The purpose of this article is to discuss practical approaches to the use of self-monitoring of blood glucose (SMBG) in clinical practice using paired glucose testing. A rationale for SMBG use and innovative tools for data collection and analysis are presented.

Method

Health care professionals from various medical specialties collaborated to review current evidence regarding the value and utility of SMBG and to formulate professional opinions regarding use of SMBG. The literature review included key SMBG studies from 2002 through 2009. Established guidelines, position papers, and other evidence were also reviewed for this report. Reference Manager Software was used to search ISI Web of Science, PubMed, and Z39.50 site databases.

Results

Although the utility of SMBG in non–insulin-treated type 2 diabetes remains controversial, a recent report from the International Diabetes Federation recommends SMBG use in this population if it is used to educate/motivate individuals and/or monitor and adjust therapy. Health care providers must develop strategies to use SMBG in ways that address these criteria.

Conclusions

Paired SMBG (testing before/after specific events) promotes diabetes knowledge and self-management skills and facilitates assessment of the impact of behavioral changes, medical nutrition therapy, and pharmacologic interventions on glycemic levels. New tools have been developed to assist in using paired testing in clinical practice.

The purpose of this article is (1) to investigate if type 2 diabetes management programs with Latino participants address emotional well-being in addition to the standard diabetes self-care behaviors and (2) to describe the approaches taken to improve psychological and diabetes management outcomes.

Methods

Online article and research databases, Internet searches, and review of article citations were used to identify relevant articles published 1995-2008. Type 2 diabetes management interventions with a psychological (emotion or cognitive) component or outcome measure and Latino sample were selected. Articles were limited to randomized clinical/controlled trials and pre-post comparative studies.

Results

Thirteen interventions met the inclusion criteria for this review. Eight studies included emotion outcome measures, and 13 included at least one cognitive outcome measure. One study was specifically designed to improve emotional well-being. This study was not targeted for Latinos but did include Latino participants. A specialized depression case manager and collaborative care model showed significant improvements in depression and mental functioning. Psychological improvements were also found in those studies that assessed cognitive outcomes and were based on cognitive theories. The most frequent cognitive outcomes assessed were diabetes knowledge, problem solving, and self-efficacy.

Conclusions

Few type 2 diabetes interventions address emotional well-being in Latinos. More attention has been directed toward designing culturally sensitive community-based programs for improving behavior and physical outcomes. Because some Latino groups believe that negative emotions cause diabetes and because depression and anxiety are associated with poor self-management, programs should address emotional well-being as an important aspect of diabetes management.

The purpose of this study is to examine the association between family history of diabetes (FHD), body mass index (BMI), and acculturation with children's BMI status.

Methods

Baseline data from a randomized community intervention trial promoting healthy eating and physical activity were collected in children living in San Diego, California. A self-administered survey was completed by primary caregivers at each school assessing maternal diabetes, BMI, acculturation, and socioeconomic status (SES). Anthropometric data (height, weight, and BMI) from mothers and children were also collected.

Results

A total of 812 caregivers completed the baseline survey. Adjusting for maternal age, marital status, and socioeconomic level, women who had been diagnosed with diabetes or gestational diabetes or who received diabetes treatment were significantly more likely to have overweight children. Maternal BMI was also associated with children's weight. Maternal acculturation level was marginally associated with children's BMI.

Conclusions

FHD, gestational diabetes, and BMI were associated with children's overweight status. More comprehensive interventions are needed to prevent obesity in Latino children and adults.

The purpose of this project is to identify rates of depression and document mental health needs of adults with diabetes who obtained care in free clinics. Data were collected to determine if there is a relationship between diabetes and depression and missed appointments in a sample of patients who were low-income, uninsured, and represented a variety of racial groups.

Methods

A sample of 183 adults with diabetes participated by completing paper and computerized questionnaires. Instruments included the Patient Health Questionnaire 9 (to measure prevalence of depression), the RAND 36 Health Survey (to measure quality of health), the Audit of Diabetes Dependent Quality of Life (to measure diabetes-dependent quality of life), and the Diabetes Empowerment Scale (to measure self-efficacy).

Results

The prevalence of depression at a moderate or greater level in the sample was found to be 30.1%. Levels of quality of health and self-efficacy were found to be reduced among those with the presence of depression. A significant increase in the rate of depression was found among those who had attended the free clinic for a longer period. No significant differences were found in diabetes-dependent quality of life and missed appointments among those with depression compared with those without.

Conclusions

Rates of depression among adults with diabetes in a free clinic setting were found to be comparable with the highest rates reported by other studies of insured populations. Results of this study support the need to develop mental health treatment programs for free clinic settings.

The purpose of this study was to examine the influence of diet family support on glucose outcome in Korean immigrants with type 2 diabetes, taking into consideration patient gender.

