If diabetes is a public health problem, why not treat it as one? A population-based approach to chronic illness

Public Health and Palliative Care

Meeting the needs of people at the end of life (EOL) is a public health (PH) concern, yet a PH approach has not been widely applied to EOL care. The design of hospice in the United States, with its focus on cost containment, has resulted in disparities in EOL care use and quality. Individuals with non-cancer diagnoses, minoritized individuals, individuals of lower socioeconomic status, and those who do not yet qualify for hospice are particularly disadvantaged by the existing hospice policy. New models of palliative care (both hospice and non-hospice) are needed to equitably address the burden of suffering from a serious illness.

Bounded Justice and the Limits of Health Equity

Programs, policies, and technologies - particularly those concerned with health equity - are often designed with justice envisioned as the end goal. These policies or interventions, however, frequently fail to recognize how the beneficiaries have historically embodied the cumulative effects of marginalization, which undermines the effectiveness of the intended justice. These well-meaning attempts at justice are bounded by greater socio-historical constraints. Bounded justice suggests that it is impossible to attend to fairness, entitlement, and equity when the basic social and physical infrastructures underlying them have been eroded by racism and other historically entrenched isms. Using the case of Brazil's National Health Policy for the Black Population, this paper proposes that bounded justice can contribute to justice discourses by serving as a concept, a proffering to a multi-disciplinary conceptual framework, and a potential analytic for those interested in the design of policy, technology, and programmatic interventions towards health equity.

Socioeconomic inequalities and type 2 diabetes complications: A systematic review

BACKGROUND AND OBJECTIVES

A socioeconomic gradient related to type 2 diabetes (T2D) prevalence has been demonstrated in high-income countries. However, there is no evidence of such a socioeconomic gradient regarding diabetes complications. Thus, the aim of this systematic review was to collect data on risk of complications according to socioeconomic status in patients with T2D.

METHODS

PubMed and EMBASE were searched for English-language observational studies evaluating the prevalence or incidence of micro- and macrovascular complications according to individual and geographical socioeconomic status (SES). Observational studies reporting the prevalence and risk of micro- and macrovascular diabetes complications, according to an individual or geographical index of deprivation, were selected, and estimated crude and adjusted risks for each complication were reported.

RESULTS

Among the 28 included studies, most described a clear relationship between SES and diabetes complications, especially retinopathy (in 9 of 14 studies) and cardiopathy (in 8 of 9 studies). Both individual and area-based low SES was associated with an increased risk of complications. However, very few studies adjusted their analyses according to HbA_1c level.

CONCLUSION

Evaluation of SES is necessary for every T2D patient, as it appears to be a risk factor for diabetes complications. However, the available studies are insufficient for gradation of the impact of low socioeconomic level on each of these complications. Regardless, strategies for the improved screening, follow-up and care of high-risk patients should now be implemented.

The Juntos Pilot Study: A Diabetes Management Intervention for Latino Caregiving Dyads

Purpose

The purpose of this study was to design a culturally sensitive dyad-level diabetes intervention to improve glycemic control for older Latino adults with type 2 diabetes.

Methods

This study used a pretest-posttest noncontrol group design. The intervention was developed from formative research with Mexican-origin caregiving dyads. The curriculum was adapted from 2 randomized trials of community interventions specifically designed for Latino older adults with type 2 diabetes. The curriculum consisted of communication skill-building exercises and dyad decision making on lifestyle changes to improve the older adult’s blood glucose levels. Thirty-two community-dwelling dyads completed a 6-week program of one-on-one sessions with a trained program facilitator. Main outcomes were feasibility and acceptability of the Juntos program. The authors assessed feasibility by examining participant burden and retention and acceptability by participant exit interviews. Although underpowered for outcomes, A1C, health status, and dyadic communication were also assessed to evaluate whether trends suggested the effectiveness of the intervention.

Results

Most participants viewed Juntos as an acceptable program and wanted the program expanded in terms of length and scope. All outcomes showed improvement from baseline through 6 months postintervention.

Conclusions

Results show that Juntos is acceptable to Mexican-origin caregiving dyads and is a promising approach for effectively controlling type 2 diabetes among older Latino adults who have a family caregiver.

Development and Evaluation of an Internet-Based Diabetes Nutrition Education Resource

Nutritional education for pre- and type 2 diabetes empowers individuals to make positive dietary and lifestyle choices. As the world migrates to digital devices, opportunities arise for education resources to reach a broad spectrum of society. This study aimed to develop and test the effectiveness of an electronic nutritional education resource for people with pre- and type 2 diabetes within the multi-ethnic New Zealand population. A needs assessment was conducted via ethnic-specific discussion groups (n = 29), followed by a population-based online survey (n = 448). An educational resource, including an educational video and pre- and post-questionnaires, was developed and tested online among 156 participants (17 with pre- and type 2 diabetes, 118 interested lay public and 21 health professionals). There was a strong desire to learn nutrition through simple, visual, practical, and culturally appropriate online educational resources. After interacting with the educational resource, the accuracy of identifying foods that increase blood glucose concentration improved by 17.4% (p = 0.013) in people with pre- and type 2 diabetes, 12.8% (p = 0.003) in health professionals, and 16.3% (p < 0.001) in interested lay public. There was an improvement among ethnic minority participants of 14.1% (p = 0.003). Most participants expressed intentions to make positive dietary and lifestyle choices. The electronic nutrition education resource was found to be an effective means for delivering education. It has potential to bridge the gap between the limited supply of healthcare resources and the increasing demand for diabetes nutrition education.

Associations between a Mediterranean diet pattern and inflammatory biomarkers in European adolescents

AIM

To test whether the Mediterranean diet score and each food-subgroup is associated with inflammatory biomarkers in European adolescents.

METHODS

In 464 adolescents (13-17 years) of the European HELENA study, data were available on body composition, inflammation markers, and food intake determined by two computerized 24-h recalls. The Mediterranean diet score and its food-subgroups (Vegetables, Fruits and Nuts, Pulses, Cereal and Roots, Monounsaturated/Saturated fat ratio, Dairy, Fish, Meat and Alcohol) were evaluated. A set of inflammation-related biomarkers was measured: IL-1, IL-2, IL-4, IL-5, IL-6, IL-10, TGFβ-1, TNF-α, sVCAM-1, sICAM1, sE-selectin, white blood cells, lymphocytes, CD3, CRP, GGT, ALT, and homocysteine. Multivariate and multiple linear regression analyses were adjusted for age, sex, country, socioeconomic status, paternal and maternal education, adiposity, and smoking habits.

