The biggest problem in diabetes

"Once I take that one bite": the consideration of harm reduction as a strategy to support dietary change for patients with diabetes

BACKGROUND

Despite well-established guidelines to treat diabetes, many people with diabetes struggle to manage their disease. For many, this struggle is related to challenges achieving nutrition-related lifestyle changes. We examined how people with diabetes describe barriers to maintaining a healthy diet and considered the benefits of using a harm reduction approach to assist patients to achieve nutrition-related goals.

METHODS

This is a secondary analysis of 89 interviews conducted with adults who had type 1 or type 2 diabetes. Interviews were analyzed using a content analysis approach. Themes regarding food or diet were initially captured in a "food" node. Data in the food node were then sub-coded for this analysis, again using a content analysis approach.

RESULTS

Participants frequently used addiction language to talk about their relationship with food, at times referring to themselves as "an addict" and describing food as "their drug." Participants perceived their unhealthy food choices either as a sign of weakness or as "cheating." They also identified food's ability to comfort them and an unwillingness to change as particular challenges to sustaining a healthier diet.

CONCLUSION

Participants often described their relationship with food through an addiction lens. A harm reduction approach has been associated with positive outcomes among those with substance abuse disorder. Patient-centered communication incorporating the harm reduction model may improve the patient-clinician relationship and thus improve patient outcomes and quality-of-life while reducing health-related stigma in diabetes care. Future work should explore the effectiveness of this approach in patients with diabetes.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov, NCT02792777. Registration information submitted 02/06/2016, with the registration first posted on the ClinicalTrials.gov website 08/06/2016. Data collection began on 29/04/2016.

Levels and Correlates of Numeracy Skills in Lebanese Adults with Diabetes: A Cross-Sectional Study

Diabetes numeracy skills are required in the interpretation of food labels, insulin pump dosage, the interpretation of blood glucose meter data, and the determination of carbohydrate intake. This study assessed the levels and correlates of numeracy skills in Lebanese adults with diabetes to identify those most at risk of uncontrolled diabetes. In total, 299 adults with diabetes, mean age 47.4 ± 19.8 years, took the questionnaire. It consisted of self-developed items on sociodemographic and health-related factors, in addition to the Diabetes Numeracy Test-15 (DNT-15) and the Single Item Literacy Screener. Many participants (62%) scored < 10 on the DNT-15 indicating insufficient numeracy skills. DNT-15 scores were positively associated with literacy, exercise, healthy diet, perceived diabetes control, frequency of glycaemia measurement, ability to afford treatment, and ease of understanding information related to diabetes. Age, BMI, and complications were negatively correlated with DNT-15 score. Numeracy skills were higher in males, single individuals, and in people with type 1 diabetes, fewer complications, controlled HbA1c, higher income, higher education, a prior visit to a dietician, and ability to maintain personal care despite COVID-19. Interventions to strengthen numeracy skills would empower individuals with diabetes, lead to appropriate self-management behaviors, and prevent health complications in at-risk individuals.

Medical nutrition therapy of pediatric type 1 diabetes mellitus in India: Unique aspects and challenges

Medical nutrition therapy (MNT) is a vital aspect of management of type 1 diabetes mellitus (T1DM) and should be tailored to ethnic and family traditions and the socioeconomic and educational status of the patient. In this article, we discuss the unique aspects of MNT in children and adolescents with T1DM in the Indian setting, with focus on the challenges faced by patients, dieticians and physicians and how these can be overcome. The authors reviewed the available literature on MNT in T1DM from India and prepared the document based on their vast collective clinical experience in treating patients with T1DM from different regions in India. Indian diets are predominantly carbohydrate-based with high glycemic index (GI) and low protein content. Various methods are available to increase the protein and fiber content and reduce the GI of food in order to limit glycemic excursions. Insulin regimens need to be tailored to the child's school timings, meal schedule, and the availability of a responsible adult to supervise/administer insulin. All patients, irrespective of economic and education background, should be taught the broad principles of healthy eating, balanced diet and carbohydrate counting. There are various barriers to dietary compliance, including joint family system, changing lifestyles, and other factors which need to be addressed. There is a need to customize dietary management according to patient characteristics and needs and develop standardized patient educational material on principles of healthy eating in various regional languages.

