Predictors of Subjective Cognitive Decline Among People With Diabetes: Data From the Behavioral Risk Factor Surveillance System

PURPOSE

The purpose of this study was to examine the prevalence of subjective cognitive decline (SCD) and SCD-related functional limitations among people with diabetes and to identify socioeconomic and comorbidity risk factors associated with SCD.

METHODS

This study analyzed data from the 2017 Behavioral Risk Factor Surveillance System (BRFSS) with background variables (race, gender, education, and age), health-related factors (self-rated health, BMI, insurance, and comorbid conditions), and health behaviors (smoking, exercise, alcohol consumption) entered simultaneously to estimate logistic regression models of SCD.

RESULTS

Within the sample (n = 5263 adults with diabetes), 48% were age ≥65 years; 50% were male; 55% were non-Hispanic White; and of the 15% who reported having SCD, 57% had functional limitations. Increased odds of reporting SCD were observed among individuals who were Hispanic (odds ratio [OR] = 2.21, P < .001), male (OR = 1.47, P < .01), depressed (OR = 3.85, P < .001), or had arthritis (OR = 1.43, P < .03). Participants with better self-rated health had a reduced likelihood of SCD (OR = 0.51, P < .001).

CONCLUSIONS

Health care providers should assess high-risk patients for self-rated cognitive dysfunction and offer early interventions.

Lessons learned from eight teams: The value of pilot and feasibility studies in self-management science

Designing and conducting effective intervention research is an important domain of nursing science. Nurse scientists have long recognized people with chronic conditions need effective self-management strategies across the lifespan, so they have led the way in establishing theoretical and practical grounds for the science of self-management. Guidance from pilot and feasibility research for self-management interventions is scarce. Documented exemplars of successes and failures in pilot and feasibility study designs are scant in the literature. The purpose of this paper is to illustrate methodological approaches using pilot and feasibility examples. To maximize collective lessons learned in self-management science study design, features of our pilot and feasibility research strategies that yielded both desirable and undesirable outcomes are described, analyzed, and paired with alternative solutions. A National Institute of Nursing Research P30 grant center, awarded grants to 8 pilot investigators to pilot self-management interventions. A wide variety of chronic conditions were addressed, including heart failure, chronic kidney disease, multiple sclerosis, diabetes, and HIV. The investigators provided their experiences of study implementation. Common themes across the studies were identified. There were four lessons learned from these studies: 1) maximize resources and develop enough evidence for subsequent studies; 2) embed patient-centered feasibility within implementation testing with new patient populations; 3) develop a flexible participant recruitment plan to allow for adjustments when unexpected barriers arise; and 4) define study-specific data collection procedures to demonstrate feasibility. Researchers conducting preliminary small-scale self-management intervention research must balance resources to develop and implement interventions to meet pilot and feasibility objectives.

Targeting cognitive function: Development of a cognitive training intervention for diabetes

AIM

The aim of this project was to develop and demonstrate the feasibility of a comprehensive cognitive training intervention to build self-efficacy for implementation of cognitive strategies in people with diabetes.

BACKGROUND

People with diabetes are at greater risk than the general population for developing cognitive dysfunction. Some attention has been paid to the effect of cognitive impairments on diabetes self-management, but even when cognitive problems have been identified, few interventions have been tailored for those with diabetes.

METHODS

The intervention combines in-person classes and home-based online computer training. Development, in 2017, included (a) adaptation of prior established, tested interventions; (b) interviews with stakeholders; and (c) integration of course content.

RESULTS

Information provided by the stakeholders was used to modify an existing intervention to meet the needs of people with diabetes so that feasibility testing could occur. Despite initial difficulty with recruitment, the intervention was found to be feasible, and nineteen participants found it to be acceptable.

CONCLUSION

This comprehensive cognitive training intervention targeting type 2 diabetes and cognitive dysfunction demonstrates that existing interventions can be adapted for use with people with diabetes.

A Nurse-Led Cognitive Training Intervention for Individuals With Type 2 Diabetes

Diabetes increases the risk for cognitive impairment and doubles the rate of cognitive decline after diagnosis. In turn, cognitive dysfunction makes diabetes self-management more difficult. Nurses who help manage these conditions are focused on identifying patients at risk for complications, promoting symptom management, and preventing further decline. The purpose of the current study was to develop and pilot test a nurse-led comprehensive cognitive training intervention for individuals with type 2 diabetes mellitus (T2DM), the Memory Attention and Problem Solving Skills in Persons With Diabetes Mellitus (MAPSS-DM). The 8-week intervention combined in-person classes and online computer training. Development included: (a) adaptation of established, tested interventions; (b) interviews with stakeholders; (c) integration of course content; and (d) pilot testing of the intervention in a one-group, pre-/posttest design (N = 19). Postintervention scores improved in all areas; improvements were statistically significant for diet adherence (t[18] = -2.41, p < 0.005), memory ability (t[18] = 5.54, p < 0.01), and executive function (t[18] = 3.11, p < 0.01). Fifty-eight percent of participants stated the intervention helped their diabetes self-management, and 74% indicated they wanted to continue using cognitive strategies learned in the intervention. Results from this study showed the MAPSS-DM to be a promising cognitive training intervention for individuals with T2DM.

