Know diabetes by heart: Education about the linkage between cardiovascular disease and diabetes

Abstract

Objective:

The objective of this study was to investigate how a 1-hour education session that highlights American Heart Association/American Diabetes Association’s Know Diabetes by Heart (KDBH) messaging changed the knowledge and behavioural intention of participants.

Design:

Single group, quasi-experimental study evaluating the impact of the KDBH education intervention on participants’ knowledge and intentions to engage in risk-lowering behaviours related to the link between diabetes and cardiovascular disease.

Setting:

A free, 1-hour, synchronously delivered education session was offered through an online platform and facilitated by Cooperative Extension agents.

Methods:

A pre- and post-Qualtrics survey was used to assess changes in knowledge and intended behaviours. Slides were provided by the American Diabetes Association and tailored for clarification and evaluation purposes.

Results:

The study included 259 adults with an average age of 54 years (standard deviation [SD] = 16.67) and 72.97% being 46 years or older. When participants were asked if having type 2 diabetes put them at risk for development of hypertension, unhealthy cholesterol levels, heart attack, or stroke, 84.84% answered correctly at baseline. After session completion, the percentage correct increased to 92.2% (p = .002). Individual’s knowledge of cardiovascular disease as the leading cause of death for people with type 2 diabetes was assessed; 66.80% answered correctly pre-intervention. After completing the KDBH programme, 95.37% answered correctly (p = .001). In addition, more than half of those with type 2 diabetes reported intended to adopt several behaviours related to reducing the risk of cardiovascular disease at the completion of the programme.

Conclusions:

The pilot study indicates successful information transfer in a 1-hour education session focused on chronic disease risks associated with T2DM. Results support the use of synchronous online platforms for diabetes and heart disease information transfer. Future prospective studies measuring sustained knowledge, behaviour adoption and incidence of heart-disease before and after education are needed.

Keywords

Cardiovascular disease diabetes health behaviour health education knowledge

Background

Over the past four decades, rates of diabetes have steadily increased in United States of America (USA). In 2020, the US Centres for Disease Control and Prevention (CDC, 2020) reported that approximately 34.2 million US residents had been diagnosed with diabetes, with more than 90%–95% of those having type 2 diabetes (T2DM). Alarmingly, diabetes is linked to a 75% increase in adult mortality (Das et al., 2020), with cardiovascular disease (CVD) being the leading cause (CDC, 2020). For the vast majority of people, the link between diabetes and heart disease is the result of type 2 diabetes mellitus (T2DM), the most common form of the disease (Goodarzi and Rotter, 2020). Compared to those without the disease, people with T2DM are 2–4 times more likely to experience early death due to heart attack or stroke and other diabetes-related complications, such as cardiovascular autonomic neuropathy, heart failure, peripheral vascular disease and diabetic retinopathy (Dal Canto et al., 2019; Halter et al., 2014).

Individuals with diabetes must make several daily self-management decisions and carry out difficult health care tasks to manage their condition (Powers et al., 2016). Perreault et al. (2019) suggested that patients with T2DM tend to have a poor understanding of their risk of heart disease, heart attack and stroke (Perreault et al., 2019). A meta-analysis of Diabetes Self-Management and Education group programmes, however, shows that diabetes education can serve as an important preventive measure for diabetes control and that the benefit of sharing experiences in group education can motivate participants to increase self-care and cooperation with their therapeutic team (Mikhael et al., 2020).

To address the lack of understanding about the link between T2DM and CVD, the American Heart Association and the American Diabetes Association joined forces to create the Know Diabetes by Heart (KDBH) initiative (American Heart Association, 2022). This initiative aims to educate and support people with type 2 diabetes through information transfer and online patient resources (American Diabetes Association, 2015). The American Heart Association and American Diabetes Association sponsored the implementation of the initiative in South Carolina. Information from KDBH was disseminated through the Clemson University Cooperative Extension Service, the community service arm of all land grant universities,¹ in partnership with several certified diabetes care and education specialists at Prisma Upstate (Cavicchioli et al., 2016).

Extension Rural Health and Nutrition agents live and work in local communities to transfer university-generated scientific information to the public. The COVID-19 pandemic restricted the delivery of in-person extension programmes for more than a year in South Carolina. Extension agents realised a need for new and innovative ways to meet the organisation’s mission to provide scientifically based education to the public. A 1-hour KDBH education session was provided to the general public and a pre- to postsession test was used to measure changes in knowledge about the link between diabetes and CVD. Clemson University Cooperative Extension’s Rural Health and Nutrition Agents implemented the KDBH pilot study with the following objectives in mind: (1) increase participants’ knowledge of the link between diabetes and CVD, (2) measure intention to engage in behaviours that support reducing the risks related to diabetes and CVD and (3) increase participants’ awareness of resources available to support diabetes and CVD self-management.

