Innovative Diabetes Interventions in the U.S. Hispanic Population

Randomized trial of an integrated care intervention among Latino adults: Sustained effects on diabetes management

We examined the 12-month maintenance effects of a previously successful integrated model of diabetes care at improving glycemic management and psychological well-being among Latino adults with type 2 diabetes (T2D). A randomized controlled trial (2015-19) compared an integrated care intervention (ICI) with usual care among 456 adults with T2D. The ICI included integrated medical and behavioral care and health education over 6 months. Assessments were completed at baseline, 3, 6, 9, and 12 months. Most participants were female (63.7%) with a mean age of 55.7 years. In multilevel models, significant Group × Time (quadratic) interaction effects were found for HbA1c [Bint = 0.10, 95% confidence interval (CI) 0.02, 0.17, P < .01] and anxiety symptoms (Bint = 0.20, 95% CI 0.05, 0.35, P < .009), but not depression symptoms (Bint = 0.15, 95% CI -0.01, 0.31, P < .07). Analyses of instantaneous rate of change in the ICI group showed significant decreases at 3 and 6 months for both HbAc1 (B = -0.31 at 3 months; B = -0.12 at 6 months) and anxiety symptoms (B = -0.92 at 3 months; B = -0.46 at 6 months), and no significant instantaneous changes at 9 or 12 months, suggesting that initial improvements were largely maintained. The usual care group showed a small decrease in anxiety symptoms at 6 months (B = -0.17), but no other significant changes at any time-point for anxiety or HbA1c (all Ps > .05). This culturally tailored integrated care model shows potential in producing and sustaining positive effects on clinical and psychological outcomes above standard care.

Glycemic and Cost Outcomes among Hispanic/Latino People with Type 2 Diabetes in the USA Initiating Dulaglutide versus Basal Insulin: a Real-World Study

INTRODUCTION

Optimal glycemic management after diabetes onset remains a challenge in Hispanic/Latino adults with type 2 diabetes (T2D), often resulting in poor health outcomes and higher rates of diabetes-related complications. The aim of this study was to examine and compare demographic and clinical characteristics, glycemic outcomes, health care resource utilization (HCRU), and costs among injection-naïve Hispanic/Latino adults with T2D initiating dulaglutide or basal insulin.

METHODS

This retrospective, observational study used administrative claims data from the Optum Research Database. Hispanic/Latino adults with T2D were assigned to dulaglutide or basal insulin cohorts on the basis of pharmacy claims and were propensity-score matched on demographic and baseline characteristics. Measures of glycemic management included 12 month follow-up glycated hemoglobin (HbA1c) and change in HbA1c from baseline. Follow-up all-cause and diabetes-related HCRU and costs, including costs per 1% change in HbA1c, were compared between cohorts.

RESULTS

The final propensity-score matched sample included 2872 patients: 1436 patients in each cohort. Mean (SD) reduction in HbA1c from baseline to 12 month follow-up was greater in the dulaglutide cohort compared with the basal insulin cohort [-1.40% (1.88) versus -0.92% (2.07); p < 0.001]. The dulaglutide cohort had significantly lower proportions of patients with ≥ 1 all-cause and diabetes-related outpatient visits, emergency room visits, and inpatient stays compared with the basal insulin cohort (p < 0.05). The dulaglutide cohort had significantly lower all-cause total costs per 1% HbA1c reduction than the basal insulin cohort ($13,768 versus $19,128; p < 0.001). Diabetes-related costs per 1% reduction were numerically lower for the dulaglutide cohort, but the difference was not statistically significant ($9737 versus $11,403; p = 0.081).

CONCLUSIONS

Dulaglutide demonstrated better glycemic outcomes and lower all-cause costs per 1% HbA1c reduction among Hispanic/Latino adults compared with those initiating basal insulin. Our real-world findings in the Hispanic/Latino population were consistent with results obtained from the overall population and confirm the glycemic benefits of dulaglutide observed in clinical settings.

