Ethnic and gender differences in psychosocial factors, glycemic control, and quality of life among adult type 2 diabetic patients

Contributors to depressive symptoms among Korean immigrants with type 2 diabetes

BACKGROUND

Patients with diabetes have a higher prevalence of depression than the general population. Korean immigrants with type 2 diabetes are understudied.

OBJECTIVES

The aim of this study was to identify the prevalence and correlates of depressive symptoms in Korean immigrants.

METHODS

In this cross-sectional descriptive study, a community sample of 164 Korean immigrant adults with type 2 diabetes were assessed for depressive symptoms using the Center for Epidemiological Studies Depression scale. Predictors of depression were grouped into three categories: demographic (age, gender, education, English proficiency), clinical (duration of diabetes, comorbidities, insulin use), and psychosocial (general health, diabetes-related quality of life [QOL], family support).

RESULTS

Approximately 56% of participants had Center for Epidemiological Studies Depression Scale scores of ≥16. Higher levels of depression were associated with greater impact of diabetes on QOL (b = 5.68, p = .001), worse overall health (b = -0.09, p = .012), and less family support (b = -4.02, p = .042). The relationship between depression and diabetes impact on QOL was stronger for men than women (b = 6.67, p = .020).

DISCUSSION

Depressive symptoms are common among Korean immigrants with type 2 diabetes. Assessing diabetes-related QOL, general health, and family support may be of value in better understanding depressive symptoms among this population. Among Korean immigrant men with type 2 diabetes, specific attention should be paid to diabetes-related QOL.

Spiritual and religious beliefs and practices and social support's relationship to diabetes self-care activities in African Americans

PURPOSE

The purpose of this study is to investigate the relationship among spiritual and religious beliefs and practices, social support, and diabetes self-care activities in African Americans with type 2 diabetes, hypothesizing that there would be a positive association.

METHOD

This cohort study used a cross-sectional design that focused on baseline data from a larger randomized control trial. Diabetes self-care activities (summary of diabetes self-care activities) and sociodemographic characteristics were assessed, in addition to spiritual and religious beliefs and practices and social support based on the systems of belief inventory subscales I (beliefs and practices) and II (social support).

RESULTS

There were 132 participants: most were women, middle-aged, obese, single, high school educated, and not employed. Based on Pearson correlation matrices, there were significant relationships between spiritual and religious beliefs and practices and general diet. Additional significant relationships were found for social support with general diet, specific diet, and foot care. Based on multiple linear regression, social support was a significant predictor for general diet, specific diet, and foot care. Sex was a significant predictor for specific diet, and income was a significant predictor for blood glucose testing.

CONCLUSIONS

The findings of this study highlight the importance of spiritual and religious beliefs and practices and social support in diabetes self-care activities. Future research should focus on determining how providers integrate patients' beliefs and practices and social support into clinical practice and include those in behavior change interventions.

Medication adherence in patients with type 2 diabetes mellitus treated at primary health clinics in Malaysia

PURPOSE

Diabetes mellitus is a growing global health problem that affects patients of all ages. Even though diabetes mellitus is recognized as a major chronic illness, adherence to antidiabetic medicines has often been found to be unsatisfactory. This study was conducted to assess adherence to medications and to identify factors that are associated with nonadherence in type 2 diabetes mellitus (T2DM) patients at Primary Health Clinics of the Ministry of Health in Malaysia.

MATERIALS AND METHODS

The cross-sectional survey was carried out among T2DM patients to assess adherence to medication in primary health clinics. Adherence was measured by using the Medication Compliance Questionnaire that consists of a total of seven questions. Other data, such as patient demographics, treatment, outcome, and comorbidities were also collected from patient medical records.

RESULTS

A total of 557 patients were recruited in the study. Approximately 53% of patients in the study population were nonadherent. Logistic regression analysis was performed to predict the factors associated with nonadherence. Variables associated with nonadherence were age, odds ratio 0.967 (95% confidence interval [CI]: 0.948-0.986); medication knowledge, odds ratio 0.965 (95% CI: 0.946-0.984); and comorbidities, odds ratio 1.781 (95% CI: 1.064-2.981).

CONCLUSION

Adherence to medication in T2DM patients in the primary health clinics was found to be poor. This is a cause of concern, because nonadherence could lead to a worsening of disease. Improving medication knowledge by paying particular attention to different age groups and patients with comorbidities could help improve adherence.

