The AH-HA! Project: Transforming Group Diabetes Self-Management Education Through the Addition of Flash Glucose Monitoring

Background: The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a nondidactic "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM). Methods: In this single-arm pilot study, 35 adults with T2D duration 1-5 years, ages 21-75 years, not using insulin and HbA1c ≥8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures. Results: There was a significant gain in percentage time in range (% TIR) 70-180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop-in percentage time above range (TAR) >180 mg/dL from 44% to 25% (Ps = 0.01). Overall well-being rose significantly (P = 0.04), whereas diabetes distress showed a nonsignificant drop. Participants reported improvements in healthy eating (P < 0.001) and physical activity, although the latter did not reach statistical significance. Conclusions: These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging patient-driven "discovery learning" approach to education.

One size does not fit all: Nutrition strategies for people with diabetes

Several nutrition strategies and eating patterns can help support self-management among persons with diabetes. This article details the effectiveness of popular eating patterns and nutrition strategies, as well as the role of nurses in facilitating informed patient choices and decisions.

Diabetes: Changing the conversation

Nurses can make a difference by carefully considering the language they use to talk to or about patients with diabetes. This article discusses the importance of words and messages in healthcare, particularly in diabetes education.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Changing Patients' Treatment Preferences and Values with a Decision Aid for Type 2 Diabetes Mellitus: Results from the Treatment Arm of a Randomized Controlled Trial

INTRODUCTION

Failure to intensify treatment for type 2 diabetes mellitus (T2DM) when indicated, or clinical inertia, is a major obstacle to achieving optimal glucose control. This study investigates the impact of a values-focused patient decision aid (PDA) for T2DM antihyperglycemic agent intensification on patient values related to domains important in decision-making and preferred treatments.

METHODS

Patients with poorly controlled T2DM who were taking a metformin-containing regimen were recruited through physicians to access a PDA presenting evidence-based information on T2DM and antihyperglycemic agent class options. Participants' preferences for treatment, decision-making, and the relative importance they placed on various values related to treatment options (e.g., dosing, weight gain, side effects) were assessed before and after interacting with the PDA. Changes from baseline were calculated (post-PDA minus pre-PDA difference) and assessed in univariate generalized linear models exploring associations with patients' personal values.

RESULTS

Analyses included 114 diverse patients from 27 clinics across the US. The importance of avoiding injections, concern about hypoglycemia, and taking medications only once a day significantly decreased after interacting with the PDA [- 1.1 (p = 0.002), - 1.3 (p < 0.001), - 1.1 (p = 0.004), respectively], while the importance of taking medications that avoided weight gain increased [0.8 (p = 0.004)]. Prior to viewing the PDA, most patients (58.8%) had not begun thinking about the decision of adding a medication, and few (12.3%) indicated that they had already made a decision. Post-PDA, 46.5% could state a medication preference.

CONCLUSION

The values-focused PDA for T2DM medication intensification prepared patients to make a shared decision with their clinician and changed patients' values regarding what was important in making that decision. Helping patients understand their options and underlying values can promote shared decision-making and may reduce clinical inertia delaying treatment intensification.

FUNDING

Janssen Scientific Affairs, LLC.

The Use of Language in Diabetes Care and Education

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA), convened to discuss language in diabetes care and education. This document represents the expert opinion of the task force. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words-whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

The Use of Language in Diabetes Care and Education

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators and the American Diabetes Association, convened to discuss language in diabetes care and education. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words, whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

Exploring the role of the patient-physician relationship on insulin adherence and clinical outcomes in type 2 diabetes: Insights from the MOSAIc study

BACKGROUND

The 2-year prospective MOSAIc (Multinational Observational Study assessing Insulin use: understanding the challenges associated with progression of therapy) study is investigating whether patient-, physician-, and health system-related factors affect outcomes in patients with type 2 diabetes (T2D). This baseline subanalysis investigated how aspects of the patient-physician relationship are associated with diabetes-related distress, insulin adherence, and glycemic control.

