Racial differences in diabetes self-management and quality of care in Texas

Promotore-Led Versus Registered Nurse-Led Diabetes Self-Management Education in Mexican Americans: A Randomized Clinical Trial

PURPOSE

The purpose of this study is to compare the benefits of a diabetes self-management program led by registered nurses (RNs) versus community health workers (promotores) for Spanish-speaking Mexican Americans with type 2 diabetes (T2DM).

METHODS

Three hundred thirty Spanish-speaking Mexican American adults with T2DM were randomly assigned to "Tomando Control de Su Diabetes" delivered for six 2.5-hour sessions either by promotores or RNs. The primary outcome measure was the Summary of Diabetes Self-Care Activities (SDSCA). Evaluations were made at baseline, 6 weeks, and at 3, 6, and 12 months. Mixed-effects regression models were fit to test if participants had differential changes in the SDSCA total score by group over time, controlling for demographic and clinical factors.

RESULTS

SDSCA scores were significantly higher at all time points compared to baseline and not statistically different between the 2 groups. Only years of education correlated with improvement in diabetes self-management behaviors. No moderating variables predicted improvement between groups.

CONCLUSIONS

Spanish-speaking Mexican American adults with T2DM who participated in a diabetes educational program with promotores or RNs demonstrated similar improvements. Promotores may increase the accessibility of effective diabetes self-management training for this difficult-to-reach population.

Improving Access to Eye Care: A Systematic Review of the Literature

PURPOSE

The goals were to develop a working and inclusive definition of access to eye care, identify gaps in the current system that preclude access, and highlight recommendations that have been identified in prior studies. This manuscript serves as a narrative summary of the literature.

CLINICAL RELEVANCE

Health care disparities continue to plague the nation's well-being, and eye care is no exception. Inequities in eye care negatively affect disease processes (i.e., glaucoma, cataracts, diabetic retinopathy), interventions (surgical treatment, prescription of glasses, referrals), and populations (gender, race and ethnicity, geography, age).

METHODS

A systematic review of the existing literature included all study designs, editorials, and opinion pieces and initially yielded nearly 2500 reports. To be included in full-text review, an article had to be US-based, be written in English, and address 1 or more of the key terms "barriers and facilitators to health care," "access," and "disparities in general and sub-specialty eye care." Both patient and health care professional perspectives were included. One hundred ninety-six reports met the inclusion criteria.

RESULTS

Four key themes regarding access to eye care from both patient and eye care professional perspectives emerged in the literature: (1) barriers and facilitators to access, (2) utilization, (3) compliance and adherence, and (4) recommendations to improve access. Common barriers and facilitators included many factors identified as social determinants of health (i.e., transportation, insurance, language, education). Utilization of eye care was largely attributable to having coverage for eye care, recommendations from primary care professionals, and improved health status. Geographic proximity, age, and lack of transportation surfaced as factors for compliance and adherence. There were a variety of recommendations to improve access to eye care, including improving presence in community health clinics, reimbursement for physicians, and funding of community-based programs such as DRIVE and REACH.

CONCLUSIONS

The eye care profession has abundant evidence of the disparities that continue to affect marginalized communities. Improving community-based programs and clinics, addressing social determinants of health, and acknowledging the effects of discrimination and bias on eye care serve as ways to improve equity in this field.

Trends and Variations in Emergency Department Use Associated With Diabetes in the US by Sociodemographic Factors, 2008-2017

IMPORTANCE

Little is known about emergency department (ED) use among people with diabetes and whether the pattern of ED use varies across geographic areas and population subgroups.

OBJECTIVE

To estimate recent national- and state-level trends in diabetes-related ED use overall and by race and ethnicity, rural or urban location, and insurance status.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study of adults visiting the ED with a diabetes-related diagnosis used serial data from the Nationwide Emergency Department Sample, a nationally representative database, and discharge records from 11 state emergency department databases for 2008, 2011, 2014, and 2016 to 2017. Data were analyzed from March 16 to November 9, 2020.

EXPOSURES

Reported race and ethnicity, rural or urban location, and insurance status. Data were stratified to generate state-specific estimates.

MAIN OUTCOMES AND MEASURES

Rates of ED use for all-cause visits among adults with diabetes (all-cause diabetes visits) and visits with primary diagnoses of diabetes-specific complications.

RESULTS

A larger portion of all-cause diabetes ED visits (n = 32 433 015) were by female (56.8%) and middle-aged (mean [SD] age, 58.4 [16.3] years) adults with diabetes. Nationally, all-cause diabetes ED visits per 10 000 adults increased 55.6% (95% CI, 50.6%-60.6%), from 257.6 (95% CI, 249.9-265.3) visits in 2008 to 400.8 (95% CI, 387.6-414.0) visits in 2017. All-cause diabetes ED visits increased more for urban (58.3%; 95% CI, 52.5%-64.1%) and uninsured subgroups (75.3% [95% CI, 59.8%-90.8%]) than for their counterparts. Diabetes-specific ED visits (weighted number of 1 911 795) nationally increased slightly among all subgroups. State-specific ED use rates show wide state-to-state variations in ED use by race and ethnicity, rural or urban location, and insurance. On average across states, diabetes-specific ED use among Black patients was approximately 3 times (rate ratio, 3.09 [95% CI, 2.91-3.30]) greater than among non-Hispanic White patients, and among Hispanic patients, it was 29% greater (rate ratio, 1.29 [95% CI, 1.19-1.40]) than among non-Hispanic White patients. The mean rate of ED use among rural patients was 34% greater (rate ratio, 1.34 [95% CI, 1.26-1.44]) than among urban patients. The mean rates of ED use among patients with Medicaid (rate ratio, 6.65 [95% CI, 6.49-6.82]) and Medicare (rate ratio, 4.37 [95% CI, 4.23-4.51]) were greater than among privately insured adults.

CONCLUSIONS AND RELEVANCE

This study suggests that disparities in diabetes-related ED use associated with race and ethnicity, rural or urban location, and insurance status were persistent from 2008 to 2017 within and across states, as well as nationally. Further geographic and demographic-specific analyses are needed to understand the sources of inequity.