Feeding in adults with type II diabetes mellitus in three public hospitals in Cundinamarca, Colombia

Introduction: Type II diabetes mellitus (DMII) is one of the main causes of morbidity and mortality both worldwide and in Colombia. It mainly affects men and women over 45 years of age. Inadequate control of this disease can generate greater health complications making it one of the most costly diseases in the country. Treatment includes activities other than glycemic control and requires constant monitoring by medical personnel and educational processes directed at the patient and his or her family. Objective: To characterize the feeding of patients with DMII in three public hospitals of Cundinamarca. Materials and methods: We conducted a cross-sectional descriptive study of 212 patients that analyzed sociodemographic characteristics, frequency of consumption and feeding practices. Results: Most of the population was over 45 years old and had a low educational level. In total, 52% had a dietary plan, but only 8.9% received nutritional guidance from a nutritionist. The consumption of carbohydrates predominated, with low consumption of proteins, vitamins, minerals, and fiber. The consumption of sugars was lower in patients with a dietary plan (p <0.05). Conclusions: Most of the patients did not have an adequate nutrition; moreover, there was low adherence to dietary treatment, weakness in nutritional counseling and barriers to food access. These results can contribute to improving policies for the prevention and control of DMII and strategies based on the sociocultural context of the patients.

A nurse-led interdisciplinary approach to promote self-management of type 2 diabetes: a process evaluation of post-intervention experiences

RATIONALE, AIMS AND OBJECTIVES

Self-management of type 2 diabetes through diet, exercise and for many medications, are vital in achieving and maintaining glycaemic control in type 2 diabetes. A number of interventions have been designed to improve self-management, but the outcomes of these are rarely explored from a qualitative angle and even fewer through a process evaluation.

METHOD

A process evaluation was conducted using a qualitative design with participants randomized to an intervention. Seventy-three people living with type 2 diabetes and hyperglycaemia for a minimum of 1 year, randomized to one of two interventions (n = 34 to an education intervention and n = 39 to an education and acceptance and commitment therapy intervention) completed stage one of the process evaluation, immediately following the intervention through written feedback guided by open-ended questions. A purposive sample of 27 participants completed semi-structured interviews at 3 and 6 months post intervention. Interview data were transcribed and data analysed using a thematic analysis.

RESULTS

The majority of participants described an increase in knowledge around diabetes self-management and an increased sense of personal responsibility. Participants also described changes in self-management activities and reflected on the challenges in instigating and maintaining change to improve diabetes management.

CONCLUSION

The complexities of implementing change in daily life to improve glycaemic control indicate the need for ongoing support post intervention, which may increase and maintain the effectiveness of the intervention.

The relationship of diabetes-related distress and depressive symptoms with physical activity and dietary behaviors in adults with type 2 diabetes: A cross-sectional study

AIMS

Diabetes-related distress (DD) and depressive symptoms (DS) may influence self-management behaviors in people living with type 2 diabetes (T2D). We examined the association of DD and DS with physical activity (PA) and adherence to recommended dietary behaviors in adults with T2D.

METHODS

Using baseline data from 2040 adults with T2D in the Alberta's Caring for Diabetes (ABCD) cohort study, DD, DS, PA and adherence to dietary behaviors were assessed. A composite variable for presence of DD and DS was computed for analyses. ANOVA and logistic regression tested independent associations of DS and DD with PA and adherence to diet.

RESULTS

Participants were 64±10.6years, 45% female, 76% with annual household income≤$80,000, and 86% with high school education or more. Those with DD alone were 1.8 times (95% CI 1.1, 2.9) and those with DD and DS combined were 2.0 times (95% CI 1.1, 3.7) more likely not to meet PA guidelines compared to those without DD or DS. The presence of DS alone was not significantly associated with meeting PA guidelines (OR 1.4; 95% CI 0.7, 3.0). Compared to those without DD or DS, patients with DD alone (OR 1.5; 95% CI 1.4, 3.4), DS alone (OR 5.2; 95% CI 2.7, 9.7), or DD and DS combined (OR 2.5; 95% CI 1.6, 3.8) were more likely to have poor adherence to recommended dietary behaviors.

CONCLUSIONS

Greater distress or depressive symptoms were associated with worse self-management behaviors in adults with T2D. Attention to mental health status may improve participation in PA and adherence to diet recommendations in these patients.

