Diet modification challenges faced by marginalized and nonmarginalized adults with type 2 diabetes: A systematic review and qualitative meta-synthesis

The role of family in supporting adherence to diabetes self-care management practices: An umbrella review

AIMS

Synthesize a review of reviews of the family's role in supporting adherence to diabetes self-care management practices (DSMP) for adults with type 2 diabetes (DM2).

DESIGN

An umbrella review.

DATA SOURCES

Scopus, Web of Science including MEDLINE, CINAHL via EBSCO, PubMed and Science Direct were searched for systematic reviews from their year of establishment until June 2021.

REVIEW METHODS

The review followed the Joanna Briggs Institute (JBI) guidelines for umbrella reviews. The JBI data extraction form for systematic reviews and research syntheses was used for data extraction. Methodological quality was assessed using the JBI Critical Appraisal Checklist for Systematic reviews and Research Syntheses.

RESULTS

Nineteen reviews met the inclusion criteria. The key findings were summarized using a narrative and thematic analysis methods. Four main themes were identified: family interactions and diabetes self-management, family support as informal social support, factors affecting families' roles, and tailoring culturally sensitive family-based interventions.

CONCLUSION

There appears to be a consensus regarding the impact of family on adults' self-management of DM2. Additional research is needed to comprehend the role of the family in underrepresented populations and examine what constitutes a family and the diverse family functions in different groups.

IMPACT

Enhancing adherence to self-care management practices is crucial for the well-being of adults with DM2. Family support is a key to successful self-care management at home. However, understanding the unique needs of adults with DM2 and their families can help healthcare professionals plan appropriate support strategies and sustainable family-based interventions.

NO PATIENT OR PUBLIC CONTRIBUTION

This review did not incorporate direct patients or public input as it summarizes evidence from previously published systematic reviews.

A multiple case study of pre-diabetes care undertaken by general practice in Aotearoa/New Zealand: de-incentivised and de-prioritised work

BACKGROUND

In Aotearoa/New Zealand (NZ) general practices diagnose and manage pre-diabetes. This work is important as it has the potential to delay or prevent the onset of Type 2 Diabetes (T2DM), reduce NZ's health inequities, and the burden that T2DM places on health care services. However, no study has previously examined how this work routinely occurs in NZ.

METHODS

Two case studies of practices serving ethnically and socio-economically diverse populations, followed by cross-case analysis.

RESULTS

The NZ health care context including funding mechanisms, reporting targets, and the disease centred focus of care, acted together to dis-incentivise and de-prioritise pre-diabetes care in general practices. The social determinants of health differentially influenced patients' ability to engage with and respond to pre-diabetes care, significantly impacting this work. Differing perspectives about the significance of pre-diabetes and gaps in systematic screening practices were identified. Interventions used were inconsistent and lacked comprehensive ongoing support.

CONCLUSIONS

Complex multi-layered factors impact on pre-diabetes care, and many of the barriers cannot be addressed at the general practice level. The practice serving the most disadvantaged population who concurrently have higher rates of pre-diabetes/T2DM were more adversely affected by the barriers identified.

The effectiveness of self-management programme based on multilevel social resources utilization in diabetes mellitus patients: A randomized controlled study

AIMS

This study aimed to test the effects of a novel diabetes self-management education (DSME) programme focused on multilevel social resources utilization on improving self-management behaviour, social resources utilization and haemoglobin A_lc (HbA_1c ) in patients with type 2 diabetes mellitus (T2DM).

METHODS

A randomized controlled design was used. A total of 118 participants with T2DM from two communities were recruited through randomized sampling, and randomly assigned to the novel DSME group or the traditional DSME group. DSME focusing on multilevel social resources utilization was implemented in the novel DSME group. Data were collected at baseline (T₀ ), at the end of the intervention (T₁ ) and 3 months after the end of intervention (T₂ ) from 3 March to 16 November 2014.

RESULTS

Comparing these two groups, the participants in the novel DSME group reported significantly better improvement in self-management behaviour and social resources utilization at T₁ and T₂ (all p < 0.01). A significant difference was found in the mean improvement of HbA_1c level between the two groups at T₂ (p < 0.05).