RESULTS

The Mediterranean diet score was positively associated with CRP, and negatively with sVCAM-1. The subgroups showed the following positive/negative associations: Vegetables with IL-10(+), CRP(+), CD3(+), ALT(+), lymphocytes(+), sE-selectin(-); Fruits and Nuts with IL-4(-), TNF-alpha; Pulses with IL-5(+), IL-6(+), IL-2(-); Cereals and Roots with IL-6(-), IL-10(-); Monounsaturated/Saturated-fat ratio with IL-6(+), TGFβ-1(+), sVCAM-1(+boys, -girls), homocysteine(-); Dairy with IL-1(+), IL-5(+), IL-6(+), IL-10(+), TGFβ-1(+), homocysteine(-); Fish with homocysteine(-); Meat with IL-2(+), IL-10(+); Alcohol with CRP(+), lymphocytes(-). Sex differences were found.

CONCLUSION

Some specific food-inflammation associations were found, suggesting that diet is to a certain extent already related to inflammation in adolescents and can be used in disease prevention. Also some counterintuitive results were found, which might be due to grouping very different foods into a single group, besides considering that the human body may respond differently depending on the interaction between diet, lifestyle, genetics, biochemical individuality, age and sex.

Weight suppression as a predictor variable in the treatment of eating disorders: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Weight suppression (WS) has been suggested to predict outcome following psychological treatment for an eating disorder (ED). Some findings are contradictory and have not been considered systematically. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The review suggests that weight gain at post-treatment is reliably predicted by pretreatment WS, but findings regarding other outcomes (e.g., treatment dropout) are less consistent. Approximate effect sizes for observed relationships are identified, alongside support for biobehavioural theories of metabolic adaptation to weight loss. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Degree of WS at pretreatment is associated with weight gain and is important for clinicians to consider before offering treatment to patients with EDs. Patients high in WS might benefit from further support (e.g., psychoeducation) prior to beginning treatment. ABSTRACT: Introduction Weight suppression (WS-the difference between highest body weight and current body weight) has been proposed as a predictor of treatment outcome within eating disorders (EDs), although this hypothesis has not been consistently supported. Aim/Question Review the association between pretreatment WS and outcome following psychological treatment for EDs. Method A comprehensive electronic database search for published and unpublished literature from 1979 to 2017. Reference lists were also inspected. Eligibility criteria were determined according to relevant guidelines and a quality appraisal was conducted. Results Twelve studies met inclusion criteria (one was subsequently excluded based on insufficient data). Greater WS was generally associated with weight gain at post-treatment although not with other treatment outcomes. Discussion The existing evidence, with data from 1,566 participants, is summarized according to three main post-treatment outcomes: weight change; treatment completion; and symptom abstinence. Patients with disordered eating and greater WS may need to gain more weight than others during treatment to achieve good outcomes. Recommendations for future studies are provided. Implications for practice Evidence-based treatments for EDs may benefit from considering WS when planning treatment, such as further psychoeducation on weight changes. Societal interventions regarding promotion of healthy eating may also draw on these findings.

Diabetic Retinopathy and the Cascade into Vision Loss

Vision loss from diabetic retinopathy should be unnecessary for patients with access to diabetic retinopathy screening, yet it still occurs at high rates and in varied contexts. Precisely because vision loss is only one of many late-stage complications of diabetes, interfering with the management of diabetes and making self-care more difficult, Vision Threatening Diabetic Retinopathy (VTDR) is considered a "high stakes" diagnosis. Our mixed-methods research addressed the contexts of care and treatment seeking in a sample of people with VTDR using safety-net clinic services and eye specialist referrals. We point to conceptual weaknesses in the single disease framework of health care by diagnosis, and we use the framework of "cascades" to clarify why and how certain non-clinical factors come to bear on long-term experiences of complex chronic diseases.

Assessment of Knowledge of Diabetes Mellitus in the Urban Areas of Klang District, Malaysia

Diabetes is the most common cause of non-traumatic lower limb amputations and cardiovascular diseases. However, only a negligible percentage of the patients and subjects knew that the feet are affected in diabetes and diabetes affects the heart. Hence, a cross-sectional study was carried out to evaluate the knowledge of diabetes mellitus among the public of different age group, gender, ethnicity, and education level. A sample of 400 participants was randomly selected and data was collected using a structured questionnaire under non-contrived setting. The results showed that there is a statistically significant difference in knowledge on diabetes mellitus among different age groups and different ethnic origin but there is no significant difference in the knowledge among different gender and education level. Out of 400 respondents, 284 respondents (71%) knew that diabetes mellitus is actually a condition characterized by raised blood sugar. Age and education level of respondents were found to be the predominant predictive factors on diabetes knowledge, whereas the gender of respondents did not affect the findings of this study. An improved and well-structured educational programme that tackles the areas of weaknesses should be recommended to increase the level of knowledge on diabetes among Malaysians.

The Robert Wood Johnson Foundation Diabetes Initiative

PURPOSE

The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings.

METHODS

The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination.

RESULTS

Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care.

CONCLUSIONS

The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

Transitioning the Adult with Type 2 Diabetes From the Acute to Chronic Care Setting: Strategies to Support Pragmatic Implementation Success

Scientific evidence is available to guide the how to of medications management when patients with diabetes are hospitalized or present to the Emergency Department. However, few clinical trials in the diabetes field have addressed the execution, coupled with established implementation effectiveness evaluation frameworks to help inform and assess implementation practices to support the transition in care. These deficiencies may be overcome by (1) applying the principles of implementation and delivery systems science; (2) engaging the principles of human factors (HF) throughout the design, development, and evaluation planning activities; and (3) utilizing mixed methods to design the intervention, workflow processes, and evaluate the intervention for sustainability within existing care delivery models. This article provides a discussion of implementation science and human factors science including an overview of commonly used frameworks which can be applied to structure design and implementation of sustainable and generalizable interventions.

