Quality of life and application of the transtheoretical model to diabetes self -management behaviors in older adults with type 2 diabetes

One in five adults 65 years and older has diabetes. Coping with diabetes is a lifelong task, and much of the responsibility for managing the disease falls upon the individual. Reports of non-adherence to recommended treatments are high. Understanding the additive impact of diabetes on quality of life issues is important. The purpose of this study was to investigate the quality of life and diabetes self-management behaviors in ethnically diverse older adults with type 2 diabetes. The SF-12v2 was used to measure physical and mental health quality of life. Scores were compared to general, age sub-groups, and diabetes-specific norms. The Transtheoretical Model (TTM) was applied to assess perceived versus actual behavior for three diabetes self-management tasks: dietary management, medication management, and blood glucose self-monitoring. Dietary intake and hemoglobin A1c values were measured as outcome variables. Utilizing a cross-sectional research design, participants were recruited from Elderly Nutrition Program congregate meal sites (n = 148, mean age 75). ^ Results showed that mean scores of the SF-12v2 were significantly lower in the study sample than the general norms for physical health (p < .001), mental health (p < .01), age sub-group norms (p < .05), and diabetes-specific norms for physical health (p < .001). A multiple regression analysis found that adherence to an exercise plan was significantly associated with better physical health (p < .001). Transtheoretical Model multiple regression analyses explained 68% of the variance for % Kcal from fat, 41% for fiber, 70% for % Kcal from carbohydrate, and 7% for hemoglobin A 1c values. Significant associations were found between TTM stage of change and dietary fiber intake (p < .01). Other significant associations related to diet included gender (p < .01), ethnicity (p < .05), employment (p < .05), type of insurance (p < .05), adherence to an exercise plan (p < .05), number of doctor visits/year ( p < .01), and physical health (p < .05). Significant associations were found between hemoglobin A1c values and age ( p < .05), being non-Hispanic Black (p < .01), income (p < .01), and eye problems (p < .05). ^ The study highlights the importance of the beneficial effects of exercise on quality of life issues. Furthermore, application of the Transtheoretical Model in conjunction with an assessment of dietary intake may be valuable in helping individuals make lifestyle changes. ^

Psychosocial barriers to self -care among Hispanic women with type 2 diabetes mellitus

This cross-sectional survey-designed study investigated the presence and influence of psychosocial barriers to diabetes self-management practices among Hispanic women with type 2 diabetes mellitus. Women (n = 128) who were diagnosed and being treated for type 2 diabetes were recruited from the Miami-Dade area in South Florida. A Beck Depression Inventory-II, Diabetes Care Profile, Diabetes Knowledge Test, Diabetes Empowerment, Multidimensional Health Locus of Control, and Perceived Stress Scales were administered, along with assessment of diet through a 24-hour recall and anthropometric evaluation by body composition analysis and body mass index computation. ^ Mean (± SD) age for subjects was 50.15 ± 15.93 and age at diagnosis was 42.46 ± 14.69. Mean glycosylated hemoglobin (A 1C) was 8.55 ± 1.39. Diabetes education had not been received by 46.9% of subjects. Psychosocial status had previously been evaluated in only 4 participants. Forty percent of participants were assessed as depressed and 17% moderately to severely so. Depression correlated significantly (p < 0.01) with A1C (r = 0.242), perceived stress (r = 0.566), and self-rated health (r = −0.523). Perceived stress correlated significantly (p < 0.01) with A1C (r = 0.388), understanding of diabetes (r = 0.282), self-rated health (r = −0.372) and diabetes empowerment (r = −0.366). For Cuban women, perceived stress (β = 0.418, p = 0.033) was the only significant predictor of A1C, while among non-Cuban Hispanic women, self-reported health (β = −0.418, p = 0.003) and empowerment (β = 0.432, p = 0.004) were better predictors. The most desirable DM status among the women surveyed (high diet adherence, low exercise barriers, and A1C ≤ 7) was associated with superior self-rated health, more support from family and friends, and greater empowerment. ^ This study revealed the error in considering Hispanics a homogenous entity in treating disease, as their cultural backgrounds and concentration in a community can greatly influence management of a chronic disease like diabetes. The strong correlations found between diabetes-related health indicators and psychosocial factors such as depression and perceived stress suggest that psychosocial assessment of patients must be more strongly advocated in diabetes care. Psychosocial assessment of ethnically diverse diabetic populations is especially vital if greater knowledge is to be gained about their barriers to self-care so that diabetes treatment and thus outcomes are enhanced. ^

