The Science of Diabetes Self-Management and Care

Purpose The purpose of this article is to introduce diabetes educators to the emerging concept of universal design (UD): the design of products, environments, and services to be used by persons with a wide range of abilities, without needing adaptation or specialized design.

Method Drawing from the use of the term universal design in a variety of types of writing, this article covers the definition of UD, the contrast of average-person design with UD, principles of UD, and implications for diabetes self-management education (DSME).

Summary Implications for DSME are (1) diabetes consumer medical devices (such as blood glucose meters and insulin pumps) can be designed using UD principles, with a goal of successful use by the largest number of persons possible, and (2) diabetes educators can use UD principles in the design of diabetes education programs to reach the largest number of learners possible without the need for special accommodations.

Conclusions Adoption of UD principles by designers of diabetes medical devices could benefit persons with disabilities, increase the potential market for the manufacturer, and have unexpected benefits for people of average abilities. Adoption of UD principles for DSME programs would not require a paradigm change because diabetes educators already do many activities that could contribute to UD of an education program. By replacing average-person design of DSME programs with UD, diabetes educators can promote full participation in DSME for individuals with the wide range of abilities normally present in target populations without the need for added adaptations or specialized design.

The purpose of this article is to provide treatment algorithms proven to be effective in meeting the standards of care of the American Diabetes Association to nurses and pharmacists who are given the authority to make independent clinical decisions (under the overall supervision of a physician).

Purpose The purpose of this article was to review the published literature and evaluate the economic benefits and costs associated with diabetes education.

Methods The Medline database (1991-2006) and Google were searched. Articles that addressed the economic and/or financial outcomes of a diabetes-related self-care or educational intervention were included. The study aim, population, design, intervention, financial and economic outcomes, results, and conclusions were extracted from eligible articles.

Results Twenty-six papers were identified that addressed diabetes self-management training and education. Study designs included meta-analysis (1); randomized controlled trials (8); prospective, quasi-experimental, and pre-post studies (8); and retrospective database analyses (9). The studies conducted cost analyses (6), cost-effectiveness analyses (13), cost-utilization analyses (7), and number needed to treat analyses (2). More than half (18) of the 26 papers identified by the literature review reported findings that associated diabetes education (and disease management) with decreased cost, cost saving, cost-effectiveness, or positive return on investment. Four studies reported neutral results, 1 study found that costs increased, and 3 studies did not fit into these categories.

Conclusions The findings indicate that the benefits associated with education on self-management and lifestyle modification for people with diabetes are positive and outweigh the costs associated with the intervention. More research is needed to validate that diabetes education provided by diabetes educators is cost-effective.

Purpose The purpose of this study is to review the literature on usual dietary intake in children with type 1 diabetes (T1D) and to discuss approaches to promote dietary change with potential efficacy.

Methods Search strategies included a MEDLINE search for English-language articles that estimated usual dietary intake in children with T1D and a screening of the reference lists from original studies. The keywords used were diet, dietary intake, nutrition, type 1 diabetes, children, adolescents, and youth. Studies were included if they were observational, contained a sample of children with T1D, and estimated usual dietary intake.

Results Nine studies fulfilled the criteria (6 US, 3 European). Of the 4 studies with a control group, 3 reported that both total fat and saturated fat intake were higher in the children with T1D. Six studies examined the percent of total calories from saturated fat; mean intake ranged from 11 to 15%, exceeding ADA recommendations (< 7%). Fruit, vegetable, and fiber intakes were low among children with T1D. No prior studies have addressed dietary change in this population. The behavior-change literature suggests that nutrition education alone is unlikely to be adequate, but that incorporation of behavioral approaches offers potential efficacy in promoting healthful dietary change.

Conclusions Children with T1D are not meeting dietary guidelines, and in some areas their diets are less healthful than children without diabetes. As these dietary behaviors may affect the risk of long-term complications, the incorporation of behavioral approaches promoting healthy eating into routine clinical practice is warranted.

Purpose The purpose of this article is to present the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TOD2AY) study and a description of the implementation of the standard diabetes education (SDE) program.

Methods A total of 218 participants (one third of the eventual sample of 750) were initially enrolled in the study. To date, the mean age of participants was 14.3 + 2.1 years, with 63% being female. Families of study participants were largely low or middle income (more than half report family income <$35000) and about three-quarters were minority.

Results More than three-quarters (79%) of families achieved full mastery of the entire SDE program. Mastery required on average 5.5 + 1.3 sessions. In addition, 62% of the families were able to achieve mastery of the session topic in a single visit.

Conclusions In summary, the TOD2AY study SDE program fills the need for effective, engaging materials for youth and their families to use in mastering essential type 2 diabetes skills and knowledge.

Purpose The purpose of this study was to describe diabetes self-management practices and service utilization among Gullah families in South Carolina.

Methods Data were obtained from 1276 persons with type 2 diabetes through interviews using the Family Health History Questionnaire. This was a primary analysis of a project conducted in conjunction with a parent study (Project SuGar) which focused on the molecular aspects of diabetes. Descriptive statistics were used for data analysis.

