Caring for people with diabetes: A fresh look at an old disease.

ABSTRACT: This article describes current evidence-based approaches to the care and education of adults living with diabetes. It also highlights revisions in the 2022 Standards of Care and evidence-based strategies nurses can use to be more effective.

Michigan Men's diabetes project (MenD): protocol for a peer leader diabetes self-management education and support intervention.

BACKGROUND: Black men are more likely to be diagnosed with type 2 diabetes (T2D) compared to non-Hispanic White men, and this disparity increases among men over the age of 55. A growing body of literature demonstrates the critical role of gender in the management of health behaviors such as T2D and shows that male gender norms can conflict with healthy behaviors. These studies suggest that tailoring diabetes self-management interventions to address the needs of Black men may be critical to helping them to achieve optimal health outcomes. Further, our own research on Blacks with T2D found gender disparities in participation in diabetes interventions, with males participating at significantly lower rates than females. Peer leaders are trained lay individuals who are used to provide ongoing diabetes self-management support to people with diabetes, particularly in minority communities. However, despite studies showing that diabetes management interventions using peer leaders have been successful, the majority of peer leaders as well as the participants in those studies are women. The limited studies to date suggest that Black men with T2D prefer peer-led, male-to-male T2D programs, however, this research consists primarily of nonrandomized, small sample feasibility studies calling for additional studies to establish the efficacy of these approaches. The proposed study will develop and preliminarily validate the effectiveness of an adapted peer leader diabetes self-management support (PLDSMS) intervention designed to improve diabetes-related lifestyle and self-management behaviors in Black men (over 55) with T2D. METHOD: We propose to tailor an existing intervention by 1) our using male peers and 2) modifying the peer leader training content to focus on material appropriate for men. The proposed study includes a developmental phase (development of the intervention with expert feedback, followed by feasibility testing with Black men) and a validation phase [randomized clinical trial (RCT)]. DISCUSSION: If successful, this study will lead to the development and dissemination of an intervention that will address the unique needs of Black men with T2D, helping them to achieve optimal diabetes self-management and health outcomes. TRIAL REGISTRATION: Registered at ClinicalTrials.gov with an ID NCT04760444 on February 17, 2021.

One size does not fit all: Nutrition strategies for people with diabetes.

Several nutrition strategies and eating patterns can help support self-management among persons with diabetes. This article details the effectiveness of popular eating patterns and nutrition strategies, as well as the role of nurses in facilitating informed patient choices and decisions.

Applying the theoretical domains framework to identify determinants to mental healthcare use among older African Americans with type 2 diabetes: a qualitative study.

OBJECTIVES: There is a paucity of research focused on enhancing access to mental healthcare for older African Americans with type 2 diabetes (T2D), who may be at risk for or living with comorbid depression. This study aims to identify barriers and facilitators to mental healthcare utilisation among this population, guided by the theoretical domains framework (TDF). DESIGN: This qualitative study involved 30 interviews with older African American adults diagnosed with T2D. The interview questions were aligned with TDF domains to capture participant perspectives on barriers and facilitators to mental healthcare use. SETTING: Interviews were conducted via telephone by a licensed clinician trained in social work. Each session lasted 60-90 min and was transcribed and analysed. PARTICIPANTS: The study included 30 African American adults (15 males and 15 females), aged 60 and above, living in an urban area in the Midwest. PRIMARY AND SECONDARY OUTCOMES: The primary outcome was the identification of themes from participant responses, analysed using thematic content techniques and categorised into TDF constructs. Demographic data served as the secondary outcome. RESULTS: Nine key themes were identified, categorised under major TDF domains and constructs. Significant barriers included (1) systemic racism ('knowledge'), (2) normalisation of depressive symptoms ('beliefs about consequences'), (3) perceived stigma ('beliefs about consequences') and 4) costs of medications and healthcare ('environmental context and resources'). Facilitators to seeking mental healthcare included (1) empowerment ('beliefs about capabilities'), (2) perceived benefits of mental health exams ('beliefs about consequences'), (3) positive provider experiences ('reinforcement'), (4) recognition of depressive symptoms as a motivator ('goals') and (5) support networks ('social influences'). CONCLUSION AND IMPLICATIONS: Key findings highlight that fostering positive patient-provider relationships and enhancing self-recognition of depressive symptoms can significantly encourage mental healthcare utilisation among older African Americans with T2D. These findings suggest that future interventions should focus on strengthening these relationships and improving self-awareness to better mental health outcomes.