Methods

A total of 143 Korean immigrants with type 2 diabetes were recruited from a West Coast Koreatown. On completing questionnaires (demographic, health history, and the Diabetes Family Behavior Checklist-II [DFBC]), a participant was given a finger stick blood test for glycosylated hemoglobin (A1C). Body mass index (BMI) and waist-to-hip ratio (WHR) were calculated after measurements were taken. Analyses assessed the independent associations of diet family support, gender, and diet family support by gender interactions with glucose outcome.

Results

A higher level of diet family support was significantly associated with lower A1C, indicating the beneficial effect of diet family support on glucose control. Although the main effect of gender on A1C was not significant, the effect of the product term of family support and gender was, indicating that the significant beneficial impact of diet family support on A1C depends on gender. The impact is much more pronounced in men (B = -.516) than women (B = -.038).

Conclusions

Family support, specific to diet, is significantly associated with glucose outcomes in Korean immigrants with type 2 diabetes. That is, more perceived family support was associated with better glucose control. The positive impact of family support on glucose outcome was significantly stronger in men than in women, even after other factors were taken into consideration.

The purpose of this study is to test the efficacy of a culturally tailored comprehensive type 2 diabetes management intervention for Korean American immigrants (KAIs) with type 2 diabetes.

Methods

A randomized controlled pilot trial with 2 parallel arms (intervention vs control) with a delayed intervention design was used. A total of 79 KAIs, recruited from the Baltimore-Washington area, completed baseline, 18-week, and 30-week follow-ups (intervention, n = 40; control, n = 39). All participants had uncontrolled type 2 diabetes (hemoglobin A1C ≥7.5%) at baseline. The authors' comprehensive, self-help intervention program for type 2 diabetes management (SHIP-DM) consisted of a 6-week structured psychobehavioral education, home glucose monitoring with teletransmission, and bilingual nurse telephone counseling for 24 weeks. The primary outcome of the study was A1C level, and secondary outcomes included an array of psychobehavioral variables.

Results

Using analysis of covariance, the findings support that the proposed intervention was effective in significantly lowering A1C and fasting glucose and also in improving psychosocial outcomes in the sample. Specifically, the amount of reduction in A1C among intervention group participants was 1.19% at 18 weeks and 1.31% at 30 weeks, with 10% and 15.5% of the participants achieving the suggested goal of A1C <7% at 18 and 30 weeks of follow-up, respectively.

Conclusions

The results highlight the clinical efficacy of the SHIP-DM intervention composed of a 6-week education program, self-monitoring, and follow-up counseling, in terms of maintaining the improved intervention effects obtained and in terms of glucose control.

The purpose of this pilot study was to test a dance intervention and explore the role of peer support to improve the diabetes outcomes of A1C, weight, body fat, and blood pressure in African American women with type 2 diabetes.

Methods

This study was conducted in a community-based outpatient clinic. A mixed methods design was used. A total of 46 women, 26 to 83 years of age, were randomized to either the 12-week dance group or usual care group. Both between group and intraindividual group differences were analyzed from baseline to 12 weeks. Focus group interviews explored the role of peer support through semistructured discussions for the women enrolled in the dance group.

Results

Results showed significant group mean differences in systolic blood pressure (BP) and body fat. Paired t tests showed significant reductions in all the diabetes outcomes for the dance group and significant increases in glycolated hemoglobin (A1C) and systolic BP for the usual care group. The emergent themes of the focus groups were that a diabetes diagnosis was devastating, and changing eating habits and taking medications was often difficult. Peer support in the dance group was expressed as camaraderie, enjoyment, and laughter, which fostered attendance.

Conclusions

Dancing 2 times per week for 12 weeks produced significant group differences in systolic BP and body fat and significant intraindividual changes. The implications are that dancing in a supportive environment with peers may be an effective strategy for diabetes educators to help those with diabetes to become more physically active and improve diabetes outcomes and overall health.

Purpose

The authors assessed the effect of a medical nutrition therapy (MNT) program on perinatal complications in Mexico City.

Methods

Quasi-experimental design with a historical control. Women were assigned to a MNT program (n = 88) and were followed up with every 2 weeks until delivery (2004-2007). The control group (n = 86) was selected from medical charts (2001-2003) and the same inclusion criteria were used. In each group, 55% of women had type 2 diabetes mellitus and 45% had gestational diabetes. The MNT program included a moderate intake of carbohydrate (40%-45% of total energy) and reduction in energy intake, capillary glucose self-monitoring, and education. The control group received usual hospital routine care. Statistical analysis included descriptive statistics, chi-square, and multivariate logistic regression (OR, 95% CI) as indicated.

Results

Women in the MNT program had a lower risk of preeclampsia, fewer maternal hospitalization, and neonatal deaths in both types of diabetes. Low birth weight was less frequent only in women with gestational diabetes receiving MNT, while neonatal intensive care unit admissions were lower only in women with type 2 diabetes.

