Nurse-led cardiovascular risk factor intervention leads to improvements in cardiovascular risk targets and glycaemic control in people with Type 1 diabetes when compared with routine diabetes clinic attendance.

AIM: To compare the effects of a dedicated cardiovascular risk factor clinic run by a nurse consultant with routine diabetes clinic attendance in achieving glycaemic and cardiovascular risk targets in patients with Type 1 diabetes. METHODS: Eighty-one patients (45 male, mean age 34.6 years, mean duration of diabetes 15 years) with an HbA(1c) ≥ 8% (64 mmol/mol) and at least one other risk factor for the development of cardiovascular disease were randomized to receive either routine care or intensive nurse-led cardiovascular risk factor intervention. HbA(1c) , non-fasting lipid profile, blood pressure, weight, BMI and insulin dose were recorded at baseline, 6, 12 and 24 months. RESULTS: At baseline there were no differences between the groups. At 12 months, there were significant improvements in the nurse-led cardiovascular risk factor group: HbA(1c) [10.1% (87 mmol/mol) vs. 9.3% (78 mmol/mol), P < 0.001], total cholesterol (5.8 vs. 4.3 mmol/l, P < 0.001), systolic blood pressure (127 vs. 115 mmHg, P < 0.001) and diastolic blood pressure (71 vs. 65 mmHg, P < 0.05). Improvements were maintained in all variables at 24 months except diastolic blood pressure. In the routine group, only total cholesterol improved significantly (5.8 vs. 5.2 mmol/l, P < 0.01) after 12 months and this was maintained at 24 months. CONCLUSION: A nurse consultant cardiovascular risk factor clinic has a beneficial effect on cardiovascular risk targets in Type 1 diabetes, probably attributable to the increased use of lipid-lowering and anti-hypertensive agents and this was maintained at 24 months. Glycaemic control also improved.

Aerobic fitness and hand grip strength in Type 1 diabetes: relationship to glycaemic control and body composition.

AIM: To clarify the relationship of aerobic fitness and handgrip strength with glycaemic control (HbA1c), body composition and lipid profile in Type 1 diabetes. METHODS: Aerobic capacity (Chester Step Test), handgrip strength and body composition (bioelectrical impedance) were measured in 141 patients with Type 1 diabetes. RESULTS: Aerobic capacity correlated positively with HbA1c and lean body mass and negatively with body mass index and fat mass. Handgrip strength correlated positively with aerobic capacity and negatively with HbA1c and fat mass. In addition, there was a positive correlation between HbA1c and total cholesterol. CONCLUSION: Patients with Type 1 diabetes who have good aerobic capacity have poorer glycaemic control. However, this was an observational study and the results must be interpreted with caution. Further investigation into how these patients manage blood glucose during exercise is required.

Hospital in-patients with diabetes: increasing prevalence and management problems.

AIMS: To re-assess the prevalence, management problems, clinical outcomes and discharge summaries of hospital in-patients with diabetes. METHODS: Case records of all patients occupying in-patient beds were audited on a single weekday in 2003 in a large urban hospital and repeated after 3 months. Data was compared with an identical audit 12 years previously. RESULTS: Over 12 years the number of beds available for admission (1191) had reduced by 25% with a bed occupancy of 97%. Diabetes prevalence had increased from 7.0% to 11.1% (P < 0.01) (97% Type 2). Diabetes management was considered inappropriate in 29%, more than in 1991 (20%). After 3 months, discharge summaries had been completed on 75% of patients but diabetes was mentioned in only 53%. CONCLUSION: The prevalence of in-patient diabetes (11.1%) was over 50% greater and diabetes management was suboptimal in more patients than in 1991. In many length of stay was prolonged and almost half of the discharge summaries did not mention diabetes. These findings have major implications for service delivery and resource planning.

Nodules of fibrocollagenous scar tissue induced by subcutaneous insulin injections: a cause of poor diabetic control.

A 46 year old man with longstanding type 1 diabetes developed major weight loss and marked deterioration in diabetic control. He had been persistently injecting insulin into areas of abdominal lipohypertrophy within which hard collagenised fibrous tissue nodules had developed. Injecting insulin at different sites dramatically improved blood glucose control. Fibrocollagenous nodules induced by insulin injections have not been previously described. Examination of a further 73 type 1 patients revealed lipohypertrophy in 44% and hard subcutaneous nodules on two.

