Diabetes Education Services Research Articles

Emergency Department Use in Black Individuals With Diabetes.

The prevalence of diabetes is higher in Black than in White individuals, and Blacks seek emergency department (ED) care for diabetes more often than Whites. This randomized controlled trial compared the efficacy of a novel intervention called the Diabetes Interprofessional Team to Enhance Adherence to Medical Care (DM I-TEAM) to usual medical care (UMC) to prevent return diabetes-related ED visits and hospitalizations over 12 months in 200 Black individuals with diabetes after an ED visit. The trial also identified baseline variables associated with return ED visits and hospitalizations. The DM I-TEAM provided diabetes education and behavioral activation services delivered by race-concordant research assistants, telehealth visits with a diabetes care and education specialist and primary care physicians, and clinical pharmacist recommendations. Participants had a mean age of 64.9 years, and 73.0% were women. There was no treatment group difference in return diabetes-related ED visits or hospitalizations over 12 months (DM I-TEAM n = 39 [45.3%] vs. UMC n = 37 [38.5%], χ2 = 0.864, P = 0.353). Baseline variables that were associated with return diabetes-related ED visits or hospitalizations were longer duration of diabetes, higher number of chronic health conditions, higher number of previous ED visits or hospitalizations, greater anticholinergic medication burden, lower satisfaction with primary care physicians, and lower trust in physicians (all P ≤0.05). Among Black individuals with diabetes, the DM I-TEAM interprofessional intervention was no better than UMC at preventing return diabetes-related ED visits or hospitalizations. High medical morbidity, greater anticholinergic medication burden, low satisfaction with primary care physicians, and physician mistrust were associated with diabetes-related ED visits or hospitalizations independent of treatment. Before clinical interventions such as the DM I-TEAM can be effective, reducing system-level barriers to health, improving physician-patient relationships and medication prescribing, and building community health care capacity will be necessary.

Nurse-led vascular risk assessment in a regional Victorian Indigenous primary care diabetes clinic: An integrated Diabetes Education and Eye disease Screening [iDEES] study.

The aim was to describe vascular risk factors in Australian adults with diabetes attending an Indigenous primary care nurse-led diabetes clinic. This was a cross-sectional descriptive single-site study. Vascular risk factor data were extracted from the electronic health records of participants in the nurse-led integrated Diabetes Education and Eye disease Screening (iDEES) study at a regional Victorian Indigenous primary health-care clinic between January 2018 and March 2020. Of 172 eligible adults, 135 (79%) provided data. Median (IQR) age was 56 (46-67) years; 89% were Indigenous; 95% had Type 2 diabetes of median (IQR) duration of 6 (2-12) years and 48 (36%) were male. Median HbA1c, blood pressure, cholesterol (total; LDL and HDL), triglycerides, eGFR, CRP and BMI were 8.0% (64 mmol/mol), 127/78 mm Hg, 4.2; 1.9; 1.1 mmol/L, 2.3 mmol/L, 89 ml/min/1.73 m2 , 7.0 mg/L and 32.4 kg/m2 . Of nine clinical risk factors, the median (IQR) number of risk factors at target was 4 (3-5) for women and 3 (2-5) for men, pχ2 =0.563. Clinical targets for BMI, HbA1c, blood pressure, triglycerides, total cholesterol, LDL cholesterol, urine albumin: creatinine ratio, HDL cholesterol and smoking were met by 14%, 34%, 38%, 39%, 44%, 52%, 54%, 62% and 64%, respectively. A nurse-led model of integrated clinical risk factor assessment and diabetes education identified suboptimal levels of clinical risk factor control for avoiding diabetes chronic complications amongst Australian adults with diabetes in an Indigenous primary care setting. A nurse-led model of diabetes care integrating clinical risk factor assessment into a diabetes education service is achievable. Understanding by stakeholders, including people with diabetes, their clinicians and health services, of the importance of regular monitoring of risk factors impacting diabetes complications is important. The novel nurse-managed iDEES primary-care model of care can assist. This study was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001204235).