Self-Management of Chronic Disease by Older Adults

This article summarizes the literature describing the at-home management of and psychosocial coping with five chronic diseases (heart disease, asthma, chronic obstructive pulmonary disease, arthritis, and diabetes) by the general population of adults. It also reviews the literature describing self-management of these chronic diseases by older adults. Conclusions drawn subsequent to the review are (a) that there are strong commonalities in the essential nature of tasks that exist across disease entities, (b) that the context for self-management of disease by the ill elderly is likely to differ somewhat from the context for other age groups. Questions for future research are posed.

The Role of Narrative and Other-Referencing in Attenuating Psychological Reactance to Diabetes Self-Care Messages

This study charts pathways through message resistance to enhance the persuasiveness of diabetes self-care messages. A 2 (narrative) × 2 (other-referencing) × 2 (message) × 4 (order) experiment with adult diabetics (N = 58) tested whether packaging overt recommendations as a story rather than an informational argument (i.e., narrative structure) and highlighting the impact of health decisions on family and friends rather than the individual (i.e., other-referencing) can effectively attenuate psychological reactance to messages encouraging healthy diet and physical activity. Narrative and other-referencing each led to lower perceived threat to choice, less state anger and counterarguing, less negative cognitive responses, more positive attitudes toward the ad and the behaviors promoted, and greater intended compliance with message recommendations. Findings illustrate two strategies that communicators may employ in order to benefit from clear, direct health messages while avoiding the reactance they may provoke. Moreover, findings inform message design for diabetes self-care education.

Challenges of Diabetes Self-Management in Adults Affected by Food Insecurity in a Large Urban Centre of Ontario, Canada

Objective. To explore how food insecurity affects individuals' ability to manage their diabetes, as narrated by participants living in a large, culturally diverse urban centre. Design. Qualitative study comprising of in-depth interviews, using a semistructured interview guide. Setting. Participants were recruited from the local community, three community health centres, and a community-based diabetes education centre servicing a low-income population in Toronto, Ontario, Canada. Participants. Twenty-one English-speaking adults with a diagnosis of diabetes and having experienced food insecurity in the past year (based on three screening questions). Method. Using six phases of analysis, we used qualitative, deductive thematic analysis to transcribe, code, and analyze participant interviews. Main Findings. Three themes emerged from our analysis of participants' experiences of living with food insecurity and diabetes: (1) barriers to accessing and preparing food, (2) social isolation, and (3) enhancing agency and resilience. Conclusion. Food insecurity appears to negatively impact diabetes self-management. Healthcare professionals need to be cognizant of resources, skills, and supports appropriate for people with diabetes affected by food insecurity. Study findings suggest foci for enhancing diabetes self-management support.

When does Spousal Social Control Provoke Negative Reactions in the Context of Chronic Illness?: The Pivotal Role of Patients' Expectations

Spouses often monitor and seek to alter each other's health behavior, but such social control attempts can provoke behavioral resistance and emotional distress. Expectations regarding spouses' roles in their partners' health may influence reactions to spousal social control, with resistance and hostility less likely to occur among people who believe spouses should be involved in their partners' health. Evidence consistent with this idea emerged in a study of 191 patients with type 2 diabetes. Patients with greater expectations for spousal involvement (particularly females) generally reacted less negatively to spousal control. The findings help to clarify when people with a chronic illness are likely to resist and resent, rather than appreciate, spousal control.

Gender and Nutrition Management in Type 2 Diabetes

Purpose: The literature suggests that adherence to dietary recommendations may differ between women and men with type 2 diabetes due to family obligations and spousal support.

Methods: To assess division of household labour between spouses, retrospective chart review of 561 individuals who attended the Diabetes Education Centre at the Toronto Western Hospital was performed. Qualitative interviews were also performed with 12 married clients (six female and six male) and seven spouses of clients (three female, four male) to understand how the sharing of household labour influences adherence to nutrition guidelines in type 2 diabetes.

Results: Results indicate a significant gender difference in responsibility for meal preparation (χ2(3)=140.64, p<.001) and grocery shopping (χ2(3)=88.24, p<0.001), with women more often engaging in these household activities than men. Male clients are more likely to be actively supported by their wives in the form of meal preparation and verbal encouragement, while female clients are only passively supported by their husbands.

Conclusions: The results suggest that diabetes educators should recognize gender differences in household labour and support when counselling their clients to ensure that both men and women have the help they need to successfully manage their diabetes.

Marital interactions in the process of dietary change for type 2 diabetes

OBJECTIVE

To explore how couples adjust to dietary management of type 2 diabetes.