The Michigan Men's Diabetes Project Randomized Clinical Control Trial: A Pilot/Feasibility Study of a Peer-Led Diabetes Self-Management and Support Intervention for Black Men With Type 2 Diabetes.

Black men are disproportionately affected by type 2 diabetes (T2D) and experience higher diabetes-related complications than non-Hispanic White men. To address the complex barriers in diabetes self-management for Black men, we implemented a 3-month peer-led and empowerment-based Diabetes Self-Management Education (DSME) and Support (DSMS) intervention in Metro Detroit. Twenty-five Black men ≥55 years of age with self-reported T2D were randomized to the intervention group (n=12)-10 hr of DSME and 9 hr of DSMS-or enhanced usual care (EUC) group (n=13)-10 hr of DSME. Peer leaders (n = 3) were trained by certified diabetes care and education specialists (CDCESs) to cofacilitate the support sessions. Outcomes (hemoglobin A1c [HbA1c], diabetes self-care activities, and diabetes distress) were assessed preintervention and postintervention. In the intervention and EUC groups, mean HbA1c decreased by 0.20% (p = .52, SD = 0.99) and 0.13% (p = .68), respectively. General diet (p = .03, M change: 1.32, SD = 1.71) and blood glucose monitoring (p < .05, M change: 0.50, SD = 0.74) scores improved among those in the intervention group. General diet scores also improved in the EUC group: mean change: 1.77, p = .08, although changes were not statistically significant. Changes in diabetes distress scores differed based on the number of sessions attended, with a significant decrease in those attending 7 to 12 sessions (n = 7), >50%, (p = .003, M change: -5.71, SD = 3.20). Implementing a peer-led DSMS program for Black men was feasible, adopted, and led to positive changes in outcomes. Scaling up the intervention and assessing sustainability is warranted.

An mHealth Text Messaging Program Providing Symptom Detection Training and Psychoeducation to Improve Hypoglycemia Self-Management: Intervention Development Study.

BACKGROUND: Hypoglycemia remains a challenge for roughly 25% of people with type 1 diabetes (T1D) despite using advanced technologies such as continuous glucose monitors (CGMs) or automated insulin delivery systems. Factors impacting hypoglycemia self-management behaviors (including reduced ability to detect hypoglycemia symptoms and unhelpful hypoglycemia beliefs) can lead to hypoglycemia development in people with T1D who use advanced diabetes technology. OBJECTIVE: This study aims to develop a scalable, personalized mobile health (mHealth) behavioral intervention program to improve hypoglycemia self-management and ultimately reduce hypoglycemia in people with T1D who use advanced diabetes technology. METHODS: We (a multidisciplinary team, including clinical and health psychologists, diabetes care and education specialists, endocrinologists, mHealth interventionists and computer engineers, qualitative researchers, and patient partners) jointly developed an mHealth text messaging hypoglycemia behavioral intervention program based on user-centered design principles. The following five iterative steps were taken: (1) conceptualization of hypoglycemia self-management processes and relevant interventions; (2) identification of text message themes and message content development; (3) message revision; (4) patient partner assessments for message readability, language acceptability, and trustworthiness; and (5) message finalization and integration with a CGM data-connected mHealth SMS text message delivery platform. An mHealth web-based SMS text message delivery platform that communicates with a CGM glucose information-sharing platform was also developed. RESULTS: The mHealth SMS text messaging hypoglycemia behavioral intervention program HypoPals, directed by patients' own CGM data, delivers personalized intervention messages to (1) improve hypoglycemia symptom detection and (2) elicit self-reflection, provide fact-based education, and suggest practical health behaviors to address unhelpful hypoglycemia beliefs and promote hypoglycemia self-management. The program is designed to message patients up to 4 times per day over a 10-week period. CONCLUSIONS: A rigorous conceptual framework, a multidisciplinary team (including patient partners), and behavior change techniques were incorporated to create a scalable, personalized mHealth SMS text messaging behavioral intervention. This program was systematically developed to improve hypoglycemia self-management in advanced diabetes technology users with T1D. A clinical trial is needed to evaluate the program's efficacy for future clinical implementation.

Academy of Nutrition and Dietetics: Revised 2022 Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (Competent, Proficient, and Expert) in Adult Weight Management.