Conclusions

An intensive MNT program, including counseling, education, and capillary glucose self-monitoring, has a positive effect over preeclampsia, maternal hospitalization, and neonatal death in women with diabetes in pregnancy. MNT guidelines should be implemented in Mexican health care facilities treating diabetes in pregnancy.

To compare patients' perceptions of injection-related problems with clinicians' estimates of those problems.

Methods

Data were obtained through 2 Internet surveys, one of US adults self-identified as taking insulin to treat diabetes and the second of health care professionals who treat people with diabetes who inject insulin, including primary care physicians, endocrinologists, and diabetes educators.

Results

A substantial majority of patients would like to reduce the number of injections they take each day; almost half said that they would be more likely to take their insulin injections regularly if a product were available to ease the pain. A much smaller proportion of patients reported that (1) injections were a serious burden, (2) they were dissatisfied with the way they took insulin, (3) injections had a substantial negative impact on quality of life, (4) they skipped injections they should take, or (5) injection-related problems affected the number of injections they were willing to take. Half of the patients said they mentioned injection-related problems to their provider; a similar number reported that their providers had not given them a solution to problems with injection-related pain and bruising. Although awareness of products to ease injection pain was high among providers (especially diabetes educators), this information was not effectively transmitted to patients.

Conclusions

Patients should be encouraged to discuss their injection-related concerns, and providers should regularly ask about injection-related problems. Providers should offer patients information about tools to reduce injection-related worries, preferably by having them available to show and demonstrate.

This article shares an innovative educational practice for increasing the knowledge base of direct-care registered nurses related to diabetes management. Outcome data include quantitative analysis of test scores, qualitative responses of changes in practice, and participation in monthly diabetes resource meetings.

Conclusion

Diabetes educators will find the DiaBEATes Nurse Champion program useful for structuring educational programs within various practice settings. The case studies are useful tools for evaluating specific application of diabetes knowledge.

Background

The nearly 24 million people with diabetes strain the health care system in terms of resources and health care dollars. According to the American Diabetes Association (ADA) a hospital stay for a patient with diabetes costs almost 3 times the stay of a patient without diabetes.¹ The higher costs associated with caring for a patient with diabetes is partly attributed to inadequate knowledge regarding current diabetes treatment options and the failure of some health care workers to accept professional responsibility for diabetes management.^2,3

More than 24 million adults and children in the United States are living with diabetes, and the vast majority of those individuals have type 2 diabetes. The clinical benefits of good glycemic control have been well established. Most patients eventually require the use of multiple hyperglycemic drugs in combination to approach or achieve the American Diabetes Association's recommended target A1C value of 7%. The role of incretin-based therapies for both glycemic control and β-cell protection has become an area of intense interest and development. Although current practice guidelines do not include specific recommendations about when and how to incorporate incretin-based agents, a consensus statement published by the American Diabetes Association/European Association for the Study of Diabetes suggests the addition of a glucagon-like peptide-1 (GLP-1) agonist for patients not at goal A1C with metformin and lifestyle changes. The goal of this article is to review this class of agents, discuss their role in the treatment of type 2 diabetes, and address the practical aspects of integrating incretin-based agents into the management of patients with diabetes.

Conclusion

Currently, 3 incretin-based therapies are available and widely used in clinical practice. Several more agents are either under review by the Food and Drug Administration (FDA) or are in the very late stages of development. For diabetes educators trying to help their patients understand the differences among their antidiabetic medications, a comprehensive understanding of these agents and their role in therapy is imperative.

The purpose of this study was to evaluate the impact of diabetes self-management education/training (DSME/T) on financial outcomes (cost of patient care).

Methods

Commercial and Medicare claims payer-derived datasets were used to assess whether patients who participate in diabetes education are more likely to follow recommendations for care than similar patients who do not participate in diabetes education, and if claims of patients who participate in diabetes education are lower than those of similar patients who do not.

Results

Patients using diabetes education have lower average costs than patients who do not use diabetes education. Physicians exhibit high variation in their referral rates to diabetes education.

Conclusions

The collaboration between diabetes educators and physicians yields positive clinical quality and cost savings. The analysis indicates that quality can be improved, and cost reduced, by increasing referral rates to diabetes education among low-referring physicians, specifically among men and people in disadvantaged areas. More needs to be done to inform physicians about ways to increase access to diabetes education for underserved populations.

The purpose of this study is to estimate the cost-effectiveness of diabetes self-management programs in real-world community primary care settings. Estimates incorporated lifetime reductions in disease progression, costs of adverse events, and increases in quality of life.

Methods

Clinical results and costs were based on programs of the Diabetes Initiative of the Robert Wood Johnson Foundation, implemented in primary care and community settings in disadvantaged areas with notable health disparities. Program results were used as inputs to a Markov simulation model to estimate the long-term effects of self-management interventions. A health systems perspective was adopted.