Ensuring fidelity: key elements to consider in disseminating a diabetes telemanagement program for underserved Hispanic/Latinos living with type 2 diabetes

Background

The Hispanic/Latino population has greater risk (estimated >50%) of developing type 2 diabetes (T2D) and developing it at a younger age. The American Diabetes Association estimates costs of diagnosed diabetes in 2017 was $327 billion; with medical costs 2.3x higher than patients without diabetes. The purpose of this manuscript is to describe the methodology utilized in a randomized controlled trial aimed at evaluating the efficacy of a diabetes telemanagement (DTM) program for Hispanic/Latino patients with T2D. The intent is to provide information for future investigators to ensure that this study can be accurately replicated.

Methods

This study was a randomized controlled trial with 240 participants. Eligible patients (Hispanic/Latino, aged 18+, living with T2D) were randomized to Comprehensive Outpatient Management (COM) or DTM. DTM was comprised of usual care, including routine clinic visits every three months, as well as: Biometrics (a tablet, blood glucose meter, blood pressure monitor, and scale); Weekly Video Visits (facilitated in the patient's preferred language); and Educational Videos (including culturally congruent diabetes self-management education and quizzes). COM consisted of usual care including routine clinic visits every three months. For this study, COM patients received a glucometer, glucose test strips, and lancets. Establishing a therapeutic nurse-patient relationship was a fundamental component of our study for both groups. First contact (post-enrollment) centered on ensuring that patients and caregivers understood the program, building trust and rapport, creating a non-judgmental environment, determining language preference, and establishing scheduling availability (including evenings and weekends). DTM were provided with a tablet which allowed for self-paced education through videos and weekly video visits. The research team and Community Advisory Board identified appropriate educational video content, which was incorporated in diabetes educational topics. Video visits allowed us to assess patient involvement, motivation, and nonverbal communication. Communicating in Spanish, and awareness of diverse Hispanic/Latino backgrounds was critical, as using relevant and commonly-used terms can increase adherence and improve outcomes. Shared decision-making was encouraged to make realistic health care choices.

Conclusion

Key elements discussed above provide a framework for future dissemination of an evidence-based DTM intervention to meet the needs of underserved Hispanic/Latino people living with T2D.

Brief peer coaching complements daily digital messages for chronic disease prevention among young adult Latinas

Young Latinas face multiple health challenges that place them at high risk for chronic diseases. Digital health promotion interventions can offer education and support to activate self-care and preventive behaviors. This pilot study evaluated a brief, theory-informed, culturally tailored intervention, Examen Tu Salud, that provided daily text and multimedia messages and weekly peer coaching via videoconference to improve health behaviors among young adult Latina women. Thirty-four participants who self-identified as Latina, female, and 18-29 years old were recruited from an urban college in Northern California to participate in a brief pilot test of the new intervention. Paired sample T-tests assessed health behavior and health activation changes from baseline to 1 month follow-up. Program participation and satisfaction were analyzed to assess feasibility of the intervention. Among 31 participants (91% completion), there were medium to large improvements in health outcomes. Confidence in preventing and managing one's health (t[30] = 5.18, p < .001, d = 0.93), days of moderate-intensity physical activity (t[30] = 3.50, p < .001, d = 0.63), and fruit (t[30] = 3.32, p = .001, d = 0.60) and vegetable (t[30] = 2.04, p = .025, d = 0.37) consumption in a typical day increased. Intervention satisfaction and engagement with health coaches was high. We found that a brief digital coaching intervention designed for young adult Latinas has the potential to improve health activation and behaviors. More attention is needed to prevent chronic conditions among a growing number of Latinos in the USA.

The STAR-MAMA RCT: Bilingual Mobile Health Coaching for Postpartum Weight Loss

INTRODUCTION

Gestational diabetes and overweight during pregnancy are associated with future type 2 diabetes. Postpartum weight loss can reduce diabetes risk. However, effective interventions for postpartum weight loss are lacking, in particular for Latina populations, despite their disproportionate burdens of gestational diabetes, overweight, and diabetes.

