The Science of Diabetes Self-Management and Care

Purpose To translate the Diabetes Prevention Program (DPP) lifestyle intervention into a clinical setting and evaluate its effectiveness.

Methods The authors implemented a group-based version of the DPP lifestyle curriculum in a large academic medicine practice. It is delivered by a nurse educator over 12 weekly sessions with optional reenrollment, available on a self-pay basis, and implemented using existing clinical resources (eg, electronic medical record referrals, scheduling, conference rooms, communication technology). The program was evaluated using a controlled before-after design, including all patients referred between April 1, 2005, and February 1, 2007. Patients with a body mass index (BMI) ≥25 kg/m2 were eligible if their primary care providers felt the program was medically appropriate and safe. Change in weight (kg) and frequency of achieving ≥7% weight loss were examined.

Results Referred patients were primarily female (84%), with an average age of 49.91 years (SE, 1.46) and average BMI of 39.65 kg/m2 (SE, 0.73). Among eligible patients, 93% of enrollees and 80% of nonenrollees had follow-up weights recorded within the evaluation window. Over 1 year, mean weight change was —5.19 kg (95% confidence interval [CI], —7.71 to —2.68) among enrollees and +0.21 kg (CI, —1.0 to 1.93) among nonenrollees (P < .001). A ≥7% loss was found for 27% of enrollees and 6% of nonenrollees ( P = .001).

Conclusions An evidence-based lifestyle intervention can be effectively translated into the clinical setting. Use of existing resources may facilitate patient flow and minimize cost. This provider-integrated preventive care approach may provide a model for incorporating knowledge from behavioral science into clinical care.

Purpose The purpose of this study was to evaluate the feasibility of translating the Diabetes Prevention Program (DPP) lifestyle intervention into practice in the general community.

Methods In 2008, the Montana Diabetes Control Program, working collaboratively with 4 health care facilities, implemented an adapted group-based DPP lifestyle intervention. Adults at high risk for diabetes and cardiovascular disease were recruited and enrolled (n = 355). Eighty-three percent (n = 295) of participants completed the 16-session program. Participants set targets to reduce fat intake and increase physical activity (≥150 minutes per week) to achieve a weight loss goal of 7%.

Results Seventy percent of participants achieved the physical activity goal of ≥150 minutes per week. There was a significant decrease among participants' weight from baseline (mean ± SD, 99.3 ± 19.7 kg) to week 16 (92.6 ± 18.8 kg; mean difference, 6.7 ± 4.0 kg, P < .001). Forty-five percent of the participants achieved the 7% weight loss goal, and 67% achieved at least 5% weight loss. Participants who were 60 years of age and older, had a diagnosis of hypertension, met their physical activity goal of ≥150 minutes per week, and those more frequently monitoring their fat intake were more likely to meet the 7% weight loss goal compared with participants without these characteristics.

Conclusion The findings suggest that it is feasible to recruit and retain high-risk participants and achieve weight loss and physical goals in a group setting that are comparable with those achieved in the DPP.

Purpose The purpose of this article is to describe efforts to develop and administer a formal curriculum to train community workers to deliver a group-based adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention in YMCA settings. The DPP demonstrated that a structured diet and physical activity intervention that achieves and maintains modest weight loss for overweight adults with impaired glucose tolerance can significantly reduce the development of diabetes. Although tens of millions of American adults could benefit from access to the DPP lifestyle intervention, there currently is no available model for nationwide dissemination of this highly beneficial and cost-effective approach to diabetes prevention. A description of 2 ongoing randomized pilot studies provides information about the feasibility and effectiveness of future efforts to apply this new training curriculum on a national scale.

Conclusions Diabetes educators are challenged to partner with community organizations and other health care workers for extensive distribution of the DPP lifestyle intervention messages.

Purpose Diabetes self-management education is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care.

Methods To address this potential barrier to successful diabetes teaching and counseling, the authors developed the Diabetes Literacy and Numeracy Education Toolkit (DLNET).

Conclusion The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and used by all members of the multidisciplinary diabetes care team. The material's content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. Although designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Purpose To examine factors related to access to diabetes self-management education (DSME), including services delivered and sought; patient, physician, and program barriers to access; educator outreach and expansion efforts; and perceptions of alternative DSME delivery strategies.

