Supporting diabetes self-management in primary care: pilot-study of a group-based programme focusing on diet and exercise

Diabetes self-management education (DSME) for older persons in Western countries: A scoping review

Diabetes mellitus is a chronic metabolic health condition affecting millions globally. Diabetes is a growing concern among aging societies, with its prevalence increasing among those aged 65 and above. Enabling disease self-management via relevant education is part of high-quality care to improve health outcomes and minimize complications for individuals living with diabetes. Successful diabetes self-management education (DSME) programs usually require tailoring for the intended audience; however, there is limited literature about the preferences of older persons in Western countries concerning DSME. As such, a broad overview of DSME for older persons was an identified need. To map the available evidence on DSME for persons aged 65 years and older in Western countries, the JBI methodology for conducting and reporting scoping reviews was used. In this scoping review, we considered all studies about DSME for older persons with T1D and T2D in Western countries where lifestyles, risks, prevention, treatment of diabetes, and approaches to self-management and DSME are similar (e.g., North America, Western and Northern Europe and Australasia). Systematic keyword and subject heading searches were conducted in 10 databases (e.g., MEDLINE, JBI EBP) to identify relevant English language papers published from 2000 to 2022. Titles and abstracts were screened to select eligible papers for full-text reading. Full-text screening was done by four independent reviewers to select studies for the final analysis. The review identified 2,397 studies, of which 1,250 full texts were screened for eligibility. Of the final 44 papers included in the review, only one included participants' understanding of DSME. The education programs differed in their context, design, delivery mode, theoretical underpinnings, and duration. Type of research designs, outcome measures used to determine the effectiveness of DSME, and knowledge gaps were also detailed. Overall, most interventions were effective and improved clinical and behavioural outcomes. Many of the programs led to improvements in clinical outcomes and participants' quality of life; however, the content needs to be adapted to older persons according to their culture, different degrees of health literacy, preference of education (e.g., individualized or group), preference of setting, degree of frailty and independence, and comorbidities. Few studies included the voices of older persons in the design, implementation, and evaluation of DSME programs. Such experiential knowledge is vital in developing educational programs to ensure alignment with this population's preferred learning styles, literacy levels, culture, and needs-such an approach could manifest more substantive, sustained results.

Evaluation of a Synchronous, Online Diabetes Nutrition Education Program for American Indians and Alaska Natives With Type 2 Diabetes: Facilitators and Participants' Experiences

OBJECTIVE

To explore the overall experiences of key players involved in a culturally adapted, online, synchronous diabetes nutrition education program across 5 reservation tribal and intertribal urban Indian clinics.

METHODS

A multimethods design, including postclass surveys with Likert-scale and short-answer questions, was completed after each of the 5 classes. Participants (n = 54) and class facilitators/coordinators (n = 10) completed postclass surveys (n = 189 and 58, respectively). A subset of participants (n = 24) and all class facilitators/coordinators (n = 10) engaged in online focus groups after the conclusion of program implementation. Qualitative thematic methods and frequency distributions were used to analyze the data.

RESULTS

Most participants reported that the classes were enjoyable (94%), culturally respectful (77%), and easily accessed online (68%). Qualitative themes included (1) class satisfaction, (2) class improvements, (3) preference for class facilitator, and (4) recommendations to improve recruitment and retention.

CONCLUSIONS AND IMPLICATIONS

These findings will guide program modifications to provide improved diabetes nutrition education for American Indians and Alaska Natives adults with type 2 diabetes.

Effect of diabetes nutrition education on the dietary feeding practices and lifestyle of type 2 diabetic patients

BACKGROUND

Type 2 diabetes mellitus (T2DM) is one of the most common global diseases of public concern. In developing countries like Uganda, dietary habits and sedentary lifestyle are the major factors for rapidly rising incidence of DM. Therefore, awareness about diabetes dietary practices and life style are paramount in the control of the disease.

METHODOLOGY

One hundred type 2 diabetic patients were randomly selected and divided into two groups of intervention and control (50 patients in each group) to participate in the study. The intervention consisted of two educational sessions each for 30 min with various learning segments. A conversation map for type 2 diabetes, 24-h dietary recall and glycemic load tables were used. Data were collected using a pre-tested questionnaire before intervention and on monthly basis for a period of four months of intervention. Data were entered and analyzed using SPSS software version 21.

RESULTS

There was a significant (p < 0.001) increase in water, vegetables, fruits, and number of meals intake per day coupled with quitting alcohol, soda, and beer among the intervention group. On the other hand, it was revealed that meat and milk consumption significantly reduced by 81.6 and 82.4% respectively among the intervention group. At the end of study period, milk, meat, vegetable, beer, soda, cigarettes intake, and duration of physical activity increased among the control group.