Methods

Study design

This single group quasi-experimental study evaluated the impact of the KDBH education session on participants’ diabetes and CVD knowledge and intension to engage in future behaviours such as talking to a health provider about ways to decrease risk of CVD and following a healthy diet. The study was approved by the Institutional Review Board of the Office of Research Compliance at Clemson University. The intervention took the form of a free, 1-hour, synchronously delivered education session online. The programme was offered multiple days per week at different times during the day to address potential scheduling barriers for participants. A pretest and post-test were used to measure changes in knowledge and intent to engage in behaviours. The pre-test/post-test used for this study was adapted with permission from a general evaluation tool provided by the American Diabetes Association.

Recruitment and subjects

Study participants were recruited through advertisements on social media, Facebook, Eventbrite and through newsletters. Electronic and paper flyers advertising the programme were given to community partners and practitioners for distribution to community members and patients. Practitioners were also provided with KDBH prescription pads for easy referral to the programme. Participants self-selected by signing up for more information about the online session. Phone calls were made to people who expressed an interest in participation through Facebook and Eventbrite and were subsequently enrolled in upcoming education sessions. The primary target audience was individuals with type 2 diabetes; however, the programme was made available to all individuals over the age of 18, regardless of diabetes diagnosis.

Programme delivery

Extension Rural Health and Nutrition Agents from the Clemson University Cooperative Extension Service delivered the 1-hour KDBH session as a synchronous online session. There were 22 different Extension Agents and 9 student interns involved in the delivery of the KDBH session. Every effort was made to have two people at each session; one who worked on the technical aspect of data collection and the other to facilitate the presentation of the educational slides.

At the start of the session, participants were provided with an image of a QR code. Participants were directed to scan the QR code, which resulted in the pretest opening on their smart mobile device. If no mobile device was available during the online sessions, participants were given a link to access the pre-test at the beginning of the session and the post-test at the conclusion of the session.

The pretest was delivered through Qualtrics, and participants were given 5–10 minutes to complete the pretest before the agent moved on to the education portion of the session. A technical assistant was at each of the KDBH sessions, monitoring the completion of the pretest through Qualtrics. The technical assistant informed the Extension agent when most participants had completed the pre-test. Extension agents then facilitated the session using a PowerPoint presentation provided by the American Diabetes Association.

Session slides were provided by the American Diabetes Association with permission to add slides as needed for concept clarification and evaluation purposes. Slides addressed relevant information about diabetes, CVD, and the link between the two. They included information on recommended behaviours, such as talking with your healthcare provider, maintaining a healthy weight and other actions to reduce the risk of CVD. After the educational slides, participants were asked to scan a QR code or click on a link to access the Qualtrics post-test and given 5–10 minutes to complete the post-test. Extension Agents concluded the sessions with a discussion about resources that are available locally, through complimentary Extension programming, and from the American Diabetes Association website.

Intervention measures

The evaluation measures for the educational intervention were participant knowledge related to the linkage between cardiovascular and diabetes disease and intention to engage in CVD risk-lowering behaviours. Knowledge questions such as ‘Having type 2 diabetes increases the risk for developing which of the following conditions’, and ‘What is the leading cause of death for people with type 2 diabetes’ were included in the pretest and posttest.

Answers to these questions were presented as multiple choice and participants were asked to select the correct answer based on their knowledge of the diseases before and after the educational slides were presented. One behaviour-related question ( ‘have you had a conversation with your healthcare provider about the link between type 2 diabetes and cardiovascular disease?’) was included on the pretest. The behaviour questions on the posttest were asked only to those who reported a diagnosis of T2DM and were presented in the following way: ‘As a result of this presentation, how likely are you to engage in the following behaviours over the next 3 months? Please use a scale of 1–5 with 1 = not at all likely and 5 = very likely’. A list of the eight behaviours presented was provided to participants.

All 259 participants were referred to resources at the completion of the session. Appropriate links were provided for resource access and for Eventbrite registrations to complementary programmes. Due to KDBH being offered through multiple states and agencies, we were unable to track the analytics describing the extent to which participants accessed the online resources.

