National standards for diabetes self-management education. Task Force to Review and Revise the National Standards for Diabetes Self-Management Education Programs

The Value of Medical Nutrition Therapy and Diabetes Self-Management Education and Support in Diabetes Care and Education: A Call to Action to Increase Referrals and Recognize Insurance Coverage Variation

PURPOSE OF REVIEW

Evidence over the past few decades have proven the benefits and cost savings of diabetes self-management education and support (DSMES) and medical nutrition therapy (MNT). Yet, the benefits continue to be underutilized. Little evidence is available to definitively assess insurance coverage for both services. Strategies are presented to more efficiently assess coverage as well as Identify methods to increase referrals and more effectively bill for both services.

RECENT FINDINGS

Estimated statistics for both type 1 and type 2 diabetes reveal increases globally, especially in those under 20 and over 65. Individuals meeting the current A1C guidelines are still well below current recommendations. The economic costs of diabetes continue to rise. Both DSMES and MNT are effective, cost-saving methods that are critical components to the ongoing care of people with diabetes. While insurance coverage does vary based on each specific type, billing correctly and following the requirements for NSDSMES are essential to receive appropriate reimbursement for services.

An Effective Model of Diabetes Care and Education: The ADCES7 Self-Care Behaviors™

PURPOSE

The ADCES7 Self-Care Behaviors^™ (ADCES7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the Association of Diabetes Care and Education Specialists (ADCES) that at the cornerstone of diabetes self-management education and support, the ADCES7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The ADCES7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management as well as diabetes self-management education and support, ADCES has evaluated the ADCES7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and ADCES's vision and expansion beyond diabetes to refresh the ADCES7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

Empowerment of Patients in the Process of Rehabilitation

The management and appropriate treatment of peritoneal dialysis (PD) patients is an ongoing challenge in current health care. We believe that health education—consisting of knowledge, skills, and self-awareness—is a useful mechanism for patient empowerment. Patients should have an awareness of their disease, and as health care providers, PD nurses have the role of focusing their patients on preventive care, rather than of simply training patients. An empowerment program is a valuable intervention for improving the self-management of patients. It can both improve quality of life and assist in rehabilitation.

An Effective Model of Diabetes Care and Education: Revising the AADE7 Self-Care Behaviors®

PURPOSE

The AADE7 Self-Care Behaviors^® (AADE7) is a robust framework for self-management of diabetes and other related conditions, such as prediabetes and cardiometabolic diseases. It is the position of the American Association of Diabetes Educators (AADE) that, at the cornerstone of diabetes self-management education and support, the AADE7 is the framework for achieving behavior change that leads to effective self-management through improved behavior and clinical outcome measures. The AADE7 model guides the health care team in effective person-centered collaboration and goal setting to achieve health-related outcomes and improved quality of life. Continued research and evidence are critical to expand this model and broaden its application to other chronic conditions. Given the advances in the science of diabetes management, as well as in diabetes self-management education and support, AADE has evaluated the AADE7 within the framework of these advances, including the digital and dynamic health care landscape.

CONCLUSION

This revised position statement blends the updates in research and AADE's vision and expansion beyond diabetes to refresh the AADE7 framework. This revision reflects the perspectives of all members of the health care team as they problem solve with individuals who are at risk for or who have diabetes and related conditions to achieve healthier outcomes.

USING GUESSING GAME TO INCREASE COMPLICATION AWARENESS OF PATIENTS WITH NEWLY DIAGNOSED TYPE 2 DIABETES

Background

Prevention of complications is widely considered as the main aim of diabetes control. And diabetes education is the cornerstone for type 2 diabetes (T2D) management. However, traditional lecture-based diabetes patient education activities have small and short-lasting efficacy. Therefore, technology-based initiatives for diabetes patient education are urgently required.

Objective

To evaluate Guessing, a popular game, as tool in increasing complication awareness of patients with newly diagnosed T2D during diabetes care.

Patients and Methods

In a cohort study, 103 patients were split into Guessing Game group and control group. The opinions of patients and educators in Guessing Game group were surveyed. Patient performance was evaluated by test scores and the attendance to diabetes complication screening clinic.

Results

A majority of patients and all educators believed that Guessing Game enhanced complication awareness. Educatees achieved higher total scores and test scores in "Fill in the Gaps" (one of 2 types of test item), more actively attended complication screening clinic, after using Guessing Game as an education tool.

Conclusion

Guessing Game is an attractive and effective educational intervention to increase complication awareness of T2D patients.

Impact of structured education on glucose control and hypoglycaemia in Type-2 diabetes: a systematic review of randomized controlled trials

Evidence for the use of structured education in diabetes management is accumulating and has shown positive influence in the management of Type-2 diabetes.

Objective

To assess the impact of structured education on glucose control and hypoglycaemia in the management of Type-2 diabetes.

Methods

A systematic review was done using Medline via Ovid and EMBASE databases of published English literature between 1980 and 2014. Included studies were randomized control trials that assessed the impact of structured education on glucose control and hypoglycaemia.

Results

Out of the 12,086 full text articles were identified, 36 full text articles were finally considered for this review after applying both inclusion and exclusion criteria, of which 34 were exclusively on the effect of structured diabetes education on glucose control whilst 2 were studies on the effects of structured diabetes education on glucose control and hypoglycaemia. Majority of the studies included a predominant Caucasian population. There was heterogeneity in the included studies such as intervention methods and intensity as well as follow up periods. Group based education was preferred over individual education by most studies. Overall, most of the studies showed a significant positive effect on glycaemic control compared with control groups. One study showed a significant impact of structured education on hypoglycaemia.