Elderly people with hypothalamic-pituitary disease and untreated GH deficiency: clinical outcome, body composition, lipid profiles and quality of life after 2 years compared to controls.

OBJECTIVE: Elderly patients with GH deficiency (GHD) have significant impairments in multiple aspects of quality of life (QOL) but similar lipid profiles compared to age-matched control subjects. There are, however, no data on changes in these parameters with time. This study assessed the impact of untreated GHD over a period of 2 years in a group of elderly patients with hypothalamic-pituitary disease in relation to new illnesses and differences in body composition, circulating lipid profile levels and QOL. Control subjects were also followed for 2 years. SUBJECTS: Twenty-seven elderly patients (> 65 years) with hypothalamic-pituitary disorders and GHD (mean peak stimulated GH response 1.6 mIU/l, range 0.6--5.0) were studied initially. Two years later 21 (13 males) agreed to attend for reassessment. Mean age was then 72.7 +/- 5.04 years (range 67--85). Eighteen patients had pituitary tumours, three had craniopharyngiomas. Twenty-seven control subjects were studied at baseline and 17 (7 males) agreed to attend for reassessment. Mean age was then 75.9 +/- 6.97 years (range 67--88). METHODS: Weight, body mass index (BMI), total fat mass (FM) (bioelectrical impedance), serum IGF-1 and fasting lipid profile (total cholesterol, triglyceride, HDL cholesterol, LDL cholesterol) were measured. QOL was assessed in both groups using five interviewer-administered self-rating questionnaires: the Nottingham Health Profile, Short Form-36, Hospital Anxiety and Depression Scale, Mental Fatigue Questionnaire and Life Fulfillment Scale. The GHD group also completed the Disease Impact Scale. RESULTS: Two of the 27 patients with GHD died during the 2-year follow-up (myocardial infarction and probable cerebrovascular accident). Four controls could not be traced but there were no deaths in the other 23. In the 21 GHD patients after 2 years, mean serum IGF-1 and BMI were unchanged (12.6 +/- 5.8 vs. 13.3 +/- 5.1 nmol/l, P = 0.5 and 28.3 +/- 4.3 vs. 29.1 +/- 4.2, P = 0.5, respectively) at the 2-year follow-up and there were no significant changes in the lipid profiles. However, there was a significant reduction in fat mass (31.7 +/- 11.2 vs. 28.5 +/- 10.9%, P = 0.04). In the 17 control subjects after 2 years, serum IGF-1 levels (17.2 +/- 4.0 vs. 15.7 +/- 5.6 nmol/l, P = 0.4), BMI and fat mass were unchanged. However, there was a significant fall in total cholesterol levels over the 2-year follow-up (6.3 +/- 0.9 vs. 5.7 +/- 0.9 mmol/l, P < 0.0001), although LDL cholesterol, triglycerides and HDL cholesterol were unchanged. Analysing the QOL data, the GHD patients had less energy (P < 0.05), more depression (P < 0.05), more pain (P < 0.05) and lower life fulfillment scores (P < 0.01) after 2 years. However, the control subjects also had less energy (P < 0.05), less vitality (P < 0.05) and lower self-esteem (P < 0.05), more depression (P < 0.05), worse mental health (P < 0.05), life fulfillment personal (P < 0.01), life fulfillment material (P < 0.02), physical functioning and role physical functioning (P < 0.05) after 2 years. Comparing the patients and controls at baseline, there were significant differences in IGF-1, BMI, FM, LDL cholesterol, personal life fulfillment, mental fatigue, general health and mental health. However, after 2 years, only BMI and depression scores were significantly different. CONCLUSION: These patients with untreated GHD did not have deterioration of body composition or lipid profiles when reassessed after a period of 2 years. In fact, fat mass fell. The control subjects did have a significant decrease in total cholesterol but no change in other lipids or body composition. Some quality of life domains did deteriorate in the patients with GHD. However, the control subjects also had worse quality of life scores after 2 years which were then little different from the GHD patients. These results raise doubts about the benefits of GH replacement in elderly people with GHD.

Elderly people with hypothalamic-pituitary disease and growth hormone deficiency: lipid profiles, body composition and quality of life compared with control subjects.