DESIGN

Couples were interviewed, first together and then separately, during the first year after diagnosis and 1 year later.

SETTING

Qualitative interviews conducted in hospital classrooms using a semistructured interview guide.

PARTICIPANTS

Couples (N = 20) with a recently diagnosed spouse who met the study criteria were purposefully selected from volunteers solicited from hospital-based diabetes classes.

PHENOMENON OF INTEREST

Processes used by the couple to address the prescribed diet.

ANALYSIS

Thematic analysis of interview transcripts using grounded theory to identify patterns of adaptation processes used over time.

RESULTS

Three couple categories emerged (cohesive, enmeshed, and disengaged), representing adaptation to the diabetic diet. Initially, 5 couples were cohesive (teamwork approach), 7 were enmeshed (nondiabetic spouse responsible for the diet; spouse was dependent), and 8 were disengaged (spouses functionally separate; spouse was solely responsible for the diet management). A year later, the majority of couples were disengaged (n = 14), 1 couple remained cohesive, and 4 couples remained enmeshed. Themes of flexibility, roles, rules, and communication varied across categories.

CONCLUSIONS AND IMPLICATIONS

Understanding categories of marital adjustment to the diabetic diet may improve nutrition-based diabetes interventions. Further study is needed to verify these findings in larger and more diverse populations.

Dietary pattern of self-care among Asian and Caucasian diabetic patients

Diabetes mellitus is a growing pandemic and its self-care management rests primarily with the individual. This qualitative case study investigated the self-care dietary pattern among a group of 25 Asians and 24 Caucasians diagnosed with type 1 or type 2 diabetes. Data collected from a semi-structured interview and a 7-day health diary explored the self-care activities undertaken by the participants to establish metabolic control. From an analytical perspective, the collective responses were placed on a continuum ranging from strict adherence, moderately flexible adherence to very flexible adherence. The findings suggest that most of the participants were located in the latter two categories of diet related to self-care. Implications for healthcare professionals in promoting self-care will be discussed.

Association of British Clinical Diabetologists (ABCD): survey of specialist diabetes care services in the UK, 2000. 4. Dietetic services and nutritional issues

AIMS

To examine the provision of, and variations in, dietetic services for diabetes in secondary care in the UK.

METHOD

A postal survey of all secondary care providers of diabetes services.

RESULTS

There was a 77% response rate. A dedicated dietician supported diabetes services in 73% of responses, but only 45% were able to see newly diagnosed patients within 1 month. Only 3% of responses documented that dietetic services provided the recommended minimum 22 h weekly input to diabetes care, and an annual dietetic review was said to be available in 15%. An opportunity for more frequent visits was most likely if there was poor glycaemic control (78% of responses), particularly when services were provided by a dedicated diabetes dietician. Although dieticians frequently provided input to patient education (88%), specific training for this purpose and provision for continuing education of these individuals was less common (14% and 63%, respectively). Nutritional guidelines were available in 74%, but only 31% of responses documented current guidelines on obesity management. Of bids for additional dietetic resources, only 21% had been successful. There was evidence of regional variation in service provision, and no greater provision of dietetic services in areas with a large South Asian population and an expected high prevalence of diabetes. In broad terms, dietetic services for diabetes care had not altered in comparison with a similar survey in 1997.

CONCLUSIONS

The level of dietetic support of secondary care diabetes services remains dramatically lower than recommended in advisory documents, and appears to have changed little over the last 3 years. This is compounded by marked regional differences, and was no better in areas with a higher than average prevalence of diabetes. The survey also highlights the need for more co-ordinated and structured education and training of dieticians as well as more consistency in nutritional guidelines.

The effect of flexible low glycemic index dietary advice versus measured carbohydrate exchange diets on glycemic control in children with type 1 diabetes

OBJECTIVE

To determine the long-term effect of low glycemic index dietary advice on metabolic control and quality of life in children with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Children with type 1 diabetes (n = 104) were recruited to a prospective, stratified, randomized, parallel study to examine the effects of a measured carbohydrate exchange (CHOx) diet versus a more flexible low-glycemic index (GI) dietary regimen on HbA(1c) levels, incidence of hypo- and hyperglycemia, insulin dose, dietary intake, and measures of quality of life over 12 months.

