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Several medications that are proven to reduce cardiovascular events exist for individuals with type 2 diabetes mellitus (T2DM) and atherosclerotic cardiovascular disease, however they are substantially underused in clinical practice. Clinician, patient, and system-level barriers all contribute to these gaps in care; yet, there is a paucity of high quality, rigorous studies evaluating the role of interventions to increase utilization. The COORDINATE-Diabetes trial randomized 42 cardiology clinics across the United States to either a multifaceted, site-specific intervention focused on evidence-based care for patients with T2DM or standard of care. The multifaceted intervention comprised the development of an interdisciplinary care pathway for each clinic, audit-and-feedback tools and educational outreach, in addition to patient-facing tools. The primary outcome is the proportion of individuals with T2DM prescribed three key classes of evidence-based medications (high-intensity statin, angiotensin converting enzyme inhibitor or angiotensin receptor blocker, and either a sodium/glucose cotransporter-2 inhibitor (SGLT-2i) inhibitor or glucagon-like peptide 1 receptor agonist (GLP-1RA) and will be assessed at least 6 months after participant enrollment. COORDINATE-Diabetes aims to identify strategies that improve the implementation and adoption of evidence-based therapies. [ABSTRACT FROM AUTHOR]

Background and purpose To describe the design of an ongoing anticoagulation certificate program and annual renewal update for pharmacists. Educational activity and setting Components of the anticoagulation certificate program include home study, pre- and posttest, live sessions, case discussions with evaluation and presentation, an implementation plan, and survey information (program evaluation and use in practice). Clinical reasoning skills were assessed through case work-up and evaluation prior to live presentation. An annual renewal program requires pharmacists to complete home study and case evaluations. Findings A total of 361 pharmacists completed the anticoagulation certificate program between 2002 and 2015. Most (62%) practiced in ambulatory care and 38% in inpatient care settings (8% in both). In the past four years, 71% were working in or starting anticoagulation clinics in ambulatory and inpatient settings. In their evaluations of the program, an average of 90% of participants agreed or strongly agreed the lecture material was relevant and objectives were met. Summary Pharmacists are able to apply knowledge and skills in management of anticoagulation. This structured practice-based continuing education program was intended to enhance pharmacy practice and has achieved that goal. The certificate program in anticoagulation was relevant to pharmacists who attended the program. [ABSTRACT FROM AUTHOR]

The prevalence of type 2 diabetes continues to increase in minority and underserved patients, who are also more likely to have poorer control of diabetes and related risk factors for complications. Although the Look AHEAD trial has demonstrated improved risk factor control among overweight or obese diabetes patients who received an intensive lifestyle intervention, translating such findings into accessible programs is a major public health challenge. The purpose of this paper is to report the design and baseline characteristics of the Lifestyle Interventions for the Treatment of Diabetes study (LIFT Diabetes). The overall goal is to test the impact of a community-based lifestyle weight loss (LWL) intervention adapted from Look AHEAD on cardiovascular disease risk at 12-months and 24-months among minority and lower income diabetes patients. Secondary outcomes include body weight, physical activity, medication use, cost, resource utilization, and safety. The primary hypothesis being tested is that the LWL will result in 10% relative reduction in CVD risk compared to the DSM. We have randomized 260 overweight or obese adults with diabetes one of two 12-month interventions: a LWL condition delivered by community health workers or a diabetes self-management (DSM) education condition. The baseline demographic characteristics indicate that our sample is predominantly female, obese, low income, and ethnic minority. Translating evidence-based, lifestyle strategies, and targeting minority and underserved patients, will yield, if successful, a model for addressing the burden of diabetes and may favorably impact health disparities. [ABSTRACT FROM AUTHOR]

Aims To evaluate the demographic and health correlates of reporting diabetes symptoms, and the relationship between diabetes symptoms and self-management behaviors in rural older adults. Methods Cross-sectional interviews were conducted with 489 African American, American Indian, and white female and male adults 60 years and older. Participants with diabetes were recruited from eight North Carolina counties. Participants completed the 34-item Diabetes Symptom Checklist (DSC). Associations of demographic and health characteristics with reported symptoms were evaluated. Multivariate linear regression models were used to examine the associations of DSC scores and diabetes self-management. Results Participants had low scores on the DSC. They largely practiced appropriate diabetes self-management behaviors (self-foot checks, fruit and vegetable consumption, and self-monitoring blood glucose). Correlates of DSC included women having higher scores for hypoglycemia, psychological total, and fatigue dimensions. Neuropathic pain and vision dimensions were significantly associated with educational attainment. Most DSC dimensions were associated with ethnicity or economic status. Taking oral diabetes medicine was correlated with hyperglycemia; insulin use was associated with most DSC dimensions. HbA1c was not associated with any DSC dimension; diabetes duration >10 years was correlated with all dimensions except neuropathic pain and vision. Higher levels of psychological fatigue were significantly associated with fewer self-management behaviors. Discussion/Conclusions Demographic and health characteristics are associated with reported symptoms. Fatigue is a symptom negatively associated with diabetes self-management behavior in older adults. Health care providers are uniquely positioned to assess patient symptoms and potential relationships with successful diabetes management. [ABSTRACT FROM AUTHOR]