Trends in risk factors and management strategies used by people with type 2 diabetes in New South Wales, Australia

Adopting healthy lifestyle behaviours is an important component of Type 2 diabetes (T2D) self-management, which can lower risks of further health complications. Monitoring lifestyle risk factors including overweight or obesity, healthy diet and physical activity behaviours, alcohol consumption, smoking and psychological distress remain important. This study examined prevalence trends in these factors and adoption of three diabetes lifestyle self-management strategies in adults (aged 40+) with T2D in New South Wales (NSW), Australia. Analyses were conducted on NSW Adult Population Health Survey data, 2004–2019 (n = 142,168), using predicted probabilities from generalised linear models, weighted to population estimates. Throughout the study period overweight or obesity prevalence remained higher amongst those with T2D (83.1% to 81.7%) compared to those without diabetes (61.0 to 61.2%); only 8.9% of those with T2D were trying to lose weight. During the study period, there were declines in the proportions of those with T2D reporting sufficient fruit consumption [63.9% to 50.1%], moderate vegetable consumption (3 serves) [49.0% to 37.7%], and achieving sufficient physical activity [40.0% to 34.0%]. There were also declines in those reporting they manage their diabetes through following a special diet [73.6% to 55.9%] and exercising most days [33.5% to 22.2%]. This study highlights potential gaps in T2D secondary prevention and suggests more targeted diabetes education services are needed to address lifestyle risks. Increased understanding of why fewer people with T2D adopt these lifestyle management strategies is needed to inform policy and practice.

A Risk Stratification Approach to Allocating Diabetes Education and Support Services.

The objective of this study was to describe a predictive modeling approach to risk stratify people with type 2 diabetes for diabetes self-management education and support (DSMES) services. With data from a large health system, a predictive model including age, glycated hemoglobin (HbA1c), and insulin use among other factors, was developed to assess risk of future high HbA1c. The model was retrospectively applied to a cohort of people who received DSMES over a 2-year period to assess the impact of DSMES on glycemia by risk strata. Of 6934 eligible people, 4014 (58%) were in the composite low-risk group and 2604 (38%) were in the composite high-risk group. Mean HbA1c change after DSMES was -0.38% in the low-risk group and -0.84% in the high-risk group. This analysis demonstrates the potential application of predictive modeling as one approach to target DSMES resources to people who will benefit most.

The effect of diabetes education and short message service reminders on metabolic control and disease management in patients with type 2 diabetes mellitus

AimThe aim of this study was to evaluate the effect of diabetes education and short message service reminders on metabolic control and disease management in patients with type 2 diabetes mellitus who were registered in a family health center and who were using oral antidiabetics. MethodsThis pre-test and post-test control group interventional study was conducted between 2017 and 2019. For one-way analysis of variance, effect size=0.40, α=0.05 and 80% power for each group was considered to be appropriate for 48 participants. Considering probability of losses during the study, 101 patients with type-2 DM were selected to include in the study. At the beginning of the study of all the patients, metabolic (HbA1c, FBS, triglycerides, cholesterol, HDL, LDL), anthropometric (BMI), blood pressure (BP) and scales assessments were performed. The Follow-Up Form for Patients with Diabetes, Diabetes Self-Care Scale (DSCS) and World Health Organization (WHO) (5) Goodness Scale were used as data collection tools. In the study, the structured group-based education program consisting of five modules was given to the intervention group in two sessions. Immediately after the education program, short message reminders about diabetes management were sent twice a week for a six-month period to intervention group. During the study, each group was invited to the family health center to perform the third- and sixth-month evaluations. Data were analyzed by SPSS version 19. In the study, categorical variables were evaluated with Chi-squared test. The differences of the groups over time were evaluated using the Friedman test and binary comparisons of differences by Wilcoxon test. The changes among groups over time were evaluated by Mann–Whitney test. ResultsIn the evaluations for the third and sixth months, it was found that there was a statistically significant difference between the intervention and control groups in terms of HbA1c, fasting blood sugar, lipid values (except triglycerides), blood pressure, body mass index and the scales results (p<0.001). ConclusionDiabetes education and SMS reminders sent for six months were effective in improving metabolic control and disease management in patients with type 2 diabetes mellitus.