Mental health and relational self-management experiences of patients with type 2 diabetes and stage 3 chronic kidney disease

Self-management (SM) behaviors reduce disease burden from advancing diabetic kidney disease. From a parent study about patients' transition experience to SM, this study report presents coping resources that support SM and barriers from two focus group interviews (n = 6). Ethnographic analysis identified two patterns: (a) mental health self-management characterized by coping, and (b) relational self-management characterized by social support. Practice implications include focused assessment of perceived social support and social network, dating advisement, and workplace management. Future study considerations include inquiry about diabetes and dating relationships and workplace resources for SM support.

Special considerations of care and risk management for African American patients with type 2 diabetes mellitus

It is well documented that African American populations are disproportionately affected by type 2 diabetes mellitus compared with their white counterparts. They have a higher prevalence of diabetes, a higher rate of diabetes-related complications, greater disability from these complications, and poorer control and quality of care. In order to improve diabetes care and outcomes in African Americans (and indeed all patients with diabetes), a multifactorial approach is needed to target all risk factors-not solely hyperglycemia-simultaneously. Culturally appropriate initiatives to improve lifestyle behaviors are a first step in management. Community-based programs, including those mediated through church groups, have reported varying degrees of success in effecting such beneficial lifestyle changes. If these measures fail to achieve desirable levels of blood glucose, blood pressure, and serum lipids, pharmacologic therapy is indicated. However, few evidence-based recommendations regarding the use of some drugs in African Americans currently exist due to their underrepresentation in randomized controlled clinical trials. Other essential components of diabetes care include regular screening for diabetic nephropathy and neuropathy, and eye and foot examinations, with prompt referral to specialists when important clinical changes are detected.

Relationships among self-efficacy, social support, social problem solving, and self-management in a rural sample living with type 2 diabetes mellitus

Self-management behaviors are important for control of type 2 diabetes mellitus. Therefore, determining factors that promote effective self-management behaviors may be significant for improving the well-being of patients with type 2 diabetes mellitus. This study examined relationships among self-efficacy, social support, social problem solving, and diabetes self-management behaviors. Further, this study evaluated whether social support and social problem solving were mediators of the relationship between self-efficacy and diabetes self-management behaviors in those living with type 2 diabetes mellitus. Using a cross-sectional, descriptive correlational design, data from a convenience sample of 152 rural people living with type 2 diabetes mellitus were examined. Findings indicated that self-efficacy was a strong predictor of diabetes self-management. The effect of social support on diabetes self-management differed among men and women in the sample. Social support and social problem solving were significantly associated with diabetes self-management in men. Neither social support nor social problem solving were mediators of the relationship between self-efficacy and diabetes self-management in this sample. These findings suggest that nurses need to consider implementing interventions to improve patients' self-efficacy and potentially influence diabetes self-management.

Sex differences in the impact of diabetes on the risk of geriatric conditions

AIM

To examine whether sex differences exist in the relationship between diabetes and geriatric conditions.

METHODS

This was a cross-sectional analysis of 2629 community-dwelling older adults, drawn from the 2003 wave of the "Survey of Health and Living Status of the Elderly in Taiwan." Selected geriatric conditions included cognitive impairment, depression, falls and urinary incontinence (UI). Diabetes and comorbid conditions (heart disease, hypertension, chronic lung disease, stroke, hip fracture, arthritis, chronic kidney disease and cancer) were assessed using questionnaires.

RESULTS

A greater proportion of older women, compared with men, had cognitive impairment (15.8% vs 7.3%), depression (22.6% vs 10.4%), falls (26.7% vs 16.3%), and UI (20.9% vs 15.1%). After adjustment for basic demographics and comorbid conditions, diabetes was associated with increased risk for cognitive impairment (RR 1.85 [CI 1.12-3.05], P=0.017), depression (RR 2.03 [CI 1.39-2.97], P=0.0003) and falls (RR 1.72 [CI 1.2-2.48], P=0.003), but not UI (RR 1.4 [CI 0.9-2.1], P=0.067) among older women. However, we did not find any associations in men.

CONCLUSIONS

Diabetes was associated with excessive risk for geriatric conditions among older women, but not men. The effect of sex differences on the relationship between diabetes and geriatric conditions requires further exploration.

A systematic review of patient-reported and economic outcomes: value to stakeholders in the decision-making process in patients with type 2 diabetes mellitus

BACKGROUND

The need for an approach to measuring health results that incorporates patients' and payers' perspectives has generated a wide range of health care outcomes (HCOs), but it is yet unknown whether these HCOs are appropriate or valid for the health care decision-making process.

OBJECTIVE

The goal of this study was to assess HCOs, patient-reported outcomes (PROs), and economic outcomes in terms of validity and appropriateness to health care decision making in type 2 diabetes mellitus (T2DM).

