Self-Care Disparities Among Adults with Type 2 Diabetes in the USA

Assessment of diabetes self-care behaviors and knowledge among Marshallese adults with type 2 diabetes in the Republic of the Marshall Islands

AIMS

The aim of this study is to assess and document engagement in type 2 diabetes mellitus (T2DM) self-care behaviors and self-reported diabetes knowledge among Marshallese adults living in the Republic of the Marshall Islands (RMI).

METHODS

The study uses data from a T2DM health screening study completed in the RMI; survey and biometric data were captured as part of the health screenings. Study objectives were examined using descriptive statistics to describe the characteristics of the participants, their diabetes self-care behaviors, and their levels of self-reported diabetes knowledge.

RESULTS

Results indicate many Marshallese diagnosed with T2DM did not engage in adequate self-care behaviors, including blood sugar checks and foot examinations. Participants reported having forgone needed medical care and medication due to issues with cost and/or access, and participants reported low levels of diabetes knowledge.

CONCLUSIONS

The results demonstrate the need for further work in improving engagement in diabetes self-care by Marshallese living in the RMI. Increased engagement in self-care and diabetes education programs may help Marshallese with T2DM to improve control of their glucose and avoid long-term health complications, as well as reduce costs to the healthcare system.

Socioeconomic factors associated with poor medication adherence in patients with type 2 diabetes

PURPOSE

This study aims to determine initiation and persistence for patients with type 2 diabetes receiving their first prescription of an antidiabetic agent and the associations with socioeconomic factors.

METHODS

A cohort study including 8515 patients with type 2 diabetes who were prescribed their first antidiabetic medication between 2012 and 2019 in Uppsala, Sweden, was followed during 2 years. Medical records were linked to national registers on dispensed drugs and socioeconomic data. Adherence was assessed based on patients' medication claims within 30 days of prescription (initiation) and continued claims after 24 months (persistence). Multivariable logistic regression was used to determine the associations with the socioeconomic factors age, sex, living status, country of birth, education, occupation, and income.

RESULTS

Within 30 days, 92.4% of the patients claimed their first prescription, and 64.0% were still being dispensed the initially prescribed medication after 24 months. Unemployed patients had lower initiation rates, and women had lower persistence rates. Factors associated with both low initiation and persistence were low income, young or old age, birth outside Europe, and being prescribed other diabetes drugs than metformin monotherapy.

CONCLUSION

Socioeconomic factors have different impact on the initiation of a new medication and the persistence to treatment in type 2 diabetes. It is important to acknowledge these differences to develop appropriate interventions to improve medication nonadherence.

Effect of the Theory-driven Educational Intervention on Self-Care Behavior and Glycosylated Hemoglobin Level in Patients with Type 2 Diabetes

BACKGROUND AND AIMS

The diabetics' lack of knowledge about self-care and incorrect beliefs in this care are the reasons for their admission to hospitals. The present study aimed to examine the impact of education based on the theory of planned behavior (TPB) on intention, self-care behavior, and glycosylated hemoglobin (HbA1c) levels in patients with Type 2 Diabetes.

METHODS

The present study was conducted on 60 diabetic patients who were randomly classified into intervention and control groups. In the intervention group, self-care education based on TPB was held, but the control group only received routine care. The data were collected using a fourpart questionnaire including characteristics, items of patients' knowledge, items of TPB constructs, and items of diabetes self-care. Data were analyzed in SPSS software.

RESULTS

In intervention group, mean score of self-care behavior and its domains significantly changed from (total: 52.26±14.75, diabetic diet: 22.20±6.05, exercise: 5.17±4.04, blood sugar testing: 5.03 ± 4.15, medication: 5.40±2.28, foot care: 13.47±8.42) into 76.66±8.87, 29.43±5.48, 7.60±2.60, 8.73±2.31, 6.48±1.09, 23.53±3.09, respectively three months after intervention (p<0.01). In this case, these changes were not seen in the control group. The mean level of HbA1c in the intervention group (6.38±0.16) was significantly lower than before the intervention (7.56±1.08) and the control group (8.02±0.25) three months after intervention (p<0.01).

CONCLUSION

Education based on the TPB was effective in improving the patients' self-care behavior and HbA1c index. Therefore, we suggest all medical centers to use the TPB as an effective and low-cost educational approach to improve diabetics' self-care behavior and health.

Glycemic outcomes of a family-focused intervention for adults with type 2 diabetes: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Family/friend Activation to Motivate Self-care (FAMS) is a self-care support intervention delivered via mobile phones. We evaluated FAMS' effects on hemoglobin A1c (HbA1c) and intervention targets among adults with type 2 diabetes in a 15-month RCT.

METHODS

Persons with diabetes (PWDs) were randomized to FAMS or control with their support person (family/friend, optional). FAMS included monthly phone coaching and text messages for PWDs, and text messages for support persons over a 9-month intervention period.

RESULTS

PWDs (N = 329) were 52 % male, 39 % reported minoritized race or ethnicity, with mean HbA1c 8.6 ± 1.7 %. FAMS improved HbA1c among PWDs with a non-cohabitating support person (-0.64 %; 95 % CI [-1.22 %, -0.05 %]), but overall mean effects were not significant. FAMS improved intervention targets including self-efficacy, dietary behavior, and family/friend involvement during the intervention period; these improvements mediated post-intervention HbA1c improvements (total indirect effect -0.27 %; 95 % CI [-0.49 %, -0.09 %]) and sustained HbA1c improvements at 12 months (total indirect effect -0.19 %; 95 % CI [-0.40 %, -0.01 %]).

CONCLUSIONS

Despite improvements in most intervention targets, HbA1c improved only among PWDs engaging non-cohabitating support persons suggesting future family interventions should emphasize inclusion of these relationships. Future work should also seek to identify intervention targets that mediate improvements in HbA1c.

Cultural Beliefs About Diabetes-Related Social Exclusion and Diabetes Distress Impact Self-Care Behaviors and HbA1c Among Patients with Type 2 Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) disproportionally impacts Latin Americans (Latinos) in the U.S. compared to non-Latino Whites, as reflected by an increased risk for disease complications and higher mortality rates. Guided by an Integrative Model of Culture, Psychological Processes, and Health Behavior, the purpose of the present study was to examine the role of cultural beliefs and diabetes distress as determinants of self-care behaviors and HbA1c among Latino patients with T2DM.