STUDY DESIGN

This was a community-based RCT.

SETTING/PARTICIPANTS

Researchers recruited pregnant individuals with gestational diabetes or BMI>25 kg/m2 from safety-net health care settings and Women, Infants, and Children offices in Northern California in 2014-2018. Of 180 individuals randomized to intervention (n=89) or control (n=91), 78% identified as Latina, 61% were primarily Spanish speaking, and 76% perceived their diabetes risk to be low.

INTERVENTION

The intervention consisted of a 5-month postpartum telephone-based health coaching intervention delivered in English or Spanish.

MAIN OUTCOME MEASURES

Data were collected through surveys at enrollment and 9-12 months after delivery and chart review up to 12 months after delivery. The primary outcome, weight change from prepregnancy to 9-12 months after delivery, was compared between the groups, overall and within strata defined a priori according to language (Spanish or English) and diabetes risk perception (none/slight or moderate/high).

RESULTS

The intent-to-treat estimated intervention effect was +0.7 kg (95% CI= -2.4 kg, +3.8 kg; p=0.67). In stratified analyses, intervention effects remained nonsignificant but varied in direction: effects were favorable among English speakers and those with higher perceived diabetes risk, and unfavorable among Spanish speakers and those with lower perceived risk. Analyses were conducted in 2021-2022.

CONCLUSIONS

A postpartum health coaching intervention, designed for low-income Latina women at increased risk for diabetes, did not reduce postpartum weight gain. Intervention effects were nonsignificantly more favorable among English speakers versus Spanish speakers, and among those who perceived their diabetes risk to be high versus low.

TRIAL REGISTRATION

This study is registered at www.

CLINICALTRIALS

gov NCT02240420.

COVID-19 stressors for Hispanic/Latino patients living with type 2 diabetes: a qualitative study

Background and aim

During the early stages of the COVID-19 pandemic, nationwide lockdowns caused disruption in the diets, physical activities, and lifestyles of patients with type 2 diabetes. Previous reports on the possible association between race/ethnicity, COVID-19, and mortality have shown that Hispanic/Latino patients with type 2 diabetes who are socioeconomically disadvantaged are disproportionately affected by this novel virus. The aim of this study was to explore stressors associated with changes in diabetes self-management behaviors. Our goal was to highlight the health disparities in these vulnerable racial/ethnic minority communities and underscore the need for effective interventions.

Methods and participants

Participants were enrolled in part of a larger randomized controlled trial to compare diabetes telehealth management (DTM) with comprehensive outpatient management (COM) in terms of critical patient-centered outcomes among Hispanic/Latino patients with type 2 diabetes. We conducted a thematic analysis using patient notes collected from two research nurses between March 2020 and March 2021. Two authors read through the transcripts independently to identify overarching themes. Once the themes had been identified, both authors convened to compare themes and ensure that similar themes were identified within the transcripts. Any discrepancies were discussed by the larger study team until a consensus was reached.

Results

Six themes emerged, each of which can be categorized as either a source or an outcome of stress. Sources of stress associated with the COVID-19 pandemic were (1) fear of contracting COVID-19, (2) disruptions from lockdowns, and (3) financial stressors (e.g., loss of income). Outcomes of COVID-19 stressors were (1) reduced diabetes management (e.g., reduced diabetes monitoring and physical activity), (2) suboptimal mental health outcomes (e.g., anxiety and depression), and (3) outcomes of financial stressors.

Conclusion

The findings indicated that underserved Hispanic/Latino patients with type 2 diabetes encountered a number of stressors that led to the deterioration of diabetes self-management behaviors during the pandemic.

Investigating Racial and Ethnic Differences in Diabetes Self-Management Education Among Adults With Diabetes

PURPOSE

The purpose of this study was to examine racial and ethnic differences in diabetes self-management education (DSME) participation among adults with diabetes.