Conclusion

Structured education has positive impact on glucose control and hypoglycaemia in Type-2 diabetes and must be incorporated in routine care.

Funding

The study was funded by the authors.

Diabetes Self-Management: A Key to Better Health-Related Quality of Life in Patients with Diabetes

OBJECTIVE

The aims of this study were to assess health-related quality of life (HRQOL) among adult patients with diabetes attending primary health care diabetes clinics in Kuwait and to examine the factors associated with the HRQOL of patients with diabetes.

METHODS

This cross-sectional study was conducted among 503 patients with diabetes attending 26 primary health care diabetes clinics in Kuwait. A self- administered questionnaire on participants' socio-demographic and clinical characteristics, in addition to the Diabetes Self-Management Questionnaire (DSMQ) to assess patients' diabetes self-management (DSM), was used. The SF-12 was employed to assess the HRQOL, producing the following 2 outcomes: physical health composite (PHC) and mental health composite (MHC).

RESULTS

The mean age of participants was 52 ± 0.8 years, and 53.1% were males and 49.0% were Kuwaitis. The median DSM sum score was 6.5. Male patients with diabetes showed a significantly better median DSM sum score than female patients with diabetes. The overall median score of HRQOL was 61.7/100, with a better median PHC versus MHC score of quality of life (66.7/100 and 56.7/100, respectively). Multivariate analysis revealed a significant direct association between DSM and better primary health composite and MHC scores. It also showed that female gender and reporting 2 or more diabetic complications were significantly associated with a poor PHC.

CONCLUSIONS

Kuwaiti patients with diabetes showed a modest level of HRQOL. Patients' DSM, gender, and diabetes complications were significant independent correlates to HRQOL. Appraisal of the HRQOL of patients with diabetes as an essential component of diabetes management in clinical settings is suggested. Further studies to examine the impact of good DSM on HRQOL improvement are needed.

Impact of the self-care education program on quality of life in patients with type II diabetes

INTRODUCTION

Diabetes is an irreversible disease requiring lifetime self-care and rehabilitation. Patient education to improve their ability in administering self-care is also effective, lowering the risks of developing complications and promoting the quality of life. This study was conducted to assess the effect of self-care educational programs in promoting the quality of life of diabetic patients.

METHODS

In this pre-test/post-test intervention study design, 30 diabetes patients were included on the basis of a non-randomized sampling, using each subject as her/his own control. The self-care educational program was introduced to participants by researcher through two 55-min sessions. Quality of life by using Iranian Short Form Health Survey was assessed before and after the educational sessions. The paired t-test was used to compare the total and subscale mean scores of the Quality of life before and after the training.

RESULTS

Finding showed that there was a significant increase in General health (P=0.027), Physical role (P<0.001), Physical functioning (P=0.027), Social functioning (P=0.029) and Body pain (P=0.020).

CONCLUSION

The results from the present study demonstrate that structured patient education improves patients 'well-being' after the teaching program. Diabetes educational program should be a basis for the management of diabetes.

Effect of a newly-devised nutritional guide based on self-efficacy for patients with type 2 diabetes in Japan over 2 years: 1-year intervention and 1-year follow-up studies

AIMS/INTRODUCTION

We devised a new system called "Educational Guidance" (E-Guide) for nutritional education based on self-efficacy. The present study aimed to examine the effects of E-Guide use on glycemic control among patients with type 2 diabetes.

MATERIALS AND METHODS

We carried out an interventional and observational study that included 74 patients with type 2 diabetes. The extent of glycemic control in the 39 patients who received guidance through the E-Guide (E-Guide group) was compared with that of 35 patients who received conventional nutritional guidance (control group). We carried out a 1-year follow-up survey (subanalysis) based on the electronic health records of 18 patients from the E-guide group and 19 patients from the control group. These patients continued treatment at Hikone Municipal Hospital, Hikone, Shiga, Japan. Changes in glycated hemoglobin levels, body mass index and medication dose were examined from time of enrollment to the end of the 1-year intervention, and during the 1-year follow-up.

RESULTS

Decreases in glycated hemoglobin levels were more pronounced in the E-Guide group than in the control group during the intervention period (P < 0.05). The levels further decreased during the follow-up period (P < 0.01). In the E-Guide group, body mass index decreased significantly throughout the follow-up period (P < 0.001). Additionally, increased medication doses were significantly less common in the E-Guide group than in the control group (P < 0.01).

CONCLUSIONS

Intervention based on our "E-Guide" is more useful and powerful than the conventional methods for glycemic control and self-care behavior among patients with type 2 diabetes in Japan.

