OBJECTIVES:This study investigated ethnic differences in diabetes-specific knowledge, illness perceptions, self-management, and metabolic control among black-African, black-Caribbean,and white-British populations with type 2 diabetes. The study also examined associations between demographic/disease characteristics and diabetes-specific knowledge, illness perceptions, self-management, and metabolic control in each of the three ethnic groups.DESIGN:Cross-sectional.SETTING:Diabetes/retinal screening clinics in Hackney and Brent, London.METHODS:Black-African, black-Caribbean and white-British populations with type 2 diabetes were asked to participate. Questionnaires measuring demographic/disease characteristics, diabetes-specific knowledge, self-management, and illness perceptions were used for data collection. Data for glycated hemoglobin (HbA1c) and microvascular complications were obtained from medical records. Ethnic differences in diabetes-related measures were estimated using analysis of variance/covariance. Multiple regression techniques were used to determine relationships between demographic/disease characteristics and measured diabetes-related outcomes.RESULTS:Three hundred and fifty-nine patients participated in the study. White-British participants had high diabetes-specific knowledge compared to their black-African and black-Caribbean counterparts. Black-Africans reported better adherence to self-management recommendations than the other ethnic groups. Compared to the white-British patients, black-African and black-Caribbean participants perceived diabetes as a benign condition that could be cured. Educational status and treatment category were determinants of diabetes-specific knowledge in all three ethnic groups. However, different demographic/disease characteristics predicted adherence to self-management recommendations in each ethnic group.CONCLUSION:Clearly, there is disease (diabetes) knowledge-perception variation between different ethnic groups in the UK which may partly influence overall disease outcome. It is plausible to recommend screening, identifying, and dispelling misconceptions about diabetes among ethnic minority patients by health care professionals as well as emphasizing the importance of self-management in managing chronic diseases such as diabetes.

Background: The Revised Illness Perception Questionnaire (IPQ-R) has been used extensively to measure illness perceptions of several patient populations. However, the instrument was developed using participants of mainly European-origin. The reliability and validity of the IPQ-R may therefore need to be established before use among populations of different ethnic and cultural origins.Objectives: This study investigated the factor structure and internal consistency reliability of the IPQ-R in African-origin patients with type 2 diabetes.Methods: In this cross-sectional study, 221 adults of African descent with type 2 diabetes completed the IPQ-R. Participants were recruited from patients attending diabetes and retinal screening clinics in the London boroughs of Brent and Hackney. Confirmatory Factor Analysis based on the covariance matrix was used to determine factorial validity for the Timeline-acute/chronic, Consequences, Personal control, Treatment control, Illness coherence, Timeline-cyclical, Emotional representation and three causal subscales of the IPQ-R. Composite internal consistency reliability for individual subscales was determined using Cronbach's alpha coefficients.Results: After eliminating three items and re-specifying six error covariances associated with large standardised residuals and low factor loadings, the hypothesised model adequately explained the covariance of African and Caribbean patients' responses to items of the IPQ-R. Also, composite reliability coefficients of all measured subscales were acceptable and inter-correlations between subscales were in line with those reported from other population groups.Conclusions: The findings in this study suggest that although the IPQ-R may be valid and reliable across cultures, investigators may need to modify (e.g. by rewording) some of its items taking into account any linguistic origins of their populations of study. Further evaluation of the IPQ-R (including the identity subscale) in larger samples of African-origin populations is also recommended. (C) 2011 Elsevier Ltd. All rights reserved.

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abubakari a-r, jones mc, lauder w, kirk a, anderson j & devendra d (2011)   Journal of Nursing and Healthcare of Chronic Illness 3 , 245–256 Associations between knowledge, illness perceptions, self-management and metabolic control of type 2 diabetes among African and European-origin patients Aims. Using Leventhal’s Common-sense self-regulation model, this study investigated associations between illness perceptions, self-management and metabolic-control outcomes for diabetes among European and African-origin patients with type 2 diabetes. Background. Compared to the general populations of their host countries, African-origin populations in the diaspora are disproportionately affected by diabetes and its microvascular complications. However, comparatively little is known about how African-origin patients with type 2 diabetes perceive about their condition and whether such perceptions influence their self-management behaviours. Design. Cross-sectional design. Methods. Participants were recruited from diabetes clinics in London. Illness perceptions and adherence to self-management recommendations were assessed using questionnaires and data for metabolic-control outcomes were obtained from patient records. Associations between variables were investigated using correlations and multiple-regression techniques. Data collection for the study was conducted between February and June 2008. Results. In all, 359 patients participated in the study. The results indicated that perceiving diabetes with severe consequences was associated with poor self-management in both African-origin (black-African and black-Caribbean) and European-origin (white-British) patients with type 2 diabetes. However, personal control perceptions were associated with better self-management in African-origin patients. In multivariate analysis, illness perceptions explained significant proportions of the variations in self-management behaviours in both European-origin and African-origin patients. Perceived personal control over diabetes was a main determinant of the variations in self-management among European and African-origin patients. Other dimensions of illness perceptions, including consequences and emotional representations contributed to variations in self-management among African-origin patients. After controlling for demographic/disease characteristics, self-management of diabetes did not predict any metabolic-control outcome for diabetes in any ethnic group. Conclusion. Illness perceptions are important determinants of self-management among African-origin patients. Relevance to clinical practice. Illness perception-based interventions may be used to promote self-management among African-origin patients. Healthcare professionals should consider using patients’ illness perceptions to inform service delivery.

