Dietary compliance among insulin-dependent diabetics

Chronic conditions in adolescents

The health problems related to the nervous system are on rise in young infants leading to high mortality amongst this age group. A chronic medical condition (CC) is present in this age group to the tune of 10–20%. We searched the electronic database PubMed for pre-clinical as well as clinical controlled trials reporting variable chronic conditions especially in pediatric patients. Most of these reports revealed that type 1 diabetes mellitus is the most common CC in young infants. In female patients, metabolic control is often disturbed during CC in this age group. Poor metabolism regulation often results in long-term complications, including cognitive disorders. In cognitive disorders, memory loss and learning problems are the most among adolescents. Executive problems are observed to be associated with low physical activities. The review article concludes that knowledge about factors influencing treatment adherence is crucial in chronically ill infants. Further, we should focus on protective factors in order to prevent health risk behavior.

Testing A Model of Diabetes Self-Care Management

The daily management of diabetes involves a complex interaction of metabolic variables, self-care behaviors, andpsychological and social adjustments to having the disease. Diabetes patient-education programs usually focus on the self-care aspects of managing the disease with emphasis on specific cognitive knowledge and performance of daily diet, medication and exercise routines. This study presents a model of diabetes management which includes an attitudinal element -the personal meaning of having diabetes. This expanded model allows for testing of hypothesized relationships between all elements, rather than a single linear cause and effect model Data were obtained from 115 Type I and 105 type II people from three states who hadhaddiabetesforatleastoneyear. Thedata were analyzed using a structural equation analysis (LISREL VI). While the results showed that the data did not fit the proposed model well enough to allow for definitive conclusions, the results are generally supportive of the original hypothesis that the personal meaning of diabetes is an important element in the daily management of diabetes and the psychosocial adjustment to the disease.

Greater professional empathy leads to higher agreement about decisions made in the consultation

OBJECTIVE

To examine the relationship between professional expression of empathy and agreement about decisions made in the consultation.

METHODS

Consultations between 86 individuals with diabetes and four dieticians were audio-recorded. Immediately following consultations patients and dieticians independently reported decisions made in a booklet. Audio-recordings were coded directly for empathy using an amended version of the empathic communication coding system (ECCS).

RESULTS

Empathy correlated significantly with patient and professional agreement about decisions made in the consultation (τ=.283, p=.0005). Multiple regression analysis indicates that for each dietician the greater the empathy the higher the level of agreement about decisions (p<.0005). Professional empathic response to patients statements of challenge was a significant factor in increasing agreement about decisions (p=.008).

CONCLUSION

Results support the hypothesis that greater professional empathy will result in greater agreement about decisions made in consultations.

PRACTICE IMPLICATIONS

Findings have implications for empathy training and provide guidance on the communication skills needed to support expression of empathy. Patient and professional agreement about decisions made provides a simple marker of effectiveness and highlights the importance of empathy as a seminal component of professional communication skills during a patient consultation.

Hemoglobin A1c self-recording in the management of diabetes mellitus. A pilot study

HbA1c evaluates glycemic control 3-6 weeks retrospectively. To achieve improvements in glycemic control we have tested a patient-administered HbA1c control program in 12 (11 type I) diabetic patients. In the program, HbA1c was estimated once a month for 12 months and the results were mailed to the patient who recorded them in a specially designed HbA1c chart. The results in the probands were compared with 24 matched (22 type I) diabetic patients. The results showed that HbA1c fell significantly (p less than 0.01) during the year in the probands, from 8.84 +/- 1.12% to 7.48 +/- 0.95%, and was unchanged in the controls (8.41 +/- 1.78% and 8.17 +/- 1.74%, respectively). Accordingly, HbA1c self-recording improves glycemic control in diabetic patients.

Deteriorating diabetic control through adolescence-do the origins lie in childhood?

AIMS

To determine whether intra-individual measures of diabetes control deteriorated through adolescence and whether HbA1c in late childhood was predictive of HbA1c after adolescence.

METHODS

Retrospective analysis of sequential 3-6 monthly data including HbA1c, height, weight, and total daily insulin dosage in 118 patients with Type 1 diabetes aged between 8.00 and 17.99 years between 1983 and 1999.