Impact of Diabetes Education on Health Status of Diabetes Patients in Khartoum State

Diabetes education, with its role in improvement in knowledge, attitude and practice, lead to better control of the disease, and is accepted to be an important part of diabetes management. The Study aimed to determine the effect of diabetes education on health status of type 2 diabetes patients attending Diabetes Mini Clinics at Primary Health Care centers in Khartoum state, Sudan. The study design was quasi-experimental. Sample of seventy-eight type 2 diabetes patients was selected from eleven reverence family health centers, which contain diabetes mini clinic. Seventy of participants continued until the end of the study. A pre &amp;ndash;post questionnaire was used to collect the data, which entered and analyzed by using Statistical Package for the Social Sciences, percentage, mean and standard deviation and paired T. test were used to analyze the data. The level of statistical significance was set at P. value ˂ 0.05. The results showed Diabetes education had positive effect on glycemic control (P. value = .001), diastolic blood pressure (P. value = .017), and quality of life (P. value = .001). The study recommended that coverage of primary health care centers with diabetes education service is very important and other studies is needed for more evaluation.&amp;nbsp;

Integrating diabetic retinopathy screening within diabetes education services in Australia's diabetes and indigenous primary care clinics.

As diabetes occurs in all ethnicities and regions it is essential that retinopathy screening be widely available. Screening rates are lower in Indigenous than in non-Indigenous Australians. Technological advances and Medicare rebates should facilitate improved outcomes. Use of non-ophthalmic clinicians, (general practitioners, diabetes educators, health-workers and endocrinologists) to supplement coverage by ophthalmologists and optometrists would extend retinopathy screening capacity. Diabetes educators are an integral part of diabetes management. Integrating ocular screening and diabetes education in primary care settings has potential to improve synergistically retinopathy screening coverage, patient self-management, risk factor control, care satisfaction, health economics and sustainability of under-resourced services.

A mHealth Support Program for Australian Young Adults with Type 1 Diabetes: A Mixed Methods Study.

Aims and ObjectivesYoung adulthood is a life stage comprised of many turning points. For young adults with type 1 diabetes (T1DM), diabetes self-management support is crucial during this period. There is a lack of diabetes education programs and services tailored to this population. This paper presents the findings, according to the STROBE guidelines, on the usability and acceptability of a patient-informed mHealth support program (Diabetes YES) that was developed for young adults with T1DM.MethodsA total of 34 young adults aged 18–35 years with T1DM participated in the Diabetes YES program over 12 weeks. Google analytics was used to tracked website use, while a website usability survey measured ease of use. Facebook analytics was used to measure peer support engagement. Evaluation of the program was completed using Likert scales and open-ended questions.Results Participants rated the website favourably for its ease of navigation and easy to understand information. Web page visits declined sharply while peer support group engagement through Facebook remained consistent throughout the intervention period. Participants utilised weekly discussion topics to generate conversation within the peer support group. Emotional support from peers was the highest regarded benefit reported by participants.Conclusions Diabetes YES is an example of an mHealth support program that was readily accepted by young adults living with T1DM. Feasibility studies are an important formative step in the implementation of mHealth programs within mainstream healthcare. Future work should focus on the adaptability of such programs to fit within larger consumer or healthcare organisations.

