Rev Biomed 2001; 12:236-243.
Non insulin depent diabetes
mellitus metabolic control in two
different health care settings in

Original Article
Arturo Jiménez-Cruz1, Montserrat Bacardí-Gascon1, Abel Peña-Valdovinos2, Rodolfo Leyva-Pacheco1.
1Tijuana Medical School. Universidad Autónoma de Baja California, Instituto de Nutrición de BajaCalifornia. 2Clínica 27, Instituto Mexicano del Seguro Social. Tijuana, Baja California. México.
specialists. The use of insulin treatment was also Objective. The purpose of this study was to assess
health care practices and metabolic control of type endocrinology specialists. There were no statistical II diabetics in primary and secondary care settings, differences found between groups for mean fasting attended by family practitioners, orby internal blood glucose, total cholesterol, body mass index, medicine and endocrinology specialists in México.
nor for different cutoff points used for fasting blood Material and methods. A cross-sectional survey
glucose and body mass index. The internal medicine was performed in Tijuana, México, with data and endocrinology specialists had recorded obtained from four primary care clinics and a hypercholesterolemia more often than the family secondary care clinic of the Instituto Mexicano del Seguro Social. Every clinical chart with a special Discusion. It was shown that there are differences
in recording measurements and clinical outcomes between the two groups. However, the findings Results. The incidence of recording fasting blood
were not adequate with recommended criteria, or glucose was higher among the internal medicine with the advanced diabetes training of the internal and endocrinology specialists, whereas the medicine and endocrinology specialists. The results incidence of recording weight was found to be suggest that specific diabetes guidelines with higher by the family practitioners (p < 0.05). Age surveillance systems should be developed, and duration of diabetes were recorded more often according to budget availability for local sites.
by the internal medicine and endocrinology (Rev Biomed 2001; 12:236-243)
Corresponding address: Dr. Arturo Jiménez-Cruz, 2399 Eastridge Loop, Chula Vista, CA 91915, USA. E-mail: [email protected]: (619) 6568157 (USA). Received August 29, 2000. Accepted January 16, 2001. This paper is also available at http://www.uady.mx/~biomedic/rb011243.pdf
Vol. 12/No. 4/Octubre-Diciembre, 2001
A Jiménez-Cruz, M Bacardí-Gascon, A Peña-Valdovinos, R Leyva-Pacheco.
Key words: Diabetes mellitus, metabolic control,
grupos. Sin embargo, los hallazgos sugieren que Mexican population, US-MEXICO border health las prácticas de atención no cumplen con los criterios establecidos en el IMSS o con elentrenamiento de los especialistas de segundo nivel.
Los resultados sugieren que sería benéfico RESUMEN.
desarrollar protocolos de tratamiento específico y Control metabólico de la diabetes mellitus no
sistemas de vigilancia de acuerdo al presupuesto y dependiente de insulina en niveles de atención
disponibilidad de recursos de cada clínica.
médica en México.
(Rev Biomed 2001; 12:236-243)
Objetivo. El propósito de este estudio fue valorar
las prácticas de atención a la salud y el control
Palabras clave: Diabetes mellitus, control
metabólico de diabéticos tipo II en servicios de atención primaria y secundaria, atendidos porespecialistas de medicina familiar, medicinainterna y endocrionología.
Material y métodos. Se realizó un estudio
The Diabetes Control and Complications Trial transversal en Tijuana, México, con información Research Group (DCCT-RG), demonstrated that obtenida de cuatro clínicas de atención primaria in insulin-dependent diabetes mellitus (IDDM), y una clínica de atención secundaria del Instituto intensive management focused on lowering blood Mexicano del Seguro Social (IMSS). Se revisó glucose concentrations to normal ranges decreases un expediente clínico alternativamente de todos the risk of development and progression of diabetic los pacientes que tenían la tarjeta especial de complications by 40-75% (1,2). Additionally, in diabetes, desde el mes de agosto a septiembre de non insulin dependent diabetes mellitus (NIDDM) patients, some studies have demonstrated the Resultados. Los resultados muestran que la
efficacy of diet, weight loss, the use of sulfonylurea, incidencia de registro de la glucemia en ayunas metformin, and insulin to reduce hyperglycemia to near normal levels (3-6). Better metabolic control expedientes atendidos por médicos familiares (p endocrinology specialists, since these physicians < 0.05). La edad y la duración de la diabetes la have advanced training and laboratory tests and registraron con más frecuencia los especialistas de segundo nivel. El tratamiento de insulina fue centralization, lack of planning and surveillance endrocrinólogos. No se observaron diferencias systems, recommended guidelines and monitoring estadísticamente significativas en la glucemia en for treatment and biochemical tests, is difficult to ayunas, colesterol total, índice de masa corporal, achieve at the primary care level (7,8). These ni por los diferentes puntos de corte utilizados limitations are also likely to cause decreased para glicemia en ayunas o para índice de masa metabolic control at secondary care settings.