RESULTS

At 12 months, children in the low-GI group had significantly better HbA(1c) levels than those in the CHOx group (8.05 +/- 0.95 vs. 8.61 +/- 1.37%, P = 0.05). Rates of excessive hyperglycemia (>15 episodes per month) were significantly lower in the low-GI group (35 vs. 66%, P = 0.006). There were no differences in insulin dose, hypoglycemic episodes, or dietary composition. The low-GI dietary regimen was associated with better quality of life for both children and parents.

CONCLUSIONS

Flexible dietary instruction based on the food pyramid with an emphasis of low-GI foods improves HbA(1c) levels without increasing the risk of hypoglycemia and enhances the quality of life in children with diabetes.

Dietary recommendations to prevent and manage chronic pediatric health conditions: adherence, intervention, and future directions

This review provides a summary of the dietary aspects of pediatric health conditions. Within each condition, dietary recommendations are reviewed, and adherence rates, factors affecting adherence, and known interventions are reported. Findings indicate that knowledge is necessary but not sufficient for dietary change. Interventions specifically targeting diet appear more promising than interventions aimed at global treatment adherence. Behavioral interventions and group treatment modalities also appear promising. Recommendations for future research include a systematic assessment of barriers to dietary adherence across populations, integration of the research on normative development of eating behavior in childhood, and the application of this information to the design and implementation of future treatment.

Motivational strategies used by dietitians to counsel individuals with diabetes

The purposes of this study were to determine the use and perceived effectiveness of motivational strategies used by dietitians and to evaluate dietitians' perceptions of barriers to client compliance. A three-part questionnaire with 32 motivational strategies, 16 barriers to adherence, and demographic information was designed and mailed to 862 members of the American Dietetic Association's Diabetes Care and Education Dietetic Practice Group. Statistical analyses included frequency distributions, chi-square analysis, and factor analysis. Only 13 of the 32 motivational strategies were used frequently by 50% or more of the dietitians. The main strategy based on perceived effectiveness was "Tailor the diet to the client's lifestyle." Strategies perceived as effective also were used frequently by a majority of the dietitians. There were differences in use of strategies based on practice setting, CDE certification, and education level. The most significant barrier to adherence was "Complications with lifestyle/competing demands." Factor analysis revealed nine factors for motivational strategies and five factors for barriers to adherence.

Predictors of adherence to nutrition recommendations in people with non-insulin-dependent diabetes mellitus

The purpose of this study was to determine how the components of psychosocial adjustment to diabetes predict adherence to nutrition recommendations based on self-reported successful completion of contingency contracts. The relationships between the components of psychosocial adjustment and adherence to nutrition recommendations were examined in a convenience sample of patients with non-insulin-dependent diabetes mellitus participating in a contingency contracting intervention with nurses. Patients completed a standardized instrument, the Diabetes Care Profile, at the time they were enrolled into this randomized clinical trial. High and low levels of adherence to nutrition recommendations were identified by a median split of the number of contingency contracts completed for adherence to nutrition recommendations. Subjects who reported higher regimen adherence and a higher support ratio (received more diabetes-specific social support than desired) were significantly less likely to engage in contingency contracting for adherence to nutrition recommendations.

Patient perceptions of factors that affect adherence to dietary regimens for diabetes mellitus

The purpose of this study was to identify how selected factors influence patient use of diet regimens for diabetes and to determine the effect of demographic characteristics. A survey was conducted using a 75-item questionnaire designed to collect responses from people with non-insulin-dependent diabetes mellitus. Frequency distributions and chi-square analyses were performed on the survey data. Five significant relationships were identified: (1) age and emotions, (2) age and schedule, (3) gender and emotions, (4) use of a diet plan and being told why to control diet, and (5) use of a diet plan and return for follow-up education. Dietitians need to consider demographic characteristics to tailor education sessions and to focus on improving communication with patients to increase their understanding of diabetes. This study showed that increased education promoted increased adherence to dietary recommendations.

Differences in the impact of dietary restrictions on African Americans and Caucasians with NIDDM

African-American and Caucasian patients with non-insulin-dependent diabetes mellitus were surveyed to determine differences in self-reported dietary adherence. The relationship between dietary adherence and other psychosocial factors also was explored. The Diabetes Care Profile, an instrument designed to assess psychosocial factors related to diabetes, was completed by 178 patients. Correlation and regression analyses were used to examine the relationship between dietary adherence and 15 other scales in this instrument. Regression analyses revealed that selected scales were better at predicting dietary adherence for African Americans than for Caucasians. Self-care adherence was the most significant predictor of dietary adherence for African Americans while support was the most significant predictor for Caucasians. These findings suggest that cultural and social functions of food and diet should be examined and incorporated in the development of appropriate meal plans and educational interventions.