Assessment of Family Functioning and Its Relationship to Quality of Life in Diabetic and Non-Diabetic Women

Introduction: One of the most important components and health indicators, especially among people with chronic diseases is quality of life. One of the possible factors which may impact on quality of life of diabetic patients is family functioning. This study aimed to determine the relationship between family functioning and quality of life of diabetic and non-diabetic women. Methods: In this correlational cross-sectional study, 180 women (diabetics and non-diabetics) who referred to health centers in Mashhad in 2014-2015 were studied. Data were collected using SF-36 questionnaire and Mc Master Family Assessment Device (FAD). Data were analyzed using descriptive and statistical tests by SPSS ver.13 software. Results: The result showed that diabetic women reported family impairment compared with none diabetic women. There was a significant relationship between the family functioning and quality of life in diabetics and non-diabetic women. Based on the results of the stepwise regression model, among factors of family function only the factor of behavioral control was able to predict the quality of life in diabetic women. Conclusion: Regarding the study findings, good family function associated with better quality of life in diabetics and healthy women. Therefore, due to disturbed family function in diabetic's women implementation of training programs and consulting services could improve their quality of life.

Social interaction in type 2 diabetes computer-mediated environments: How inherent features of the channels influence peer-to-peer interaction

INTRODUCTION

Interventions via the internet provide support to individuals managing chronic illness. The purpose of this integrative review was to determine how the features of a computer-mediated environment influence social interactions among individuals with type 2 diabetes.

METHODS AND DESIGN

A combination of MeSH and keyword terms, based on the cognates of three broad groupings: social interaction, computer-mediated environments, and chronic illness, was used to search the PubMed, PsychInfo, Sociology Research Database, and Cumulative Index to Nursing and Allied Health Literature databases. Eleven articles met the inclusion criteria.

RESULTS

Computer-mediated environments enhance an individual's ability to interact with peers while increasing the convenience of obtaining personalized support. A matrix, focused on social interaction among peers, identified themes across all articles, and five characteristics emerged: (1) the presence of synchronous and asynchronous communication, (2) the ability to connect with similar peers, (3) the presence or absence of a moderator, (4) personalization of feedback regarding individual progress and self-management, and (5) the ability of individuals to maintain choice during participation.

CONCLUSIONS

Individuals interact with peers to obtain relevant, situation-specific information and knowledge about managing their own care. Computer-mediated environments facilitate the ability of individuals to exchange this information despite temporal or geographical barriers that may be present, thus improving T2D self-management.

Developing and Implementing "Waupaca Eating Smart": A Restaurant and Supermarket Intervention to Promote Healthy Eating Through Changes in the Food Environment

PURPOSE

Restaurants and food stores are suitable settings for healthy eating interventions. A community-academic partnership developed and implemented "Waupaca Eating Smart" (WES), a healthy eating program in restaurants and supermarkets of a rural, Midwest community. Previous interventions targeted either restaurants or small food stores nearly all in urban areas. Intervention design and implementation is rarely documented, making replication difficult for interested researchers and communities. In this article, we report the activities we undertook to develop and implement WES.

METHODS

Working with a local nutrition and activity coalition, we used evidence-based strategies guided by the social ecological model and social marketing principles to inform the content of WES. Formative assessment included a review of the literature, statewide key informant interviews and focus groups with restaurant and food store operators and patrons, a local community survey, and interviews with prospective WES businesses. WES was implemented in seven restaurants and two supermarkets and evaluated for feasibility and acceptance using surveys and direct observation of WES implementation.

FINDINGS

Prior to this intervention, only one of seven restaurants had three or more meals that met WES nutrition criteria. By the end of the program, 38 meals were labeled and promoted to restaurant customers, and the team had staffed four side salad taste tests for supermarket customers. Four and 10 months after intervention launch, the majority of the program's strategies were observed in participating outlets, suggesting that these program's strategies are feasible and can be sustained. Operators reported strong satisfaction overall.

CONCLUSIONS

A combined restaurant- and supermarket-based healthy eating intervention is feasible and positively valued in rural communities. Further research is needed to better understand how to foster sustainability of these interventions and their impact on customer food choices.

From Individuals to International Policy: Achievements and Ongoing Needs in Diabetes Advocacy

Diabetes impacts tens of millions of people in the United States of America and 9 % of the worldwide population. Given the public health implications and economic burden of diabetes, the needs of people with diabetes must be addressed through strategic and effective advocacy efforts. Diabetes advocacy aims to increase public awareness about diabetes, raise funds for research and care, influence policy impacting people with diabetes, and promote optimal individual outcomes. We present a framework for diabetes advocacy activities by individuals and at the community, national, and international levels and identify challenges and gaps in current diabetes advocacy. Various groups have organized successful diabetes advocacy campaigns toward these goals, and lessons for further advancing diabetes advocacy can be learned from other health-related populations. Finally, we discuss the role of healthcare providers and mental/behavioral health professionals in advocacy efforts that can benefit their patients and the broader population of people with diabetes.

A multifaceted quality improvement intervention for CVD risk management in Australian primary healthcare: a protocol for a process evaluation

BACKGROUND

Cardiovascular disease (CVD) is the leading cause of death and disability worldwide. Despite the widespread availability of evidence-based clinical guidelines and validated risk predication equations for prevention and management of CVD, their translation into routine practice is limited. We developed a multifaceted quality improvement intervention for CVD risk management which incorporates electronic decision support, patient risk communication tools, computerised audit and feedback tools, and monthly, peer-ranked performance feedback via a web portal. The intervention was implemented in a cluster randomised controlled trial in 60 primary healthcare services in Australia. Overall, there were improvements in risk factor recording and in prescribing of recommended treatments among under-treated individuals, but it is unclear how this intervention was used in practice and what factors promoted or hindered its use. This information is necessary to optimise intervention impact and maximally implement it in a post-trial context. In this study protocol, we outline our methods to conduct a theory-based, process evaluation of the intervention. Our aims are to understand how, why, and for whom the intervention produced the observed outcomes and to develop effective strategies for translation and dissemination.

METHODS/DESIGN

We will conduct four discrete but inter-related studies taking a mixed methods approach. Our quantitative studies will examine (1) the longer term effectiveness of the intervention post-trial, (2) patient and health service level correlates with trial outcomes, and (3) the health economic impact of implementing the intervention at scale. The qualitative studies will (1) identify healthcare provider perspectives on implementation barriers and enablers and (2) use video ethnography and patient semi-structured interviews to understand how cardiovascular risk is communicated in the doctor/patient interaction both with and without the use of intervention. We will also assess the costs of implementing the intervention in Australian primary healthcare settings which will inform scale-up considerations.