METHODS

Patients with T2D taking insulin for ≥3 months were recruited at primary care and specialty practice sites in 18 countries. Physicians provided usual care. Clinical history and most recent HbA1c values were collected; patients were surveyed regarding their perception of physician interactions, diabetes-related distress level, and insulin adherence.

RESULTS

The analysis population comprised 4341 patients. Four (of six) domains showed a significant relationship with total diabetes-related distress (P < 0.01). Poor insulin adherence was associated with greater diabetes-related distress (adjusted odds ratio [aOR] 1.14; 95% confidence interval [CI] 1.06-1.22), higher Discrimination (aOR 1.13; 95% CI 1.02-1.27) and Hurried Communication (aOR 1.35; 95% CI 1.20-1.53) scores, and a lower Explained Results score (aOR 0.86; 95% CI 0.77-0.97). Poor insulin adherence was associated with a 0.43% increase in HbA1c, whereas a 1-unit increase in total diabetes-related distress and Hurried Communication scores was associated with a 0.171% and 0.145% increase in HbA1c, respectively.

CONCLUSIONS

Patients distressed about living with T2D, and dissatisfied with aspects of their interactions with physicians, exhibited poor insulin adherence. Perceived physician inattention and lack of engagement (and diabetes-related distress) directly affect insulin adherence and glycemic control.

US Nurses’ Perceptions of Their Role in Diabetes Care

PURPOSE

The purpose of this study was to examine nurse and physician perceptions of nurse involvement and roles in diabetes care.

METHODS

The study used a cross-sectional design with face-to-face or telephone interviews of diabetes health care professionals in 13 countries from Asia, Australia, Europe, and North America. This article focuses on the data from US health care providers. The US sample included 51 generalist nurses, 50 diabetes specialist nurses, 166 generalist physicians, and 50 diabetes specialist physicians.

RESULTS

Nurses and physicians agreed that nurses should take a larger role in managing diabetes. Most common differences identified between nurses and physicians were that nurses provide better education, spend more time with patients, were better listeners, and knew their patients better than physicians. All nurses had a high perceived need for better understanding of psychosocial issues and were more likely than physicians to suggest helping patients to take responsibility for their care. Nurses more than physicians also said better communication was needed. Generalist nurses report that they act as intermediaries and facilitate patient appointment keeping. Specialist nurses talk to patients about self-management, teach medication management, have a higher level of involvement in medication prescribing, and are more willing to take on additional responsibilities than generalist nurses.

CONCLUSIONS

There is an increased need for more involvement by nurses, particularly specialist nurses, in diabetes care.

Choosing and Using Theories in Diabetes Education Research

Diabetes educators use theories all the time, even if they are not aware of it. To teach, one must have some assumptions about how people learn and what constitutes effective teaching. The purpose of this article is to help diabetes educators interested in research and evaluation choose appropriate theories. The article will review the 4 purposes of theories, that is, description, explanation, prediction, and control, as well as the degree to which a theory has been articulated and elaborated. The importance of a theory’s personal resonance, its explanatory power, and its utility will also be examined. The article will also review how to use 1 or more theories at each stage of a research or evaluation project.

Validation of the Revised Brief Diabetes Knowledge Test (DKT2)

Purpose

The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale.

Methods

Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan’s (UofM) Diabetes Registry (n = 89). Cronbach’s coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample.

Results

The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity.

Conclusions

The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care.

Effect of a patient decision aid (PDA) for type 2 diabetes on knowledge, decisional self-efficacy, and decisional conflict

BACKGROUND

Patients with type 2 diabetes (T2DM) often have poor glycemic control on first-line pharmacologic therapy and require treatment intensification. Intensification decisions can be difficult because of many available options and their many benefits and risks. The American Diabetes Association recommends patient-centered, evidence-based tools supporting shared decision-making between patients and clinicians. We developed a patient decision aid (PDA) targeting decisions about treatment intensification for T2DM. Our objective was to determine the effectiveness of this PDA for patients with T2DM on metformin who require treatment intensification.