METHODS

Population-based, cross-sectional data from the 2020 Behavioral Risk Factor Surveillance System diabetes module were analyzed. Study cohort included 9881 adults age 18 years or older with self-reported diabetes living in 11 US states, Washington, DC, and Puerto Rico. The outcome variable was participation in DSME. Weighted descriptive statistics and multivariable logistic regression were computed to investigate the association between race and ethnicity and participation in DSME, adjusting for self-reported social determinants of health factors (eg, sex, education, employment, health insurance).

RESULTS

Overall, 19.3% self-identified as non-Hispanic Black, 16.5% as Hispanic, and 59.9% as non-Hispanic White. Of participants, 44.3% were between 66 and 80 years old, and 50.4% were women. Half (50.1%) reported participating in DSME, and 78.5% had seen clinicians for diabetes-related care 1 to 5 times in the past year. Hispanic participants were less likely to report participation in DSME (28.5%) compared to non-Hispanic Black (60.3%) and non-Hispanic White (53.4%) participants (P < .001). Adults with diabetes who were less likely to participate in DSME tend to be unmarried, have high school or lower-level education, and not exercise regularly.

CONCLUSIONS

Racial and ethnic differences exist in DSME participation. Because DSME has been shown to improve diabetes outcomes, there is a need to develop strategies promoting equity in DSME participation, particularly among Hispanic populations, to reduce health disparities in diabetes care.

Programa de diabetes: improving diabetes care for undocumented immigrants using the Chronic Care Model at a free community clinic

AIMS

This study examined whether the Chronic Care Model can be successfully applied to improve health outcome measures for uninsured, undocumented immigrants with diabetes at a free, non-federally funded community clinic.

METHODS

Data were collected from 128 uninsured, undocumented immigrants enrolled in Programa de diabetes, a comprehensive diabetes program at People's Health Clinic based on the six core elements of the Chronic Care Model. All study participants self-identified by the Hispanic ethnicity. A longitudinal study design was used to compare baseline diabetic health measures with outcome data after patient program participation over a 12-month enrollment period. Linear mixed effect model was used to determine the patient specific change in HbA1C across time, controlling for gender, age, food insecurity, income level, diabetes type, and literacy. In addition, McNemar tests were conducted to compare the coverage of eye exams and statin use before and after program enrollment.

RESULTS

After program enrollment, individual specific change in HbA1C was expected to be - 0.201 [95% CI 0.244, - 0.158] % per month after controlling for baseline covariates. There were statistically significant improvements in both eye exam coverage (p < 0.01) and statin use (p < 0.01).

CONCLUSIONS

The Chronic Care Model can be successfully applied to improve health outcome measures at a free, non-federally funded community clinic among uninsured, undocumented immigrants, who identify by the Hispanic ethnicity and have the diagnosis of diabetes. Barriers to care including food insecurity, federal poverty level and illiteracy do not preclude glycemic control.

Prevalence and management of type 2 diabetes among Chinese Americans

AIMS

: This study examines: (a) the prevalence rate of type 2 diabetes mellitus (T2DM) in Chinese Americans (CAs); (b) the influence of acculturative status (i.e. generational status and linguistic fluency) on T2DM prevalence; (c) and differences in diabetes management between CAs and Non-Hispanic Whites (NHWs).

METHODS

: We used 2011-2018 data from the California Health Interview Survey (CHIS) to analyze the prevalence rate and management of diabetes among the CAs. Chi-squares, linear regressions, and logistic regressions were used to analyze the data.

RESULTS

: After controlling for demographic, socioeconomic, and health behaviors, there were no significant differences in the T2DM prevalence rate between CAs overall or of varying acculturative statuses compared with NHWs. However, there were differences in diabetes management, with first-generation CAs being less likely to exam glucose daily, have medical care plans developed by medical providers, or have confidence in controlling diabetes compared to NHWs. CAs with limited English proficiency (LEP) were less likely to perform self-monitoring of blood glucose or have confidence in managing their diabetes care compared to NHWs. Finally, non-first generation CAs were also more likely to take diabetes medication compared to NHWs.