CONCLUSIONS

Nutrition education improves dietary feeding practices and lifestyle among type 2 diabetes patients within four months of intervention.

Challenges of Shifting Diabetes Mellitus Care From Secondary- to Primary-Level Care in Urban and Rural Districts: A Qualitative Inquiry Among Health Providers

Objectives: The study aims to understand the acceptability of Prolanis, a program that shifts the diabetes mellitus type 2 (T2DM) patient management from secondary to primary care, among Indonesian primary health care providers. Method: We completed face-to-face semistructured interviews with 14 health professionals from 3 urban and 4 rural government-owned primary health care clinics (Puskesmas) in 4 districts. We performed content analysis using the theoretical framework of acceptability (TFA) to understand which factors could facilitate or reduce acceptability. Results: Our study identifies that lack of health care providers’ acceptability to Prolanis was attributable to the negative affective attitude, low perceived effectiveness, poor self-efficacy, and work burden. The use of Prolanis output as one of the pay-for-performance indicators was deemed unsuitable because it could demotivate health providers to capture more undetected T2DM cases. This, compounded by lacking perceived benefit for the health care providers, leading to negative attitudes. Participants believed that the program improved patients’ adherence to visiting clinics routinely; however, the absence of a formal evaluation of reductions of key T2DM indicators—blood glucose level and HbA1c—causing the health providers to doubt the program effectiveness. Availability of or access to adequate blood glucose testing equipment is also of paramount importance to improve acceptability. Although the significant increase in patient load only occurred to Puskesmas with lacking doctors, an increased workload burden due to clerical works was experienced by the nonmedical workforce. The program appears to be more acceptable for health care providers in urban Puskesmas compared with their rural counterparts, attributable to better geographical accessibility and care-seeking behavior among people living in urban locations. Conclusions: This study highlights critical issues that should be addressed to improve the acceptability of Prolanis among health care professionals. Government or stakeholders play a critical role in improving program acceptability. More study is needed to capture wider variety of health care facilities’ characteristics.

The Effect of Care Provided at Home by Public Health Nurse on Control of Type II Diabetes Mellitus

AIM

The aim of the study was to examine the effect of home care provided for patients with type II diabetes by public health nurse on HbA1c, and to investigate the opinions of these patients regarding diabetes.

METHOD

The quantitative aspect of the study consisted of a pre and posttest with the control group; the qualitative aspect consisted of a semi-structured interviewing technique. The sample size was 48 patients receiving treatment within the clinic of hospital during 11th-30th April 2016. Because some patients were excluded from the study, the research was completed with a sample size of 20 for the experiment and 20 for the control group. The following forms were used during data: Pre and post measurement and qualitative interview forms. A total of seven home visits were conducted for the experiment group and two home visits for the control group, during 2nd May to 27th October, 2016.

RESULTS

HbA1c decreased by 0.75% in the experiment group (p<0.05). It was found that faulty usage of insulin was treated; all patients developed the habit of tracking blood glucose. Blood glucose of three patients continued to remain at high levels, and most of the patients failed to develop healthy eating habits and regular exercising.

CONCLUSION

According to these results, it is advised that long-term interventions be planned with the contributions of other experts.

A positive psychology-motivational interviewing intervention for patients with type 2 diabetes: Proof-of-concept trial

OBJECTIVE

Eighteen million Americans with type 2 diabetes (T2D) do not follow recommended guidelines for physical activity. Motivational interviewing (MI) has had modest effects on activity and related behaviors in T2D. Positive psychological attributes (e.g., optimism) are associated with superior medical outcomes in T2D, and positive psychology (PP) interventions promote such attributes. There had been no study in T2D of a combined PP-MI intervention to promote well-being and health behavior adherence. We developed a novel, telephone-delivered, 16-week PP-MI intervention and explored its feasibility and impact in T2D patients in a single-arm, proof-of-concept trial.

METHOD

Participants completed PP-based exercises and MI-based physical activity goal-setting activities and reviewed these activities weekly with a study trainer for 16 weeks. Feasibility and acceptability were assessed via exercise completion rates and post-exercise ratings of ease/utility (0-10 scales). Impact was explored by examining changes in physical activity (via accelerometers and self-report), other health behaviors, psychological measures, and medical outcomes (e.g., hemoglobin A1c (A1C)) from baseline to 16 weeks, using paired t tests.