Diabetes Educators

A survey evaluating the professional characteristics and practice patterns of diabetes educators was distributed across the United States. The specific survey aims were to assess whether (1) there continues to be a growing trend among US health professionals who consider themselves diabetes educators to obtain certification as certified diabetes educators (CDEs), (2) duties/services associated with diabetes self-management training (DSMT) and medical/medication management differ between diabetes educators who are CDEs versus those who are non-CDEs, and (3) educator practice patterns differ across the major geographic regions of the United States. Of the 507 diabetes educators completing the survey, 83% identified themselves as CDEs. Diabetes educators responding to similar surveys done in 1992 and 1999, 51% and 63%, respectively, identified themselves as CDEs. In this survey, a similar percentage of CDEs and non-CDEs employed DSMT practices of relatively low complexity (eg, general diabetes education) whereas a significantly higher percentage (P< .001) of CDEs employed DSMT practices of relatively high complexity (eg, insulin pump training). Significantly (P < .001) more CDEs provided medical/medication management services compared to non-CDEs. Finally, the practice patterns among CDEs were minimally influenced by region of the country. These results suggest that (1) the trend toward increased certification among diabetes educators has continued, (2) certification is associated with a greater likelihood of delivering complex DSMT services and medical/medication management, and (3) this pattern is consistent across the nation as a whole.

Divergent Perceptions of Barriers to Diabetic Retinopathy Screening Among Patients and Care Providers, Los Angeles, California, 2014-2015

Introduction

Despite availability of screening for diabetic retinopathy, testing is underused by many low-income and racial/ethnic minority patients with diabetes. We examined perceived barriers to diabetic retinopathy screening among low-income patients and their health care providers and provider staffers.

Methods

We collected survey data from 101 patients with diabetes and 44 providers and staffers at a safety-net clinic where annual diabetic retinopathy screening rates were low. Barriers specified in the survey were derived from the literature.

Results

Patients surveyed (mean [standard deviation] age, 54.0 [7.7] y; 41% were male) were primarily Hispanics (70%) and African Americans (27%) of low socioeconomic status. Overall, 55% of patients received diabetic retinopathy screening in the previous year. Patients who could not explain why this screening is needed reported more barriers than patients who could (2.5 vs 1.4 barriers, P = .02). Fewer patients reported that they experienced barriers such as transportation (15%), language issues (15%), cultural beliefs or myths (4%), denial (8%), and fear (5%), which providers and staffers considered very or extremely important (all P < .001). Financial burdens (26%) and depression (22%) were most commonly reported by patients as barriers, yet providers and staffers did not rate these barriers as important, P < .001.

Conclusion

Patients and health care providers had markedly divergent perceptions of barriers to diabetic retinopathy screening. Patients with poor understanding of the need for screening were more likely to report such barriers. These results suggest a need for active community engagement to find key elements for education programs and other interventions to increase rates of diabetic retinopathy screening, particularly among low-income, minority populations.

Effectiveness of a community-based diabetes self-management education (DSME) program in a rural agricultural setting

Introduction The purpose of this study is to assess the effectiveness of diabetes self-management education (DSME) in a rural agricultural town.

METHODS

In this prospective, education-intervention trial, 85 adults with type 2 diabetes mellitus from villages randomly assigned to DSME and 70 from villages assigned to standard care participated. The DSME group underwent a curriculum delivered by peer educators; those in the standard group received usual advice. Outcome measures were anthropometric, biochemical, health behaviors, and medication use data taken at baseline then after three and six months.

RESULTS

DSME group had a lower median A1C after three and six months. After six months, there was a 0.5% median A1C reduction in DSME group and a 0.25% increase in the standard group. There were more participants in DSME group with A1C ⩽7.0% after three and six months. By the third month, there were more participants in DSME group performing foot examination.

CONCLUSION

DSME in this rural agricultural town improved glycemic control and promoted foot examination.

Social Cognitive Theory in Diabetes Exercise Research: An Integrative Literature Review

PURPOSE

This integrative review critically examined the literature on diabetes research using Social Cognitive Theory (SCT) to determine its predictive ability in explaining exercise behavior and to identify key interventions that enhance exercise initiation and maintenance.

METHODS

Literature published between 1985 and 2002 was searched using the following keywords: SCT, self-efficacy, diabetes mellitus, non-insulin-dependent diabetes mellitus, insulin-dependent diabetes mellitus, physical activity, and exercise. The databases searched were CINAHL, Medline, and PsychInfo. Of the 38 articles retrieved from databases, 13 were reviewed.

RESULTS

A statistically significant relationship between self-efficacy and exercise behavior was found in correlational studies. Results from the predictive study support the predictability of self-efficacy for exercise behavior. Mixed results were found for the predictive ability of outcome expectancies for exercise behavior. Self-efficacy was predictive of exercise initiation and maintenance over time. The evidence for successful interventions to increase self-efficacy and exercise behavior over time was inconclusive.

CONCLUSIONS

To better understand exercise behavior and to develop effective exercise interventions, a microanalytic, theory-driven approach to studying exercise behavior is needed. Several suggestions are offered to strengthen exercise self-efficacy.

Effects of Providing Peer Support on Diabetes Management in People With Type 2 Diabetes

PURPOSE

We examined the effects of participating in a "train-the-trainer" program and being a peer supporter on metabolic and cognitive/psychological/behavioral parameters in Chinese patients with type 2 diabetes.

METHODS

In response to our invitation, 79 patients with fair glycemic control (HbA1c <8%) agreed to participate in a "train-the-trainer" program to become peer supporters. Of the 59 who completed the program successfully, 33 agreed to be peer supporters ("agreed trainees") and were each assigned to support 10 patients for 1 year, with a voluntary extension period of 3 additional years, while 26 trainees declined to be supporters ("refused trainees"). A group of 60 patients with fair glycemic control who did not attend the training program and were under usual care were selected as a comparison group. The primary outcome was the change in average HbA1c levels for the 3 groups from baseline to 6 months.