RESULTS

In females mean body mass index (BMI) increased sharply during adolescence but there was no significant increase in males. The mean total daily dose of insulin/weight (TDDI/W) increased sharply for females through puberty. Males exhibited a constant rate of increase in mean TDDI/W from pre- to post-puberty. There was a constant increase in mean HbA1c for females, with an estimated increase from pre- to post-puberty of 0.92%. In males there was only a slight increase from pre- to peri-puberty and no change subsequently. Comparing pre-puberty (8-9.99 years) and post-puberty (15-17.99 years) in the total group, 47% of patients remained in the same mean HbA1c grouping, 37% had worsened control and 16% had improved control. Analysis of change in the absolute value of mean HbA1c showed that the majority of patients had mean HbA1c values that remained within +/- 1% (54%) or +/- 2% (82%) from pre- to post-puberty. A significant proportion showed significantly worsening control with only a minority showing improved metabolic control from pre- to post-puberty.

CONCLUSIONS

The likelihood of a significant improvement in HbA1c from late childhood to adolescence is remote, with the majority of patients having either constant or deteriorating metabolic control.

The impact of patient adherence on health outcomes for patients with chronic disease in the Medical Outcomes Study

The association between adherence to medical recommendations and health outcomes (physical, role, and social functioning, energy/fatigue, pain, emotional well-being, general health perceptions, diastolic blood pressure, and glycohemoglobin) was examined in a 4-year longitudinal, observational study of 2125 adult patients with chronic medical conditions (hypertension, diabetes, recent myocardial infarction, congestive heart failure) and/or depression. Change score models were evaluated, controlling for disease and comorbidity. Patient adherence was associated minimally with improvement in health outcomes in this study. Only 11 of 132 comparisons showed statistically significant positive effects of adherence on health outcomes. We conclude that the relationship between adherence and health outcomes is much more complex than has often been assumed.

Psychosocial correlates of glycemic control: the Pittsburgh Epidemiology of Diabetes Complications (EDC) Study

The psychosocial correlates of glycemic control were examined in an incident cohort of childhood onset insulin-dependent diabetic subjects aged 18 years or older (n = 592). Glycosylated hemoglobin was measured at subjects' clinical examination, and questionnaires on diabetes self-care activity, barriers to regimen adherence and social support were completed. Demographic information was also collected. Glycosylated hemoglobin (GHb) was correlated with age, income and educational attainment (correlations coefficients between -0.1 and -0.2; P < 0.01), suggesting that older, more educated and wealthier patients have better glycemic control. GHb was also inversely associated with the degree of self-care activity (r = -0.11; P < 0.01), in particular administering injections at the recommended times and the frequency of performing blood/urine tests. Factors related to self-care behavior were identified, and included degree of social support (r = 0.14; P < 0.001) and patients' reports of difficulties adhering to their self-care regimen (r = -0.3; P < 0.0001). Gender was also related to self-care activities, with women reporting more self-care behavior than men (mean self-care scores 17.9 +/- 3.7 vs. 16.9 +/- 4.0; P < 0.01). Thus psychosocial factors (e.g. low income and education) may have an important effect on glycemic control in adults, and also (e.g. social support and adherence difficulties) seem particularly important in influencing the performance of self-care. As good metabolic control may help avoid the progression of diabetic complications, efforts need to be directed towards patients with these characteristics who are more likely to experience difficulties with self-care.

Metabolic control and diet in Finnish diabetic adolescents

The effects of dietary, clinical and demographic factors on metabolic control in 105 diabetic adolescents were studied. All patients had diabetes for longer than two years and a daily insulin dose greater than 0.5 IU/kg body weight. Low body mass index, high social class, high number of daily eating occasions, high day-to-day variation in energy intake, high number of urine tests and a long interval between insulin injection and eating were associated with good metabolic control. Many of these determinants reflect also the general compliance with the diabetic regimen. The results stress the importance of good coordination between insulin injections and eating habits.