RESULTS

Twelve participants enrolled, and 10 provided follow-up data. Seventy-eight percent of PP-MI activities were completed, and participants rated the PP-MI content and sessions as easy (mean = 8.2/10, standard deviation (SD) = 1.9) and useful (mean = 9.1/10, SD = 1.5). PP-MI was associated with improved adherence to health behaviors and overall self-care, variable effects on accelerometer-measured activity and psychological outcomes, and modest beneficial effects on body mass index and A1C.

CONCLUSION

Further testing of this intervention is warranted in a larger, controlled trial to assess its effects on important health outcomes.

The diabetes self-management educational programs and their integration in the usual care: A systematic literature review

The increasing prevalence of type 2 diabetes has highlighted the importance of evidence-based guidelines for effective prevention, management and treatment. Diabetes self-management education (SME) produces positive effects on patient behaviours and health status. We analyzed the literature to identify (i) the level of integration between usual care and SME programs and (ii) any possible differences across them in terms of outcomes. Searches were made on three databases - PubMed, Scopus and Web of Science - to identify relevant publications on diabetes SME to 2015, which also describe the provider of usual care. In total, 49 studies met the inclusion criteria. We identified three levels of integration (high, medium and low) between usual care and SME programs based on the level of involvement of usual care professionals within the SME programs. In most cases, the primary care physician was responsible for the diabetes patients. Patient health behaviors and/or outcomes improve in most of the studies, independently from the level of integration. However, findings suggest that when patients/participants could perceive that usual care provider is highly involved in SME delivery, educational programs produced results that appear to be more positive.

Patients' perceptions of pharmacist-managed diabetes services in the ambulatory care and community settings within Singapore

Background Qualitative evidence on patients' perceptions of pharmacist-managed diabetes services (PMDSs) is limited. Objective To explore patients' perceptions of PMDSs Setting Patients being cared for in the outpatient settings in Singapore. Methods This focus group included patients who were diagnosed with type 2 diabetes, spoke either English or Mandarin, attended PMDSs for at least 6 months in the ambulatory care or community settings, and were at least 21 years of age. Patients with cognitive impairments or mobility issues were excluded. Thematic analysis of transcribed audio recordings was undertaken. Main outcomes measure Patients' care experiences with PMDSs. Results A total of 26 patients from two outpatient ambulatory care clinics and three retail pharmacies were assembled into four focus groups based on the care setting. Four themes abstracted from focus group data illustrated patients' perspectives on PMDSs in fulfilling their health needs, delivery and quality of service, changes attributed to the service, and suggestions for improvement of service. The patients highlighted that PMDSs fulfilled their need for information on diabetes. They also felt comfortable speaking to the pharmacists about their health, and they appreciated the role of the pharmacists as healthcare professionals. Furthermore, the patients reported better diabetes-related self-empowerment via increased medication knowledge and lifestyle modification. Some of the patients noted that medication adherence and glycemic control had improved. Suggestions to improve PMDSs were minimal. Conclusions Overall, patients with type 2 diabetes had positive perceptions of PMDSs regardless of the care settings.

Perceived barriers to leisure time physical activity in adults with type 2 diabetes attending primary healthcare in Oman: a cross-sectional survey

OBJECTIVES

Physical activity is fundamental in diabetes management for good metabolic control. This study aimed to identify barriers to performing leisure time physical activity and explore differences based on gender, age, marital status, employment, education, income and perceived stages of change in physical activity in adults with type 2 diabetes in Oman.

DESIGN

Cross-sectional study using an Arabic version of the 'Barriers to Being Active' 27-item questionnaire.

SETTING

Seventeen primary health centres randomly selected in Muscat.

PARTICIPANTS

Individuals>18 years with type 2 diabetes, attending diabetes clinic for >2 years and with no contraindications to performing physical activity.

PRIMARY AND SECONDARY OUTCOME MEASURES

Participants were asked to rate how far different factors influenced their physical activity under the following categories: fear of injury, lack of time, social support, energy, willpower, skills, resources, religion and environment. On a scale of 0-9, barriers were considered important if scored ≥5.

RESULTS

A total of 305 questionnaires were collected. Most (96%) reported at least one barrier to performing leisure time physical activity. Lack of willpower (44.4%), lack of resources (30.5%) and lack of social support (29.2%) were the most frequently reported barriers. Using χ2 test, lack of willpower was significantly different in individuals with low versus high income (54.2%vs40%, P=0.002) and in those reporting inactive versus active stages of change for physical activity (50.7%vs34.7%, P=0.029), lack of resources was significantly different in those with low versus high income (40%vs24.3%, P=0.004) and married versus unmarried (33.8%vs18.5%, P=0.018). Lack of social support was significant in females versus males (35.4%vs20.8%, P=0.005).

CONCLUSIONS

The findings can inform the design on physical activity intervention studies by testing the impact of strategies which incorporate ways to address reported barriers including approaches that enhance self-efficacy and social support.