RESULTS

At 6 months, HbA1c was unchanged in the trainees (at baseline, 7.1 ± 0.3%; at 6 months, 7.1 ± 1.1%) but increased in the comparison group (at baseline, 7.1 ± 0.5%; at 6 months, 7.3 ± 1.1%. P = .02 for between-group comparison). Self-reported self-care activities including diet adherence and foot care improved in the trainees but not the comparison group. After 4 years, HbA1c remained stable among the agreed trainees (at baseline, 7.0 ± 0.2%; at 4 years: 7.2 ± 0.6%), compared with increases in the refused trainees (at baseline, 7.1 ± 0.4%; at 4 years, 7.8 ± 0.8%) and comparison group (at baseline, 7.1 ± 0.5%; at 4 years, 8.1 ± 0.6%. P = .001 for between-group comparison).

CONCLUSIONS

Patients with diabetes who engaged in providing ongoing peer support to other patients with diabetes improved their self-care while maintaining glycemic control over 4 years.

Factors associated with knowledge of diabetes in patients with type 2 diabetes using the Diabetes Knowledge Test validated with Rasch analysis

OBJECTIVE

In patients with Type 2 diabetes, to determine the factors associated with diabetes knowledge, derived from Rasch analysis, and compare results with a traditional raw scoring method.

RESEARCH DESIGN & METHODS

Participants in this cross-sectional study underwent a comprehensive clinical and biochemical assessment. Diabetes knowledge (main outcome) was assessed using the Diabetes Knowledge Test (DKT) which was psychometrically validated using Rasch analysis. The relationship between diabetes knowledge and risk factors identified during univariate analyses was examined using multivariable linear regression. The results using raw and Rasch-transformed methods were descriptively compared.

RESULTS

181 patients (mean age±standard deviation = 66.97±9.17 years; 113 (62%) male) were included. Using Rasch-derived DKT scores, those with greater education (β = 1.14; CI: 0.25,2.04, p = 0.013); had seen an ophthalmologist (β = 1.65; CI: 0.63,2.66, p = 0.002), and spoke English at home (β = 1.37; CI: 0.43,2.31, p = 0.005) had significantly better diabetes knowledge than those with less education, had not seen an ophthalmologist and spoke a language other than English, respectively. Patients who were members of the National Diabetes Service Scheme (NDSS) and had seen a diabetes educator also had better diabetes knowledge than their counterparts. Higher HbA1c level was independently associated with worse diabetes knowledge. Using raw measures, access to an ophthalmologist and NDSS membership were not independently associated with diabetes knowledge.

CONCLUSIONS

Sociodemographic, clinical and service use factors were independently associated with diabetes knowledge based on both raw scores and Rasch-derived scores, which supports the implementation of targeted interventions to improve patients' knowledge. Choice of psychometric analytical method can affect study outcomes and should be considered during intervention development.

Diabetes conversation map in Nigeria: A new socioeducational tool in diabetes care

The importance of diabetes education in the management of patients is very crucial. One-on-one education, didactic group lectures are traditional methods employed in Diabetes Education. In our environment, group interaction using the Diabetes Conversation Map tools may prove to be effective especially during regular meetings of the Diabetes Association.

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

Background:

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

Materials and Methods:

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

Results:

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

Conclusions:

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

Influence of the duration of diabetes on the outcome of a diabetes self-management education program

BACKGROUND

Diabetes education and lifestyle modification are critical components in controlling blood glucose levels of people with type 2 diabetes. Until now, available data on the effectiveness of education with respect to the duration of diabetes are limited. We investigated whether adherence to lifestyle behavior modification prompted by diabetes education was influenced by the duration of diabetes.

METHODS

Two hundred and twenty-five people with type 2 diabetes were recruited for an intensive, collaborative, group-based diabetes education program with annual reinforcement. We divided the patients into two groups based on the duration of their diabetes prior to the education program (≤1 year [≤1Y] vs. ≥3 years [≥3Y]). Dietary habits, physical activity, and the frequency of blood glucose self-monitoring were evaluated with a questionnaire prior to education and at the follow-up endpoint.

RESULTS

The mean follow-up period was 32.2 months. The mean hemoglobin A1c (A1C) value was significantly lower in the ≤1Y group. Self-care behaviors, measured by scores for dietary habits (P=0.004) and physical activity (P<0.001), were higher at the endpoint in the ≤1Y group than in the ≥3Y group. Logistic regression analysis revealed that a longer diabetes duration before education was significantly associated with mean A1C levels greater than or equal to 7.0% (53 mmol/mol).

CONCLUSION

Diabetes duration influenced the effectiveness of diabetes education on lifestyle behavior modification and glycemic control. More-intense, regular, and sustained reinforcement with encouragement may be required for individuals with longstanding type 2 diabetes.