OBJECTIVE: In healthy adults the secretion of growth hormone (GH) and insulin-like growth factor 1 (IGF-1) declines with ageing and body composition alters, particularly with an increase in total body fat. In elderly people, hypothalamic-pituitary disease can cause GH deficiency (GHD), compared with age matched controls. This study aimed to clarify whether GHD in the elderly is associated with differences in body composition, circulating lipid levels and quality of life (QOL) compared with control subjects. SUBJECTS: Twenty-seven elderly patients (14 males, mean age 71 years, range 65-83) with hypothalamic-pituitary disorders (23 pituitary tumours) and GHD (mean (SD) peak stimulated GH response 1.6 mIU/l (1.03) range 0.6-5) were studied. Twenty-five patients had been treated surgically (six cranial surgery, 19 transsphenoidal) and eight patients had received external cranial irradiation. Twenty-seven control subjects (14 males, mean age 72 years, range 65-86) were also studied. METHODS: Weight, body mass index (BMI), total fat mass (FM, bioelectrical impedance), waist to hip ratio (WHR), serum IGF-1, fasting blood glucose and lipid profile were measured. QOL was assessed in both groups using five interviewer administered self-rating questionnaires: The Nottingham Health Profile, Short-Form 36, Hospital Anxiety and Depression Scale, Mental Fatigue Questionnaire and Life Fulfilment Scale. The GHD group also completed the Disease Impact Scale. RESULTS: The data (mean (SD)) from males and females were analyzed separately. The male patients had a higher BMI than controls, 28.9(4.5) vs. 25.2(2.3) kg/m2 (P = 0.01) but the BMI in the female patients and controls was similar. In the female patients compared with the controls, FM was higher 39. 4(6) vs. 33.1(8.3) % (P = 0.02), WHR was also higher 0.9(0.08) vs. 0. 83(0.09) (P = 0.03) and serum IGF-1 levels were lower 10.8(6.4) vs. 18.2(6.5) nmol/l (P = 0.01). However, in the male patients, FM, WHR and IGF-1 levels were similar to the controls. Fasting blood glucose was similar in both male and female patients and the controls. Two female patients and one male control subject were taking lipid-lowering agents and were therefore excluded from the analysis of lipid profiles. Total cholesterol, triglyceride, LDL cholesterol, HDL cholesterol and total cholesterol/HDL cholesterol ratio were not significantly different for both male and female patients compared with the controls. The 27 patients with GHD reported significantly less energy (P < 0.05), mobility (P < 0.05) and personal life fulfillment (P < 0.01) than the 27 controls. There were significantly more problems with emotional reaction (P < 0.01), social isolation (P < 0.05) and mental fatigue (P < 0.05). Additionally the GHD group reported more impairment in areas of social functioning (P < 0.05), general health (P < 0.05) and mental health (P < 0.05). The GHD group reported a modest degree of disease impact (mean score of 14.1). There were no significant differences in the domains of material life fulfillment, pain, sleep, physical functioning, vitality, anxiety, depression, self-esteem or role physical functioning compared with the controls. CONCLUSION: Compared with control subjects, the elderly female patients with hypothalamic-pituitary disease and GHD had a significantly higher total fat mass, with the WHR indicating a more central fat distribution and lower female serum IGF-1 levels. In contrast, elderly male patients had similar total fat mass, WHR and IGF-1 levels compared to the controls. There were no significant differences in the lipid profiles between male or female patients compared to controls. However, many of the male patients were receiving androgen replacement which might have influenced these results. Low HDL cholesterol concentrations are probably a better predictor of future cardiovascular disease than raised LDL cholesterol levels in the elderly population and these were similar in patients and controls for both

The quality of life of adults with growth hormone deficiency: comparison with diabetic patients and control subjects.