DISCUSSION

This mixed methods evaluation will provide a detailed understanding of the process of implementing a quality improvement intervention and identify the factors that might influence scalability and sustainability.

TRIALS REGISTRATION

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Family involvement is helpful and harmful to patients' self-care and glycemic control

OBJECTIVE

We assessed the relationships between supportive and obstructive family behaviors and patients' diabetes self-care activities and HbA1C, and potential interaction effects and differences by demographic characteristics.

METHODS

In a cross-sectional study, 192 adults with type 2 diabetes completed the Diabetes Family Behavior Checklist-II, the Summary of Diabetes Self-Care Activities, and a glycemic control (HbA1C) test.

RESULTS

Participants reported similar rates of supportive and obstructive behaviors that were positively correlated (rho=0.61, p<0.001). In adjusted analyses, supportive family behaviors were associated with adherence to different self-care behaviors (β=0.20 to 0.50, p<0.05), whereas obstructive family behaviors were associated with less adherence to self-care behaviors (β=-0.28 to -0.39, p<0.01) and worse HbA1C (β=0.18, p<0.05). Supportive behaviors protected against the detrimental effect of obstructive behaviors on HbA1C (interaction β=-0.22, p<0.001). Non-Whites reported more supportive and obstructive behaviors than Whites, but race did not affect the relationships between family behaviors and self-care or HbA1C.

CONCLUSION

Involving family members in patients' diabetes management may impede patients' self-care and compromise their glycemic control unless family members are taught to avoid obstructive behaviors.

PRACTICE IMPLICATIONS

Our findings endorse interventions that help family members develop actionable plans to support patients' self-care and train them to communicate productively about diabetes management.

Inequitable access to health services for older adults with diabetes: potential solutions on a state level

Diabetes is a serious global public health challenge. The cost for health services for diabetes care has increased 41% over the past 5 years. Despite escalating health expenditure, the United States continues to have higher rates of diabetes than many other developed countries. There is a need for health care reform in the United States not only in reducing health care costs but also in improving the quality of preventative care. This study presents the testing of a multilevel model investigating variables on the individual and state levels to develop a better understanding of the most important contextual pathways that can lead to providing older adults (50+) with type 2 diabetes with the recommended preventative quality care they require. The model was tested using a three-level repeated cross-sectional design with data from various existing data sources, using a national sample of 181,870 individuals aged 50 years and older. Results showed that differences in state health care systems contributed to inequitable access. Specifically, in a state where there was a higher percentage of adults 65 and older coupled with a shortage of health care professionals, the likelihood of receiving the recommended preventative quality care decreased. Also, older adults living in states with a higher percentage of people with diagnosed diabetes but with a lower-than-average annual per capita health care expenditure fared worse in receiving quality preventative care. Last, older adults in wealthy states with higher percentages of uninsured people had the lowest odds of receiving quality preventative care. Health care reform, similar to what is currently promoted by the Patient Protection and Affordable Care Act of 2010, is recommended to improve the performance of all health care systems in all states.

Differences in diabetes self-care activities by race/ethnicity and insulin use

PURPOSE

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

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Relationship between socioeconomic status and type 2 diabetes: results from Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2012

OBJECTIVE

To examine the relationship between socioeconomic status (SES) and type 2 diabetes using the Korea National Health and Nutrition Examination Survey (KNHANES) 2010-2012.

DESIGN

A pooled sample cross-sectional study.

SETTING

A nationally representative population survey data.

PARTICIPANTS

A total of 14,330 individuals who participated in the KNHANES 2010-2012 were included in our analysis.

PRIMARY OUTCOME

Prevalence of type 2 diabetes.

RESULTS

The relationship between SES and type 2 diabetes was assessed using logistic regression after adjusting for covariates including age, gender, marital status, region, body mass index, physical activity, smoking and high-risk drinking behaviour. After adjustment for covariates, our results indicated that individuals with the lowest income were more likely to have type 2 diabetes than those with the highest income (OR 1.35; 95% CI 1.08 to 1.72). In addition, lower educational attainment was an independent factor for a higher prevalence of type 2 diabetes in Korea.

CONCLUSIONS

These findings suggest the need for developing a health policy to ameliorate socioeconomic inequalities, in particular income and education-related disparities in type 2 diabetes, along with risk factors at the individual level. In addition, future investigations of type 2 diabetes among Koreans should pay more attention to the social determinants of diabetes in order to understand the various causes of the condition.

Understanding social forces involved in diabetes outcomes: a systems science approach to quality-of-life research

PURPOSE

The field of quality-of-life (QOL) research would benefit from learning about and integrating systems science approaches that model how social forces interact dynamically with health and affect the course of chronic illnesses. Our purpose is to describe the systems science mindset and to illustrate the utility of a system dynamics approach to promoting QOL research in chronic disease, using diabetes as an example.

METHODS

We build a series of causal loop diagrams incrementally, introducing new variables and their dynamic relationships at each stage.

RESULTS

These causal loop diagrams demonstrate how a common set of relationships among these variables can generate different disease and QOL trajectories for people with diabetes and also lead to a consideration of non-clinical (psychosocial and behavioral) factors that can have implications for program design and policy formulation.

CONCLUSIONS

The policy implications of the causal loop diagrams are discussed, and empirical next steps to validate the diagrams and quantify the relationships are described.

Health-plan and employer-based wellness programs to reduce diabetes risk: The Kaiser Permanente Northern California NEXT-D Study

Primary prevention of diabetes is increasingly recognized by both health plans and employers as an important strategy to improve the health of insured populations. As a part of the Natural Experiments in Translation for Diabetes (NEXT-D) network, the Kaiser Permanente Northern California (KPNC) Division of Research is assessing the effectiveness of 2 health plan-initiated programs to prevent the onset of diabetes in patients at high risk. The first study evaluates a telephonic health-coaching program that provides counseling on healthful eating, active living, and weight loss to KPNC members. The second evaluation examines a postpartum glucose screening and educational diabetes prevention program for women with gestational diabetes mellitus that KPNC implemented in 2006. Identifying effective approaches to preventing diabetes will be of value to health care systems, policy makers, and public health officials seeking to understand the roles systems and employers can play in preventing chronic illness.