Complementary and alternative medicine use by diabetes patients in Kerala, India

The study assessed: (1) the prevalence of exclusive use of complementary and alternative medicine (CAM), exclusive use of modern medicine and combined use; (2) the factors associated with exclusive CAM use; and (3) the expenditure for CAM use among type-2 diabetes patients in rural Kerala. We surveyed 400 diabetes patients selected by multi-stage cluster sampling. Exclusive CAM use was reported by 9%, exclusive modern medicine by 61% and combined use by 30%. Patients without any co-morbidity were four times, those having regular income were three times and those who reported regular exercise were three times more likely to use exclusive CAM compared with their counterparts. Expense for medicines was not significantly different for CAM compared with modern medicine both in government and private sector. Patients with any co-morbidity were less likely to use CAM indicating that CAM use was limited to milder cases of diabetes.

Underdiagnosis of delirium on admission and prediction of patients who will develop delirium during their inpatient stay: a pilot study

INTRODUCTION

The study aimed to determine the prevalence and documentation of delirium among the elderly and if the Clock Drawing Test (CDT) can be used to predict which patients had delirium on admission and those who may develop delirium during their stay in acute medical wards.

METHODS

A single researcher performed the Mini-Mental State Examination (MMSE) and CDT on admission and discharge of 57 elderly adults at the National University Hospital, Singapore. Delirium was defined as a ≥ 3-point improvement or ≥ 2-point decline in MMSE scores from admission to discharge, where a fall denotes development of delirium and a rise denotes resolution. The case notes of the same patients were reviewed for documentation of delirium. All inpatients from two acute medical wards were examined. One CDT score and a pair of MMSE scores were collected from each patient.

RESULTS

A total of 57 patients (28 male, 29 female) were involved in the study. Their mean age was 76.0 ± 8.7 years. The prevalence of delirium based on MMSE scores was 40.4%; 16 patients had delirium on admission while seven developed delirium during their inpatient stay. However, delirium was documented in the case notes of only 7 (30%) of the 23 patients. CDT score was better than baseline MMSE score at predicting a decline in MMSE score.

CONCLUSION

The prevalence of delirium in the acute medical setting is high but underdiagnosed. The CDT may be a good screening tool to identify patients at risk of delirium during their inpatient stay. Baseline cognition screening should be performed in every elderly patient admitted to hospital.

A Randomized Controlled Trial of Acceptance and Commitment Therapy for Type 2 Diabetes Management: The Moderating Role of Coping Styles

Background and Aim

Evidence of the efficacy of existing psychological interventions for self-management in diabetes is limited. The current study aimed at assessing the effects of group-based ACT on self-management of patients with T2DM, considering the moderating role of coping styles.

Methods

One hundred and six patients with type 2 diabetes were randomly assigned either to the education alone (n = 53) or to a combination of education and group-based acceptance and commitment therapy (n = 53) over a period of 10 sessions. In each group, 50 participants completed a 3 month follow-up assessment.

Results

After 3 months, compared to patients who received education alone, those in the group-based acceptance and commitment therapy condition were more likely to use effective coping strategies, reported better diabetes self-care, and optimum glycated hemoglobin (HbA1C) levels in the target range.

Conclusions

Consideration of the role of coping style for a more accurate evaluation of the effects of acceptance and commitment therapy may be a useful addition to services provided for patients with type 2 diabetes.

Goal setting and lifestyle changes in a nurse-led counselling programme for leg ulcer patients: an explorative analysis of nursing records

AIMS AND OBJECTIVES

To describe goals set in individual nurse-led lifestyle counselling sessions in leg ulcer patients, and to explore patient and goal characteristics in relation to health behaviour change.

BACKGROUND

Goal setting is increasingly used in nurse-led counselling programmes, but the delivery is often unknown, especially in patient groups for which only recently programmes have been developed, such as patients with venous leg ulcers.

DESIGN

A secondary analysis of data collected in the intervention arm of a randomised clinical trial of counselling sessions in venous leg ulcer patients.

METHODS

Nursing records (n = 71) were explored for the number of goals set, topic, quality and course of goals during the trajectory. Furthermore, goals and patient characteristics were compared in relation to health behaviour change.

RESULTS

Forty-one patients (58%) succeeded in changing their behaviour after setting a goal. Setting goals for conducting leg exercises was chosen by most patients in this study, goals for adherence with compression therapy were chosen the least. Sixty-eight per cent of the goals met criteria for being Specific, Measurable and Time-bound. Patients who achieved behaviour change were significantly younger compared to the patients who did not. Except for age, there were no differences in characteristics between the group that did and did not achieve behaviour change.