TARGETS

Individuals with T2DM.

INTERVENTION DESCRIPTION

In-person classes and online computer training of a cognitive training intervention.

MECHANISMS OF ACTION

Participants who completed the intervention would show improved cognitive function, which would result in improved self-management adherence followed by better glycemic control.

OUTCOMES

Improved diabetes self-management and sustained use of learned cognitive strategies. [Res Gerontol Nurs. 2019; 12(4):203-212.].

Type 2 diabetes and cognitive dysfunction in minorities: a review of the literature

OBJECTIVES

The purpose of this review was to summarize the current status of knowledge regarding cognitive dysfunction and diabetes in minorities. Literature on the interaction of cognitive dysfunction and diabetes was analyzed to (a) examine the number and characteristics of studies in minority populations; (b) identify tests used to assess cognitive function in diabetes; (c) consider the impact of diabetes on cognitive function; and (d) assess the moderators of the association between diabetes and cognitive function.

DESIGN

A literature review and thematic analysis was conducted. Studies were mapped to describe their design, target population, instruments used, and the physiologic, psychosocial, and socioeconomic findings related to cognitive function and diabetes. Twelve studies met the inclusion criteria.

RESULTS

Hispanics were studied more than any other ethnic group. Rates and degree of cognitive dysfunction were more prevalent in minorities than non-Hispanic whites. Overall, 28 different tests were administered to evaluate cognitive function. There was some variation among findings regarding the relationship of cognitive function and diabetes. Risk for cognitive decline was associated with the diagnosis of diabetes alone, regardless of whether the diabetes was treated or untreated. Higher rates of discrimination were associated with greater cognitive decline Conclusion: Given the context of minority health, there is a potential for higher negative health impact due to the increased prevalence of diabetes and cognitive dysfunction and other related health disparities. Reduction of physiological risk factors for diabetes, consistency in assessment, as well as elimination of structural barriers such as access to care should be helpful in decreasing the incidence of both diabetes and cognitive decline. More research is needed to determine whether the observed differences are modifiable and to identify factors involved in the interaction of diabetes and cognitive decline-not only physiological factors, but factors related to socioeconomic status and quality of life.

The Starr County Border Health Initiative: Focus Groups on Diabetes Prevention in Mexican Americans

Purpose The purpose of the study was to conduct focus groups with Mexican Americans in an impoverished rural community on the Texas-Mexico border to identify current barriers to adopting healthier lifestyles and to obtain recommendations for diabetes prevention. Methods Three separate 2-hour focus groups were led by an experienced bilingual Mexican American moderator. Interviews included questions about cultural factors and barriers that influence lifestyle behaviors, aspects of previous diabetes self-management interventions that were helpful for motivating behavioral change, and recommendations for diabetes prevention. Results Twenty-seven participants attended a focus group session; each session involved 7 to 12 informants. Individuals were diagnosed with prediabetes or type 2 diabetes mellitus; most were female, foreign born, and Spanish speaking. Interviews documented the cultural importance of food. Informants raised priority issues for diabetes prevention, including the need to learn how to prepare healthier foods and track caloric intake. Major barriers to healthier lifestyles included high costs of healthy foods, fatigue from busy schedules and working multiple jobs, a cultural view that exercise is a waste of valuable time, and fear of deportation. Conclusions Cultural influences and barriers to implementing healthy lifestyles should be assessed regularly and strategies implemented to overcome them. Such factors may change as environmental, sociocultural, and political environments change.

Thinking About Cognitive Function: Perceptions of Cognitive Changes in People With Type 2 Diabetes

Purpose The purpose of this study is 2-fold: (1) to explore how people with diabetes view diabetes-related cognitive problems and (2) to examine participants' ideas on a cognitive rehabilitation intervention to adapt it for persons diagnosed with type 2 diabetes (T2DM). Methods A qualitative descriptive study based on narrative interviews was conducted with adults (n = 10) with T2DM. The interview data were analyzed using content analysis. Results The interviews reflected 4 major themes: search for advice regarding cognitive complaints, cognitive symptoms, impact of perceived cognitive dysfunction on diabetes self-management, and maintenance of cognitive health. Specific areas of interest for an intervention included the following: understanding how cognitive function relates to diabetes, dealing with cognitive barriers to self-management, and learning how to incorporate a "brain healthy" lifestyle into daily activities. Conclusions Findings showed that perceived cognitive impairment impacted self-management and suggested that cognitive rehabilitation interventions have potential utility for people with T2DM. Existing successful interventions can be tailored to meet the needs of those whose diabetes self-management is impacted by cognitive problems.

