SISTER (Sisters Inspiring Sisters to Engage in Relevant Diabetes Self-Care) Diabetes Study: Protocol for diabetes medical nutrition therapy randomized clinical trial among African American women

BACKGROUND

African American (AA) women with type 2 diabetes (T2D) carry disproportionate diabetes-related morbidity and mortality burdens. Diabetes medical nutrition therapy (MNT) improves glycemic, blood pressure, and cholesterol control, all critical in preventing and reducing diabetes complications. Yet, MNT does not address low motivation for dietary intake management, which is frequently reported among AA women with T2D living in the Southeastern US.

METHODS

A randomized controlled trial will be used to test the central hypothesis that diabetes MNT plus culturally-tailored motivational interviewing (MI) (diabetes MNT plus MI) is more effective than diabetes MNT alone (diabetes MNT). Two hundred ninety-one Southeastern AA women who are at risk for development and/or progression of T2D complications will be randomized to diabetes MNT plus MI or diabetes MNT. Both groups will include: 1) a 3-month active intervention period, consisting of group-based, nutritionist-facilitated MNT sessions; 2) a 3-month maintenance intervention period, including one group-based, nutritionist-facilitated maintenance support session; and 3) a 6-month inactive period. Culturally-adapted MI exercises will be integrated into the diabetes MNT plus MI group only. Primary (HbA1c) and secondary (systolic blood pressure, LDL cholesterol) outcomes will be assessed at baseline and 3, 6, and 12 months following the active intervention period.

DISCUSSION

The results from this study, called the SISTER (Sisters Inspiring Sisters to Engage in Relevant Diabetes Self-Care) Diabetes Study, are vital to the adoption and uptake of rigorously-tested MNT interventions that address motivation among AA women with T2D as a way to reduce their risk and/or progression of diabetes-related complications.

Training researchers in dissemination of study results to research participants and communities

Dissemination of research beyond the academic community is an ethical responsibility of researchers and necessary in translational research to help ensure the uptake of research findings to improve health outcomes. Often, partnerships between community and academicians do not include research dissemination plans, possibly reflecting researchers not knowing how to create these plans. This manuscript details the development process of a research dissemination training module for academicians and researchers. This training was conceptualized and developed by Core faculty and staff. Development steps were: (a) identifying researchers' dissemination needs using the Core Investigator Survey; (b) identifying communities dissemination needs/preferences using feedback from our community advisory board; (c) conducting a literature search to identify dissemination concepts from researchers and community perspectives; (d) developing the training module; (e) conducting a cognitive review with one basic science researcher and one community-based participatory researcher; (f) evaluating the training; and (g) finalizing the training module. Training attendees included 1 clinical and 3 basic science clinical researchers, a biomedical postdoctoral fellow, and 10 research staff. Of those completing the feedback survey, 60% had some experience with research dissemination. As a result of training, more than 50% of respondents strongly agreed that as researchers they have a clear understanding of dissemination, a greater understanding of the dissemination process, how to identify stakeholders and successfully develop a dissemination plan. While disseminating research findings beyond academic publications may be new to some researchers, this training provided the tools to implement dissemination practices in their current and future research.

Two-year follow-up study of a group-based diabetes medical nutrition therapy and motivational interviewing intervention among African American women

OBJECTIVES

To assess the 2-year efficacy of a combined medical nutrition therapy and motivational interviewing (MI) pilot study intervention and factors that influenced long-term dietary self-care.

RESEARCH DESIGN AND METHODS

Pilot study participants, African American women with type 2 diabetes, completed a 2-year follow-up study visit, including clinical assessments and completion of a dietary self-care questionnaire and a semi-structured interview. Wilcoxon signed-rank tests were used to evaluate differences between baseline and 2-year follow-up clinical and dietary self-care outcomes. Hierarchical coding was used to analyze semi-structured interviews and categorize facilitator and barrier themes into subthemes. Subthemes were quantified based on the number of subtheme-related comments.