METHODS

Participants included 109 Latino patients with T2DM recruited from a diabetes treatment center located in a region of Southern California with high diabetes mortality rates. Structural equation modeling was employed to examine the extent to which cultural beliefs about diabetes-related social exclusion and diabetes distress impact self-care behaviors and self-reported HbA1c.

RESULTS

Consistent with the study hypotheses, cultural beliefs about diabetes-related social exclusion predicted diabetes distress, which in turn predicted poor diabetes self-care.

CONCLUSIONS

Findings suggest an important need for intervention efforts that address both cultural and psychological factors in order to improve diabetes self-care behaviors and associated disease outcomes among Latino patients with T2DM. Future research could benefit from investigating protective aspects of culture that could help counter the negative implications of cultural beliefs about social exclusion and diabetes distress associated with poor self-care.

Diabetes self-care activities and perception and glycemic control in adult Puerto Rican residents with Type 2 Diabetes: The LLIPDS Study

Background

Individuals with diabetes frequently have comorbid health conditions and suffer longer term complications. The control of blood glucose relies on diabetes management/self-care behaviors. Poor glycemic control, commonly encountered in underserved populations with type 2 diabetes (T2D) often results from inadequate diabetes self-care activities and/or perception. We aimed to assess the association between diabetes self-care activities/perception and glycemic control in adult Puerto Rican residents with T2D.

Design and methods

We used a cross-sectional study design; our sample population was 260 individuals aged 40-65 years with T2D. We asked participants about their diabetes self-care over 8 weeks. High fasting blood glucose (≥130 mg/dL) and glycated hemoglobin (HbA1c; ≥7%) measures were defined. We estimated the strength of the following associations using logistic regression: each of three self-care activities and fasting glucose or HbA1c, adjusting for confounders.

Results

Nearly 27% of the participants reported not checking their glucose levels, 7% did not take their medications as prescribed and 31% perceived their diabetes self-care as poor. Participants with less education perceived their diabetes self-care as poor more often than their counterparts (44% vs 25%; p = 0.003). Most participants had high glycemic levels (60%) or hbA1c levels (65%). Participants who perceived their diabetes self-care as poor had higher HbA1c levels than their counterparts (adj. odds ratio: 2.14, 95% CI (1.13, 4.08)).

Conclusion

Poor diabetes self-care perception, possibly related to less education, likely explains poor glycemic control among adult Puerto Rican residents with T2D.

Glycemia Reduction in Type 2 Diabetes - Glycemic Outcomes

BACKGROUND

The comparative effectiveness of glucose-lowering medications for use with metformin to maintain target glycated hemoglobin levels in persons with type 2 diabetes is uncertain.

METHODS

In this trial involving participants with type 2 diabetes of less than 10 years' duration who were receiving metformin and had glycated hemoglobin levels of 6.8 to 8.5%, we compared the effectiveness of four commonly used glucose-lowering medications. We randomly assigned participants to receive insulin glargine U-100 (hereafter, glargine), the sulfonylurea glimepiride, the glucagon-like peptide-1 receptor agonist liraglutide, or sitagliptin, a dipeptidyl peptidase 4 inhibitor. The primary metabolic outcome was a glycated hemoglobin level, measured quarterly, of 7.0% or higher that was subsequently confirmed, and the secondary metabolic outcome was a confirmed glycated hemoglobin level greater than 7.5%.

RESULTS

A total of 5047 participants (19.8% Black and 18.6% Hispanic or Latinx) who had received metformin for type 2 diabetes were followed for a mean of 5.0 years. The cumulative incidence of a glycated hemoglobin level of 7.0% or higher (the primary metabolic outcome) differed significantly among the four groups (P<0.001 for a global test of differences across groups); the rates with glargine (26.5 per 100 participant-years) and liraglutide (26.1) were similar and lower than those with glimepiride (30.4) and sitagliptin (38.1). The differences among the groups with respect to a glycated hemoglobin level greater than 7.5% (the secondary outcome) paralleled those of the primary outcome. There were no material differences with respect to the primary outcome across prespecified subgroups defined according to sex, age, or race or ethnic group; however, among participants with higher baseline glycated hemoglobin levels there appeared to be an even greater benefit with glargine, liraglutide, and glimepiride than with sitagliptin. Severe hypoglycemia was rare but significantly more frequent with glimepiride (in 2.2% of the participants) than with glargine (1.3%), liraglutide (1.0%), or sitagliptin (0.7%). Participants who received liraglutide reported more frequent gastrointestinal side effects and lost more weight than those in the other treatment groups.

CONCLUSIONS

All four medications, when added to metformin, decreased glycated hemoglobin levels. However, glargine and liraglutide were significantly, albeit modestly, more effective in achieving and maintaining target glycated hemoglobin levels. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; GRADE ClinicalTrials.gov number, NCT01794143.).

Feasibility and Performance of Hemoglobin A1C Self-Testing During COVID-19 Among African Americans With Type 2 Diabetes

PURPOSE

The purpose of the study was to determine the feasibility of implementing A1C self-testing at home using the A1CNow® Self Check and to compare the accuracy of the A1CNow to a reference standard in African Americans with type 2 diabetes (T2D).

METHODS

African American adults with T2D were recruited from 13 different churches (N = 123). Phase 1, conducted during the early phase of the COVID-19 pandemic, examined the feasibility of A1C assessment using the A1CNow performed at home by untrained participants. Phase 2, conducted when in-person research resumed, compared A1C values concurrently measured using the A1CNow and the DCA Vantage™ Analyzer (reference standard) collected by research staff at church testing sites.

RESULTS

In Phase 1, 98.8% of participants successfully completed at least 1 at-home A1C test; the overall failure rate was 24.7%. In Phase 2, the failure rate of staff-performed A1CNow testing was 4.4%. The Bland-Altman plot reveals that A1CNow values were 0.68% lower than DCA values, and the mean differences (A1CNow minus DCA) ranged from -2.6% to 1.2% with a limit of agreement between -1.9% to 0.5%.

CONCLUSIONS

A1C self-testing is feasible for use in community settings involving African American adults with T2D. The A1CNow Self-Check underestimated A1C values when compared with the reference standard. Ongoing improvements in point-of-care devices have the potential to expand research and clinical care, especially in underserved communities.

Relationship between housing insecurity, diabetes processes of care, and self-care behaviors

Background

The aim of this analysis was to examine the influence of housing insecurity on diabetes processes of care and self-care behaviors and determine if that relationship varied by employment status or race/ethnicity.

