The Science of Diabetes Self-Management and Care

Depression affects millions of people worldwide and is prevalent among those with diabetes. The purpose of this review was to synthesize recent research on depression and adherence to dietary and physical activity recommendations in persons with type 2 diabetes (T2DM).

This systematic review is a subanalysis of an NIH-funded model-testing meta-analysis. Thirteen electronic databases were searched using terms: depression, adherence, T2DM, diabetes. Selected studies: were reported in English between 2000 and 2012, focused on adults with T2DM, and measured depression and dietary and/or physical activity adherence.

Twenty-seven studies involving 7266 participants were selected; participants were 54% female and 62 years of age, on average. When reported, depression prevalence in study samples ranged from 4.5% to 74%. Six intervention studies targeted diabetes treatment, with or without depression treatment; no studies focused solely on treating depression. Twenty-one descriptive studies examined relationships between depression and diet/physical activity adherence, finding a negative association. Only 2 of the 6 intervention studies examined this relationship; findings were inconsistent.

Depression was associated with lower adherence to diabetes self-care, as evidenced primarily by descriptive studies; results of intervention studies were conflicting. Future research should focus on the effects of treating depression on diabetes health outcomes.

The purpose of this study is to examine perceived experiences of racial discrimination (perceived discrimination) in health care and its associations with completing standards of care for diabetes management and diabetes control.

This cross-sectional study included 200 adult American Indian (AI) women with type 2 diabetes from 4 health care facilities located on tribal reservations in the Pacific Northwest. Participants completed a survey, and medical records were abstracted. Logistic regression was completed to assess associations.

Sixty-seven percent of AI women reported discrimination during their lifetime of health care. After adjusting for patient characteristics, perceived discrimination was significantly associated with lower rates of dental exam; checks for blood pressure, creatinine, and total cholesterol; and pneumococcal vaccination. The association between perceived discrimination and total number of diabetes services completed was not statistically significant. Perceived discrimination was associated with having A1C values above target levels for diabetes control in unadjusted and adjusted models, but no association was observed for blood pressure or total cholesterol.

In our sample of AI women with diabetes, two-thirds reported experiencing racial discrimination in their health care experience. Those reporting perceived discrimination completed fewer diabetes services and therefore may be at increased risk for comorbidities of diabetes. This finding supports the continued need for culturally responsive health care and programs of diabetes education to recognize perceived discrimination and its potential to impact success in self-management and services utilization.

The purpose of this study was to examine trends in the receipt of 8 recommended diabetes clinical and self-care indicators from 2001 to 2010 and assess racial/ethnic disparities in care.

This observational study examined receipt of A1C tests, annual eye and foot exams, flu vaccination, diabetes self-management education (DSME), exercise, self-monitoring of blood glucose (SMBG), and self feet examinations among US adults with diabetes using national survey data from 2001 to 2010. Analyses included estimating proportions for each indicator by year, testing differences in magnitude of change from 2001 to 2010 by race/ethnicity, and regression models to assess changes in care over time and factors associated with care.

There were significant increases from 2001 to 2010 in A1C tests, annual foot exams, flu shots, DSME, and SMBG but declines in eye and self feet exams. DSME was positively associated with receipt of several care indicators. However, only half of respondents received DSME. White and black non-Hispanics, respectively, experienced improvements in at least 3 indicators. Hispanics experienced a significant increase in exercise but were consistently less likely than whites to receive or engage in most care.

While improvements in several indicators were observed, patterns varied by race/ethnicity, with Hispanics falling short on most measures. DSME was strongly associated with most care and demonstrates the potential to improve receipt of recommended care by increasing DSME participation. With the Affordable Care Act (ACA), health professionals have a prime opportunity to leverage ACA provisions to increase access to recommended services, including DSME.

The purpose of this study is to examine differences in diabetes self-care activities by race/ethnicity and insulin use.

Data were from the 2011 Behavioral Risk Factor Surveillance System for adults with diabetes. Outcomes included 5 diabetes self-care activities (blood glucose monitoring, foot checks, nonsmoking, physical activity, healthy eating) and 3 levels of diabetes self-care (high, moderate, low). Logistic regression models stratified by insulin use were used to estimate the odds of each self-care activity by race/ethnicity.

Only 20% of adults had high levels of diabetes self-care, while 64% had moderate and 16% had low self-care. Racial/ethnic differences were apparent for every self-care activity among non–insulin users but only for glucose monitoring and foot checks among insulin users. Overall, American Indian / Alaska Natives had higher odds of glucose monitoring; blacks had higher odds of foot checks; and Hispanics had higher odds of not smoking compared with non-Hispanic Whites. Non-insulin-using American Indian / Alaska Natives had higher odds of foot checks, and non-insulin-using Hispanics had higher odds of fruit/vegetable consumption.