RESULTS

Among the 12 participants (mean age 57.1±5.7 years), improvements were observed for HbA1c (baseline: 10.25%; interquartile range [IQR]: 8.10, 11.72 and follow-up: 8.8%; IQR: 7.48,10.22), systolic blood pressure (baseline: 142 mm Hg; IQR: 134.25, 157.25 and follow-up: 127 mm Hg; IQR: 113.5, 143.25), frequency of eating high-fat foods (baseline: 3.5 days; IQR: 2.75, 4.25 and follow-up: 3 days; IQR: 2.5, 4.5), and of spacing carbohydrates throughout the day (baseline: 3 days; IQR: 3.0, 4.0 and follow-up: 4 days; IQR: 1.5, 4.5). There was a statistically significant decrease (p=0.04) in the frequency of fruit and vegetable intake (baseline: 4 days; IQR: 3.75, 7.0 and follow-up: 3.5 days; IQR: 2.75, 4.0). Dietary self-care barriers and facilitators included internal (eg, motivation) and external factors (eg, social support). Motivation (70 comments) and lack of motivation (67 comments) were the most pervasive facilitator and barrier subthemes, respectively.

CONCLUSION

Overall, diabetes-related clinical and dietary self-care outcomes were improved following a combined medical nutritional therapy/MI intervention, and motivation played an important role in dietary self-care engagement. Future research is needed to assess the added benefit of MI in improving clinical and dietary self-care outcomes and to identify best strategies to support post-intervention dietary self-care engagement.

Diabetes Education, Specialty Care, and Self-Care Advice among Obese African American Women with Type 2 Diabetes

OBJECTIVE

Healthy People 2020 (HP2020) includes benchmarks for diabetes management. The objective of our study was to describe diabetes management among African American women, a patient group that carries a disproportionate diabetes burden.

PARTICIPANTS

African American women with type 2 diabetes enrolled in dietary and weight management interventions.

MAIN OUTCOME MEASURES

Self-report assessments of diabetes education, specialty care, self-care behaviors and advice. Associations between diabetes self-care behaviors and diabetes advice using Chi-square tests.

RESULTS

Among 96 participants (age = 53 ± 9.4; BMI = 37.9 ± 7.3 kg/m(2)), reported diabetes education and foot exams were lower than HP2020 benchmarks, 48.9% vs 62.5% and 35.1% vs 74.8%, respectively and higher for dilated eye exams (70.1% vs 58.7%). The most frequently reported dietary advice was to increase fruit/vegetable intake (58%) and approximately 50% reported physical activity advice. Receiving no exercise advice was associated with greater odds of little or no physical activity (OR = 3.38) and planned exercises (OR = 2.65).

CONCLUSIONS

Receipt of diabetes education and some specialty care were below national benchmarks while health care provider advice influenced patient self-care behaviors. Increasing diabetes education and specialty care should be included within existing efforts to address the excess diabetes burden experienced by African American women. Longitudinal studies exploring the relationship between health care provider advice and self-care behaviors are needed.

Patients', caregivers', and providers' perceived strategies for diabetes care

OBJECTIVES

To explore strategies to improve type 2 diabetes mellitus (T2DM) self-management among low-income and minority groups.

METHODS

Focus groups centered on T2DM self-care behaviors were conducted using convenient sample of patients with T2DM (N = 17), caregivers (N = 5) and healthcare providers (N = 15).

RESULTS

Patients and caregivers perceived strategies included improving patient-provider communication, providers' accessibility and compassion, and flexible clinic hours. Strategies identified by providers were realistic patient's expectations, family support, and community resources.

CONCLUSIONS

To our knowledge, this study is the first to elicit strategies to improve T2DM self-management through a joint meeting of patients, caregivers, and healthcare providers. Study findings could help inform future efforts to assist patients better manage their T2DM.

Identification of patient-centered outcomes among African American women with type 2 diabetes

AIMS

African American women carry a disproportionate diabetes burden, yet there is limited information on strategies to identify outcomes women perceive as important intervention outcomes (patient-centered outcomes). This study presents a brief strategy to solicit these outcomes and to describe outcomes identified using the highlighted strategy.

