The purpose of this study is to evaluate associations between diabetes distress and a range of psychological health behaviors and concerns among persons with type 1 diabetes for the benefit of enhancing early identification and intervention of at-risk individuals.
Persons with type 1 diabetes (n = 268; 57.1% female, 91.0% white, 76.8% <18 years of age, average A1C 8.4%) completed the 2-item Diabetes Distress Screening Scale (DDS2) and a battery of psychometrically sound instruments measuring satisfaction with life, self-esteem, self-efficacy, depression, perfectionism, body image satisfaction, dietary restraint and eating, and shape and weight concerns. Each subscale score was compared within age groups (<18 years vs ≥18 years) between groups (diabetes distress level [low, moderate, high]) using analysis of variance (with Bonferroni correction or the Kruskal-Wallis test if the variables were not normally distributed).
For both age groups, high diabetes distress was independently associated with greater A1C values, higher depression scores and eating, and shape and weight concerns than those with low or moderate distress. For patients <18 years of age, those with high diabetes distress scored lower on measures of satisfaction with life, self-esteem, and self-efficacy and higher on dietary restraint and several areas of perfectionism than those with low or moderate distress.
Individuals with type 1 diabetes who have high diabetes distress also report higher A1C values and poorer psychological health concerns. A brief diabetes distress questionnaire can help to identify those who need additional screening, education and support, and treatment for overall health and well-being.
The purpose of this study was to better understand the impact that financial barriers have on patients with diabetes and the strategies that they use to cope with them.
A secondary analysis was conducted of 24 interviews with patients who had either type 1 or type 2 diabetes and perceived financial barriers, which were previously undertaken for a larger grounded theory study. Semistructured interviews were undertaken either face-to-face or by telephone. Data analysis was performed by 3 reviewers using inductive thematic analysis. Sampling for the original study continued until data saturation was achieved.
The predominant aspects of care to which participants described financial barriers were medications, diabetes supplies, and healthy food. A variety of strategies are used by these patients. Participants described that their health care providers had the potential to either play an important supporting role; or alternatively, that they could also worsen the impacts of financial barriers.
Patients with diabetes experience financial barriers to various aspects of their care. While they use a variety of strategies to overcome their barriers, their health care providers can play a particularly important role in helping them manage these important barriers that impact their care and outcomes. Providers should ask patients about the existence of financial barriers, and employ strategies to mitigate against their impact.
The purpose of this article is to describe the 4 Parent Education Through Simulation-Diabetes (PETS-D) nurse certified diabetes educators’ (CDEs) perspectives of teaching parents of children with newly diagnosed type 1 diabetes mellitus (T1DM) early diabetes management skills using formal vignettes and a human patient simulator/human patient simulation (HPS) to augment/enhance the teaching–learning process.
A qualitative descriptive approach was used. Four CDEs were interviewed by phone about their teaching experiences. Meticulous notes were taken. Data were analyzed using qualitative content analysis.
The vignettes (and use of HPS) provided structure, especially for parents who were struggling to learn. Certified diabetes educators described a short learning curve to master the use of the HPS manikin. Human patient simulation-enhanced education was described as helpful for teaching multiple caregivers about diabetes. Certified diabetes educators also described factors that affect parent learning, mechanical issues with the HPS, and additional space requirements for HPS-enhanced education.
Vignettes and HPS-enhanced education can successfully be used to educate parents of children with new-onset T1DM and were preferred by the CDEs when compared with previous teaching strategies. The results of this study support the use of both vignette-based and HPS-enhanced education when a child is newly diagnosed with T1DM. Further studies need to be done to see if these effects persist with different populations, during different stages of the disease, and for individuals with other chronic illnesses.
The purpose of the study was to evaluate an adult health care program model for emerging adults with type 1 diabetes transitioning from pediatric to adult care.
Evaluation of the Pediatric to Adult Diabetes Transition Clinic at the University of Pennsylvania included a cohort of 72 emerging adults with type 1 diabetes, ages 18 to 25 years. Data were extracted from transfer summaries and the electronic medical record, including sociodemographic, clinical, and follow-up characteristics. Pre- and postprogram assessment at 6 months included mean daily blood glucose monitoring frequency (BGMF) and glycemic control (A1C). Paired t tests were used to examine change in outcomes from baseline to 6 months, and multiple linear regression was utilized to adjust outcomes for baseline A1C or BGMF, sex, diabetes duration, race, and insulin regimen. Open-ended survey responses were used to assess acceptability amongst participants.
From baseline to 6 months, mean A1C decreased by 0.7% (8 mmol/mol), and BGMF increased by 1 check per day. Eighty-eight percent of participants attended ≥2 visits in 6 months, and the program was rated highly by participants and providers (pediatric and adult).
This study highlights the promise of an adult health care program model for pediatric to adult diabetes transition.
The purpose of this study was to examine the reliability and validity of a Spanish version of the Beliefs about Medicines Questionnaire (BMQ) as a measure to evaluate beliefs about medications and to differentiate adherent from nonadherent patients among low-income Latino patients with diabetes in the United States.
Seventy-three patients were administered the BMQ and surveyed for evidence of medication nonadherence. Internal consistency of the BMQ was assessed by Cronbach’s alpha along with performing a confirmatory factor analysis. Criterion validity was assessed by comparing mean scores on 3 subscales of the BMQ (General Overuse, General Harm, and Specific Necessity–Concerns difference score) between adherent patients and patients reporting nonadherence for 3 different reasons (unintentional nonadherence, cost-related nonadherence, and nonadherence due to reasons other than cost) using independent samples t tests.
The BMQ is a reliable instrument to examine beliefs about medications in this Spanish-speaking population. Construct validity testing shows nearly identical factor loading as the original construct map. General Overuse scores were significantly more negative for patients reporting each reason for nonadherence compared with their adherent counterparts. Necessity–Concerns difference scores were significantly more negative for patients reporting nonadherence for reasons other than cost compared with those who did not report this reason for nonadherence.
The Spanish version of the BMQ is appropriate to assess beliefs about medications in Latino patients with type 2 diabetes in the United States and may help identify patients who become nonadherent to medications for reasons other than out-of-pocket costs.
The purpose of this study was to examine the relationship between selected internal and external characteristics and communication (intended and actual) with health care providers (HCPs) about reproductive health and preconception counseling among adolescent females with diabetes.
A descriptive, correlational design was employed to conduct a secondary analysis of baseline data from a multisite, randomized controlled trial. Participants were 110 female adolescents (92% type 1 diabetes). Analysis included multiple linear regression and multivariate binary logistic regression analyses to examine the association of internal characteristics (age, race, religion, and religious beliefs) and external characteristics (ever sexually active, social support, and type of routine HCP).
Participants were from 13.3 to 20.0 years of age, 82% were Caucasian, 80% had never been sexually active, and 58% perceived low to moderate amounts of social support. For both internal and external characteristics, no significant main effects were found for actual or intended communication. For internal characteristics, there was an interaction between race and religious beliefs for the probability of actual communication. African American women who reported that their religious beliefs did not influence their sexual behavior had the lowest probability of actual communication compared to all other participants.
Race and religious beliefs should be considered when providing reproductive health information to young women with diabetes. Further research with a larger, more diverse sample is warranted. These results may be considered for future development of novel interventions with targeted messages based on these personal characteristics to empower young women to initiate conversations with HCPs about reproductive health and preconception counseling.
The purpose of this study is to examine the short-term efficacy (3 months) of early diabetes-specific READY-Girls preconception counseling (RGPC) on more general risk-taking behaviors, condom use, and sexually transmitted infections (STIs) among adolescent females with type 1 diabetes.
Secondary analysis was performed with data pooled from 2 independent randomized controlled trials to evaluate the short-term impact of RGPC. The pooled sample had 136 participants (mean age, 16.9 years; range, 13-19 years) and compared those who received the RGPC (n = 76) with a control group who received standard care (n = 60). Both groups self-reported on demographic characteristics, risk-taking behaviors (eg, substance use and unsafe sex), birth control, and STIs.