CONCLUSIONS

: Although the prevalence rate of T2DM was found to be similar between CAs and NHWs, significant differences were found in diabetes care and management. Specifically, those who were less acculturated (e.g. first generation and those with LEP) were less likely to actively manage and have confidence in managing their T2DM. These results highlight the importance of targeting immigrants with LEP in prevention and intervention efforts.

Obesity among Latinx people in the United States: A review

Obesity is a serious, chronic disease that is associated with a range of adiposity-based comorbidities, including cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease. In the United States, obesity is a public health crisis, affecting more than 40% of the population. Obesity disproportionately affects Latinx people, who have a higher prevalence of obesity and related comorbidities (such as cardiovascular disease, type 2 diabetes, and nonalcoholic fatty liver disease) compared with the general population. Many factors, including genetic predisposition, environmental factors, traditional calorie-dense Latinx diets, family dynamics, and differences in socioeconomic status, contribute to the increased prevalence and complexity of treating obesity in the Latinx population. Additionally, significant heterogeneity within the Latinx population and disparities in health care access and utilization between Latinx people and the general population add to the challenge of obesity management. Culturally tailored interventions have been successful for managing obesity and related comorbidities in Latinx people. Antiobesity medications and bariatric surgery are also important options for obesity treatment in Latinx people. As highlighted in this review, when managing obesity in the Latinx population, it is critical to consider the impact of genetic, dietary, cultural, and socioeconomic factors, in order to implement an individualized treatment strategy.

Design and Implementation of a Culturally-Tailored Randomized Pilot Trial: Puerto Rican Optimized Mediterranean-Like Diet

Background

Adhering to a Mediterranean Diet (MedDiet) is associated with a healthier cardiometabolic profile. However, there are limited studies on the MedDiet benefits for non-Mediterranean racial/ethnic minorities, for whom this diet may be unfamiliar and inaccessible and who have a high risk of chronic diseases.

Objectives

To describe the study design of a pilot trial testing the efficacy of a MedDiet-like tailored to adults in Puerto Rico (PR).

Methods

The Puerto Rican Optimized Mediterranean-like Diet (PROMED) was a single-site 4-mo parallel two-arm randomized pilot trial among a projected 50 free-living adults (25-65 y) living in PR with at least two cardiometabolic risk factors (clinicaltrials.gov registration #NCT03975556). The intervention group received 1 individual nutritional counseling session on a portion-control culturally-tailored MedDiet. Daily text messages reinforced the counseling content for 2 mo, and we supplied legumes and vegetable oils. Participants in the control group received cooking utensils and one standard portion-control nutritional counseling session that was reinforced with daily texts for 2 mo. Text messages for each group were repeated for two more months. Outcome measures were assessed at baseline, 2 and 4 m. The primary outcome was a composite cardiometabolic improvement score; secondary outcomes included individual cardiometabolic factors; dietary intake, behaviors, and satisfaction; psychosocial factors; and the gut microbiome.

Results

PROMED was designed to be culturally appropriate, acceptable, accessible, and feasible for adults in PR. Strengths of the study include applying deep-structure cultural components, easing structural barriers, and representing a real-life setting. Limitations include difficulty with blinding and with monitoring adherence, and reduced timing and sample size. The COVID-19 pandemic influenced implementation, warranting replication.

Conclusions

If PROMED is proven efficacious in improving cardiometabolic health and diet quality, the findings would strengthen the evidence on the healthfulness of a culturally-appropriate MedDiet and support its wider implementation in clinical and population-wide disease-prevention programs.

Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus Disparities

This is one of a series of articles that focuses on maximizing access to total joint arthroplasty by providing preoperative optimization pathways to all patients to promote the best results and minimize postoperative complications. Because of inequities in health care, an optimization process that is not equipped to support the underserved can potentially worsen disparities in the utilization of arthroplasty. A staggering 10.5% of the American population lives with diabetes mellitus. Diabetes prevalence is 17% higher in rural communities compared with urban communities. Rates of diabetes are higher in African American, Hispanic, and American Indian populations. Barriers to health care are higher in rural areas and for vulnerable communities, positioning the management of diabetes at the intersection of risk. Poor glycemic control is a predictor of periprosthetic joint infection. Optimization tools include assessing for food security, knowledge of a social safety net and community resources, patient diabetic literacy, and relationships with primary care providers to ensure continuous check-ins as well as partnering with specialty endocrine diabetic clinics. Several strategic recommendations, such as healthcare navigators and promotores (Latinx population), are made to enable and empower, such as continuous glucose monitoring, the preoperative patient to reach a safe preoperative optimization goal for their TJA surgery.

Diabetes self-care activities and perception and glycemic control in adult Puerto Rican residents with Type 2 Diabetes: The LLIPDS Study

Background

Individuals with diabetes frequently have comorbid health conditions and suffer longer term complications. The control of blood glucose relies on diabetes management/self-care behaviors. Poor glycemic control, commonly encountered in underserved populations with type 2 diabetes (T2D) often results from inadequate diabetes self-care activities and/or perception. We aimed to assess the association between diabetes self-care activities/perception and glycemic control in adult Puerto Rican residents with T2D.

Design and methods

We used a cross-sectional study design; our sample population was 260 individuals aged 40-65 years with T2D. We asked participants about their diabetes self-care over 8 weeks. High fasting blood glucose (≥130 mg/dL) and glycated hemoglobin (HbA1c; ≥7%) measures were defined. We estimated the strength of the following associations using logistic regression: each of three self-care activities and fasting glucose or HbA1c, adjusting for confounders.

Results

Nearly 27% of the participants reported not checking their glucose levels, 7% did not take their medications as prescribed and 31% perceived their diabetes self-care as poor. Participants with less education perceived their diabetes self-care as poor more often than their counterparts (44% vs 25%; p = 0.003). Most participants had high glycemic levels (60%) or hbA1c levels (65%). Participants who perceived their diabetes self-care as poor had higher HbA1c levels than their counterparts (adj. odds ratio: 2.14, 95% CI (1.13, 4.08)).

Conclusion

Poor diabetes self-care perception, possibly related to less education, likely explains poor glycemic control among adult Puerto Rican residents with T2D.

Technological Proficiencies, Engagement, and Practical Considerations for mHealth Programs at an Urban Safety-Net Hospital Emergency Departments: Data Analysis

Background

Safety-net emergency departments often serve as the primary entry point for medical care for low income predominantly minority patient populations. Herein, we sought to provide insight into the feasibility, technological proficiencies, engagement characteristics, and practical considerations for a mHealth intervention at a safety-net emergency department.

Objective

We aimed to analyze patient technological proficiency to understand the feasibility of and draw practical considerations for mobile phone technology (mHealth) solutions for patients with chronic disease served by safety-net emergency departments.

Methods

We analyzed data from a previous diabetes randomized clinical mHealth trial for a diabetes social support intervention. Patients from a safety-net emergency department with preexisting diabetes who used SMS text messages, owned a mobile phone, and with hemoglobin A_1c levels >8.5% were enrolled. A text message–based mHealth program to improve disease self-management was provided to all patients. Supporters of patients were randomized to receive a mailed copy or mHealth-based curriculum designed to improve diabetes support. Among enrolled patients, we surveyed mobile technological capacity and frequency of use. We performed latent class analysis to identify classes of patients by level of technological proficiency and compared demographic characteristics between the latent classes to identify demographic subgroups that may require more training or tailoring of the mHealth approach. Study engagement between classes was assessed by comparing the mean number of text messages exchanged, loss to follow-up, and early termination.