Self -management factors, influences, and conditions for type 2 diabetes among Black ethnic groups in Miami, Florida and Abidjan, Cote d'Ivoire

The Dahlgren and Whitehead ecological theory provides the framework for a cross-sectional design to compare socio-demographic characteristics, living and working conditions, and lifestyle daily habits as well as cultural and ecological factors among six diabetic multiethnic Black groups in Miami and Abidjan. Approximately 180 Black Americans (African-, Caribbean-, and Haitian-) and 180 Black Africans (Akan, Malinke, and Krou) aged 20 years and older were surveyed. During the preliminary of this study participants' attitudes and behaviors were qualitatively assessed (N=60) and a tool was developed to describe, in the main study (N=360), differences in participants' strength of commitment to diabetes lifestyle self-management. Despite similarities found in terms of age and gender, statistically significant differences were also found within and among groups in terms of living and working conditions, education level, and religion. African American groups were more likely to participate in more diabetes classes than Haitian Americans and Caribbean Americans. However, African Americans were less likely to adhere to daily dietary and weight control regimens. Although, Black African groups reported limited access to equipment, facilities, and financial support they were more likely to follow dietary and weight control recommendations than Black American groups. Overall, African American participants showed the poorest attitudes towards recommended foods, Caribbean American respondents reported the best attitudes and behaviors towards weight control regimens, and the Malinke group had significantly more strength of commitment to successful weight control. Furthermore, Black African groups had significantly more strength of commitment to successful dietary adherence and significantly less support for weight control than Black American groups. ^ Significant differences found within Black groups suggest that understanding each patient's conditions may help healthcare professionals in initiating individualized appropriate counseling before goal setting, and in developing culturally relevant type 2 diabetes management programs. Moreover, significant differences exist in strength of commitment to lifestyle adherence among Black groups in Miami and Abidjan. Cultural, socio-demographic factors and self-management habits may explain differences in participants' outcomes. At the policy level, Black groups should not be approached as a homogenous group and assessment of the vulnerability of each ethnic group may be necessary in the decision-making process.^

The Role of Family/Friend Social Support in Diabetes Self-Management for Minorities with Type 2 Diabetes

This study investigated how ethnicity, perceived family/friend social support (FSS), and health behaviors are associated with diabetes self-management (DSM) in minorities. The participants were recruited by community outreach methods and included 174 Cuban-, 121 Haitian- and 110 African-Americans with type 2 diabetes. The results indicated that ethnicity and FSS were associated with DSM. Higher FSS scores were associated with higher DSM scores, independent of ethnicity. There were ethnic differences in several elements of FSS. DSM was highest in Haitian- as compared to African-Americans; yet Haitian Americans had poorer glycemic control. The findings suggest FSS together with ethnicity may influence critical health practices. Studies are needed that further investigate the relationships among minorities with diabetes, their intimate network (family and friends) and the diabetes care process.

The association of depression and perceived stress with beta cell function between African and Haitian Americans with and without type 2 diabetes

Background: Diabetes and diabetes-related complications are major causes of morbidity and mortality in the United States. Depressive symptoms and perceived stress have been identified as possible risk factors for beta cell dysfunction and diabetes. The purpose of this study was to assess associations between depression symptoms and perceived stress with beta cell function between African and Haitian Americans with and without type 2 diabetes. Participants and Methods: Informed consent and data were available for 462 participants (231 African Americans and 231 Haitian Americans) for this cross-sectional study. A demographic questionnaire developed by the Primary Investigator was used to collect information regarding age, gender, smoking, and ethnicity. Diabetes status was determined by self-report and confirmed by fasting blood glucose. Anthropometrics (weight, and height and waist circumference) and vital signs (blood pressure) were taken. Blood samples were drawn after 8 10 hours over-night fasting to measure lipid panel, fasting plasma glucose and serum insulin concentrations. The homeostatic model assessment, version 2 (HOMA2) computer model was used to calculate beta cell function. Depression was assessed using the Beck Depression Inventory-II (BDI-II) and stress levels were assessed using the Perceived Stress Scale (PSS). Results: Moderate to severe depressive symptoms were more likely for persons with diabetes (p = 0.030). There were no differences in perceived stress between ethnicity and diabetes status (p = 0.283). General linear models for participants with and without type 2 diabetes using beta cell function as the dependent variable showed no association with depressive symptoms and perceived stress; however, Haitian Americans had significantly lower beta cell function than African Americans both with and without diabetes and adjusting for age, gender, waist circumference and smoking. Further research is needed to compare these risk factors in other race/ethnic groups.