Results

The simulation model estimates that the intervention does reduce discounted lifetime treatment and complication costs by $3385, but this is more than offset by the $15 031 cost of implementing the intervention and maintaining its effects in subsequent years. The intervention is estimated to reduce long-term complications, leading to an increase in remaining life-years and quality-adjusted life-years (QALYs). The incremental cost-effectiveness ratio is $39 563/QALY, well below a common benchmark of $50 000/QALY. Sensitivity analyses tested the robustness of the model's estimates under various alternative assumptions. The model generally predicts acceptable cost-effectiveness ratios.

Conclusions

Self-management programs for type 2 diabetes are cost-effective from a health systems perspective when the cost savings due to reductions in long-term complications are recognized. These findings may justify increased reimbursement for effective self-management programs in diverse settings.

The purpose of this study was to examine the association between cardiovascular risk factors and the presence of diabetes in a large population-level dataset.

Methods

A secondary analysis was conducted using data from the 2007 Behavioral Risk Factor Surveillance System, a population-based survey (n = 403,137) conducted in the United States.

Results

The majority of the respondents were middle-aged and overweight. Approximately half of the sample reported little or no physical activity. Estimates from a logistic regression model for a weighted sample of white, black, and Hispanic adults revealed that having hypertension or elevated cholesterol was a strong predictor of diabetes even when controlling for age, gender, race, education, income, body mass index, smoking status, and physical activity.

Conclusions

The results confirmed the importance of diabetes educators counseling patients with hypertension or hypercholesterolemia about their increased risk for developing diabetes.

The purpose of this study was to explore individual, educational, and system barriers that limit low-income diabetes patients' ability to achieve optimal diabetes self-management.

Methods

Economically disadvantaged patients with diabetes who used the Diabetes Clinic of Grady Health System in Atlanta, Georgia, participated in 3 focus group discussions.

Results

The discussions were held with mostly African Americans (n = 35) to explore barriers to achieving optimal diabetes self-management. Most participants were not married, approximately one-third had less than high school level reading skills, and 40% were not currently working. In terms of individual barriers, the emotional toll from the diagnosis of and lifestyle changes to treat diabetes was a recurrent theme, and included stress, frustration, social isolation, interpersonal conflicts, depression, and fear. Denial was often mentioned as the key factor that inhibited adherence to a healthy mode of living. The educational barriers were failure to recognize the risks and consequences of an asymptomatic condition. Many participants did not understand A1C. Finally, several system barriers were identified. The participants identified needed services, including follow-up and refresher courses, support group discussions, nutrition and medication education, availability of different education modalities, and expanded clinic hours.

Conclusions

The focus group discussions identified both barriers to diabetes management and opportunities for improving care for underserved patients with diabetes. The results are useful to improve the delivery of care and to develop quantitative studies to explore particular areas of interest. Based on these results, the current system needs to provide more support and education to patients with diabetes.

The purpose of this study was to compare pen device-naïve patients' preferences for Humalog® KwikPen^TM (insulin lispro injection) (Eli Lilly and Company, Indianapolis, IN) to use of a vial and syringe and FlexPen® (insulin aspart injection) (Novo Nordisk A/S, Bagsvaerd, Denmark).

Methods

This open-label, randomized, crossover 1-day study tested the hypotheses that KwikPen was preferred to vial and syringe, and if this was found to be a significant preference, that KwikPen was preferred to FlexPen. Accuracy of doses prepared, ease of use via insulin device assessment battery, and preference via insulin device preference battery were administered following each pen evaluation, and a final preference question administered following the evaluation of both pens. Clinical measures were not included as subjects injected into an appliance to simulate the inje tion experience. Primary outcome variables were evaluated by Question 13 of the insulin device preference battery and the final preference question.

Results

Among 232 enrolled patients randomized to 1 of 4 sequences (n = 58), Humalog KwikPen was significantly preferred over vial and syringe and over FlexPen. After patients were asked to assess Humalog KwikPen or FlexPen versus V&S by choosing "strongly agreed" or "agreed" to the following attributes: easy to use, easy to hold in their hands when injecting, and easy to press the injection button, the results exhibited significant differences in patient responses. Humalog KwikPen was significantly more accurate and was preferred to vial and syringe in appearance, quality, discretion, convenience, public use, easy to learn, easy to use, reliability, dose confidence, following insulin regimen, overall satisfaction, and recommendation to others.

Conclusions

Humalog KwikPen was significantly preferred over vial and syringe and FlexPen. When compared with vial and syringe, Humalog KwikPen and FlexPen were easier to use and operate, demonstrated superior accuracy of doses prepared, and preferred by pen-naïve users.

