|ISSN No. 1606-7754 Vol.14 No.1 April 2006|
The impact of previous diabetes education level on the control of cardiovascular risk factors in type 2 diabetic patients at the start of the North Catalonia Diabetes Study
Jerónimo Jurado1, Josep M García2, Ignàsi Gich3, José M Pou4
Primary Care, Catalan Health Institute, Olot, Girona, Spain,1Iberoamerican Cochrane Centre 2, Department of Clinical Pharmacology, Hospital of Sta. Creu i S. Pau,,3 Department of Endocrinology and Nutrition, Hospital of Santa Creu i Sant Pau, Autonomous University of Barcelona, Barcelona, Spain.4
The aim of this study was to evaluate the effect of different levels of previously received diabetes education on metabolic control, cardiovascular disease (CVD) with many CVD risk factors (CVRF), components of metabolic syndrome (MS) and the 10-year coronary heart disease (CHD) risk at the start of the North Catalonia Diabetes study (NCDS) in the Primary Care Setting. A multi-center cross-sectional descriptive study was performed in a random sample of 302 type 2 diabetes (T2DM) patients from the cohort of the NCDS. Diabetes education was classified as specialized or non-specialized. Diabetic metabolic control, CVD, CVRF, MS components and CHD risk were evaluated. A total of 79.8% patients did not receive specialized education and 20.0% were given specialist diabetes education. All T2DM patients were also controlled by general physicians and primary health care nurses. 44.4% of patients showed optimal metabolic control (HbA1c < 7.1%). Three or more CVRF were observed in 91.3% of patients, mean CHD was 10.0% and MS was present in 68.8% of T2DM patients. The initial evaluation showed a decrease in HbA1c with a better metabolic control (p<0.05) in the group that received previous specialized education. The number of components of the MS decreased significantly (p<0.05-0.001) and cardiovascular risk control improved (p<0.01) in this group. The study showed poorer metabolic control and higher prevalence of CVRF in patients without specialized diabetes education. Our results suggest that higher levels of diabetes education may play a major role in reducing cardiovascular risk in T2DM patients.(Int J Diabetes Metab 14: 61-67, 2006)
Key words: diabetes, cardiovascular risk factors, metabolic syndrome, diabetes nurse specialist, health education.
Diabetes is associated with long-term complications that increase the morbidity and mortality of the disease. The prevention of these complications requires a multidisciplinary approach, which can be achieved, in part, in the Primary Care setting.1
The DCCT trial2 in type 1 diabetes mellitus and the UKPD trial3 in type 2 diabetes mellitus (T2DM) suggested that the genesis of diabetes complications is not only related to glycaemic control but also to cardiovascular risk factors (CVRF), such as blood pressure (BP) and lipid control.
Cardiovascular disease (CVD) is the cause of approximately 70% of deaths in patients with diabetes;4 however, the main interest of diabetes education (DE) for many years has been to improve metabolic control. Training in the prevention of CVD is presently considered as important as metabolic control.5,6
T2DM has been considered by the American Heart Association7 as a CVD and it implies a cardiovascular risk equivalent to that in patients who have had previous cardiovascular events.8 Association of T2DM with another risk factor emphasizes a comprehensive management that should include optimal metabolic control of diabetes and secondary prevention of CVRF3, such as control of high BP (HBP), lipid profile and components of the metabolic syndrome (MS).7,9
There is a considerable controversy concerning findings relating to nursing intervention in T2DM patients. Several studies10 have reported minimal results after DE from non-specialized nurses,10-13 while others have found a positive effect of DE from specialized nurses on metabolic and CVRF.12,14-20
Furthermore, several authors consider that the impact of specialized nursing interventions in education could be similar to those of general practitioners in the control of diabetic populations at a PC level.17
DE is an essential and effective tool for clinical management of diseases as evidenced in a large number of studies evaluating the relationships between education and improved medical outcomes.14,20-22 Most such studies have evaluated the relationship between educational interventions and the metabolic control of glycaemia.11,12,17,18,20,23,24 Several studies have also evaluated the effect of DE intervention on BP, weight and dyslipidemia control10,13 and they have investigated the effect of different DE levels on CVRF20,25 in T2DM patients.
Despite its potential impact and strong evidence base, DE gives little attention to the reduction of cardiovascular risk.26 The number of nursing interventions in the management of CVD risk factors in diabetes is few27 and particularly sparse in Spain where no literature is available. Nevertheless, the role of nursing DE and/or a direct-nurse role in CVRF19,20 and/or metabolic MS have not been studied in depth in T2DM.
The aim of this study was to evaluate the relationship between previously received DE by different categories of nurses on the outcomes of metabolic control of diabetes, CVRF, MS components and the 10-year CHD risk in a PC setting before starting the North Catalonia Diabetes Study (NCDS). The study of the relationship between previous DE and CVRF and their control was the main objective of the study within the NCDS.