METHODS

This study was a pragmatic randomized controlled trial conducted in 27 US primary care and endocrinology clinics. Subjects were English-speaking adults with T2DM receiving metformin with persistent hyperglycemia who were recommended to consider medication intensification. Subjects were randomized to receive either the PDA or usual care (UC). Main outcome measures were change in knowledge, decisional self-efficacy, and decisional conflict.

RESULTS

Of 225 subjects enrolled, 114 were randomized to the PDA and 111 to UC. Mean [SD] age was 52 [1] years, time since T2DM diagnosis was 6 [+/-6] years, 45.3% were male, and most (55.5%) were non-Caucasian. Compared to UC, PDA users had significantly larger knowledge gains (35.0% [22.3] vs 9.9% [22.2]; P < 0.0001) and larger improvements in self-efficacy (3.7 [16.7] vs-3.9 [19.2]; P < 0.0001) and decisional conflict (-22.2 [20.6] vs-7.5 [16.6]; P < 0.0001).

CONCLUSIONS

The PDA resulted in substantial and significant improvements in knowledge, decisional conflict and decisional self-efficacy. Decisional conflict scores after PDA use were within the range that correlates with effective decision-making. This PDA has the potential to facilitate shared-decision-making for patients with T2DM.

TRIAL REGISTRATION

NCT02110979.

Role of Emerging Insulin Technologies in the Initiation and Intensification of Insulin Therapy for Diabetes in Primary Care

In Brief This article explores some of the reasons for the delay in insulin initiation in primary care and evaluates new approaches to insulin therapy that may address these barriers and, therefore, improve insulin use by primary care providers.

Peer-Led, Empowerment-Based Approach to Self-Management Efforts in Diabetes (PLEASED): A Randomized Controlled Trial in an African American Community

PURPOSE

We compared a 3-month diabetes self-management education (DSME) program followed by a 12-month peer support intervention with a 3-month DSME program alone in terms of initial and sustained improvements in glycated hemoglobin (HbA1c). Secondary outcomes were risk factors for cardiovascular disease (CVD), diabetes distress, and social support.

METHODS

We randomized 106 community-dwelling African American adults with type 2 diabetes to a 3-month DSME program followed by 12 months of weekly group sessions and supplementary telephone support delivered by peer leaders or to a 3-month DSME program with no follow-up peer support. Assessments were conducted at baseline, 3, 9, and 15 months.

RESULTS

No changes in HbA1c were observed at 3 months or at 15 months for either group. The peer support group either sustained improvement in key CVD risk factors or stayed the same while the control group worsened at 15 months. At 15 months, the peer-support group had significantly lower low-density lipoprotein cholesterol levels (-15 mg/dL, P = .03), systolic blood pressure (-10 mm Hg, P = .01), diastolic blood pressure (-8.3 mm Hg, P = .001), and body mass index (-0.8 kg/m(2), P = .032) than the DSME-alone group.

CONCLUSIONS

In this population of African American adults, an initial DSME program, whether or not followed by 12 months of peer support, had no effect on glycemic control. Participants in the peer-support arm of the trial did, however, experience significant improvements in some CVD risk factors or stay approximately the same while the control group declined.

Ethnic differences in family member diabetes involvement and psychological outcomes: results from the second Diabetes Attitudes, Wishes and Needs (DAWN2) study in the USA

OBJECTIVE

To assess differences among USA ethnic groups in psychological status of adult family members (FMs) and their involvement with the diabetes of another adult.

RESEARCH METHODS

Data are from the FM survey of the USA DAWN2 study, including 105 White non-Hispanics, 47 African Americans, 46 Hispanic Americans and 40 Chinese Americans. All FMs lived with and cared for an adult with diabetes. Analysis of covariance controlled for respondent and patient characteristics to assess ethnic group differences (P < 0.05). Multiple regression analyses identified significant (P < 0.05) independent correlates of psychological outcomes.

