Evaluating the impact of onsite diabetes education teams in primary care on clinical outcomes.

BACKGROUND: To evaluate the impact of integrating diabetes education teams in primary care on glycemic control, lipid, and blood-pressure management in type 2 diabetes patients. METHODS: A historical cohort design was used to assess the integration of teams comprising nurse and dietitian educators in 11 Ontario primary-care sites, which delivered individualized self-management education. Of the 771 adult patients with A1C ≥ 7% recruited, 487 patients attended appointments with the diabetes teams, while the remaining 284 patients did not. The intervention's primary goal was to increase the proportion of patients with A1C ≤7%. Secondary goals were to reduce mean A1C, low-density lipoprotein, total cholesterol-high density lipoprotein, and diastolic and systolic blood pressure, as recommended by clinical-practice guidelines. RESULTS: After 12 months, a higher proportion of intervention-group patients reached the target for A1C, compared with the control group. Mean A1C levels fell significantly among all patients, but the mean reduction was larger for the intervention group than the control group. Although more intervention-group patients reached targets for all clinical outcomes, the between-group differences were not statistically significant, except for A1C. CONCLUSIONS: Nurse and dietitian diabetes-education teams can have a clinically meaningful impact on patients' ability to meet recommended A1C targets. Given the study's historical cohort design, results are generalizable and applicable to day-to-day primary-care practice. Longer follow-up studies are needed to investigate whether the positive outcomes of the intervention are sustainable.

Impact of diabetes education teams in primary care on processes of care indicators.

AIMS: To evaluate the impact of the integration of onsite diabetes education teams in primary care on processes of care indicators according to practice guidelines. METHODS: Teams of nurse and dietitian educators delivered individualized self-management education counseling in 11 Ontario primary care sites. Of the 771 adult patients with HbA1c ≥7% who were recruited in a prospective cohort study, 487 patients attended appointments with the education teams, while the remaining 284 patients did not (usual care group). Baseline demographic, clinical information, and patient care processes (diabetes medical visit, HbA1c test, lipid profile, estimated glomerular filtration rate, and albumin-to-creatinine ratio, measuring blood pressure, performing foot exams, provision of flu vaccine, and referral for dilated retinal exam) were collected from patient charts one year before (pre period) and after (post period) the integration began. A multi-level random effects model was used to analyze the effect of group and period on whether the process indicators were met based on practice guidelines. RESULTS: Compared to the usual care group, patients seen by the education teams had significant improvements on indicators for semi-annual medical visit and annual foot exam. No significant improvements were found for other process of care indicators. CONCLUSIONS: Onsite education teams in primary care settings can potentially improve diabetes management as shown in two process of care indicators: medical visits and foot exams. The results support the benefits of having education teams in primary care settings to increase adherence to practice guidelines.

Emerging practices supporting diabetes self-management among food insecure adults and families: A scoping review.

BACKGROUND: Food insecurity undermines a patient's ability to follow diabetes self-management recommendations. Care providers need strategies to direct their support of diabetes management among food insecure patients and families. OBJECTIVE: To identify what emerging practices health care providers can relay to patients or operationalize to best support diabetes self-management among food insecure adults and families. ELIGIBILITY CRITERIA: Food insecure populations with diabetes (type 1, type 2, prediabetes, gestational diabetes) and provided diabetes management practices specifically for food insecure populations. Only studies in English were considered. In total, 21 articles were reviewed. SOURCES OF EVIDENCE: Seven databases: Cumulative Index of Nursing and Allied Health Literature, Cochrane Database of Systematic Reviews, Medline, ProQuest Nursing & Allied Health Database, PsychInfo, Scopus, and Web of Science. RESULTS: Emerging practices identified through this review include screening for food insecurity as a first step, followed by tailoring nutrition counseling, preventing hypoglycemia through managing medications, referring patients to professional and community resources, building supportive care provider-patient relationships, developing constructive coping strategies, and decreasing tobacco smoking. CONCLUSION: Emerging practices identified in our review include screening for food insecurity, nutrition counselling, tailoring management plans through medication adjustments, referring to local resources, improving care provider-patient relationship, promoting healthy coping strategies, and decreasing tobacco use. These strategies can help care providers better support food insecure populations with diabetes. However, some strategies require further evaluation to enhance understanding of their benefits, particularly in food insecure individuals with gestational and prediabetes, as no studies were identified in these populations. A major limitation of this review is the lack of global representation considering no studies outside of North America satisfied our inclusion criteria, due in part to the English language restriction.