Data analysis

Categorical outcomes were reported as counts and percentages. Demographics were reported as means and standard deviations. Paired t-tests were conducted to assess differences in knowledge from pre- to post-KDBH participation. Statistical significance was set at p < .05. All analyses were conducted using SAS software, Version 9.4 of the SAS System for Windows (SAS Institute, Cary, NC).

Results

The study included 259 adults, with 100 adults reporting having type 2 diabetes (40.65%) and 146 reporting not having type 2 diabetes (59.35%). The average age of participants was 54 ± 16.67 years, and 72.97% of participants were 46 years old or older. A majority (83.40%) were female with over half (63.32%) identifying as White (Table 1).

Table 1.

Sociodemographic characteristics (N = 259).

Variables	N (%)
Sex
Female	216 (83.40)
Male	43 (16.60)
Age
Average (mean [SD])	53.95 (16.67)
⩽45 years old	70 (27.03)
46–65 years old	109 (42.08)
⩾66 years old	80 (30.89)
Race
White	164 (63.32)
Black/African American	75 (28.96)
Other/Prefer not to answer	20 (7.72)
Do you have type 2 diabetes? (n = 246)
Yes	100 (40.65)
No	146 (59.35)
Had conversation with their healthcare provider about the link between type 2 diabetes and cardiovascular disease
Yes	132 (50.97)
No	117 (45.17)
Not sure	10 (3.86)

All participants were given a short pre and posttest to evaluate the KDBH session’s impact on knowledge. During the pretest, individuals were asked if having type 2 diabetes increased the risk of developing other conditions such as high blood pressure, unhealthy cholesterol levels, heart attack and stroke. While 84.84% of the participants selected the correct answer on the pretest, 92.28% selected the correct answer on the posttest. The change in knowledge for this item on the knowledge test was statistically significant (p = .002). The biggest changes occurred in participants answering ‘hypertension’ only or in those answering, ‘don’t know’. In contrast, there were 0 participants answering ‘don’t know’ on the post-test and only 4 (down from 14) participants answering hypertension on the post-test. Similarly, individuals’ knowledge regarding the leading cause of death in individuals with diabetes was assessed. Prior to programme participation, 66.80% of participants answered the question correctly. After session completion, 95.37% of individuals correctly answered correctly showing a significant increase of 28.57% (p < .001) in knowledge from baseline (Table 2).

Table 2.

Knowledge score (pre/post) intervention comparisons (N = 259).

Knowledge Questions	Pre-intervention score, n (%)	Post-intervention score, n (%)	p-value
Having type 2 diabetes increases the risk for developing which of the following conditions?			.002
High blood pressure	14 (5.41)	4 (1.54)
Unhealthy cholesterol levels	2 (0.77)	1 (0.39)
Heart attack	14 (5.41)	13 (5.02)
Stroke	3 (1.16)	2 (0.77)
All the above	220 (84.94)	239 (92.28)
Don’t know	6 (2.32)	—
What is the leading cause of death for people with type 2 diabetes?			<.001
Alzheimer’s Disease	2 (0.77)	—
Cancer	3 (1.16)	—
Cardiovascular disease	173 (66.80)	247 (95.37)
Kidney disease	41 (15.83)	6 (2.32)
Type 2 diabetes	16 (6.18)	6 (2.32)
Don’t Know	24 (9.27)	—

To determine whether the target audience of those with T2DM was impacted by the education session, the change in each knowledge question between those who reported having type 2 diabetes and those without type 2 diabetes was assessed. For the first knowledge question, asking about if type 2 diabetes increases the risk for the various development of conditions, the change from pre- to post-intervention for those with T2DM was significant (p-value = .007). In contrast, those without T2DM did not have a significant change (p-value = .181). Both groups did have significant changes in their knowledge of the leading cause of death for people with T2DM (p-value < .001).

All 259 participants completed the pre-test and post-test knowledge questions. In addition, participants who reported having type 2 diabetes were directed to answer additional questions about their likelihood of engaging in certain diabetes self-management behaviours after participation in the programme (N = 100). Responses were reported using a 5-point Likert-type Scale from ‘not at all likely’ (1) to ‘very likely’ (5). Some questions were not completed by all of those with type 2 diabetes. Table 3 details the number of participants who answered each behavioural question. Of those reporting, 81.00% of participants stated they were ‘very likely’ to talk to their healthcare provider about ways to reduce their heart disease and stroke risk. Over half of the participants (56.12%) stated they were ‘very likely’ to follow a heart-healthy diet, and 68.69% reported being ‘very likely’ to try to achieve or maintain a healthy weight. For additional questions about engaging in regular activity, stopping or reducing tobacco use, and monitoring blood glucose, blood pressure, cholesterol and weight, 54.08%, 87.23% and 74.49% of participants reported being ‘very likely’ to engage in the behaviours after the programme, respectively. Almost all individuals (90.62%) reported being moderately to ‘very likely’ to take steps to manage their stress. Finally, 82.65% out of the 98 responding individuals reported being ‘very likely’ to take their medications (Table 3).