OBJECTIVE: Adults with GH deficiency (GHD) frequently report a poor quality of life (QOL). Whether this poor QOL is specifically due to hormone deficiency or a non specific effect of a chronic condition is not known. We therefore assessed QOL in adults with hypopituitarism and GHD and compared scores with a group of patients with diabetes mellitus, another life-long condition with potentially serious complications and a group of healthy controls. PATIENTS: We studied 57 patients with hypopituitarism and GHD (peak stimulated GH response < 9 mU/l) (23 male, mean age 36.4 years, mean stimulated GH response 2.3 mU/l), secondary to a variety of hypothalamic-pituitary disorders. Fifty had been treated surgically (39 cranial surgery, 11 transsphenoidal) and 37 had received external cranial irradiation involving the hypothalamic region. Fifty-seven age and sex matched patients with diabetes mellitus (31 insulin treated, 18 on oral hypoglycaemic agents, 8 on diet alone) and 57 matched healthy controls were also studied. DESIGN AND MEASUREMENTS: We assessed and compared health related QOL in the 3 groups using 4 self rating questionnaires: Hospital Anxiety and Depression Scale, Self Esteem Scale, Mental Fatigue Questionnaire and Life Fulfilment Scale. In addition the GHD and diabetic groups also completed the Disease Impact Scale. RESULTS: The GHD group reported significantly more depression (P < 0.05) and mental fatigue (P < 0.05) and significantly less self esteem (P < 0.05) and life fulfilment (P < 0. 05) than either the group with diabetes or the controls. Patients with GHD reported significantly higher anxiety scores (P < 0.05) than the controls. Within the GHD group there were no differences in QOL scores between patients with pituitary tumours (n = 24), craniopharyngiomas/hypothalamic tumours (n = 18) or other brain tumours. In addition there were no significant differences according to surgical treatment modality or radiotherapy. However subgroup analysis revealed that the patients who had undergone transsphenoidal surgery (n = 11) differed significantly from the control group in life fulfillment and depression (P < 0.01) only and did not differ from the DM group in any of the questionnaires used. There were no significant differences between the group with diabetes and the control group in any of the measures except depression (P < 0.05). CONCLUSIONS: This study revealed a significant impairment of QOL in adults with GHD, particularly those who had undergone cranial surgery, when compared to matched patients with diabetes and healthy controls.

Diabetic peripheral neuropathy and quality of life.

The quality of life (QOL) of 79 people with type 1 and type 2 diabetes and 37 non-diabetic controls was assessed using the Nottingham Health Profile (NHP). The NHP consists of six domains assessing energy, sleep, pain, physical mobility, emotional reactions and social isolation. Symptomatic diabetic neuropathy was present in 41 of the patients. The neuropathy patients had significantly higher scores (impaired QOL) in 5/6 NHP domains than either the other diabetic patients (p < 0.01) or the non-diabetic (p < 0.001) controls. These were: emotional reaction, energy, pain, physical mobility and sleep. The diabetic patients without neuropathy also had significantly impaired QOL for 4/6 NHP domains compared with the non-diabetic control group (p < 0.05) (energy, pain, physical mobility and sleep). This quantification of the detrimental effect on QOL of diabetes, and in particular of chronic symptomatic peripheral diabetic neuropathy, emphasizes the need for further research into effective management of these patients.

Quality of life, body composition and muscle strength in adult growth hormone deficiency: the influence of growth hormone replacement therapy for up to 3 years.

OBJECTIVE: Adults with GH deficiency complain frequently of low energy levels, emotional lability and mental fatigue resulting in a low perceived quality of life (QOL). Body composition is altered with increased fat mass and decreased lean body mass and muscle strength is reduced. The aims of this study were to determine the effects of replacement GH treatment on: (a) body composition and muscle strength and (b) QOL, using specifically selected and adapted measures. DESIGN: A 12-month study (double-blind placebo-controlled for the first 6 months and open for the second 6 months) of GH replacement injections (0.125 iu/kg/week for the first month and 0.25 iu/kg/week for the following 5 months of each study period) in GH deficient adults on QOL, body composition and muscle strength. This was followed by an open study of a further 12 months' GH treatment assessing QOL and muscle strength. Finally, QOL was assessed after up to 3 years of GH replacement treatment. PATIENTS: Thirty of the 32 adult patients with GH deficiency enrolled completed the initial 12-month study (10 male, mean age 33.5 years, mean (SD) stimulated serum GH response 3.0 mU/l (2.86)). Nineteen patients then opted to continue GH treatment. Of these, 13 patients were available for assessment after a further 12 months' and 24 months' treatment. MEASUREMENTS: Health-related QOL was assessed using 2 specifically adapted scales for adults with GH deficiency: the Life Fulfillment Scale and the Impact Scale. In addition 4 other self-rating questionnaires were used: Nottingham Health Profile, Hospital Anxiety and Depression Scale, Self Esteem Scale and Mental Fatigue Scale. Body composition was assessed by DEXA and quadriceps muscle strength by measuring maximum voluntary contractions. RESULTS: In the initial 12 months' placebo-controlled study perceived energy levels increased after 6 and 12 months of GH treatment (P < 0.01 compared with baseline) in the patients receiving GH for the full 12-month period. There were no changes in energy levels throughout the study in the group receiving placebo for the first 6 months. Also small improvements in impact scores were found after 6 months of GH treatment (P < 0.05) but this was not sustained at 12 months. In both GH and placebo groups life fulfillment worsened after 6 months, but then improved to baseline values after 12 months. In the patients who persisted with GH replacement, energy levels continued to improve (at 2 years, P < 0.01 compared with baseline) but then fell (at 3 years, P = NS compared with baseline). A similar pattern was observed in emotional reaction scores. However, improvements in self-esteem were maintained (at 3 years, P < 0.05 compared with baseline). Body composition altered favourably over the initial 12-month study period with a significant increase in lean mass and decrease in fat mass in both groups after 6-12 months of GH. There were no changes in muscle strength in either group during the initial 12-month study. However, in the patients who were available for assessment after a further 12 months of GH treatment, muscle strength increased significantly (P < 0.02 compared with baseline). CONCLUSION: GH replacement treatment for 6-12 months leads to significant improvements in body composition (DEXA) but longer-term treatment may be needed to increase muscle strength. Self-esteem scores improve and are maintained after 3 years of treatment. Energy levels and emotional reaction improve during treatment for up to 2 years but decline thereafter.