MAIN OUTCOME MEASURES

FM psychological outcomes measured include well-being, quality of life (QoL), impact of diabetes on life domains, diabetes distress, and burden.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

White non-Hispanics reported less diabetes burden and distress, more negative life impact, and lower well-being than FMs from ethnic minority groups. African Americans reported the highest well-being and lowest negative life impact, Chinese Americans reported the most diabetes burden, Hispanic Americans reported the highest distress. There were no ethnic group differences in QoL. Ethnic minority FMs reported having more involvement with diabetes, greater support success, and more access to a diabetes support network than White non-Hispanics. Higher FM diabetes involvement was associated with negative psychological outcomes, while diabetes education, support success and diabetes support network size were associated with better psychological outcomes. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Minority ethnic FMs experienced both advantages and disadvantages in psychological outcomes relative to each other and to White non-Hispanics. Ethnic minority FMs had more involvement in diabetes care, support success and support from others, with the first associated with worse and the latter two with better psychological outcomes. Additional studies are needed with larger samples and broader representation of ethnic groups to better understand these associations and identify areas for intervention.

Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

OBJECTIVE

To assess differences in psychological outcomes as well as risk and protective factors for these outcomes among several USA ethnic groups and identify correlates of these psychological outcomes among adults with diabetes in the second Diabetes Attitudes, Wishes and Needs (DAWN2 * ) study.

RESEARCH DESIGN AND METHODS

The core USA DAWN2 sample was supplemented by independent samples of specific ethnic minority groups, yielding a total of 447 White non-Hispanics, 241 African Americans, 194 Hispanics, and 173 Chinese Americans (n = 1055). Multivariate analysis examined ethnic differences in psychological outcomes and risk/protective factors (disease, demographic and socioeconomic factors, health status and healthcare access/utilization, subjective burden of diabetes and social support/burden). Separate analyses were performed on each group to determine whether risk/protective factors differed across ethnic groups.

MAIN OUTCOME MEASURES

Psychological outcomes include well-being, quality of life, impact of diabetes on life domains, diabetes distress, and diabetes empowerment.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

Ethnic minorities tended to have better psychological outcomes than White non-Hispanics, although their diabetes distress was higher. Levels of most risk and protective factors differed significantly across ethnic groups; adjustment for these factors reduced ethnic group differences in psychological outcomes. Health status and modifiable diabetes-specific risk/protective factors (healthcare access/utilization, subjective diabetes burden, social support/burden) had strong associations with psychological outcomes, especially diabetes distress and empowerment. Numerous interactions between ethnicity and other correlates of psychological outcomes suggest that ethnic groups are differentially sensitive to various risk/protective factors. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Ethnic groups differ in their psychological outcomes. The risk/protective factors for psychological outcomes differ across ethnic groups and different ethnic groups are more/less sensitive to their influence. These findings can aid the development of strategies to overcome the most prominent and influential psychosocial barriers to optimal diabetes care within each ethnic group.

Health Literacy Among Insulin-Taking African Americans

Aims

To determine the levels of functional health literacy (FHL) among insulin-taking African Americans with diabetes from an urban medical practice and to determine if associations exist between FHL levels and glycemic control.

Methods

Seventy insulin-taking African Americans seen for diabetes management comprised the analysis cohort. Patients were 18 years or older, African American, had diabetes, and currently using insulin via syringe, pen, or insulin pump. All participants completed a one-time assessment of FHL levels, using the Newest Vital Sign (NVS). Scores ranged from 0 to 6 (0-1 = high likelihood of limited FHL; 2-3 = possibility of limited FHL; 4-6 = adequate FHL). A combination of t tests, Pearson’s chi-square tests, and multivariate logistic regression models were used to determine associations between glycemic control and FHL.

