The purpose of this article is to examine how Chinese herbal medicines are used in the treatment of diabetes, focusing on potential benefits and risks.
Methods
Medline, expert interviews, and Internet searches were used to identify Chinese herbal medicines with antidiabetic properties and their diabetes-related health claim, proposed antidiabetic effect, adverse effects, contraindications, and drug interactions.
Results
Twenty-three herbs and 5 herbal formulas were selected for review. Antidiabetic health claims included increasing serum insulin, decreasing blood glucose, increasing glucose metabolism, and/or stimulating pancreatic function. Side effects were few or not reported.
Conclusions
The use of Chinese herbal medicines in diabetes is promising but still far from proven. Diabetes educators need to be aware of the risks and benefits of herbal medicines. Patients should be asked about the use and source of herbal medicines and carefully monitored for drug interactions and adverse effects.
]]>The purpose of this study is to compare glycemic control between blacks and whites in a setting where patient and provider behavior is assessed, and where a uniform treatment algorithm is used to guide care.
Methods
This observational cohort study was conducted in 3542 patients (3324 blacks, 218 whites) with type 2 diabetes with first and 1-year follow-up visits to a municipal diabetes clinic; a subset had 2-year follow-up. Patient adherence and provider management were determined. The primary endpoint was A1c.
Results
At presentation, A1c was higher in blacks than whites (8.9% vs 8.3%; P < .001), even after adjusting for demographic and clinical characteristics. During 1 year of follow-up, patient adherence to scheduled visits and medications was comparable in both groups, and providers intensified medications with comparable frequency and amount. After 1 year, A1c differences decreased but remained significant (7.7% vs 7.3%; P = .029), even in multivariable analysis (P = .003). However, after 2 years, A1c differences were no longer observed by univariate (7.6% vs 7.5%; P = .51) or multi-variable analysis (P = .18).
Conclusions
Blacks have higher A1c than whites at presentation, but differences narrow after 1 year and disappear after 2 years of care in a setting where patient and provider behavior are comparable and that emphasizes uniform intensification of therapy. Presumably, racial disparities at presentation reflected prior inequalities in management. Use of uniform care algorithms nationwide should help to reduce disparities in diabetes outcomes.
]]>The purpose of this study was to document barriers and facilitators of self-management as perceived by adolescents with type 2 diabetes.
Methods
Focus groups were conducted with adolescents diagnosed with type 2 diabetes. Adolescents aged 13 to 19 years were recruited from an academic medical center diabetes clinic. Between 2003 and 2005, 6 focus groups were used to elicit responses from the adolescents related to self-management of their diabetes. Questions were asked by trained group facilitators. Transcripts were coded by 3 reviewers. Qualitative analyses were conducted using NVIVO software.
Results
A total of 24 adolescents participated in 6 focus groups. Coding resulted in 4 common domains affecting self-management: adolescent psychosocial development; the role of others with diabetes; environmental influences; and adolescents' problem-solving/coping skills. Adolescents identified both barriers to and facilitators of self-management within each domain. Barriers often related to social situations, embarrassment, seeking acceptance or perceived normalcy, and balancing competing interests. Adolescents viewed having another family member with diabetes as both a positive and a negative influence. Environmental influences, including school and family situations, had a large impact on self-management behaviors. Making sensible food choices was a common challenge. Descriptions of problem-solving or coping skills were limited, but cognitive techniques, such as reframing, were described.
Conclusion
Adolescents with type 2 diabetes identified many barriers to self-management, particularly related to interpersonal interactions, the influence of others with diabetes, and environmental influences. Results suggest that improving self-management in adolescents may require multimodal interventions to address individual, family, and social processes.
]]>The purpose of this study is to evaluate the content and adequacy of emergency department (ED) discharge instructions and factors associated with hospitalization in patients presenting with hypoglycemia.
Methods
This is a retrospective cohort study at 3 adult EDs. A 1-year consecutive sample of hypoglycemia cases were identified using ICD-9-CM codes and were confirmed by chart review. Clinical variables and written discharge instructions were analyzed by chart abstraction.
