Improvement in A1C Levels and Diabetes Self-Management Activities Following a Nutrition and Diabetes Education Program in Older Adults

Construction and Content Validation of Mobile Devices' Application Messages about Food and Nutrition for DM2 Older Adults

Older adults face a decline in the quality of their diet, which affects their health. The prevalence of DM2 is increasing, as are the associated complications. Effective nutrition education and mobile health (mHealth) interventions offer a viable solution in the scenario of the widespread use of mobile devices. This study aimed to develop and validate messages for a mobile application aimed at older adult Brazilians with DM2 who receive care at the Brazilian Unified Health System (SUS). The educational messages on healthy eating for older adults with DM2 were created from 189 excerpts selected from Brazilian official documents. A total of 37 messages were created, categorized into 20 educational, 12 motivational, and 5 congratulatory, all up to 120 characters. Twenty-one experts validated the messages for clarity and relevance, and 11 messages had to be revised to meet the criteria. Subsequently, the 36 messages approved by the experts were tested on a sample of 57 older adults, guaranteeing clarity rates of over 80%. This study developed and validated 36 messages for a mobile health app aimed at older adults with type 2 diabetes mellitus in Brazil. Expert evaluation ensured clarity and relevance, confirmed by older adult participants who evaluated clarity. This research highlights the potential of mHealth to overcome barriers to accessing healthcare in the SUS, emphasizing personalized interventions for the effective management of older adults' health.

What Drove Program Participants to Initially Attend Congregate Meals? Socialization, Health, and Other Reasons

The Congregate Nutrition Services support efforts to keep older Americans independent and engaged in their communities. We examined participants' self-reported reasons for initially attending the congregate meals program and whether reasons differed by participant characteristics. Descriptive statistics and tests of differences were used to compare participants (n = 1,072). Individuals attended congregate meals for several reasons, with the top two being socialization (36.3%) and age- or health-related reasons (18.7%). Those attending for socialization were less likely to be lower income, have food insecurity, or live with 3+ ADL limitations while participants who first attended due to age or health-related reasons were more likely to be low income, food insecure, and from historically marginalized populations. Health and social service professionals and community organizations could expand data collection on older adults in their communities and partner with congregate meal providers to encourage participation for individuals with unmet nutritional, health, and socialization needs.

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.

Providing evidence from practice: Evaluating 4.5 years of implementing diabetes education support program in carbohydrate management

OBJECTIVE

To evaluate personal and economical outcomes of CarbSmart, a 3-hour person-centered, theory-based program implemented throughout Australia, targeting optimal dietary carbohydrate management.

METHODS

More than 500 CarbSmart programs were implemented over 4.5 years. Pre-, post-, (N = 4656) and 3-month follow-up assessments (N = 188) of knowledge, empowerment, confidence, and patient activation were collected from people with diabetes. Participant satisfaction and potential annual cost-savings were calculated.

FINDINGS

Repeated measures ANCOVAs showed large improvements pre- to post-program in all outcome variables (d = 0.80-1.68), which were maintained at 3-month follow-up in a sub-sample. Participant satisfaction was high (Net Promoter Score = 72.3). Potential annual cost-savings nation-wide were estimated at US$512million.

CONCLUSION

This paper provides evidence that CarbSmart is effective in improving behavioral indicators of self-management outcomes in Australians living with diabetes.

PRACTICE IMPLICATIONS

CarbSmart has the potential to prevent diabetes-related complications. However, not engaging people living with diabetes with lower levels of patient activation at baseline was recognized as a future opportunity to improve the impact of our service. Strategies are needed to engage people with lower activation levels to improve outcomes in vulnerable and at-risk populations.

FUNDING

The development of CarbSmart was funded by Diabetes WA, the national implementation of CarbSmart by the National Diabetes Services Scheme, an initiative of the Australian Government.

Diabetes management among underserved older adults through telemedicine and community health workers

BACKGROUND

Diabetes mellitus (DM) disproportionately affects older adults from marginalized communities. In the United States, the prevalence of DM in ages ≥65 years is twofold higher than the national average for adult populations. Telemedicine and community health workers (CHWs) are emerging diabetes care models but their impact on older adults with limited resources are relatively neglected within the medical literature.