The development, reliability and validity of a disease specific quality of life model for adults with growth hormone deficiency.

OBJECTIVE: Adults with GH deficiency frequently complain of lack of energy, fatigue, social isolation and problems with sexual relationships resulting in a low perceived quality of life. Previous studies of quality of life (QOL) in GH deficient adults have involved small numbers of patients and used measures not specifically designed for this patient population. We have devised a health related QOL model specifically designed for use in adults with GH deficiency and to assess the impact of future GH replacement therapy. DESIGN: Six measurements were chosen for inclusion in the model. Two were adapted for use after clinical interviews with 12 adult GH deficient patients: the Impact and the Life Fulfilment scales. The others were the Nottingham Health Profile, the Hospital Anxiety and Depression Scale, the Self-Esteem Scale and the Mental Fatigue Questionnaire. The reliability of the 6 measures was assessed by 2 methods: test re-test correlation and internal consistency (Cronbach's alpha). The validity of the Impact and Life Fulfilment scales was assessed by correlation with the other 4 scales. PATIENTS: Questionnaires were completed by 32 adults with hypothalamic pituitary disorders and GH deficiency (11 male, mean age 35.1 years), with a stimulated maximum serum GH response less than 10 mU/l (mean 2.96). Two had previously received GH injections in childhood. The questionnaires were also completed by 32 age and sex matched control subjects. RESULTS: The 6 scales had test re-test correlations of 0.70-0.92 indicating reliability over time. The Impact and Life Fulfilment Scales and the Mental Fatigue Questionnaire had Cronbach's alpha scores of greater than 0.6 indicating their potential for use in clinical trials. The Impact and Life Fulfilment scales correlated significantly with many physical and psychological domains from the other 4 scales indicating these were valid in the assessment of health related QOL in GH deficient adults. Compared to the controls the patients with GH deficiency were significantly psychosocially disadvantaged in terms of depression, self-esteem, mental fatigue and life fulfilment. CONCLUSION: The results of the reliability and validity studies indicate that this health related quality of life model for use with adults with GH deficiency is a potentially valid and reliable tool that could be used to assess the effect of GH treatment.

Failure to prevent nicotine addition in young people with diabetes.

The habit of smoking is usually acquired at a young age and it is particularly undesirable in individuals with diabetes. A study was carried out to assess objectively the prevalence of smoking in young patients with diabetes and whether younger age at onset of diabetes (implying exposure to health education) reduced the incidence of smoking. Ninety nine young adults with diabetes attending the routine clinic were studied using a structured interview and assay of a urinary nicotine metabolite (cotinine). Forty eight percent of the cohort were smoking (raised urinary cotinine), although only 31% admitted to smoking. Thirty eight percent of the patients with childhood onset diabetes, 56% of the adolescent onset, and 47% of the young adult onset patients were smoking. Smoking was not related to glycaemic control or body mass index. In conclusion, smoking is common in young patients with diabetes and is often denied. Conventional health education does not appear to prevent children and adolescents with diabetes from starting to smoke. Anti-smoking policies and health education must therefore be reinforced and improved.