CONCLUSIONS

The novel DSME programme focused on multilevel social resources utilization can effectively enhance T2DM patients' self-management behaviour and social resource utilization and lower HbA_1c levels. More importantly, the effects could last longer.

Health professionals interface with cultural conflict in the delivery of type 2 diabetes care

OBJECTIVE

This study explored the knowledge and experiences of health professionals (HPs) caring for South Asian patients with type 2 diabetes (T2D).

DESIGN

Fourteen HPs, who supported patients with T2D, were interviewed. The recruitment strategy employed purposeful and theoretical sampling methods to recruit HPs who worked across primary and secondary care settings.

MAIN OUTCOME MEASURES

Grounded Theory (GT) methodology and analysis generated a theoretical framework that explored HP's perceptions and experiences of providing diabetes care for South Asian patients.

RESULTS

A GT, presenting a core category of Cultural Conflict in T2D care, explores the influences of HP's interactions and delivery of care for South Asian patients. This analysis is informed by four categories: (1) Patient Comparisons: South Asian vs White; (2) Recognising the Heterogeneous Nature of South Asian Patients; (3) Language and Communication; (4) HPs' Training and Experience.

CONCLUSIONS

The findings consider how the role of social comparison, social norms, and diminished responsibility in patient self-management behaviours influence HPs' perceptions, implicit and explicit bias towards the delivery of care for South Asian patients. There was a clear call for further support and training to help HPs recognise the cultural-ethnic needs of their patients.

Culturally-tailored cookbook for promoting positive dietary change among hypertensive Filipino Americans: a pilot study

Introduction

Among all Asian American subgroups, Filipino-Americans have consistently been shown to have the highest rates of hypertension, raising risks of heart attack and stroke. Despite this alarming fact, little has been done to investigate culturally-sensitive interventions to control hypertension rates in this vulnerable population. To address the lack of culturally-relevant lifestyle options for blood pressure management currently available to the Filipino community, this exploratory pilot study used a design thinking approach informed by culinary medicine to develop a culturally-tailored, heart-healthy, and low sodium recipe cookbook for Filipino Americans with hypertension and evaluate its feasibility as a hypertension intervention.

Methods

Our team developed a cookbook using participatory methods and design thinking, utilizing input from five Filipino culinary experts and a Registered Dietitian. The cookbook incorporates traditional Filipino recipes, excerpts from community members' interviews, and nutrient analyses. Twenty Filipinx-identifying individuals* who self-reported physician-diagnosed hypertension were recruited from Filipino community-based organizations, enrolled into this study, provided with the cookbook, and asked to cook at least one recipe. Pre- and post-intervention surveys were conducted and centered around behavior change and features of the cookbook.

Results

This study provided evidence for the cookbook's acceptability and feasibility, with participants' open-ended responses revealing that the recipes, nutrition labels, illustrations, and cultural aspects of the cookbook increased motivation to achieve dietary change, including reducing sodium in their diet to improve their blood pressure. Participant responses also indicated positive behavior change as a result of using the cookbook, with participants reporting increased likelihood of adopting recommended actions to lower their BP after utilizing the cookbook ( x ¯ = 80.83%), compared to before ( x ¯ = 63.75%, p < 0.008), according to Hypertension Self-Care Management scaled scores.

Discussion

In conclusion, the results of this pilot study demonstrated acceptability of this unique cookbook and provide preliminary findings consistent with increased motivation in participants to make dietary changes and improve personal health, drawing attention to the importance of considering future culturally-tailored health interventions. Next steps should include a robust, randomized controlled trial design comparing measured blood pressure outcomes of an intervention vs. control group. *Filipinx is an inclusive term representing the gender identities of all participants in our study.

It is time for a more targeted approach to prediabetes in primary care in Aotearoa New Zealand

Type 2 diabetes (T2DM), its related morbidities and entrenched diabetes-related inequities pose significant challenges for health care delivery systems in Aotearoa New Zealand (NZ). Primary care services undertake the majority of diabetes prevention work by initially detecting and managing those with prediabetes. In this viewpoint, we present available NZ data to highlight NZ trends in prediabetes and consider the current NZ clinical guidelines and the prediabetes care pathway. Multiple areas for improvement are identified to optimise diabetes prevention, potentially reduce T2DM inequities, and sustain more effective prediabetes management in primary care in NZ.