A person's weight is an anthropometric measure factored into assessing health risk, not a measure of worth, ability, or overall health. Adult weight management is a spectrum of lifelong care services available for persons whose goals can be achieved through evidence-based, weight-related interventions and intersects most practice areas of nutrition. An adult weight management registered dietitian nutritionist (RDN) is responsible for providing a psychologically safe, accessible, and respectful setting and empowering care to those seeking nutrition services. This requires the RDN to act as an advocate by proactively seeking to identify personal and external weight biases, understanding the influence of those predispositions, and acknowledging how weight-related prejudices are intricately connected with systems that influence nutrition both inside and outside of health care. Increases in average weight influence potentially counterproductive discussions about judgment, an individual's body, and relationship with health. RDNs are equipped to provide dynamic care and be on the forefront of implementing weight-inclusive built environments, policies, and person-centered communications to minimize harm and maximize benefit for the individual and society. The authors, Weight Management Dietetic Practice Group, and the Academy of Nutrition and Dietetics Quality Management Committee revised the Standards of Practice and Standards of Professional Performance for RDNs in Adult Weight Management to update established criteria of competent practice, further define core values, and set direction for future areas of opportunity. The Adult Weight Management Standards of Practice and Standards of Professional Performance are complementary tools intended for RDNs to benchmark and identify progressive routes and goals for professional advancement.

A study of certified diabetes educators: influences and barriers.

PURPOSE: There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators. METHODS: A 30-item questionnaire that addressed 4 areas--demographics, practice characteristics, education program structure, and educational processes--was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis. RESULTS: This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings. CONCLUSIONS: Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

Validation of the Revised Brief Diabetes Knowledge Test (DKT2).

PURPOSE: The purpose of this study is to examine the reliability and validity of the revised Diabetes Knowledge Test (DKT2). The original test was updated to reflect current diabetes care and education guidelines. The test has 2 components: a 14-item general test and a 9-item insulin use subscale. METHODS: Two samples were used to evaluate the DKT2. The first came from an online survey company (Qualtrics, LCC) (n = 101) and the second from University of Michigan's (UofM) Diabetes Registry (n = 89). Cronbach's coefficient alpha was used to calculate reliability. To examine validity, comparisons by type of diabetes, insulin use and oral medication use, and educational level were completed. Correlations between diabetes duration and both the general test and insulin subscale were calculated for the UofM sample. RESULTS: The two samples differed demographically. While the reliabilities between the samples were disparate, when combined, the coefficient alphas demonstrated reliability for both the general test (.77) and the insulin use subscale (.84). The validation comparisons proved to be similar; different results occurred between samples but when combined demonstrated validity. CONCLUSIONS: The reliability and validity tests were inconsistent by sample. The different results can, in part, be attributed to the demographic differences between the 2 samples. With the exception of age, the samples differed in every other measured variable. However, when the samples were combined, the analyses supported the reliability and validity of the Diabetes Knowledge Test 2. The DKT2 is a quick and low-cost method of assessing general knowledge of diabetes and diabetes self-care.

Fruit and vegetable intake in African Americans income and store characteristics.

BACKGROUND: The purpose of this study was to examine whether the characteristics of retail food stores where African-American women shopped mediated the association between their income and intake of fruits and vegetables. Food store characteristics included store type (supermarket, specialty store, limited assortment store, independent grocer), store location (suburbs, city of Detroit), and perceptions of the selection/quality and affordability of fresh produce for sale. METHODS: The analysis drew upon data from a probability sample of 266 African-American women living in 2001 in eastside Detroit, which had no supermarkets. Structural equation modeling was used to calculate a path model of direct and indirect effects. RESULTS: Women shopping at supermarkets and specialty stores consumed fruit and vegetables more often, on average, than those shopping at independent grocers. More positive perceptions of the selection/quality, but not affordability, of fresh produce at the retail outlet where they shopped was positively associated with intake, independent of store type and location as well as age, per capita income, and years of education. The results suggested an indirect association between income and fruit and vegetable intake; women with higher per capita incomes were more likely to shop at supermarkets than at other grocers, which in turn was associated with intake. CONCLUSIONS: Previous studies have shown that few supermarkets are located in the city of Detroit, a symptom of economic divestment over the past several decades. Results of this study suggest this may have negative implications for dietary quality, particularly among lower-income women.

Implementing an empowerment-based diabetes self-management education program.

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants' questions and concerns. Culturally tailored written educational materials were also provided.

Developing a new generation of ongoing: Diabetes self-management support interventions: a preliminary report.

PURPOSE: The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes. METHODS: Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed. RESULTS: Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P < .001), total cholesterol (P < .01), high-density lipoprotein (P < .05), and low-density lipoprotein (P < .001). Significant increases were also found for self-care behaviors (P < .05). CONCLUSIONS: Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Evaluating a problem-based empowerment program for African Americans with diabetes: results of a randomized controlled trial.