Resources for Health: A Social-Ecological Intervention for Supporting Self-management of Chronic Conditions

There is a pressing need for practical interventions to support self-management of chronic illness that can be integrated with primary care, and that take into account the patient's social environment. This pilot study was conducted with low-income clients of a community health center and focused on enhancing use of social-environmental resources supportive of self-management. Twenty-eight patients having at least one chronic illness, randomized to immediate versus delayed treatment conditions, met once with a health educator to develop a self-management plan, and received one follow-up phone call and two newsletters. Significant improvements in use of community resources, minutes of physical activity, and medication adherence were obtained compared to control. Integrating brief self-management counseling with social environmental support appeared effective, although much more can be done to better link counseling to primary care practice.

Clinic-integrated behavioral intervention for families of youth with type 1 diabetes: randomized clinical trial

OBJECTIVE

To test the effect on diabetes management outcomes of a low-intensity, clinic-integrated behavioral intervention for families of youth with type 1 diabetes.

METHODS

Families (n = 390) obtaining care for type 1 diabetes participated in a 2-year randomized clinical trial of a clinic-integrated behavioral intervention designed to improve family diabetes management practices. Measurement of hemoglobin A1c, the primary outcome, was obtained at each clinic visit and analyzed centrally. Blood glucose meter data were downloaded at each visit. Adherence was assessed by using a semistructured interview at baseline, mid-study, and follow-up. Analyses included 2-sample t tests at predefined time intervals and mixed-effect linear-quadratic models to assess for difference in change in outcomes across the study duration.

RESULTS

A significant overall intervention effect on change in glycemic control from baseline was observed at the 24-month interval (P = .03). The mixed-effect model showed a significant intervention by age interaction (P < .001). Among participants aged 12 to 14, a significant effect on glycemic control was observed (P = .009 for change from baseline to 24-month interval; P = .035 for mixed-effect model across study duration), but there was no effect among those aged 9 to 11. There was no intervention effect on child or parent report of adherence; however, associations of change in adherence with change in glycemic control were weak.

CONCLUSIONS

This clinic-integrated behavioral intervention was effective in preventing the deterioration in glycemic control evident during adolescence, offering a potential model for integrating medical and behavioral sciences in clinical care.

Medical advice and diabetes self-management reported by Mexican-American, Black- and White-non-Hispanic adults across the United States

BACKGROUND

Diabetes has reached epidemic proportions in the United States, particularly among minorities, and if improperly managed can lead to medical complications and death. Healthcare providers play vital roles in communicating standards of care, which include guidance on diabetes self-management. The background of the client may play a role in the patient-provider communication process. The aim of this study was to determine the association between medical advice and diabetes self care management behaviors for a nationally representative sample of adults with diabetes. Moreover, we sought to establish whether or not race/ethnicity was a modifier for reported medical advice received and diabetes self-management behaviors.

METHODS

We analyzed data from 654 adults aged 21 years and over with diagnosed diabetes [130 Mexican-Americans; 224 Black non-Hispanics; and, 300 White non-Hispanics] and an additional 161 with 'undiagnosed diabetes' [N = 815(171 MA, 281 BNH and 364 WNH)] who participated in the National Health and Nutrition Examination Survey (NHANES) 2007-2008. Logistic regression models were used to evaluate whether medical advice to engage in particular self-management behaviors (reduce fat or calories, increase physical activity or exercise, and control or lose weight) predicted actually engaging in the particular behavior and whether the impact of medical advice on engaging in the behavior differed by race/ethnicity. Additional analyses examined whether these relationships were maintained when other factors potentially related to engaging in diabetes self management such as participants' diabetes education, sociodemographics and physical characteristics were controlled. Sample weights were used to account for the complex sample design.

RESULTS

Although medical advice to the patient is considered a standard of care for diabetes, approximately one-third of the sample reported not receiving dietary, weight management, or physical activity self-management advice. Participants who reported being given medical advice for each specific diabetes self-management behaviors were 4-8 times more likely to report performing the corresponding behaviors, independent of race. These results supported the ecological model with certain caveats.

CONCLUSIONS

Providing standard medical advice appears to lead to diabetes self-management behaviors as reported by adults across the United States. Moreover, it does not appear that race/ethnicity influenced reporting performance of the standard diabetes self-management behavior. Longitudinal studies evaluating patient-provider communication, medical advice and diabetes self-management behaviors are needed to clarify our findings.

Challenges in real-life diabetes translation research: early lessons from BRIDGES projects

AIMS

Efficacious interventions for prevention of diabetes and its complications exist; however, their implementation is woefully inadequate. The purpose of this project is to qualitatively assess the early lessons learnt from implementing translational research from eleven projects supported by BRIDGES, an International Diabetes Federation program.

METHODS

Semi-structured in-depth interviews conducted with 10 researchers, seeking their views on factors relating to success and barriers to implementation. Data were collected from June to September 2010 by a trained interviewer; information was recorded, transcribed and further analyzed with MAXQDA.

RESULTS

Patient recruitment and retention were reported as challenges. Lack of availability of local multidisciplinary teams was highlighted as having a negative effect on the project. Grassroots and community participation were emphasized to have beneficial effects. Flexibility was recognized as a key for successful execution of the projects. Recommendations include: feedback from previous grantees, in the form of pre-submission workshops, and mentoring from experienced investigators with emphasis on the differences between traditional and translational researches.

CONCLUSIONS

This evaluation underscores the main contingencies to be considered for successful implementation of translational research. It emphasizes the importance of having the three stakeholders: patients, providers, and health systems, acting together in a flexible environment within real life settings.

Goal Setting Education and Counseling Practices of Diabetes Educators

Purpose

The purpose of this study was to identify goal setting education practices used by diabetes educators working with type 2 diabetes patients.

Methods

Data were collected by a mail questionnaire with 179 diabetes educators purposively selected from the 2008 American Association of Diabetes Educators membership listing.