CONCLUSIONS

Goal setting could be improved by setting goals more Specific, Measurable and Time-bound, and by setting goals on an essential topic for behaviour change. This explorative study did not show that goal characteristics, including the quality of goals, were related to patients' behaviour change.

RELEVANCE TO CLINICAL PRACTICE

The delivery of goal setting in this programme, and most likely in similar programmes, could be improved. Regular quality checks in daily goal setting practice should be considered. More research is needed into how to best provide health promotion to frail and elderly people.

"I wish they could be in my shoes": patients' insights into tertiary health care for type 2 diabetes mellitus

BACKGROUND

Insightful accounts of patient experience within a health care system can be valuable for facilitating improvements in service delivery.

OBJECTIVE

The aim of this study was to explore patients' perceptions and experiences regarding a tertiary hospital Diabetes and Endocrinology outpatient service for the management of type 2 diabetes mellitus (T2DM).

METHOD

Nine patients participated in discovery interviews with an independent trained facilitator. Patients' stories were synthesized thematically using a constant comparative approach.

RESULTS

Three major themes were identified from the patients' stories: 1) understanding T2DM and diabetes management with subthemes highlighting that specialist care is highly valued by patients who experience a significant burden of diabetes on daily life and who may have low health literacy and low self confidence; 2) relationships with practitioners were viewed critical and perceived lack of empathy impacted the effectiveness of care; and 3) impact of health care systems on service delivery with lack of continuity of care relating to the tertiary hospital model and limitations with appointment bookings negatively impacting on patient experience.

DISCUSSION

The patients' stories suggest that the expectation of establishing a productive, ongoing relationship with practitioners is highly valued. Tertiary clinics for T2DM are well placed to incorporate novel technological approaches for monitoring and follow-up, which may overcome many of the perceived barriers of traditional service delivery.

CONCLUSION

Investing in strategies that promote patient-practitioner relationships may enhance effectiveness of treatment for T2DM by meeting patient expectations of personalized care. Future changes in service delivery would benefit from incorporating patients as key stakeholders in service evaluation.

Shared Medical Appointments in Cancer Survivorship Care: A Review of the Literature

PURPOSE

The physical and psychological effects of a cancer diagnosis and treatment on an individual may be significant and require appropriate monitoring and management. Furthermore, attention to preventive care and comorbid medical conditions is critical. Innovative approaches are needed to provide quality care to this growing population.

METHODS

We reviewed the literature evaluating shared medical appointments (SMAs) in noncancer and cancer care settings. Supported by a conceptual framework and adhering to the goals of patient-centered communication, we propose how SMAs may be used in clinical practice to enhance survivorship care.

RESULTS

The literature suggests that SMAs are an effective model in noncancer settings, showing improved blood pressure and health-related quality of life, among others. Although evidence for SMAs in cancer care is limited, there is significant potential for improved patient outcomes and costs. In particular, SMAs may provide an opportunity to address medical and psychological needs while creating a structure for enhanced communication.

CONCLUSION

SMAs may offer an innovative care model for cancer survivors and their providers. Implementation and evaluation of SMAs in the care of cancer survivors is warranted.

Effects of an aquatic-based exercise program to improve cardiometabolic profile, quality of life, and physical activity levels in men with type 2 diabetes mellitus

BACKGROUND

The role of structured exercise in improving cardiometabolic profile and quality of life in patients with type 2 diabetes mellitus (2DM) has been widely demonstrated. Little is known about the effects of an aquatic-based exercise program in patients with 2DM.

OBJECTIVE

To evaluate the effects of a supervised aquatic-based exercise program on cardiometabolic profile, quality of life, and physical activity levels in patients with 2DM.

DESIGN AND SETTING

Observational study, community pre-post aquatic-based exercise program, primary care intervention.

PATIENTS

Eighteen men diagnosed with 2DM (52.2 ± 9.3 years).

METHODS

and

MAIN OUTCOME MEASUREMENTS

Cardiometabolic profile, quality of life, and physical activity levels were assessed before and after 12 weeks of an aquatic-based exercise program.

RESULTS

The results show a significant improvement of cardiometabolic assessments (maximum oxygen consumption: 24.1 versus 21.1 mL/kg/min, P < .05; blood pressure: 125.4/77 versus 130.7/82.5 mm Hg, P < .05; fasting blood glucose: 119.6 versus 132.5 mg/dL, P < .05; body mass index: 29.9 versus 31.1 kg/m², P < .005; low-density lipoprotein cholesterol: 95.2 versus 104.9 mg/dL, P < .05; and diastolic function: E/E' 9.1 versus 10.1, P < .005) and an increase in quality of life and physical activity levels (Medical Outcome Study 36-item Short Form Health Survey mental component summary: 72.3 versus 67, P < .05; Problems Area About Diabetes: 20.1 versus 33.2, P < .005) and energy expenditure in general physical activity (physical activity: 3888.7 versus 1239.5 kcal/wk, P < .05).