‘Analogy-Based Comprehensive Diabetes Education’ (ABCDE) Improves Glycemic Control of Diabetic Patients in an Underserved Population: Results of a Retrospective Chart Analysis

Diabetes is the leading global cause for blindness, kidney failure and amputations. Preventing these complications requires optimal glycemic control, and it is imperative that diabetic patients understand the fundamental concepts of diabetes care. Although patients attend formal diabetes education classes, many do not comprehend basic concepts of diabetes, and are often noncompliant with diet, exercise and medications. A novel approach termed ‘analogy-based comprehensive diabetes education’ (ABCDE) was developed to educate HIV-patients with diabetes about basic concepts of diabetes care. The object of this manuscript is to report the results of a retrospective chart review on the impact of ABCDE on glycemic outcomes in 24 patients who had failed usual care (including formal diabetes education, physician visits, and diabetic medications), and were non-adherent with diet and medications. They received only the ABCDE without any changes in pharmacotherapy. The impact on glycosylated hemoglobin (HbA1c) and fasting blood glucose (FBG) was assessed at subsequent visits. HbA1c was found to decline by 22% and 33% after 3 and 6 months, respectively, with corresponding declines in FBG by 53% and 59%, respectively. These results suggest that ABCDE in outpatient diabetes clinics could be effective in behavior modification toward improving glycemic control, and warrants additional investigation.

Patient-specific factors associated with use of diabetes self-management education and support programs in Louisiana

INTRODUCTION

The prevalence of diabetes self-management education and support (DSME/S) use among patients with newly diagnosed type 2 diabetes mellitus (T2DM) and patients with insulin prescription has not been evaluated. It is also unclear what demographic, behavioral, and clinical factors associated with use of DSME/S.

RESEARCH DESIGN AND METHODS

This retrospective analysis was based on electronic health records from the Research Action for Health Network (2013-2019). Patients with newly diagnosed T2DM were identified as 35-94 year-olds diagnosed with T2DM≥1 year after the first recorded office visit. Patients with insulin were identified by the first insulin prescription records. DSME/S (Healthcare Common Procedure Coding System G0108 and G0109) codes that occurred from 2 months before the 'new diagnosis date' or first insulin prescription date through 1 year after were defined as use of DSME/S. Age-matched controls (non-users) were identified from the Electronic Health Records (EHR). The date of first DSME/S record was selected as the index date. Logistic regression was used to estimate the associations between patient factors and use of DSME/S.

RESULTS

The prevalence of DSME/S use was 6.5% (8909/137 629) among patients with newly diagnosed T2DM and 32.7% (13,152/40,212) among patients with diabetes taking insulin. Multivariable analysis found that among patients with newly diagnosed T2DM, black and male patients were less likely to use DSME/S, while in patients with insulin, they were more likely to use the service compared with white and female counterparts, respectively. Among patients taking insulin, those with private insurance or self-pay status were significantly less likely, while those with Medicaid were more likely to use the service compared with their Medicare counterparts. A strong positive association was found between HbA1c, obesity, and DSME/S use in both cohorts, while hypertension was negatively associated with DSME/S in both cohorts.

CONCLUSION

We showed a low rate of DSME/S use in Louisiana, especially in patients with newly diagnosed T2DM. Our findings demonstrated heterogeneity in factors influencing DSME/S use between patients with newly diagnosed T2D and patients with insulin.

Trends in Medical Expenditures by Race/Ethnicity in Adults with Type 2 Diabetes 2002-2011

OBJECTIVE

The objective of the study was to examine racial/ethnic differences in medical expenditures (prescription, office-based, in-patient, out-patient, emergency room, total) over time, overall and by type of expenditure, in a nationally representative sample of adults with diabetes.

METHODS

A weighted sample of 17,820,243 adults aged ≥18 with diabetes from the Medical Expenditure Panel Survey (MEPS) dataset from 2002 to 2011 were analyzed for this study. Multiple comparison testing and general linear model (GLM) were used to test for differences in expenditures by race. Total unadjusted expenditures by racial/ethnic category stratified by different insurance categories (privately insured, publicly insured, uninsured and overall) were also estimated.

RESULTS

Non-Hispanic Whites (NHW) had more than $4000 higher expenditures than Hispanics and Other races (p < 0.0001). Prescription costs were about $410 less for Non-Hispanic Blacks (NHB) (p < 0.0001), and more than $600 less for Hispanics (p < 0.0001) and Others (p < 0.0001) compared to NHW.

CONCLUSION

Minority groups with type 2 diabetes were found to have significantly less total expenditures, with the exception of total expenditures for NHB compared to NHW. These findings indicate minorities with type 2 diabetes may be receiving less care than NHW, which has implications for the known disparities in health outcomes and complications in individuals with diabetes.

Systematic review and meta-analysis of patient race/ethnicity, socioeconomics, and quality for adult type 2 diabetes

OBJECTIVE

To review the evidence of the association between performance in eight indicators of diabetes care and a patient's race/ethnicity and socioeconomic characteristics.

DATA SOURCE

Studies of adult patients with type 2 diabetes in MEDLINE published between January 1, 2000, and December 31, 2018.

STUDY DESIGN

Systematic review and meta-analysis of regression-based studies including race/ethnicity and income or education as explanatory variables. Meta-analysis was used to quantify differences in performance associated with patient race/ethnicity or socioeconomic characteristics. The systematic review was used to identify potential mechanisms of disparities.

DATA COLLECTION

Two coauthors separately conducted abstract screening, study exclusions, data extraction, and scoring of retained studies. Estimates in retained studies were extracted and, where applicable, were standardized and converted to odds ratios and standard errors.

PRINCIPAL FINDINGS

Performance in intermediate outcomes and process measures frequently exhibited differences by race/ethnicity even after adjustment for socioeconomic, lifestyle, and health factors. Meta-analyses showed black patients had lower odds of HbA1c and blood pressure (BP) control (OR range: 0.67-0.68, P < .05) but higher odds of receiving eye or foot examination (OR range: 1.22-1.47, P < .05) relative to white patients. A high school degree or more was associated with higher odds of HbA1c control and receipt of eye examinations compared to patients without a degree. Meta-analyses of income included a handful of studies and were inconsistently associated with diabetes care performance. Differences in diabetes performance appear to be related to access-related factors such as uninsurance or lacking a usual source of care; food insecurity and trade-offs at very low incomes; and lower adherence among younger and healthier diabetes patients.