No effect of RGPC emerged on risk-taking behaviors, condom use, and STIs. Only 25% (n = 36) of the adolescents were sexually active at baseline, and 29% (n = 39) were sexually active at 3 months. Their overall mean age of sexual debut was 15.4 years, with more than half reporting an episode of unprotected sex. Condoms were the most frequent type of birth control used by both groups at both time points. By 3 months, only 4 participants had been diagnosed with an STI. Over time, subjects in both groups became more sexually active and used more condoms.
RGPC did not appear to directly affect general risk-taking behaviors or STIs, since it focuses on diabetes and reproductive health issues. Condom use did increase over time in both groups. More information on risk-taking behaviors and STIs should be included in diabetes-specific preconception counseling programs, including RGPC.
The purpose of this pilot study was to develop and evaluate a culturally adapted, language-translated diabetes prevention program for Chinese Americans.
This pilot study had a single-group repeated-measures design. Participants were 25 first-generation (n = 20) or second-generation (n = 5) Chinese Americans at risk for diabetes because of overweight (using the Asian-specific criterion of body mass index ≥ 23) and either prediabetes or metabolic syndrome. The 16-session program was administered over 6 months in separate Mandarin (n = 9) and English (n = 16) groups. Outcomes were assessed at baseline and at 3 and 6 months. Four participants dropped out. Multilevel regression models were used to examine change in study outcomes over time.
Participants lost an average of 5.4% of their body weight across the 6 months of the study. Self-report questionnaires suggested improved dietary intake and increased physical activity. Both total and low-density lipoprotein cholesterol levels improved. There were no statistically significant changes in fasting plasma glucose or A1C levels. Participants reported high satisfaction with and acceptance of the program.
Results suggest that the culturally adapted Group Lifestyle Balance program for Chinese Americans was both acceptable and effective. The culturally adapted program warrants further examination using scientific approaches for dissemination and implementation.
The purpose of this study was to determine the use of clinical-guideline–recommended antihypertensive regimens among Mexican Americans (MAs) and non-Hispanic blacks and whites with type 2 diabetes and hypertension.
A secondary data analysis based on National Health and Nutrition Examination Survey 2003-2012 cohort data included 1857 noninstitutionalized civilian MA, black, and white adults with type 2 diabetes and hypertension. Unadjusted and adjusted 2-way analysis of variance models evaluated whether there was a difference in the use of recommended antihypertensive regimens across race/ethnic group.
There was no difference in the use of recommended regimens across race/ethnic group (MAs, 79.1%; blacks, 81.7%; whites, 82.3%). Similarly, there was no difference between blood pressure goal levels and the use of recommended therapies across race/ethnicity (P = .632). Mexican Americans were least likely and blacks most likely to be on 3 or more antihypertensive drug classes (16.8% vs 28%). Furthermore, MAs were least likely to be on recommended add-on therapies such as calcium channel blockers and diuretics.
Racial/ethnic medication use disparities were observed when looking at the number of antihypertensive drug classes per patient regimen, and add-on therapy use was evaluated. Along with lifestyle modifications, frequent antihypertensive regimen reassessment is necessary.
The purpose of this study was to explore how adults with prediabetes perceive their risk of developing diabetes and examine their preferences for evidence-based treatment options to prevent diabetes.
A qualitative study was conducted in 2 large Midwest primary care practices, involving in-depth semistructured interviews with 35 adult patients with prediabetes.
This ethnically diverse (77% nonwhite) sample of middle-aged primary care patients exhibited multiple diabetes risk factors. Knowledge gaps about prediabetes and its medical management were pervasive. Most patients overestimated the risk of developing diabetes and were not familiar with evidence-based treatment options for prediabetes. They suggested that receiving brief, yet specific information about these topics during the study interview motivated them to act. The majority of participants considered both intensive lifestyle intervention and metformin acceptable treatment options. Many preferred initial treatment with intensive lifestyle intervention but would take metformin if their efforts at lifestyle change failed and their primary care physician recommended it. Some participants expressed wanting to combine both treatments.
This qualitative study highlights potential opportunities to promote patient-centered dialogue about prediabetes in primary care settings. Providing patients specific information about the risk of developing diabetes and evidence-based treatment options to prevent or delay its onset may encourage action. Physicians’ prediabetes counseling efforts should be informed by the finding that most patients consider both intensive lifestyle intervention and metformin acceptable treatment options.
The purpose of this report is (1) to describe the use of the American Association of Diabetes Educators’ (AADE’s) model of implementation of the National Diabetes Prevention Program through nationally certified diabetes self-management education (DSME) programs and (2) to report the aggregated program outcomes as defined by the Diabetes Prevention and Recognition Program standards of the Centers for Disease Control and Prevention (CDC).
In 2012, the AADE worked with the CDC to select 30 certified DSME programs for National Diabetes Prevention Program delivery. For the following 3 years, the AADE continued to work with 25 of the 30 original programs. Results for all CDC recognition standards have been collected from these 25 programs and analyzed as aggregated data over the course of 36 months.
At the end of the full-year program, average percentage body weight loss for participants across all 25 programs exceeded the CDC’s minimum requirement of 5% weight loss. All programs on average met the CDC requirements for program attendance.
Increasing access to the National Diabetes Prevention Program, through an array of networks, including certified DSME programs, will better ensure that people are able to engage in an effective approach to reducing their risk of diabetes.
Evidence-based guidelines recommend regular depression screening among individuals with type 2 diabetes mellitus (T2DM). The purpose of this study is to examine depression screening patterns among a primary care population with T2DM, through use of the Patient Health Questionnaire-9 (PHQ-9).
In total, 1817 patients with T2DM were analyzed through a retrospective observational study at 2 sites, a regional health center and a federally qualified health center (FQHC). The T2DM sample was divided into those with and without a major depressive disorder (MDD) diagnosis. Depression screening rates and depression severity were assessed through the PHQ-9.
Both sites had higher rates of PHQ-9 screening among individuals with a history of MDD (64.82%) vs those without MDD (11.39%). Individuals from the FQHC without a history of depression had a higher mean PHQ-9 score (10.11) than those with a previous MDD diagnosis at both RHS and FQHC (7.16 and 9.85, respectively).
Depression screening rates among individuals with diabetes and no history of MDD were remarkably low. Patients with diabetes but no MDD diagnosis who sought health care at a FQHC clinic had more depressive symptoms than those with a history of MDD at both sites. Individuals with diabetes and who have a MDD diagnosis are much more likely to receive regular depression screening than those without MDD, which leaves a substantial proportion of patients with undetected depression. Depression screening must be enhanced for all individuals with diabetes, particularly for low-income individuals and those without a previous diagnosis of MDD.
The purpose of this study was to examine factors that influence physical activity counseling of diabetes educators delivering diabetes self-management/support (DSME/S).
Diabetes educators were surveyed about their DSME/S counseling at the American Association of Diabetes Educators Pennsylvania State Diabetes Conference to explore (1) time dedicated to physical activity counseling, (2) importance placed on physical activity as a treatment for diabetes, (3) knowledge of the 2008 Physical Activity Guidelines for Americans, (4) level of confidence with physical activity counseling, and (5) barriers associated with physical activity counseling.
A sample of 119 diabetes educators with 13.0 ± 8.6 years of DSME/S experience participated in the survey (95.8% female; 94.1% white; 60.5% nurses; 73.9% Certified Diabetes Educators). Of 4 common DSME/S content areas (healthy eating, taking medications, monitoring blood glucose, and physical activity), physical activity was ranked as the third most important behind healthy eating and taking medications, with 14.5 ± 12.1 minutes per session spent counseling on physical activity. The proportion of educators acknowledging the current physical activity guidelines for moderate-intensity aerobic activity, vigorous-intensity aerobic activity, and resistance training was 74%, 20.5%, and 62.8%, respectively. Being "very confident" for counseling on physical activity was reported by 54.7%, while "inability to engage patients in physical activity" and "time allotted for DSME/S visits" were the most challenging personal and practice barriers reported, respectively. Physical activity is an important lifestyle behavior for the treatment of diabetes.