Proximal and distal influences on dietary change among a diverse group with prediabetes participating in a pragmatic, primary care nurse-led intervention: a qualitative study

OBJECTIVE

To understand motivators, facilitators and challenges to dietary change amongst a diverse sample of New Zealanders with prediabetes participating in a primary care nurse-led individualised dietary intervention.

DESIGN

A qualitative study involving semi-structured, face-to-face interviews with a stratified sample of adults with prediabetes and BMI ≥ 25 kg/m2, purposefully selected from a larger 2-year primary care-based prediabetes dietary intervention study. Thematic analysis was undertaken. A socio-ecological model guided interpretation.

SETTING

Hawke's Bay, Aotearoa/New Zealand, April 2018-March 2020.

PARTICIPANTS

Fifty-eight people aged 28-69 years, with similar numbers of men and women, indigenous Māori and non-Māori, and those who had and had not regressed to normoglycaemia at 6 months.

RESULTS

Motivators for wanting to make dietary changes were determination not to progress to diabetes; wanting to be healthy and contribute to others and encouragement by others. Facilitators for adopting and maintaining changes were a strong desire to be healthy; personal determination and feeling supported. Challenges were compromised control over life and environmental factors; feeling unsupported by others; social occasions; financial constraints and living with other health conditions. Developing their own strategies to overcome challenges was empowering, enabling a sense of control. These factors were similar across demographic and glycaemic outcome groups.

CONCLUSIONS

Influences on dietary change involved personal, interpersonal, organisational, environmental and policy factors. Although findings appeared similar across groups, dietary interventions need to address the specific ways motivators, facilitators and challenges manifest for individuals and social groups and be tailored accordingly within the context of the wider obesogenic and socio-economic environment.

Database selection and data gathering methods in systematic reviews of qualitative research regarding diabetes mellitus - an explorative study

BACKGROUND

Systematic reviews (SRs) are considered one of the most reliable types of studies in evidence-based medicine. SRs rely on a comprehensive and systematic data gathering, including the search of academic literature databases. This study aimed to investigate which combination of databases would result in the highest overall recall rate of references when conducting SRs of qualitative research regarding diabetes mellitus. Furthermore, we aimed to investigate the current use of databases and other sources for data collection.

METHODS

Twenty-six SRs (published between 2010 and 2020) of qualitative research regarding diabetes mellitus, located through PubMed, met the inclusion criteria. References of the SRs were systematically hand searched in the six academic literature databases CINAHL, MEDLINE/PubMed, PsycINFO, Embase, Web of Science, and Scopus and the academic search engine Google Scholar. Recall rates were calculated using the total number of included references retrieved by the database or database combination divided by the total number of included references, given in percentage.

RESULTS

The SRs searched five databases on average (range two to nine). MEDLINE/PubMed was the most commonly searched database (100% of SRs). In addition to academic databases, 18 of the 26 (69%) SRs hand searched the reference lists of included articles. This technique resulted in a median (IQR) of 2.5 (one to six) more references being included per SR than by database searches alone. 27 (5.4%) references were found only in one of six databases (when Google Scholar was excluded), with CINAHL retrieving the highest number of unique references (n = 15). The combinations of MEDLINE/PubMed and CINAHL (96.4%) and MEDLINE/PubMed, CINAHL, and Embase (98.8%) yielded the highest overall recall rates, with Google Scholar excluded.

CONCLUSIONS

We found that the combinations of MEDLINE/PubMed and CINAHL and MEDLINE/PubMed, CINAHL, and Embase yielded the highest overall recall rates of references included in SRs of qualitative research regarding diabetes mellitus. However, other combinations of databases yielded corresponding recall rates and are expected to perform comparably. Google Scholar can be a useful supplement to traditional scientific databases to ensure an optimal and comprehensive retrieval of relevant references.