CONCLUSIONS

Patient race/ethnicity and education were associated with differences in diabetes quality measures. Depending on the approach used to rate providers, not adjusting for these patient characteristics may penalize or reward providers based on the populations they serve.

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.

Racial and Ethnic Differences in Out-of-Pocket Expenses among Adults with Diabetes

BACKGROUND

Racial and ethnic minority groups have a higher prevalence of diabetes, increased risk for adverse complications, and worse health outcomes compared to Non-Hispanic Whites. Evidence suggests they also have higher healthcare expenses associated with diabetes care. Therefore, the objective of this study was to assess racial and ethnic differences in out-of-pocket (OOP) costs among a nationally representative sample of adults with diabetes.

METHODS

Cross-sectional study of 17,702 adults (aged ≥18 years) with diabetes from years 2002-2011 in the Medical Expenditure Panel Survey Household Component. The outcome was OOP expenditures, and the primary predictor was race/ethnicity. Descriptive statistics summarized the sample population. Unadjusted mean values were computed to compare OOP expenses over time. A two-part model was used to estimate adjusted incremental OOP expenses.

RESULTS

For the overall sample, OOP expenditures decreased significantly over time. In addition, compared to NHWs, racial and ethnic minority groups had significantly lower OOP costs per year when adjusted for sociodemographic characteristics, comorbid conditions, and time. NHBs paid $481 less than NHWs; Hispanics paid $591 less than NHWs; and individuals in the 'Other' racial/ethnic category paid nearly $645 less compared to NHWs (p < 0.001).

CONCLUSIONS

Racial/ethnic minority patients with diabetes had significantly less OOP expenses compared to NHWs, possibly due to differences in healthcare utilization. OOP expenses decreased significantly over time for all racial and ethnic groups. Additional research is needed to understand the factors associated with differences in OOP expenditures among racial groups.

Depression, distress and self-efficacy: The impact on diabetes self-care practices

The prevalence of type 2 diabetes is increasing in Malaysia, and people with diabetes have been reported to suffer from depression and diabetes distress which influences their self-efficacy in performing diabetes self-care practices. This interviewer administered, cross sectional study, conducted in the district of Hulu Selangor, Malaysia, involving 371 randomly selected patients with type 2 diabetes, recruited from 6 health clinics, aimed to examine a conceptual model regarding the association between depression, diabetes distress and self-efficacy with diabetes self-care practices using the partial least square approach of structural equation modeling. In this study, diabetes self-care practices were similar regardless of sex, age group, ethnicity, education level, diabetes complications or type of diabetes medication. This study found that self-efficacy had a direct effect on diabetes self-care practice (path coefficient = 0.438, p<0.001). Self-care was not directly affected by depression and diabetes distress, but indirectly by depression (path coefficient = -0.115, p<0.01) and diabetes distress (path coefficient = -0.122, p<0.001) via self-efficacy. In conclusion, to improve self-care practices, effort must be focused on enhancing self-efficacy levels, while not forgetting to deal with depression and diabetes distress, especially among those with poorer levels of self-efficacy.

Disparities in Diabetes Care Quality by English Language Preference in Community Health Centers

OBJECTIVE

To conduct a parallel analysis of disparities in diabetes care quality among Latino and Asian community health center (CHC) patients by English language preference.

STUDY SETTING/DATA COLLECTION

Clinical outcomes (2011) and patient survey data (2012) for Type 2 diabetes adults from 14 CHCs (n = 1,053).

STUDY DESIGN

We estimated separate regression models for Latino and Asian patients by English language preference for Clinician & Group-Consumer Assessment of Healthcare Providers and System, Patient Assessment of Chronic Illness Care, hemoglobin A1c, and self-reported hypoglycemic events. We used the Blinder-Oaxaca decomposition method to parse out observed and unobserved differences in outcomes between English versus non-English language groups.

PRINCIPAL FINDINGS

After adjusting for socioeconomic and health characteristics, disparities in patient experiences by English language preference were found only among Asian patients. Unobserved factors largely accounted for linguistic disparities for most patient experience measures. There were no significant differences in glycemic control by language for either Latino or Asian patients.

CONCLUSIONS

Given the importance of patient retention in CHCs, our findings indicate opportunities to improve CHC patients' experiences of care and to reduce disparities in patient experience by English preference for Asian diabetes patients.

Effects of Food Label Use on Diet Quality and Glycemic Control Among Latinos With Type 2 Diabetes in a Community Health Worker-Supported Intervention

OBJECTIVES

To determine the impact of an intervention led by community health workers (CHWs) on food label use and to assess whether food label use and diet quality mediate the intervention's impact on glycemic control.

METHODS

From 2006 to 2010, 203 Latinos (intervention group, n = 100; control group, n = 103) in Hartford County, Connecticut, with type 2 diabetes were randomized to an intervention that included 17 CHW-led home-based sessions over a 12-month period in addition to the standard of care available in both study arms. Data on food label use, diet quality, covariates, and glycated hemoglobin (HbA1c) were collected at baseline and at 3, 6, 12, and 18 months. Data were analyzed via mixed effects and multilevel structural equation modeling.

RESULTS

Food label use in the intervention (vs control) group was significantly higher at 3, 12, and 18 months (odds ratio = 2.99; 95% confidence interval = 1.69, 5.29). Food label use and diet quality were positive mediators of improved HbA1c levels.

CONCLUSIONS

Culturally tailored interventions led by CHWs could increase food label use. Also, CHW-delivered food label education may lead to better diet quality and improve glycemic control among Latinos with type 2 diabetes.