In This Issue…

A wide variety of clinical and basic science articles comprise this issue of the Canadian Journal of Diabetes. Some of the topics covered in this issue are included below. Cimo and Dewa present a qualitative study aimed at exploring the perspectives of adults with type 2 diabetes and mental illness. The authors studied the challenges to engaging in self-care behaviours and accessing diabetes education services (pages 372–81). They highlight the importance of addressing these issues in this population, given the increased prevalence of type 2 diabetes among individuals with mental health illnesses and poorer self-care practices and, ultimately, the poorer outcomes observed in this population. The authors conducted focus groups with individuals who self-identified as having type 2 diabetes and major depressive disorders. Transcripts were analyzed and major themes identified. Participants identified a wide range of barriers to care, including physiological, physical and social challenges. The authors suggest that addressing these issues will be necessary to close the gaps in care that currently exist in this population. Combined aerobic and anaerobic exercise improved the oxidative capacity of skeletal muscle and improved insulin sensitivity in a rodent model of type 1 diabetes, according to the authors of this study (pages 404–11). The improvement in the oxidative capacity of muscle in the combined aerobic and anaerobic group was greater than that of the aerobic-only group. This result led the authors to suggest that combined exercise training may result in a synergistic effect on the oxidative capacity of muscle. Contrary to their original hypothesis, combined aerobic and anaerobic exercise did not reduce lipid accumulation in the skeletal muscle; this was seen in the aerobic-only exercise group. The authors hypothesize that although lipid stores were not decreased, the composition of the lipid stores may differ in the combined aerobic and anaerobic exercise group. They suggest that the fat stores in the aerobic- and anaerobic-exercised rodents are potentially composed of energy-rich neutral triacylglycerol molecules in comparison to the insulin-desensitizing diacylglycerol molecules seen in unexercised animals. Thus, the animals undergoing combined aerobic and anaerobic exercise would have access to energy stores without the effect of insulin resistance. The authors suggest that combined exercise may promote positive metabolic adaptation with increased capacity to both store and oxidize lipids, compared with aerobic activity alone. This is an intriguing hypothesis that is yet to be confirmed among those living with type 1 diabetes. Increased awareness of the criteria and contraindications for islet-cell transplantation is needed for people living with type 1 diabetes and health-care providers, according to Ling et al (pages 419–25). In this article, the authors describe the referral patterns and initial eligibility assessment for the largest clinical islet-cell transplant program in Canada. The authors undertook a retrospective chart review (2009 to 2012) to identify the most common factors resulting in an applicant's being deemed eligible or ineligible for islet-cell transplantation. Overall, only 19% of applicants were deemed acceptable for listing for transplant. The majority of applicants were self-referrals, and among the indications for no transplant, severe hypoglycemia and glucose lability were the most common causes of ineligibility. In addition, the use of a suboptimal insulin regimen was the most common exclusion criterion identified. The majority of applicants were from Alberta. Only a small number of applications came from the 2 most populous provinces (Ontario and Quebec), despite neither of these provinces having a transplant program at the time. In addition to increasing awareness of eligibility for islet-cell transplantation, the authors suggest that their findings can be used as benchmarks for future studies and ongoing program evaluation. Conflicts of interest: None.

Transitional Needs of Australian Young Adults With Type 1 Diabetes: Mixed Methods Study.

BackgroundYoung adulthood is marked by transitions that impact diabetes self-management behaviors, which require ongoing diabetes education and support. Traditional diabetes education programs and services currently do not meet the needs of many young adults with type 1 diabetes mellitus (T1DM) as they continue to fall through the cracks of clinical services. Age-centered diabetes education programs and services present an opportunity for young adults to meet in a supportive environment and gain a better understanding about diabetes management.ObjectiveThe aim of the study was to identify the health and well-being needs of Australian young adults aged between 18 and 35 years with T1DM to develop appropriate solutions to keep them engaged with diabetes self-management.MethodsIn total, 13 semistructured individual interviews and self-reported surveys were obtained to understand participants’ experiences with diabetes education programs and services. Together with survey data, transcribed interviews were analyzed into themes and categories using comparative analysis to identify the health and well-being needs of young adults with T1DM during young adulthood.ResultsDiabetes education and service needs for young adults with T1DM related to improving access to existing diabetes education programs and services, having credible informational resources, as well as having personalized diabetes management advice. Participants especially valued relevant and real-time information and opportunities for peer support, mostly sourced from Web-based platforms.ConclusionsThere is a need for diabetes education programs and services to be age-appropriate and easily accessible, to provide relevant and credible information, and to provide opportunities for peer support to better support young adults with T1DM. These findings also support the use of diabetes education programs or services delivered online through mHealth systems in this population.

EXPANSION of diabetes education in a United States–Mexico border community (Expanding Services for Patients to Acquire New Skills, Set Goals, and Improve Overall Knowledge)

ObjectivesTo describe the process used by a pharmacy team at a community health center to coordinate and expand diabetes education services (English and Spanish) for a predominantly Hispanic, Spanish-speaking population. SettingThe project was implemented at 2 clinics in a federally qualified community health center system based in a low-income southwest U.S.–Mexico border community. Practice innovationThis project enhanced accessibility to diabetes education to improve knowledge, skills, and goal setting through existing pharmacy services at the primary clinic and 1 rural satellite clinic. EvaluationThe success of the project was evaluated quantitatively. Metrics used to evaluate enhancement of existing practices included enrollment and completion rates, number of sessions, and diabetes leadership meetings. ResultsOver the 5-month project period assessed, 7 interdisciplinary professionals were certified as Diabetes Empowerment Education Program educators. Four sessions were conducted at both clinics. A total of 31 participants completed the diabetes classes. An educational attainment of 8th grade or less was reported in 91% of the rural participants compared with 50% of the urban participants. Ten interdisciplinary leadership meetings centered on recruitment, progress toward goals, and action items to ensure quality of classes. A nurse practitioner and pharmacist piloted a shared-visit model with 5 patients during a 45-minute time period. ConclusionSuccessful diabetes education services occurred by implementing an evidence-based curriculum, identifying provider champions, increasing patient enrollment through provider referrals, and generating reports. Patient accountability was facilitated by setting patient-centered goals for knowledge and skills. Last, support groups provided ongoing support once patients graduated from a structured diabetes program.