Impact of community-based diabetes education on program attenders and nonattenders

This study reports on the differential impact of a moderately intensive diabetes education program on program attenders and dropouts. Sixty-one individuals with diabetes mellitus participated in a diabetes education program to increase knowledge, self-care, and metabolic control. Program attenders demonstrated a significant increase in diabetes knowledge and foot care irrespective of whether they attended the control or education groups. A discriminant analysis suggested that the nonattenders were more poorly educated, had less income, were younger, had had diabetes twice as long, reported more barriers to self-care, and were in poorer health than attenders. These results suggest that patients who attend interventions may be able to benefit from even minimal levels of intervention, while program dropouts may need special assistance to overcome obstacles to program participation.

Demographic, knowledge, physiological, and behavioral variables as predictors of compliance with dietary treatment goals in hypertension

The Hypertension Prevention Trial (HPT) was a multicenter, randomized trial testing calorie control, sodium restriction, and potassium increases in the prevention of hypertension in 841 men and women. Thirty four variables that were potentially related to changes in urine sodium, urine potassium, and weight were examined individually and together across 3 years of treatment and maintenance sessions. Univariate and multivariate analysis did not reveal a consistent pattern of variables associated with successful attainment of treatment goals or failure to do so. Baseline levels of urine sodium, urine potassium, and weight were the variables most consistently associated with compliance. Household composition, such as number of people living in the house or marital status and control over selection and preparation of foods, was associated with compliance in sodium reduction treatments. Number of complaints about the diets were positively associated with noncompliance. Attendance at treatment sessions was generally associated with compliance especially for weight loss. Practical implications of these results are discussed.

Services and cost of hospitalization for children and adolescents with insulin-dependent diabetes mellitus in New South Wales

Data on services for Australian children and adolescents with diabetes are limited. The purpose of the present study was to examine the availability, utilization and some of the costs of services for persons of less than 20 years of age with insulin-dependent diabetes mellitus in New South Wales, and to make recommendations for future services. The numbers of prevalent and incident cases of insulin-dependent diabetes mellitus in the zero- to 19-years' age-group in each of the health regions of the State were estimated using data from the insulin-dependent diabetes mellitus register of the Southern Metropolitan Health Region. Information on the available services for young persons with diabetes was obtained from doctors and diabetes educators around the State, and on the utilization of services in the Southern Metropolitan Health Region from interviewing the families of persons whose names are listed in the diabetes register. An estimated range of the annual direct cost of hospital admissions for diabetes in the zero- to 19-years' age-group in New South Wales was calculated by use of the data collected from the diabetes register, the hospital separation data from the NSW Department of Health, the NSW Department of Health estimated bed-day cost and the estimated average cost of a bed day for diabetic patients at The Children's Hospital Camperdown. Services for children and adolescents with insulin-dependent diabetes mellitus in this State are most comprehensive in central Sydney. However, even these excellent services are not utilized fully by the children and their families. The annual cost of hospitalization for diabetes in the zero- to 19-years' age-group in New South Wales is estimated to be approximately +1.5 million. There needs to be an equally high standard of care for all diabetic children in the State; however, the utilization of services, as well as the services themselves, need to be improved and the cost-effectiveness of new services needs to be evaluated.

Patient-provider interactions and patient outcomes

Research shows that a number of provider interactional skills are empirically related to patient adherence, making interaction skills a necessary and important part of clinical competence. These skills fall into three broad categories: techniques to elicit and modify patients' health and treatment beliefs, to aid recall of information, and to aid adherence. Specific skills in each category are discussed. Research further shows that health care providers can be taught effective communication skills, and that one of the most effective teaching techniques is audio or video feedback in which the provider's interaction with a patient is judged by tutor and peers using explicit, empirically based criteria.

Influencing the personal meaning of diabetes: research and practice

Diabetes patient education involves the cognitive, psycho motor, and affective domains. This paper focuses on the influence diabetes patient education has on how people feel about having diabetes and what it means to them. Our research suggests that diabetes patient education can contribute to more positive attitudes about diabetes and that diabetes educators should address the affective domain directly. Strategies for influencing the personal meaning of diabetes are presented and discussed.