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Editor – Sweis and colleagues showed discrepancies between histology and serology in the diagnosis of coeliac disease (CD) (Clin Med August 2009 pp 346–8), and suggest we reduce our reliance on serology testing in diagnosing and excluding CD. However, we feel there are major reasons to

Diabet. Med. 27, 1159–1167 (2010)AbstractAims To determine the blood glucose lowering effect of cinnamon on HbA1c, blood pressure and lipid profiles in people with type 2 diabetes.Methods 58 type 2 diabetic patients (25 males and 33 females), aged 54.9 ± 9.8, treated only with hypoglycemic agents and with an HbA1c more than 7% were randomly assigned to receive either 2g of cinnamon or placebo daily for 12 weeks.Results After intervention, the mean HbA1c was significantly decreased (P<0.005) in the cinnamon group (8.22% to 7.86%) compared with placebo group (8.55% to 8.68%). Mean systolic and diastolic blood pressures (SBP and DBP) were also significantly reduced (P<0.001) after 12 weeks in the cinnamon group (SBP: 132.6 to 129.2 mmHg and DBP: 85.2 to 80.2 mmHg) compared with the placebo group (SBP: 134.5 to 134.9 mmHg and DBP: 86.8 to 86.1 mmHg). A significant reduction in fasting plasma glucose (FPG), waist circumference and body mass index (BMI) was observed at week 12 compared to baseline in the cinnamon group, however, the changes were not significant when compared to placebo group. There were no significant differences in serum lipid profiles of total cholesterol, triglycerides, HDL and LDL cholesterols neither between nor within the groups.Conclusions Intake of 2g of cinnamon for 12 weeks significantly reduces the HbA1c, SBP and DBP among poorly controlled type 2 diabetes patients. Cinnamon supplementation could be considered as an additional dietary supplement option to regulate blood glucose and blood pressure levels along with conventional medications to treat type 2 diabetes mellitus.

AIMS:To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in body weight in Muslim patients with Type 2 diabetes receiving Humalog Mix 50 and human Mixtard 30 twice daily during Ramadan fasting. METHODS:Data were collected from Muslim patients with Type 2 diabetes attending primary care practices in North-West London, who were on Mixtard 30 insulin twice daily before Ramadan. Group 1 had their evening insulin changed to Humalog Mix 50 (n = 26) 2 weeks before Ramadan, i.e. taking Mixtard 30 at predawn meal and Humalog Mix 50 at the sunset meal during Ramadan. As the major proportion of the daily caloric intake was consumed at the sunset meal, the rationale of switching the evening dose from human Mixtard 30 to Humalog Mix 50 was to provide more rapid-acting insulin that has shorter time of onset and peak time for the large evening meal to improve the postprandial glucose control without increasing the risk of hypoglycaemia. Group 2 continued on Mixtard 30 twice daily (n = 26). All patients received structured education about how to identify and manage hypoglycaemia during Ramadan. RESULTS:Group 1 had a mean HbA1c reduction of 0.48% (p = 0.0001) before and after Ramadan, whereas group 2 had a mean HbA1c increase of 0.28% (p = 0.007). Group 1 was associated with a small reduction of 0.04 (p = 0.81) in the mean number of hypoglycaemic events during Ramadan compared with before Ramadan, whereas group 2 was associated with an increase of 0.15 (p = 0.43), although these differences between the groups were not statistically significant following adjustment for baseline factors [LSM difference between groups = 0.135, p = 0.36, 95% confidence limits (-0.16, 0.43)]. CONCLUSION:Changing to humalog Mix 50 during Ramadan resulted in improvement in glycaemic control without increasing the incidence of hypoglycaemia.