OBJECTIVES

The purpose of this systematic review was to explore the impact of telemedicine and CHW interventions for improving A1C levels and self-management behaviors among underserved older adults with DM.

DATA SOURCES

A systematic literature search was performed in PubMed, CINAHL, Embase, and Cochrane databases using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses as a reporting guideline.

CONCLUSIONS

Diabetes self-management education (DSME) administered through telemedicine and CHW interventions were effective for improving A1C levels, self-care adherence, and patient and provider satisfaction among adults aged ≥50 years. Common barriers to diabetes care include inadequate resources, lack of transportation, inconsistent means of communications, social isolation, and low motivation. Community health workers and telemedicine were effective in improving disease management and optimizing care coordination within the vulnerable adult populations.

IMPLICATIONS FOR PRACTICE

Well-coordinated, evidence-based, and population-centered interventions can overcome the unique disparities experienced by underserved older adults with diabetes. Incorporating DSME-guided telemedicine and CHW interventions into primary care can mitigate diabetes-related complications in older populations. The lack of evidence specific to adults aged ≥65 years calls for a universally accepted age range when referring to older adults in future research.

Evidence-based diabetes care for older people with Type 2 diabetes: a critical review

In our ageing society diabetes imposes a significant burden in terms of the numbers of people with the condition, diabetes-related complications including disability, and health and social care expenditure. Older people with diabetes can represent some of the more complex and difficult challenges facing the clinician working in different settings, and the recognition that we have only a relatively small (but increasing) evidence base to guide us in diabetes management is a limitation of our current approaches. Nevertheless, in this review we attempt to explore what evidence there is to guide us in a comprehensive scheme of treatment for older adults, often in a high-risk clinical state, in terms of glucose lowering, blood pressure and lipid management, frailty care and lifestyle interventions. We strive towards individualized care and make a call for action for more high-quality research using different trial designs.

Factors associated with glycaemic control in patients with diabetes mellitus: A systematic literature review

OBJECTIVES

To perform a systematic review search and critically review the empirical evidence concerning the factors affecting glycaemic control in patients with type 1 or 2 diabetes mellitus.

BACKGROUND

Previous primary studies have investigated the factors associated with glycaemic control among patients with type 1 or 2 diabetes, but attempts to amalgamate these evidences have been methodologically limited. Hence, a robust review of the evidence is essential to explore factors that can be addressed to promote good glycaemic control in patients with diabetes.

DESIGN

Mixed-method systematic review using the Preferred Reporting Items for Systematic review and Meta-Analysis 2009 flow diagram, integrating evidence from qualitative and quantitative studies (see Supporting Information File S1).

METHODS

A systematic review of the literature published between 2006-2017 was conducted in seven electronic databases (CINAHL, MEDLINE, Scopus, EMBASE, PsycINFO, PubMed and ScienceDirect) using the search terms "diabetes mellitus," "glycemic control," "self-concept," "knowledge," "self-efficacy," "empowerment," "race," "ethnicity," "duration," "medication," "obesity" and "comorbidity."

RESULTS

A total of 1,582 articles were initially retrieved, and 24 of these articles were included in this systematic literature review. The overall empirical evidence suggested that higher socio-economic status, greater dietary knowledge, and higher self-efficacy and empowerment improve glycaemic control among patients with diabetes mellitus.

CONCLUSIONS

This review presented the factors associated with glycaemic control that may pose significant socio-economic problems to most nations worldwide and impede development nationally, regionally and even globally. Greater emphasis needs to be placed on implementing lifestyle changes on a societal level to stem the tide of the epidemic.

RELEVANCE TO CLINICAL PRACTICE

There is a need to implement self-management initiatives, that incorporate dietary knowledge, to empower patients with diabetes in their own care. Future public health policy must be geared towards increasing the capability of dealing with the rising incidence of diabetes and implementing primary prevention.