Methods

Using nationally representative data from the Behavioral Risk Factor Surveillance System (2014-2015), 16,091 individuals were analyzed for the cross-sectional study. Housing insecurity was defined as how often respondents reported being worried or stressed about having enough money to pay rent/mortgage. Following unadjusted logistic models testing interactions between housing insecurity and either employment or race/ethnicity on diabetes processes of care and self-care behaviors, stratified models were adjusted for demographics, socioeconomic status, health insurance status, and comorbidity count.

Results

38.1% of adults with diabetes reported housing insecurity. Those reporting housing insecurity who were employed were less likely to have a physicians visit (0.58, 95%CI 0.37,0.92), A1c check (0.45, 95%CI 0.26,0.78), and eye exam (0.61, 95%CI 0.44,0.83), while unemployed individuals were less likely to have a flu vaccine (0.84, 95%CI 0.70,0.99). Housing insecure White adults were less likely to receive an eye exam (0.67, 95%CI 0.54,0.83), flu vaccine (0.84, 95%CI 0.71,0.99) or engage in physical activity (0.82, 95%CI 0.69,0.96), while housing insecure Non-Hispanic Black adults were less likely to have a physicians visit (0.56, 95%CI 0.32,0.99).

Conclusions

Housing insecurity had an influence on diabetes processes of care and self-care behaviors, and this relationship varied by employment status and race/ethnicity. Diabetes interventions should incorporate discussion surrounding housing insecurity and consider differences in the impact by demographic factors on diabetes care.

Behavioral Sciences in the Optimization of Pharmacological and Non-Pharmacological Therapy for Type 2 Diabetes

Type 2 diabetes mellitus is one of the main chronic diseases worldwide, with a significant impact on public health. Behavioral changes are an important step in disease prevention and management, so the way in which individuals adapt their lifestyle to new circumstances will undoubtedly be a predictor of the success of the treatments instituted, contributing to a reduction in the morbidity and mortality that may be associated with them. It is essential to prepare and educate all diabetic patients on the importance of changing behavioral patterns in relation to the disease, with health professionals assuming an extremely important role in this area, both from a pharmacological and non-pharmacological point of view, and also ensuring the monitoring of the progress of these measures. Diabetes is a chronic disease that requires a high self-management capacity on the part of patients in order to achieve success in treating the disease, and non-adherence to therapy or non-compliance with the previously defined plan, together with an erratic lifestyle, will contribute to failure in controlling the disease. The lower adherence to pharmacological and non-pharmacological treatment in diabetes is mainly correlated to socio-economic aspects, lower health literacy, the side effects associated with the use of antidiabetic therapy or even the concomitant use of several drugs. This article consists of a narrative review that aims to synthesize the findings published in the literature, retrieved by searching databases, manuals, previously published scientific articles and official texts, following the methodology of the Scale for Assessment of Narrative Review Articles (SANRA). We aim to address the importance of behavioral sciences in the treatment of diabetes, in order to assess behavior factors and barriers for behavior changes that have an impact on the therapeutic and non-therapeutic optimization in patients with type 2 diabetes mellitus control.

Peer Coaching to Improve Diabetes Self-Management Among Low-Income Black Veteran Men: A Mixed Methods Assessment of Enrollment and Engagement

PURPOSE

We undertook a study to ascertain patient characteristics associated with enrollment and engagement in a type 2 diabetes peer health coaching program at an urban health care facility serving predominantly Black veteran men, to improve the targeting of such programs.

METHODS

A total of 149 patients declined enrollment in a randomized controlled trial but provided sociodemographic, clinical, and psychosocial information. A total of 290 patients enrolled and were randomized to 2 peer coaching programs; they provided sociodemographic, clinical, and survey data, and were analyzed according to their level of program engagement (167 engaged, 123 did not engage) irrespective of randomization group. Qualitative interviews were conducted with 14 engaged participants.

RESULTS

Patients who enrolled were more likely to be Black men, have higher levels of education, have higher baseline hemoglobin A_1c levels, describe their diabetes self-management as "fair" or "poor," and agree they "find it easy to get close to others" (P <.05 for each). At the program's end, patients who had engaged were more likely than those who had not to describe their peer coaches as being supportive of their autonomy (mean score, 85.4 vs 70.7; P <.001). The importance of coaches being encouraging, supportive, and having common ground/shared experiences with participants also emerged as key themes in interviews with engaged participants.

CONCLUSION

Individuals with greatest perceived need were more likely to enroll in our trial of peer coaching, but the only factor associated with engagement was finding one's coach to support autonomy. Our findings reinforce the importance of training and ensuring fidelity of peer coaches to autonomy-supportive communication styles for participant engagement. In tailoring peer support programs for Black men, future research should elucidate which shared characteristics between participant and peer coach are most important for engagement and improved outcomes.Visual abstract.

A Closer Look at Racial Differences in Diabetes Outcomes Among a Community Sample: Diabetes Distress, Self-care, and HbA1c

OBJECTIVE

Approximately 34 million people in the U.S. have diabetes. With this illness come substantial changes to psychological and physical health. However, type 2 diabetes disproportionately affects non-Hispanic Black compared with non-Hispanic White populations. The purpose of this study was to examine racial differences in psychological, behavioral, and physical health over time among individuals recently diagnosed with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were collected from a community sample of 193 adults recently diagnosed with type 2 diabetes (44% female; 45% Black). Measures of distress, self-care behaviors, and HbA1c were taken at an initial interview (time 1) and 6 months later (time 2). Individuals wore an Actical accelerometer to assess physical activity and participated in three 24-h dietary recall interviews to assess dietary intake within 2 weeks of the initial interview.

RESULTS

From time 1 to time 2, Black women showed the highest increase in depressive symptoms. There was a greater increase in regimen and physician distress among White compared with Black participants. White men and Black women reported a decline in medication adherence over time. There were no racial differences in changes in physical activity across 6 months. However, Black individuals had higher overall calorie consumption with greater protein, saturated fat, and cholesterol intake than White individuals. There were no race or sex differences in changes in glycemic stability.

CONCLUSIONS

Initial adjustment to a diagnosis of type 2 diabetes differentially influences Black and White men and women in terms of depressive symptoms, diabetes distress, and self-care.