METHODS

This systematic review of studies published between January 1, 1996, and November 1, 2010, comprised an electronic literature search of MEDLINE and Centre for Reviews and Dissemination databases. Studies included were clinical trials, observational studies, economic analyses, and studies on the development and validation of HCOs in T2DM in the adult population. HCOs were assessed and classified according to their relevance for decision makers in terms of feasibility for routine use, validity, sensitivity, reliability, understanding, and scope.

RESULTS

Two independent reviewers screened 4497 citations. Of these, 281 potentially eligible full articles were retrieved, and 185 met the inclusion criteria. A total of 121 HCOs in T2DM were identified: 80 (66.1%) PROs and 41 (33.9%) economic outcomes. Only 44.6% of the outcomes assessed were appropriate and valid for health care decision making. Greater deficiencies in evidence were found for PROs (61.3%), followed by economic outcomes (43.9%).

CONCLUSIONS

A large number of HCOs are being used in the health care decision-making process, but a significant proportion of these new outcomes have not been properly validated. Despite the fact that appropriate measures will depend on the specific needs of the decision makers, researchers need to use HCOs for which evidence of quality and appropriateness is available.

Type 2 diabetes affects hippocampus volume differentially in men and women

BACKGROUND

Type 2 diabetes mellitus (T2DM) has been shown to result in medical complications on several organ systems including the kidneys, eyes, cardiovascular system, and most recently described the brain, including the hippocampus. There is also evidence that females are disproportionately affected by these medical complications. Brain volume reductions have also been associated with chronic low-grade inflammation and dyslipidaemia. This study investigated the relationships among T2DM, gender, inflammation, dyslipidaemia, and hippocampal volumes.

METHOD

Participant groups consisted of 40 obese adults with T2DM and 47 lean adults, group-matched on age, gender, race, and education. Each participant underwent medical examination including a standard panel of blood tests, a magnetic resonance imaging, and cognitive evaluation.

RESULTS

We show that there is a gender difference in the association of T2DM and hippocampal volumes: diabetic women are most affected despite having better glucose control than their male counterparts. Although females with T2DM had disproportionately lower high density lipoprotein as well as better haemoglobin A1c, neither of these results explained why females with T2DM had the smallest hippocampal volumes.

CONCLUSIONS

These important findings indicate that in addition to the higher rate of traditional medical complication, females with T2DM are likely to suffer more brain complications than males. These observations, if supported by larger studies, suggest that in the future gender could be considered when customizing diabetes treatment.

Glycemic control among Latinos with type 2 diabetes: the role of social-environmental support resources

OBJECTIVE

Although active diabetes self-management is required to achieve glycemic control, adherence is poor among ethnic minorities, especially Latinos. Research shows that individuals who report greater social-environmental support resources for disease management manage their diabetes more effectively than those with fewer support resources.

METHODS

Path analysis was conducted to investigate the value of a multiple-mediator model in explaining how support resources for disease management influence hemoglobin A1c (HbA1c) levels in a sample of 208 Latinos with Type 2 diabetes recruited from low-income serving community clinics in San Diego County. We hypothesized that the relationship between support resources for disease-management and HbA1c would be mediated by diabetes self-management and/or depression.

RESULTS

Participants who perceived greater support resources for disease-management reported better diabetes self-management (β = .40, p < .001) and less depression (β = -.19, p < .01). In turn, better diabetes self-management and less depression were associated with tighter glycemic control (HbA1c; β = -.17, p < .05 and β = .15, p < .05, respectively). Once the indirect effects via diabetes self-management (95% CI [-.25; -.03]) and depression (95% CI [-.14; -.01]) were statistically controlled, the direct pathway from support resources to HbA1c was markedly reduced (p = .57).

CONCLUSIONS

These findings demonstrate the important connection that support resources for disease management can have with diabetes self-management, emotional well-being, and glycemic control among Latinos. Thus, programs targeting diabetes self-management and glycemic control in this population should consider culturally relevant, multilevel influences on health outcomes.

Gender differences in diabetes-related lower extremity amputations

BACKGROUND

Diabetes is a major cause of morbidity and mortality in the United States, with much of the economic and social costs related to macrovascular and microvascular complications, such as myocardial infarctions, renal failure, and lower extremity amputations. While racial/ethnic differences in diabetes are well documented, less attention has been given to differences in diabetes outcomes by gender.

QUESTIONS/PURPOSES

Does gender influence the rate of diabetes-related lower extremity amputations and/or the rate of mortality after amputation?