Mediators of depression in adults with diabetes

Several factors have been related to depression for people with diabetes, but mechanisms of depression in this population remain unclear. The purpose of this research was to test mastery and self-esteem as mediators of disease-related depression in people with diabetes. A sample of 180 adults ages 21 to 81 participated in the cross-sectional, correlational study. Mastery and self-esteem mediated the relationships between depression and two predictors, effects of diabetes complications and general social support. Feelings of self-esteem alone mediated the effect of regimen demands. The effect of diabetes on daily activities had a significant, direct (i.e., nonmediated) relationship to depressive symptoms. The entire model predicted 53% of variance in depression scores (p = .0001). These findings suggest nursing strategies for managing depression in patients with diabetes.

Liberalized diet in patients with type 1 diabetes

OBJECTIVE

To document that strict dietary regimen are not necessary in the context of intensified insulin therapy.

DESIGN

German multicentre, prospective cohort study; 6 years follow-up.

SETTING

Ambulatory examination using a mobile ambulance.

SUBJECTS

A total of 636 type 1 diabetic patients (age 33 +/- 7 years, diabetes duration 15 +/- 7 years; mean +/- SD), who had participated in a structured, 5-day, in-patient, group treatment and teaching programme for intensification of insulin therapy and liberalization of the diabetes diet 6 years prior to follow-up.

MAIN OUTCOME MEASURES

Relations between the extent to which patients practise a liberalized diet, the degree of metabolic control (HbA1c, severe hypoglycaemia, body mass index, cholesterol), and the patients' perceived burden through dietary treatment.

RESULTS

In the total patient group, HbA1c was 7.9 +/- 1.6%, and the incidence of severe hypoglycaemia was 0.17 cases per patient during the preceding year; 31% patients injected insulin < or = 3 times per day, 58% 4-7 times per day, and 11% used insulin pump therapy. Only 11% patients reported following a meal plan, whereas 89% continually changed timing and amount of carbohydrate intake; only 5% had the same number of meals every day, whereas as many as 20% varied the number of meals per day by four or more; 53% skipped main meals; 85% habitually consumed sugar or sugar containing foods. Patients with a higher degree of diet liberalization injected insulin or used an insulin pump therapy more frequently, and perceived their dietary treatment to be less burdensome. No clinically significant associations were found between the extent of diet liberalization and metabolic control.

CONCLUSIONS

Under the conditions where type 1 diabetic patients have the opportunity to participate in an intensified insulin treatment and teaching programme, liberalization of the diabetes diet is not associated with adverse effects on glycaemic control, but is associated with less perceived burden through dietary treatment.

Situational obstacles to dietary adherence for adults with diabetes

OBJECTIVE

To develop a taxonomy of everyday situations that create obstacles for adherence to dietary management in patients with diabetes.

SUBJECTS

Twenty-six adults with diabetes (12 with insulin-dependent diabetes mellitus and 14 with non-insulin-dependent diabetes mellitus) were recruited from an outpatient diabetes clinic.

MAIN OUTCOME MEASURES

Subjects were interviewed to identify problem situations that create obstacles for dietary adherence. The resulting 69 situations were judged for the presence or absence of 32 environmental features using a reliable coding system.

STATISTICAL ANALYSIS

A hierarchical cluster analysis was used to identify homogeneous groups of dietary adherence obstacles.

RESULTS

Twelve types of problem situations were identified: negative emotions, resisting temptation, eating out, feeling deprived, time pressure, tempted to relapse, planning, competing priorities, social events, family support, food refusal, and friends' support.

CONCLUSIONS

The resulting taxonomy provides an outline for the detailed assessment of obstacles to dietary adherence. An individual's ability to cope with this array of obstacles to dietary adherence should be assessed so treatment can be individualized.