Latinos understanding the need for adherence in diabetes (LUNA-D): a randomized controlled trial of an integrated team-based care intervention among Latinos with diabetes

We developed and tested a culturally appropriate, team-based, integrated primary care and behavioral health intervention in low income, Spanish-speaking Latinos with type 2 diabetes, at a federally qualified health center. This pragmatic randomized controlled trial included 456 Latino adults, 23-80 years, 63.7% female, with diabetes [recruitment glycosylated hemoglobin (HbA1c) ≥ 7.0%/53.01 mmol/mol)]. The Special Intervention occurred over 6 months and targeted improvement of HbA1c, blood pressure, and lipids. The intervention included: (i) four, same-day integrated medical and behavioral co-located visits; (ii) six group diabetes self-management education sessions addressing the cultural dimensions of diabetes and lifestyle messages; (iii) and care coordination. Usual Care participants received primary care provider led standard diabetes care, with referrals to health education and behavioral health as needed. HbA1c and lipids were obtained through electronic health records abstraction. Blood pressure was measured by trained research staff. Multi-level models showed a significant group by time interaction effect (B = -0.32, p < .01, 95% CI -0.49, -0.15), indicating statistically greater improvement in HbA1c level over 6 months in the Special Intervention group (ΔHbA1c = -0.35, p = <.01) versus Usual Care (ΔHbA1c = -0.02, p = .72). Marginally significant group by time interactions were also found for total cholesterol and diastolic blood pressure, with significant improvements in the Special Intervention group (p < .05). This culturally appropriate model of highly integrated care offers strategies that can assist with self-management goals and disease management for Latinos with diabetes in a federally qualified health center setting.

Effects of a Tailored Text Messaging Intervention Among Diverse Adults With Type 2 Diabetes: Evidence From the 15-Month REACH Randomized Controlled Trial

OBJECTIVE

Text messaging interventions have high potential for scalability and for reductions in health disparities. However, more rigorous, long-term trials are needed. We examined the long-term efficacy and mechanisms of a tailored text messaging intervention.

RESEARCH DESIGN AND METHODS

Adults with type 2 diabetes participated in a parallel-groups, 15-month randomized controlled trial and were assigned to receive Rapid Education/Encouragement and Communications for Health (REACH) for 12 months or control. REACH included interactive texts and tailored texts addressing medication adherence and nontailored texts supporting other self-care behaviors. Outcomes included hemoglobin A1c (HbA1c), diabetes medication adherence, self-care, and self-efficacy.

RESULTS

Participants (N = 506) were approximately half racial/ethnic minorities, and half were underinsured, had annual household incomes <$35,000, and had a high school education or less; 11% were homeless. Average baseline HbA1c was 8.6% ± 1.8%; 70.0 ± 19.7 mmol/mol) with n = 219 having HbA1c ≥8.5% (69 mmol/mol). Half were prescribed insulin. Retention was over 90%. Median response rate to interactive texts was 91% (interquartile range 75%, 97%). The treatment effect on HbA1c at 6 months (-0.31%; 95% CI -0.61%, -0.02%) was greater among those with baseline HbA1c ≥8.5% (-0.74%; 95% CI -1.26%, -0.23%), and there was no evidence of effect modification by race/ethnicity or socioeconomic disadvantage. REACH improved medication adherence and diet through 12 months and self-efficacy through 6 months. Treatment effects were not significant for any outcome at 15 months. REACH reduced barriers to adherence, but barrier reduction did not mediate outcome improvements.

CONCLUSIONS

REACH engaged at-risk patients in diabetes self-management and improved short-term HbA1c. More than texts alone may be needed to sustain the effects.

Self-management among type 2 diabetes patients via the WeChat application: A systematic review and meta-analysis

WHAT IS KNOWN AND OBJECTIVE

The incidence of diabetes has been rising worldwide and is expected to increase to affect 591.9 million people by 2035 in China. Strict control of blood glucose can significantly reduce the risk of diabetic complications, but traditional interventions lack continuity, timeliness and teleonomy. The development of mobile health management has become a hot topic, as a very popular app in China, WeChat platform, has a large number of users every day. Many studies show the health management of patients with diabetes through WeChat can achieve the ideal effect. This study aims to evaluate the application of WeChat based on clinical research data, provide clinical evidence for medical staff and promote the self-management of patients with diabetes.

METHODS

The PubMed, EMBASE, Cochrane Library, CNKI and Wanfang database were searched to identify related reports that were published up to 9 March 2020. The quality of included studies was assessed by Cochrane Collaboration risk assessment tool. Measures of interest were mean difference (MD) and 95% confidence interval (CI). Random-effect model was used according to the absence or presence of significant heterogeneity. Heterogeneity among trials was evaluated by I² test. Publication bias was assessed by funnel plots.

RESULTS AND DISCUSSION

Thirty-eight articles involved 2,709 controls and 2,709 patients who used WeChat were identified. Relative to the traditional group, WeChat group had a lower level in fasting plasma glucose (FPG in mmol/L; MD: 1.36, 95% CI 1.10-1.62, P < .00001), so did 2hPG (MD: 1.91, 95% CI 1.48-2.35, P < .00001) and HbA1C (MD: 1.07, 95% CI 0.86-1.27, P < .00001). Self-efficacy scale improved significantly, including diet score (MD: -1.31, 95% CI -1.77 to -0.86, P < .00001), exercise score (MD: -1.92, 95% CI -2.44 to -1.40, P < .00001), medication taking score (MD: -1.45, 95% CI: -1.94 to -0.97, P < .00001), monitoring of blood glucose score (MD: -1.17, 95% CI -1.83--0.51, P = .0005) and foot care score (MD: -1.71, 95% CI -2.08 to -1.34, P < .00001). Patients' understanding of the disease and satisfaction with follow-up increased significantly, whereas the incidence of adverse reactions and complications decreased.

WHAT IS NEW AND CONCLUSION

WeChat follow-up appears to be helpful to improve the level of blood glucose and self-management, reduce the incidence of adverse reactions and complications, and improve the satisfaction rate of patients with type 2 diabetes. It should be noted that this meta-analysis has limitations, such as small sample sizes and the low quality of included literature, as well as the lack of research in Western countries. Therefore, more high-quality studies with larger samples are needed in the future to verify our results.