METHODS

Thirty-four African-American women with type 2 diabetes were enrolled in group-based, diabetes/weight management interventions. A diabetes educator asked participants to write down their intervention expectations followed by verbal sharing of responses. Expectation-related themes were identified using an iterative, qualitative, team analytic approach based on audio-recorded responses.

RESULTS

The majority of the expectation-related themes (6 of 10) were reflective of self-care education/management and weight loss-related patient-centered outcomes. The remaining themes were associated with desires to help others prevent or manage diabetes, reduce negative diabetes-related emotions, get rid of diabetes, and stop taking diabetes medications.

CONCLUSION

This study adds to a limited body of knowledge regarding patient-centered outcomes among a group that experiences a disproportionate diabetes burden. Future work could include integrating outcomes that are less commonly addressed in diabetes-related lifestyle interventions (e.g., diabetes-related negative emotions), along with more commonly addressed outcomes (e.g., weight loss), to increase the patient-centeredness of the interventions.

Growth patterns in children with sickle cell anemia during puberty

BACKGROUND

Previous studies of children with homozygous sickle cell anemia (SCA) show impaired growth and maturation. The correlation of this suboptimal growth with metabolic and hematological factors during puberty is poorly understood.

PROCEDURE

We studied a group of pre-adolescent children with SCA (19 males, 14 females) and healthy controls (16 males, 15 females) matched for race, sex, body size, and pubertal development. Height, weight, body mass index (BMI), and body composition changes were longitudinally assessed over a 2-year period and compared between the groups and with Z scores based on US growth charts. These changes were correlated with hemoglobin (Hgb) concentration and with energy expenditure (EE) measured using indirect whole-room calorimetry.

RESULTS

Children with SCA progressed through puberty slower than control children. While, after 2 years, pubertal males with SCA were shorter, their annual increases in weight were not different from controls. The mean fat free mass (FFM) increments were significantly less in males and females with SCA than in control children. In males with SCA, growth in height declined over time and was significantly slower than in matched controls (P < 0.05).

CONCLUSION

Growth delays were present during puberty in children with SCA. Decreased growth velocity in children with SCA was independently associated with decreased Hgb concentration and increased total EE.

Validity of a multisensor armband in estimating 24-h energy expenditure in children

Physical activity (PA) and energy expenditure (EE) in children are frequently assessed using portable activity monitors. Algorithms used to predict EE by these monitors are often based on adult populations and may not be accurate for children.

PURPOSE

To evaluate the accuracy of the SenseWear Pro Armband (SWA) for assessing EE in African American children during treadmill exercise, sedentary activities, rest, sleep, and total 24-h EE, using indirect room calorimetry (IRC) as a reference standard.

METHODS

Participants were healthy African American children (10 boys, 11 girls; age: 11.6 +/- 0.9 yr; weight: 47.3 +/- 13.0 kg; height: 151.6 +/- 8.8 cm; BMI: 20.4 +/- 4.8 kg.m). EE was measured simultaneously using IRC and SWA during a 24-h stay in the IRC. Recorded activities included sedentary behaviors, treadmill exercise, rest periods, and sleep. Results from both methods were matched minute-by-minute and compared by Bland-Altman plot. Multiple linear regression analysis was used to describe the relationship between EE assessed by both methods and children's descriptive characteristics.

RESULTS

SWA overestimated EE compared with IRC during all activities and time periods, ranging from 116% during sleep to 143% during rest after treadmill exercise. The SWA-predicted EE was improved by using linear regression modeling. Simple equations for sedentary activities and treadmill exercise were EE [kcal.min] = 0.462EE (SWA) [kcal.min] + 0.015 x body weight [kg], and EE [kcal.min] = 0.637EE (SWA) [kcal.min] + 0.034 x body weight [kg], respectively. The prediction equation for RMR was RMR [kcal.min] = 0.453EE (SWA) [kcal.min] + 0.011 x body weight [kg].