CONCLUSIONS

These findings demonstrate that an aquatic-based exercise program produces benefits for the cardiovascular system and metabolic profile and appears to be safe and effective in improving quality of life and increasing physical activity levels in patients with 2DM.

Can physical activity interventions for adults with type 2 diabetes be translated into practice settings? A systematic review using the RE-AIM framework

Despite the strong evidence base for the efficacy of physical activity in the management of type 2 diabetes, a limited number of physical activity interventions have been translated and evaluated in everyday practice. This systematic review aimed to report the findings of studies in which an intervention, containing physical activity promotion as a component, has been delivered within routine diabetes care. A comprehensive search was conducted for articles reporting process data relating to components of the RE-AIM (Reach, Effectiveness, Adoption, Implementation and/or Maintenance) framework. Twelve studies met the selection criteria. Of the nine studies which measured physical activity as an outcome, eight reported an increase in physical activity levels, five of which were significant. Tailoring recruitment, resources and intervention delivery to the target population played a positive role, in addition to the use of external organisations and staff training. Many interventions were of short duration and lacked long-term follow-up data. Findings revealed limited and inconsistent reporting of useful process data.

Facilitating healthy coping in patients with diabetes: a systematic review

PURPOSE

The purpose of this study is to summarize recent literature on approaches to supporting healthy coping in diabetes in 2 specific areas: (1) the impact of different approaches to diabetes treatment on healthy coping and (2) the effectiveness of interventions specifically designed to support healthy coping.

METHODS

A PubMed search identified 129 articles published August 1, 2006, to April 30, 2011, addressing diabetes in relation to emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem solving, couples therapy, or marital therapy.

RESULTS

Evidence suggests that treatment choice may significantly influence quality of life, with treatment intensification in response to poor metabolic control often improving quality of life. The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes; cognitive behavior therapy and collaborative care for treating depression; and family therapy for improving coping in youths.

CONCLUSIONS

Healthy coping in diabetes has received substantial attention in the past 5 years. A variety of approaches show positive results. Research is needed to compare the effectiveness of different approaches in different populations and determine how to overcome barriers to intervention dissemination and implementation.

Sustaining short-term improvements over the long-term: results from a 2-year diabetes self-management support (DSMS) intervention

AIM

This study examined the long-term impact of a 24-month, empowerment-based diabetes self-management support (DSMS) intervention on sustaining health-gains achieved from previous diabetes self-management education (DSME).

METHODS

Prior to the intervention, all participants received 6 months of mailed DSME consisting of weekly educational newsletters coupled with clinical feedback. The intervention consisted of 88 weekly group-based sessions that participants were encouraged to attend as frequently as they needed. Sessions were guided by participants' self-management questions and also emphasized experiential learning, coping, goal-setting, and problem-solving. Baseline, 6-month, and 30-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL.

RESULTS

This report is based on 60 African-American adults with type 2 diabetes (n=89 recruited at baseline) who completed the study. Post 6-month DSME, participants demonstrated significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), healthy diet (p<0.01), blood glucose monitoring (p<0.05) and foot exams (p<0.01). Post 24-month intervention, participants sustained the improvements achieved from the 6-month DSME and reported additional improvements for healthy diet (p<0.05), carbohydrate spacing (p<0.01), insulin use (p<0.05), and quality of life (p<0.05).

CONCLUSIONS

Findings suggest that an empowerment-based DSMS model can sustain or improve diabetes-related health gains achieved from previous short-term DSME.

Differences in weight gain in hypertensive and diabetic elderly patients primary care study

BACKGROUND

Treatment and care of elderly patients with diabetes and hypertension means a hard task in primary care. Patients with these two components of metabolic syndrome are often overweight or obese. Although some parameters of metabolic syndrome are usually measured in a medical setting, checking body weight is usually done by the patients.

AIM

The aim of this study is to analyse the patients' self-recorded data on weight and compare them according to hypertension and diabetes.

PATIENTS AND METHODS

Five hundred and forty people (225 men and 315 women) between 60 and 75 years of age were eventually selected in primary care settings. Retrospective self-recorded data on recent weights and every decade since the age of 20, as well as the decade prior to diagnosis were collected. The data of patients with and without diabetes and/or hypertension were compared.