corporal. Los especialistas de segundo nivel registraron con mayor frecuencia los resultados recording of some indicators of metabolic control and metabolic control of diabetic patients in an Discusión. No se observaron diferencias
urban primary care setting attended at primary and antropométricas o variables clínicas entre los dos Revista Biomédica
Metabolic control of diabetes mellitus type 2 .
with 344,400 potential users having clinical A cross-sectional analysis was performed with records. The patients are attended by family data obtained from four Instituto Mexicano del practitioners in four clinical sites with 60 offices.
Seguro Social (IMSS) outpatient clinics attended On the average, twenty patients are seen by those by 20 family practitioners, and an outpatient clinic physicians per six-hour shift. All physicians in the attended by eight internal medicine and three clinics have the responsibility of registering each endocrinology specialists. From August 18 to patient diagnosed with diabetes mellitus on a SDF.
September 18, 1995 every other patient’s clinical At the primary care, in the IMSS clinics there chart with a special diabetes form (SDF), from the is no access to computers or nutritional counseling.
family practitioner group was reviewed, and all Laboratory support is available for fasting blood subsequent patient visits by the internal medicine glucose, albumin, creatinine, total cholesterol, and endocrinology group were also reviewed.
triglyceride, common hematologic studies, and uri There were 1912 patient clinical charts from the analysis, but glucose tolerance tests, glycosilated family practitioner group and 139 from the internal hemoglobin and lipoproteins are not available.
medicine and endocrinology specialists group that According to the IMSS guidelines, patients with diabetes are referred to an internal medicine physician in a secondary care clinic when they meet clinical charts: gender, age, weight, height, clinical the following criteria: clinical course of more than course, date of last clinical appointment, fasting 15 years, FBG higher than 250 mg/dL; have blood glucose (FBG), total cholesterol (TC), additional diseases such as hypertension, cardiopathy, stroke, tuberculosis, kidney failure, hypertension types, and dietary prescriptions and lack of response to oral hypoglycemic or long term body mass index (BMI). BMI was calculated as diabetes complications. In addition, patients are weight in kilograms divided by height in square supposed to be referred to the endocrinologist with meters (kg/m2). Patients younger than 30 years old, the following criteria: all insulin dependent diabetes treated with insulin since diagnosis, and/or with a mellitus patients, non insulin dependent diabetics body mass index lower than 25 kg/m2 for women with insulin resistance, those allergic to insulin, or and 27 kg/m2 for men were excluded. Any patient those patients with lack of response to oral charts lacking height, weight, or age records were hypoglycemic. On average, 10 patients are seen by also excluded. Descriptive statistics were a specialist during a 6-hour shift. At the secondary conducted for all selected variables. Categories IMSS care level in Tijuana, there is no access to were calculated according to FBG, TC, and BMI.
computers. There is a dietetic department with Differences between means were obtained from a eight staff members (two of them dietitians- “t” test for independent samples. FBG, TC, and nutritionists) for hospitalized patients. However, the BMI were selected at designated cutoff points only one dietitian-nutritionist provides nutritional to test association according to physician group.
counseling to patients at the outpatient clinic. On Chi-square tests were performed to assess average, the dietitian sees seven patients in a daily differences. Endocrinologist and internal medicine 3-hour shift. At this level, laboratory support is the specialists were grouped together when there was same as that available for primary care level no difference in clinical and biochemical variables.
physicians, and special orders may be requested The city of Tijuana, (México) has a population from private laboratories for tests such as of approximately 990,815 inhabitants (1995, census). The IMSS clinics cover approximately420,100 individuals or 43% of the total population, Vol. 12/No. 4/Octubre-Diciembre, 2001
A Jiménez-Cruz, M Bacardí-Gascon, A Peña-Valdovinos, R Leyva-Pacheco.
The family practitioners group had clinical groups. Tables 3 (categories according to CT, charts containing a FBG recording totaled 94.1%, TC 66%, and weight 98.5%. Whereas for the internal medicine and endocrinology specialists differences between both groups at selected cutoff group FBG recording totaled 99% (p < 0.01); total cholesterol in 76% (p < 0.02); weight in 93% (p <0.0001) (table 1). Only 5% of the familypractitioners had noted any type of dietary DISCUSSION.
prescription, compared to 40% of the internal Our results showed that even basic clinical medicine and endocrinology specialists. None of variables, such as age, weight, glucose, cholesterol, the patients of the family practitioners had a dietary blood pressure, were not well recorded in either record nor received nutrition counseling. On the group (table 1). These findings are consistent with other hand, 33% of the internal medicine and previous studies reported in Mexico (7,8).
endocrinology patients had a dietary record and Additionally, the care provided to NIDDM patients 12% had received nutrition counseling.
did not meet the recommended guidelinesestablished by the American Diabetes Association (9). Unfortunately, Mexico has no national nor local Frequencies of recorded clinical variables.
diabetes guidelines for neither primary norsecondary care settings.