OBJECTIVE: The objective of this study was to evaluate the impact of a problem-based empowerment patient education program specifically tailored for urban African Americans with type 2 diabetes. RESEARCH DESIGN AND METHODS: The study used a randomized controlled trial (RCT) pretest/post-test design with repeated measures. Patients were randomly assigned to either a six-week intervention group or a six-week wait-listed control group. After completing the six sessions, patients were invited to participate in one of two follow-up conditions; attend a monthly support group or receive a monthly phone call from a nurse. Assessment measures included HbA1C, lipids, blood pressure, weight, self-management behavior and psychosocial adaptation. RESULTS: Both control and intervention patients showed a broad array of small-to-modest positive changes during the six-week RCT. These gains were maintained or improved upon during the one-year follow-up period. For patients in the two follow-up conditions, a positive correlation was seen between the number of follow-up contacts and their one-year HbA1C values. CONCLUSIONS: We believe that results of this study can be attributed to volunteer bias, study effects (ie, providing study data on several occasions to patients and their physicians during the one-year study period), and impact of the interventions. However, the study design does not allow us to examine the relative impact of these three factors on the patient improvements seen over the one-year study period.

Academy of Nutrition and Dietetics: standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in adult weight management.

Weight management encompasses the inter-relationship of nutrition, physical activity, and health behavior change. Nutrition is key for the prevention and treatment of obesity and chronic disease and maintenance of overall health. Thus, the Weight Management Dietetic Practice Group, with guidance from the Academy of Nutrition and Dietetics Quality Management Committee, has developed Standards of Practice and Standards of Professional Performance for Registered Dietitian Nutritionists (RDNs) in Adult Weight Management as a resource for RDNs working in weight management. This document allows RDNs to assess their current skill levels and to identify areas for further professional development in this expanding practice area. This document describes the current standards for weight management practice for RDNs. The Standards of Practice represent the four steps in the Nutrition Care Process as applied to the care of patients/clients. The Standards of Professional Performance consist of six domains of professionalism: Quality in Practice, Competence and Accountability, Provision of Services, Application of Research, Communication and Application of Knowledge, and Utilization and Management of Resources. Within each standard, specific indicators provide measurable action statements that illustrate how the standard can be applied to practice. The indicators describe three skill levels (competent, proficient, and expert) for RDNs working in weight management. The Standards of Practice and Standards of Professional Performance are complementary resources for the Registered Dietitian Nutritionist in weight management.

Informal diabetes education: impact on self-management and blood glucose control.

PURPOSE: The purpose of this study was to determine if participation in screening clinics to detect and treat diabetes-related eye disease also led to informal patient learning that had an impact on self-management behavior and blood glucose control. METHODS: To evaluate the evidence for patient learning over time, the data of patients who returned as advised for 2 subsequent annual diabetes disease screenings were analyzed. Evaluation measures included medication use, self-management behavior, and hemoglobin A1c (A1C). RESULTS: During the 2-year study period, the use of insulin increased by 37% at the first exam, 43% at the second exam, and 42% at the third exam (P = .02). No significant changes were found in the use of oral medication. Glucose self-monitoring also increased by 61% at the first exam, 71% at the second exam, and 76% at the third exam (P < .01). Mean A1C values for returning participants declined by 9.2% at the first exam, 8.9% at the second exam, and 8.6% at the third exam (P = .03). CONCLUSIONS: The screening clinics had an educational impact associated with behavior change (improved self-management and glucose control) even though the clinics were not intended to produce such change. Therefore, caregivers should consider that patient learning can and should be part of every diabetes care encounter.

Conducting community-based, culturally specific, eye disease screening clinics for urban African Americans with diabetes.

The purpose of this study was to evaluate the need for, and efficacy of, community-based culturally specific eye disease screening clinics for urban African Americans with diabetes. The study employed a variety of culturally specific methods in the design and performance of 43 community-based eye disease screening clinics in southeastern Michigan. One thousand, thirty-seven subjects were recruited for the study. Of that number, 817 identified themselves as African Americans and are the focus of this report. Of the 817 African-American patients screened, 84 (10%) needed to be examined by an ophthalmologist immediately (< 30 days), and 180 (22%) needed to be examined soon (within 1 to 3 months), while 544 (67%) were advised to return for another exam a year later. The project demonstrated that it was possible to use culturally specific techniques to identify a significant number of urban African Americans with diabetes in need of eye screening and treatment. However, lack of health insurance proved to be the primary barrier to receiving needed treatment. Although the project was successful, it is not a solution to what is essentially a health systems problem, ie, inadequate access to appropriate diabetes care for a significant number of our population.