Table 3.

Scores on the behavioural questions reported by participants with Type 2 diabetes (N = 100).

Behaviour–As a result of this presentation, how likely are you engage in the following behaviours over the next 3 months? Please use a scale of 1–5 with 1 = not at all likely and 5 = very likely. N (%)
Behavioural Question	1 = not at all likely	2	3	4	5 = very likely
Talk to your health care provider about ways to reduce your risk for heart disease and stroke (n = 100)		1 (1.00)	7 (7.00)	11 (11.00)	81 (81.00)
Follow a heart-healthy diet (n = 98)			6 (6.12)	37 (37.76)	55 (56.12)
Actively try to achieve or maintain a healthy weight (n = 99)			10 (10.10)	21 (21.21)	68 (68.69)
Increase or continue to do regular physical activity (n = 98)		1 (1.02)	13 (13.27)	31 (31.63)	53 (54.08)
Stop or reduce tobacco use, if applicable (n = 47)	5 (10.64)		1 (2.13)		41 (87.23)
Take steps to manage stress (n = 96)	1 (1.04)		8 (8.33)	26 (27.08)	61 (63.54)
Monitor and keep track of your blood glucose, blood pressure, cholesterol and weight (n = 98)	1 (1.02)		4 (4.08)	20 (20.41)	73 (74.49)
Take your medications as prescribed (n = 98)			2 (2.04)	15 (15.31)	81 (82.65)

Our study findings indicate that for each of the behaviours listed on the post-test, more than 85% of the participants with type 2 diabetes said they were ‘moderately’ or ‘very likely’ to engage in those behaviours. The behaviours in which participants were most likely to engage included taking medications as prescribed (97.96%), monitoring blood glucose or blood pressure (94.9%), following a heart healthy diet (93.88%), talking to their healthcare provider about heart disease (92%) and taking steps to manage stress (90.62%). Additional behaviours participants rated as ‘very likely’ to engage in were actively maintaining a healthy weight (89.9%) followed by stopping or reducing tobacco use (%) and increasing or continuing to do regular physical exercise (85.44%).

Discussion

A cross-sectional study design was chosen as a simple means of testing the plausibility of using an online, 1 hour education session to increase participant awareness and improve knowledge at one point in time. The pilot study assessed the potential for this education strategy to (1) increase knowledge related to the link between diabetes and CVD and (2) influence intention for behaviour engagement after participating in the KDBH education session. Health education programmes tailored to address knowledge gaps about heart disease have the potential to lead to changes in areas such as nutrition, physical activity and smoking, all of which are risk factors for heart disease (Bergman et al., 2011).

While significant increases in knowledge were identified, increased knowledge does not necessarily result in altered behaviour (Serdula et al., 2004). While behaviours were not measured directly in this study, intention to engage in the listed behaviours demonstrates participants’ recognition that these behaviours are beneficial to decreasing the risk of heart disease and may reflect patient motivation for implementing or sustaining beneficial self-care behaviours.

The low number of participants answering correctly on the pre-test for knowledge in the current study supports claims from previous research and highlights the gap in knowledge about the link between T2DM and heart disease in the general public and those with T2DM (Mohammad et al., 2021;Mosca et al., 2000; Niknian et al., 1989). Mohammad et al. (2021) suggested the need for initiatives that educate and support the prevention of CVD in patients with T2DM. It has been widely demonstrated through meta-analysis and research reviews that information transfer through sustained educational initiatives about diabetes can be effective at improving markers of diabetes and heart disease, including improvements in HbA1 C, lipid profiles, knowledge and self-care behaviours (Boegner et al., 2008; De Silva Chaves et al., 2021; Loveman et al., 2008; Mikhael et al., 2020; Rashed et al., 2016; Świątoniowska et al., 2019). Świątoniowska et al. (2019) specifically emphasised the importance of diabetes education as a strategy for increasing patient awareness of the cardiovascular risk factors associated with T2DM, adding commentary about the benefits of group education. The authors suggested that group education can provide significant social support and be a valuable method for increasing patient motivation for self-care behaviours (Świątoniowska et al., 2019). The current study supports these claims, finding that participation in a group diabetes education session effectively increased participant knowledge and potential motivation for self-care behaviours. The change in knowledge from pre- to post-participation and the high levels of intent to engage in self-care behaviours suggest that the 1-hour KDBH education session delivered through an online, synchronous platform successfully resulted in information transfer, thus addressing the knowledge gap of the link between T2DM and CVD and for motivating participants in self-care behaviours beyond the programme participation. The results of the pilot study support the need for the incorporation of the KDBH information into the existing, prospective study of the Health Extension for Diabetes programme and can inform future development of the ADA Standards of Care in Diabetes. Moreover, the results can drive provider policy for increasing in-office education related to T2DM and CVD and external referral to community-based education programmes.