CONCLUSION

EE estimated using SWA was significantly higher than EE measured using IRC in African American children ages 10-14 yr. Bias in individual EE estimated using SWA could be improved by an adjustment for the body weight of a child. The SWA manufacturer should work with researchers on improving existing algorithms for children.

Defects in postabsorptive plasma homeostasis of fatty acids in sickle cell disease

BACKGROUND

The chronic hemolytic anemia experienced by sickle cell disease (SCD) patients leads to adverse effects on oxygen transport by the blood and to a decrease in oxygen availability for peripheral tissues. Limited tissue oxygen availability has the potential to modify events of intracellular metabolism and, thus, alter lipid homeostasis.

METHODS

The impact of SCD on plasma fatty acid homeostasis was determined in 8 African American SCD patients and in 6 healthy African American control subjects under postabsorptive conditions and during a 3-hour IV infusion of a nutrient solution containing lipid, glucose, and amino acids.

RESULTS

SCD patients had higher fasting levels of plasma nonesterified fatty acids (NEFA), triglycerides, and phospholipids than healthy controls. Similarly, SCD patients had higher fasting levels of fatty acids in plasma triglycerides and phospholipids than healthy controls. Infusion of nutrients resulted in equivalent plasma NEFA profiles, total NEFA, and triglycerides in SCD patients and controls. However, the plasma phospholipid concentrations and fatty acid composition of plasma triglycerides and phospholipids were significantly higher in SCD patients; in particular, plasma pools of oleic acid were consistently increased in SCD. Plasma free oleic acid levels were elevated basally, leading to increased oleic acid content in triglycerides and phospholipids both post absorptively and during nutrient infusion.

CONCLUSIONS

There is an underlying defect in lipid metabolism associated with SCD best manifested during the fasting state. This abnormality in lipid homeostasis has the potential to alter red blood cell (RBC) membrane fluidity and function in SCD patients.

Energy expenditure, inflammation, and oxidative stress in steady-state adolescents with sickle cell anemia

Sickle cell anemia (HbSS) is characterized by hypermetabolism, chronic inflammation, and increased oxidative stress, but the relationship between these factors is undefined. In this study, we examined indicators of inflammatory process and markers of oxidative damage and their impact on resting energy expenditure (REE) in stable HbSS adolescents (n = 35) and healthy controls carrying normal hemoglobin genotype (HbAA) (n = 39). C-reactive protein (CRP), white blood cell (WBC) count, and proinflammatory cytokines were measured as markers of inflammation and 2,3-dinor-5,6-dihydro-15-F2t-isoprostane (F2-IsoPM) as a marker of oxidative stress. REE was measured by indirect calorimetry. WBC counts (11.90 +/- 5.3 x10/muL versus 5.6 +/- 1.9 x10/muL; p < 0.001), serum CRP (9.1 +/- 11.0 mug/mL versus 0.4 +/- 0.7 mug/mL; p < 0.001) and serum IL-8 (7.5 +/- 4.4 pg/mL versus 5.5 +/- 4.8 pg/mL; p = 0.011) were higher in HbSS than HbAA, suggesting an anti-inflammatory response in HbSS. Higher urinary F2-IsoPM in HbSS (1.2 +/- 0.4 versus 0.7 +/- 0.3 ng/mg creatinine; p < 0.001) indicates increased oxidative stress. Fat free mass (FFM), hemoglobin (Hgb), interleukin (IL)-8, and F2-IsoPM were independent predictors of REE in HbSS (overall r = 0.778; p < 0.001). Low-grade inflammation and increased oxidative stress are present in adolescents with HbSS in the absence of acute crisis, and their markers are correlated with elevated REE.