Effect of Medical Advice for Diet on Diabetes Self-Management and Glycemic Control for Haitian and African Americans with Type 2 Diabetes

Adequate care of type 2 diabetes is reflected by the individual’s adherence to dietary guidance; yet, few patients are engaged in diabetes self-care at the recommended level, regardless of race/ethnicity. Few studies on the effect of dietary medical advice on diabetes self-management (DSM) and glycemic control have been conducted on Haitian and African American adults with type 2 diabetes. These relationships were assessed in total of 254 Blacks with type 2 diabetes (Haitian Americans = 129; African Americans = 125) recruited from Miami-Dade and Broward Counties, Florida by community outreach methods. Although dietary advice received was not significantly different between the two Black ethnicities, given advice “to follow a diet” as a predictor of “using food groups” was significant for Haitian Americans, but not for African Americans. Haitian Americans who were advised to follow a diet were approximately 3 times more likely to sometimes or often use food groups (or exchange lists) in planning meals. Less than optimal glycemic control (A1C > 7.2) was inversely related to DSM for African Americans; but the relationship was not significant for Haitian Americans. A one unit increase in DSM score decreased the odds ratio point estimate of having less than optimal glycemic control (A1C > 7.2%) by a factor of 0.94 in African Americans. These results suggest that medical advice for diet plans may not be communicated effectively for DSM for some races/ethnicities. Research aimed at uncovering the enablers and barriers of diet management specific to Black ethnicities with type 2 diabetes is recommended.

Relationship of Omega-3 Fatty Acids on C-Reactive Protein and Homocysteine in Haitian and African Americans with and without Type 2 Diabetes

Background: Omega-3 fatty acids (n-3) may be protective of cardiovascular risk factors for vulnerable populations. The purpose of this study was to assess the association between n-3 with, C-reactive protein (CRP), and homocysteine (HCY) in Black minorities with and without type 2 diabetes. Methods: A cross-sectional study was conducted with 406 participants: Haitian Americans (HA): n=238. African Americans (AA): n=172. Participants were recruited from a randomly generated mailing lists, local diabetes educators, community health practitioners and advertisements from 2008-2010. Sociodemographics and anthropometrics were collected and used to adjust analyses. All dietary variables were collected using the semi-quantitative food frequency questionnaire (FFQ) and used to quantify vitamin components. Blood was collected to measure CVD risk factors (blood lipids, HCY, and CRP). Results: African Americans had higher waist circumferences and C-reactive protein and consumed more calories as compared to Haitian Americans. Omega 3 fatty acid intake per calorie did not differ between these ethnicities, yet African Americans with low n-3 intake were three times more likely to have high C-reactive protein as compared to their counterparts [OR=3. 32 (1. 11, 9. 26) p=0.031]. Although homocysteine did not differ by ethnicity, African Americans with low omega 3 intake (<1 g/day) were four times as likely to have high homocysteine (>12 mg/L) as compared to their counterparts, adjusting for confounders [OR=4.63 (1.59, 12.0) p=0.004]. Consumption of n-3 by diabetes status was not associated with C-reactive protein or homocysteine levels. Conclusions: Consumption of n-3 may be protective of cardiovascular risk factors such as C-r

Perceived Stress and Self‑rated Health of Haitian and African Americans with and without Type 2 Diabetes