Results

Average age was 58.7, 59.1% were female, 90.8% with type 2 diabetes, and 15.1% using an insulin pump. Glycemic control was: A1C < 7%: 22.9%, A1C < 8%: 47.1%. Of participants, 47.1% had adequate FHL, 31.4% had possible limited FHL, and 21.4% had a high likelihood of limited FHL. Also, 67.7% of participants with A1C ≥ 8% had a high likelihood of limited FHL. After adjusting for age and gender, participants with a high likelihood of limited FHL were 6.2 times (95% confidence interval [CI], 1.4-28.3) more likely to have A1C ≥ 8%.

Conclusions

Insulin-taking African Americans with a high likelihood of limited FHL are approximately 6 times more likely to have an A1C ≥ 8% compared to patients with a possibility of limited FHL, or adequate FHL, demonstrating the need for focused interventions tailored to FHL needs.

Digital photography as an educational food logging tool in obese patients with type 2 diabetes: lessons learned from a randomized, crossover pilot trial

PURPOSE

The purpose of this pilot study is to investigate the utility of, and areas of refinement for, digital photography as an educational tool for food logging in obese patients with type 2 diabetes (T2DM).

METHODS

Thirty-three patients aged 18 to 70 with T2DM, body mass index at least 30 kg/m(2), and A1C 7.5% to 9% were recruited from an endocrinology clinic and randomized to a week of food logging using a digital camera (DC) or paper diary (PD), crossing over for week 2. Patients then viewed a presentation about dietary effects on blood glucose, using patient DC and blood glucose entries. Outcomes of adherence (based on number of weekly entries), changes in mean blood glucose and frequency of blood glucose checks, and patient satisfaction were compared between methods. Patient feedback on the DC intervention and presentation was also analyzed.

RESULTS

Thirty patients completed the study. Adherence was identical across methods. The mean difference in number of entries was not significant between methods. This difference increased and neared statistical significance (favoring DC) among patients who were adherent for at least 1 week (21 entries, with 2 entries per day for 5 of 7 days, n = 25). Mean blood glucose did not significantly decrease in either method. Patient satisfaction was similar between interventions. Feedback indicated concerns over photograph accuracy, forgetting to use the cameras, and embarrassment using them in public.

CONCLUSION

Although the DC method was comparable to PD in adherence, blood glucose changes, and patient satisfaction in this pilot trial, patient feedback suggested specific areas of refinement to maximize utility of DC-based food logging as an educational tool in T2DM.

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.

Training peers to provide ongoing diabetes self-management support (DSMS): results from a pilot study

OBJECTIVE

This study determined the feasibility of training adults with diabetes to lead diabetes self-management support (DSMS) interventions, examined whether participants can achieve the criteria required for successful graduation, and assessed perceived efficacy of and satisfaction with the peer leader training (PLT) program.

METHODS

We recruited nine African-American adults with diabetes for a 46-h PLT pilot program conducted over 12 weeks. The program utilized multiple instructional methods, reviewed key diabetes education content areas, and provided communication, facilitation, and behavior change skills training. Participants were given three attempts to achieve the pre-established competency criteria for diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy.

RESULTS

On the first attempt 75%, 75%, 63%, and 75% passed diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy, respectively. Those participants who did not pass on first attempt passed on the second attempt. Participants were highly satisfied with the program length, balance between content and skills development, and preparation for leading support activities.

CONCLUSION

Findings suggest that it is feasible to train and graduate peer leaders with the necessary knowledge and skills to facilitate DSMS interventions.

PRACTICAL IMPLICATIONS

With proper training, peer support may be a viable model for translating and sustaining DSMS interventions into community-based settings.

Feasibility of group lifestyle intervention for diabetes prevention in Arab Americans

AIMS

To assess the feasibility and acceptability of a community-based, culturally-specific, Diabetes Prevention Program (DPP)-adapted, group lifestyle intervention in Arab-Americans.