The purpose of this study was to evaluate nurse satisfaction using pen devices compared with vials/syringes to administer insulin to hospitalized patients with diabetes.

Methods

A quasi-experimental 1-group posttest only study design was utilized to distribute a satisfaction survey to 54 registered nurses in a community hospital after implementation of insulin pen devices from July 2005 to May 2006 on 2 medical-surgical floors. Nurses completed a voluntary, anonymous, self-administered, postassessment, investigator-developed survey asking about the number of years practiced as a nurse and experience administering insulin to patients. The survey also asked about insulin administration satisfaction questions comparing insulin pen devices to vials/syringes, and estimated time to teach patients to self-inject insulin using either delivery method during the study period.

Results

In comparison to vials/syringes, the majority of nurses agreed that insulin pens were more convenient, simple and easy to use, and an overall improvement compared with conventional vials/syringes. There were no insulin-related needlestick injuries using the insulin pens and safety needles.

Conclusion

Nurses were satisfied with multiple aspects of insulin pens compared with vials/syringes. Implementation of insulin pen devices does not increase nursing time spent to teach patients to self-inject insulin and does not increase insulin-related needlestick injuries.

The purpose of this study was to examine the relationship between psychological and social factors and diabetes outcomes in people with type 2 diabetes and their family members.

Methods

A total of 153 patients with type 2 diabetes were assessed at a diabetes outpatient clinic and postal questionnaires were sent to nominated family members. The measures examined were diabetes knowledge, social support, well-being, and illness perceptions.

Results

When compared with those with diabetes, family members reported lower positive well-being and lower levels of satisfaction with support. They also perceived diabetes as a more cyclical illness, which was controlled more by treatment than by the individual. Family members also reported that the person with diabetes was more emotionally distressed and knew more about diabetes than the patient had actually reported himself or herself. There were no differences between the family members of those in good or poor glycaemic control.

Conclusions

This study reinforces the importance of understanding social context and illness beliefs in diabetes management. It also highlights the potential for including family members in discussions and education about diabetes management.

The main purpose of this article was to investigate the value of a self-regulation approach for weight reduction interventions in patients with type 2 diabetes. In addition, the potentially moderating effect of other intervention characteristics was explored.

Methods

In a meta-analysis of 34 studies, overall effect sizes were calculated for weight and A1C. The focus of the analysis was, however, on the moderating effect of intervention characteristics, especially whether interventions that score high on self-regulation produce stronger effects.

Results

The overall effect sizes (d) for weight loss in the short term (<6 months) were low and even lower in the longer term (>6 months). The overall effect sizes for A1C outcomes were higher and remained stable in the longer term. Interventions that scored high on self-regulation characteristics produced significantly better effects on both weight and A1C outcomes. Furthermore, "goal reformulation" increased the effect on weight outcomes whereas "emotion regulation" increased the effect on A1C. With respect to the other intervention characteristics, only the "inclusion of a patient's partner or relative" increased the effect on weight loss.

Conclusions

This meta-analysis underlines the importance of a self-regulation approach for weight reduction interventions in diabetes patients, in particular, for A1C outcomes. However, more research is needed to fully understand the relationship among self-regulation, weight, and A1C.

The purpose of this study was to assess type 2 diabetes knowledge, perceptions, risk factor awareness, and prevention practices among African American and Hispanic families with a history of diabetes.

Methods

Ninth and tenth grade Houston area students who had a parent who spoke English or Spanish and had a family history of type 2 diabetes were recruited. Student interviews took place during lunch. Parents were interviewed via telephone. Open-ended questions in the interview guide assessed knowledge of diabetes and risk factors, diabetes prevention practices, and perceived risk. Students reported dietary behaviors. Responses were recorded.

Results

Interviews were conducted with 39 parents (95% female, 49% African-American, 51% Hispanic) and 21 ninth and tenth grade adolescents (71% female, 43% African-American, 57% Hispanic). The majority were overweight. Approximately one-half of both groups reported some knowledge of diabetes. The majority (74%) of parents correctly identified family history as a risk factor, but few adolescents responded correctly. Being overweight was identified as a risk factor by 26% of the parents and 10% of the adolescents. Losing weight was not acknowledged as a way to reduce diabetes risk. Sweetened beverage consumption consisted of 2 cans/day and 43% reported to have skipped breakfast.

Conclusions

Overall, there was a lack of knowledge about risk and prevention of type 2 diabetes among African American and Hispanic families at risk. From a public health perspective, there is a critical need for innovative prevention programs targeting families at risk for diabetes.

The purpose of this article is to examine the relationship between organizational characteristics as measured by the Chronic Care Model (CCM) and patient self-management behaviors among patients with type 2 diabetes.