Content Analysis: First-Time Patient User Challenges with Top-Rated Commercial Diabetes Apps

Background/Introduction: Using a mobile application (app) may improve diabetes self-management. However, the use of diabetes apps is low, possibly due to design and usability issues. The purpose of this study was to identify barriers to app use among adult patients with diabetes who were testing diabetes apps for the first time. Materials and Methods: We conducted a content analysis of observation notes and patient comments collected during the testing of two top commercially available diabetes apps as part of a crossover randomized trial. Participants were adult patients with type 1 or type 2 diabetes on insulin therapy. We analyzed field notes and transcriptions of audio recordings. Open coding derived categories of usability issues, which then were grouped into themes and subthemes on usability problem types. Results: A total of 92 adult Android smartphone users were recruited online (e.g., Facebook) and in-person postings. Three major themes described problems with data input, app report display and presentation, and self-learning options. Data entry modes were problematic because of overcrowded app screens, complicated "save data" steps, and a lack of data entry confirmation. The app icons, wording, entry headings, and analysis reports were not intuitive to understand. Participants wanted self-learning options (e.g., pop-up messages) during app use. Conclusions: Patient testing of top commercially available diabetes apps revealed key usability design issues in data entry, app report, and self-help learning options. Good app training for patients is necessary for both initial use and long-term use of diabetes apps to support self-management.

Mixed-Methods Randomized Evaluation of FAMS: A Mobile Phone-Delivered Intervention to Improve Family/Friend Involvement in Adults' Type 2 Diabetes Self-Care

BACKGROUND

Family and friends have both helpful and harmful effects on adults' diabetes self-management. Family-focused Add-on to Motivate Self-care (FAMS) is a mobile phone-delivered intervention designed to improve family/friend involvement, self-efficacy, and self-care via monthly phone coaching, texts tailored to goals, and the option to invite a support person to receive texts.

PURPOSE

We sought to evaluate how FAMS was received by a diverse group of adults with Type 2 diabetes and if FAMS improved diabetes-specific family/friend involvement (increased helpful and reduced harmful), diabetes self-efficacy, and self-care (diet and physical activity). We also assessed if improvements in family/friend involvement mediated improvements in self-efficacy and self-care.

METHODS

Participants were prospectively assigned to enhanced treatment as usual (control), an individualized text messaging intervention alone, or the individualized text messaging intervention plus FAMS for 6 months. Participants completed surveys at baseline, 3 and 6 months, and postintervention interviews. Between-group and multiple mediator analyses followed intention-to-treat principles.

RESULTS

Retention, engagement, and fidelity were high. FAMS was well received and helped participants realize the value of involving family/friends in their care. Relative to control, FAMS participants had improved family/friend involvement, self-efficacy, and diet (but not physical activity) at 3 and 6 months (all ps < .05). Improvements in family/friend involvement mediated effects on self-efficacy and diet for FAMS participants but not for the individualized intervention group.

CONCLUSIONS

The promise of effectively engaging patients' family and friends lies in sustained long-term behavior change. This work represents a first step toward this goal by demonstrating how content targeting helpful and harmful family/friend involvement can drive short-term effects.

TRIAL REGISTRATION NUMBER

NCT02481596.

User Engagement Among Diverse Adults in a 12-Month Text Message-Delivered Diabetes Support Intervention: Results from a Randomized Controlled Trial

Background

Text message–delivered interventions are a feasible and scalable approach for improving chronic disease self-care and reducing health disparities; however, information on long-term user engagement with these interventions is limited.

Objective

The aim of this study is to examine user engagement in a 12-month text message–delivered intervention supporting diabetes self-care, called REACH (Rapid Education/Encouragement And Communications for Health), among racially and socioeconomically diverse patients with type 2 diabetes (T2D). We explored time trends in engagement, associations between patient characteristics and engagement, and whether the addition of a human component or allowing patients to change their text frequency affected engagement. Qualitative data informed patients’ subjective experience of their engagement.

Methods

We recruited patients with T2D for a randomized trial evaluating mobile phone support relative to enhanced treatment as usual. This analysis was limited to participants assigned to the intervention. Participants completed a survey and hemoglobin A1c (HbA1c) test and received REACH text messages, including self-care promotion texts, interactive texts asking about medication adherence, and adherence feedback texts. For the first 6 months, texts were sent daily, and half of the participants also received monthly phone coaching. After 6 months, coaching stopped, and participants had the option to receive fewer texts for the subsequent 6 months. We defined engagement via responses to the interactive texts and responses to a follow-up interview. We used regression models to analyze associations with response rate and thematic and structural analysis to understand participants’ reasons for responding to the texts and their preferred text frequency.

Results

The participants were, on average, aged 55.8 (SD 9.8) years, 55.2% (137/248) female, and 52.0% (129/248) non-White; 40.7% (101/248) had ≤ a high school education, and 40.7% (101/248) had an annual household income <US $25,000. The median response rate to interactive texts was 91% (IQR 75%-97%) over 12 months. Engagement gradually declined throughout the intervention but remained high. Engagement did not differ by age, gender, education, income, diabetes duration, insulin status, health literacy, or numeracy. Black race and worse baseline medication adherence and HbA1c were each associated with lower engagement, although the effects were small. Nearly half of the participants chose to continue receiving daily texts for the last 6 months of the intervention. Participants who continued daily text messages said they wanted to continue experiencing benefits to their health, whereas those who chose fewer texts said that the daily texts had helped them create routines and they no longer needed them as often. Engagement was not impacted by receiving coaching or by participants’ chosen text frequency.

Conclusions

Well-designed interactive text messages can engage diverse patients in a self-care intervention for at least 1 year. Variation in and reasons for frequency preference suggest that offering a frequency choice may be important to users’ engagement.

Associations Between Racial and Ethnic Groups and Foot Self-Inspection in People With Diabetes

OBJECTIVE

Daily foot self-inspection may permit earlier detection and treatment of a foot lesion, reducing the risk of infection and lower-limb amputation (LLA). Though race and ethnicity are strongly associated with LLA risk, with higher risk seen in African Americans (AA), American Indians/Alaska Natives (AI/AN), and Native Hawaiians/Pacific Islanders (NH/PI), associations between foot self-inspection and racial and ethnic groups are inconsistent. We aimed to assess differences in foot self-inspection among people with diabetes by race/ethnicity.

RESEARCH DESIGN AND METHODS

Using national, cross-sectional data from the 2015-2017 Behavioral Risk Factor Surveillance System surveys and including 88,424 individuals with diabetes, we estimated prevalence ratios (PRs) and associated 95% CIs of daily foot checking for sores or irritation by racial and ethnic groups using log-binomial linear regression models, after accounting for survey weights.