Results

Many diabetes educators (52%) reported that more than 75% of their patients set goals for diabetes control. Independent factor patterns for the frequency of information collected from the patient for the first diabetes education session showed that educators either focused on patients’ self-management practices (exercise and dietary practices, knowledge, and social impacts of diabetes) or issues with learning about self-management, such as understanding the patient’s learning style and motivation for managing diabetes. Factor patterns overall showed diverse approaches to working with patients, including strategies used with patients struggling with dietary goals and the importance of tasks to complete during the first patient session.

Conclusion

Although most educators reported practices that were largely patient centered as promoted by the American Diabetes Association (ADA) and models of chronic disease management, patterns of practice suggest that diabetes educators vary considerably in how they apply education practices, especially with dietary self-management education.

Perceived weight discrimination amplifies the link between central adiposity and nondiabetic glycemic control (HbA1c)

BACKGROUND

While the preclinical development of type 2 diabetes is partly explained by obesity and central adiposity, psychosocial research has shown that chronic stressors such as discrimination have health consequences as well.

PURPOSE

We investigated the extent to which the well-established effects of obesity and central adiposity on nondiabetic glycemic control (indexed by HbA(1c)) were moderated by a targeted psychosocial stressor linked to weight: perceived weight discrimination.

METHODS

The data came from the nondiabetic subsample (n = 938) of the Midlife in the United States (MIDUS II) survey.

RESULTS

Body mass index (BMI), waist-to-hip ratio, and waist circumference were linked to significantly higher HbA(1c) (p < 0.001). Multivariate-adjusted models showed that weight discrimination exacerbated the effects of waist-to-hip ratio on HbA(1c) ( p < 0.05), such that people who had higher waist-to-hip ratios and reported weight discrimination had the highest HbA(1c) levels.

CONCLUSION

Understanding how biological and psychosocial factors interact at nondiabetic levels to increase vulnerability could have important implications for public health and education strategies. Effective strategies may include targeting sources of discrimination rather than solely targeting the health behaviors and practices of overweight and obese persons.

Engagement in a diabetes self-management website: usage patterns and generalizability of program use

Background

Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change.

Objective

This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as “Ask an Expert” to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes.

Methods

We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the “Action Plan” section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk.

Results

Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m², 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P < .001). Spearman nonparametric correlations indicated few significant associations between patient characteristics and summary website engagement variables, and key factors such as ethnicity, baseline computer use, age, health literacy, and education were not related to use. Partial correlations indicated that engagement, especially in self-monitoring, was most consistently related to improvement in healthy eating (r = .20, P = .04) and reduction of dietary fat (r = -.31, P = .001). There was also a significant correlation between self-monitoring and improvement in exercise (r = .20, P = .033) but not with medication taking.

Conclusions

Participants visited the website fairly often and used all of the theoretically important sections, but engagement decreased over 4 months. Usage rates and patterns were similar for a wide range of participants, which has encouraging implications for the potential reach of online interventions.

Trial Registration

NCT00987285; http://clinicaltrials.gov/show/NCT00987285 (Archived by WebCite at http://www.webcitation.org/5vpe4RHTV)

The new era of comparative effectiveness: will public health end up left behind?

The Patient Protection and Affordable Care Act created the nation's first comprehensive comparative effectiveness research (CER) program. According to some optimistic accounts, CER will revolutionize clinical practice and transform the health care delivery system. But what about public health? There are reasons for concern that it could end up left behind in the new era of comparative effectiveness. This article analyzes the considerable promise and serious limitations of applying CER to public health. It also highlights important issues that will likely emerge for public health law and policy as the health care system transitions to greater reliance on CER.

The impact of health literacy on self-monitoring of blood glucose in patients with diabetes receiving care in an inner-city hospital

BACKGROUND

Self-monitoring of blood glucose (SMBG) is considered to be 1 of the cornerstones of diabetes self-management. It is unclear whether inadequate health literacy affects SMBG.

OBJECTIVE

The objective of this study was to examine the relationship between health literacy and SMBG.

METHODS

This was a cross-sectional survey of 189 patients with diabetes, aged 18 to 65 years, receiving care in a large urban, public health care setting. We measured health literacy using the shortened version of the Test of Functional Health Literacy in Adults. The diabetes care profile was used to determine the use of self-monitoring of blood glucose.

RESULTS

Most (60.9%) of the survey participants were assessed as functionally health literate. The majority (90.9%) of the study participants reported testing their blood sugar at least once daily. Although adequate health literacy was associated with recording of blood sugar testing (p = .049), we found no statistically significant relationship between health literacy and the frequency of SMBG. Persons self-reporting having diabetes for more than 10 years were less likely to self-monitor blood glucose (odds ratio, 0.33; 95% CI, 0.11-0.99).

CONCLUSIONS

SMBG frequency is not independently associated with health literacy, but SMBG result recording is noted among patients with inadequate literacy.

Diet-specific family support and glucose control among Korean immigrants with type 2 diabetes

PURPOSE

The purpose of this study was to examine the influence of diet family support on glucose outcome in Korean immigrants with type 2 diabetes, taking into consideration patient gender.

METHODS

A total of 143 Korean immigrants with type 2 diabetes were recruited from a West Coast Koreatown. On completing questionnaires (demographic, health history, and the Diabetes Family Behavior Checklist-II [DFBC]), a participant was given a finger stick blood test for glycosylated hemoglobin (A1C). Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated after measurements were taken. Analyses assessed the independent associations of diet family support, gender, and diet family support by gender interactions with glucose outcome.

RESULTS

A higher level of diet family support was significantly associated with lower A1C, indicating the beneficial effect of diet family support on glucose control. Although the main effect of gender on A1C was not significant, the effect of the product term of family support and gender was, indicating that the significant beneficial impact of diet family support on A1C depends on gender. The impact is much more pronounced in men (B = -.516) than women (B = -.038).

CONCLUSIONS

Family support, specific to diet, is significantly associated with glucose outcomes in Korean immigrants with type 2 diabetes. That is, more perceived family support was associated with better glucose control. The positive impact of family support on glucose outcome was significantly stronger in men than in women, even after other factors were taken into consideration.

Organizational readiness in specialty mental health care

BACKGROUND

Implementing quality improvement efforts in clinics is challenging. Assessment of organizational "readiness" for change can set the stage for implementation by providing information regarding existing strengths and deficiencies, thereby increasing the chance of a successful improvement effort. This paper discusses organizational assessment in specialty mental health, in preparation for improving care for individuals with schizophrenia.