Abstract: Aims: Cognitive impairment is common in older adults with diabetes, yet it is unclear to what extent cognitive function is associated with health literacy. We hypothesized that cognitive function, independent of education, is associated with health literacy. Methods: The sample included 537 African American, American Indian, and White men and women 60 years or older. Measures of cognitive function included the Mini-Mental State Examination (MMSE), Verbal Fluency, Brief Attention, and Digit Span Backward tests. Health literacy was assessed using the S-TOFHLA. Results: Cognitive function was associated with health literacy, independent of education and other important confounders. Every unit increase in the MMSE, Digit Span Backward, Verbal Fluency or Brief Attention was associated with a 20% (p <.001), 34% (p <.001), 5% (p <.01), and 16% (p <.01) increase in the odds of having adequate health literacy, respectively. Conclusions: These results suggest that cognitive function is associated with health literacy in older adults with diabetes. Because poor cognitive function may undermine health literacy, efforts to target older adults on improving health literacy should consider cognitive function as a risk factor. [Copyright &y& Elsevier]

Abstract: Aims: To measure dietary fat intake using the Puget Sound Eating Patterns (PEP) questionnaire, a validated 19-item food questionnaire, and to quantify how reduced dietary fat intake affects cardiovascular risk factors in adults with type 2 diabetes. Methods: Randomized controlled trial including a subsample of 1781 Action to Control Cardiovascular Risk in Diabetes (ACCORD) participants. Participants received dietary counseling to consume a reduced-fat diet. Outcome measures included HbA1c, fasting lipid profile, blood pressure, and weight. Longitudinal linear regression analyses were used to evaluate relationships between baseline and follow-up PEP scores and cardiovascular risk factors. Results: PEP scores decreased significantly from baseline to 12-month follow up with a mean difference of −0.09±0.39, P <0.001. All of the fat intake subscales showed significant improvement at 12 months from baseline. White race, female gender, and more hours per week of physical activity were correlated with a decline in PEP scores at 1-year. A longitudinal decrease in dietary fat intake was associated with significantly less weight gain at 12- and 36-months and lower serum triglycerides at 1 year. Conclusions: Reduced fat intake as measured by a brief questionnaire was associated with significant improvement in some cardiovascular risk factors (triglycerides and weight), but not in others. [Copyright &y& Elsevier]

Abstract: Many current popular weight-loss diets advocate restricting carbohydrates, but risks and benefits of these diets for patients with diabetes is unclear. We searched for articles published in English between 1980 and April 2006 regarding carbohydrate-restricted diets that included and reported separate results for adult, nonpregnant patients with type 2 diabetes. Articles were limited to studies completed in the United States and Canada. Available data on study design; carbohydrate composition of diet; duration of diet; and the outcomes of weight, lipid levels (total, low-density lipoprotein and high-density lipoprotein cholesterol, and triglycerides), hemoglobin A1c percent and/or fasting glucose were extracted. A total of 56 studies or reviews were evaluated. Thirteen studies met our inclusion criteria. Meta-regression analyses show that hemoglobin A1c, fasting glucose, and some lipid fractions (triglycerides) improved with lower carbohydrate−content diets. Overall effect on weight was equivocal among the studies evaluated in this meta-analysis. Randomized, controlled studies of restricted-carbohydrate diets in patients with diabetes need to be conducted in order to evaluate the overall sustainability of outcomes and long-term safety. [Copyright &y& Elsevier]

Purpose: To determine whether diabetes remains an important contributor to mortality among the elderly.Methods: A 5% national sample of Medicare claims was utilized to create a retrospective cohort study. Participants were 148,562 persons with at least one hospitalization or two outpatient visits for diabetes in 1994, who were alive on January 1, 1995, were ⩾65 years old, and were not in managed care in 1994; and 148,562 age, gender, and race matched controls without diabetes. Deaths were ascertained through 1999. Survival and proportional hazards analysis were used to calculate rates and relative risks.Results: The mortality rate was 100.2/1000 person years (PY) among seniors with diabetes compared with 60.6/1000 PY without diabetes (age adjusted relative risk (RR) = 1.83, 95% CI: 1.81–1.86). Non-white minorities had a similar RR associated with diabetes (Hispanic 2.37, Asian 1.95, Native American 2.38, blacks 1.64) as whites (1.86). The mortality risk associated with diabetes decreased with increasing age, but remained significantly elevated even among those aged 85 years and older. In contrast, the absolute excess mortality attributed to diabetes increased with age.Conclusion: The excess mortality associated with diabetes amongst all older ages suggests that greater attention to optimal diabetes treatment and prevention is needed. [Copyright &y& Elsevier]