Reported Health Behaviour Changes after a Diagnosis of Gestational Diabetes Mellitus among Ethnic Minority Women Living in Canada.

The aim of this cross-sectional study was to examine differences in health behaviours among ethnic minority and Caucasian women after a diagnosis of gestational diabetes mellitus (GDM). Data were derived from medical charts and a questionnaire among a multi-ethnic cohort of 898 Canadian pregnant women diagnosed with GDM attending prenatal diabetes clinics in Ontario, Canada. Health behaviours were compared between ethnic minority and Caucasian women, adjusting for relevant covariates. The mean age was 33.9 ± 6.1 years; 60.0 % self-reported to be part of an ethnic minority group. After adjustment for socio-demographic, behavioural and clinical characteristics, ethnic minority women were more likely to report reducing their meal portion sizes (odds ratio [OR] 1.98; 95.0 % confidence interval [CI] 1.20-3.26) and increasing their physical activity (OR 1.71; 95.0 % CI 1.12-2.62) in response to a GDM diagnosis compared to Caucasian women. Ethnic minority women were more likely to report changes in health behaviours after a GDM diagnosis. Further research is needed to determine the impact of these findings on maternal health and perinatal outcomes, during and after delivery.

Self-management, health service use and information seeking for diabetes care among Black Caribbean immigrants in Toronto.

OBJECTIVE: The objective of this research was to explore self-management practices and the use of diabetes information and care among Black-Caribbean immigrants with type 2 diabetes. METHOD: The study population included Black-Caribbean immigrants and Canadian-born participants between the ages of 35 to 64 years with type 2 diabetes. Study participants were recruited from community health centres (CHCs), diabetes education centres, hospital-based diabetes clinics, the Canadian Diabetes Association and immigrant-serving organizations. A structured questionnaire was used to collect demographics and information related to diabetes status, self-management practices and the use of diabetes information and care. RESULTS: Interviews were conducted with 48 Black-Caribbean immigrants and 54 Canadian-born participants with type 2 diabetes. Black-Caribbean immigrants were significantly more likely than the Canadian-born group to engage in recommended diabetes self-management practices (i.e. reduced fat diet, reduced carbohydrate diet, non-smoking and regular physical activity) and receive regular A1C and eye screening by a health professional. Black-Caribbean immigrant participants were significantly more likely to report receiving diabetes information and care through a community health centre (CHC) and nurses and dieticians than their Canadian-born counterparts. CONCLUSIONS: CHCs and allied health professionals play an important role in the management of diabetes in the Black-Caribbean immigrant community and may contribute to this group's favourable diabetes self-management profile and access to information and care. Additional research is necessary to confirm whether these findings are generalizable to the Black-Caribbean community in general (i.e. immigrant and non-immigrant) and to determine whether the use of CHCs and/or allied health professionals is associated with favourable outcomes in the Black-Caribbean immigrant community as well as others.

Exploring differences in Canadian adult men and women with diabetes management: results from the Canadian Community Health Survey.