OBJECTIVE

To assess organizational readiness for change in specialty mental health in order to facilitate locally tailored implementation strategies.

DESIGN

EQUIP-2 is a site-level controlled trial at nine VA medical centers (four intervention, five control). Providers at all sites completed an organizational readiness for change (ORC) measure, and key stakeholders at the intervention sites completed a semi-structured interview at baseline.

PARTICIPANTS

At the four intervention sites, 16 administrators and 43 clinical staff completed the ORC, and 38 key stakeholders were interviewed.

MAIN RESULTS

The readiness domains of training needs, communication, and change were the domains with lower mean scores (i.e., potential deficiencies) ranging from a low of 23.8 to a high of 36.2 on a scale of 10-50, while staff attributes of growth and adaptability had higher mean scores (i.e., potential strengths) ranging from a low of 35.4 to a high of 41.1. Semi-structured interviews revealed that staff perceptions and experiences of change and decision-making are affected by larger structural factors such as change mandates from VA headquarters.

CONCLUSIONS

Motivation for change, organizational climate, staff perceptions and beliefs, and prior experience with change efforts contribute to readiness for change in specialty mental health. Sites with less readiness for change may require more flexibility in the implementation of a quality improvement intervention. We suggest that uptake of evidence-based practices can be enhanced by tailoring implementation efforts to the strengths and deficiencies of the organizations that are implementing quality improvement changes.

Knowledge of diabetes risk factors and preventive measures among attendees of a primary care center in eastern Saudi Arabia

BACKGROUND AND OBJECTIVE

Few studies have been conducted in Saudi Arabia to assess the level of awareness and knowledge of the population about diabetes mellitus (DM) risk factors and preventative measures. The objective of this study was to measure this knowledge among attendees of a primary care center in eastern Saudi Arabia.

METHODS

A sample of 300 male and female Saudis aged 18 years and older from the catchment area of the Aqrabya Primary Care Center were randomly selected for this cross-sectional survey. Data were collected through a structured face-to-face interview using a pre-piloted Arabic instrument. Regression analysis was used to identify the predictors of knowledge.

RESULTS

The 288 participants interviewed included 100 males and 188 females. The mean (SD) age was 44.7 (12.6) years for males and 33.8 (12.4) years for females. Fewer than 50% of participants knew about DM risk factors and preventive measures. In a regression model that included age, sex and education, education had a statistically significant positive association with knowledge of risk factors (odds ratio 12.5, 95% CI 6.26-25.2, P<.001) and preventive measures (odds ratio 7.6, 95% CI 4.01-14.2, P<.001), and age had a statistically significant negative association with knowledge of DM risk factors (odds ratio 0.377, 95% CI 0.207-0.685, P=.001) and prevention (odds ratio 0.407, 95% CI 0.231-0.717, P=.001). The main risk factor stated by participants was obesity (35.8%), while the main preventive measure mentioned was weight reduction (37.9%).

CONCLUSION

Attendees had poor knowledge of DM risk factors and preventive measures. The level of education and age were important predictors of knowledge. Programs for health education of the community about DM risk factors and preventive measures are needed.

The neighborhood food resource environment and the health of residents with chronic conditions: the food resource environment and the health of residents

BACKGROUND

Residence in disadvantaged neighborhoods is associated with poorer access to healthy foods.

OBJECTIVE

To understand associations between the neighborhood food resource environment and residents' health status and body mass index (BMI) for adults with and without chronic conditions.

DESIGN

Cross-sectional multilevel analysis.

PARTICIPANTS

2,536 adults from the 2000-2001 Los Angeles Family and Neighborhood Survey.

MEASUREMENTS

The food resource environment was defined as the number of chain supermarkets, independent supermarkets, small markets, or convenience stores per roadway miles in the census tract. The main dependent variables were self-rated health, dichotomized as excellent or fair/poor, and body mass index (BMI). Multilevel regression models examined the association between the food resource environment and both BMI and the odds of reporting excellent health after adjustment for neighborhood SES and individual characteristics.

RESULTS

More chain supermarkets per roadway mile in a census tract was associated with higher adjusted rates of reporting excellent health (33%, 38%, and 43% for those in the lowest, middle, and highest tertiles of chain supermarkets) and lower adjusted mean BMI (27, 26, and 25 kg/m(2)) for residents without a chronic condition, but not those with a chronic condition. In contrast, having more convenience stores per roadway mile was associated with lower health ratings only among adults with a chronic condition (39%, 32%, and 27% for the lowest to highest tertile of convenience stores).

CONCLUSION

Health status and BMI are associated with the local food environment, but the associations differ by type of market and presence of a chronic condition.

Nurse care manager collaboration with community-based physicians providing diabetes care: a randomized controlled trial

PURPOSE

The purpose of this study was to demonstrate the potential value of close collaboration at the office level of a nurse care manager with community-based primary care physicians in the care of adult patients with type 2 diabetes, particularly those physicians not affiliated with an integrated care system that some managed care organizations provide.

METHODS

Patients with type 2 diabetes were recruited from the general population of a large metropolitan area. Each received a comprehensive evaluation of his or her diabetes with results reported to patients and their physicians (basic intervention). A random one-half of patients were additionally assigned to individual counseling, problem identification, care planning, and management recommendations by a nurse care manager (individualized intervention). The patients receiving only the basic intervention served as the control group to those receiving the individualized intervention. Re-evaluation of all patients at 6 months after their entry into the study determined the effectiveness of the nurse-directed individualized intervention using A1C, blood pressure, and cholesterol as outcome measures.

RESULTS

Of 220 patients recruited, 197 had type 2 diabetes, randomly assigned only the basic intervention (102 patients) or individualized intervention (95 patients). Postintervention data were obtained on 164 patients (83%). Significant improvement occurred in mean systolic blood pressure and A1C of all patients in the individualized but not the basic intervention only group. Patients with a systolic blood pressure>or=130 mm Hg at baseline showed improvement if they had more than 2 contacts with the study nurse but not if they had less than 2 contacts.

CONCLUSIONS

A nurse care manager collaborating at the office level with community-based primary care physicians can enhance the care provided to adult patients with type 2 diabetes. For those many physicians not affiliated with an integrated care system featured by some managed care organizations, this collaboration could underlie a team approach (nurse/patient/physician) for the ambulatory patient with diabetes that would be an essential element in a chronic disease model of care for diabetes at the community level.