Findings suggest that there are challenges to physical activity counseling within DSME/S. Strategies to improve physical activity counseling by diabetes educators warrant attention.
The purpose of this study was twofold: (1) to describe the content of recent diabetes education programs and their outcomes in terms of glycemic control, disease management, and psychosocial criteria for children and adolescents with type 1 diabetes and (2) to gauge the match between these programs and the recommendations of the International Society for Pediatric and Adolescent Diabetes (ISPAD).
The integrative review was carried out according to the Cochrane recommendations. Thirteen databases were searched for evaluations of education programs published from 2009 to 2014. Program characteristics and outcomes were described. Quality of studies was assessed, and program match with ISPAD recommendations was gauged.
Of 2528 studies found, 43 covering 36 education programs intended for youth with type 1 diabetes were retained for review. Nine of these centered on self-care competencies, 18 on psychosocial competencies, and 9 on both types of competency (mixed program). Programs varied widely in terms of organization, procedure, and content. Glycemic control was an indicator assessed in the majority of programs, but only half of these (for the most part, self-care programs) reported positive findings in this regard. Few programs seemed to affect psychosocial indicators. An online mixed program, which was the program that best met the ISPAD recommendations, proved to have an influence on glycemic control and several psychosocial criteria.
Various avenues can be considered to improve participant engagement in education programs and to align these programs more closely with international recommendations. Further research is required to enhance knowledge in this field.
The purpose of this study is to characterize risk factors associated with type 2 diabetes in young adults aged 18 to 29 years to develop a noninvasive risk assessment tool for use with younger American populations.
The self-assessment tool was developed with the Strong Heart Family Study data. A total of 590 young American Indian adults (242 men) who had normoglycemia and were not receiving diabetes treatment were included. Risk factors recommended by the American Diabetes Association were used to assess diabetes risk in these young adults. A logistic regression model was developed to calculate the predicted probability. The area under the receiver operating characteristic curve was used to evaluate the model.
The final model showed that parental history of diabetes, obesity level, alcohol consumption, and high fasting glucose, even within normal range, were significantly associated with onset of prediabetes/diabetes in 5 years. The area under the receiver operating characteristic curve value was 0.68 with original and validated data, indicating that the risk assessment tool had reasonably good discrimination ability.
This new noninvasive screening tool, based on data from American Indian young adults, has potential to screen young adults’ early-onset diabetes risk. Future studies are warranted to test this risk assessment tool in other racial/ethnic young adults.
Substance use behaviors often emerge during adolescence, and adolescents with type 1 diabetes (T1D) may be at risk for engaging in traditional substance use (eg, alcohol, tobacco, and illicit substances) as well as a unique form of substance use: insulin misuse. The purpose of this exploratory study was to examine substance use and insulin misuse in adolescents with T1D.
Sixty adolescents aged 12 to 20 years with T1D (n = 60) completed surveys on substance use, insulin misuse, and diabetes self-management during a routine diabetes appointment. Demographic measures were summarized by mean (SD) or percentage. Prevalence of substance use and insulin misuse was calculated and stratified by demographic and clinical characteristics. Two-sample t test (continuous variables) and chi-square analysis (categorical variables) determined statistically significant differences.
The prevalence of ever using substances was 36.7%, and that for ever misusing insulin was 19%. Older participants (17.1 ± 1.8 vs 15.6 ± 1.9 years; P < .01) and those with depression (31.8% vs 7.9%; P = .02) were more likely to use substances. Disordered eating behaviors were the most frequently reported reason for insulin misuse. Self-harm intent was reported by one-third of insulin misusers. Substance use and insulin misuse were not related to glycemic control or diabetes self-management behaviors.
The diabetes care team should be aware that substance use and insulin misuse are common in adolescents with T1D. Screening for these risky behaviors is critical in those who are older or have mental health disorders. Effective education, prevention, and treatment strategies targeted at these behaviors are needed to improve the overall health of this population.
The purpose of this continuous quality improvement project was to improve access to diabetes self-management education (DSME) and to evaluate the impact on glycemic and weight control by translating an academic medical center’s DSME program, accredited per the Education Recognition Program (ERP) of the American Diabetes Association, into a program offered at primary care clinics (PCCs).
Certified diabetes educators from the medical center trained PCC registered dietitian nutritionists, registered nurses, and social workers to provide DSME in their community-based clinic. Main outcomes of this retrospective, pretest/posttest, observational project were to evaluate enrollment in DSME classes and change in A1C and weight as patients underwent a combined intervention of diabetes education classes with or without consultation and support from a PCC registered dietitian nutritionist or registered nurse.
PCC DSME was associated with increased enrollment in DSME classes and a significant reduction of A1C and weight at 3 and 6 months post-DSME. Greatest A1C and weight reductions were observed in patients with newly diagnosed diabetes. Reductions were also seen in patients with diabetes duration ≥10 years, participants taking insulin, and those with depression.
PCC DSME availability increased access to group diabetes education and resulted in reduced A1C and weight for participants. This model was successful in translating an established academic accredited DSME-ERP into a PCC. Results have implications for increasing access to diabetes education programs and improving diabetes control for patients not located near major hospital-based DSME programs.
The purpose of this study was to examine the impact of a home-based diabetes prevention and management program on high-risk American Indian youth.
Together on Diabetes (TOD) was designed via a participatory approach with 4 tribal communities in the southwestern United States. A multisite pre- and postevaluation design was used to evaluate the efficacy of the TOD intervention on improving youth’s psychosocial, knowledge, behavioral, and physiological outcomes at 4 time points from baseline to 12 months postenrollment.
A total of 256 youth and 225 support persons were enrolled in the TOD program. At 12 months postenrollment, improvements were observed in youth’s quality of life (P < .001), depressive symptoms (P < .001), knowledge related to TOD content (P < .001), standardized body mass index scores (P = .004), and hypertension (P = .026). Improvements in mean A1C were observed among diabetic youth with baseline A1C >6.5% (P = .036).
The TOD program was feasible, acceptable, and effective in lowering diabetes risk among reservation-based American Indian youth. It is the first efficacious youth-focused diabetes prevention and management program developed and implemented in partnership with tribal communities.
The purpose of this study is to examine the relationship between depressive symptoms and diabetes self-care in African American and Hispanic/Latino patients with type 2 diabetes and whether the association, if any, is mediated by diabetes-related self-efficacy.
The sample included self-report baseline data of African American and Hispanic/Latino patients with type 2 diabetes who were aged ≥18 years and enrolled in a diabetes self-management intervention study. Depressive symptoms were assessed with the 9-item Patient Health Questionnaire. The Summary of Diabetes Self-care Activities measured engagement in healthy eating, physical activity, blood glucose checking, foot care, and smoking. The Diabetes Empowerment Scale–Short Form assessed diabetes-related psychosocial self-efficacy. Indirect effects were examined with the Baron and Kenny regression technique and Sobel testing.
Sample characteristics (n = 250) were as follows: mean age of 53 years, 68% women, 54% African American, and 74% with income <$20 000. Depressive symptoms showed a significant inverse association with the self-care domains of general diet, specific diet, physical activity, and glucose monitoring in the African American group. In Hispanics/Latinos, depression was inversely associated with specific diet. Self-efficacy served a significant mediational role in the relation between depression and foot care among African Americans.
Self-efficacy mediated the relationship between depression and foot care in the African American group but was not found to be a mediator of any self-care areas within the Hispanic/Latino group. In clinical practice, alleviation of depressive symptoms may improve self-care behavior adherence. Diabetes education may consider inclusion of components to build self-efficacy related to diabetes self-care, especially among African American patients.
The purpose of this longitudinal qualitative study was to explore Latino caregiving dyads’ experiences with managing diabetes in the home.
The authors used Sebern’s Shared Care construct as a framework for understanding the realities that some Latino older adults and their caregivers face in managing diabetes. Twelve caregiving dyads completed a semistructured interview followed by weekly participant observation in their homes over 3 to 4 months. Data were analyzed using a grounded theory approach.