Strategies for Reducing Salt and Sugar Intakes in Individuals at Increased Cardiometabolic Risk

Non-communicable diseases (NCDs) are the first causes of death worldwide. Reduction in the dietary intake of salt and sugars is important lifestyle advice that is useful for NCD prevention. However, the simple recommendations of reducing salt and sugars by healthcare professionals are often ineffective; innovative strategies are therefore necessary. This review aimed at describing the current knowledge about the strategies to reduce dietary salt and sugar intake, including both strategies for the food industry to reduce the salt or sugar of its products and recommendations for health professionals in a clinical context, such as the replacement with substitutes in foods, the gradual reduction to allow a progressive consumer adaptation towards less intense taste, and the different spatial distribution of tastants within the food matrix with taste intensity enhancement. In addition, the cross-modal interaction between two or more different sensory modalities as an innovative strategy for enhancing sweetness and saltiness perception was described. Finally, the dietary tips for salt and sugar reduction were summarized in order to create a comprehensive guide of dietary advices for healthcare professionals for optimizing the management of patients at increased cardiometabolic risk.

Identifying Needs and Barriers to Diabetes Dietary Education in Chinese People with Type 2 Diabetes and Their Family Members in Guangzhou: A Qualitative Study

PURPOSE

The purpose of this exploratory qualitative study was to identify the needs and barriers to diabetes dietary education issues in a Chinese context among people with type 2 diabetes and also their family members.

PATIENTS AND METHODS

Nineteen patients with type 2 diabetes and 15 family members were randomly selected from a larger study in Guangzhou. Descriptive phenomenological qualitative inquiry guided this study.

RESULTS

Both patients and their family members claimed a variety of needs regarding diabetes dietary information and that it should be patient-centered. In addition, both groups identified the effectiveness and helpfulness of diabetes diet-related health education, but family members reported a lack of professional education. Patients reported that the barriers to diabetes diet-related health education were: 1) patients' different faculties of memory and acceptance, 2) educators' methods of explaining the information, 3) lack of advertising and intensity of publicity both inside and outside of the hospital. Family members identified that diabetes diet-related health education assisted them with taking care of patients with diabetes and it was also beneficial for themselves to gain more dietary knowledge and develop healthy dietary habits.

CONCLUSION

It is necessary to make some adjustment to traditional diabetes dietary education. It may be a good strategy to investigate the needs and faculties of memory and acceptance of people with diabetes before starting a diabetes education program. Hospitals should intensify their publicity of diabetes education and make it more attractive to patients with diabetes and their family members. Educators should add information specifically for family members while conducting diabetes education. Tertiary hospitals could provide standardized training regarding diabetes-related health education to community family physicians; in this way, diabetes education could gradually be transferred to them and both groups of clinicians could share in the education.

Effects of health literacy, screening, and participant choice on action plans for reducing unhealthy snacking in Australia: A randomised controlled trial

BACKGROUND

Low health literacy is associated with poorer health outcomes. A key strategy to address health literacy is a universal precautions approach, which recommends using health-literate design for all health interventions, not just those targeting people with low health literacy. This approach has advantages: Health literacy assessment and tailoring are not required. However, action plans may be more effective when tailored by health literacy. This study evaluated the impact of health literacy and action plan type on unhealthy snacking for people who have high BMI or type 2 diabetes (Aim 1) and the most effective method of action plan allocation (Aim 2).

METHODS AND FINDINGS

We performed a 2-stage randomised controlled trial in Australia between 14 February and 6 June 2019. In total, 1,769 participants (mean age: 49.8 years [SD = 11.7]; 56.1% female [n = 992]; mean BMI: 32.9 kg/m2 [SD = 8.7]; 29.6% self-reported type 2 diabetes [n = 523]) were randomised to 1 of 3 allocation methods (random, health literacy screening, or participant selection) and 1 of 2 action plans to reduce unhealthy snacking (standard versus literacy-sensitive). Regression analysis evaluated the impact of health literacy (Newest Vital Sign [NVS]), allocation method, and action plan on reduction in self-reported serves of unhealthy snacks (primary outcome) at 4-week follow-up. Secondary outcomes were perceived extent of unhealthy snacking, difficulty using the plans, habit strength, and action control. Analyses controlled for age, level of education, language spoken at home, diabetes status, baseline habit strength, and baseline self-reported serves of unhealthy snacks. Average NVS score was 3.6 out of 6 (SD = 2.0). Participants reported consuming 25.0 serves of snacks on average per week at baseline (SD = 28.0). Regarding Aim 1, 398 participants in the random allocation arm completed follow-up (67.7%). On average, people scoring 1 SD below the mean for health literacy consumed 10.0 fewer serves per week using the literacy-sensitive action plan compared to the standard action plan (95% CI: 0.05 to 19.5; p = 0.039), whereas those scoring 1 SD above the mean consumed 3.0 fewer serves using the standard action plan compared to the literacy-sensitive action plan (95% CI: -6.3 to 12.2; p = 0.529), although this difference did not reach statistical significance. In addition, we observed a non-significant action plan × health literacy (NVS) interaction (b = -3.25; 95% CI: -6.55 to 0.05; p = 0.054). Regarding Aim 2, 1,177 participants across the 3 allocation method arms completed follow-up (66.5%). There was no effect of allocation method on reduction of unhealthy snacking, including no effect of health literacy screening compared to participant selection (b = 1.79; 95% CI: -0.16 to 3.73; p = 0.067). Key limitations include low-moderate retention, use of a single-occasion self-reported primary outcome, and reporting of a number of extreme, yet plausible, snacking scores, which rendered interpretation more challenging. Adverse events were not assessed.