Racial/Ethnic Differences in Use of Health Care Services for Diabetes Management

Research demonstrates consistent racial/ethnic disparities in access to and use of health care services for a variety of chronic conditions. Yet we know little about whether these disparities exist for use of health care services for diabetes management. Racial/ethnic minorities disproportionately suffer from diabetes, complications from diabetes, and diabetes-related mortality. Proper diabetes management can reduce the risk of complications and premature mortality. Using a large national data set (N = 37,705) of White, Black, Hispanic, Asian, and Native American U.S. adults aged 65 years and older who have been diagnosed with diabetes, we examine three specific types of health care provider (HCP) use for diabetes management: number of times seen by a health care professional for diabetes, number of times feet have been checked by a health care professional, and number of visits for a glycosylated hemoglobin check. We found that net of controls for a variety of demographic and socioeconomic characteristics, Blacks and Hispanics had significantly more visits to a HCP for their diabetes and significantly more glycosylated hemoglobin checks than Whites, and Blacks and Native Americans had significantly more HCP feet checks than Whites. Our results suggest that the reduced access to health care services traditionally found among racial/ethnic minorities does not hold for access to health care services for diabetes management, where racial/ethnic minority diabetics are actually more likely to use care than are White diabetics. Future research should examine whether higher use of health care services for diabetes among racial/ethnic minorities is due to greater disease severity among racial/ethnic minorities than among non-Hispanic Whites.

Popular Glucose Tracking Apps and Use of mHealth by Latinos With Diabetes: Review

BACKGROUND

Diabetes mellitus in the United States is an increasingly common chronic disease, costing hundreds of billions of dollars and contributing to hundreds of thousands of deaths each year. The prevalence of diabetes is over 50% higher in Latinos than in the general population, and this group also suffers from higher rates of complications and diabetes-related mortality than NHWs. mHealth is a promising new treatment modality for diabetes, though few smartphone apps have been designed specifically for Latinos.

OBJECTIVE

The objectives of our study were: (1) to identify the most common features of the most popular diabetes apps and consider how such features may be improved to meet the needs of Latinos; (2) to determine the use of diabetes apps among a sample of online Hispanics in the US.

METHODS

Our study consisted of two parts. First, 20 of the most popular diabetes apps were reviewed in order to ascertain the most prevalent features and functionalities. Second, an online survey was fielded through a popular health website for Latinos (HolaDoctor) inquiring about respondents' use of diabetes apps.

RESULTS

Approximately one-third of apps reviewed were available in Spanish. The most common features were blood glucose recording/annotation and activity logs. The majority of apps permitted exportation of data via e-mail but only a third enabled uploading to an online account. Twenty percent of apps reviewed could connect directly with a glucometer, and 30% had reminder functionalities prompting patients to take medications or check blood glucose levels. Over 1600 online surveys were completed during the second half of April 2014. More than 90% of respondents were from the United States, including Puerto Rico. The majority of respondents used a device running on an Android platform while only a quarter used an iPhone. Use of diabetes apps was approximately 3% among diabetic respondents and 3.6% among diabetic respondents who also had a smartphone. Among app users, blood glucose and medication diaries were the most frequently used functionalities while hemoglobin A1c and insulin diaries were the least used. A significant majority of app users did not share their progress on social media though many of these were willing to share it with their doctor.

CONCLUSIONS

Latino diabetics have unique needs and this should be reflected in diabetes apps designed for this population. Existing research as well as our survey results suggest that many Latinos do not possess the prerequisite diabetes knowledge or self-awareness to fully benefit from the most prevalent functionalities offered by the most popular diabetes apps. We recommend developers incorporate more basic features such as diabetes education, reminders to check blood glucose levels or take medications, Spanish language interfaces, and glucometer connectivities, which are relatively underrepresented in the most popular diabetes apps currently available in Spanish.

Effect of perceived racial discrimination on self-care behaviors, glycemic control, and quality of life in adults with type 2 diabetes

OBJECTIVE

This study used a large sample size of black and white patients with type 2 diabetes to investigate the influence of perceived racial discrimination on biologic measures (glycemic control, blood pressure, and LDL cholesterol), the mental component of quality of life (MCS), and health behaviors known to improve diabetes outcomes.

METHODS

602 patients were recruited from two adult primary care clinics in the southeastern United States. Linear regression models were used to assess the associations between perceived racial discrimination, self-care, clinical outcomes, MCS, adjusting for relevant covariates. Race-stratified models were conducted to examine differential associations by race.

RESULTS

The mean age was 61 years, with 64.9 % non-Hispanic black, and 41.6 % earning less than $20,000 annually. Perceived discrimination was significantly negatively associated with MCS (β = -0.56, 95 % CI -0.90, 0.23), general diet (β = -0.37, CI -0.65, -0.08), and specific diet (β = -0.25, CI -0.47, -0.03). In African Americans, perceived discrimination was significantly associated with higher systolic blood pressure (β = 10.17, CI 1.13, -19.22). In Whites, perceived discrimination was significantly associated with lower MCS (β = -0.51, CI -0.89, -0.14), general diet (β = -0.40, CI -0.69, -0.99), specific diet (β = -0.25, CI -0.47, -0.03), and blood glucose testing (β = -0.43, CI -0.80, -0.06).

CONCLUSIONS

While no association was found with biologic measures, perceived discrimination was associated with health behaviors and the MCS. In addition, results showed a difference in influence of perceived discrimination by race.

Policy dilemmas in Latino health care and implementation of the Affordable Care Act

The changing Latino demographic in the United States presents a number of challenges to health care policy makers, clinicians, organizations, and other stakeholders. Studies have demonstrated that Latinos tend to have worse patterns of access to, and utilization of, health care than other ethnic and racial groups. The implementation of the Affordable Care Act (ACA) of 2010 may ameliorate some of these disparities. However, even with the ACA, it is expected that Latinos will continue to have problems accessing and using high-quality health care, especially in states that are not expanding Medicaid eligibility as provided by the ACA. We identify four current policy dilemmas relevant to Latinos' health and ACA implementation: (a) the need to extend coverage to the undocumented; (b) the growth of Latino populations in states with limited insurance expansion;

Effectiveness of diabetes self-management education on quality of life in diabetic elderly females

INTRODUCTION

Diabetes is a chronic illness that requires continuing medical care and patient self-management education to reduce the risk of long-term and acute complications. The aim of the present study was to determine the effectiveness of diabetes self-management education on quality of life in elderly females with diabetic mellitus (type 2) in Shiraz, Iran, 2013.