Diet was the most commonly discussed and observed aspect of diabetes care and also a source of strain within dyads. Dyads talked and acted congruently about food preparation and the challenges of diet adherence but had conflicting views on whether the care receiver’s diabetes was under control. Analysis also revealed a discordance between views and observed actions of diabetes care related to monitoring blood glucose levels.
Findings suggest that caregivers or other key family members should be considered as active participants in diabetes management among Latinos, which is consistent with American Diabetes Association and Institute of Medicine recommendations for a patient- and family-centered approach to improve care. In addition, family environments that are in flux, chaotic, or low in resources may benefit from increased support to initiate and maintain diabetes management behaviors.
The purpose of the study was to examine the differences in clinical, psychosocial, and demographic factors by sex and weight status.
Baseline data were analyzed from 318 adolescents (mean age = 12.3 ± 1.1 years, 55.0% female, 62.7% white) with type 1 diabetes (T1D) from a multisite clinical trial. Differences were examined between normal weight (body mass index ≥5th and <85th percentile) and overweight/obese (body mass index ≥85th percentile) boys and girls with T1D in clinical, psychosocial, and demographic factors. Descriptive and multiple logistic regression analyses were used.
Overweight/obesity was prevalent (39.0%) and common in girls (42.6%) and boys (33.1%). In bivariate analyses, overweight/obese girls had parents with lower educational attainment, longer diabetes duration, and significantly worse self-management and psychosocial health as compared with normal weight girls. There were no differences between overweight/obese and normal weight girls in A1C, therapy type, race/ethnicity, or household income. No significant differences were found between normal weight and overweight/obese boys. In multivariate analysis, parental educational attainment (master or higher vs high school diploma or less) and perceived stress were significantly associated with overweight/obesity in girls. Longer duration of T1D bordered statistical significance.
Overweight/obesity is prevalent among adolescents with T1D. Clinical, psychosocial, and demographic factors are associated with overweight/obesity in girls but not boys. Greater attention to weight status and aspects of health that are germane to adolescents with T1D is warranted.
Correct insulin injection technique is a crucial aspect of diabetes management. The purpose of this article is (1) to outline the medical literature, including patient-based studies and surveys, surrounding the type of issues and problems that patients encounter with injectable insulin therapy and the degree to which correct insulin technique is being applied and (2) to review the latest recommendations for insulin injection technique and discuss the key aspects that diabetes educators and other health care professionals should be communicating to their patients to ensure that injection technique is optimized.
Examination of the literature and multiple patient surveys demonstrates that patients continue to have many issues with insulin injection technique, highlighting the pressing need for effective patient education. In addition, many patients are not using insulin pen devices correctly. Widespread lack of injection site rotation and reuse of needles have resulted in high rates of lipohypertrophy. Lipohypertrophy has in turn been associated with significantly increased levels of unexplained hypoglycemia and glycemic variability and significantly increased insulin costs. By providing clear, evidence-based consensus recommendations, initiatives such as the Forum for Injection Technique are helping to address these issues but will be successful only if concerted efforts in patient education and reeducation are made to ensure that these recommendations are implemented consistently. This should involve all stakeholders in insulin therapy—particularly diabetes educators, who are at the forefront of patient education.
The purpose of this study was to evaluate a 4-month telephone-based goal-setting and decision support intervention among adults with type 2 diabetes mellitus (T2DM) and multiple risk factors for cardiovascular disease (CVD).
A randomized pretest-posttest control group design was employed. Overweight or obese adults aged 40 to 75 years with T2DM and ≥1 additional CVD risk factor were provided with individualized CVD risk information. At baseline and each biweekly telephone call, the multiple-goal group self-selected both diet- and physical activity–related goals, the single goal group set a single goal, and the control group received information about community health resources. Dietary intake was assessed via a food frequency questionnaire, physical activity via questionnaire, and A1C and blood lipids via fasting fingerstick sample. Between-group differences for clinical (ie, A1C, blood pressure, and blood lipids), physical activity, and dietary variables were evaluated using Kruskal-Wallis, Mann-Whitney U, analysis of variance, and t tests.
From pre- to postintervention, the single-goal group demonstrated significant improvement in systolic blood pressure and intake of servings of fruits, vegetables, and refined grains (all P < .05). The multiple-goal group reported significant reduction in percent energy from total, saturated, monounsaturated, and trans fat intake and significant increase in leisure time walking (all P < .05).
A multiple-goal approach over 4 months can improve dietary and physical activity outcomes, while a single-goal approach may facilitate improvement in one behavioral domain. Additional research is needed to evaluate maintenance of the achieved changes.
The purpose of this study was to describe the experience of Hispanic adolescents with type 1 diabetes (T1DM) from the perspectives of adolescents and their diabetes clinicians.
Nine Hispanic adolescents with T1DM and 7 clinicians at a tertiary academic medical center participated in in-depth individual semistructured interviews. Adolescents were purposively sampled to obtain a range in age and metabolic control. Based on interpretive descriptive methodology, data were coded and combined into themes, which were constructed separately for the 2 groups and then compared across groups. Data were analyzed concurrently with data collection.
Adolescents and clinicians reported similar themes related to (1) cultural aspects of living with T1DM; (2) finding the balance of: food, insulin, and exercise; being "perfect at diabetes" versus being a "normal teenager"; and being independent versus needing support, and (3) ways to improve life for Hispanic adolescents with T1DM. Although there were some key cultural distinctions, Hispanic adolescents with T1DM and their clinicians described life and daily management issues as being similar to those of their non-Hispanic peers.
Hispanic adolescents with T1DM have unique experiences and beliefs that affect their living with T1DM, but in many respects, their experiences are similar to those of their non-Hispanic peers with T1DM. Hispanic adolescents with T1DM want their clinicians to learn about their personal lives. Preferably, clinicians and parents should speak the same language. If not possible, interpreters should be used instead of having adolescents translate during clinic appointments.
The purpose of the study was to describe perception of risk for developing diabetes among foreign-born Spanish-speaking US Latinos.
Participants (N = 146), recruited at food-pantry distribution events and free clinics, were surveyed using the Risk Perception Survey for Developing Diabetes in Spanish. Type 2 diabetes risk factors measured included body mass index, physical activity, and A1C.
Sample characteristics were mean (SD) age of 39.5 (9.9) years, 58% with less than a high school graduate-level education, and 65% with a family income less than $15,000/year. Prevalence of risk factors was 81% overweight or obese, 47% less than 150 minutes/week moderate/vigorous-intensity physical activity, and 12% A1C consistent with prediabetes. Of the 135 participants with complete data, 31% perceived a high/moderate risk for developing diabetes. In univariate logistic regression analyses, 9 of 18 potential variables were significant (P < .05) predictors of perception of risk. When these 9 variables were entered into a multiple logistic regression model, 5 were significant predictors of perception of risk: history of gestational diabetes, high school graduate or above, optimistic bias, worry, and perceived personal disease risk.
Use of the Spanish-language translation of the Risk Perception Survey for Developing Diabetes revealed factors influencing perception of risk for developing diabetes. Results can be used to promote culturally acceptable type 2 diabetes primary prevention strategies and provide a useful comparison to other populations.
This article describes the stakeholder-driven design, development, and testing of web-based, multimedia decision aids for youth with type 1 diabetes who are considering the insulin pump or continuous glucose monitoring and their parents. This is the initial phase of work designed to develop and evaluate the efficacy of these decision aids in promoting improved decision-making engagement with use of a selected device.
Qualitative interviews of 36 parents and adolescents who had previously faced these decisions and 12 health care providers defined the content, format and structure of the decision aids. Experts in children’s health media helped the research team to plan, create, and refine multimedia content and its presentation. A web development firm helped organize the content into a user-friendly interface and enabled tracking of decision aid utilization. Throughout, members of the research team, adolescents, parents, and 3 expert consultants offered perspectives about the website content, structure, and function until the design was complete.