Effect of a Diabetes Self-Efficacy Enhancing Program on Older Adults With Type 2 Diabetes: A Randomized Controlled Trial

This randomized controlled trial examined the effect of a diabetes self-efficacy enhancing program (DSEEP) on older adults with type 2 diabetes. The 8-week DSEEP consisted of a guidebook on diabetes self-care, a 1-day workshop, and fortnightly follow-up telephone calls. In total, 113 participants (56 in intervention group and 57 in control group) completed the study. Data were collected at baseline and at 8 weeks from the baseline. Outcome measures included self-efficacy, diabetes self-care activities, health-related quality of life, glycated hemoglobin (HbA1c) and unplanned health care service usage. Compared with participants in the control group, those who received DSEEP had significantly higher increase in self-efficacy and diabetes self-care activities, lower HbA1c, and lesser unplanned health service usage. However, there was no significant difference in health-related quality of life between the two groups. The DSEEP increased self-efficacy, which successfully enhanced self-care activities and reduced HbA1c.

The impact of educational intervention on physical activity, nutrition and laboratory parameters in type II diabetic patients

Background

Diabetes is one of the most common chronic diseases that is now widely spread around the world, and day by day the number of patients is increasing. The purpose of this study was to determine the impact of educational intervention on physical activity, nutrition and laboratory parameters in type 2 diabetic patients.

Methods

This semi-experimental study was performed from March to October 2015 on 100 patients with type 2 diabetes who referred to the Niknejad health center. The type of sampling was simple random. Data were collected using a questionnaire including demographic questions, assessment of nutritional status and physical activity, history of diabetes, physical measurements and laboratory parameters of patients. Data were analyzed using SPSS 16, and descriptive and analytical tests (paired-samples t-test) and the results were significant at the level of (p<0.05).

Results

In present study, body measurements, the mean number of units of fruit and vegetable intake per day, type of oil consumption, the mean number of days of fish intake per week or the mean number of days with intense physical activity per week, had no significant difference before and after the intervention, while the variables of FBS level (p<0.003), rate of HbA_1c (p<0.027), the mean number of days of fruit intake (p<0.001) and vegetable intake (p<0.037) per week and the mean number of days with moderate physical activity (p<0.03) of patients, had significant difference before and after the intervention.

Conclusion

According to the findings of this study, to improve BMI, fish intake, type of oil consumption and also increased daily fruit and vegetable intake in these patients, a variety of educational-supportive interventions are recommended.

Diabetes self-care and the older adult

The prevalence of diabetes is highest in older adults, a population that is increasing. Diabetes self-care is complex with important recommendations for nutrition, physical activity, checking glucose levels, and taking medication. Older adults with diabetes have unique issues that impact self-care. As people age, their health status, support systems, physical and mental abilities, and nutritional requirements change. Furthermore, comorbidities, complications, and polypharmacy complicate diabetes self-care. Depression is also more common among the elderly and may lead to deterioration in self-care behaviors. Because of concerns about cognitive deficits and multiple comorbidities, adults older than 65 years are often excluded from research trials. Thus, little clinical evidence is available and the most appropriate treatment approaches and how to best support older patients' self-care efforts are unclear. This review summarizes the current literature, research findings, and expert and consensus recommendations with their rationales.

Systematic review of the psychometric properties and theoretical grounding of instruments evaluating self-care in people with type 2 diabetes mellitus

AIM

To determine the psychometric properties and theoretical grounding of instruments that evaluate self-care behaviour or barriers in people with type 2 diabetes.

BACKGROUND

There are many instruments designed to evaluate self-care behaviour or barriers in this population, but knowledge about their psychometric validation processes is lacking.

DESIGN

Systematic review.

DATA SOURCES

We conducted a search for psychometric or validation studies published between January 1990-December 2012. We carried out searches in Pubmed, CINAHL, PsycINFO, ProQuolid, BibliPRO and Google SCHOLAR to identify instruments that evaluated self-care behaviours or barriers to diabetes self-care.

REVIEW METHODS

We conducted a systematic review with the following inclusion criteria: Psychometric or clinimetric validation studies that included patients with type 2 diabetes (exclusively or partially) and which analysed self-care behaviour or barriers to self-care and proxies like self-efficacy or empowerment, from a multidimensional approach. Language: Spanish or English. Two authors independently assessed the quality of the studies and extracted data using Terwee's proposed criteria: psychometrics properties, dimensionality, theoretical ground and population used for validation through each included instrument.