BACKGROUND: Over 2 million Canadians are known to have diabetes. In addition to the economic burden placed on the healthcare system, the human cost associated with diabetes poses a heavy burden on those living with diabetes. The literature shows that apparent differences exist in diabetes complications and diabetes management between men and women. How self-care management and utilization of health services differ by sex is not clearly understood.The purpose of this study was to explore sex differences in diabetes self-care and medical management in the Canadian population, using a nationally representative sample. METHODS: Data collected from the cross-sectional, population-based Canadian Community Health Survey (2007-2008) were used in these analyses. A bootstrap variance estimation method and bootstrap weights provided by Statistics Canada were used to calculate 95% confidence intervals. Bivariate analyses identified variables of interest between females and males that were used in subsequent multivariate analyses. RESULTS: A total of 131,959 respondents were surveyed for the years of 2007 and 2008, inclusive. Fully adjusted multinomial and logistic regression analyses revealed sex differences for those living with diabetes. Compared to men with diabetes, women were more likely to be in the lowest income quintiles than the highest (OR: 1.8, 95% CI: 1.3-2.6) and were more likely not to have a job in the previous week (OR: 1.8, 95% CI: 1.4-2.4). Women were also more likely to avoid foods with fats or high calories (OR: 2.1, 95% CI: 1.4-3.0 and OR: 2.2, 95% CI: 1.6-3.0, respectively), to be concerned about heart disease (OR: 1.6, 95% CI: 1.1-2.2), and to be non-smokers (OR: 2.2, 95% CI: 1.6-3.0). However, despite their increased concern, women checked their blood-glucose less frequently on a daily basis than men (µwomen = 1.7, 95% CI: 1.7-1.8; µmen = 3.1, 95% CI: 2.9-3.2). Women were more likely to have an anxiety disorder (OR: 2.3, 95% CI: 1.7-3.2) and a mood disorder (OR: 2.4, 95% CI: 1.8-3.1), and more likely to be physically inactive (OR: 1.5, 95% CI: 1.2-1.8). CONCLUSIONS: Our findings underscore the importance of addressing sex differences which may interfere with diabetes self-care. In women, addressing socioeconomic and psychological barriers, as well as limitations to active living are important; in men, the benefit of more effective nutrition therapy and smoking cessation interventions are suggested. The results for this study highlight the need to further investigate and eliminate disparities between the sexes in order to optimize health outcomes among Canadians with diabetes.

Profiles of smokers and non-smokers with type 2 diabetes: initial visit at a diabetes education centers.

AIMS: This study explores differences in psychosocial, behavioral and clinical characteristics among smoking and non-smoking individuals with diabetes attending diabetes education centers (DEC). METHODS: A questionnaire was administered to 275 individuals with type 2 diabetes attending two DECs between October 2003 and 2005. The participants' characteristics were analyzed and multivariable linear and ordinal regressions were performed to adjust for variables correlated with smoking. RESULTS: Findings revealed that smokers, compared to non-smokers, had lower outcome expectations of the benefits of self-management, lower diastolic blood pressure, and followed their recommended diet and tested blood glucose levels less often than non-smokers. Smokers also had lower intentions to use resources outside and within the DEC. CONCLUSIONS: Results demonstrate poorer self-care behaviors among smokers compared to non-smokers and further suggest cognitive and behavioral differences between smokers and non-smokers regarding participation and attitudes toward self-management practices. These findings identify issues that need to be addressed in diabetes self-management programs to allow for more effective interventions tailored to the healthcare needs of this specific population.

Exploration of the relationship between household food insecurity and diabetes in Canada.

OBJECTIVE: To determine the household food insecurity (HFI) prevalence in Canadians with diabetes and its relationship with diabetes management, self-care practices, and health status. RESEARCH DESIGN AND METHODS: We analyzed data from Canadians with diabetes aged >or=12 years (n = 6,237) from cycle 3.1 of the Canadian Community Health Survey, a population-based cross-sectional survey conducted in 2005. The HFI prevalence in Canadians with diabetes was compared with that in those without diabetes. The relationships between HFI and management services, self-care practices, and health status were examined for Ontarians with diabetes (n = 2,523). RESULTS: HFI was more prevalent among individuals with diabetes (9.3% [8.2-10.4]) than among those without diabetes (6.8% [6.5-7.0]) and was not associated with diabetes management services but was associated with physical inactivity (odds ratio 1.54 [95% CI 1.10-2.17]), lower fruit and vegetable consumption (0.52 [0.33-0.81]), current smoking (1.71 [1.09-2.69]), unmet health care needs (2.71 [1.74-4.23]), having been an overnight patient (2.08 [1.43-3.04]), having a mood disorder (2.18 [1.54-3.08]), having effects from a stroke (2.39 [1.32-4.32]), lower satisfaction with life (0.28 [0.18-0.43]), self-rated general (0.37 [0.21-0.66]) and mental (0.17 [0.10-0.29]) health, and higher self-perceived stress (2.04 [1.30-3.20]). The odds of HFI were higher for an individual in whom diabetes was diagnosed at age <40 years (3.08 [1.96-4.84]). CONCLUSIONS: HFI prevalence is higher among Canadians with diabetes and is associated with an increased likelihood of unhealthy behaviors, psychological distress, and poorer physical health.