RESULTS

The current mean body weight was significantly higher in all groups than at the age of 20. Compared with the control group, hypertensive men and women were approximately of the same weight in their twenties and, also, recently, but they gained more weight in the 4th and 5th decades of their life. Diabetics started at higher weights. The greatest weight gain was observed as follows: between 20-30 years and 30-40 years in men and women, respectively, as well as between 50-60 years of age and in the last decade prior to diagnosis in both genders. Weight gain in the control group was steady at a lower rate.

CONCLUSIONS

Weight gain between 20-40 years of age could be an important factor in the aetiology of diabetes. Stable or at least limited weight gain may be a preventive factor. Considering the limitations of the study, further and decades long epidemiological evaluations are suggested in a larger study population.

Complementary and alternative medicine use amongst Palestinian diabetic patients

OBJECTIVES

To measure the frequency of herbal medicine use among patients with diabetes mellitus in Palestine; to determine demographic characteristics that may increase the likelihood of Complementary and Alternative Medicine (CAM) use and to find out how benefits, if any, were perceived by patients.

METHOD

Cross-sectional survey of patients attending the outpatient diabetes departments at 7 Governmental Hospitals. The method was based on semi-structured questionnaires.

RESULTS

A total of 1883 patients with diabetes were interviewed. Of the participants, 51.9% (n = 977) reported taking herbs primarily bought from Palestine (98%) and used in crude form mainly as decoctions (44.1%). The five most common herbal products used were: Trigonella berythea (Fabaceae) (n = 191, 19.6%), Rosmarinus officinalis (Lamiaceae) (n = 132, 13.5%), Olea europaea (Oleaceae) (n = 131, 13.4%), Teucrium capitatum (Lamiaceae) (n = 111, 11.4%), and Cinnamomum zeylanicum (Lauraceae) (n = 105, 10.8%). Most CAM users were above 40 years old 79.6% (n = 778), predominantly female (53.2%) and residents of refugee camps and rural areas (59.3, and 53.5, respectively). The recommendations of a family member or friend was the main factor prompting the use of CAM (40.2 and 37.1%). Most CAM users (71.7%) were satisfied with the perceived effects. Interestingly, 68% of patients recruited in the study did not disclose CAM use to their physicians or pharmacists.

CONCLUSION

Use of herbal therapies in diabetes is highly prevalent in Palestine. More than 70% of those using CAM (977, 51.9%) reported positive benefits including a feeling of slowing down disease progression, symptom relief, disease resolution or a reduction in the side effects of allopathic medication. Use of CAM should be explored with patients before clinical decisions are made. There is a need for health education relating to herbal use in conjunction with conventional medicines in diabetes.

Organizing and delivering diabetes education and self-care support: findings of scoping project

OBJECTIVE

To provide an overview of current research and development on the organization and delivery of diabetes education and self-care support, incorporating stakeholder perspectives.

METHOD

Four methods were used: literature review (159 papers and 52 grey literature items); patient participation event (n = 38); online survey of professionals (n = 423) and patients (n= 495); and, a conference.

RESULTS

The literature review identified themes relating to the organization and delivery of diabetes and self-care support: structure and flexibility in models of education; accessibility; patient choice; integrating self-care within the overall care system; quality improvement; peer educators; health literacy; efficiency in delivery; telecare models; feedback technologies; care planning; psychological intervention; and self-care outcome measures. This generated four models to provide a framework to help shape the development of diabetes self-care: a diabetes education pathway; integrating self-care and clinical care; choice as a method of optimizing care; and an integrated framework for delivering diabetes self-care.

CONCLUSION

The clinical benefit of the identified models need to be evaluated.

Complementary and alternative medicine use among Jordanian patients with diabetes

PURPOSE

This study explores the prevalence, type, frequency, purpose and pattern of herbal preparation use as complementary and alternative medicine (CAM) in a cohort of patients with diabetes in Jordan.

METHOD

The study took the form of a cross-sectional survey of patients attending the outpatient departments at The National Centre for Diabetes, Endocrine and Genetics (NCDEG), in Amman. The method was based on semi-structured questionnaire.

RESULTS

A total of 1000 diabetes patients were interviewed. Of the participants, 16.6% (n=166) reported using herbs. Most of CAM users were in the age group 51-60 years (n=73, 44.0%) and predominantly female (59.6%). 139 of the CAM users (83.7%) had at least obtained a high school degree. The most common herbal product to be used was green tea (20.5%).

CONCLUSION

This study confirmed that there is an appreciable prevalence of herbal use among patients with diabetes in Jordan.

Is There a Connection Between Diabetes and Psychological Dysfunction?

This review discusses evidence-based perspectives on the relationship between diabetes and psychological distress. Future directions for inquiry and clinical management also are addressed.

