Provider-patient communication and metabolic control.

OBJECTIVE: To determine whether nurses' and NIDDM patients' communication styles during consultations are related to subsequent metabolic control and to examine factors influencing patterns of communication in these consultations. RESEARCH DESIGN AND METHODS: A total of 47 NIDDM patients participated in the study and completed the following procedures: 1) assessment of baseline HbA1, 2) attended 3.5 days of diabetes education, 3) returned in 1 mo for a follow-up consultation with a nurse, and (4) returned in 9-12 wk for a follow-up HbA1 assessment. The communication variables coded from the consultations were the frequency with which nurses produced controlling, informative, and patient-centered utterances and the frequency with which patients sought information, engaged in decision making, and expressed negative affect. RESULTS: The results were as follows: 1) patients experienced poorer metabolic control after interacting with nurses who were more controlling and directive in their communication with patients (r = 0.39, P < 0.01); 2) the nurses' use of patient-centered responses was directly related to the degree to which patients expressed feelings (r = 0.34, P < 0.01) and exhibited decision-making behavior (r = 0.62, P < 0.01); and 3) several of the nurses' and patients' communicative behaviors were related to patient characteristics such as age, sex, education, and baseline HbA1 levels. CONCLUSIONS: The results suggest that providers' attempts to exert considerable control during consultations with NIDDM patients may be counterproductive and contribute to poorer outcomes. The findings also indicate that patient-centered behaviors (e.g., encouraging the patient's involvement, respecting the patient's opinion, and offering support) facilitate the patient's ability to be an active participant in the consultation.

Medical management of obesity.

Medical therapy for obesity is still unsuccessful in the majority of patients at five-year follow-up. Physicians should not become discouraged, however, because the number of successful participants in weight loss programs is increasing. An effective medical weight loss program requires five basic elements: (1) an effective means of caloric restriction, either a balance of fuel sources in patients who are less than 30% above ideal body weight, or a very-low-calorie diet in patients with obesity that is a significant threat to their health; (2) extensive nutritional instruction, to enable the patient to make wise food choices that are varied and palatable; (3) an individual exercise program sufficient to maintain the patient's goal weight on maintenance food; (4) behavioral modification, to allow patients to control their food consumption; and (5) a mechanism for continuing support. Now that low-fat diets and very-low-calorie diets allow effective means of safe and rapid weight loss, progress must be made in preventing weight regain. Obesity is a lifelong disease, with remissions followed by relapses. Long-term therapeutic success depends on the rapid reinstitution of therapy by a nonjudgemental support team when a relapse occurs.

Efficacy of diabetes education: classroom versus individualized instruction.

A pilot study was conducted using the concerns based adoption model (CBAM) developed at the University of Texas-Austin. This model uses two diagnostic dimensions: stages of concern (SC) and levels of use (LU). Movement in these dimensions is an important determinant of self-motivated disease management. It is postulated that this self-motivation is the basis of long-term adherence to the patient's therapeutic regimen and results in the decreased use of medical services. Twenty patients who attended a series of formal diabetes education classes were compared with 20 patients who received individualized instruction. Classroom education was significantly more effective in increasing the SC about diabetes management. However, the increase in LU (technical skills) was not significantly different in either setting. At 2- to 3-month follow-up evaluation, results indicated that retention of skills and motivation are excellent and that SC and LU continued to improve. In summary, this study demonstrated that classroom education is technically equivalent, more cost-effective, and may be more conducive to learning than individualized instruction.

Radioiodine uptake following iodine-131 therapy for Graves' disease: an early indicator of need for retreatment.

Forty-five patients with Graves' disease were studied prospectively to determine if 24-hour I-131 uptake measurements alone or in combination with serum thyroid hormone levels at six weeks would determine the necessity for retreatment of the thyrotoxicosis. All patients with an I-131 uptake greater than 30% at six weeks required retreatment. No patient with an I-131 uptake of less than 15% required retreatment. Patients with uptakes between 15% and 30% were variable. An elevated free thyroxin index at 6 weeks is not helpful to determine which patients will remain thyrotoxic. Patients with a free thyroxin index within the normal range at six weeks can be predicted to be euthyroid by 12 weeks if their 24-hour I-131 uptake is between 15% and 30% and to be hypothyroid if their 24-hour I-131 uptake is below 15%. There was no difference between patient groups treated initially with antithyroid medication and those who were not.

Management of obesity.

We live in an overweight society. Although food consumption has not increased dramatically over the last two decades, physical activity has markedly diminished. However, recent studies suggest that weights up to 20% above ideal body weight do not carry a significant risk of increased mortality in the absence of other chronic diseases. A team approach helps maintain patient motivation, the key to an effective weight-loss program. An efficient weight-loss and weight-maintenance program in the moderately obese patient includes modification of eating patterns, an individualized balanced fuel-source diet, and an exercise program to allow caloric deficit of approximately 500 calories a day. We must realize that for morbidly obese patients in whom the amount of caloric restriction necessary to reach and maintain a desirable body weight may be incompatible with a reasonable quality of life, surgery is warranted. The aggressiveness of our therapeutic regimen should always depend on the risk of morbidity and mortality associated with the patient's degree of obesity.

Isolated menarche in juvenile hypothyroidism.

Isolated menarche is an unusual presentation of the advanced sexual development relative to bone age found in some patients with juvenile hypothyroidism. A case is presented, demonstrating that hypothyroidism should be considered in the evaluation of vaginal bleeding in childhood, particularly if skeletal maturation is delayed.

Relationship of circulating thyroid antibodies to coronary artery disease.

A study of the relationship between circulating thyroid antibodies and coronary artery disease was performed. In 180 patients, the state of the coronary arteries was determined by cardiac catheterization and antithyroglobulin and antimicrosomal antibodies were measured using immunoprecipitation. The prevalence of risk factors for coronary artery disease and the mean age of the groups with and without coronary artery disease were similar. There was no significant difference in the prevalence of thyroid antibodies in patients with or without coronary artery disease.