The impact of medication synchronization on quality care criteria in an independent community pharmacy

ObjectivesTo determine the impact of a comprehensive medication synchronization program in an independent community pharmacy by (1) evaluating changes in Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP) scores and (2) examining the change in monthly prescription volume. SettingIndependent community pharmacy in Morgantown, WV. Practice descriptionWaterfront Family Pharmacy is a single-location independent community pharmacy located in Morgantown, WV. The pharmacy consists of four full-time pharmacists and is the primary practice site for one community pharmacy PGY-1 resident. The pharmacy provides a variety of clinical services, including vaccine administration, medication therapy management, and diabetes education services. Practice innovationIn September 2014, Waterfront Family Pharmacy started a comprehensive medication synchronization program. EvaluationChange in Electronic Quality Improvement Platform for Plans and Pharmacies (EQuIPP) scores and change in monthly prescription volume. ResultsAt the end of 6 months there was improvement in all targeted EQuIPP scores. There was a 7% improvement in proportion of days covered (PDC) for cholesterol-reducing agents, a 9.5% improvement in PDC for oral glycemic agents, a 1.2% improvement in PDC for renin-angiotensin system antagonists, and a 1.8% reduction in the use of high-risk medications in the elderly. There was also an average increase in monthly prescription volume of 4.8% over the first 6 months after the implementation of the comprehensive medication synchronization program. ConclusionThe implementation of a comprehensive medication synchronization program in an independent community pharmacy may result in benefits including improved EQuIPP scores and increased prescription volume.

Perception of Educators about Quality of Diabetes Education Services at Primary Health Care Level in Khartoum State, Sudan

Introduction: Promoting positive life style is a strategy for delaying and reducing the incidence of diabetes complications. Objective: To determine the perception of educators about the quality of education services provided to diabetic patients at the health centers in Khartoum State. Methods: A qualitative descriptive study carried out among 22 educators working at governmental and non-governmental health centers. Mini focus groups of discussion were moderated by a qualified social researcher and a trained note taker. The guiding questions included general information and several questions about education services for diabetic patients. Ethical clearance was obtained from relevant ethical committees. Informed consent was obtained from educators. Content analysis of data was carried and organized in to themes. The themes were organized according to the dimensions of quality of care, structure, process and outcome.

Specialist nurses’ experiences of using ‘The Viewer’, a consolidated electronic medical records system: a pre-post implementation survey

Objective: Evaluate changes in specialty areas nurses’ knowledge and perceptions of a consolidated electronic medical record (EMR) system before and after implementation. Design: A survey deployed pre- and six months post-implementation of ‘The Viewer’. Setting: Regional Hospital and Health Service, Queensland. Subjects: Nurses working in specialist areas including community health, palliative care, discharge planning, wound and stoma care, diabetes education and renal dialysis satellite services (n=110) were invited to participate in the study. Response rate of the pre-implementation survey (n=42, 38%) was much higher than the post-implementation subset (n=10, 24%). A major health service restructure that included losses of nursing positions in specialist areas significantly affected postimplementation results. Intervention: An EMR system called ‘The Viewer’ to access consolidated electronic medical records of patient information produced by different parts of the organisation. Main Outcome Measures: Changes in participants’ knowledge and perceptions of ‘The Viewer’, and their satisfaction with the quality, ease of use and access to patient information. Results: Pre-implementation, specialist nurses reported dissatisfaction with most aspects of the current patient information system but high confidence and comfort in using electronic systems. Post implementation satisfaction scores either remained the same or increased. Satisfaction with ease of access to consolidated patient data (U = 125.0, p = 0.038, r = 0.29) and usefulness of electronic systems (U = 115.0, p = 0.031, r = 0.30) increased significantly post-implementation of ‘The Viewer’. Conclusion: Specialist nurses are positive about the possibilities EMRs offer to centralise, consolidate and improve access to patient data.