Primary Care
Secondary Care
Statistical differences found for age, duration of diabetes, and treatment (table 2), did not meet IMSS referral criteria for internal medicine physicians and endocrinologists. Furthermore, the lack of statistical differences found in FBG, TC, and BMI, suggests that the IMSS referral system is not functioning well, nor has it been monitored.
Patients seen by the internal medicine and endocrinology specialists are older, had diabetes for a longer period and are being treated more frequently with insulin. However, the differencesreported still do not meet the referral criteria sulfonylurea agents in NIDDM was higher with the patients from the family practitioner group and internal medicine and endocrinology specialists 50 (64% excluded) patients from the internal (33%), than shown in the family practitioner group medicine and endocrinology specialists group (11.5%). These data are closer to those found at a were evaluated for statistical differences. This major health management organization (HMO) in high exclusion rate was due to insufficient data in California (10). However, the Californian HMO the charts. Table 2 shows selected variables and patients included primary care and specialized type of health care setting. Statistical differences physicians, small medical communities, and large were determined for age, duration of diabetes, and academic medical schools. A higher percentage, type of treatment. No significant differences for of Mexican American NIDDM patients in the US Revista Biomédica
Metabolic control of diabetes mellitus type 2 .
Clinical variables and type of health care setting.
Primary Care
Secondary Care
population, treated with insulin and self performing resource availability than to cultural background.
blood glucose tests at least once a day (11) has been reported. This suggests that treatment with patients reported from the Narpes Community in insulin might be due more to physician training and Western Finland (12). However, FBG and TC in Categories according to cholesterol, FBG, and care settings.
Cutoff Points
Vol. 12/No. 4/Octubre-Diciembre, 2001
A Jiménez-Cruz, M Bacardí-Gascon, A Peña-Valdovinos, R Leyva-Pacheco.
Body Mass Index according to sex and health care settings.
Body Mass Index
Primary Care
Secondary Care
the family practitioner group (220 and 185 mg/dL), patients had been involved in diabetes education, and the internal medicine and endocrinology including glucose self-monitoring and diet specialists group (240 and 196 mg/dL) from México were much higher than the patients from It was expected that patients seen by internal Narpes, Finland (217 mg and 256 mg/dL). Narpes, medicine and endocrinology specialists in Tijuana is a rural area, and their patients received treatment would be more likely to meet the recommended at the primary health care center where authors quality criteria and achieve better metabolic reported more than 42% with good control (122- control, but the findings did not show this to be 144 mg/dL), and 51% had acceptable control (12).
true. Our results are consistent with those reported Those results were observed in 42 percent of from the Medical Outcome Study of different patients treated by diet alone, which might indicate systems and specialists in three states of the USA that even at a rural primary care center involving (15-17). In that study, the authors suggested that adequate treatment good metabolic control could there was no evidence to show adverse quality of care for moderately ill patients with diabetes when The patients in the present study were found treated by general practitioners. The only to be older with a longer duration of diabetes statistically significant clinical sign and laboratory reported than those from a diabetes clinic in measurement found was seen in the frequency of Salmiya, in the urban area of Hawally Goverantore, foot ulcers, which improved among the patients of Kuwait (13). However, the mean BMI between the endocrinologists (15-17). Another cross-sectional Kuwait populations was similar with 31.8 Kg/m2 study based on Medicare claims from primary care and 28.5 kg/m2 in women and men respectively.
practices in the USA describes that general The Kuwait diabetes clinic (13) had more patients practitioners are less likely to meet recommended with diet alone prescribed (23.7%), while none of guideline criteria than internists (18).
those seen at the IMSS Tijuana clinics had been In our study, the patients registered with prescribed diet as the sole treatment.
glycosilated hemoglobin and diet counseling were The use of insulin treatment in the Tijuana more prevalent in the EIMS group. This could be groups is much lower and TC levels are higher than attributed to the availability of glycohemoglobin those patients studied at the primary care level from tests and having a dietitian available. However, by 8 Michigan communities in 1981 and 1991 (14).
recommended standards (ADA, 1993), glycosilated The Michigan community study found that insulin hemoglobin was under registered in 71% of the treatment decreased from 52 to 39%. However, patients, and the availability of the dietitian was Revista Biomédica
Metabolic control of diabetes mellitus type 2 .