With the decision aid websites completed, the next phase of the project is a randomized controlled trial of usual clinical practice alone or augmented by use of the decision aid websites.
Stakeholder-driven development of multimedia, web-based decision aids requires meticulous attention to detail but can yield exceptional resources for adolescents and parents contemplating major changes to their diabetes regimens.
The purpose of this study was to develop and test the feasibility of a parent-to-parent support intervention for parents whose child has recently been diagnosed with type 1 diabetes in the United Kingdom.
The research team conducted a formative evaluation, working with parents to design an individual-level parent-to-parent support intervention. Issues of recruitment, uptake, attrition, pattern of contact, and intervention acceptability were assessed.
A US program was adapted in collaboration with a parents’ advisory group. Of 19 parents nominated as potential mentors by their pediatric diabetes specialist nurses, 12 (63%) volunteered and 11 continued for the 12-month intervention period. Thirty-three children were diagnosed with diabetes in the study period, with 25 families eligible to participate as recipients of the intervention; 9 parents from 7 of those families participated, representing 28% of those eligible. Feedback from parents and clinic staff identified peer support as a welcome service. Lessons were learned about the nature of the supporting relationship (eg, proximity, connectedness, and managing endings) that will enhance the design of future peer support programs.
Parent-to-parent support in the context of newly diagnosed childhood diabetes in the United Kingdom is feasible to deliver, with good engagement of mentors and clinic staff. The program was acceptable to parents who chose to participate, although uptake by parents whose child had been recently diagnosed was lower than expected. The results merit further investigation, including exploration of parent preference in relation to peer support.
Insulin infusion sets (IISs) are an essential component of safe and effective insulin pump therapy. Establishing best practices for their use has been impeded by a lack of formal study and limited resources for clinician and patient education. Recent innovations in IIS science promise to change this status quo by increasing awareness of such problems as unexplained hyperglycemia and infusion set occlusion.
In August 2015, a panel of diabetologists and certified diabetes educators from various disciplines was convened to reconsider IIS-related complications of pump therapy, to better characterize infusion set factors affecting patient experience, and to update priorities for optimizing current technologies. Actionable guidelines were provided for addressing common issues, including skin reactions, site rotation and set changes, dislodgment of the infusion set, and partial or complete blockage of the catheter. These issues may underlie episodes of IIS failure and/or unexplained hyperglycemia.
Development of practical tools and standardized guidelines for empowering patients to prevent, diagnose, and troubleshoot IIS problems that contribute to unexplained hyperglycemia will be necessary to realize the full benefit of insulin pump therapy along the continuum of diabetes education.
The purpose of this study was to investigate the impact of diabetes self-management education on glycemic control and perceptions of empowerment in Armenian American immigrants diagnosed with type 2 diabetes.
A quasi-experimental pre and post design was used to investigate the impact of using education on self-management as measured by A1C levels and empowerment scores. Nine hours of diabetes self-management education classes were offered in the Armenian language to 75 clients at 2 adult health day care centers over 6 weeks. The participants were mostly first-generation Armenian immigrants aged 65 years and older. A1C results, the 8-item Diabetes Empowerment Scale (DES), and the 15-item Armenian Ethnic Orientation Questionnaire–Revised (AEOQ-R) were used to determine the impact of education on self-care management.
After institutional review board approval was obtained, 75 participants completed the study. A paired t test indicated that the postintervention mean A1C level was significantly lower than the preintervention mean A1C level. The postintervention mean DES score was significantly greater than the preintervention mean DES score. No mediating effects of age, gender, acculturation, and number of years with the disease were identified for either A1C or DES score.
The findings demonstrate the efficacy of the diabetes self-management education classes in improving diabetes self-care management skills.
The purpose of this qualitative study was to understand how acculturation influences diabetes risk among urban immigrant Latinas (Hispanic women).
Five focus groups were conducted with 26 urban immigrant Latinas who were at high clinical risk for developing diabetes. The focus group sessions were audiotaped and transcribed verbatim. The authors independently analyzed transcripts using an inductive method of open coding and established themes by consensus.
All participants were foreign born and had low levels of acculturation. During the acculturation process, they noted changes in their lifestyle behaviors and the family context in which those behaviors are shaped. They reported that since living in the United States, their improved economic circumstances led to increased consumption of less healthy foods and beverages and a more sedentary lifestyle. They also described changing family roles and responsibilities, including working outside the home, which constrained healthy food choices. However, they perceived that their position of influence within the family offered opportunities to help family members prevent diabetes.
Lifestyle interventions to prevent diabetes in Latinas should address their acculturation experiences, which affect family functioning and health behaviors related to diabetes risk. For example, given the perceived link between Latinas’ improved economic circumstances and their diabetes risk, prevention programs should incorporate strategies to help Latinas avoid adopting less healthy lifestyle behaviors that become affordable during the acculturation process.
The purpose of the current study was to pilot-test a positive psychology intervention to improve adherence to diabetes management in adolescents with type 1 diabetes.
A total of 39 adolescents (ages, 13-17 years) with type 1 diabetes and their caregivers were randomized to a positive psychology intervention (n = 20) or an attention control (education) intervention (n = 19). The intervention condition used positive psychology exercises (eg, gratitude, self-affirmation), small gifts, and parent affirmations to boost positive affect. Outcomes included frequency of blood glucose monitoring, quality of life, and glycemic control.
No main effects for treatment were observed at the 6-month follow-up. However, there was a significant association between adolescents’ levels of positive affect and measures of adherence, including self-report and meter downloads of glucose monitoring.
The results from the current study support the assertion that positive affect in the context of diabetes education is an important factor to consider in adolescents with type 1 diabetes.
The purpose of this study was to investigate how an intergenerational legacy of type 2 diabetes affected the knowledge, attitudes, and treatment strategies of Hispanic young adults with diabetes.
Eight Hispanic young adults (ages 18-30 years) participated in a series of in-home longitudinal qualitative interviews, and 11 of their family members completed single in-home interviews, regarding their diabetes management practices. Interview transcripts were analyzed thematically by a team of researchers.
Five themes emerged that characterized the influence of an intergenerational legacy of diabetes on young adults: food and family (how meal preparation and eating are shared within families), doing together (activity participation is contingent on others’ participation), knowledge and expectations (expectations for the future and understandings of diabetes are shaped by family members), miscarried helping (well-intentioned actions have negative consequences), and reciprocal support (children and parents support each other’s diabetes care).
Hispanic young adults’ knowledge, attitudes, and self-care practices related to diabetes are strongly influenced by the diabetes management practices of family members with diabetes, which often depart from current standards of diabetes care. Care providers should consider family members as a potentially significant influence, either positive or negative, on the diabetes self-care practices of this population.
The purpose of this study is to examine whether travel distance would pose a barrier to participation in proposed diabetes intervention programs for Guyanese immigrants at faith-based organizations (FBOs). This study also suggests the most collectively accessible set of FBOs that could serve as intervention sites.
Data were extracted from a cross-sectional health interview survey conducted in Schenectady, New York, in 2011. The shortest driving distances from homes to FBOs and to the city’s only diabetes education center (DEC) were analyzed among Guyanese and non-Guyanese adults with diabetes and prediabetes (n = 238), using spatial algorithms and Geographic Information System resources.
The Guyanese were more likely to belong to a FBO than the non-Guyanese (77.8% vs 61.2%). The mean driving distance to FBO was 1.19 miles (95% CI, 0.98-1.39) for the Guyanese, which was significantly shorter than that for the non-Guyanese (2.87 miles, 95% CI, 1.93-3.82). The Guyanese had uniformly shorter mean and median driving distances in all sociodemographic and health status subcategories as well. Moreover, a higher percentage of the Guyanese lived closer to FBO than to DEC compared to non-Guyanese (52.2% vs 34.7%). It was found that having diabetes intervention at the 4 most popular FBOs (2 Hindu temples and 2 Christian churches) and DEC would provide the most collectively accessible arrangement for the Guyanese.