METHOD

The study was conducted from January to April 2014 at the Jahandidegan center, a day center affiliated to Shiraz welfare organization. The instrument used for the study was the Quality of life Questionnaire (WHO QOL-BREF) SF26. After an explanation of the aim of the study by the researcher, 90 participants with all the required criteria and G.H.Q score ? 23 were selected as the study sample for the intervention. Participants divided into experimental and control groups, and completed WHO QOL-BREF before the intervention, 2 and 3 months after the last session of education.

RESULT

It is shown that 2 and 3 months after the intervention, QOL scores had a significant difference between the two groups. In other words, the training sessions improved the score of QOL in the intervention group (P < 0.001) versus control group (P = 0.5).

CONCLUSION

The Behavioral Intervention Program significantly improved the quality of life outcomes of the diabetic elderly females. Thus, it is concluded that the diabetic individuals can be significantly improved following instruction by health care providers.

Diabetes self-management activities for Latinos living in non-metropolitan rural communities: a snapshot of an underserved rural state

The Latino community continues to grow in the rural Midwest, and diabetes is a pertinent disease for research in this demographic. Patient self-management is an important aspect of comprehensive care for diabetes and may mitigate complications. A cross-sectional survey assessed various activities including self-monitoring of blood glucose, personal foot inspection, diet adherence, and diabetes self-management education. Less than half of the sample performed self-monitoring of blood glucose daily (40 %), adhered strictly to special diabetes diet recommendations (44 %), or attended a diabetes self-management education class (48 %). Participants advised on personal foot inspection were three times more likely to perform the self-care activity. Improvements are indicated in these self-management activities. Further research is needed to discern disparities and barriers in self-monitoring of blood glucose among this target population. An increased emphasis on enrollment in diabetes self-management classes should target foreign-born Latinos with lower levels of education.

A family-based diabetes intervention for Hispanic adults and their family members

AIMS

The purpose of this quasi-experimental, 1-group longitudinal study is to examine the effects of a family-based intervention program on diabetes self-management behaviors, A1C, other biomarkers, psychosocial factors, and health-related quality of life in Hispanics with diabetes.

METHODS

Adult patients with diabetes (n = 36) and family members (n = 37) were recruited from a community clinic in rural central North Carolina. Patients and family members attended an 8-week culturally tailored diabetes educational program taught in Spanish. Data were collected pre- and post-intervention for both patients and family members, with an additional data collection for patients 1 month post-intervention.

RESULTS

Most patients and family members were female, and almost all were immigrants. A1C decreased by 4.9% on average among patients from pre-intervention to 1 month post-intervention. Patients showed significant improvements in systolic blood pressure, diabetes self-efficacy, diabetes knowledge, and physical and mental components of health-related quality of life. Higher levels of intake of healthy foods and performance of blood glucose tests and foot inspections were reported. Family members significantly lowered body mass index and improved diabetes knowledge from pre-intervention to immediately post-intervention. No significant changes in levels of physical activity were found among patients with diabetes or family members.

CONCLUSIONS

Findings suggest that including family members in educational interventions may provide emotional and psychological support to patients with diabetes, help to develop healthy family behaviors, and promote diabetes self-management.

All-cause, cardiovascular, and cancer mortality rates in postmenopausal white, black, Hispanic, and Asian women with and without diabetes in the United States: the Women's Health Initiative, 1993-2009

Using data from the Women's Health Initiative (1993-2009; n = 158,833 participants, of whom 84.1% were white, 9.2% were black, 4.1% were Hispanic, and 2.6% were Asian), we compared all-cause, cardiovascular, and cancer mortality rates in white, black, Hispanic, and Asian postmenopausal women with and without diabetes. Cox proportional hazard models were used for the comparison from which hazard ratios and 95% confidence intervals were computed. Within each racial/ethnic subgroup, women with diabetes had an approximately 2-3 times higher risk of all-cause, cardiovascular, and cancer mortality than did those without diabetes. However, the hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups. Population attributable risk percentages (PARPs) take into account both the prevalence of diabetes and hazard ratios. For all-cause mortality, whites had the lowest PARP (11.1, 95% confidence interval (CI): 10.1, 12.1), followed by Asians (12.9, 95% CI: 4.7, 20.9), blacks (19.4, 95% CI: 15.0, 23.7), and Hispanics (23.2, 95% CI: 14.8, 31.2). To our knowledge, the present study is the first to show that hazard ratios for mortality outcomes were not significantly different between racial/ethnic subgroups when stratified by diabetes status. Because of the "amplifying" effect of diabetes prevalence, efforts to reduce racial/ethnic disparities in the rate of death from diabetes should focus on prevention of diabetes.

Racial and ethnic disparities in diabetes complications in the northeastern United States: the role of socioeconomic status

The role of socioeconomic status (SES) in explaining racial/ ethnic disparities in diabetes remains unclear. We investigated disparities in self-reported diabetes complications and the role of macro (eg, income, education) and micro (eg, owning a home or having a checking account) SES indicators in explaining these differences. The sample included individuals with a diagnosis of diabetes (N=795) who were aged, on average, 55 years, and 55.6% non-Hispanic white, 25.0% African American, and 19.4% Hispanic. Approximately 8% reported nephropathy, 35% reported retinopathy, and 16% reported cardiovascular disease. There were significant disparities in the rates of complications among non-Hispanic white, African American, and Hispanic participants, with Hispanic participants having the highest rates of nephropathy, retinopathy, and cardiovascular disease. Macro SES indicators (eg, income) mediated racial differences (ie, non-Hispanic whites vs African Americans) in self-reported retinopathy, a combination of macro and more micro SES indicators (eg, education, income, and ownirg a home or having a checking account) mediated racial/ethnic differences (ie, non-Hispanic white vs Hispanic participants) in self-reported cardiovascular disease, and only micro SES indicators (eg, owning a home or having a checking account) mediated differences between lower-income SES racial/ethnic minority groups (ie, African American vs Hispanic participants) in self-reported retinopathy and cardiovascular disease. Findings underscore that indicators of SES must be sensitive to the outcome of interest and the racial/ethnic groups being compared.