METHODS

I reviewed the literature utilizing peer-reviewed publications found through MEDLINE searches. WHERE ARE WE NOW?: Major complex gender differences exist in diabetes-related lower extremity amputations: men are more likely to undergo lower extremity amputations, but women apparently have higher mortality related to these procedures. The reasons for such differences are not entirely clear, but it appears biologic factors may play important roles (increased rates of peripheral vascular disease and peripheral neuropathy in men, interaction between gender and cardiac mortality in women). WHERE DO WE NEED TO GO?: More research is warranted to confirm gender differences in diabetes-related lower extremity amputation mortality and explore underlying mechanisms for the gender differences in lower extremity amputations and its associated mortality. HOW DO WE GET THERE?: Exploring gender disparities in diabetes-related outcomes, such as lower extremity amputations, will need to become a national priority from a research (eg, National Institutes of Health) and policy (eg, Centers for Medicare and Medicaid Services) perspective. Only when we have a better understanding of the causes of such differences can we begin to make strides in addressing them.

Sex-specific differences in glycemic control and cardiovascular risk factors in older patients with insulin-treated type 2 diabetes mellitus

BACKGROUND

Because women have been excluded from many study populations in investigations of diabetes care, there is insufficient information on sex-specific differences in glycemic control.

OBJECTIVE

The aim of the present study was to assess whether treatment goals for glycemic and cardiovascular risk factor control are achieved equally in older, Central European, female and male patients with type 2 diabetes mellitus (T2DM).

METHODS

In a retrospective cross-sectional study, data were analyzed from consecutive older (aged ≥60 years) female and male patients with insulin-treated T2DM who attended a diabetes outpatient clinic between January 2007 and April 2008 at the Medical University of Vienna, Austria. Sex-specific differences in glycosylated hemoglobin (HbA₁(c)) levels were assessed as the primary outcome. LDL-C and HDL-C, as well as systolic and diastolic blood pressure (SBP and DBP, respectively), were assessed as secondary outcomes and were adjusted for age, duration of diabetes, duration of insulin treatment, body mass index, insulin units per kilogram per day, and secondary causes of diabetes. P values were adjusted using the Bonferroni correction.

RESULTS

Data were analyzed from 183 female and 209 male patients with insulin-treated T2DM. In multivariate linear regression models, women had significantly higher levels of LDL-C (P = 0.008), HDL-C (P < 0.001), SBP (P < 0.001), and DBP (P = 0.034), but not HbA₁(c) (P = NS). Multivariate logistic regression models revealed that women were significantly less likely to meet treatment goals for blood pressure (SBP, P = 0.044; DBP, P = 0.024), but not for cholesterol or HbA₁(c) levels (P = NS for LDL-C, HDL-C, and HbA₁(c)).

CONCLUSION

In this study of older patients with insulin-treated T2DM, whereas glycemic control was comparable between women and men, a more adverse cardiovascular risk factor profile was observed in female patients.

No observable differences in glycemic response to maltitol in human subjects from 3 ethnically diverse groups

Consumption of a low glycemic index (GI) diet may be helpful in the management and prevention of diabetes and cardiovascular disease. The investigation of GI has been predominantly confined to white subjects. We hypothesized that differences in glycemic response (GR) may be observable in subjects of different ethnic origin. The objective of the present study was to determine GR to a high GI (glucose) and low GI (maltitol) test drink in subjects of different ethnic origin. In a randomized, single-blind crossover trial, 10 whites, 10 South Indians and 10 Chinese subjects consumed either glucose or maltitol test drink containing 50 g of one of the test products on different occasions. Capillary blood glucose samples were taken at 15 and 10 minutes before and 0, 15, 30, 45, 60, 90, 120, 150, and 180 minutes after consumption of the test drink. The incremental area under the curve of glucose and maltitol were not significantly different between the 3 groups. The mean GR for maltitol was 33.5% in whites, 32.9% in Chinese, and 23.1% in South Indians. The results presented here confirmed that there are no observable differences noted in GR to a high-GI or low-GI test drink between the 3 ethnically diverse groups. We conclude that different ethnic groups exhibit similar GR to low- and high-GI drinks, and GR to maltitol is similar irrespective of ethnic background.

Physical activity, obesity, nutritional health and quality of life in low-income Hispanic adults with diabetes

The study examined relationships among age, body mass index (BMI), physical activity, nutritional health, quality of life, and health-related quality of life in Hispanic adults with diabetes (N = 59) using the PRECEDE-PROCEED planning model as a framework. Data were collected through face-to-face interviews at clinics and communities. A regression model with predisposing factors (age, BMI), and behavior (nutritional health and physical activity) significantly predicted quality of life (R(2) = 0.21, F = 3.63, p < .05) explaining 21% of variance. Physical activity and nutrition were the strongest predictors. Culturally competent intervention strategies must include factors that improve and enhance quality of life.