Assessment of two culturally competent diabetes education methods: individual versus individual plus group education in Canadian Portuguese adults with type 2 diabetes.

OBJECTIVE: To examine the impact of two culturally competent diabetes education methods, individual counselling and individual counselling in conjunction with group education, on nutrition adherence and glycemic control in Portuguese Canadian adults with type 2 diabetes over a three-month period. DESIGN: The Diabetes Education Centre is located in the urban multicultural city of Toronto, Ontario, Canada. We used a three-month randomized controlled trial design. Eligible Portuguese-speaking adults with type 2 diabetes were randomly assigned to receive either diabetes education counselling only (control group) or counselling in conjunction with group education (intervention group). Of the 61 patients who completed the study, 36 were in the counselling only and 25 in the counselling with group education intervention. We used a per-protocol analysis to examine the efficacy of the two educational approaches on nutrition adherence and glycemic control; paired t-tests to compare results within groups and analysis of covariance (ACOVA) to compare outcomes between groups adjusting for baseline measures. The Theory of Planned Behaviour was used to describe the behavioural mechanisms that influenced nutrition adherence. RESULTS: Attitudes, subjective norms, perceived behaviour control, and intentions towards nutrition adherence, self-reported nutrition adherence and glycemic control significantly improved in both groups, over the three-month study period. Yet, those receiving individual counselling with group education showed greater improvement in all measures with the exception of glycemic control, where no significant difference was found between the two groups at three months. CONCLUSIONS: Our study findings provide preliminary evidence that culturally competent group education in conjunction with individual counselling may be more efficacious in shaping eating behaviours than individual counselling alone for Canadian Portuguese adults with type 2 diabetes. However, larger longitudinal studies are needed to determine the most efficacious education method to sustain long-term nutrition adherence and glycemic control.

Incidence of neural tube defects in Ontario, 1986-1999.

BACKGROUND: Prenatal screening and the promotion of folic acid intake could affect the incidence of neural tube defects (NTDs). We examined trends in the total NTD incidence, as detected in live births, stillbirths and therapeutic abortions, from 1986 to 1999 in Ontario. METHODS: To capture cases of NTDs we used data from the Canadian Congenital Anomalies Surveillance System and hospital data on therapeutic abortions. We calculated the total incidence of NTDs by combining the numbers of NTDs occurring in live births, stillbirths and therapeutic abortions. RESULTS: The total NTD incidence rate increased from 11.7 per 10,000 pregnancies in 1986 to 16.2 per 10,000 in 1995, and it subsequently decreased to 8.6 per 10,000 by 1999. The NTD birth rate (live births and stillbirths) decreased from 10.6 per 10,000 births in 1986 to 5.3 per 10,000 in 1999. The rate of therapeutic abortions with an NTD or hydrocephalus rose from 17.5 per 10,000 abortions in 1986 to 50.7 per 10,000 in 1995 and fell to 28.7 per 10,000 abortions in 1999. INTERPRETATION: The total NTD incidence rate increased from 1986 to 1995, probably because of increased prenatal screening and better detection of NTDs. The decline from 1995 to 1999 may have been due to increased folic acid intake among women at the time of conception.