Self-Management Decision Making of Cuban Americans With Type 2 Diabetes

PURPOSE

Although researchers have studied how individuals manage type 2 diabetes, none have examined how Cuban Americans do so. This article explores how Cuban Americans make self-management choices and examines whether an empowerment framework is viable for informing interventions.

DESIGN

A qualitative descriptive study was conducted ( n = 20) with Cuban Americans with type 2 diabetes. Individual interviews were analyzed with content analysis.

RESULTS

Motivation and temporal factors, such as knowledge of symptoms and the ability to plan ahead, positively affect self-management. Cultural factors, such as access to cultural foods, negatively affect self-management. Empowerment formed a comprehensive lens through which self-management decisions were acted on.

CONCLUSION

Given the cultural context, empowerment and unique barriers and facilitators can affect diabetes self-management in this population. Strategies to promote healthy decisions must take into account the strengths of this community as well as its challenges.

Biobehavioral determinants of glycemic control in type 2 diabetes: A systematic review and meta-analysis

OBJECTIVES

To conduct a model-driven meta-analysis of correlational research on psychological and motivational predictors of diabetes outcomes, with adherence factors as mediators.

METHODS

A comprehensive literature search of published and unpublished studies located a sample of 775 individual correlational or predictive studies reported across 739 research reports.

RESULTS

Results varied according to the outcome variable included in the regression models. Depression had a larger negative effect on adherence to physical activity than on dietary adherence. Coping and self-efficacy were strongly related to dietary adherence, which was strongly related to improved glycemic control. Medication adherence was related to glycosylated hemoglobin, whereas medications and self-monitoring were related to fasting blood glucose. Adding appointment keeping to the models did not significantly alter the results.

CONCLUSION

Self-efficacy was the most consistent predictor of all adherence behaviors and dietary adherence was the most significant predictor of HbA1c. Physical activity was the most predictive factor of BMI and glucose self-monitoring the most predictive of FBG.

PRACTICE IMPLICATIONS

Metabolic control is a primary goal in T2DM, so the best pathway to attaining that goal appears to be an emphasis on self-efficacy and dietary adherence.

Blood glucose self-monitoring patterns in Mexican Americans: further lessons from the Starr County Border Health Initiative

BACKGROUND

The purpose was to describe patterns of home self-monitoring of blood glucose (SMBG) in Mexican Americans with type 2 diabetes mellitus enrolled in a diabetes self-management education protocol. Research questions were as follows: (1) What were the patterns and rates of home glucose self-monitoring over the 6-month course of the study? (2) What were the differences in monitoring rates between experimental and control groups? (3) What were the relationships between rates of monitoring and glycosylated hemoglobin (A1C), gender, and years with diabetes?

SUBJECTS AND METHODS

We used a randomized (by group) repeated-measures pretest/posttest control group design. Glucometer data from an experimental group (diabetes self-management education plus nurse case management) and a comparison group (diabetes self-management education only) were analyzed. Data were collected at baseline and at 3 and 6 months.

RESULTS

Overall average SMBG rates were low. Experimental and control group monitoring levels were not significantly different. More females than males never monitored glucose values, but more females than males checked at least one time per week. Those participants who checked their glucose levels more than once per week had diabetes for a longer period of time. Rates of monitoring were not strongly associated with A1C levels at 3 and 6 months, but at 6 months A1C levels were statistically significantly different based on whether or not individuals monitored their glucose levels (P=0.03, n=71).

CONCLUSIONS

SMBG rates were low in this study despite SMBG education and access to free glucometers and test strips. The lower rates of SMBG may reflect the effects of unexpected environmental challenges, but exact causes remain unclear. Reasons for low rates of SMBG need to be explored further, especially in underserved communities.

Depression and adherence to lifestyle changes in type 2 diabetes: a systematic review

PURPOSE

Depression affects millions of people worldwide and is prevalent among those with diabetes. The purpose of this review was to synthesize recent research on depression and adherence to dietary and physical activity recommendations in persons with type 2 diabetes (T2DM).

METHODS

This systematic review is a subanalysis of an NIH-funded model-testing meta-analysis. Thirteen electronic databases were searched using terms: depression, adherence, T2DM, diabetes. Selected studies: were reported in English between 2000 and 2012, focused on adults with T2DM, and measured depression and dietary and/or physical activity adherence.

RESULTS

Twenty-seven studies involving 7266 participants were selected; participants were 54% female and 62 years of age, on average. When reported, depression prevalence in study samples ranged from 4.5% to 74%. Six intervention studies targeted diabetes treatment, with or without depression treatment; no studies focused solely on treating depression. Twenty-one descriptive studies examined relationships between depression and diet/physical activity adherence, finding a negative association. Only 2 of the 6 intervention studies examined this relationship; findings were inconsistent.