Background:  Vitamin D deficiency is associated with a greater risk of developing type 2 diabetes mellitus (T2DM). Studies looking at the effect of vitamin D replacement on glycaemic control in type 2 diabetics are few and conflicting. In addition, none have been published looking at the South Asian population despite both T2DM and vitamin D deficiency being gross burdens in this population. The aim of this study was to determine the effect of using vitamin D and calcium replacement therapy on glycaemic control in South Asian patients with T2DM and vitamin D inadequacy.

Diabet. Med. 27, 327–331 (2010)AbstractBackground and Aims During Ramadan, Muslims fast from dawn to dusk for one lunar month. The majority of Muslim diabetic patients are unaware of complications such as hypoglycaemia during fasting. The safety of fasting has not been assessed in the UK Muslim population with diabetes. The aim of this study was to determine the impact of Ramadan‐focused education on weight and hypoglycaemic episodes during Ramadan in a Type 2 diabetic Muslim population taking oral glucose‐lowering agents.Methods We retrospectively analysed two groups. Group A attended a structured education programme about physical activity, meal planning, glucose monitoring, hypoglycaemia, dosage and timing of medications. Group B did not. Hypoglycaemia was defined as home blood glucose < 3.5 mmol/l.Results There was a mean weight loss of 0.7 kg after Ramadan in group A, compared with a 0.6‐kg mean weight gain in group B (P < 0.001). The weight changes observed were independent of the class of glucose‐lowering agents used. There was a significant decrease in the total number of hypoglycaemic events in group A, from nine to five, compared with an increase in group B from nine to 36 (P < 0.001). The majority were in patients treated with short‐acting sulphonylureas (group A—100%, group B—94%). At 12 months after attending the programme, glycated haemoglobin (HbA1c) reduction were sustained in group A.Conclusions Ramadan‐focused education in diabetes can empower patients to change their lifestyle during Ramadan. It minimizes the risk of hypoglycaemic events and prevents weight gain during this festive period for Muslims, which potentially benefits metabolic control.

Abstinence from food and liquid during daylight hours is observed by Muslim individuals during the month of Ramadan. Even though the Koran exempts the sick from fasting, many people with diabetes still fast during this religious period. It is essential for patients, family and healthcare professionals to be aware of the religious attitude to and health implications of fasting. Major changes in dietary habits, daily physical activities and sleeping patterns during Ramadan have significant impact on the glycaemic control, lipid profile, weight and dietary intake. Hence, the patient is encouraged to have appropriate pre‐Ramadan assessment and education in order to stratify and modify his or her risk with fasting. Dose and timing adjustments to insulin and to some oral hypoglycaemic agents, especially sulphonylureas, may well be necessary during Ramadan. Copyright © 2010 John Wiley & Sons, Ltd.

Liraglutide–-a once-daily human glucagon-like peptide-1 receptor agonist for treatment of Type 2 diabetes–-provides effective glycemic control with a lower incidence of hypoglycemia than therapies such as glimepiride and exenatide, and reduces body weight and systolic blood pressure. This article briefly discusses efficacy and safety results from the Liraglutide Effect and Action in Diabetes (LEAD) program, before considering practical issues of identifying and educating patients who may be suitable for liraglutide therapy.

#### Summary points The holy month of Ramadan is one of five main pillars of being a Muslim. Most Muslims are passionate about fasting during this month. Although the Koran exempts sick people from the duty of fasting,1 2 many Muslims with diabetes may not perceive themselves as sick and are keen to fast. A large epidemiological study of Muslims with diabetes in 13 Muslim countries (n=12 914)—the EPIDIAR study—showed that 43% of patients with type 1 and 79% of those with type 2 diabetes fasted during Ramadan.3 As the month of Ramadan follows the lunar calendar, the fasting month is brought forward by about 10 days each year, which means that over time the season in which Ramadan falls changes. For the next decade Ramadan will fall in the summer in the northern hemisphere. As daylight hours vary considerably between summer and winter months in non-equatorial countries, the length of the fast (which lasts from dawn to sunset) increases in the summer (to about 16-20 hours). People with diabetes who fast are at risk of adverse events, and the risks may increase with longer fasting periods. We review the evidence for optimum management of diabetic patients who wish to fast …

Aims:  To compare hypoglycaemic events, glycated haemoglobin (HbA1c) and changes in bodyweight in metformin‐treated Muslim patients with type 2 diabetes receiving adjunctive treatment with vildagliptin or gliclazide during Ramadan fasting.

A 48 year old post-menopausal woman presents with a smooth midline swelling in her neck, which has been present for more than 10 years. On examination, you find that it is consistent with an enlarged thyroid gland.