Results
Six hundred thirty-six charts of patients with possible hypoglycemia were reviewed, of which 436 (64%) hypoglycemia cases were confirmed. The median age was 64. Hypoglycemia was associated with sulfonylurea use for 78 (16%) patients and insulin alone for 286 (65%) patients. Written discharge instructions advised frequent blood glucose checks in 21% of patients and medication dose adjustment in 27% of patients and rarely recommended avoiding recurrent hypoglycemia (3%), checking glucose before driving (0.4%), or obtaining glucagon emergency kits (2%). Hospitalization resulted from 177 (41%) visits and was associated with older age (age 65-74 [odds ratio 5.7] and age ≥75 [odds ratio 7.9]), sulfonylurea use (odds ratio 3.5), ≥3 hypoglycemic episodes (odds ratio 3.1), no documented diabetes medications (odds ratio 2.1), current primary care provider (odds ratio 4.2), and hypoglycemia as a secondary diagnosis (odds ratio 4.7).
Conclusions
ED written discharge instructions appeared inadequate in providing recommended education for patients with severe hypoglycemia. Older age and sulfonylurea use were independently associated with hospital admission. Although hypoglycemia is generally considered a self-limited condition, 2 of every 5 patients required hospitalization, which likely reflects an older and more complex patient population.
]]>The purpose of this study is to characterize the adherence and medication management barriers for adults with poorly controlled type 2 diabetes mellitus (DM) (those with A1c 9% or above) and to identify specific adherence characteristics associated with poor diabetes control.
Methods
This was a cross-sectional analysis of baseline data from a randomized,
controlled diabetes intervention conducted in University of Washington (UW)
Medicine Clinics in the greater Seattle, Washington,
area.
Results
Seventy-seven subjects (mean A1c, 10.4%; mean duration of DM, 7 years) were studied. The most common adherence challenges included paying for medications (34%), remembering doses (31%), reading prescription labels (21%), and obtaining refills (21%). Taking morethan 2 doses of DM medication daily (β = .78, SE = 0.32, P = .02) and difficulty reading the DM medication prescription label (β = .76, SE = 0.37, P = .04) were significantly associated with higher hemoglobin A1c. Self-reported adherence was not related to A1c control.
Conclusions
In this study, we identified 2 factors that were associated with poorer A1c control. These findings highlight the importance of identifying potential challenges to medication adherence for those with DM and providing support to minimize or resolve these barriers to control.
]]>The purpose of this study was to evaluate the effects of a culturally sensitive diabetes education program for Hispanics with type 2 diabetes.
Methods
This study is a prospective cohort study to test the impact of a comprehensive diabetes education program on blood glucose control on Hispanics with type 2 diabetes. The educational program focused on maintaining glycemic control and general aspects of managing diabetes and complications. The study participants were recruited by flyers placed in Hispanic markets and in ambulatory care clinics. A total of 34 Hispanic male and female subjects with type 2 diabetes participated in the study. The concentrations of glucose, insulin, hemoglobin A1c (HbA1c), total cholesterol, triglycerides, low-density lipoprotein and high-density lipoprotein (HDL) cholesterol were analyzed at baseline and at 3 months.
Results
A significant mean change was observed for HbA1c, fasting plasma glucose, cholesterol/HDL ratio, and HDL after 3 months of education compared with baseline. There were significant reductions in weight, total fat, percent fat, trunk fat, and waist-to-hip ratio compared with baseline. After 3 months, subjects showed a significant positivecorrelation between changes in body mass index and insulin and weight, total fat, trunk fat, and fat free mass and insulin.
Conclusions
A culturally sensitive program conducted in Spanish had a significant impact on important clinical parameters in Hispanic subjects with diabetes in a relatively short time period. The study demonstrates the importance of designing education intervention studies that are sensitive to cultural diversity, particularly in at-risk diabetic subjects.
]]>Few comprehensive and practical instruments exist to measure the receipt of self-management support for chronic illness. An instrument was developed to measure resources and support for self-management (RSSM) for the survey component of the evaluation of the Robert Wood Johnson Foundation's Diabetes Initiative. It includes items to measure an ecological range of RSSM. This article describes the development and validation of the instrument, focusing on individuals' reported access to RSSM from providers and from nonclinical, social, and community sources.
Methods
Cross-sectional analyses of the second wave of a survey of participants in the Diabetes Initiative (68% response rate, n = 957) were used.