RESULTS

Sixteen instruments achieved the inclusion criteria for the review. We detected important methodological flaws in many of the selected instruments. Only the Self-management Profile for Type 2 Diabetes and Problem Areas in Diabetes Scale met half of Terwee's quality criteria.

CONCLUSION

There are no instruments for identifying self-care behaviours or barriers elaborated with a strong validation process. Further research should be carried out to provide patients, clinicians and researchers with valid and reliable instruments that are methodologically solid and theoretically grounded.

Impact of an education program on patient anxiety, depression, glycemic control, and adherence to self-care and medication in Type 2 diabetes

Background:

Diabetes mellitus (DM) requires continuous medical care, patients’ self-management, education, and adherence to prescribed medication to reduce the risk of long-term complications. The aim of this study was to assess the benefits of an education program on diabetes, patient self-management, adherence to medication, anxiety, depression and glycemic control in type 2 diabetics in Saudi Arabia.

Materials and Methods:

This was a prospective study, conducted among 104 diabetic patients at a major tertiary hospital in Riyadh, Saudi Arabia, between May 2011 and October 2012. Education materials given to diabetic patients included pamphlets/handouts written in Arabic, the national language. Special videotapes about DM were made and distributed to all participants. In addition, specific educational programs through the diabetes educators and one-on-one counseling sessions with the doctor were also arranged. Patients were interviewed using a structured interview schedule both during the baseline, and after 6 months of the program. The interview schedule included, socio-demographics, clinical characteristics, diabetes self-management, adherence to medication, anxiety, and depression. Glycemic control was considered poor, if hemoglobin A1c (HbA1c) was ≥ 7%.

Results:

The mean age of the study population was 57.3 ± 14.4 years. Seventy one were males (68.3%) and 33 (31.7%) were females. After six months of the diabetes education program, there were significant improvements in patients’ dietary plan (P = 0.0001), physical exercise (P = 0.0001), self-monitoring of blood glucose (SMBG) (P = 0.0001), HbA1c (P = 0.04), adherence to medication (P = 0.007), and depression (P = 0.03).

Conclusions:

Implementation of education programs on diabetes among type 2 diabetic patients is associated with better outcomes such as their dietary plan, physical exercise, SMBG, adherence to medication, HbA1c and depression.

Health literacy, self-efficacy, and self-care behaviors in patients with type 2 diabetes mellitus

PURPOSE

The study purpose was to explore the relationships among health literacy, self-efficacy, and self-care behaviors of patients with type 2 diabetes.

DATA SOURCES

A cross-sectional study with a descriptive correlational design was conducted. Patients (N = 150) with type 2 diabetes were recruited from diabetes clinics in the Marshall Islands. Levels of health literacy, self-efficacy, and self-care behaviors were assessed by a questionnaire.

CONCLUSIONS

Health literacy, receiving diabetes education, and employment status together explained 11.8% of the variance in self-efficacy (F((3,147)) = 7.58, p < .001). Patients who had higher health literacy, received more diabetes-related education, were currently employed and had better self-efficacy. Self-efficacy and marital status together explained 16.7% of the variance in self-care behaviors (F((2,148)) = 15.96, p < .001). Patients who had higher self-efficacy and who were married had better self-care behaviors.

IMPLICATIONS FOR PRACTICE

Strategies are needed to incorporate the concept of self-efficacy in the design of diabetes education to promote patients' self-care behaviors, with an emphasis on dealing with hyper- or hypoglycemia, following the diet plan, and checking blood sugar levels as recommended. Diabetes education material that requires a lower literacy level may be needed for older or unemployed adult populations.

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.

Associations between health care factors and self-reported health status among individuals with diabetes: results from a community assessment

To identify the influence of select health care variables on self-reported physical and mental health status of individuals with diabetes. Data from the 2006 Brazos Valley Health Status Assessment (BVHSA) were analyzed. Aspects of health care were defined through exploratory factor analysis. Structural equation modeling was used to create relationships between health care aspects, personal characteristics of the participants, and self-reported physical and mental health status of individuals with diabetes. The significant predictors of self-reported physical health status were the number of co-morbid chronic diseases (β = 0.27, P = .002), and medical system access (β = -0.20, P = .035). The significant predictor of self-reported mental health status was the number of co-morbid chronic diseases (β = 0.35, P < .001). Self-reported physical (β = 0.27, P = .028) and mental (β = 0.29, P = .020) health status were both predictive of physician communication of mental health issues. Communication about mental health issues strongly relates to both self-reported physical and mental health status and should be an important part of physicians' care for individuals with diabetes. Further, the nuances of medical system access for diabetes care should be further examined.