CONCLUSIONS

In our study we observed nominal improvements in effectiveness of action plans tailored to health literacy; however, these improvements did not reach statistical significance, and the costs associated with such strategies compared with universal precautions need further investigation. This study highlights the importance of considering differential effects of health literacy on intervention effectiveness.

TRIAL REGISTRATION

Australia and New Zealand Clinical Trial Registry ACTRN12618001409268.

Protein intake is more stable than carbohydrate or fat intake across various US demographic groups and international populations

BACKGROUND

The optimal macronutrient composition of the diet is controversial and many adults attempt to regulate the intake of specific macronutrients for various health-related reasons.

OBJECTIVE

The objective was to compare stability and ranges of intakes of different macronutrients across diverse adult populations in the USA and globally.

METHODS

US dietary intake data from NHANES 2009-2014 were used to determine macronutrient intake as a percentage of total energy intake. Variability in macronutrient intake was estimated by calculating the difference between 75th and 25th percentile (Q3-Q1) IQRs of macronutrient intake distributions. In addition, intake data from 13 other countries with per capita gross domestic product (GDP) over $10,000 US dollars (USD) were used to assess variability of intake internationally since there are large differences in types of foods consumed in different countries.

RESULTS

Protein, carbohydrate, and fat intake (NHANES 2009-2014) was 15.7 ± 0.1, 48.1 ± 0.1, and 32.9 ± 0.1% kcal, respectively, in US adults. The IQR of protein intake distribution (3.73 ± 0.11% kcal) was 41% of carbohydrate intake distribution (9.18 ± 0.20% kcal) and 58% of fat intake distribution (6.40 ± 0.14% kcal). The IQRs of carbohydrate and fat intake distributions were significantly (P <0.01) influenced by age and race; however, the IQR of protein intake was not associated with demographic and lifestyle factors including sex, race, income, physical activity, and body weight. International mean protein intake was 16.3 ± 0.2% kcal, similar to US intake, and there was less variation in protein than carbohydrate or fat intake.

CONCLUSION

Protein intake of the US population and multiple international populations, regardless of demographic and lifestyle factors, was consistently ∼16% of total energy, suggesting biological control mechanism(s) tightly regulate protein intake and, consequently, influence intake of other macronutrients and food constituents. Substantial differences in intake of the other macronutrients observed in US and international populations had little influence on protein intake. This trial was registered at the ISRCTN registry as ISRCTN46157745 (https://www.isrctn.com/ISRCTN4615774).

Diabetes detachment: How cultural, contextual, and personal barriers influence low-income young women with diabetes in Appalachia

AIM

This study explored the experiences of young low-income women with type 2 diabetes (T2D) in Appalachia, Tennessee.

BACKGROUND

Diabetes care remains suboptimal across the United States particularly in underserved communities.

METHODS

The study employed a descriptive qualitative case study collecting data using in-depth interview of a group of low-income women in their 20s with T2D. Data was analyzed using qualitative content analysis.

RESULTS

The findings identified three themes: "frustration and stigma lead to detachment care," "frozen by fear and unable to overcome resource limitations" and "social support and an empowered perspective lead to a positive outlook." Cultural barriers combined with contextual and personal barriers resulted in detachment from diabetes care among study participants.