Results
Confirmatory factor analyses supported grouping the 17 items into 5 subscales, measuring key aspects of RSSM: individualized assessment, collaborative goal setting, enhancing skills, ongoing follow-up and support, and community resources (comparative fit index = 0.97, Tucker-Lewis fit index = 0.99, and root meansquare error of approximation = 0.06). The overall scale and 5 subscales were internally consistent (Cronbach ≥ .70) and were significantly, positively related to diabetes self-management behaviors, supporting their construct validity.
Conclusions
This instrument shows promise for measuring RSSM. Although it was developed for diabetes programs, its ecological orientation and link to the broad framework of chronic care suggest broader application.
]]>To examine the associations between 2 potential facilitators of healthy behaviors (self-efficacy and social support), and both physical activity and body mass index (BMI) among women with histories of gestational diabetes mellitus (GDM).
Methods
Two hundred and twenty-eight women with histories of GDM who were enrolled in a managed care plan were surveyed. A cross-sectional analysis was used to assess the association between women's social support from family and friends for physical activity and self-efficacy for physical activity with women's physical activity levels. The association between women's social support from family and friends for healthy diet and self-efficacy for not overeating and their dietary habits also were examined. Finally, the association between all of these psychosocial constructs and body mass index (BMI) were assessed before and after adjustment for covariates.
Results
Participants reported low to moderate social support and self-efficacy scores, suboptimal performance of physical activity, suboptimal dietary scores, and high BMIs. Self-efficacy and social support from family and friends for physical activity were associated with physical activity. Social support from family and friends for a healthy diet was associated with better dietary scores, and the association between self-efficacy for not overeating and healthy diet bordered on significance. No significant associations existed between psychosocial constructs and BMI.
Conclusions
Psychosocial constructs such as social support and self-efficacy are associated with physical activity and dietary habits. However, associations with BMI are weak. Further exploration of constructs associated with BMI may be needed to design effective weight-loss interventions in this population.
]]>Most drugs currently used to treat diabetes address the primary metabolic defects in type 2 diabetes mellitus, which are insulin resistance and pancreatic islet dysfunction. Incretin augmentation therapies, such as glucagon-like peptide-1 receptor agonists and dipeptidyl peptidase IV inhibitors, restore glucose homeostasis by addressing some of the unmet needs in diabetes therapies related to -cell dysfunction and chronic β-cell dysfunction. This new group of drugs offers certain advantages because its use is characterized by a low incidence of hypoglycemia and the absence of weight gain. Moreover, the use of fixed-dose combinations of dipeptidyl peptidase IV inhibitors with other oral antidiabetic agents seems very attractive to patients because of their reduced pill intake and minimized financial burden, which may improve adherence.
An efficient strategy to slow down the epidemic of diabetes must include these emerging therapies and regimens, coupled with intensive patient education that includes information on treatment benefits and adverse effects, medication costs, and medication regimen complexity.
]]>The purpose of this study was to examine the relationships between maternal environment (child behavior and coping resources), diabetes self-efficacy, diabetes management behaviors, and child glycemic control.
Methods
Study participants were recruited from 3 outpatient clinics in the Midwest and included 41 mothers of children with type 1 diabetes, ages 6 to 10. All participants completed the following measures: Coping Resources Inventory, Behavioral Assessment System for Children-Parent Report, Maternal Self-Efficacy for Diabetes Scale, Diabetes Management Scale—Parent, and 24-hour diabetes behavior recall. Downloaded glucose data and child HgbA1c were obtained by chart review. Stepwise multiple regression was used to determine the influence of maternal environment on maternal diabetes self-efficacy and diabetes management behavior. Pearson product moment correlations were used to determine if relationships existed between maternal self-efficacy, diabetes management behaviors, and child metabolic control.
Results
Coping resources contributed significantly to mothers' diabetes self-efficacy. No significant relationship was found between the mothers' environment and diabetes management behavior. Self-efficacy did not predict maternal diabetes management behaviors. The blood glucose testingand maternal recall of diabetes behaviors were correlated to metabolic control.
Conclusions
Mothers with coping resources felt more confident in managing their children's diabetes. Child behavior did not influence a mother's diabetes management behaviors. Mothers who were consistent in their diabetes management behaviors had children in better metabolic control. More information is needed to determine what mothers view as barriers in providing diabetes care for their children.
]]>The purpose of this study was to examine coronary heart disease (CHD) risk perception, risk factor status, and factors associated with CHD risk perception in Korean immigrants with type 2 diabetes mellitus.