Methods

The study design was cross-sectional. The study setting included 20 primary care clinics from South Texas. The sample included approximately 30 consecutive patients that were enrolled from each clinic for a sample of 617 patients. For the data collection procedures, the CCM survey was completed by caregivers in the clinic. Self-management behaviors were obtained from patient exit surveys. For measures, the CCM consisted of 6 structural dimensions: (1) organization support, (2) community linkages, (3) self-management support, (4) decision support system, (5) delivery system design, and (6) clinical information systems. Patient self-management behavior included whether the patient reported always doing all 4 of the following behaviors as they were instructed: (1) checking blood sugars, (2) following diabetes diet, (3) exercising, and (4) taking medications. For data analyses, to account for clustering of patients within clinics, hierarchical logistic regression models were used.

Results

Self-management support was positively associated with medication adherence, while decision support system was positively associated with exercise and all 4 self-management behaviors. Surprisingly, community linkages were negatively associated with medication adherence, while clinical information system was negatively associated with diet and all 4 behaviors. A total score, including all dimensions, was positively associated with only exercise.

Conclusions

Health care providers and diabetes educators in primary care clinics should consider how organizational characteristics of the clinic might influence self-management behaviors of patients. The focus should be on better access to evidence-based information at the point of care and self-management needs and activities.

The purpose of this study was to determine the safety and effectiveness of implementing standing orders for nurse case managers to adjust antihyperglycemic medications.

Methods

A retrospective cohort design was used to assess outcomes in American Indian and Alaska Native people who received case management and medication adjustment and those who received only standard primary care. Patients with diabetes and evidence of keeping regular follow-up appointments for diabetes care (N = 2345) who all had baseline A1C ≥ 7.0% were divided into 3 mutually exclusive groups for analysis: (1) those seen only by primary care providers (PCP; n = 1574); (2) those seen by nurse case managers (NCM; in addition to primary care) for diabetes education services only (n = 711); and (3) those who, in addition to a PCP and NCM visit, had medications adjusted by the nurse case managers (MA; n = 60). Outcome variables were number of visits with documentation of hypoglycemia (safety) and rate of A1C change (effectiveness).

Results

Documented hypoglycemia occurred more frequently with more intensive treatment. The MA group experienced the greatest rate of hypoglycemic events. The difference in hypoglycemia incidence between the groups was significant, but the number of events was small. Glycemic control improved most rapidly in the MA group, even after adjusting for potentially confounding variables.

Conclusions

In this setting, hypoglycemia occurs infrequently in all groups, but at higher rates with more intensive treatment. Nurse case management, whether with or without medication adjustment, is effective in improving short-term glucose control.

The purpose of this article is to describe the development and implementation of an educational program for the initiation of real-time continuous glucose monitoring (CGM) technology for personal use, not 3-day CGMS^TM diagnostic studies. The education program was designed to meet the needs of patients managing their diabetes with either diabetes medications or insulin pump therapy in an outpatient diabetes education center using a team-based approach.

Methods

Observational research, complemented by literature review, was used to develop an educational program model and teaching strategies. Diabetes educators, endocrinologists, CGM manufacturer clinical specialists, and patients with diabetes were also interviewed for their clinical observations and experience.

Results

The program follows a progressive educational model. First, patients learn in-depth about real-time CGM technology by attending a group presensor class that provides detailed information about CGM. This presensor class facilitates self-selection among patients concerning their readiness to use real-time CGM. If the patient decides to proceed with real-time CGM use, CGM initiation is scheduled, using a clinic-centered protocol for both start-up and follow-up.

Conclusions

Successful use of real-time CGM involves more than just patient enthusiasm or interest in a new technology. Channeling patient interest into a structured educational setting that includes the benefits and limitations of real-time CGM helps to manage patient expectations.

The purpose of this article is to facilitate translation of the Consensus Statement to practice for diabetes educators and other professionals who contribute to the care of individuals with diabetes.

Methods

The 2007 Consensus Statement from the American Diabetes Association (ADA), European Association for the Study of Diabetes (EASD), International Federation of Clinical Chemistry and Laboratory Medicine (IFCC), and International Diabetes Federation (IDF) called for the standardization of glycated hemoglobin measurement in reporting and use of average glucose values in clinical practice.

Results

Conversion of glycated hemoglobin percentage to average blood glucose was anchored historically in early laboratory techniques linked to disease outcomes rather than to definitive laboratory standardization. Recently, the A1C-Derived Average Glucose (ADAG) study demonstrated that A1C values can be accurately expressed as estimated average glucose (eAG) and endorsed eAG as the best way to standardize the expression of laboratory values of glycated hemoglobin.

Conclusions

Adoption of the 2007 Consensus Statement will influence clinical practice and decision making and subsequently influence self-management for individuals with diabetes.

The purpose of this study was to evaluate the hypothesis that using estimated average glucose (eAG) while instructing patients yields better knowledge retention than using the term hemoglobin A1C (A1C).