Effects of self-care, self-efficacy, social support on glycemic control in adults with type 2 diabetes

Background

A number of studies have examined the influence of self-efficacy, social support and patient-provider communication (PPC) on self-care and glycemic control. Relatively few studies have tested the pathways through which these constructs operate to improve glycemic control, however. We used structural equation modeling to examine a conceptual model that hypothesizes how self-efficacy, social support and patient-provider communication influence glycemic control through self-care behaviors in Chinese adults with type 2 diabetes.

Methods

We conducted a cross-sectional study of 222 Chinese adults with type 2 diabetes in one primary care center. We collected information on demographics, self-efficacy, social support, patient-provider communication (PPC) and diabetes self-care. Hemoglobin A1c (HbA1c) values were also obtained. Measured variable path analyses were used to determine the predicted pathways linking self-efficacy, social support and PPC to diabetes self-care and glycemic control.

Results

Diabetes self-care had a direct effect on glycemic control (β = −0.21, p = .007), No direct effect was observed for self-efficacy, social support or PPC on glycemic control. There were significant positive direct paths from self-efficacy (β = 0.32, p < .001), social support (β = 0.17, p = .009) and PPC (β = 0.14, p = .029) to diabetes self-care. All of them had an indirect effect on HbA1c (β =–0.06, β =–0.04, β =–0.03 respectively). Additionally, PPC was positively associated with social support (γ = 0.32, p < .001).

Conclusions

Having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to glycemic control. So longitudinal studies are needed to explore the effect of self-efficacy, social support and PPC on changes in diabetes self-care behaviors and glycemic control.

Determinants of lifestyle behavior in type 2 diabetes: results of the 2011 cross-sectional survey on living with chronic diseases in Canada

BACKGROUND

Lifestyle behavior modification is an essential component of self-management of type 2 diabetes. We evaluated the prevalence of engagement in lifestyle behaviors for management of the disease, as well as the impact of healthcare professional support on these behaviors.

METHODS

Self-reported data were available from 2682 adult respondents, age 20 years or older, to the 2011 Survey on Living with Chronic Diseases in Canada's diabetes component. Associations with never engaging in and not sustaining self-management behaviors (of dietary change, weight control, exercise, and smoking cessation) were evaluated using binomial regression models.

RESULTS

The prevalence of reported dietary change, weight control/loss, increased exercise and smoking cessation (among those who smoked since being diagnosed) were 89.7%, 72.1%, 69.5%, and 30.6%, respectively. Those who reported not receiving health professional advice in the previous 12 months were more likely to report never engaging in dietary change (RR = 2.7, 95% CI 1.8 - 4.2), exercise (RR = 1.7, 95% CI 1.3 - 2.1), or weight control/loss (RR = 2.2, 95% CI 1.3 - 3.6), but not smoking cessation (RR = 1.0; 95% CI: 0.7 - 1.5). Also, living with diabetes for more than six years was associated with not sustaining dietary change, weight loss and smoking cessation.

CONCLUSION

Health professional advice for lifestyle behaviors for type 2 diabetes self-management may support individual actions. Patients living with the disease for more than 6 years may require additional support in sustaining recommended behaviors.

Perceptions of barriers in managing diabetes: perspectives of Hispanic immigrant patients and family members

PURPOSE

Hispanics show poorer self-management of type 2 diabetes than non-Hispanic whites. Although previous studies have reported socioeconomic and cultural barriers to diabetes self-management by Hispanics, little is known about perceived barriers to diabetes self-management from the perspectives of both Hispanics and their family members. The purpose of the study was to explore perceived barriers among Hispanic immigrants with diabetes and their family members.

METHODS

A qualitative study using 5 focus groups was conducted. A total of 73 Hispanic immigrants with type 2 diabetes (n = 36) and family members (n = 37) were recruited in the southeastern United States for a family-based intervention study of diabetes-self management. Participants were asked to describe their perceptions of barriers to self-management. The 5 sessions were audiotaped and transcribed, translated from Spanish into English, and analyzed using standard content analysis. Demographics, hemoglobin A1C levels, blood pressure, and body mass index (BMI) were obtained both for participants with diabetes and for their family members.

RESULTS

Barriers to diabetes self-management identified by participants with diabetes were in 3 major themes categorized as: suffering from diabetes, difficulties in managing the disease, and lack of resources/support. Two key themes emerged pertaining to family members: we can provide support and we lack knowledge.

CONCLUSIONS

Perceived barriers to diabetes self-management described by Hispanic immigrants with diabetes and family members indicate a lack of intervention strategies to meet their needs. Interventions should include culturally relevant resources, family support, and diabetes self-management skills education.

Influence of patient characteristics on assessment of diabetes self-management support

BACKGROUND

Factors contributing to patient-reported experiences of diabetes self-management support are not understood well, particularly over time.

OBJECTIVES

The aim of the study was to identify the contribution of patient characteristics to patient-reported quality of SMS.

METHODS

Using secondary data from a prospective clinical trial (n = 339) comparing three approaches of providing diabetes self-management support (Group Medical Visits, Automated Telephone Support, and Usual Care) in a diverse, underserved population, the influence of patient characteristics (e.g., age, gender, income, and health status) was examined on Patient Assessment of Chronic Illness Care ratings.

RESULTS

At baseline, older age (p = .014), being female (p = .038), and having lower income (p = .001) were associated with lower ratings. Income and interactions involving income combined explained 12% of the variance in baseline ratings. Compared with White patients, African American and Asian patients tended to have higher baseline ratings (p = .076 and p = .045, respectively). Race or ethnicity influenced perceptions throughout the trial, explaining 5% of the variance at baseline and 2% of the variance in 1-year changes in Patient Assessment of Chronic Illness Care ratings. As expected, over 1 year, ratings increased more for patients in both intervention groups compared with the control group (p < .001).

DISCUSSION

Ratings of healthcare quality are influenced by patient characteristics independent of the nature of the care provided. Understanding more precisely how these differences are associated with differences in clinical processes will be particularly important for efforts aiming to integrate patient-reported measures into assessments of healthcare quality during routine clinical care and clinical trials.

