RM. Hypoglycemia in stable, insulin-treated veterans with type 2 diabetes: a prospective study of 1662 episodes. Journal of Diabetes and Its Complications. 2005; 19(1): 10-7.
2. Murata GH, Duckworth WC, Hoffman RM, Wendel CS, Mohler MJ, Shah JH. Hypoglycemia in type 2 diabetes: a critical review. Biomedicine & Pharmacotherapy = Biomedecine & Pharmacotherapie. 2004; 58(10): 551-9.
3. Murata GH, Shah JH, Duckworth WC, Wendel CS, Mohler MJ, Hoffman RM. Food frequency questionnaire results correlate with metabolic control in insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study. Journal of The American Dietetic Association. 2004; 104(12): 1816-26.
4. Murata GH, Hoffman RM, Shah JH, Wendel CS, Duckworth WC. A probabilistic model for predicting hypoglycemia in type 2 diabetes mellitus: The Diabetes Outcomes in Veterans Study (DOVES). Archives of Internal Medicine. 2004; 164(13): 1445-50.
5. Murata GH, Duckworth WC, Shah JH, Wendel CS, Hoffman RM. Factors affecting hypoglycemia awareness in insulin-treated type 2 diabetes: The Diabetes Outcomes in Veterans Study (DOVES). Diabetes Research and Clinical Practice. 2004; 65(1): 61-7.
6. Murata GH, Hoffman RM, Duckworth WC, Wendel CS, Shah JH. Contributions of weekly mean blood glucose values to hemoglobin A1c in insulin-treated type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES). American Journal of The Medical Sciences. 2004; 327(6): 319-23.
7. Murata GH, Shah JH, Adam KD, Wendel CS, Bokhari SU, Solvas PA, Hoffman RM, Duckworth WC. Factors affecting diabetes knowledge in Type 2 diabetic veterans. Diabetologia. 2003; 46(8): 1170-8.
8. Murata GH, Shah JH, Wendel CS, Hoffman RM, Adam KD, Bokhari SU, Solvas PA, Duckworth WC. Risk factor management in stable, insulin-treated patients with Type 2 diabetes: the Diabetes Outcomes in Veterans Study. Journal of Diabetes and Its Complications. 2003; 17(4): 186-91.
9. Murata GH, Shah JH, Hoffman RM, Wendel CS, Adam KD, Solvas PA, Bokhari SU, Duckworth WC. Intensified blood glucose monitoring improves glycemic control in stable, insulin-treated veterans with type 2 diabetes: the Diabetes Outcomes in Veterans Study (DOVES). Diabetes Care. 2003; 26(6): 1759-63.
10. Hoffman RM, Shah JH, Wendel CS, Duckworth WC, Adam KD, Bokhari SU, Dalton C, Murata GH. Evaluating once- and twice-daily self-monitored blood glucose testing strategies for stable insulin-treated patients with type 2 diabetes : the diabetes outcomes in veterans study. Diabetes Care. 2002; 25(10): 1744-8.

DRA: Chronic Diseases, Health Services and Systems
DRE: Prevention, Quality of Care, Resource Use and Cost
Keywords: Behavior (patient), Diabetes, Self-care
MeSH Terms: none