The effect of a diet education with six iso-caloric meals on the body weight and blood glucose of diabetes type 2 patients

The treatment of Diabetes should not only be sought through drug administration; diet is also a part of its treatment. The aim of this study was to determine the effect of a diet with six meals having equal calories on the body weight and blood glucose on diabetes type 2 patients. This research is an Experimental study conducted in 2009 on 181 patients with diabetes. The patients visited the IDSF (Iranian Diabetes Society of Fars) weekly and the patients to be studied were randomly divided into two groups of 85 and 96 patients, respectively. The participants were repeatedly requested to consume their calculated calorie in six equal parts. The average age in the Experimental and Control groups were 51.2 ± 13.3 and 53.1 ± 9.4, respectively. The mean body weight and fasting blood glucose at the beginning of the study in Experimental and Control groups were 66.3 ± 9.4 and 69.1 ± 11.1 kg, 198.9 ± 35.1, and 199.8 ± 39.1 mg.dL-1, respectively. At the end of the study, however, the values were 63.5 ± 7.5 and 66.98 ± 9 kg, 139.5 ± 34.6 and 164.2 ± 22.1 mg.dL-1, respectively. Only the mean fasting blood glucose at the end of the study revealed a significant difference (p-value = 0.001). The results show that educating those afflicted with Diabetes Type 2 aiming at changing their diet can greatly help them manage their blood glucose.

[Evaluation of the educational practices in promoting self-management in type 2 diabetes mellitus]

The objective of this is study to evaluate the educational practices in promoting the self-management of diabetes mellitus. Subjects were twenty-six individuals with type 2 diabetes, who participated in the educational program at a teaching hospital in Belo Horizonte, Minas Gerais. The subjects were followed for four months in 2008. The educational group practices consisted of three monthly meetings, in which recreational and interactive dynamics were performed, and individual sessions were held using dialogic education. The evaluation was performed using a specific questionnaire: self-care and clinical exams in the beginning and four months after the intervention. The mean age of the subjects was 60.9 ±8.4 years; the mean time of disease was 8.7±6.7 years; most (55.6% or 27 individuals) had incomplete primary education and a family income between 1 and 3 minimum salaries. Satisfactory results were found in the self-care test. It was also observed that HbA1c levels dropped down and the educational practices improved self-care and self-management of the disease.

Overcoming barriers to diabetes control in geriatrics

INTRODUCTION

Diabetes mellitus is approaching epidemic proportions in most countries and has captured the attention of physicians at local, national and global levels. The elderly population remains at a higher risk for diabetes mellitus (1), and the disease poses unique concerns for geriatricians, primary care physicians, nurses and specialised pharmacists who provide care to the elderly. Glycaemic control, geriatric-related syndromes and cardiovascular risk factors considerably affect the elderly patient's functional status and life expectancy (2). Geriatric syndromes may include polypharmacy, chronic pain, injurious falls, cognitive impairment, urinary incontinence and depression. Higher rates of premature death; functional disability; and chronic illnesses, such as hypertension, cerebrovascular accidents, dementia and coronary artery disease, often affect elderly diabetic patients.

DISCUSSION

Collaborative efforts are continually needed to allocate and maximise utilisation of resources to help empower older adults with diabetes to overcome barriers to disease management. Healthcare providers are increasingly challenged by the complexity of problems that face old patients, and must therefore be prepared to assess and treat diabetes mellitus within the milieu of many geriatric-related chronic illnesses. Healthcare providers must tailor individualised treatment methods, with the ultimate goal of not only achieving laboratory norms but also improving the quality of life for this vulnerable population.

CONCLUSION

There is a need for extra care and overcoming barriers to diabetes control in old patients as a dynamic and a continuous task that needs coordination of healthcare systems and professionals at all levels of care.

Information and communication technologies for better patient self-management and self-efficacy

Achieving benefits from the introduction of ICTs as part of processes aimed at building sustainable self-efficacy and self-management is very difficult, not least because of a desire to avoid simply replacing patient dependency on health professionals with dependency on technology. Chronic illnesses require ongoing attention that differs from traditional, encounter-based care for acute illnesses. Patients with chronic illnesses such as asthma, cardiovascular disease, depression, diabetes, heart failure and migraine headaches play a central role in managing the broad array of factors that contribute to their health. Individuals with diabetes, for example, provide close to 95% of their own care. Self-efficacy is enhanced when patients succeed in solving patient-identified problems. Patients with chronic conditions make day-to-day decisions about - self-manage - their illnesses. The paper highlights that in deploying ICTs, it is important to ensure that solutions implemented are based on a detailed understanding of users, their needs and complex interactions with health professionals, the health system and their wider environment.

Comparing the processes: accreditation and recognition

Diabetes education programs are developed to serve the diabetes community by offering quality education that meets a set of standards and is then eligible for third-party insurance reimbursement. Three organizations are authorized by the U.S. Centers for Medicare and Medicaid Services to determine whether diabetes education programs meet required standards. Each of the three relies on the 2007 edition of the National Standards for Diabetes Self-Management Education. This article summarizes similarities among and unique qualities of each of the organization's approaches to assuring quality.

Capacitação de profissionais da atenção primária à saúde para educação em Diabetes Mellitus

OBJETIVO: Apresentar o delineamento das oficinas educativas em Diabetes Mellitus e uma estratégia avaliativa voltada à atualização dos profissionais de saúde da atenção primária. MÉTODOS: As oficinas foram implementadas, utilizando metodologia participativa, técnicas lúdicas, vivências e dinâmicas de grupo, envolvendo a participação de 85 profissionais de saúde das Unidades Básicas de Saúde de Belo Horizonte/MG. Os conhecimentos sobre a doença e as competências requeridas para o autocuidado foram aferidos mediante a aplicação de instrumento especifico. As oficinas foram avaliadas com base em instrumento próprio. RESULTADOS: Foram observadas limitações no conhecimento dos profissionais centrados na fisiopatologia e nos exames complementares da doença. As oficinas contribuíram para o despertar do potencial reflexivo, crítico e criativo dos profissionais para a mudança no processo educativo. Foi considerada uma estratégia pedagógica, de fácil compreensão, interativa e lúdica. CONCLUSÕES: As oficinas contribuíram para o planejamento do processo educativo e a estruturação de um modelo de avaliação das práticas de promoção, da saúde e educação em Diabetes.