Results Diabetes self-management behaviors were not consistent with recommendations from the American Diabetes Association. Over half (55.6%) reported exercising, but only 27.7% reported self-glucose monitoring. Service utilization was poor, less than half, (41.1%) reported referral to a diabetic class/diet, 32.8% reported making yearly visits to the ophthalmologist, 22.3% reported visiting the dentist, and only 12.8% reported visiting the podiatrist.

Conclusions Although some self-management behaviors were identified, Gullah family members remain at risk for preventable diabetes complications. Education must reflect behaviors and beliefs valued by Gullah individuals. Culturally appropriate educational programs may increase use of health care services aimed at decreasing preventable complications of type 2 diabetes in the Gullah population.

Purpose The purpose of this article is to describe the process of educating families and children with type 1 diabetes on real time continuous glucose monitoring (RT-CGM) and to note the similarities and differences of training patients using continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDI).

Methods A total of 30 CSII participants and 27 MDI participants were educated using the Navigator RT-CGM in a clinical trial. Time spent with families for visits and calls was tracked and compared between patient groups. The Diabetes Research in Children Network (DirecNet) educators were surveyed to assess the most crucial, time intensive, and difficult educational concepts related to CGM.

Results Of the 27 MDI families, an average of 9.6 hours was spent on protocol-prescribed visits and calls (not measured in CSII) and 2 hours on participant-initiated contacts over 3 months. MDI families required an average of 5.4 more phone contacts over 3 months than CSII families. According to the DirecNet educators, lag time and calibrations were the most crucial teaching concepts for successful RT-CGM use. The most time was spent on teaching technical aspects, troubleshooting, and insulin dosing. The most unanticipated difficulties were skin problems including irritation and the sensor not adhering well.

Conclusion Educators who teach RT-CGM should emphasize lag time and calibration techniques, technical device training, and sensor insertion. Follow-up focus should include insulin dosing adjustments and skin issues. The time and effort required to introduce RT-CGM provided an opportunity for the diabetes educators to reemphasize good diabetes care practices and promote self-awareness and autonomy to patients and families.

Background The clinical benefits of any new treatment depend substantially on patient acceptance and treatment satisfaction, because only well-accepted treatments will be widely used. Thus, it is important to understand how patients experience a new treatment.

Objective This study assessed the psychometric properties of a questionnaire (PRAM-TSQ) designed to measure treatment satisfaction in patients using pramlintide (an analog of amylin, a glucoregulatory hormone co-secreted with insulin), which is designed to improve glucose control.

Methods Patients with diabetes completed the 14-item PRAM-TSQ at the end of 2 separate placebo-controlled, double-blind, randomized clinical trials in which they added active or placebo pramlintide to their established insulin regimen. Factor analysis was used to assess item clustering for the PRAM-TSQ, and the Cronbach's α measure of inter-item agreement was used to assess scale reliability. PRAM-TSQ validity was assessed by comparing scores between treatment arms, and effect sizes were measured by the η statistic. Validity was also assessed by associations (Pearson correlations) between the PRAM-TSQ and clinical study outcomes (end of study values and during study changes in clinical measures: postprandial glucose [PPG], A1C, weight, and insulin requirements).

Results Scaling revealed 4 PRAM-TSQ components: Global Benefits, Specific Benefits, Absence of Side Effects, Treatment Preference. The total composite PRAM-TSQ had good reliability in both studies (type 1 α = .93; type 2 α = .94); subscale reliabilities ranged from .65 to 94. Composite scores differed for pramlintide-treated and placebo-treated patients (type 1 P < .01; type 2 P < .05), and were associated with lower PPG, weight, and insulin requirements (all P < .05). Results were similar for PRAM-TSQ subscales assessing Global Benefits and Treatment Preference; Specific Benefits subscale scores were associated with lower PPG and weight (all P < .05).

Conclusions The PRAM-TSQ shows evidence of being a valid, reliable instrument for assessing treatment satisfaction in patients using pramlintide. The subscales are comprehensive and sensitive to the known potential effects of pramlintide treatment. Diabetes educators can use patient responses to the PRAM-TSQ to facilitate treatment adherence by reminding patients of treatment benefits they experience and by helping patients overcome negative effects they report.

Purpose Telemedicine technology may offer an avenue to implement diabetes self-management education (DSME) for people with diabetes in underserved rural communities. The continuous quality improvement process was used to identify the problem, collect and analyze data, and develop and implement a DSME program via telemedicine (DSME-T) in an underserved rural community.

Methods A pilot study was conducted in 2006, implementing a DSME-T utilizing facilities at the University of Arkansas for Medical Sciences and a rural community hospital in Arkansas (Ozark Health, Inc). A total of 38 people were enrolled to receive DSME-T. Participant knowledge, self-efficacy, and self-care practices were assessed before participants began the education program and after they had completed it. Also, select clinical measures (glycosylated hemoglobin, lipid profile, and urine microalbumin) were collected.

Results A total of 66% of participants (n = 25) completed the DSME-T program. A significantly greater proportion of participants demonstrated improved knowledge (39% vs 83%; P = .012), endorsed greater self-efficacy (54% vs 86%; P = .016), and reported more frequent self-care practices to manage their diabetes at the conclusion of the study period.

Conclusions The results of this pilot study suggest that DSME-T may offer opportunities for DSME among rural residents with diabetes. Plans are in place to explore the possibility of sustaining and expanding the program to other underserved rural communities.