RESULTS

Compared with whites (who had a weighted prevalence [P] of daily foot self-inspection of 57%), AA (P 67%, PR 1.18 [95% CI 1.14, 1.23]), AI/AN (P 66%, PR 1.15 [95% CI 1.07, 1.25]), and NH/PI (P 71%, PR 1.25 [95% CI 1.03, 1.52]) had higher prevalences of daily foot self-inspection. The prevalence of daily foot inspection was significantly lower among Asians (P 35%, PR 0.62 [95% CI 0.48, 0.81]) and Hispanics (P 53%, PR 0.93 [95% CI 0.88, 0.99]) compared with whites. Associations did not vary importantly by insulin use, years since diabetes diagnosis, or having received diabetes self-management education.

CONCLUSIONS

The higher frequency of foot self-inspection in racial and ethnic groups at elevated risk of diabetes-related LLA is not sufficient to eliminate LLA disparities; additional interventions are needed to achieve this aim.

New research directions on disparities in obesity and type 2 diabetes

Obesity and type 2 diabetes disproportionately impact U.S. racial and ethnic minority communities and low-income populations. Improvements in implementing efficacious interventions to reduce the incidence of type 2 diabetes are underway (i.e., the National Diabetes Prevention Program), but challenges in effectively scaling-up successful interventions and reaching at-risk populations remain. In October 2017, the National Institutes of Health convened a workshop to understand how to (1) address socioeconomic and other environmental conditions that perpetuate disparities in the burden of obesity and type 2 diabetes; (2) design effective prevention and treatment strategies that are accessible, feasible, culturally relevant, and acceptable to diverse population groups; and (3) achieve sustainable health improvement approaches in communities with the greatest burden of these diseases. Common features of guiding frameworks to understand and address disparities and promote health equity were described. Promising research directions were identified in numerous areas, including study design, methodology, and core metrics; program implementation and scalability; the integration of medical care and social services; strategies to enhance patient empowerment; and understanding and addressing the impact of psychosocial stress on disease onset and progression in addition to factors that support resiliency and health.

Development and Evaluation of a Blood Glucose Monitoring YouTube Video for Marshallese Patients Using a Community-Based Participatory Research Approach

The purpose of this study was to (a) describe the development of a culturally appropriate glucose monitoring video using a community-based participatory research approach and (b) assess the cultural appropriateness and effectiveness of the video. The topic of the video-using a glucometer and the importance of performing blood glucose checks-was chosen by Marshallese community stakeholders. The video was produced in Marshallese with English subtitles and disseminated through YouTube. Participants were recruited from August 16, 2016 to September 12, 2016 in a diabetes clinic that serves Marshallese patients in northwest Arkansas. Fifty participants completed a survey at pre- and postintervention, with questions capturing demographic information and questions on glucose monitoring self-efficacy using an adapted version of the Stanford Patient Education Research Center's Diabetes Self-Efficacy Scale. Twenty of those participants who completed the survey also completed semistructured interviews that assessed cultural appropriateness and effectiveness of the video. Participants reported significant increases in self-efficacy related to glucometer use and the importance of performing blood glucose checks (p < .001) and a 1.45% reduction in A1C between preintervention and 12 weeks postintervention (p = .006). Qualitative results indicated the video was both culturally appropriate and effective. The findings of this study were consistent with evidence in the literature, which shows health education videos can be effective at improving health behaviors. Using a community-based participatory research approach to prioritize video topics, and including members of the community in the creation and dissemination of the videos, could aid in ensuring the videos are effective and culturally appropriate.

Innovative Diabetes Interventions in the U.S. Hispanic Population

IN BRIEF In the United States, Hispanics have a 66% greater risk of developing type 2 diabetes and, once diagnosed, exhibit worse outcomes than non-Hispanic whites. It is therefore imperative to ensure that interventions meet the specific needs of this at-risk group. This article provides a selective review of the evidence on innovative, real-world approaches (both live and technology-based) to improving behavioral, psychosocial, and clinical outcomes in underserved Hispanics with type 2 diabetes. Key aspects of successful live interventions have included multimodal delivery, greater dosage/attendance, and at least some in-person delivery; effective technology-based approaches involved frequent but intermittent communication, bi-directional messaging, tailored feedback, multimodal delivery, and some human interaction. Across modalities, cultural tailoring also improved outcomes. Additional research is needed to address methodological limitations of studies to date and pinpoint the most efficacious components and optimal duration of interventions. Future efforts should also attend to variability within the U.S. Hispanic population to ensure acceptability and sustainability of interventions in this diverse group.

Beyond Race Disparities: Accounting for Socioeconomic Status in Diabetes Self-Care

INTRODUCTION

Among patients with type 2 diabetes, racial disparities are prevalent across a variety of outcomes; however, inconsistent disparities in determinants of outcomes warrants exploring the impact of other, related factors. This study sought to examine whether disparities in health literacy, numeracy, self-care behaviors, and HbA1c persisted between non-Hispanic blacks and non-Hispanic whites after applying a robust adjustment for socioeconomic status (SES).

METHODS

From 2016 to 2018, adult patients with type 2 diabetes (N=444) were recruited from primary care clinics. Participants self-reported demographics; indicators of SES (i.e., income, education, health insurance, housing status, and financial strain); subjective health literacy and numeracy; and self-care behaviors. Participants also completed an HbA1c test. In 2018, differences were examined between non-Hispanic blacks and non-Hispanic whites in health literacy, numeracy, self-care, and HbA1c, first unadjusted and then adjusted using propensity score weighting.

RESULTS

In unadjusted analyses, compared with non-Hispanic whites, non-Hispanic blacks had lower health literacy (p=0.039) and numeracy (p<0.001); less medication adherence (p=0.009); use of information for dietary decisions (p=0.013); and problem eating behaviors (p<0.001; i.e., non-Hispanic blacks reported fewer problems); and higher HbA1c levels (p=0.005). After adjusting for all SES indicators, only the reverse disparity in problem eating behaviors (p=0.016) and the disparity in HbA1c (p=0.011) remained.

CONCLUSIONS

Findings highlight the importance of considering SES when examining disparities in health-related skills and behaviors. Moving beyond education and income to inclusion of more comprehensive markers of SES can improve understanding of how SES may contribute to disparities and the ability to appropriately target factors leading to inequality.