Food insecurity, food and nutrition programs, and aging: experiences from Georgia

Food insecurity and hunger are real and growing problems in the United States. Among older adults, the prevalence of food insecurity is at a 14-year high and occurred in more than 8% of households with older adults in 2008 according to USDA. However, the rate is at least 10% higher when less severe degrees of food insecurity are considered. Emerging research suggests that several segments of the older adult population are particularly vulnerable to food insecurity, including those receiving or requesting congregate meals, home-delivered meals, and other community-based services. Thus, national and state estimates of food insecurity may obscure problems in specific subgroups of older adults. Older adults are at high risk of chronic health problems that can be exacerbated by food insecurity, poor nutritional status, and low physical activity. To help improve targeting of food and nutrition programs to those most in need because of food insecurity and/or nutrition-related chronic health problems, the purposes of this review are (1) to define the prevalence and consequences of food insecurity; (2) to discuss the outcomes of some food, nutrition, disease prevention, and health promotion programs targeted to older adults in Georgia, the state with the 3rd highest prevalence of food insecurity; and (3) to make recommendations for research, service, and advocacy related to monitoring and alleviating food insecurity and related health problems in older adults.

Fruit and vegetable intake and knowledge increased following a community-based intervention in older adults in Georgia senior centers

Our purpose was to evaluate a community-based fruit and vegetable intervention conducted in rural and urban areas of Georgia. Participants were a convenience sample from Georgia senior centers that completed a pre-test, the intervention, and a post-test (N = 558, mean age = 75, 83% female, 47% white, 53% black). The 4-month intervention had eight sessions focused on practical ways to increase intake of fruits and vegetables at meals and snacks and included physical activity. Pre- and post-tests examined self-reported intakes of fruits and vegetables at breakfast, lunch, the evening meal, and snacks, knowledge of recommended intakes, and barriers to intake. Following the intervention, the number of participants reporting consumption of at least 7 servings of fruits and vegetables daily increased by 21-percentage points (P < or = 0.001), knowledge that 7 to 10 servings of fruits and vegetables are recommended daily (for 1,600 to 2,200 calories) increased from 7% to 57% (P < or = 0.001), and three barriers to fruit and vegetable intake decreased (P < or = 0.05): "difficulties with digestion," "too many are recommended," and "too much trouble." Regression analyses indicated that increased intake following the intervention was independently associated with living in more urban rather than rural areas, improved knowledge of intake recommendations, decrease in perception of cost as a barrier, and increase in digestive problems as a barrier (P < or = 0.05). These results provide an evidence base for the effectiveness of this community intervention for improving knowledge and intake and decreasing barriers to fruit and vegetable intake in older adults.

Physical activity and physical function improved following a community-based intervention in older adults in Georgia senior centers

We evaluated a community-based physical activity intervention in Georgia senior centers. Participants were a convenience sample that completed the pre-test only (n = 592), or the pre-test, the intervention, and a post-test (n = 418, 98% aged 60 and older, mean age = 75, 83% female, 56% black). The 4-month physical activity intervention, based on the Health Belief Model, included 16 sessions that focused on educator-led chair exercises, promotion of walking, using a pedometer, and recording daily steps. Pre- and post-tests assessed physical activity and physical function, categorized as poor, moderate, or good (Short Physical Performance Battery). Following the intervention, participants improved their physical function (good physical function at pre-test vs. post-test: 16.5% vs. 25.3%, P < or = 0.001), increased minutes of physical activity by 26% (P < or = 0.001) and step counts by 29% (P < or = 0.0001, sub-sample, n = 95), and decreased reports of "it's not safe" as a barrier to physical activity (P < or = 0.05). Increased physical activity (P < or = 0.01) was associated with improved physical function following the intervention. The results of this evaluation provide an evidence base for the effectiveness of this community intervention for improving physical activity and physical function in older adults.