Gender Dissimilarity in Type 2 Diabetes Risk Factors: a Chinese Study.

Gender has been identified as a significant factor that contributes to variations on unhealthy behavior engagement and disparity in health outcomes; however, gender dissimilarity in type 2 diabetes-related behavioral risks has not been fully understood in a non-Western social setting. Recognizing gender-specific behavioral risks of type 2 diabetes is important in improving the disease associated health outcomes and healthcare service. This study identifies gender-specific behavioral factors associated with type 2 diabetes diagnoses among middle-aged and older adults in a Chinese context. Data are selected from the China Health and Nutrition Survey (CHNS) 2009. There are 259 male cases and 280 female cases individually matched with their nondiabetic controls on age. Higher level of total carbohydrate intake and physical inactivity is associated with a higher risk of type 2 diabetes diagnoses in both genders (p < .001). Odds ratios of type 2 diabetes diagnoses are higher only among male cigarette smokers and heavy alcohol drinkers. This study provides evidence regarding gender-specific behavioral risks of type 2 diabetes suggesting the need for improving type 2 diabetes related research, prevention, education, and healthcare services for middle-aged and older adults in China.

Clinic-Based Versus Outsourced Implementation of a Diabetes Health Literacy Intervention

We compared two implementation approaches for a health literacy diabetes intervention designed for community health centers. A quasi-experimental, clinic-randomized evaluation was conducted at six community health centers from rural, suburban, and urban locations in Missouri between August 2008 and January 2010. In all, 486 adult patients with type 2 diabetes mellitus participated. Clinics were set up to implement either: 1) a clinic-based approach that involved practice re-design to routinely provide brief diabetes education and counseling services, set action-plans, and perform follow-up without additional financial resources [CARVE-IN]; or 2) an outsourced approach where clinics referred patients to a telephone-based diabetes educator for the same services [CARVE-OUT]. The fidelity of each intervention was determined by the number of contacts with patients, self-report of services received, and patient satisfaction. Intervention effectiveness was investigated by assessing patient knowledge, self-efficacy, health behaviors, and clinical outcomes. Carve-out patients received on average 4.3 contacts (SD = 2.2) from the telephone-based diabetes educator versus 1.7 contacts (SD = 2.0) from the clinic nurse in the carve-in arm (p < 0.001). They were also more likely to recall setting action plans and rated the process more positively than carve-in patients (p < 0.001). Few differences in diabetes knowledge, self-efficacy, or health behaviors were found between the two approaches. However, clinical outcomes did vary in multivariable analyses; carve-out patients had a lower HbA1c (β = -0.31, 95 % CI -0.56 to -0.06, p = 0.02), systolic blood pressure (β = -3.65, 95 % CI -6.39 to -0.90, p = 0.01), and low-density lipoprotein (LDL) cholesterol (β = -7.96, 95 % CI -10.08 to -5.83, p < 0.001) at 6 months. An outsourced diabetes education and counseling approach for community health centers appears more feasible than clinic-based models. Patients receiving the carve-out strategy also demonstrated better clinical outcomes compared to those receiving the carve-in approach. Study limitations and unclear causal mechanisms explaining change in patient behavior suggest that further research is needed.

The Impact of Diabetes Counseling and Education

The purpose of this study is to examine outcomes in adult patients with type 2 diabetes mellitus who received diabetes counseling and education (C/E) services compared with those who did not. A matched, retrospective cohort study of 17 483 C/E recipients and 17 470 non-C/E controls was followed for up to 12 months. Outcomes included glycemic control (glycosylated hemoglobin A1C levels <7.0%), hypoglycemic events, and health care utilization and costs. Compared with the non-C/E group, patients in the C/E group had significantly lower A1C (7.7% vs 7.2%) and were more likely to achieve glycemic control at 6 months' follow-up; they were also more likely to have a hypoglycemic event. During the 1-year period following the index date, C/E recipients had more inpatient visits (0.21 vs 0.20 visits per patient) and ambulatory visits (21.5 vs 18.6 visits per patient) compared with non-C/E controls. The increased use of health care services in the C/E groups was associated with $2388 higher annual overall costs and $827 higher diabetes-related costs. Diabetes C/E is associated with improved glycemic control, albeit with a slight increase in the risk of hypoglycemia. C/E was associated with higher health care costs across 12 months. Further analyses are needed to evaluate long-term cost-effectiveness of diabetes counseling and education.