Educating Patients With Diabetes About Cardiovascular Disease Risk

In persons with diabetes mellitus, atherosclerosis is increased, develops prematurely, and is associated with an accelerated progression of atherosclerotic changes. More than 55% of deaths from diabetes are from cardiovascular disease. Central to the optimal management of diabetes and the prevention of chronic complications is effective patient education. The necessity of optimal glycemic control in the prevention of long-term diabetes-related complications, particularly microvascular disease, has been a primary focus of diabetes education during the past decade. It has become clear that to prevent cardiovascular disease in persons with diabetes, an increased emphasis on patient education aimed at reducing cardiovascular disease risk factors is essential. This review explores the scope, impact, and prevention of diabetes-related cardiovascular disease, focusing on integration of cardiovascular disease risk reduction during patient teaching and education programs.

A pilot study of diabetes education via telemedicine in a rural underserved community--opportunities and challenges: a continuous quality improvement process

PURPOSE

Telemedicine technology may offer an avenue to implement diabetes self-management education (DSME) for people with diabetes in underserved rural communities. The continuous quality improvement process was used to identify the problem, collect and analyze data, and develop and implement a DSME program via telemedicine (DSME-T) in an underserved rural community.

METHODS

A pilot study was conducted in 2006, implementing a DSME-T utilizing facilities at the University of Arkansas for Medical Sciences and a rural community hospital in Arkansas (Ozark Health, Inc). A total of 38 people were enrolled to receive DSME-T. Participant knowledge, self-efficacy, and self-care practices were assessed before participants began the education program and after they had completed it. Also, select clinical measures (glycosylated hemoglobin, lipid profile, and urine microalbumin) were collected.

RESULTS

A total of 66% of participants (n = 25) completed the DSME-T program. A significantly greater proportion of participants demonstrated improved knowledge (39% vs 83%; P = .012), endorsed greater self-efficacy (54% vs 86%; P = .016), and reported more frequent self-care practices to manage their diabetes at the conclusion of the study period.

CONCLUSIONS

The results of this pilot study suggest that DSME-T may offer opportunities for DSME among rural residents with diabetes. Plans are in place to explore the possibility of sustaining and expanding the program to other underserved rural communities.

Feasibility and acceptability of continuous glucose monitoring and accelerometer technology in exercising individuals with type 2 diabetes

AIMS AND OBJECTIVES

The aim of this study was to develop role model data for an intervention to motivate non-exercising individuals with type 2 diabetes mellitus to engage in regular physical activity. Toward that end, the study 1) described Continuous Glucose Monitoring System data and obtained role model CGMS graphs, 2) described a monitor to measure exercise amount and intensity and 3) explored participants' experiences of the monitors and perceptions of the glucose monitoring data.

BACKGROUND

Physical activity is a cornerstone of diabetes treatment yet the majority of individuals with diabetes are inactive. Thus, increasing physical activity in these individuals demands innovative interventions.

DESIGN

A two-phase, multi-method design was used.

METHODS

In phase 1, a descriptive design was used to describe physical activity patterns and glucose levels for 72 hours in nine exercising adults with type 2 diabetes. In phase 2, a focus group interview was used to collect data from seven phase-1 participants. Verbatim transcripts of the audio taped focus group were analysed for themes and trends.

RESULTS

The glucose monitor data captured lower glucose levels after exercise. Compared to formal diabetes education, visual data from the glucose monitoring technology were perceived as more relevant to participants' particular, everyday experiences with exercise, diet and stress. Participants reported a reinforced commitment to their exercise and diet regimens after using Continuous Glucose Monitoring System. Technology issues were identified, e.g. discomfort wearing activity monitors and forgetting to enter calibration and event data in glucose monitors.

RELEVANCE TO CLINICAL PRACTICE

Participants found that visual glucose monitoring data reinforced self-management behaviors, such as exercise. Our results suggest that data depicting the response of glucose levels to diet and exercise could be a useful tool to change behavior in individuals with type 2 diabetes.

A telecommunications intervention for frontier patients with diabetes

The purpose of this study was to determine whether a telecommunications diabetes self-management (DSM) intervention would improve health-related outcomes among frontier participants with diabetes. A one-group pre-test/post-test quasi-experimental design with two groups of participants was used. Differences between pre and post-test periods on measures of physical and emotional health, knowledge of diabetes, and self-care behaviors were measured. Overall, participants did better along measures of blood pressure, HbA(1c), self-efficacy, knowledge of diabetes, understanding of DSM, monitoring behaviors, and reported less personal and social disruption from diabetes. Six-month follow-up results showed continued positive outcomes.