The results suggest that the short driving distance to FBO is a likely enabler that can encourage regular utilization of the faith-based intervention for the Guyanese.
The purpose of this study is to describe participant experiences of a household-level, community health worker-led intervention to improve diabetes-related health behaviors and outcomes.
The Home Health Parties (HHP) aimed to improve diabetes self-management among Hispanics living in a rural, agricultural area in eastern Washington State. Trained promotores (community health workers) delivered a series of education sessions and distributed incentives to support diabetes-related behavior change. Open-ended, semi-structured questionnaires were administered to a random sample of 40 HHP participants. Qualitative methods were used to code and analyze the interview transcripts.
Four primary themes emerged from interviews: (1) participants’ desire for improving knowledge about diabetes; (2) experiences of building skills for diabetes management; (3) developing social support; and (4) embracing household-level change.
This study shows that involving family members and increasing social support are effective strategies for improving health behaviors and chronic health outcomes among vulnerable Hispanics living with diabetes. Our findings demonstrate several important considerations regarding the design of diabetes management interventions for rural Hispanic populations including the following: (1) promotores are critical as they provide social support and encourage behavior change by building relationships based on trust and cultural understanding; (2) well-designed tools that provide step-by-step examples of healthy behaviors, such as cookbooks, and tools that aid participants to monitor behavior change, such as pedometers and glucose monitors, serve to build skills and improve confidence to achieve goals; and (3) targeting households is a promising strategy for individual and family lifestyle changes that benefit the entire family unit.
Enhancing linkages between patients and community programs is increasingly recognized as a method for improving physical activity, nutrition, and weight management. Although interactive mapped community program guides may be beneficial, there remains a dearth of articles that describe the processes and practicalities of creating such guides. This article describes the development of an interactive web-based mapped community program guide at a safety net institution and the lessons learned from that process.
This project demonstrated the feasibility of creating 2 maps: a program guide and a population health map. It also revealed some key challenges and lessons for future work in this area, particularly within safety net institutions. Our work underscores the need for developing partnerships outside the health care system and the importance of employing community-based participatory methods. In addition to facilitating improvements in individual wellness, mapping community programs has the potential to improve population health management by health care delivery systems such as hospitals, health centers, or public health systems, including city and state departments of health.
Ongoing interaction between diabetes educators and patients is necessary for making and sustaining behavior changes essential for glycemic control and subsequently reducing the complications of diabetes.
The purpose of this study was to determine the feasibility of diabetes self-management support (DSMS) delivered via telephone or secure message and to compare clinical outcomes (A1C, LDL), behavioral goal achievement, and health maintenance task completion.
In sum, 150 persons with type 2 diabetes who completed diabetes self-management education self-selected DSMS methods: 1 in-person visit (n = 47), 3 brief visits by phone (n = 44), or 3 by secure message (n = 59) through electronic health record. DSMS included evaluation of goal achievement, barriers and facilitators, problem solving, and review of health maintenance exams. Self-reported data were collected at 9 months.
There were no significant differences among groups in main outcomes between baseline and 9-month follow-up. Behavioral goals were achieved by 59% of in-person participants, 73% phone, and 77% secure message. Sixty-two completed the intervention per protocol: fewer online than in-person or phone groups. Mean attempts to contact participants was significantly greater in the secure message group. Phone contact was significantly longer than secure message.
Telephone and secure message was feasible for providing DSMS. Three brief contacts by phone or secure message resulted in similar outcomes when compared to an in-person visit. Secure messaging required less staff time, but increased patient engagement is needed.
The purpose of this study is to investigate the racial/ethnic disparities in health-related quality of life (HRQOL) among adults with self-reported diabetes and identify the different risk factors related to HRQOL for specific racial/ethnic groups in the United States.
National Health and Nutrition Examination Survey (NHANES) 2001-2010 participants (ages 20 years and older) who were self-identified as non-Hispanic white, non-Hispanic black, or Hispanic and with self-reported diabetes were included in the analysis (n = 2594). The Centers for Disease Control and Prevention’s HRQOL-4 was used to assess factors associated with HRQOL through multivariate logistic regression models with survey weighting. Stepwise model selection was applied to select the most significant factors for HRQOL in each racial/ethnic group.
Hispanic participants were less likely to report 14 or more mentally unhealthy days and activity-limited days compared to non-Hispanic white counterparts, adjusting for age, sex, education, marital status, family poverty–income ratio (PIR), body mass index, smoking status, insurance coverage, and diabetes duration. Current smoking status and obesity were significantly associated with worse HRQOL among whites and blacks. Marital status predicted better HRQOL only among Hispanics. Having insurance coverage predicted better HRQOL among both blacks and Hispanics. Increased family PIR had a favorable association with the 4 HRQOL domains consistently among all races/ethnicities.
Minimal racial/ethnic disparities in HRQOL were observed among US adults with self-reported diabetes. Support is offered for more individualized health care and communication with patients to target care and interventions that improve health and quality-of-life indicators.
The purpose is to provide an overview of a 20-year research program aimed at testing diabetes self-management education interventions culturally tailored for Mexican Americans residing in an impoverished rural community on the Texas-Mexico border.
The research program involved focus group interviews to obtain community input, pilot testing to refine instruments and interventions, and community-based randomized controlled trials to examine intervention effects. Here the authors summarize lessons learned related to the (1) overall effects of culturally tailored diabetes self-management education; (2) impact of culture on study design, intervention development, health outcomes, and community acceptance; (3) benefits of and findings from multiple focus groups held over time in the community; and (4) personal and cultural motivators for behavioral change that were evident among study participants.
Postintervention reductions in A1C ranged from 1.4 to 1.7 percentage points. Individuals who attended ≥ 50% of intervention sessions achieved a 6–percentage point reduction in A1C. Intervention teams included bilingual Mexican American nurses, dietitians, and promotoras, all recruited from the local community. Focus group interviews indicated that a traditional promotora model was not acceptable to the participants who wanted knowledgeable health professionals, or perceived authority figures, to lead intervention sessions while promotoras provided logistical support. Free glucometers and strips, family participation, and interpersonal dynamics within intervention groups motivated individuals to make healthier lifestyle choices.
Culturally tailored diabetes interventions are effective in improving the health of socially disadvantaged minorities who bear a disproportional burden of type 2 diabetes, and these interventions are cost-effective.
The purpose of this study was to evaluate the efficacy of Prevent, an online social network-based translation of the Diabetes Prevention Program (DPP) lifestyle intervention, against the Centers for Disease Control and Prevention (CDC) Diabetes Prevention and Recognition Program (DPRP) outcome standards and weight loss outcomes of other DPP translations.
Two hundred twenty participants previously diagnosed with prediabetes were recruited online and enrolled in Prevent, a DPP-based group lifestyle intervention that integrates a private online social network, weekly lessons, health coaching, and a wireless scale and pedometer. Participants underwent a core 16-week intensive lifestyle change intervention and were then offered to continue with a post-core lifestyle change maintenance intervention, with the entire intervention (core plus post-core) totaling 12 months.
One hundred eighty-seven participants met inclusion criteria for the core program and achieved an average of 5.0% and 4.8% weight loss at 16 weeks and 12 months, respectively. They also had a 0.37% reduction in their A1C level at final measurement. One hundred forty-four of these same participants also met inclusion criteria for the post-core program and achieved an average of 5.4% and 5.2% weight loss at 16 weeks and 12 months, respectively, and a 0.40% reduction in A1C at final measurement.
Results indicate that Prevent meets CDC DPRP outcome standards for diabetes prevention programs and performs favorably to other DPP translations. Considering national initiatives to address the obesity and diabetes epidemics, online delivery platforms like Prevent offer an effective and scalable solution.
The purposes of this review were to identify the needs and concerns of family caregivers of persons with type 2 diabetes and to develop recommendations for future research on family caregivers of American Indians with type 2 diabetes. Searching the Cumulative Index to Nursing and Allied Health, Ovid, and PubMed, an extensive literature review was conducted using 10 search terms for articles published from 1990 to 2013. References of retrieved studies were also searched.