CONCLUSION

Within Appalachia, leveraging the existing familism values along with culturally congruent education and support can help alleviating the burden of diabetes care.

'It's Important to Make Changes.' Insights about Motivators and Enablers of Healthy Lifestyle Modification from Young Aboriginal Men in Western Australia

Lifestyle modification can improve the health of people with or at risk of non-communicable diseases; however, initiating and maintaining positive health behaviours including healthy eating and physical activity is challenging. Young remote Aboriginal people who had successfully made significant healthy lifestyle changes were sought out to explore how they achieved this success. Four Aboriginal men aged 20⁻35 years were identified and consented to participate. Their perceptions of motivation for change, strategies, and facilitators and barriers were explored through in-depth interviews. Themes developed from the interviews included self-efficacy, self-reliance, and increased knowledge and altered health beliefs underpinning change. Participants with diabetes were highly motivated to avoid diabetes complications and had a strong belief that their actions could achieve this. In a setting with high levels of disadvantage, participants had relatively favourable socioeconomic circumstances with solid social supports. These findings highlight that lifestyle modification programs that foster internal motivation, enhance key health knowledge, and modify health beliefs and risk perception are needed. Increasing diabetes awareness among at-risk young people is important, emphasising the largely preventable and potentially reversible nature of the condition. Broad health improvements and individual changes will be facilitated by equitable socioeconomic circumstances and environments that support health.

Food Perceptions and Dietary Changes for Chronic Condition Management in Rural Peru: Insights for Health Promotion

Peru is undergoing a nutrition transition and, at the country level, it faces a double burden of disease where several different conditions require dietary changes to maintain a healthy life and prevent complications. Through semistructured interviews in rural Peru with people affected by three infectious and noninfectious chronic conditions (type 2 diabetes, hypertension, and neurocysticercosis), their relatives, and focus group discussions with community members, we analyzed their perspectives on the value of food and the challenges of dietary changes due to medical diagnosis. The findings show the various ways in which people from rural northern Peru conceptualize good (buena alimentación) and bad (mala alimentación) food, and that food choices are based on life-long learning, experience, exposure, and availability. In the context of poverty, required changes are not only related to what people recognize as healthy food, such as fruits and vegetables, but also of work, family, trust, taste, as well as affordability and accessibility of foods. In this paper we discuss the complexity of introducing dietary changes in poor rural communities whose perspectives on food are poorly understood and rarely taken into consideration by health professionals when promoting behavior change.

Challenges in everyday life among recently diagnosed and more experienced adults with type 2 diabetes: A multistage focus group study

AIMS AND OBJECTIVES

To identify perceived challenges related to self-management among recently diagnosed adults and those with longer experience of type 2 diabetes as a foundation for the future development of a person-centred information and communication technology service.

BACKGROUND

Learning self-management of type 2 diabetes includes mastering the skills required to complete complex emotional and physical tasks. A service developed with the participation of stakeholders may be an alternative way to meet rising needs for self-management.

DESIGN

Qualitative descriptive design influenced by a participatory approach.

METHODS

Multistage focus group interviews among one group of recently diagnosed (≤3 years, n = 4) adults and one group with longer experience (≥5 years, n = 7) of type 2 diabetes.

RESULTS

Challenges in self-management in everyday life with type 2 diabetes were identified: understanding; developing skills and abilities; and mobilising personal strengths. Both groups described challenges in understanding the causes of fluctuating blood glucose and in developing and mobilising skills for choosing healthful food and eating regularly. The recently diagnosed group was more challenged by learning to accept the diagnosis and becoming motivated to change habits while the experienced group was mainly challenged by issues about complications and medications.

CONCLUSION

Adults with diabetes have different needs for support during different phases of the disease. From a person-centred perspective, it would be desirable to meet individual needs for self-management on peoples' own terms through a technological service that could reach and connect to a large number of people.

RELEVANCE TO CLINICAL PRACTICE

Diabetes nurses need to address the knowledge needs of patients with diabetes and support them in developing self-management skills. Consistent with person-centred care, practitioners should also encourage patients' abilities to mobilise their own personal strengths to maintain self-management.