On the road to the national objectives: a case study of Diabetes Prevention and Control Programs

The purpose of this case study research was to understand common characteristics of high-performing Diabetes Prevention and Control Programs (DPCPs) that enable them to achieve national diabetes objectives within a Model of Influence. The case consisted of five selected DPCPs in California, Kentucky, Minnesota, New York, and Utah. Visits to each site facilitated data collection including document reviews, interviews, and observations. Data analysis involved content analysis, developing typologies, pattern matching, member checking, and triangulation. Results indicate that high-performing DPCPs share the following common characteristics in efforts to achieve national objectives: (1) fit the context, (2) assume multiple roles, (3) build relationships, (4) negotiate systems, (5) frame with a public health perspective, and (6) understand that there is "something about diabetes." Results provide insights for public health leadership to strengthen capacities of comparable state-based programs.

The relationship between neighborhood characteristics and self-rated health for adults with chronic conditions

OBJECTIVES

We sought to determine whether the association between neighborhood characteristics and health differs for people with and without a chronic condition.

METHODS

We analyzed data from 2536 adults from the Los Angeles Family and Neighborhood Survey and evaluated the relationship between the presence of a chronic condition at the individual level, neighborhood socioeconomic status (SES), and self-rated health. We constructed multilevel models to evaluate the relationship between the neighborhood SES index and self-rated health for people with and without chronic conditions, after adjustment for other individual characteristics.

RESULTS

Having a chronic condition was associated with substantially poorer self-rated health among participants in a deprived area than among those in a more advantaged area.

CONCLUSIONS

Residence in a disadvantaged neighborhood may be associated with barriers to the management of a chronic condition. Further work is needed to identify the specific characteristics of disadvantaged areas associated with poorer self-rated health for adults with chronic conditions.

Assessing sources of support for diabetes self-care in urban and rural underserved communities

The ability of adults with diabetes to manage their illness properly and prevent complications is, in part, a function of support provided by the people and institutions surrounding them. Using data from over 200 adults with diabetes in two medically underserved communities--one urban and one rural--this study examines the self-care specific support provided by four key sources: family and friends, community organizations, one's neighbors and neighborhood, and resources in the wider community. More specifically, this study aims to assess the support needs of adults with diabetes in these communities by estimating their rates of various self-care behaviors, the amount of support provided by key sources, and the associations between support from these sources and adherence to recommended diabetes self-care behaviors. Descriptive findings indicate that close to 40% of the sample failed to report at least moderate levels of adherence, and that physical activity in the rural community, and smoking in the urban community represent particular problem areas. Individuals from the urban sub-sample reported receiving more support from all of the sources assessed. Logistic regression models indicated that one's neighbors and neighborhood resources appear to have a broad influence on adherence to diabetes self-care behaviors. Support from family and friends, as well as from community organizations, also seems to be important. These results have implications for the design of interventions aimed at bolstering support for diabetes self-care, and point to the need for an enhanced focus on strengthening the social environmental resources of adults with diabetes.

The answer to diabetes prevention: science, surgery, service delivery, or social policy?

The diabetes and obesity epidemics are closely intertwined. International randomized controlled trials demonstrate that, in high-risk individuals, type 2 diabetes can be prevented or at least delayed through lifestyle modification and, to a lesser degree, medication. We explored the relative roles of science, surgery, service delivery, and social policy in preventing diabetes. Although it is clear that there is a role for all, diabetes is a complex problem that demands commitment across a range of government and nongovernment agencies to be effectively controlled. Accordingly, we argue that social policy is the key to achieving and sustaining social and physical environments required to achieve widespread reductions in both the incidence and prevalence of diabetes.

Implementing diabetes self-management training programs: breaking through the barriers in primary care

OBJECTIVE

To review issues, examples, and recommendations for the delivery of diabetes self-management training (DSMT) services in the primary care setting.

METHODS

Barriers to provision of DSMT at the point of care and strategies to overcome such challenges are discussed. In addition, new avenues to support continuing diabetes education are presented.

RESULTS

Diabetes is a complex disease that requires education, monitoring, and medication adjustment to achieve treatment goals. Unfortunately, adequate support is seldom available for the increased time and effort needed for optimal management of diabetes. Health-care delivery systems are designed to provide a response to acute illnesses and are poorly configured to meet the needs of patients with complex chronic illnesses. Although team care and DSMT have proved to be effective, they have infrequently been integrated in primary care offices, where most patients with diabetes receive treatment. It is encouraging that the studies conducted to date have generally found office-based counseling and educational strategies to be effective for the vast majority of patients with diabetes. Community-based programs that extend DSMT have also been successful.

CONCLUSION

Diabetes is a chronic disease that requires providers to deliver multifaceted care and patients to be proficient in many self-care skills. Team care and DSMT approaches have been found to yield beneficial results, yet such strategies are seldom used in the primary care office. Thus, models that support the team approach to delivery of diabetes care and self-management education interventions should be explored and encouraged.

Diabetes decision support: initial experience with the Vermont diabetes information system

Interventions that have proven effective in the management of chronic illness have often been difficult to establish in widespread practice. The Chronic Care Model provides a framework for implementing interventions, but it is expensive and difficult to implement. We developed a decision support system based on this model to improve the care of adults who have diabetes and receive primary care in Vermont or adjacent New York. The Vermont Diabetes Information System uses a network of community laboratories for providing data to produce flowsheets, reminders, action alerts, and population reports that are sent to primary care providers by fax and to patients by mail. Currently, 7295 patients are cared for by 124 primary care providers in 62 practices and are enrolled in a randomized controlled trial to study its effects.

Epidemiology of type 2 diabetes: focus on ethnic minorities

African Americans and other ethnic minority groups suffer disproportionately from type 2 diabetes and its complications than do white Americans. Genetic and environmental factors contribute to the ethnic disparities in diabetes and its complications. The key elements of a comprehensive diabetes management strategy include monitoring, education, dietary modification, exercise, and medications. The progressive nature of diabetes requires the use of more than one agent. Drug combinations should be selected for their therapeutic fire power and complementary mechanisms of action, and exogenous insulin need not be delayed unnecessarily if oral agents are ineffective.