Dietary variation in diabetics

The day to day variation in the energy and carbohydrate intake of 168 children with diabetes on Tyneside and Teesside was less than that of 405 non-diabetic children. It was, however, still considerable, the average range of carbohydrate intake over three days being 51 g. The variation in carbohydrate intake was not related to diabetic control nor to the families' knowledge of diabetes. Compliance with the dietary prescription deteriorated during the day. These findings support a qualitative approach to the dietary prescriptions for diabetics.

Meta-analysis of the effects of educational and psychosocial interventions on management of diabetes mellitus

A meta-analysis of the literature of controlled studies of educational and psychosocial interventions in the treatment of diabetes mellitus yielded 93 studies of 7451 patients testing the effects of eight intervention types: (1) didactic education, (2) enhanced education, (3) diet instruction, (4) exercise instruction, (5) self-monitoring instruction, (6) social learning/behavior modification, (7) counseling, and (8) relaxation training. An overall mean effect size (ES) of +0.51 +/- 0.11 was found moderate but significant (P less than 0.05) improvements for all intervention subjects. Physical outcome and knowledge gain were most affected, followed by psychological status and compliance. Diet instruction and social learning interventions showed the strongest (ES = +0.68 +/- 0.58 and ES = +0.57 +/- 0.42, respectively) and relaxation training the weakest (ES = +0.30 +/- 0.74) effects. Associations between study and sample characteristics and mean ES values were explored with type of setting and methodological weaknesses such as single group design and non-random assignment achieving statistical significance. Neither intervention type, number of visits, sex, age, nor type of diabetes were significantly correlated with mean ES values. Implications of these findings for clinical treatment and future research are discussed.

Dietary survey of Finnish adolescent diabetics and non-diabetic controls

Food consumption data of 152 diabetic and 74 non-diabetic adolescents were collected by means of two 48 h recall interviews. The nutrient density of the diet was systematically higher for the diabetics than the controls. The energy intake from protein was higher for the diabetics (18% vs. 15%), and correspondingly the proportion of fat lower (33% vs. 36%). The ratio of polyunsaturated to saturated fatty acids was higher for the diabetics (0.49 vs. 0.39) and the share of energy from sucrose for the controls (14% vs. 4%). The intra-individual variation in nutrient intakes was higher for the controls. The diet of the diabetics met reasonably well the recommendations for diabetics and also the general recommendations for a healthy population. However, the differences between the diabetics and controls regarding food consumption, nutrient intake and intra-individual variation of nutrient intake decreased with age.

Self-care behaviors and glycemic control in type I diabetes

This study investigated the degree of adherence to different aspects of the diabetic treatment regimen (insulin injections, glucose testing, diet, and exercise), the consistency of adherence across different regimen areas, and relationships between adherence and glycemic control. A predominantly adult community sample of 93 insulin dependent outpatients participated in the prospective study that involved two series of home interviews separated by a 6-month interval. Multiple measures of adherence (e.g. self-report, interview/recall, self-monitoring, and objective indices) were collected for each regimen area. Results indicated that the degree of adherence was higher for medication taking and glucose testing than for regimen tasks requiring greater lifestyle modifications such as diet and exercise; there were few strong relationships between subjects' adherence to one area of the regimen and the extent to which they adhered to other regimen tasks; and no clear relationship between adherence and glycemic control could be demonstrated through either bivariate or multivariate analyses. It is recommended that regimen adherence be considered in the context of other factors that may influence glycemic control (e.g. stress, individual metabolic factors, appropriateness of regimen prescriptions) rather than assuming a one-to-one relationship between adherence and control.

Nutrition education for risk factor reduction and patient education: a review

Studies of adult nutrition education and counseling for weight reduction, diabetes, cancer, low-fat diets, sodium-restricted diets, and renal diets are reviewed and synthesized. Nutrition education consists of three phases: assessment or problem diagnosis, intervention, and evaluation and monitoring. This article examines the importance of accurate problem diagnosis, the use of behavioral and biological measures of nutrition education effectiveness, and the types and effects of reported strategies. In addition, the issues of maintaining behavioral changes, nutrition education providers and their training, and settings for nutrition education are discussed. Implications and suggestions for advances in practice, theory, and research in patient nutrition education are presented.