Participation in specific diabetes self-care behaviors differs by race/ethnicity and by insulin use. Yet, few adults with diabetes of any race/ethnicity engage in high levels of self-care. Findings suggest that culturally tailored messages about diabetes self-care may be needed, in addition to more effective population promotion of healthy lifestyles and risk reduction behaviors to improve diabetes control and overall health. Diabetes educators can be a catalyst for adopting a population approach to diabetes management, which requires addressing both prevention and management of diabetes for all patients.

The purpose of this study was to explore gender differences in lay knowledge of type 2 diabetes symptoms among community-dwelling Caucasian, Latino, Filipino, and Korean Americans.

A cross-sectional survey was administered to a convenience sample of 904 adults (172 Caucasians, 248 Latinos, 234 Koreans, and 250 Filipinos) without diabetes at community events, community clinics, churches, and online in the San Francisco Bay Area and San Diego from August to December 2013. Participants were asked to describe in their own words signs and/or symptoms of diabetes. A multiple logistic regression analysis was performed to examine the association of lay symptom knowledge with gender after controlling for potential confounding factors.

Overall, the average age of the sample populations was 44 (SD ±16.1) years, 36% were male, and 58% were married. Increased thirst/dry mouth following increased urinary frequency/color/odor and increased fatigue/lethargy/low energy were the most frequently reported signs and symptoms (19.8%, 15.4%, and 13.6%, respectively). After controlling for known confounding factors, women were 1.6 (95% confidence interval, 1.2-2.3, P = .004) times more likely than men to report at least 1 diabetes symptom. However, this gender difference in knowledge of diabetes signs and symptoms did not significantly differ across Caucasians, Latinos, Filipinos, and Korean Americans (P = .87).

The findings underscore the importance of improving public knowledge and awareness of signs and symptoms of diabetes, particularly in men.

The purpose of this study is to evaluate the impact of a school-based health program in which family medicine residents trained healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes.

A mixed methods study included 97 adolescents from 3 San Francisco Bay Area high schools serving primarily ethnic minority youth of low socioeconomic status. Physicians came to schools once a week for 8 weeks and trained 49 adolescents to become coaches. Student coaches and 48 nonparticipant students completed pre- and posttest intervention questionnaires, and 15 student coaches and 9 family members with diabetes gave in-depth interviews after participation. Linear regression was used to determine differences in knowledge and psychosocial assets on pre- and posttests between student coaches and nonparticipant students, and NVIVO was used to analyze interview transcripts.

After controlling for initial score, sex, grade, and ethnicity, student coaches improved from pre- to posttest significantly compared to nonparticipants on knowledge, belonging, and worth scales. Student coaches reported high satisfaction with the program. Articulated program benefits included improvement in diet, increased physical activity, and improved relationship between student coach and family member.

Overall, this program can increase diabetes knowledge and psychosocial assets of at-risk youth, and it holds promise to promote positive health behaviors among at-risk youth and their families.

The purpose of this study was to examine diabetes-related behavioral and psychosocial outcomes as well as patient satisfaction with the Telemedicine for Reach, Education, Access, and Treatment (TREAT) model.

TREAT employs telemedicine services provided by an endocrinologist at an urban area in partnership with a diabetes educator in a rural area, working together with patients and primary care providers (PCPs). Thirty-five patients with type 2 diabetes were referred by PCPs and received glycemic management and education in the TREAT model. A diabetes educator operated the videoconferencing equipment, remained with the patient to receive and review plan communicated by the endocrinologist during the visit, coordinated services, administered surveys, and provided self-management education and support. Empowerment, self-care, diabetes distress, adherence to monitoring, and patient satisfaction were assessed by survey at baseline and follow-up.

There was significant improvement in empowerment, self-care (adherence to diet and monitoring), and reduction in diabetes distress. Patients reported high levels of satisfaction.

In rural areas, the TREAT model delivers improvements in behavioral and psychosocial outcomes and high patient satisfaction. The TREAT model may be a viable option for rural communities that suffer from a shortage of team-based diabetes specialist and self-management support services.

The purpose of this study was to investigate the behavioral effects of a theory-driven, mobile phone–based intervention that combines automated text messaging and remote nursing, using an automated, interactive text messaging system.

This was a mixed methods observational cohort study. Study participants were members of the University of Chicago Health Plan (UCHP) who largely reside in a working-class, urban African American community. Surveys were conducted at baseline, 3 months (mid-intervention), and 6 months (postintervention) to test the hypothesis that the intervention would be associated with improvements in self-efficacy, social support, health beliefs, and self-care. In addition, in-depth individual interviews were conducted with 14 participants and then analyzed using the constant comparative method to identify new behavioral constructs affected by the intervention.

The intervention was associated with improvements in 5 of 6 domains of self-care (medication taking, glucose monitoring, foot care, exercise, and healthy eating) and improvements in 1 or more measures of self-efficacy, social support, and health beliefs (perceived control). Qualitatively, participants reported that knowledge, attitudes, and ownership were also affected by the program. Together these findings were used to construct a new behavioral model.

This study’s findings challenge the prevailing assumption that mobile phones largely affect behavior change through reminders and support the idea that behaviorally driven mobile health interventions can address multiple behavioral pathways associated with sustained behavior change.