Validation of an information-motivation-behavioral skills model of self-care among Chinese adults with type 2 diabetes

BACKGROUND

Self-care is a crucial component of diabetes management. But comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We tested the Information-Motivation-Behavioral Skills (IMB) model in a sample of Chinese adults with Type 2 diabetes.

METHODS

A cross-sectional study of 222 Chinese adults with type 2 diabetes was conducted in a primary care center. We collected information on demographics, provider-patient communication (knowledge), social support (motivation), self-efficacy (behavioral skills), and diabetes self-care (behavior). The values of total cholesterol (TC), low-density lipoprotein cholesterol (LDL-C) and high-density lipoprotein cholesterol (HDL-C) were also obtained. Measured variable path analyses were used to the IMB framework.

RESULTS

Provider-patient communication (β = 0.12, p = .037), and social support (β = 0.19, p = .007) and self-efficacy (β = 0.41, p < .001) were independent, direct predictors of diabetes self-care behavior. Diabetes self-care behaviors had a direct effect on TC/HDL-C (β = -0.31, p < .001) and LDL-C/HDL-C (β = -0.30, p < .001).

CONCLUSIONS

Consistent with the IMB model, having better provider-patient communication, having social support, and having higher self-efficacy was associated with performing diabetes self-care behaviors; and these behaviors were directly linked to lipid control. The findings indicate that diabetes education programs should including strategies enhancing patients' knowledge, motivation and behavioral skills to effect behavior change.

Glucose control in diabetes: the impact of racial differences on monitoring and outcomes

Type 2 diabetes is the seventh leading cause of death in the US and is projected to increase in prevalence globally. Minorities are disproportionately affected by diabetes and data suggest that clinical outcomes consistently fall below American Diabetes Association recommendations. The purpose of this systematic review was to examine ethnic differences in self-monitoring and outcomes in adults with type 2 diabetes. Medline was searched for articles published between January 1990 and January 2012 by means of a reproducible strategy. Inclusion criteria included (1) published in English, (2) targeted African Americans, Hispanic, or Asian adults, ages 18+ years with type 2 diabetes, (3) cross-sectional, cohort, or intervention study, and (4) measured change in glycemic control, BP, lipids, or quality of life by race. Twenty-two papers met the inclusion criteria and were reviewed. Overall, significant racial differences and barriers were found in published studies in diabetes management as it pertains to self-monitoring and outcomes. African Americans tend to consistently exhibit worse outcomes and control when compared to other minority populations and non-Hispanic Whites. In conclusion, significant racial differences and barriers exist in diabetes management as it pertains to self-monitoring and outcomes when compared to non-Hispanic Whites. Explanatory and intervention studies are needed to determine the mechanisms and mediators of these differences and strategies to reduce these disparities. In addition, more research is needed to investigate the impact of racial differences in self-monitoring and outcomes on quality of life.

Factors influencing health care utilization in older Hispanics with diabetes along the Texas-Mexico border

Little is known about predictors of health care utilization for older Hispanics with chronic conditions. This study aimed to determine: (1) the level of health care access for older Hispanics with type 2 diabetes living in a US-Mexico border area; and (2) personal and health correlates to health care utilization (ie, physician visits, eye care, emergency room [ER] use). This was a cross-sectional study based on a community assessment conducted at a clinic, senior centers, and colonias. Colonias are impoverished neighborhoods with substandard living conditions along the US-Mexico border. Hispanics living in colonias are one of the most disadvantaged minority groups in the United States. The study sample consisted of 249 Hispanics age 60 years and older who have type 2 diabetes. Descriptive analyses, multiple linear regression, and generalized linear models were conducted. Older age (P = 0.02) and affordability of physician fees (P = 0.02) were significant correlates to more frequent physician visits. Factors significantly associated with eye care were being insured (P = 0.001) and reporting high cholesterol (P = 0.005). ER use was significantly associated with younger age (60-64 years old; P = 0.03) and suffering from hypertension (P = 0.02). Those who received diabetes education (P = 0.04) were less likely to use the ER. Identifying patterns of health care utilization services in aging underserved minorities who are disproportionately affected by diabetes may lead to culturally appropriate preventive practices and timely access to health care. Adequate health care access can decrease or delay the onset of diabetes complications in older Hispanics with type 2 diabetes who live along the US-Mexico border.

Improving treatment in Hispanic/Latino patients

The prevalence of type 2 diabetes mellitus is higher in Hispanic/Latino individuals living in the United States compared with their non-Hispanic white counterparts. Many factors contribute to the increased prevalence of type 2 diabetes, including biological characteristics, socioeconomic conditions, and cultural aspects. The contribution of genetics to the risk of type 2 diabetes in Hispanic/Latino patients is becoming increasingly clear, but this inherent risk factor cannot be modified. However, certain socioeconomic and cultural factors, such as reduced access to healthcare, language barriers, cultural beliefs, and lack of cultural competence by the healthcare provider, are modifiable and should be overcome in order to improve the management of type 2 diabetes in Hispanic/Latino patients. At the healthcare system level, policies should be put into place to reduce disparities between Hispanics/Latinos and non-Hispanic whites regarding health insurance coverage and access to healthcare. At the healthcare provider and patient level, cultural beliefs should be taken into consideration when selecting adequate treatment. Overall, type 2 diabetes management should be individualized by identifying the preferred language and level of acculturation for each patient. These considerations are necessary to further improve communication through culturally appropriate educational materials and programs. These strategies may help to overcome the barriers in the treatment of type 2 diabetes in Hispanic/Latino patients.

The provision of diabetes-monitoring exams to older Latinos

OBJECTIVES

To explore factors associated with the provision of diabetes-monitoring practices among older Latinos with type 2 diabetes.

METHOD

Data from 547 Latinos (≥ 55 years) were analyzed from the 2007 California Health Interview Survey. Multivariate logistic regression modeled the relationship between health status and sociodemographic factors and the receipt of semiannual HbA1c tests, annual foot exams, and annual retinal exams.