Results

Of 1876 patients who were approached, 44.2% (n=829) of patients had a stable mobile phone and were able to use text messages. Among them 166 met the trial inclusion and enrolled, 90% (149/166) of the cohort were ethnically diverse. Significant variance was found in technology capacity and frequency of use. Our latent class analysis classified 75% (124/166) of patients as highly technologically proficient and 25% (42/166) patients as minimally technologically proficient. Age (P<.001) and level of education (P<.001) were associated with class membership. Highly technologically proficient patients were younger and had higher levels of education (45.74 years old; high school or more: 90%) than minimally technologically proficient patients (53.64 years old; high school or more: 18%). Highly technologically proficient participants exchanged a mean of 40 text messages with the system coordinators compared to a mean of 10 text messages by minimally technologically proficient patients (P<.001).

Conclusions

This study found that nearly half of the patients screened at the safety-net emergency department were equipped for an SMS text message–based mHealth intervention. In the small sample of patients who were enrolled, the majority were classified as highly technologically proficient. These highly proficient patients had greater study engagement. mHealth use in emergency departments may be an opportunity to improve health of ethnically diverse populations by pairing sophisticated chronic disease self-management program with SMS text message–based and traditional in-person interventions to reach patients through the method that is most familiar and comfortable.

International Registered Report Identifier (IRRID)

RR2-10.1016/j.cct.2019.03.003

Maximizing diabetes education efforts in vulnerable populations - newer delivery concepts

PURPOSE OF REVIEW

Patients from ethnic/minority backgrounds or low socioeconomic status face numerous barriers to achieving ideal diabetes care goals. The purpose of this review is to describe the burden of diabetes in vulnerable populations; discuss the etiologic factors leading to health disparities in diabetes; and present challenges and solutions to improving diabetes care through novel diabetes self-management education and support interventions.

RECENT FINDINGS

Recent interventions to alleviate health disparities utilize a combination of community health workers, peer leaders and technology-based approaches to provide diabetes self-management education and support and overcome barriers to diabetes control such as low literacy, difficulty with transportation, and cultural beliefs. These interventions achieve clinically meaningful improvements in blood glucose control as measured by haemoglobin A1C and are effective in addressing psychosocial outcomes such as diabetes distress. Research is underway to address food insecurity through food delivery and use behavioural economics principles to provide financial incentives to diabetes control.

SUMMARY

Combining human interaction through peer or community health worker led diabetes educational efforts and support with technology-based interventions shows promise in improving diabetes outcomes for vulnerable populations.

Dulce Digital-Me: protocol for a randomized controlled trial of an adaptive mHealth intervention for underserved Hispanics with diabetes

BACKGROUND

By 2034, the number of US individuals with diabetes is predicted to increase from 23.7 to 44.1 million, and annual diabetes-related spending is expected to grow from $113 to $336 billion. Up to 55% of US Hispanics born in the year 2000 are expected to develop diabetes during their lifetime. Poor healthcare access and cultural barriers prevent optimal care, adherence, and clinical benefit, placing Hispanics at disproportionate risk for costly diabetes complications. Mobile technology is increasingly prevalent in all populations and can circumvent such barriers. Our group developed Dulce Digital, an educational text messaging program that improved glycemic control relative to usual care. Dulce Digital-Me (DD-Me) has been tailored to a participant's individual needs with a greater focus on health behavior change.

METHODS

This is a three-arm, parallel group, randomized trial with equal allocation ratio enrolling Hispanic adults with low income and poorly managed type 2 diabetes (N = 414) from a San Diego County Federally Qualified Health Center. Participants are randomized to receive Dulce Digital, Dulce Digital-Me-Automated, or Dulce Digital-Me-Telephonic. The DD-Me groups include Dulce Digital components plus personalized goal-setting and feedback delivered via algorithm-driven automated text messaging (DD-Me-Automated) or by the care team health coach (DD-Me-Telephonic) over a 12-month follow-up period. The study will examine the comparative effectiveness of the three groups in improving diabetes clinical control [HbA1c, primary outcome; low-density lipoprotein cholesterol (LDL-C), and systolic blood pressure (SBP)] and patient-provider communication and patient adherence (i.e., medication, self-management tasks) over 12 months and will examine cost-effectiveness of the three interventions.