Abstract: Background: Oral glucose-lowering agents are used to treat patients with type 2 diabetes mellitus (T2DM). Most patients require multiple agents to maintain glycemic targets. Dipeptidyl peptidase-4 (DPP-4) inhibitors are administered as monotherapy and in combination therapy for the treatment of T2DM. Objective: The aim of this article was to provide a thorough review of published tolerability data on 5 DPP-4 inhibitors. Methods: PubMed and Web of Science were searched for English-language clinical trials published from January 2000 to June 2001, using the following key words: dipeptidyl peptidase-4 inhibitor, vildagliptin, alogliptin, sitagliptin, saxagliptin, linagliptin, safety, tolerability, efficacy, effect, AE, and adverse effect. Studies were considered for inclusion if they were randomized, double-blind trials performed in patients ≥18 years of age with T2DM and with a hemoglobin A1c of ≥6.5%; included ≥1 arm that received monotherapy with DPP-4; and reported adverse events (AEs). Studies in patients with a history of type 1 or secondary forms of diabetes, significant diabetic complications or cardiovascular disease within the 6 months before the start of the study, hepatic disease or abnormalities, and/or renal abnormalities were excluded. Results: A total of 45 clinical trials, 5 pharmacokinetic studies, and 28 meta-analyses or reviews were included. The duration of studies ranged from 7 days to 104 weeks. The most commonly reported AEs were nasopharyngitis, upper respiratory infections, all-cause infections, headache, gastrointestinal symptoms, and musculoskeletal pain. Based on the findings from the studies, the DPP-4 inhibitors had minimal impact on weight and were not associated with an increased risk for hypoglycemia relative to placebo. Rates of nasopharyngitis were higher with the DDP-4 inhibitors than with placebo. Pancreatitis was reported at lower rates with the DPP-4 inhibitors compared with other oral antihyperglycemic agents. Cardiovascular events were limited, and postmarketing studies are ongoing. Conclusions: The tolerability of DPP-4 inhibitors is supported by published clinical trials. The rates of weight gain, gastrointestinal AEs, and hypoglycemia were minimal with the DPP-4 inhibitors studied. [Copyright &y& Elsevier]

This mixed methods study examines the relationship between outcome expectations, self-efficacy, and self-care behaviors in individuals with type 2 diabetes (T2DM). It also explores the personal values motivating these behaviors through in-depth interviews. Adults with T2DM (n = 108, M age = 57 years, 58% female, 48% Black) completed questionnaires and participated in in-depth interviews using a laddering technique. Ordinary least squares regression models were used to analyze the relationships between self-efficacy, outcome expectations, and four self-care behaviors (physical activity, dietary choices, blood glucose monitoring, and medication usage). The findings indicate that self-efficacy is significantly and positively associated with diet and physical activity. Both outcome expectations for blood glucose testing and self-efficacy are significantly and positively associated with self-reported monitoring. However, neither outcome expectation nor self-efficacy is associated with medication usage. The in-depth interviews revealed three common values related to self-care behaviors: maintaining health and longevity, agentic values of self-control, achievement, and self-esteem, and a sense of belonging. This study sheds light on the complexity of diabetes self-management, offering insights into individuals' values, behavioral strategies, and the influence of control perceptions on this relationship, revealing both differences and commonalities in stated values. By understanding how personal values drive diabetes self-care behaviors, practitioners can assist patients in establishing meaningful connections between their values and the challenges of living with diabetes. • Balancing personal values with diabetes management can be a challenge for patients. • Discrepancies between personal values and diabetes self-care are influenced by self-efficacy. • Recognizing personal values' impact on self-care helps practitioners provide targeted support. • Commonalities in values emerged, including health and longevity, agency, and belonging. [ABSTRACT FROM AUTHOR]

There is an independent progressive epidemiologic relation between glycemia and cardiovascular disease (CVD) events; however, whether lowering glucose levels with currently available therapies can reduce CVD events remains unknown. The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trial is designed to answer this question in high-risk patients with type 2 diabetes mellitus. In ACCORD, 10,251 patients with type 2 diabetes and other CVD risk factors or CVD were randomly allocated to intensive glycemic control, targeting a glycosylated hemoglobin (HbA1c) level <6%, or standard glycemic control, targeting an HbA1c level of 7.0%–7.9%. All participants are provided with diabetes education, glucose-monitoring equipment, and antidiabetic medications. All participants in the intensive glycemic control group are started on ≥2 classes of agents. Doses are intensified or a new medication class is added every month if HbA1c levels are ≥6% or if >50% of premeal or postmeal capillary glucose readings are >5.6 mmol/L (100 mg/dL) or >7.8 mmol/L (140 mg/dL), respectively. All drug combinations are permitted, and drugs are reduced only because of side effects or contraindications. Annual training, menus of approaches for intensification, regular electronic messaging, audits of achieved glycemia, and central feedback to sites support glycemic intensification strategies in intensive participants. In participants in the standard glycemic control group, therapy is intensified whenever HbA1c is ≥8%, and antihyperglycemic drugs that promote hypoglycemia (ie, insulin or insulin secretagogues) are reduced if HbA1c persistently decreases to <7% in the setting of hypoglycemia. ACCORD addresses the hypothesis that aggressive glucose lowering prevents CVD events in patients with type 2 diabetes. It is focused on the levels of glycemia achieved using a variety of strategies, not on the specific therapies used. It will also provide information on how to safely approach near-normal levels of glucose control in clinical practice and evidence to support future clinical guidelines for diabetes management in older adults. [Copyright &y& Elsevier]