METHODS

Overweight (BMI ≥ 27 kg/m(2)) Arab-Americans aged ≥ 30 years and without a history of diabetes were recruited to participate in a 24-week group lifestyle intervention. The DPP core-curriculum was culturally rewritten, translated into Arabic, and delivered in weekly sessions over a 12-week period. Follow-up was performed at week-24. The primary goals were to achieve ≥ 7% weight loss and ≥ 150 min/week of physical activity. An intent-to-treat analysis was performed.

RESULTS

Of the 71 participants (mean age ± SD 47 ± 10 years, 38% males), 44% achieved ≥ 7% weight loss, 59% achieved ≥ 5% reduction in weight, and 78% reached the physical activity goal of ≥ 150-min/week. The mean ± SD weight loss was 5.2 ± 4.4 kg at week-24 (p<0.0001), Marked reduction in body measurements, daily energy and fat intake were noted. Retention was high with 86% completing the intervention.

CONCLUSIONS

This trial demonstrates that a culturally-specific, DPP-adapted, group lifestyle intervention implemented in a community setting is feasible and effective in Arab-Americans.

The development of a pilot training program for peer leaders in diabetes: process and content

PURPOSE

The goal of this study is to describe the process of developing a program that trains peers to facilitate an empowerment-based diabetes self-management support intervention.

METHODS

To guide and advise the development process, the authors formed a peer leader training action committee. The committee was an interdisciplinary group (principal investigator, nurse-certified diabetes educators, dietitian-certified diabetes educators, nutritionist, physician, and 3 community members) that met every 3 months over a 1-year period for continuous quality improvement meetings. During meetings, the committee reviewed and supervised the curriculum development, provided feedback, and informed modifications and improvements.

RESULTS

The resulting peer leader training program is a 46-hour program with 2 training sessions conducted per week over a 12-week period. The competency-based training program is based on the theory of experiential learning, and it consists of 3 major components--namely, building a diabetes-related knowledge base, developing skills (communication, facilitation, and behavior change), and applying skills in experiential settings. All components are integrated within each training session using a range of instructional methods, including group brainstorming, group sharing, role-play, peer leader simulations, and group facilitation simulations.

CONCLUSION

Through the process described above, the authors developed a training program that equips peer leaders with the knowledge and skills to facilitate empowerment-based diabetes self-management support interventions. Future directions include conducting and evaluating the peer training program.

Standards of care for diabetes: what's new?

Each year, the American Diabetes Association (ADA) publishes standards of medical care for people with diabetes. The ADA updates these standards based on the latest evidence so that healthcare professional scan incorporate this evidence into their care. The standards also summarize and rate the levels of evidence on which the recommendations are based. This article describes new recommendations in the 2010 Standards of Medical Care in Diabetes (the 2010 Standards).

Patient empowerment: myths and misconceptions

OBJECTIVE

The purpose of this article is to clarify the concept of empowerment and to correct common misconceptions about its use in diabetes care and education.

METHODS

The patient empowerment approach is well suited to helping patients make self-selected changes related to weight, nutrition, and physical activity. Although the concept of patient empowerment has become an integral part of diabetes education, an accurate understanding and authentic application of empowerment has not occurred as readily. The empowerment approach is clarified and common misconceptions have been corrected.

RESULTS

Embracing empowerment means making a paradigm shift that is often difficult because the traditional approach to care is embedded in the training and socialization of most health care professionals (HCPs).

CONCLUSION

Unlike the traditional approach, empowerment is not something one does to patients. Rather, empowerment begins when HCPs acknowledge that patient are in control of their daily diabetes care. Empowerment occurs when the HCPs goal is to increase the capacity of patients to think critically and make autonomous, informed decisions. Empowerment also occurs when patients are actually making autonomous, informed decisions about their diabetes self-management.

PRACTICE IMPLICATIONS

Clarity about all aspects of the empowerment approach is essential if it is to be used effectively.