DISCUSSION

Our comparative evaluation of three mHealth approaches will elucidate how technology can be integrated most effectively and efficiently within primary care-based chronic care model approaches to reduce diabetes disparities in Hispanics and will assess two modes of personalized messaging delivery (i.e., automated messaging vs. telephonic by health coach) to inform cost and acceptability.

TRIAL REGISTRATION

NCT03130699-All items from the WHO Trial Registration data set are available in https://clinicaltrials.gov/ct2/show/study/NCT03130699 .

Patient Decision-Making About Self-Disclosure of a Type 2 Diabetes Diagnosis: A Qualitative Study

BACKGROUND

Effective self-management of type 2 diabetes requires receiving support, which can result from disclosing the diagnosis to a support network, including coworkers, family, and friends. As a primarily invisible disease, diabetes allows people to choose whether to disclose. This study qualitatively explores the factors that influence a person's decision to disclose diabetes to others.

METHODS

Research coordinators recruited 22 interview participants, ranging in age from 32 to 64 years, whose medical records included a diagnosis code for type 2 diabetes. Participants received care from one of two U.S. medical centers. Semi-structured interviews lasted approximately 1 hour and were audio-recorded and professionally transcribed. Verification strategies such as memo-keeping and maintaining methodological coherence/congruence were used throughout analysis to promote rigor.

RESULTS

In patients' descriptions of their decision-making processes regarding whether to disclose their diagnosis, six themes emerged. Three motivations prompted open disclosure: 1) to seek information, 2) to seek social support, and 3) to end the succession of diabetes, and the other three motivations prompted guarded disclosure: 4) to prepare for an emergency, 5) to maintain an image of health, and 6) to protect employment.

CONCLUSION

Based on our findings, we recommend three communicative actions for clinicians as they talk to patients about a diabetes diagnosis. First, clinicians should talk about the benefits of disclosure. Second, they should directly address stereotypes in an effort to de-stigmatize diabetes. Finally, clinicians can teach the skills of disclosure. As disclosure efficacy increases, a person's likelihood to disclose also increases. Individuals can use communication as a tool to gain the knowledge and support they need for diabetes self-management and to interrupt the continuing multigenerational development of diabetes within their family.

Delivering the Same Intervention to Hispanic/Latinos With Pre-diabetes and Diabetes. Early Evidence of Success in a Longitudinal Mixed Method Study

Background

Despite nationwide efforts to address the diabetes epidemic and reduce prevalence disparities, higher rates persist among the poor, especially those with limited literacy. Currently, individuals with abnormal glycemia who have pre-diabetes and diabetes qualify for different programs. However, evidence suggests that, for low-income Hispanic/Latinos, offering a single intervention to all those with abnormal glycemia may provide a more culturally acceptable and effective approach. Our objective was to explore the feasibility of such an intervention led by community health workers (CHWs) among low-income Hispanic/Latinos with diabetes and at risk for diabetes.

Methods

Using a quasi-experimental mixed method design, we assessed weight, glycosylated hemoglobin, diabetes knowledge, and behavior changes of Hispanic/Latinos participants with pre-diabetes and diabetes living in Southern California. Biometric measurements, blood tests, and surveys were collected at baseline and 3 months post-intervention. Interviews and focus group discussions provided qualitative data.

Results

Although the program was less costly, results exceeded those reported for low-income H/L attending the National Diabetes Prevention Program and did not differ between pre-diabetes and diabetes groups. Instead, including individuals at different stages of the dysglycemic spectrum seemed to have enhanced the intervention. Physician referral and attendance of family/friends were associated with better outcomes.

Conclusion

Our findings indicate that a joint prevention/self-management intervention led by CHWs for low-income Hispanic/Latinos with diabetes and with pre-diabetes is feasible and cost-effective, providing results that could help reduce the success gap. Incorporating suggestions and replicating this study on a larger scale could help determine whether or not results are reproducible.