Methods

Patients with diabetes who had poor baseline understanding of A1C (determined by a 4-question survey) were randomized into 1 of 2 groups: A1C or eAG. Depending on randomization, providers discussed patients' current status and personal targets for glycemic control using either the term A1C or estimated average glucose. Patients had a telephone survey 3–4 weeks later, assessing change in knowledge of glycemic control.

Results

The 80 participants who completed follow-up had similar baseline characteristics, including poor understanding of A1C and poor recall of previous A1C values. At the 3–4 week follow-up, average score for each survey question improved significantly in both groups, with mean composite score increasing in the A1C group by 32% and in the eAG group by 33%. There was no suggestion of a difference in degree of improvement between groups.

Conclusions

Patients previously unfamiliar with the meaning of A1C, using either term (A1C or eAG) resulted in an equal improvement in knowledge. Within this study, eAG was not a more understandable term, or an easier concept for patients to remember. Further research is needed to test whether use of the term A1C should be replaced by eAG.

To evaluate the effectiveness of a structured education group program in metabolic control in patients with type 2 diabetes.

Methods

A randomized controlled trial was conducted in a public teaching hospital and tertiary care center. Participants were 104 patients with type 2 diabetes not using insulin (aged 59 ± 9.5 years, diabetes duration of 10.5 ± 6.70 years, 53% women) randomized to attend an 8-hour structured group education program (delivered in 4 sessions, for 4 weeks, by a trained nurse educator) or to usual care. A pretest and posttest assessed the patients' knowledge before and after the course. The main outcome measures were A1C, weight, blood pressure, and lipids at 4-month intervals, up to 12 months.

Results

A1C levels decreased significantly in the intervention group after the 4th month and remained lower than in the control group until the 12th month (multivariate analysis of covariance, with baseline A1C as a covariate). Weight, blood pressure levels, total cholesterol, and high-density lipoprotein levels improved significantly, and similarly, in both groups.

Conclusions

A structured education group program centered in self-management improves the glycemic control in patients with type 2 diabetes, reaching the peak effect at 4 months, and lasting for up to 12 months.

The purpose of this study was to identify changes needed to make the diabetes education materials and programs of the Diabetes Association of Greater Cleveland (DAGC) accessible for people who have visual impairment and diabetes (PVID).

Methods

Using the principles and techniques of participatory action research (PAR), 5 PVID and 4 staff members of a local diabetes association met once a month for a year to plan, implement, and evaluate progress toward full accessibility of all diabetes education materials and programs. The researcher served as facilitator.

Results

Four "transformational moments" are presented through which the PAR process enabled PVID and diabetes professionals to learn to understand and trust each other. Changes made to increase accessibility included production of 2 recordings for providing access to print information about diabetes; planning public education program publicity and locations for access; development of guidelines to help speakers make their diabetes education presentations accessible for people who cannot see slides and gestures; and presentation of an inservice for the entire staff of the diabetes association, including information about how they live with visual impairment, and common courtesies that make communication with PVID more effective.

Conclusions

Diabetes education programs should include planning for full accessibility for PVID. Diabetes organizations should publish teaching materials in accessible format.

The purpose of this study is to assess the validity of the patient activation construct as measured by the Patient Activation Measure (PAM) survey by correlating PAM scores with diabetes self-management behaviors, attitudes, and knowledge in a predominantly minority and uninsured population.

Methods

A convenience sample of patients presenting to an urban public hospital diabetes clinic was surveyed and contacted by phone 6 months later. The survey included questions about activation, health behaviors, and health care utilization.

Results

A total of 287 patients agreed to participate. Most were African American, female, and uninsured. Most respondents (62.2%) scored in the highest category of activation according to the PAM. Activated patients were more likely to perform feet checks, receive eye examinations, and exercise regularly. Activation was consistently associated with less reported difficulty in managing diabetes care but not with A1C knowledge. PAM scores at the initial interview were highly correlated with scores at 6-month follow-up. Activation level did not predict differences in health care utilization during the 6 months following the survey.

Conclusions

Higher scores on the PAM were associated with higher rates of self-care behaviors and ease in managing diabetes; however, the indigent urban population reported higher activation scores than found in previous studies. The relationship between activation and outcomes needs to be explored further prior to expanding use of this measure in this patient population.

The purpose of this study is to compare the glycemic and insulinemic responses following the ingestion of recently developed diabetes-specific enteral formulas versus a standard and a high-fat formula.

Methods

Fifteen type 2 diabetes patients were selected to participate in a randomized, double-blind, crossover study. Two enteral formulas (47 energy percent [En%] carbohydrate, 34En% fat, and 4 g fiber/200 mL) were defined with either isomaltulose (formula 1) or sucromalt (formula 2) as the main carbohydrate source. For comparison, an isoenergetic diabetes-specific, high-fat (33En% carbohydrate, 50En% fat, 2.9 g fiber/200 mL) and a standard formula (55En% carbohydrate, 30En% fat, 2.8 g fiber/200 mL) were tested.