Sex, race, and the role of relationships in diabetes health: intersectionality matters

Previous research has seldom used an intersectionality framework to consider how sex and race affect diabetes health, nor has it examined the role of sex and race in the well-established link between romantic relationship quality and health. This study targeted 200 adults with type 2 diabetes (46% Black; 45% female) and examined whether sex, race, and the interaction between sex and race predicted behavioral and psychological health, or moderated the link between relationship quality and health outcomes. Black women reported poorer diabetes self-care and lower self-efficacy compared to other groups. Relationship quality was associated with better self-care, increased self-efficacy, and lower depressive symptoms. The association between relationship quality and medication adherence was stronger for Black women, and the association between relationship quality and self-efficacy was stronger for both Black women and White men. Results suggest that Black women with diabetes experience more health disadvantages than other groups, but some of these disadvantages might be attenuated by supportive romantic relationships.

Out-of-home informal support important for medication adherence, diabetes distress, hemoglobin A1c among adults with type 2 diabetes

Adults with type 2 diabetes mellitus (T2DM) often receive self-management support from adult children, siblings or close friends residing outside of their home. However, the role of out-of-home support in patients' self-management and well-being is unclear. Patients (N = 313) with HbA1c > 7.5% were recruited from community primary care clinics for a mobile health intervention trial and identified an out-of-home informal support person, herein called a CarePartner; 38% also had an in-home supporter. We tested cross-sectional adjusted associations between CarePartner relationship characteristics and patients' self-management, diabetes distress, and HbA1c and whether having an in-home supporter modified these associations. Greater CarePartner closeness was associated with a greater odds of perfect medication adherence (AOR = 1.19, p = .029), more fruit/vegetable intake (β = 0.14, p = .018), and lower diabetes distress (β = - 0.14, p = .012). More frequent CarePartner contact was associated with better HbA1c among patients with an in-home supporter but with worse HbA1c among patients without an in-home supporter (interaction β = - 0.45, p = .005). Emotional closeness with a CarePartner may be important for supporting T2DM self-management and reducing diabetes distress. CarePartners may appropriately engage more frequently when patients with no in-home supporter have poorly controlled diabetes.

Diabetes Self-Care Behaviors Among Marshallese Adults Living in the United States

Marshallese experience high rates of type 2 diabetes. Proper management of diabetes requires multiple self-care behaviors, yet little is known about Marshallese's diabetes-related self-care behaviors. Survey data from 111 Marshallese adults with diabetes were used to examine relationships between self-care behaviors and socio-demographic characteristics. The most common self-care behavior was attending annual doctor visits, while the least common was maintaining a normal weight. Age group, education level, and having a regular doctor were significantly associated with engaging in self-care behaviors. Having a regular doctor had the most effect on performing self-care behaviors (p = 0.006); although, only 38.7% reported having a regular doctor. To minimize diabetes-related complications, efforts to improve self-care behaviors among the Marshallese should be developed. Alternatives to traditional healthcare providers, such as community health workers, may be a viable strategy with this population given only one-third reported having a regular doctor.

The "A to Z" of Managing Type 2 Diabetes in Culturally Diverse Populations

Type 2 diabetes affects racial/ethnic minorities at an alarming rate in the US and in many countries around the world. The quality of health care provided to these groups is often suboptimal, resulting in worse patient-related outcomes when compared to those in mainstream populations. Understanding the complex biological elements that influence the development and course of the disease in high-risk populations is extremely important but often insufficient to implement effective prevention and treatment plans. Multiple factors must be addressed in routine diabetes clinical care. This paper discusses various key factors, organized in alphabetical order. These are acculturation, biology, clinician's cultural awareness, depression and diabetes-specific emotional distress, educational level, fears, group integration, health literacy, intimacy and sexual dysfunction, judging, knowledge of the disease, language, medication adherence, nutritional preferences, other forms of medicine (alternative), perception of body image, quality of life, religion and faith, socio-economic status, technology, unconscious bias, vulnerable groups, asking why?, exercise, "you are in charge" and zip it! Considering these factors in the development of type 2 diabetes prevention and treatment programs will help improve diabetes-related outcomes in culturally diverse populations and reduce health care disparities.

Assessing barriers to diabetes medication adherence using the Information-Motivation-Behavioral skills model

AIMS

Medication nonadherence is a prevalent and costly problem among patients with type 2 diabetes. Applications of theory can inform and improve adherence promotion interventions. We used a new assessment based on the Information-Motivation-Behavioral skills (IMB) model of adherence to assess patient-reported barriers and test the theoretical model.

METHODS

Participants (N = 237) completed a card sorting task to identify barriers to adherence, a survey, and a hemoglobin A1c (HbA1c) test. We identified the most commonly reported adherence barriers and examined associations between patient characteristics and barriers mapped onto each of the IMB constructs. We used structural equation modeling to test the IMB model and determine if barriers as reported on this measure predict patients' self-reported diabetes medication adherence and, in turn, HbA1c levels.

RESULTS

The most frequently reported barriers were forgetting doses, thinking brand name medicine works better than generic medicine, not seeing immediate benefit, and feeling burned out with taking diabetes medicine. Younger age and lower health literacy were associated with higher barrier scores for all IMB model constructs. Information and social motivation barriers affected adherence via behavioral skills barriers (indirect effects -0.19, CI [-0.33, -0.09] and -0.24, CI [-0.37, -0.14], respectively). The IMB barrier constructs explained 44% of the variance in diabetes medication adherence which, in turn, was significantly associated with and explained 8% of the variance in HbA1c (both p < .001).

CONCLUSIONS

Results suggest this assessment task can identify patient-specific barriers to diabetes medication adherence. Interventions targeting patient-specific barriers using this assessment could improve adherence and HbA1c.

US ethnic group differences in self-management in the 2nd diabetes attitudes, wishes and needs (DAWN2) study

AIMS

Understanding the relationship between ethnicity and self-management is important due to disparities in healthcare access, utilization, and outcomes among adults with type 2 diabetes from different ethnic groups in the US.

METHODS

Self-reports of self-management and interest in improving self-management from US people with diabetes (PWD) in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) study, a multinational, multi-stakeholder survey, were analyzed, including 447 non-Hispanic White, 241 African American, 194 Hispanic American, and 173 Chinese American PWD (>18 years).