Analysis of the 2004-2007 literature on therapeutic patient education in diabetes: results and trends

The purpose of this study is to identify the recent characteristics and the developments of therapeutic education in diabetes through an analysis of the international articles published from 2004 to 2007. Studies were selected from several databases: Medline, Embase, Eric, Cochrane central database, using the following keywords: diabetes, patient education, self management, programs. Two authors independently reviewed each study and selected the data using the same categories of analysis. Articles consistently related to patient education in diabetes (80 among 118) were included. The selected articles have been published in 43 scientific journals. The majority of them concern TPE for adult patients with type 2 diabetes. TPE is delivered in several structures and education to groups of patients represents the most widespread educational strategy mostly provided by a multiprofessional team. A total of 70% of the studies show the effectiveness of TPE based on bioclinical, educational, psychosocial, economical criteria. The problem of barriers to TPE concerns 21% of the studies we have analysed and most of the authors propose the implementation of specifically-designed TPE programs as strategy to overcome them. A large number of studies still assess the positive effects of TPE. Nowadays the problems of accessibility to TPE and the barriers to this practice have become a major issue for research.

Adaptation and testing of instruments to measure diabetes self-management in people with type 2 diabetes in mainland China

PURPOSE

The purpose of this study was to test the psychometric properties of instruments used to measure diabetes self-management (DSM) that were modified and translated into Chinese.

METHOD

A convenience sample of 30 people with type 2 diabetes in Beijing, China, completed a questionnaire consisting of six instruments that had been translated and modified for use with a Chinese population. The reliability and validity were examined.

RESULTS

The Cronbach's alpha for the six instruments varied from .62 to .87. Factors analysis was performed, with variances explained by factors ranging from 61.6% to 97.9%.

CONCLUSIONS

The findings of the psychometric testing of the modified and translated instruments support the use of these tools to assess DSM and its influencing factors in Chinese people with type 2 diabetes.

Diabetes self-management education: a review of published studies

Diabetes self-management is seen as the cornerstone of care for all individuals with diabetes who want to achieve successful health-related outcomes and is considered most effective when delivered by a multidisciplinary team with a comprehensive plan of care. There is a growing body of literature on both educational and psychosocial interventions, aimed at helping individuals to better manage their diabetes. However, the progress of this research and its implications for clinical practice remain unclear and sometimes controversial. This paper therefore aims to further clarify this literature by considering published evidence for the effectiveness of self-management education, including community-based peer support groups and ongoing home telephone support.

Patient and provider perceptions of diabetes: measuring and evaluating differences

OBJECTIVE

This study measures diabetes care perceptions of patients and their providers, and examines perceptions differences of patient-provider pairs.

METHODS

Patient and provider perceptions were assessed using the Diabetes Semantic Differential Scales (DSDS) which ask respondents to rate diabetes care concepts using contrasting adjective pairs. The DSDS was scored by two methods: using means and using factor analysis. Persons with diabetes 40-years-old or older were recruited. Using a "snowball" sampling strategy, potential provider participants were identified by their patients; 71 providers agreed. These providers represented 51% of the patient participants and created 138 patient-provider pairs.

RESULTS

For the mean scores, there were significant differences between patients and providers for 5 of the 18 semantic differentials (28%). Similarly, the factor scores indicated significant differences for 14 of 54 factors (26%). The effect sizes indicated practical differences.

CONCLUSION

Significant differences exist between patient and provider perceptions. Generally, patients have the more positive diabetes perceptions.

PRACTICE IMPLICATIONS

During patient and provider discussions, participants can perceive diabetes concepts differently. The DSDS can determine perception differences. While it is best to use factor analyses to score the DSDS, mean scores are more easily calculated and indicate the broad conceptual areas where patient and provider differ.

Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems

OBJECTIVE

We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support.

METHODS

Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (response rate 47%) recruited from four urban US public hospital systems. In multivariate models, we measured the association of race/ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients' interest in three self-management support strategies (telephone support, group medical visits, and Internet-based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance.

RESULTS

Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in Internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95% CI 1.97-6.05) and group medical visits (OR 2.45, 95% CI 1.49-4.02), but less interested in Internet self-management support (OR 0.56, 95% CI 0.33-0.93). African-Americans were more interested than Whites in all three self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences.

CONCLUSION

Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy.

PRACTICE IMPLICATIONS

Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.

Assessment of health-related quality of life (HRQoL) of patients with type 2 diabetes in Turkey

We measured the health-related quality of life (HRQoL) in a sample of 376 type 2 diabetes patients in Turkey using the Diabetes Quality of Life (DQOL) instrument and examined which patient socio-demographic and diabetes-related clinical characteristics are associated with better quality of life (QoL). The influence of patient socio-demographic and clinical characteristics on QoL was examined using independent sample t-tests and one-way analysis of variance. Diabetes significantly affected the HRQoL of patients included in this study. The mean score of the total DQOL measure was higher among patients who were less than 40 years of age, male, married, had less than 8 years of education, lived with their family and had no family history of diabetes (p<0.05). Similarly, patients with less than 5 years of disease duration, no complications or prior hospitalization, receive insulin, and with HbA(1)c<7 reported significantly better overall HRQoL (p<0.05). Patients with BMI<24 had higher levels of satisfaction with diabetes than those with BMI>or=24 (p<0.05). Diabetes-related HRQoL information is clearly of supreme importance to family physicians and policy makers to identify and implement appropriate interventions for achieving better management of diabetes and ultimately improving the QoL of diabetes patients.