Evaluation of a Diabetes Education Video Among the Tz'utujil Maya in Guatemala

The prevalence of diabetes is rising throughout Latin America, particularly in the Tz’utujil Maya town of Santiago Atitlan, Guatemala. Major gaps in biomedical knowledge about the causes, chronicity, and long-term complications of diabetes have been reported in rural Guatemala among diabetes patients. In one rural Guatemalan study, respondents believed that ‘‘strong emotions’’ caused diabetes. Diabetes education services are limited in Santiago Atitlan, as the primary language for 94% of the population is Tz’utujil Maya, one of 21 distinct Mayan dialects spoken in Guatemala, and few biomedical clinicians are conversant in this non-written language. To address this need, a health education video was developed for a target audience of Tz’utujil-speaking community residents living with type 2 diabetes mellitus for use by the local hospital and other healthcare posts. Health education videos are an increasingly utilized medium of communication, with over 500 American hospitals currently having produced publicly available health education videos. The purpose of this letter is to provide an evaluation for this Tz’utujil-language diabetes education video. Mixed qualitative and quantitative methods for this study included semistructured interviews and preand post-testing of the video’s content immediately before and after the video screening as a rough metric of understanding and retention. The stratified random sample included 20 community residents (stratified as 17 urban and three rural) who were selected via randomly generated Global Positioning System points on a satellite map of the town. A Tz’utujil–Spanish translator was present to assist with each semistructured interview. Responses from the interviews were captured on digital audio recordings and paper-based field notes. Interviews were conducted between 09:00 and 15:00 h Monday– Friday in March 2010 and typically lasted 30–60 min. SPSS version 12.0 for Windows (SPSS Inc., Chicago, IL) was used to analyze preand post-video responses using v tests and t tests for comparisons of means. The study was approved by the Committee on Human Research at the University of California, San Francisco and the Mayor and Ministry of Health of Santiago Atitlan, Guatemala.

Identification of barriers to appropriate dietary behavior in low-income patients with type 2 diabetes mellitus.

ObjectiveTo identify barriers to appropriate dietary behavior in an urban, low-income population of patients with type 2 diabetes and to examine a new instrument in the identification of these barriers in this population.MethodsA cross-sectional survey was developed, validated, and anonymously administered to low-income adults with type 2 diabetes in an academic family medicine physician group practice with a pharmacist-operated diabetes education and comanagement service. The survey consisted of three key subscales: determinants of food selection, importance of life challenges, and barriers to appropriate eating.ResultsThe survey was administered to 98 patients with a mean age of 51.98 years, a mean duration of diabetes of 9.76 years, and a mean hemoglobin A1c of 7.99%. When asked to rate factors most important in food selection, the highest mean responses were taste (3.97 out of 5) and cost (score of 3.94 out of 5). Barriers that the majority of respondents agreed or strongly agreed were important included: stress causing over-eating or unhealthy food choices, difficulty resisting the temptation to eat unhealthy food, and healthy food being too expensive. The Cronbach’s Alpha for the subscales of food selection, importance of life challenges, and barrier were 0.673, 0.853, and 0.786, respectively.ConclusionsIn a low-income, urban, predominantly African American and Caucasian diabetic population, cost of healthy food, stress-related inappropriate eating, and the temptation to eat unhealthy food were the most frequently reported barriers to healthy eating. Diabetes education programs serving similar populations should evaluate the presence of these barriers. The survey instrument was a reliable measure of the constructs it purported to measure.

Paxton House: Integrating mental health and diabetes care for people with serious mental illnesses in a residential setting.

This report provides a program description of a supported housing residence for individuals with co-occurring diabetes and serious mental illnesses and preliminary health outcome data. Weight, blood glucose levels and satisfaction survey data were collected retrospectively on 13 individuals referred to the program. Results indicate that individuals lost weight and fasting glucose readings fell into the ADA recommended range in the first six months of participation. Overall, consumers participating in the program were satisfied with the diabetes education and monitoring services provided. While preliminary results suggest that consumers benefit, this study only begins to address how integrated behavioral health and diabetes-specific programming in residential settings meets the needs of persons with severe mental illnesses and diabetes. A more thorough understanding of the impact of these programs on consumers' health outcomes is needed to inform how to deliver diabetes management curricula and support consumers to improve their overall health.