RESULTS

Overall, self-management behavior was highest for medication taking and lowest for physical activity. Non-Hispanic Whites had lowest physical activity and highest adherence to insulin therapy. Chinese Americans had lowest foot care and highest healthy eating. Overall, interest was highest for improving healthy eating and physical activity. Chinese Americans and Hispanic Americans were more interested than non-Hispanic Whites in improving most self-management behaviors. Chinese Americans were more interested than African Americans in improving most self-management behaviors. Healthcare providers telling PWD that their A1c needs improvement was associated with lower self-rated glucose control, which was associated with higher PWD interest in improving self-management behaviors.

CONCLUSIONS

Diabetes care providers should use patient-centered approaches and consider ethnicity in tailoring self-management support.

Mobile Phone Support for Diabetes Self-Care Among Diverse Adults: Protocol for a Three-Arm Randomized Controlled Trial

Background

Nonadherence to self-care is common among patients with type 2 diabetes (T2D) and often leads to severe complications. Moreover, patients with T2D who have low socioeconomic status and are racial/ethnic minorities disproportionately experience barriers to adherence and poor outcomes. Basic phone technology (text messages and phone calls) provides a practical medium for delivering content to address patients’ barriers to adherence; however, trials are needed to explore long-term and sustainable effects of mobile phone interventions among diverse patients.

Objective

The aim of this study is to evaluate the effects of mobile phone–based diabetes support interventions on self-care and hemoglobin A_1c (HbA_1c) among adults with T2D using a 3-arm, 15-month randomized controlled trial with a Type 1 hybrid effectiveness-implementation approach. The intervention arms are (1) Rapid Encouragement/Education And Communications for Health (REACH) and (2) REACH + Family-focused Add-on for Motivating Self-care (FAMS).

Methods

We recruited primary care patients with T2D (N=512) from Federally Qualified Health Centers and an academic medical center, prioritizing recruitment of publicly insured and minority patients from the latter. Eligible patients were prescribed daily diabetes medication and owned a cell phone with text messaging capability. We excluded patients whose most recent HbA_1c result within 12 months was <6.8% to support detection of intervention effects on HbA_1c. Participants were randomly assigned to REACH only, REACH + FAMS, or the control condition. REACH provides text messages tailored to address patient-specific barriers to medication adherence based on the Information-Motivation-Behavioral skills model, whereas FAMS provides monthly phone coaching with related text message content focused on family and friend barriers to diet and exercise adherence. We collect HbA_1c and self-reported survey data at baseline and at 3, 6, and 12 months, and again at 15 months to assess sustained changes. We will use generalized estimating equation models to test the effects of REACH (either intervention arm) on HbA_1c relative to the control group, the potential additive effects of FAMS, and effects of either intervention on adherence to self-care behaviors and diabetes self-efficacy.

Results

The trial is ongoing; recruitment closed December 2017. We plan to perform analyses on 6-month outcomes for FAMS in July 2018, and project to have 15-month data for REACH analyses in April 2019.

Conclusions

Our study will be one of the first to evaluate a long-term, theory-based text messaging intervention to promote self-care adherence among racially/ethnically and socioeconomically diverse adults with T2D. Moreover, our study will assess the feasibility of a family-focused intervention delivered via mobile phones and compare the effects of text messaging alone versus text messaging plus phone coaching. Findings will advance our understanding of how interventions delivered by phone can benefit diverse patients with chronic conditions.

Trial Registration

ClinicalTrials.gov NCT02409329; https://clinicaltrials.gov/ct2/show/NCT02409329 (Archived by WebCite at http://www.webcitation.org/6yHkg9SSl); NCT02481596; https://clinicaltrials.gov/ct2/show/NCT02481596 (Archived by WebCite at http://www.webcitation.org/6yHkj9XD4)

Effect of Changing Work Stressors and Coping Resources on the Risk of Type 2 Diabetes: The OHSPIW Cohort Study

OBJECTIVE

Little is known about the relationship between changing psychosocial work conditions and type 2 diabetes. We determined whether changing work stressors and coping resources affect the risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

In this prospective cohort (2003-2014) of 3,740 workers without diabetes (OHSPIW [Occupational Health Study of Petroleum Industry Workers]), participants completed an evaluation of work-related stress and coping resources and type 2 diabetes diagnosis at baseline and 12 years follow-up (two waves). The changes in work stressors and coping resources were measured with the Occupation Stress Inventory-Revised and the Instrument for Stress-Related Job Analysis (Version 6.0). Type 2 diabetes was diagnosed on the basis of an oral glucose tolerance test supplemented by physician report.

RESULTS

Increased task stressors (relative risk [RR] 1.57 [95% CI 1.03-2.63]) and decreased coping resources (RR 1.68 [95% CI 1.02-2.83]) were associated with risk of type 2 diabetes. The main risk factors were increased role overload, increased role insufficiency, increased physical environment stressors, decreased self-care, and decreased rational coping. Increased coping resources also had a buffering effect on increased task stressors and type 2 diabetes.

CONCLUSIONS

Changes in work stressors and coping resources have an influence on the risk for type 2 diabetes, highlighting the importance of preventive measures against adverse psychosocial work conditions and reduced coping resources for diabetes prevention in the workplace.

Differential and Combined Effects of Physical Activity Profiles and Prohealth Behaviors on Diabetes Prevalence among Blacks and Whites in the US Population: A Novel Bayesian Belief Network Machine Learning Analysis

The current study assessed the prevalence of diabetes across four different physical activity lifestyles and infer through machine learning which combinations of physical activity, sleep, stress, and body mass index yield the lowest prevalence of diabetes in Blacks and Whites. Data were extracted from the National Health Interview Survey (NHIS) dataset from 2004-2013 containing demographics, chronic diseases, and sleep duration (N = 288,888). Of the total sample, 9.34% reported diabetes (where the prevalence of diabetes was 12.92% in Blacks/African Americans and 8.68% in Whites). Over half of the sample reported sedentary lifestyles (Blacks were more sedentary than Whites), approximately 20% reported moderately active lifestyles (Whites more than Blacks), approximately 15% reported active lifestyles (Whites more than Blacks), and approximately 6% reported very active lifestyles (Whites more than Blacks). Across four different physical activity lifestyles, Blacks consistently had a higher diabetes prevalence compared to their White counterparts. Physical activity combined with healthy sleep, low stress, and average body weight reduced the prevalence of diabetes, especially in Blacks. Our study highlights the need to provide alternative and personalized behavioral/lifestyle recommendations to generic national physical activity recommendations, specifically among Blacks, to reduce diabetes and narrow diabetes disparities between Blacks and Whites.