On the basis of the search criteria, 6 studies exploring the needs and concerns of family caregivers of persons with type 2 diabetes were identified. Findings were placed in 5 predetermined categories derived from Bakas et al’s needs and concerns framework: (1) finding information and resources related to type 2 diabetes, (2) dealing with the emotions and behaviors of the care recipient, (3) providing physical care, (4) providing instrumental care, and (5) dealing with one’s own personal responses to caregiving. The cross-cultural literature helped identify common ground and specific literature about the experiences of American Indian caregivers. Further research is needed on the needs of caregivers of persons with type 2 diabetes, particularly those in the Native American and other minority populations. Findings can be used to develop interventions to improve outcomes for these caregivers.
The purpose of this study was to refine and expand a culturally tailored individual-level diabetes self-management intervention to a family-level intervention.
Using community-based participatory research principles, Mexican American adults (n = 12) with type 2 diabetes mellitus (T2DM) and family members (n = 12) in the United States–Mexico border region participated in 6 focus group interviews, conducted by bilingual, bicultural facilitators. Facilitators and barriers to T2DM management were identified. Transcripts were analyzed using qualitative content analysis.
Through an iterative analysis process, 5 categories represented participants with T2DM: (1) strategies my family can use to support our managing T2DM, (2) be sensitive to my challenges, (3) stop telling me what to eat or do, (4) how can we peacefully coexist, and (5) I feel supported. Categories identified by family members were (1) changing behaviors together, (2) sharing not controlling, (3) supporting positive behaviors, and (4) your behaviors frustrate me.
The family was reinforced as a major influence for successful T2DM management. Family support requires that families value and develop knowledge and skills for T2DM management. This family intervention builds on family assets and relationships, shifting from traditional externally motivated individual models to create a shared commitment to manage T2DM among Mexican American adults.
The purpose of this study is to explore the influence of the social environment, including family and community relationships, on diabetes-related dietary change behaviors in a low-income, predominantly African American community with limited access to healthy foods.
Study methods included interviews and focus groups with adults with diabetes and family members of individuals with diabetes in a low-income African American community. In this analysis, interview participants included 11 participants with diabetes, one with prediabetes, and 8 family members or close friends with diabetes. Information from 4 participants with diabetes and 6 with family members with diabetes was included from 6 focus groups. Transcripts were analyzed via thematic iterative coding influenced by social cognitive theory to understand the influence of family and community relationships on dietary change.
Participants’ social environments strongly influenced diet-related behavioral change. Family members without diabetes provided reinforcements for dietary change for those with diabetes by preparing healthy food and monitoring intake, as well as by adopting dietary changes made by those with diabetes. Family and community members served as sources of observational learning about the potential impacts of diabetes and enhanced behavioral capability for dietary change among people with diabetes by providing dietary advice and strategies for making healthy choices.
This study demonstrates the ways in which family and community members can influence dietary change in people with diabetes. Interventions targeting diabetes management should incorporate families and communities as sources of information, learning, and support.
Little is known about the relationship of worry about hypoglycemia with diabetes-specific and typical youth behaviors among emerging adults with type 1 diabetes. This study’s purpose was to examine the relationship among worry about hypoglycemia, diabetes management, and glycemic control within the context of alcohol use, hypoglycemia-related weight control behaviors, depressive symptoms, and impulse control among emerging adults with type 1 diabetes.
The sample was 181 emerging adults with type 1 diabetes who were part of a larger study. Path analysis was used to test associations among worry about hypoglycemia, diabetes management, hypoglycemia-related weight control behaviors (WCB), alcohol use, impulse control, depressive symptoms, and glycemic control.
Path model fit and modification indices suggested that a feedback loop between worry about hypoglycemia and diabetes management should be incorporated into the original model. Youth with fewer depressive symptoms reported fewer hypoglycemia-related WCB and less worry about hypoglycemia; those with higher impulse control had less alcohol use and better diabetes management; those with lower alcohol use had more worry about hypoglycemia; and better glycemic control was associated with better diabetes management.
Health care professionals need to understand how multiple factors related to worry about hypoglycemia and diabetes management interact in emerging adults. In the context of depressive symptoms, impulse control, alcohol use, and hypoglycemia-related WCB, the path model results suggest several potential avenues for intervening to improve glycemic control in emerging adults.
The purpose of this study was to examine the motivational, attitudinal, and behavioral predictors of interest in genetic testing (GT) in those with and without awareness of their risk for type 2 diabetes (T2DM).
A convenience sample of adults visiting emergency departments, libraries, or an online research registry was surveyed. Responses from adults without diabetes who reported 1 or more risk factors for T2DM (eg, family history, body mass index > 25) were included in the analyses (n = 265).
Participants were 37 ± 11 years old, white (54%), and female (69%), with some college education (53%) and an annual income below $25 000 (44%). Approximately half (52%) expressed interest in GT for T2DM. Individuals were stratified by perceived risk for T2DM (risk aware or risk unaware). Among the risk aware, younger age (P < .04) predicted greater interest in GT. Among the risk unaware, family history of T2DM (P < .008) and preference to know genetic risk (P < .0002) predicted interest in GT. Both groups identified the need for low-cost GT.
GT is an increasingly available and accurate tool to predict T2DM risk for patients. In this sample, GT was a salient tool for those with and without awareness of their T2DM risk. Financial accessibility is critical to use of this tool for both groups.
The National Member Practice Survey (NPS) of the American Association of Diabetes Educators (AADE) is conducted biannually to describe the current diabetes education practice in the United States and identify trends, opportunities, and areas for improvement.
The 2012 NPS contained 49 questions about diabetes education providers, patients, and programs. The survey, sent electronically to approximately 13 000 AADE members, was completed by 3644 members. Testing was completed using a significance level of .05 or 95% confidence.
While nurses and dietitians continued to comprise the majority of diabetes educators in 2012, a significant increase from 2010 occurred in the respondents identified as pharmacists (5% vs 4%). Individuals holding the certified diabetes educator (CDE) credential decreased slightly in 2012 from 2010. Practice settings for diabetes education increased significantly in 2012 versus 2010 for hospital outpatient/clinic (44% vs 37%) and hospital inpatient (20% vs 15%) settings. Prediabetes education was provided by 78% of respondents. Nearly 53% of educators indicated they devoted more than 4 hours per week to data entry, significantly higher than any other amount of time. Collection of clinical and behavioral outcomes increased significantly in 2012 from 2010.
Results of the 2012 NPS provide evidence that the practice of diabetes education is continuing to adapt to evolving models of health care in the United States by expanding the mix of practitioners providing education, engaging in necessary system support activities, and broadening the range of patients seen to include individuals at risk of developing diabetes.
The purpose of this qualitative study was to explore nutritional behaviors and attitudes among Latino women with type 2 diabetes.
Women over 18 years old and previously diagnosed with type 2 diabetes were recruited to participate in semi-structured qualitative interviews in their homes in Los Angeles, California, and Las Vegas, Nevada. Recruitment was conducted through flyers posted in local businesses. Interviews were conducted in Spanish or English. Data were transcribed and analyzed using an iterative process that involves reading interview transcripts and designating themes that arise from the data.
Acquisition of nutritional knowledge and behavioral capability were positively associated with observational learning, formal nutritional education, and culturally competent meal planners. The use of traditional remedies and the consultation of naturistas reveal a tendency toward medical pluralism. In the home environment, husbands had the greatest influence on Latina women’s attitudes and perceived choices.
The social environment, including support and reinforcement, is critical for Latinas’ nutritional success. Observational learning is critical for Latinas’ behavioral capability.
The purpose of this project was to determine how prevalent control solution calibration is in patients who perform self-monitoring of blood glucose (SMBG).
Eighteen patients with or parents of children with type 1 diabetes mellitus were surveyed to gauge patients’ knowledge of control testing and the prevalence of its use. US census data of educational attainment of residents in the surveyed region were used. The availability of control solution (CS) in all pharmacies in 8 cities in mid San Mateo County, California, was evaluated as well. User manuals from 6 leading blood glucose monitor (BGM) manufacturers were retrieved for their indications for using CS.