Effectiveness of the introduction of a Chronic Care Model-based program for type 2 diabetes in Belgium

Background

During a four-year action research project (2003-2007), a program targeting all type 2 diabetes patients was implemented in a well-defined geographical region in Belgium. The implementation of the program resulted in an increase of the overall Assessment of Chronic Illness Care (ACIC) score from 1.45 in 2003 to 5.5 in 2007. The aim of the follow-up study in 2008 was to assess the effect of the implementation of Chronic Care Model (CCM) elements on the quality of diabetes care in a country where the efforts to adapt primary care to a more chronic care oriented system are still at a starting point.

Methods

A quasi-experimental study design involving a control region with comparable geographical and socio-economic characteristics and health care facilities was used to evaluate the effect of the intervention in the region. In collaboration with the InterMutualistic Agency (IMA) and the laboratories from both regions a research database was set up. Study cohorts in both regions were defined by using administrative data from the Sickness Funds and selected from the research database. A set of nine quality indicators was defined based on current scientific evidence. Data were analysed by an institution experienced in longitudinal data analysis.

Results

In total 4,174 type 2 diabetes patients were selected from the research database; 2,425 patients (52.9% women) with a mean age of 67.5 from the intervention region and 1,749 patients (55.7% women) with a mean age of 67.4 from the control region. At the end of the intervention period, improvements were observed in five of the nine defined quality indicators in the intervention region, three of which (HbA1c assessment, statin therapy, cholesterol target) improved significantly more than in the control region. Mean HbA1c improved significantly in the intervention region (7.55 to 7.06%), but this evolution did not differ significantly (p = 0.4207) from the one in the control region (7.44 to 6.90%). The improvement in lipid control was significantly higher (p = 0.0021) in the intervention region (total cholesterol 199.07 to 173 mg/dl) than in the control region (199.44 to 180.60 mg/dl). The systematic assessment of long-term diabetes complications remained insufficient. In 2006 only 26% of the patients had their urine tested for micro-albuminuria and only 36% had consulted an ophthalmologist.

Conclusion

Although the overall ACIC score increased from 1.45 to 5.5, the improvement in the quality of diabetes care was moderate. Further improvements are needed in the CCM components delivery system design and clinical information systems. The regional networks, as they are financed now by the National Institute for Health and Disability Insurance (NIHDI), are an opportunity to explore how this can be achieved in consultation with the GPs. But it is clear that, simultaneously, action is needed on the health system level to realize the installation of an accurate quality monitoring system and the necessary preconditions for chronic care delivery in primary care (patient registration, staff support, IT support).

Trial Registration

Trial registration number: ClinicalTrials.gov Identifier: NCT00824499

Implementation of a program for type 2 diabetes based on the Chronic Care Model in a hospital-centered health care system: "the Belgian experience"

Background

Most research publications on Chronic Care Model (CCM) implementation originate from organizations or countries with a well-structured primary health care system. Information about efforts made in countries with a less well-organized primary health care system is scarce. In 2003, the Belgian National Institute for Health and Disability Insurance commissioned a pilot study to explore how care for type 2 diabetes patients could be organized in a more efficient way in the Belgian healthcare setting, a setting where the organisational framework for chronic care is mainly hospital-centered.

Methods

Process evaluation of an action research project (2003–2007) guided by the CCM in a well-defined geographical area with 76,826 inhabitants and an estimated number of 2,300 type 2 diabetes patients. In consultation with the region a program for type 2 diabetes patients was developed. The degree of implementation of the CCM in the region was assessed using the Assessment of Chronic Illness Care survey (ACIC). A multimethod approach was used to evaluate the implementation process. The resulting data were triangulated in order to identify the main facilitators and barriers encountered during the implementation process.

Results

The overall ACIC score improved from 1.45 (limited support) at the start of the study to 5.5 (basic support) at the end of the study. The establishment of a local steering group and the appointment of a program manager were crucial steps in strengthening primary care. The willingness of a group of well-trained and motivated care providers to invest in quality improvement was an important facilitator. Important barriers were the complexity of the intervention, the lack of quality data, inadequate information technology support, the lack of commitment procedures and the uncertainty about sustainable funding.

Conclusion

Guided by the CCM, this study highlights the opportunities and the bottlenecks for adapting chronic care delivery in a primary care system with limited structure. The study succeeded in achieving a considerable improvement of the overall support for diabetes patients but further improvement requires a shift towards system thinking among policy makers. Currently primary care providers lack the opportunities to take up full responsibility for chronic care.

Trial registration number

ClinicalTrials.gov Identifier: NCT00824499