Patient adherence to medication requirements for therapy of type 2 diabetes

Type 2 diabetes is a complex, progressive endocrine and metabolical disease that typically requires substantial lifestyle changes and multiple medications to lower blood glucose, reduce cardiovascular risk and address comorbidities. Despite an extensive range of available and effective treatments, < 50% of patients achieve a glycaemical target of HbA(1c) < 7.0% and about two-thirds die of premature cardiovascular disease. Adherence to prescribed therapies is an important factor in the management of type 2 diabetes that is often overlooked. Inadequate adherence to oral antidiabetes agents, defined as collecting < 80% of prescribed medication, is variously estimated to apply to between 36% and 93% of patients. All studies affirm that a significant proportion of type 2 diabetes patients exhibit poor adherence that will contribute to less than desired control. Identified factors that impede adherence include complex dosing regimens, clinical inertia, safety concerns, socioeconomic issues, ethnicity, patient education and beliefs, social support and polypharmacy. This review explores these factors and potential strategies to improve adherence in patients with type 2 diabetes.

Collaborative care management of major depression among low-income, predominantly Hispanic subjects with diabetes: a randomized controlled trial

OBJECTIVE

To determine whether evidence-based socioculturally adapted collaborative depression care improves receipt of depression care and depression and diabetes outcomes in low-income Hispanic subjects.

RESEARCH DESIGN AND METHODS

This was a randomized controlled trial of 387 diabetic patients (96.5% Hispanic) with clinically significant depression recruited from two public safety-net clinics from August 2005 to July 2007 and followed over 18 months. Intervention (INT group) included problem-solving therapy and/or antidepressant medication based on a stepped-care algorithm; first-line treatment choice; telephone treatment response, adherence, and relapse prevention follow-up over 12 months; plus systems navigation assistance. Enhanced usual care (EUC group) included standard clinic care plus patient receipt of depression educational pamphlets and a community resource list.

RESULTS

INT patients had significantly greater depression improvement (> or =50% reduction in Symptom Checklist-20 depression score from baseline; 57, 62, and 62% vs. the EUC group's 36, 42, and 44% at 6, 12, and 18 months, respectively; odds ratio 2.46-2.57; P < 0.001). Mixed-effects linear regression models showed a significant study group-by-time interaction over 18 months in diabetes symptoms; anxiety; Medical Outcomes Study Short-Form Health Survey (SF-12) emotional, physical, and pain-related functioning; Sheehan disability; financial situation; and number of social stressors (P = 0.04 for disability and SF-12 physical functioning, P < 0.001 for all others) but no study group-by-time interaction in A1C, diabetes complications, self-care management, or BMI.

CONCLUSIONS

Socioculturally adapted collaborative depression care improved depression, functional outcomes, and receipt of depression treatment in predominantly Hispanic patients in safety-net clinics.

Review of type 2 diabetes management interventions for addressing emotional well-being in Latinos

PURPOSE

The purpose of this article is (1) to investigate if type 2 diabetes management programs with Latino participants address emotional well-being in addition to the standard diabetes self-care behaviors and (2) to describe the approaches taken to improve psychological and diabetes management outcomes.

METHODS

Online article and research databases, Internet searches, and review of article citations were used to identify relevant articles published 1995-2008. Type 2 diabetes management interventions with a psychological (emotion or cognitive) component or outcome measure and Latino sample were selected. Articles were limited to randomized clinical/controlled trials and pre-post comparative studies.

RESULTS

Thirteen interventions met the inclusion criteria for this review. Eight studies included emotion outcome measures, and 13 included at least one cognitive outcome measure. One study was specifically designed to improve emotional well-being. This study was not targeted for Latinos but did include Latino participants. A specialized depression case manager and collaborative care model showed significant improvements in depression and mental functioning. Psychological improvements were also found in those studies that assessed cognitive outcomes and were based on cognitive theories. The most frequent cognitive outcomes assessed were diabetes knowledge, problem solving, and self-efficacy.

CONCLUSIONS

Few type 2 diabetes interventions address emotional well-being in Latinos. More attention has been directed toward designing culturally sensitive community-based programs for improving behavior and physical outcomes. Because some Latino groups believe that negative emotions cause diabetes and because depression and anxiety are associated with poor self-management, programs should address emotional well-being as an important aspect of diabetes management.