CONCLUSION

Depression was associated with lower adherence to diabetes self-care, as evidenced primarily by descriptive studies; results of intervention studies were conflicting. Future research should focus on the effects of treating depression on diabetes health outcomes.

Managing complex research datasets using electronic tools: a meta-analysis exemplar

Meta-analyses of broad scope and complexity require investigators to organize many study documents and manage communication among several research staff. Commercially available electronic tools, for example, EndNote, Adobe Acrobat Pro, Blackboard, Excel, and IBM SPSS Statistics (SPSS), are useful for organizing and tracking the meta-analytic process as well as enhancing communication among research team members. The purpose of this article is to describe the electronic processes designed, using commercially available software, for an extensive, quantitative model-testing meta-analysis. Specific electronic tools improved the efficiency of (a) locating and screening studies, (b) screening and organizing studies and other project documents, (c) extracting data from primary studies, (d) checking data accuracy and analyses, and (e) communication among team members. The major limitation in designing and implementing a fully electronic system for meta-analysis was the requisite upfront time to decide on which electronic tools to use, determine how these tools would be used, develop clear guidelines for their use, and train members of the research team. The electronic process described here has been useful in streamlining the process of conducting this complex meta-analysis and enhancing communication and sharing documents among research team members.

A consensus linkage map identifies genomic regions controlling fruit maturity and beta-carotene-associated flesh color in melon (Cucumis melo L.)

The nutritional value and yield potential of US Western Shipping melon (USWS; Cucumis melo L.) could be improved through the introgression of genes for early fruit maturity (FM) and the enhancement of the quantity of beta-carotene (QbetaC) in fruit mesocarp (i.e., flesh color). Therefore, a set of 116 F(3) families derived from the monoecious, early FM Chinese line 'Q 3-2-2' (no beta-carotene, white mesocarp) and the andromonoecious, late FM USWS line 'Top Mark' (possessing beta-carotene, orange mesocarp) were examined during 2 years in Wisconsin, USA to identify quantitative trait loci (QTL) associated with FM and QbetaC. A 171-point F(2-3) based map was constructed and used for QTL analysis. Three QTL associated with QbetaC were detected, which explained a significant portion of the observed phenotypic variation (flesh color; R (2) = 4.0-50.0%). The map position of one QTL (beta-carM.E.9.1) was uniformly aligned with one carotenoid-related gene (Orange gene), suggesting its likely role in QbetaC in this melon population and putative relationship with the melon white flesh (wf) gene. Two major (FM.6.1 and FM.11.1; R (2) >or= 20%) and one minor QTL (FM.2.1; R (2) = 8%) were found to be associated with FM. This map was then merged with a previous recombinant inbred line (RIL)-based map used to identify seven QTL associated with QbetaC in melon fruit. This consensus map [300 molecular markers (187 co-dominant melon and 14 interspecific; 10 LG)] provides a framework for the further dissection and cloning of published QTL, which will consequently lead to more effective trait introgression in melon.

Mapping of genetic loci that regulate quantity of beta-carotene in fruit of US Western Shipping melon (Cucumis melo L.)

Melon (Cucumis melo L.) is highly nutritious vegetable species and an important source of beta-carotene (Vitamin A), which is an important nutrient in the human diet. A previously developed set of 81 recombinant inbred lines (RIL) derived from Group Cantalupensis US Western Shipper market type germplasm was examined in two locations [Wisconsin (WI) and California (CA), USA] over 2 years to identify quantitative trait loci (QTL) associated with quantity of beta-carotene (QbetaC) in mature fruit. A moderately saturated 256-point RIL-based map [104 SSR, 7 CAPS, 4 SNP in putative carotenoid candidate genes, 140 dominant markers and one morphological trait (a) spanning 12 linkage groups (LG)] was used for QbetaC-QTL analysis. Eight QTL were detected in this evaluation that were distributed across four LG that explained a significant portion of the associated phenotypic variation for QbetaC (R (2) = 8 to 31.0%). Broad sense heritabilities for QbetaC obtained from RIL grown in WI. and CA were 0.56 and 0.68, respectively, and 0.62 over combined locations. The consistence of QbetaC in high/low RIL within location across years was confirmed in experiments conducted over 2 years. QTL map positions were not uniformly associated with putative carotenoid genes, although one QTL (beta-car6.1) interval was located 10 cM from a beta-carotene hydroxylase gene. These results suggest that accumulation of beta-carotene in melon is under complex genetic control. This study provides the initial step for defining the genetic control of QbetaC in melon leading to the development of varieties with enhanced beta-carotene content.