Self-management support in "real-world" settings: an empowerment-based intervention

OBJECTIVE

This study examined the impact of a 6-month, empowerment-based diabetes self-management support (DSMS) intervention on clinical outcomes, self-care behaviors, and quality of life (QOL) compared to a 6-month control period.

METHODS

This control-intervention cohort study recruited 77 African-American adults with type 2 diabetes. Baseline, 6-month, and 12-month assessments measured A1C, weight, body mass index (BMI), blood pressure, lipids, self-care behaviors, and QOL. During the control period, participants received weekly educational newsletters. During the intervention period, participants attended weekly DSMS groups as frequently as they needed. Sessions were guided by participants' self-management questions and concerns, and also emphasized experiential learning, coping, problem-solving, and goal-setting.

RESULTS

The control period found significant improvements for diastolic BP (p<0.05), serum cholesterol (p<0.001), following a healthy diet (p<0.01), and monitoring blood glucose (p<0.01). The intervention period found significant additional improvements for A1C (p<0.001), weight (p<0.05), BMI (p<0.05), and LDL (p<0.001). Compared to the control period, participation in the intervention led to a significant reduction in A1C (p<0.01).

CONCLUSION

Findings suggest that an empowerment-based, DSMS intervention is promising for improving and/or maintaining diabetes-related health, particularly A1C.

PRACTICAL IMPLICATIONS

Incorporating empowerment principles in DSMS interventions may be useful for supporting patients' self-management efforts in "real-world" settings.

Evaluating the Efficacy of an Empowerment-Based Self-Management Consultant Intervention: Results of a Two-Year Randomized Controlled Trial

OBJECTIVES: This study was conducted to determine if an empowerment-based Diabetes Self-Management Consultant (DSMC) was more effective than a group receiving Mailed metabolic Assessments Only (MAO) in improving diabetes-related quality of life and blood glucose control. MATERIALS AND METHODS: A two-year clinical trial, in which 310 patients with type 2 diabetes were randomized to the DSMC intervention or the MAO group. The DSMC met with the patient to review the baseline assessments, then met with this review was patient and the patient's physician. Subsequently patients received monthly telephone calls from the DSMC who used the empowerment approach to help patients identify self-management problems, consider options, set goals and make adjustments to their diabetes self-management plans. RESULTS: The Diabetes Self-Management Consultant (DSMC) intervention resulted in improvements in diabetes related quality of life (PAID) p= .008, the Empowerment Scale p= .024, A1C p= .016, Perceived understanding of diabetes p= .001 and satisfaction with diabetes care p= .019 as compared to the MAO group. DISCUSSION/CONCLUSION: The DSMC the intervention resulted in a broad array of modest diabetes related improvements. A promising area for future research would be to test the efficacy of combining an empowerment-based DSMC intervention with case management using algorithm-based medication adjustments for higher risk patients.

The therapeutic role of incretin mimetics and DPP-4 inhibitors

PURPOSE

Gastric inhibitory peptide (GIP) and glucagon-like peptide-1 (GLP-1) stimulate the secretion of insulin when blood glucose levels are elevated and inhibit the postprandial release of glucagon. An increased understanding of the role of these incretin hormones in insulin and blood glucose regulation has resulted in the development of new types of medications for managing diabetes. GLP-1 agonists and dipeptidyl peptidase-IV (DPP-4) inhibitors are 2 classes of medications that have been shown to offer benefits for patients with type 2 diabetes. To use and teach patients how to use these medications effectively, educators need to understand their mechanisms of action, indications and contraindications, side effects, and effectiveness. Expanding the number of options available has increased the complexity of providing care and education, but also offers new opportunities to help our patients achieve better outcomes.

CONCLUSION

This article provides an overview of the physiology of insulin regulation and the roles of GIP, GLP-1, and DPP-4; discusses how the action of incretin hormones is affected by diabetes; and describes the therapeutic agents in these classes and their potential use by people with diabetes.