It was found that although 82% of respondents claimed to know what CS is, 58% claimed to never use this product. In the analyzed geographic region, the educational attainment was above the educational level for the entire San Francisco Bay Area and the United States. CS in our region was stocked by only 15% of pharmacies that sold BGM equipment, even though 6 major BGM manufacturers in the aggregate listed 10 indications for its use.
It was concluded that BGM users are frequently not using CS to calibrate their monitors. The low availability of CS at pharmacies might contribute to the low demand for this product. It can be concluded that patients who perform SMBG need education from diabetes educators about proper CS calibration. Without the use of CS, BGMs are not being used according to manufacturer’s specifications. This misuse could lead to erroneous results and erode the potential benefits of SMBG.
The purpose of the study was to determine the effects of gender on participation in a community-based, culturally tailored diabetes lifestyle intervention, led by trained community health workers (CHW) and conducted with African Americans and Latinos with type 2 diabetes.
This study utilized data collected from 180 participants. Multivariable binary and cumulative logistic regression models were used to analyze associations between gender and race/ethnicity with study completion and participation in 3 aspects of the intervention: group classes, CHW home visits, and CHW-accompanied doctor visits.
Among Latinos, men were less likely than women to complete the study, attend group classes, and complete CHW home visits. There were no gender differences in participation seen among African Americans.
Diabetes management interventions may need to adapt their designs to optimize retention and participation of Latino men. Among African American men, the CHW model may be promising. Reasons for low participation among Latino men should receive more study. Future studies should assess whether similar findings apply in other communities and populations.
The purpose of this study is to examine the relationship between negative emotions and bio-behavioral risk factors among Korean immigrants at risk for type 2 diabetes (T2DM).
Data were collected from 148 Korean immigrant adults who are "at risk" for T2DM as defined by having family history of T2DM in first-degree relatives, body mass index greater than 23, or history of gestational diabetes in women. Participants completed questionnaires and underwent biological measures. Negative emotions included feeling nervous, hopeless, restless, anxious, and stressed as well as depressive symptoms.
High percentages of participants had T2DM risk factors including overweight, greater than normal waist to hip ratio, and blood glucose readings that are indicative of T2DM. Feeling stressed was the most commonly reported negative emotion (66%), followed by feeling anxious (51%), restless (38%), nervous (30%), and hopeless (13%). Experience of negative emotions was significantly related to behavioral risk factors; higher levels of experiencing negative emotions were related to increased soda intake and a decreased likelihood of doing at least 10 minutes of moderate exercise. Stress and anxiety were each negatively related to moderate exercise, and depressive symptoms were negatively related to both moderate and vigorous exercise. No significant relationship was found between negative emotions and biological risk factors.
Findings suggest that negative emotions, individually and taken together, may be related to T2DM risk behaviors in high-risk Korean immigrants. Behavioral interventions to prevent T2DM in this population should consider assessing and addressing negative emotions.
The purpose of the study was to determine the feasibility and efficacy of a generic chronic disease self-management program for people with type 2 diabetes.
English-speaking adults with type 2 diabetes who were part of a larger US national translation study of the Stanford Chronic Disease Self-Management Program (CDSMP) were invited to be part of the current study. In addition to completing self-report questionnaires, participants submitted blood samples at baseline, 6 months, and 12 months. Of the 114 participants, half had A1C values between 6% and 6.9% and half had values of 7.0% or more.
Adults with diabetes successfully participated in CDSMP workshops in a community health setting. Participants demonstrated statistically significant improvements in health indicators and behaviors but no reductions in health care utilization. Participants with A1C of 7% and above had A1C reductions at 6 months, with smaller reductions at 12 months. Those with baseline A1C less than 7% had no changes in A1C at 6 or 12 months.
The results suggest that the CDSMP is a useful and appropriate program for lowering A1C among those with A1C above 7% and for improving health status for people with diabetes, regardless of their A1C.
The purpose of this comparative effectiveness study is to compare diabetes self-management support (DSMS) approaches and determine who can be most effective in helping patients maintain/improve clinical outcomes, self-care behaviors, distress, and satisfaction following diabetes self-management education (DSME) delivered in primary care.
After receiving DSME, 141 participants were randomized to receive DSMS delivered by a trained supporter: educator, peer, practice staff, or usual education during a 6-month follow-up period. DSMS groups were compared to determine which supporter helped participants to maintain/improve A1C, blood pressure, lipids, weight, self-care, and distress. DSMS satisfaction was also examined.
There was a significant improvement in A1C, empowerment, aspects of self-care, and distress following DSME at 6 weeks. Those in the educator DSMS group best sustained improved A1C while those in the other DSMS groups maintained glycemic improvements but began to show trends toward worsening. No significant differences or clear trends were seen in other clinical, behavioral, or psychosocial outcomes. The Program Reinforcement Impacts Self-Management (PRISM) study demonstrates that following DSME, participants maintained improved glycemia, lipid, weight, and self-care behaviors and reductions in distress throughout the delivery of DSMS interventions regardless of DSMS supporter. All of the participants reported satisfaction with DSMS.
These findings reaffirm the critical role of educators but suggest that others may serve as DSMS supporters. Results suggest that DSME delivered in primary care is effective and multiple DSMS agents are reasonable. As patient-centered self-management approaches are being explored in primary care, delivery of DSME and DSMS becomes paramount.
The purpose of this study was to explore the level of physical activity, barriers to physical activity, and strategies used to meet physical activity goals in people with type 2 diabetes (T2DM).
A descriptive, cross-sectional design was used in a sample of 75 adults with T2DM enrolled in a worksite diabetes disease management program (WDDMP). Participants self-reported the length of time they engaged in moderate-intensity physical activity, the frequency of general and specific physical activity, and barriers to participating in physical activity.
Participants who chose to work on physical activity as part of their diabetes self-management had a higher stage of change for physical activity and participated in more general and specific physical activity than did those participants who did not choose to work on physical activity. Participants who were active reported fewer barriers to physical activity and chose to work on more self-care areas to control their diabetes than did those participants who were inactive.
Participants who chose to work on physical activity participated in more general and specific physical activity and had a higher stage of change for physical activity. Stage of change affects physical activity. While results provide support for the stages of change construct of the transtheoretical model of change, the results do not support that the WDDMP assisted participants in achieving their physical activity goals.
The purpose of this study is to identify factors related to achieving a LDL <100 mg/dL.
Data from a recent randomized control trial of nurse case management versus usual care conducted at the Minneapolis Veterans Affairs Health Care System were analyzed. The trial consisted of 556 veterans with diabetes mellitus (DM) and at least 1 of the following: blood pressure (BP) >140/90 mmHg, and/or glycated hemoglobin (A1C) >9.0%, and/or LDL >100 mg/dL. The current analysis is focused on 275 patients in either treatment group who, at baseline, had LDL >100 mg/dL. Baseline characteristics and variables obtained during the trial of the 95 patients who reached goal LDL were compared to the 180 who did not.
Patients who reached goal LDL had higher rates of preexisting coronary artery disease (CAD), cerebrovascular accident (CVA), congestive heart failure (CHF), and HMG-coenzyme A reductase inhibitor (statin) use. After adjustment for baseline LDL, preexisting CAD, CVA, and CHF increased the odds of patients achieving a goal LDL <100 mg/dL. This is possibly secondary to the increased prevalence of these conditions in patients with DM. These patients also likely had multiple other providers involved in their care promoting attainment of lower LDL. Baseline statin usage was not related to achieving a LDL<100 mg/dL, however, patients declining to take a statin at any time during the trial had decreased odds of reaching goal LDL. Patients with preexisting neuropathy were also less likely to reach goal LDL.
Preexisting CAD, CVA, or CHF all increased the odds of patients achieving a goal LDL <100 mg/dL while declining statin therapy and preexisting neuropathy reduced the odds.