Situational obstacles to adherence for adolescents with diabetes

Twenty adolescents with insulin-dependent diabetes mellitus were interviewed to obtain samples of problem situations that create obstacles to dietary adherence. The resulting 57 situations were analyzed using a reliable coding system to determine the presence or absence of 28 stimulus features. A hierarchical cluster analysis was used to identify 10 relatively homogeneous categories of obstacles to dietary adherence: being tempted to stop trying; negative emotional eating; facing forbidden foods; peer interpersonal conflict; competing priorities; eating at school; social events and holidays; food cravings; snacking when home, alone, or bored; and social pressure to eat. Diabetes educators should consider an individual's ability to cope with this array of obstacles to adherence when individualizing treatment. Dietary intervention then can be personalized to address specific situational obstacles.

Life-style modification for weight control to improve diabetes health status

The purpose of this study was to describe the relationship among variables which are associated with life-style modification, knowledge of diabetes, social support, health practices, and body mass index, to examine their effect on health status, and to test the effectiveness of a community based life-style modification program for weight control. Adults (n = 66) with non-insulin-dependent diabetes mellitus participated in either a treatment or control group. The treatment consisted of 5 weekly 90-min sessions on modifying eating and exercise patterns. All participants completed a personal resource questionnaire (PRQ), health practices survey (HPS), and diabetes health status questionnaire (DHS) at intake, 5 weeks, and 4 months. Knowledge of diabetes was assessed only at intake. Knowledge of diabetes, social support, and health practices explained 27% of the variance in health status, but health practices explained the largest (18%) proportion of the variance and was the only study variable significantly affected by the life-style modification program.

Facilitating diabetes self-management

The purpose of this study was to enhance sensitivity to and understanding of the perceptions of persons with diabetes by analyzing these individuals' unsolicited comments on structured questionnaires. Twenty of 66 adults with non-insulin-dependent diabetes mellitus (NIDDM) who participated in a study to modify their eating habits wrote a total of 122 unsolicited comments on three different questionnaires. A systematic analysis of the content of these comments resulted in seven coding categories: personal philosophy; knowledge deficit; weight or blood sugar problems; diet, exercise, or medication problems; self-care activity; stress; and success. Further analysis resulted in a trilevel schema (survival, regulation, success) depicting how individuals learn to manage their diabetes. The problem-identification and seeking-help behaviors identified in the survival level gradually changed to learning to live with the regimen in the regulation level. Respondents whose activities were in the success level demonstrated more autonomy than persons in the other two levels. A health orientation rather than a problem orientation also was seen in the success level. Consequently, teaching strategies should be tailored to the client's level of self-care, with an emphasis on assisting them toward the success level.

Evaluation of an activated patient diabetes education newsletter

This study evaluated a monthly, activated patient newsletter sent to over 7000 patients in Michigan with diabetes. The newsletter provided concise and action-oriented information about diabetes care. Patients who had signed up to receive the newsletter during the first 4 months of the project (1863) were surveyed to determine how many patients found the newsletter helpful; 80% (1498) of the patients replied. Patients who found the newsletter most helpful were older; had lower incomes, and reported more complications, less understanding of diabetes, and being in poorer overall health. They also were more likely to have non-insulin-dependent diabetes mellitus (NIDDM) than insulin-dependent diabetes mellitus (IDDM). We concluded that the activated patient newsletter is a useful public health/patient education intervention for persons with diabetes. Such a newsletter should be part of a coordinated system of ongoing patient care, education, screening, and social and psychological support.

Parental versus professional perceptions of obstacles to pediatric diabetes care

Parents of children with insulin-dependent diabetes mellitus (IDDM) (n = 38) were surveyed to identify common and difficult obstacles to diabetes care. A list of these obstacles was cross-validated by a second parent sample (n = 47) who rated each item according to how common and difficult each item was for them. The list then was rated by a sample of diabetes professionals (n = 15) to evaluate the extent of agreement between parents and health care professionals regarding the frequency with which these obstacles occur and the difficulty they pose to everyday diabetes care. Professionals disagreed with parents regarding which obstacles were most common and difficult, generally rating problems as significantly more common and difficult (t = 5.20, P = < .001) than did the parents who experienced them. The results of the survey underscore the importance of health care providers evaluating the concerns of the local patient community when developing educational and treatment services for these patients.