Prerequisites for age-appropriate education in type 1 diabetes: a model programme for paediatric diabetes education in Germany

Continuous diabetes education for children, adolescents and their parents are widely accepted as an integral part of every type 1 diabetes therapy. Especially in paediatric diabetes care age-appropriate, demand-oriented and individualized practical information and skills training are mandatory for achieving good metabolic control and psychosocial well-being. A paediatric multidisciplinary diabetes team experienced in an intensified insulin therapy with a differential substitution of prandial and basal insulin needs (MDI or CSII) and in child psychology is required to initiate and maintain lifelong diabetes self-management. In Germany an education programme for children aged 6-12 years and another programme for adolescents and young adults have previously been evaluated in multicenter studies. Programmes were considered with respect to applicability, acceptance by target groups and efficacy (knowledge, competence, quality of life and glycaemic control). Furthermore, a programme specifically designed for parents of children affected was evaluated. Contents, modular structures, developmental psychological background and didactic concepts of all above mentioned programmes are presented in detail. Apart from teaching insulin therapy according to current guidelines special emphasis is laid on translating this knowledge into everyday self-management behaviour. In addition, emotional coping with the chronic disease and its psychosocial consequences is supported. In the context of the Disease-Management-Program for Type 1 Diabetes in Germany these programmes for young people were certified and reimbursed nationwide by health insurances.

The missing link: improving quality with a chronic disease management intervention for the primary care office

Bold steps are necessary to improve quality of care for patients with chronic diseases and increase satisfaction of both primary care physicians and patients. Office-based chronic disease management (CDM) workers can achieve these objectives by offering self-management support, maintaining disease registries, and monitoring compliance from the point of care. CDM workers can provide the missing link by connecting patients, primary care physicans, and CDM services sponsored by health plans or in the community. CDM workers should be supported financially by Medicare, Medicaid, and commercial health plans through reimbursements to physicians for units of service, analogous to California's Comprehensive Perinatal Services Program. Care provided by CDM workers should be standardized, and training requirements should be sufficiently flexible to ensure wide dissemination. CDM workers can potentially improve quality while reducing costs for preventable hospitalizations and emergency department visits, but evaluation at multiple levels is recommended.

Incidence of lipohypertrophy in diabetic patients and a study of influencing factors

This study examines the incidence of lipohypertrophy in diabetic individuals as well as the factors that have an influence on causing this condition. In consideration of the period of development of lipohypertrophy, the research sampling consisted of 215 diabetics who had been using insulin for at least 2 years. Observation and palpation techniques were used in assessing lipohypertrophy in these diabetics. Data were evaluated using percentages, chi(2) and logistic regression analysis. Results of the study established lipohypertrophy in 48.8% of the individuals comprising the sampling. It was seen that the incidence of lipohypertrophy in these individuals was affected by their level of education, the frequency that they changed needles, the frequency of changing their injection sites and the amount of time they had been using insulin, the difference proving to be statistically significant (p<0.05). In the logistic regression analysis, it was found that the amount of time insulin had been used (p=0.001), the frequency of changing injection sites (p=0.004) and the frequency of changing needles (p=0.004) had an influence on the development of lipohypertrophy. These results show that the amount of time insulin is used and the procedure for injection both affect the development of lipohypertrophy.

Seeing in 3-D: examining the reach of diabetes self-management support strategies in a public health care system

The authors examined whether tailored self-management support (SMS) strategies reach patients in a safety net system and explored variation by language, literacy, and insurance. English-, Spanish-, and Cantonese-speaking diabetes patients were randomized to weekly automated telephone disease management (ATDM) or monthly group medical visits. The SMS programs employ distinct communication methods but share common objectives, including behavioral "action plans." Reach was measured using three complementary dimensions: (a) participation among clinics, clinicians, and patients; (b) patient representativeness; and (c) patient engagement with SMS. Participation rates were high across all levels and preferentially attracted Spanish-language speakers, uninsured, and Medicaid recipients. Although both programs engaged a significant proportion in action planning, ATDM yielded higher engagement, especially among those with limited English proficiency and limited literacy. These results provide important insights for health communication and translational research with respect to realizing the public health benefits of SMS and can inform system-level planning to reduce health disparities.

Translation, cultural adaptation, cross-validation of the Turkish diabetes quality-of-life (DQOL) measure

OBJECTIVE

The aim of this study was to test the validity and reliability of the Turkish version of the diabetes quality of life (DQOL) questionnaire for use with patients with diabetes.

METHODS

Turkish version of the generic quality of life (QoL) scale 15D and DQOL, socio-demographics and clinical parameter characteristics were administered to 150 patients with type 2 diabetes. Study participants were randomly sampled from the Endocrinology and Diabetes Outpatient Department of Dr. Lutfi Kirdar Kartal Education and Research Hospital in Istanbul, Turkey.

RESULTS

The Cronbach alpha coefficient of the overall DQOL scale was 0.89; the Cronbach alpha coefficient ranged from 0.80 to 0.94 for subscales. Distress, discomfort and its symptoms, depression, mobility, usual activities, and vitality on the 15 D scale had statistically significant correlations with social/vocational worry and diabetes-related worry on the DQOL scale indicating good convergent validity. Factor analysis identified four subscales: satisfaction", impact", "diabetes-related worry", and "social/vocational worry".

CONCLUSION

Statistical analyses showed that the Turkish version of the DQOL is a valid and reliable instrument to measure disease related QoL in patients with diabetes. It is a simple and quick screening tool with about 15 +/- 5.8 min administration time for measuring QoL in this population.