Personalized follow-up increases return rate at urban eye disease screening clinics for African Americans with diabetes: results of a randomized trial.

OBJECTIVE: To evaluate the effectiveness of using personalized follow-up, as compared to reminder letters, in increasing return rates at urban eye disease screening clinics for African Americans with diabetes, and to identify factors predictive of the patient's likelihood of returning for annual follow-up exams. RESEARCH DESIGN AND METHODS: All patients attending free community-based retinopathy screening clinics who were advised to return in one year for another diabetes eye evaluation (DEE) were randomized to standard or personalized follow-up interventions. Patients in the standard follow-up group received reminder letters a month before it was time to return for their next annual DEE. Patients in the intensive personalized intervention also received the letters, but those patients who did not call for an appointment within 10 days received a phone call from project staff, encouraging them to return for a DEE. RESULTS: One hundred thirty-two African Americans with diabetes were randomized to one of the 2 treatments. The return rate for the intensive, personalized follow-up group was 66%, significantly (P=.001) higher than the 35% return rate for the standard follow-up group. CONCLUSION: This study demonstrated the efficacy of personal contact by telephone in improving return rates for annual DEEs in this population of patients. This finding is consistent with one of the key design principles of the project, which was to establish credible personal relationships with community leaders and patients as a means to maximize the utilization of the eye screening clinics.

Outcomes of a church-based diabetes prevention program delivered by peers: a feasibility study.

PURPOSE: This purpose of this study was to investigate the feasibility and potential health impact of a church-based diabetes prevention program delivered by peers. METHODS: Thirteen at-risk African American adults were recruited to a peer-led diabetes prevention program adapted from the National Diabetes Education Program's Power to Prevent curriculum. The program consisted of 6 core education sessions followed by 6 biweekly telephone support calls. Components of feasibility examined included recruitment, attendance, and retention. Baseline, 8-week, and 20-week assessments measured clinical outcomes (percentage body weight change, waist circumference, lipid panel, blood pressure) and lifestyle behaviors (eg, physical activity and diet). RESULTS: Of the 13 participants enrolled at baseline, 11 completed the intervention. Mean attendance across 6 core sessions was 5.2 classes (87%). At 8 weeks, significant improvements were found for physical activity (P = .031), waist circumference (P = .049), serum cholesterol (P = .036), systolic blood pressure (P = .013), and fat intake (P = .006). At 20 weeks, not only did participants sustain the improvements made following the core intervention, but they also demonstrated additional improvements for HDL (P = .002) and diastolic blood pressure (P = .004). CONCLUSION: Findings suggest that it is feasible to conduct a peer-led diabetes prevention program in a church-based setting that has a potentially positive impact on health-related outcomes.

Health literacy among insulin-taking African Americans: a need for tailored intervention in clinical practice.

AIMS: To determine the levels of functional health literacy (FHL) among insulin-taking African Americans with diabetes from an urban medical practice and to determine if associations exist between FHL levels and glycemic control. METHODS: Seventy insulin-taking African Americans seen for diabetes management comprised the analysis cohort. Patients were 18 years or older, African American, had diabetes, and currently using insulin via syringe, pen, or insulin pump. All participants completed a one-time assessment of FHL levels, using the Newest Vital Sign (NVS). Scores ranged from 0 to 6 (0-1 = high likelihood of limited FHL; 2-3 = possibility of limited FHL; 4-6 = adequate FHL). A combination of t tests, Pearson's chi-square tests, and multivariate logistic regression models were used to determine associations between glycemic control and FHL. RESULTS: Average age was 58.7, 59.1% were female, 90.8% with type 2 diabetes, and 15.1% using an insulin pump. Glycemic control was: A1C < 7%: 22.9%, A1C < 8%: 47.1%. Of participants, 47.1% had adequate FHL, 31.4% had possible limited FHL, and 21.4% had a high likelihood of limited FHL. Also, 67.7% of participants with A1C ≥ 8% had a high likelihood of limited FHL. After adjusting for age and gender, participants with a high likelihood of limited FHL were 6.2 times (95% confidence interval [CI], 1.4-28.3) more likely to have A1C ≥ 8%. CONCLUSIONS: Insulin-taking African Americans with a high likelihood of limited FHL are approximately 6 times more likely to have an A1C ≥ 8% compared to patients with a possibility of limited FHL, or adequate FHL, demonstrating the need for focused interventions tailored to FHL needs.