6.- DCCT Research Group. Effect of intensive diabetes Our results suggest that there are gaps in management on macrovascular events and risk factors inthe diabetes control and complications trial. Am J Card meeting the diabetes treatment practice guidelines in México. Additionally, the lack of nutritionalcounseling and diabetes education should be 7.- Peña-Valdovino A, Jiménez-Cruz A, Leyva-Pacheco R, examined to promote improved treatment. The Bacardí-Gascón M. Poor metabolic control in diabetic results also suggest the need of developing basic patients at the primary care level. Diabetes Res Clin Pract1997; 37:179-84.
clinical diabetes guidelines according to the budgetof each individual institution and community, 8.- González-Villalpando CG, Stern MP, Arredondo-Pérez including internal and external monitoring and B, Martínez-Díaz S. The level of metabolic control in low evaluation. Finally, diabetes guidelines at the income Mexico City diabetics. The Mexico City Diabetes primary care level in developing countries such as Study. Arch Med Res 1994; 25: 387-92.
Mexico should include hiring a specialist in 9.- American Diabetes Association. Standards of medical nutrition counseling and diabetes education since care for patients with diabetes mellitus. Diabetes Care 1994; these measures have proven to be cost-effective 10.- Peters AL, Legorreta AP, Ossorio RC, Davidson MB.
Quality of outpatient care provided to diabetic patients.
We appreciate Dr. Elizabeth Jones for the very useful comments and editing of the manuscript.
11.- Harris MI, Cowie CC, Howie LJ. Self monitoring ofblood glucose by adults with diabetes in the United Statespopulation. Diabetes Care 1993; 16:1116-23.
1.- DCCT Research Group. The effect of intensive treatment
12.- Eriksson J, Forsen B, Haggblom M, Teppo AM, Groop of diabetes on the development and progression of long- L. Clinical and metabolic characteristics of type 1 and type term complications in insulin-dependent diabetes mellitus: 2 diabetes: an epidemiological study from the Narpes the diabetes control and complications trial. N Engl Med Community in Western Finland. Diabetic Med 1992; 9:654- 2.- Nathan DM. Inferences and implications. Do results 13.- Abdella NA, Khogali MM, Salman AD, Ghuneimi from the diabetes control and complications trial apply in SA, Bajaj JS. Pattern of non-insulin dependent diabetes NIDDM? Diabetes Care 1995; 18: 251-7.
mellitus in Kuwait. Diabetes Res Clin Pract 1995; 29:129-36.
3.- Klimt CR, Knatterud GL, Meinert CL, Prout TE. TheUniversity Group Diabetes Program: a study of the effect 14.- Hiss RG, Anderson RM, Hess GE, Stepien CJ, Davis of hypoglycemic agents on vascular complications in WK.Community diabetes care: a 10-year perspective.
patients with adult-onset diabetes. I. Design, methods and baseline charcteristics. II. Mortality results. Diabetes 1970;19 (Suppl. 2): 747-830.
15.- Greenfield S,Nelson EC, Zubkoff M, Manning W,Rogers W, Kravitz RL, et al. Variations in resource 4.- Hadden DR, Blair ALT, Wilson EA, et al. Natural utilization among medical specialties and systems of care.
history of diabetes presenting age 40-69 years: a prospective Results from the Medical Outcomes Study. JAMA 1992; study of the influence of intensive dietary therapy. Q J Med 16.- Greenfield S, Rogers W, Mangotich M, Carney MF, 5.- Wang PH, Lau J, Chalmers TC. Meta-analysis of effects Tarlov AR. Outcomes of patients with hypertension and of intensive blood-glucose control on late complications of non-insulin-dependent diabetes mellitus treated by different type I diabetes. Lancet 1993; 341: 1306-9.
systems ans specialities. Results from the MedicalOutcomes Study. JAMA 1995; 274:1436-44.
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A Jiménez-Cruz, M Bacardí-Gascon, A Peña-Valdovinos, R Leyva-Pacheco.
17.- Fihn SD. Physician speciality, systems of health care,and patient outcomes. JAMA 1995; 274:1503-08.
18.- Weiner JP, Parente ST, Garnick DW, Fowles J,Lawthers AG, Palmer H. Variation in office-based quality:A claims-based profile of care provided to medicare patientswith diabetes. JAMA 1995; 273:1503-8.
19.- Franz MJ, Splett PL, Monk A, Barry B, McClain K,Weaver T, et al. Cost-effectiveness of medical nutritiontherapy provided by dietitians for persons with non-insulindependent diabetes mellitus. J Am Diet Assoc 1995;95:1018-24.

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