Finally, Hanson et al. (2022) identified patient preferences in delivery methods for diabetes education session. They found that preferences for diabetes education were almost equally divided between those preferring in-person education and those preferring virtual education opportunities. While not measured directly, successful enrollment into the current educational session and effective information transfer for those participating suggest a level of acceptance of online education delivery methods in this population. As a result, this study adds an element to the body of literature related to information transfer through synchronous, online platforms and supports this delivery method for future diabetes education initiatives.

Limitations

While benefits exist with cross-sectional studies including lower costs and fewer resources required, limitations are inherent to this study design. The current study design did not have stratification or randomisation, a control group, or a large sample size. Because of this, the findings cannot be generalised more broadly. In addition, the use of a pre- and post-test posed additional challenges. The testing, in itself, may direct participants to essential material required only to achieve a better score, thus creating bias. The design was chosen because the KDBH study required rapid implementation during the COVID-19 pandemic, thereby limiting resources, delivery options and the ability to recruit and educate participants using more traditional methods. The results would be stronger had the study been designed and administered as a prospective study with a randomised participant sample.

In addition, limitations exist concerning the demographics of our sample. The KDBH education sessions reported in this study targeted individuals with T2DM but allowed for all adults over the age of 18 to participate. It is possible that some participants may have knowingly or unknowingly reported ‘no’ or ‘don’t know’ to the questions on the pretest. Also, individuals with type 1 diabetes were excluded from the behaviour questions assessed with the posttest. However, individuals with type 1 diabetes are still at risk for CVD and need to engage in each of the self-management behaviours assessed. There was also a lack of diversity in the sample, specifically with respect to gender and race. Our sample comprised only 16.6% men and 28.96% of participants were Black. This is a limitation because in the USA men are almost twice as likely to develop T2DM than women and Black men are 60% more likely to be diagnosed with T2DM than white men (CDC, 2020). This limitation in demographic diversity limits the generalisability of the findings. In general, larger and more representative numbers of black and male participants with T2DM would have allowed for greater generalisability from the study.

Because behaviour was not measured directly on the pre-test or measured through longitudinal follow-up we cannot definitively conclude that knowledge about T2DM and CVD or participation in the 1-hour session resulted in the engagement of associated behaviours. It is possible that the high levels of intent to engage in behaviours identified on the post-test were due to self-selection in the education session. Those who chose to enrol in the session were probably already somewhat or highly motivated to learn more about diabetes and behaviours related to decreasing the risk of CVD. Motivation could also be related to participant age. Almost 31% of the participants were over the age of 65 in the pilot study. Świątoniowska et al. (2018) found that individuals with diabetes have a moderate level of adherence to recommended behaviours from health professionals and that compliance with behavioural recommendations increased with age. Results from the current study would be strengthened by measuring baseline behaviour before participation using validated tools. Follow-up surveys to determine which behaviours were initiated, ended or sustained after participation in the education session would allow us to attribute behaviour change more directly to the session itself.

Conclusions

While results of cross-sectional studies should be interpreted with caution, this pilot study indicates successful information transfer in a 1-hour education session focused on the chronic disease risks associated with T2DM. Results support the use of synchronous online platforms for diabetes and heart disease information transfer. Participant intention to engage in diabetes and CVD-related self-care behaviours was high for those participating in a self-registered online session, but future work should include a prospective study that can measure sustained knowledge, behaviour adoption and the incidence of heart disease-related morbidity and mortality before and after education.

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: this research was supported through the Know Diabetes by Heart community grant funded by the American Diabetes Association.

ORCID iDs

Michelle Parisi

Danielle McFall

Notes

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