Methods Internet surveys were completed by 1169 adults with diabetes (661 with prior DSME, 508 with no prior DSME) from a national community survey panel, 1871 educators who were AADE members, and 629 physicians (212 diabetes specialists, 417 primary care practitioners) from a national physician survey panel.

Results Physicians want patients to receive more self-management support, but some report that patients are told to do things with which the physician does not agree. Provider (physician and educator)—delivered DSME is more highly regarded among those who have received it than among those who have not received it. Physicians generally have positive perceptions of provider-delivered DSME, and educators see physicians as key to encouraging DSME use in patients. Some physicians are concerned about losing patients sent to DSME, and 11% of patients report changing physicians as a result of DSME. Most DSME programs have grown recently as a result of recruiting efforts and adding new programs/services; most programs plan more such efforts. Patients prefer traditional DSME sources/settings and are moderately accepting of media sources.

Conclusions Additional efforts are required to guarantee that all people with diabetes receive the DSME they need. This will require increased referral by physicians, increased follow-through by patients, and increased availability of DSME in forms that make it appealing to patients and physicians.

Purpose The purpose of this study is to explore mothers' perspectives about reproductive health (RH) discussions with their adolescent daughters with diabetes.

Methods This study of mothers used a sequential explanatory mixed-method design with 2 phases. Phase 2, the focus of this report, was a qualitative descriptive study using open-ended semistructured telephone interviews. Ten mothers from a larger study sample were selected by purposeful sampling. Qualitative content analysis techniques were used to analyze the interview transcripts.

Results The following 4 themes describing mothers' perspectives about RH discussions with their adolescent daughters with diabetes were identified: (1) maternal awareness, (2) maternal knowledge, (3) triggers for initiating RH discussions, and (4) maternal fears/concerns. Several mothers were aware of their daughters' sexual activity and were aware that their daughters should preplan a pregnancy. They knew that an unplanned pregnancy may have detrimental effects on their daughters' health and feared that their daughters would have an unplanned pregnancy. A major trigger for mothers to initiate RH discussions was when a daughter had a steady boyfriend. Mothers' fears and concerns were focused around their daughters' having an unplanned pregnancy. Overall, mothers reported they were not comfortable with RH conversations.

Conclusions Mothers fear unplanned pregnancies for their daughters with diabetes and want to discuss RH issues with them but are uncomfortable doing so. Diabetes educators could be instrumental in educating and providing communication skills to mothers to help foster RH communication with their adolescent daughters with diabetes.

Purpose The purpose of this pilot study was to determine the feasibility of offering the authors' Diabetes Coaching Program (DCP), adapted for African Americans, in a sample of African American adults with type 2 diabetes.

Methods The study used a 1-group, pretest-posttest design to test the acceptance and potential effectiveness of the DCP. Subjects were a convenience sample of 16 African Americans (8 women, 8 men) with type 2 diabetes; 12 subjects (6 women, 6 men) completed the program. The DCP included 4 weekly class sessions devoted to resilience education and diabetes self-management, followed by 8 biweekly support group meetings. Psychosocial process variables (resilience, coping strategies, diabetes empowerment) and proximal (perceived stress, depressive symptoms, diabetes self-management) and distal outcomes (body mass index [BMI], fasting blood glucose, HbA1C, lipidemia, blood pressure) were assessed at baseline and at 6 months after study entry. Qualitative data were collected at 8 months via a focus group conducted to examine the acceptability of the DCP.

Results Preliminary paired t tests indicated statistically significant improvements in diabetes empowerment, diabetes self-management, BMI, HbA1c, total cholesterol, low-density lipoprotein cholesterol, and systolic and diastolic blood pressure. Medium to large effect sizes were reported. Resilience, perceived stress, fasting blood glucose, and high-density lipoprotein cholesterol improved, but changes were not statistically significant. Focus group data confirmed that participants held positive opinions regarding the DCP and follow-up support group sessions, although they suggested an increase in program length from 4 to 8 weeks.

Conclusions The pilot study documented the feasibility and potential effectiveness of the DCP to enhance diabetes empowerment, diabetes self-management, and reductions in the progression of obesity, type 2 diabetes, and cardiovascular disease in the African American community. Randomized experimental designs are needed to confirm these findings.

Purpose The purpose of this qualitative descriptive study was to explore the sociocultural influences and social context associated with living with type 2 diabetes among migrant Latino adults.