Dietary vitamin A has both chronic and acute effects on vitamin A indices in lactating rats and their offspring

To further investigate the effect of dietary vitamin A (VA) intake on milk VA concentrations and pup VA status, female rats were fed 2 concentrations of VA [0 (n = 9) or 50 micromol/kg diet (n = 10)] during pregnancy and lactation. Plasma retinol concentrations were significantly higher (30-40%) during lactation than before pregnancy or after weaning but were not influenced by dietary VA. In rats fed VA, VA concentrations during lactation were significantly higher in milk (1.5-3 times), mammary tissue (>100%), liver (4 times), pup plasma (20-40%), and pup liver (1.1-6.7 times). In Expt. 2, when VA intake was switched on d 7 of lactation from 0 to 50 micromol/kg, milk VA concentrations (2.24 +/- 0.42 micromol/L; mean +/- SD, n = 6) increased significantly (1.7 times) by d 9 to the same level as in rats administered 50 micromol/kg (6.04 +/- 0.60 micromol/L; n = 6). When VA was removed from the diet on d 7, concentrations declined significantly (by 50%) and by d 11 were the same as those in rats given 0 micromol/kg. We conclude that the rapid effect of changes in dietary VA intake are attributable to changes in the delivery of chylomicron VA to mammary tissue and milk.

Increased rat mammary tissue vitamin A associated with increased vitamin A intake during lactation is maintained after lactation

Although increases in dietary vitamin A increase milk vitamin A, little is known about effects of vitamin A intake on mammary tissue vitamin A levels during and after the reproductive cycle. First, we measured vitamin A concentrations in milk, mammary tissue and liver of lactating rats fed 0, 4, or 50 micromol of vitamin A/kg diet during pregnancy and through d 12 of lactation. Liver vitamin A concentration was significantly affected by diet in lactating females and pups 12 d after parturition. Milk vitamin A concentrations were significantly higher (7.1 +/- 2.2 micromol/L, n = 8) in dams fed 50 micromol/kg than in those fed 0 or 4 micromol/kg (1.9 +/- 0.3, n = 5 and 2.9 +/- 0.7 micromol/L, n = 7; P < 0.001), as were mammary tissue vitamin A concentrations (5.1 +/- 1.1 versus 2.2 +/- 0.4 and 2.4 +/- 0.6 nmol/g; P < 0.001). Next, we maintained female rats on 50 or 10 micromol vitamin A/kg diet during pregnancy and lactation and then on 4 micromol/kg diet after pups were weaned on d 21. On d 21, mammary tissue vitamin A concentrations were 3.14 +/- 0.75 versus 1.52 +/- 0.21 nmol/g in dams fed 50 versus 10 micromol/kg (n = 4/group; P < 0.001). Mammary tissue vitamin A concentrations were not significantly affected by time from 7 to 49 d after lactation and averaged 8.5 +/- 0.4 and 4.9 +/- 0.8 nmol/g on d 49 in dams fed 50 versus 10 micromol/kg (n = 4; P < 0.001). We conclude that diet-induced differences in rat mammary tissue vitamin A developed during pregnancy and lactation are maintained for > or =7 wk after lactation.

Vitamin A intake affects the contribution of chylomicrons vs. retinol-binding protein to milk vitamin A in lactating rats

To investigate the influence of vitamin A intake on the contribution of chylomicrons vs. holo retinol-binding protein to milk vitamin A, female rats were fed diets containing either 10 (n = 6) or 50 micromol vitamin A/kg body (n = 4) during pregnancy and through d 13 of lactation. [3H]Vitamin A was incorporated into each diet beginning on d 6 of lactation. Vitamin A concentrations on d 13 were significantly higher in dam liver (x 3), pup liver (x 2.6), milk (x 2.5) and mammary tissue (x 1.3) in rats consuming the higher level of vitamin A. In both groups, vitamin A specific activities in plasma and milk reached apparent plateaus by 2.33 d after addition of [3H]vitamin A to the diets. Vitamin A specific activity in milk was higher than in plasma at all times in both groups. The estimated minimum contribution of chylomicrons to milk vitamin A was 32 +/- 3% in rats fed the lower level of vitamin A vs. 52 +/- 10% at the higher level (P = 0.014). We concluded that dietary vitamin A, like triglycerides, may be directed to mammary tissue during lactation for preferential secretion into milk; thus, increasing vitamin A intakes will increase the contribution of dietary vitamin A to milk. In contrast to milk, mammary tissue vitamin A turns over very slowly.