RESULTS

The majority of older Latino diabetics received foot exams (87%) and retinal exams (77%), but the provision of semiannual HbA1c tests (30%) was low. Higher English-language proficiency and health insurance coverage were associated with the provision of HbA1c tests and foot exams, but not retinal exams. Insulin therapy was positively associated with semiannual HbA1c testing, but negatively associated with foot exams.

DISCUSSION

There are considerable missed opportunities in the provision of diabetes monitoring for older Latinos, particularly those with limited English proficiency, less comprehensive insurance, and noninsulin therapy.

Development and Implementation of a Culturally Tailored Diabetes Intervention in Primary Care

Diabetes education for ethnic minorities should address variations in values underlying motivations, preferences, and behaviors of individuals within an ethnic group. This paper describes the development and implementation of a culturally tailored diabetes intervention for Puerto Rican Americans that can be delivered by a health care paraprofessional and implemented in routine clinical care. We describe a formative process, including interviews with providers, focus groups with patients and a series of multidisciplinary collaborative workshops used to inform intervention content. We highlight the intervention components and link them to a well-validated health behavior change model. Finally, we present support for the intervention's clinical effects, feasibility, and acceptability and conclude with implications and recommendations for practice. Lessons learned from this process should guide future educational efforts in routine clinical care.

Racial differences in diabetes-related psychosocial factors and glycemic control in patients with type 2 diabetes

BACKGROUND

We examined whether diabetes-related psychosocial factors differ between African American and white patients with type 2 diabetes. We also tested whether racial differences in glycemic control are independent of such factors.

METHODS

Baseline glycosylated hemoglobin (HbA(1c)) and survey measures from 79 African American and 203 white adult participants in a diabetes self-management clinical trial were analyzed.

RESULTS

Several psychosocial characteristics varied by race. Perceived interference of diabetes with daily life, perceived diabetes severity, and diabetes-related emotional distress were higher for African Americans than for whites, as were access to illness-management resources and social support. Mean HbA(1c) levels were higher among African Americans than whites (8.14 vs 7.40, beta = 0.17). This difference persisted after adjusting for demographic, clinical, and diabetes-related psychosocial characteristics that differed by race (beta = 0.18). Less access to illness-management resources (beta = -0.25) and greater perceived severity of diabetes (beta = 0.21) also predicted higher HbA(1c).

DISCUSSION

Although racial differences in diabetes-related psychosocial factors were observed, African Americans continued to have poorer glycemic control than whites even after such differences were taken into account. Interventions that target psychosocial factors related to diabetes management, particularly illness-management resources, may be a promising way to improve glycemic control for all patients.

Validation of an Information-Motivation-Behavioral Skills model of diabetes self-care (IMB-DSC)

OBJECTIVE

Comprehensive behavior change frameworks are needed to provide guidance for the design, implementation, and evaluation of diabetes self-care programs in diverse populations. We applied the Information-Motivation-Behavioral Skills (IMB) model, a well-validated, comprehensive health behavior change framework, to diabetes self-care.

METHODS

Patients with diabetes were recruited from an outpatient clinic. Information gathered pertained to demographics, diabetes knowledge (information); diabetes fatalism (personal motivation); social support (social motivation); and diabetes self-care (behavior). Hemoglobin A1C values were extracted from the patient medical record. Structural equation models tested the IMB framework.

RESULTS

More diabetes knowledge (r=0.22 p<0.05), less fatalistic attitudes (r=-0.20, p<0.05), and more social support (r=0.27, p<0.01) were independent, direct predictors of diabetes self-care behavior; and through behavior, were related to glycemic control (r=-0.20, p<0.05).

CONCLUSIONS

Consistent with the IMB model, having more information (more diabetes knowledge), personal motivation (less fatalistic attitudes), and social motivation (more social support) was associated with behavior; and behavior was the sole predictor of glycemic control.

PRACTICE IMPLICATIONS

The IMB model is an appropriate, comprehensive health behavior change framework for diabetes self-care. The findings indicate that in addition to knowledge, diabetes education programs should target personal and social motivation to effect behavior change.

Motivational Interviewing (MI) to Change Type 2DM Self Care Behaviors: A Nursing Intervention

AIMS

This paper evaluates a novel nursing intervention designed to improve physical and psychological outcomes for adult patients with Type 2 DM.

BACKGROUND

Self care behaviors are an important component of diabetes treatment, yet for many reasons, patients do not adhere to suggested plans. Motivational Interviewing (MI) is a patient centered strategy that helps overcome ambivalence to change. Nurses, who frequently educate patients with diabetes about self care, can use MI as a way to improve health behaviors.

METHODS

As a component of a large RCT, focus groups were used to evaluate the impact of an MI nursing intervention. Nineteen patients (8% of treatment group) participated in four different groups. IPA was used to explore patient response to the intervention.

RESULTS/FINDINGS

Patients were able to reflect on and identify responses to sessions with the study nurses that differed from "typical" health care provider visits. Many of their descriptions captured the essence of MI practice.

CONCLUSION

MI is a viable and useful technique for nurses to use in educating and caring for persons with Type 2 DM.

Adherence to diabetes self-care behaviors in English- and Spanish-speaking Hispanic men

We conducted a qualitative study to elicit attitudes, attributions, and self-efficacy related to diabetes self-care in both English- and Spanish-speaking Hispanic men. Transcripts from six focus groups (three in English and three in Spanish) were reviewed by the authors to extract principal and secondary themes. Participants could describe their medication and lifestyle regimens and were aware of whether they were adherent or nonadherent to physician recommendations. Lack of skills on how to incorporate diet and regular physical activity into daily living, lack of will power, and reluctance to change culturally rooted behaviors emerged as significant barriers to diabetes self-management. Medication adherence is for some men the principal diabetes self-care behavior. Nonadherence appeared to fit two profiles: 1) intentional, and 2) nonintentional. In both instances low self-efficacy emerged as a significant influence on attainment and maintenance of diabetes self-care goals. Participants also expressed a strong sense of fatalism regarding the course of their disease, and seemed to have little motivation to attempt long-term dietary control. Educational and counseling messages should stress that a diagnosis of diabetes is not a death sentence, and full functional capacity can be maintained with good control.