Methods
A community sample of 143 Korean adults with type 2 diabetes, aged 30 to 80 years old, completed questionnaires and biological measures. A multiple regression analysis was conducted to evaluate the relationships between CHD knowledge, general health, smoking, medications for CHD risk factors, demographic variables (independent variables), and the perception of CHD risk (dependent variable).
Results
Participants had low perception of CHD risk, with most (76.9%) indicating their risk to be the same or lower than people of the same age and sex in the general population. Overall, CHD risk factor control was suboptimal according to American Diabetes Association guidelines. Only 41.3% of participants met the HbA1c goal of less than 7%. More than half (55%) had uncontrolled blood pressure, and a similar proportion (53.6%) had higher low-density lipoprotein cholesterol than the target goal. CHD knowledge and self-reported general health influenced the perception of CHD risk. More CHD knowledge and poor general health were associated with higher perception of CHD risk.
Conclusions
To increase the perception of CHD risk in Korean immigrants with type 2 diabetes, diabetes educators and clinicians should educate such patients about CHD risk factors and discuss their risk status at every visit. Those who report their health to be good deserve particular attention.
]]>The purpose of this review was to propose a model that describes the influences on the behavior and psychological functioning of people at risk for diabetes-related foot complications.
Methods
A literature search was conducted in Medline (1950-2005), CINAHL (1982-2005), and PsycInfo (1967-2005) databases and in reference lists of journal articles and relevant books. The search focused on published literature in the English language that was related to concepts such as diabetes-related foot complications, behavior, and psychology.
Results
The literature reviewed was arranged to reflect the reciprocal relationship between the personal, environmental, and behavioral factors of people at risk of diabetes-related foot complications. The model proposed uses the concept of reciprocal determinism to illustrate how these factors interact and influence the development of diabetes-related foot complications.
Conclusion
The concept of reciprocal determinism may be useful when developing further investigation into educational and behavioral interventions in this clinical population.
]]>The purpose of this study was to describe how coping styles among African Americans with type 2 diabetes relate to diabetes appraisals, self-care behaviors, and health-related quality of life or well-being.
Methods
This cross-sectional analysis of baseline measures from 185 African Americans with type 2 diabetes enrolled in a church-based randomized controlled trial uses the theoretical framework of the transactional model of stress and coping to describe bivariate and multivariate associations among coping styles, psychosocial factors, self-care behaviors, and well-being, as measured by validated questionnaires.
Results
Among participants who were on average 59 years of age with 9 years of diagnosed diabetes, passive and emotive styles of coping were used most frequently, with older and less educated participants using more often passive forms of coping. Emotive styles of coping were significantly associated with greater perceived stress, problem areas in diabetes, and negative appraisals of diabetes control. Both passive and active styles of coping were associated with better diabetes self-efficacy and competence in bivariate analysis. In multivariate analysis, significant proportions of the variance in dietary behaviors and mental well-being outcomes (general and diabetes specific) were explained, with coping styles among the independent predictors. A positive role for church involvement in the psychological adaptation to living with diabetes was also observed.
Conclusions
In this sample of older African Americans with diabetes, coping styles were important factors in diabetes appraisals, self-care behaviors, and psychological outcomes. These findings suggest potential benefits in emphasizing cognitive and behavioral strategies to promote healthy coping outcomes in persons living with diabetes.
]]>The purpose of this study is to explore the attitudes that contribute to psychological insulin resistance (PIR) in insulin-naive patients with type 2 diabetes and to identify predictors of PIR.
Methods
A prospective study using 2 self-report surveys and incorporating demographic and health variables was conducted to determine the prevalence of PIR among a sample of 100 adult, insulin-naive patients with type 2 diabetes at an outpatient diabetes center in a university-affiliated teaching hospital.
Results
Thirty-three percent of patients with type 2 diabetes were unwilling to take insulin. The most commonly expressed negative attitudes were concern regarding hypoglycemia, permanent need for insulin therapy, less flexibility, and feelings of failure. Less than 40% expressed fear of self-injection or thought that injections were painful. However, compared with willing subjects, unwilling subjects were more likely to fear injections and thought injections would be painful, life would be less flexible, and taking insulin meant health would deteriorate (P < .005 for all comparisons). Poorer general health and higher depression scores also correlated with PIR.
Conclusions
The results of the surveys, which were generally consistent, identified several remediable misconceptions regarding insulin therapy and suggest targets for educational interventions.
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