Methods A qualitative descriptive study using grounded theory techniques was conducted. In-depth semistructured interviews were completed with 10 participants (6 female and 4 male) ranging in age from 46 to 65 years and with a duration of diabetes diagnosis ranging from 1.5 to 40 years.

Results An overarching meta-theme of self-management in a social environment emerged. Every aspect of the process of self-management, as described in the 4 major themes—(1) family cohesion, (2) social stigma of disease, (3) social expectations/perception of “illness,” and (4) disease knowledge and understanding—was influenced by the social context.

Conclusions The familist traditions, central to the Mexican culture, had both positive and negative consequences on diabetes management. Tailoring clinical care and developing novel education approaches, to include family and community, is central to improving the health of this population. Recognizing and acknowledging the social stigma associated with diabetes, for this population, will promote understanding and improve clinician-patient communication. The sociocultural influences that affect diabetes management practices (eg, include family, in particular the primary female caregiver, and establish community- and home-based education sessions) must be integrated into clinical practice. Future research focused on population-defined health and disease self-management, novel educational interventions, and family and community interventions focusing on the concept of social stigma of disease is indicated to further affect the health disparities of this population.

Purpose The purpose of this secondary analysis was to describe and compare physiological, psychosocial, and self-management characteristics of urban black and rural white women with type 2 diabetes (T2D) in the northeast United States.

Methods A descriptive, cross-sectional secondary analysis was conducted with baseline data from 2 independent study samples: rural white women and urban black women.

Results Results revealed the sample were on average educated, working, low-income, mid-life women with poor glycemic and blood pressure control, despite having a usual source of primary care. When compared, black women were younger, had lower income levels, worked more, and were often single and/or divorced. They had worse glycemic control, significantly higher levels of diabetes-related emotional distress, and less support than white women.

Conclusion Despite differences in geography and study findings, both groups had suboptimal physiological and psychosocial levels that impede self-management. These findings serve to aid in the understanding of health disparities, emphasizing the importance of developing and evaluating effective interventions of diabetes care for women with T2D.

The purpose of this article is to demonstrate the complexity of the type 1 diabetes regimen and to highlight the essential role of the diabetes educator in safely training and implementing the myriad skills in a developmentally appropriate manner for children and adolescents. A review of literature and a task analysis were preformed and suggest that the complexity of the regimen is often not adequately addressed. Reviewed research assessed the regimen using measures with on average about 25 items while the task analysis contains over 600 tasks. The article discusses implications for clinical practice, including implications for measurement in research, targeting of interventions by diabetes educators, and the gradual transfer of regimen control to youth. It is argued that given the magnitude of the self-management task, education cannot be accomplished in the limited time that general practice physicians, pediatricians, or endocrinology specialists can spend with each patient. It is concluded that youth must be helped to internalize the importance of the regimen tasks and that transfer of these tasks to youth requires a developmentally sensitive approach to education. Diabetes educators serve an essential role in which they help young patients and their parents manage and master this overwhelming experience through promoting youth's involvement in tasks when full responsibility is not yet appropriate. The regimen is too complex for youth to undertake self-management without multidisciplinary support.

Purpose The purpose of this review is to summarize community interventions based on the National Institutes of Health (NIH) Diabetes Prevention Program (DPP) curriculum and to describe differences in curriculum and its effect on outcome measurements.

Methods A keyword search of PubMed and review of citation lists of relevant articles yielded 161 articles. Primary outcomes of interest were achievement of the DPP study goals: 5% to 7% loss of body weight and increased moderate physical activity to at least 150 minutes per week. A secondary outcome of improvement in metabolic syndrome components was also included. Inclusion criteria included application of a DPP-based curriculum to a community setting and publication in English.

Results Seven articles were included in the review. Interventions were conducted across a variety of settings. All showed a significant amount of weight loss immediately following a DPP-based curriculum, varying in length from 6 to 24 weeks. Three held significance by 12 months. Two articles reported on physical activity improvements. Two articles reported improvement in metabolic syndrome components.

Conclusion Although the most effective intervention for type 2 diabetes prevention may not yet be identified, DPP-based interventions show promise for long-term sustainability. The DPP intervention is effective in treating overweight and obesity across a variety of settings and thus may prevent chronic diseases in which overweight and obesity are risk factors. Public health practitioners can use this successful intervention to help individuals lead healthier lives.