Guidelines vs practice in the delivery of diabetes nutrition care

The American Dietetic Association and the American Diabetes Association have published recommendations for the nutrition care of people with diabetes. However, the frequency of this care is rarely documented. As part of a study of diabetes care and education practices, the Michigan Diabetes Research and Training Center collected extensive data from 440 randomly selected adults who receive diabetes care from community physicians. These data provided a basis for comparison between diabetes nutrition care as recommended and as delivered in typical American communities. In this population (mean age = 61 years; 54% women), 89% (393) had non-insulin-dependent diabetes mellitus (NIDDM). Of these, 152 were managed with insulin (NIDDM/I) and 241 were not managed with insulin (NIDDM/NI). Most of the NIDDM/NI group was overweight (71%) and had elevated levels of glycated hemoglobin (62%) and serum cholesterol (53%). Yet they were significantly less likely than those with NIDDM/I to see a dietitian. The most frequently reported reason for not seeing a dietitian was that a physician had not referred them (53%). More than 90% of those with NIDDM/I or NIDDM/NI who were referred to a dietitian saw one. Because this population was from randomly selected communities, physicians, and patients, the results are probably generalizable to other regions of the United States. This study shows that in community practice, insulin use is the primary marker of the need for nutrition intervention, and the lack of physician referral to a dietitian is an important barrier to people receiving recommended diabetes nutrition care.

Perceived and actual knowledge of diet by individuals with non-insulin-dependent diabetes

A study was conducted to investigate both the perceived and actual knowledge of diet by 101 individuals with non-insulin-dependent diabetes mellitus (NIDDM). A survey instrument was developed containing three sections: perceptions of diet knowledge, demonstrated knowledge of diet, and demographic information. Perceived and actual knowledge of diet in the study group were compared with the following variables: years of education, types of diabetes regimen, participation in care, recency of dietary instruction, understanding of diet, and levels of self blood glucose monitoring (SBGM). Analysis indicated significant differences for knowledge and levels of education, perceptions and knowledge and recency of instruction, perceptions and knowledge and understanding of diet, and perceptions and self blood glucose monitoring. A positive linear relationship was noted between perceptions and actual knowledge of the diabetic diet.

A regional diabetes nutrition education program: its effect on knowledge and eating behavior

The effect of a nutrition education program on knowledge and self-care behavior in a group of individuals with diabetes was evaluated. The nutrition education program was developed using outlines and knowledge tests produced by the University of Michigan Diabetes Research and Training Center. The program, sponsored by the American Diabetes Association, Akron Chapter, was presented free of charge to Northeast Ohio area residents. Forty-four individuals participated in the study. Results indicated a statistically significant (p < 0.01) gain in knowledge but no statistically significant change in eating behavior for the sample. However, post-food records indicated that the mean for the percentage of total kcalories (kcals) from protein and fat (ie, 20% and 28%, respectively) were within the American Diabetes Association's recommendations of no more than 20% of kcals from protein and 30% of kcals from fat. In addition, the percentage of kcals from carbohydrate and the recommended total number of kcals improved toward the recommended levels.

Patterns of diet related self-care in diabetes

Our understanding of self-care actions can be enhanced by examining both the meanings attached to them and the context in which they take place. This article discusses patterns of diet-related self-care in a group of people with insulin-dependent diabetes. The study, based on a phenomenological perspective, consisted of 91 interviews with 34 people who discussed their everyday experience of living with diabetes. Individuals' response to the diabetes diet can be characterized on a continuum that includes strict adherence to diet to no adherence. Factors influencing how individuals responded to the diabetes diet can be grouped into three categories encompassing individual, diabetes-related and contextual influences. Many individuals sought an appropriate balance between health and well-being. When the pursuit of health did not compromise well-being adherence to diet was not a problem. When the pursuit of health conflicted with well-being individuals took liberties with the diet in order to minimize its impact. Implications for promoting self-care in people with diabetes are discussed.

Parents' understanding of and guilt over their children's blood glucose control

Parents (n =145) of 86 children with diabetes who attended an educational seminar wrote anonymous responses to questions about poor glycemic control, guilt feelings, and coping behaviors. Children from this group were similar to our clinic population in age, sex, duration of diabetes, and HbA1 levels. Results revealed a wide range of ideas about the meaning of poor control, intense feelings of guilt, and maladaptive responses. The largest number of parents had feelings of guilt relating to dietary issues. Parents of children with diabetes have stresses that frequently may go unrecognized and may require professional help to overcome.

Problems perceived by adults in adhering to a prescribed diet

Content analysis of inter views with 21 subjects regarding their adherence to prescribed diabetic diets showed the following problems in order of fre quency of mention: self- discipline, influence of other persons, impact of events, control of emo tions, lack of material resources, self-image, and time constraints.