Results

Ingestion of formulas 1 and 2 and the high-fat formula resulted in an attenuated blood glucose response when compared with the standard formula (P < .05). In accordance, peak plasma glucose concentrations were significantly lower when compared with the standard formula (189 ± 3.6 mg/dL [10.5 ± 0.2 mmol/L], 196.2 ± 3.6 mg/dL [10.9 ± 0.2 mmol/L], 187.2 ± 3.6 mg/dL [10.4 ± 0.2 mmol/L], and 237.6 ± 3.6 mg/dL [13.2 ± 0.2 mmol/L], respectively). Plasma insulin responses were lower after consumption of the newly developed and high-fat formulas. Ingestion of the high-fat formula resulted in a greater postprandial triglyceride response (P < .05).

Conclusions

Diabetes-specific enteral formulas rich in slowly digestible carbohydrate sources can be equally effective in attenuating the postprandial blood glucose response as low-carbohydrate, high-fat enteral formulas without elevating the plasma triglyceride response.

The purpose of this study is to determine the effectiveness of a community-based diabetes self-management program comparing treatment participants to a randomized usual-care control group at 6 months.

Methods

A total of 345 adults with type 2 diabetes but no criteria for high A1C were randomized to a usual-care control group or 6-week community-based, peer-led diabetes self-management program (DSMP). Randomized participants were compared at 6 months. The DSMP intervention participants were followed for an additional 6 months (12 months total). A1C and body mass index were measured at baseline, 6 months, and 12 months. All other data were collected by self-administered questionnaires.

Results

At 6 months, DSMP participants did not demonstrate improvements in A1C as compared with controls. Baseline A1C was much lower than in similar trials. Participants did have significant improvements in depression, symptoms of hypoglycemia, communication with physicians, healthy eating, and reading food labels (P < .01). They also had significant improvements in patient activation and self-efficacy. At 12 months, DSMP intervention participants continued to demonstrate improvements in depression, communication with physicians, healthy eating, patient activation, and self-efficacy (P < .01). There were no significant changes in utilization measures.

Conclusions

These findings suggest that people with diabetes without elevated A1C can benefit from a community-based, peerled diabetes program. Given the large number of people with diabetes and lack of low-cost diabetes education, the DSMP deserves consideration for implementation.

The purpose of this study was to develop, implement, and evaluate the effectiveness of a self-instructional preconception counseling (PC) training program for Certified Diabetes Educators (CDEs) to enhance PC knowledge and self-efficacy.

Methods

A 1-group, pre-post test study was conducted with 31 CDEs from a large medical center in western Pennsylvania. The self-instructional program included selected readings, such as the American Diabetes Association's position statement on PC of women with diabetes and an interactive CD-ROM, "Reproductive-Health Awareness for Teenage Women With Diabetes" ("READY-Girls"). Paper-and-pencil knowledge and self-efficacy questionnaires regarding PC and pregnancies of women with diabetes were completed by the CDEs before and immediately following the self-instructional program. Upon completion, participants received 5.0 Continuing Nursing Education contact hours (CNEs) from the State Nurses Association.

Results

Prior to receiving the program, all of the participants indicated they would benefit from further training on PC. Pretest knowledge scores averaged in the 70th percentile; following the program, the participants significantly increased (P < .01) PC knowledge and self-efficacy in providing PC to women with diabetes, including adolescents.

Conclusions

Although CDEs knew relevant information, they lacked some specific knowledge about PC, and they lacked confidence in their knowledge and in their ability to counsel patients. Diabetes educators can benefit from an education program to provide PC to their female patients, including adolescents. Computer or Web-based accessibility could make this a low-cost and easily disseminated program.

The practice analysis described in this report was conducted by the National Certification Board for Diabetes Educators (NCBDE) to (1) provide a basis for documenting the continuing validity of the Certification Examination for Diabetes Educators, (2) define new areas that should be assessed in future certification examinations, and (3) ensure that the content of certification examinations is related to practice.

Methods

The study involved developing a diabetes educator job task list and survey, distributing 4103 surveys, and analyzing survey responses from a multidisciplinary and geographically representative sample of certified diabetes educators.

Results

Eight hundred thirty-six surveys were suitable for analysis, with relevant demographic subgroups adequately represented. Based on survey data, an examination matrix and detailed content outline was constructed that will be used by NCBDE to assemble future test forms.

Conclusions

Certification examination specifications were developed directly related to the important activities that diabetes educators perform. Future forms of the certification examination will continue to be matched to job-related, criterion-referenced test specifications and will have strong evidence of content validity. Future forms of the exam will contain 200 items at specified cognitive levels with a representative sampling of tasks within 3 core areas from the detailed content outline.