Background: Blacks have a higher incidence of diabetes and its related complications. Self-rated health (SRH) and perceived stress indicators are associated with chronic diseases. The aim of this study was to examine the associations between SRH, perceived stress and diabetes status among two Black ethnicities. Materials and Methods: The cross-sectional study included 258 Haitian Americans and 249 African Americans with (n = 240) and without type 2 diabetes (n = 267) (N = 507). Recruitment was performed by community outreach. Results: Haitian-Americans were less likely to report ‘fair to poor’ health as compared to African Americans [OR=0.58 (95% CI: 0.35, 0.95), P = 0.032]; yet, Haitian Americans had greater perceived stress than African Americans (P = 0.002). Having diabetes was associated with ‘fair to poor’ SRH [OR=3.14 (95% CI: 2.09, 4.72),P < 0.001] but not perceived stress (P = 0.072). Haitian-Americans (P = 0.023), females (P = 0.003) and those participants having ‘poor or fair’ SRH (P < 0.001) were positively associated with perceived stress (Nagelkerke R2=0.151). Conclusion: Perceived stress associated with ‘poor or fair’ SRH suggests that screening for perceived stress should be considered part of routine medical care; albeit, further studies are required to confirm our results. The findings support the need for treatment plans that are patient-centered and culturally relevant and that address psychosocial issues.

Ethnic Differences in Insulin Resistance, Adiponectin Levels and Abdominal Obesity: Haitian Americans and African Americans, with and without Type 2 Diabetes Mellitus

Background: Metabolic outcomes of obesity and its associated disorders may not be equivalent across ethnicity and diabetes status. Aim: In this paper, we examined the association of abdominal obesity, by ethnicity and diabetes status, for indicators of glucose metabolism in Blacks. Methods: A cross sectional study was conducted in Haitian Americans (n= 186) and African Americans (n= 148) with and without type 2 diabetes mellitus (T2DM). Student’s t-test and Chi-squared test were used to assess differences in mean and proportion values between ethnicities with and without type 2 diabetes mellitus. Relationship between insulin resistance, ethnicity, diabetes status, abdominal obesity, and adiponectin levels were analyzed by analysis of covariance while controlling for confounding variables. Results:Haitian American participants were older (P = .032), had higher fasting plasma glucose (P = .036), and A1C (P = .016), but had lower levels of Hs-CRP (P < .001), insulin and HOMA2-IR and lower abdominal obesity (P = .030), than African Americans. Haitian Americans had significantly lower HOMA2-IR (P = .008) than African Americans when comparing both ethnicities with T2DM, high abdominal obesity, and adiponectin levels lower than the median ( Conclusion: The clinical significance of observed differences in insulin resistance, abdominal obesity, and adiponectin levels between Haitian Americans and African Americans could assist in forming public health policies that are ethnic specific.

Use of Hemoglobin A1C to Detect Haitian-Americans with Undiagnosed Type 2 Diabetes

OBJECTIVE: To evaluate the validity of hemoglobin A1C (A1C) as a diagnostic tool for type 2 diabetes and to determine the most appropriate A1C cutoff point for diagnosis in a sample of Haitian-Americans. SUBJECTS AND METHODS: Subjects (n = 128) were recruited from Miami-Dade and Broward counties, FL. Receiver operating characteristics (ROC) analysis was run in order to measure sensitivity and specificity of A1C for detecting diabetes at different cutoff points. RESULTS: The area under the ROC curve was 0.86 using fasting plasma glucose ≥ 7.0 mmol/L as the gold standard. An A1C cutoff point of 6.26% had sensitivity of 80% and specificity of 74%, whereas an A1C cutoff point of 6.50% (recommended by the American Diabetes Association – ADA) had sensitivity of 73% and specificity of 89%. CONCLUSIONS: A1C is a reliable alternative to fasting plasma glucose in detecting diabetes in this sample of Haitian-Americans. A cutoff point of 6.26% was the optimum value to detect type 2 diabetes.

The Effect of Carbohydrate Amount, Quality and Type on Arterial Pulse Pressure in Cuban-Americans with and Without Type 2 Diabetes

Background: Arterial pulse pressure, the difference between systolic and diastolic blood pressure, has been used as an indicator (surrogate measure) of arterial stiffness. High arterial pulse pressure (> 40) has been associated with increased cardiovascular disease and mortality. Several clinical trials have reported that the proportion of calories from carbohydrate has an effect on blood pressure. The primary objective of this study was to assess arterial pulse pressure and its association with carbohydrate quantity and quality (glycemic load) with diabetes status for a Cuban American population. Methods: A single point analysis included 367 participants. There was complete data for 365 (190 with and 175 without type 2 diabetes). The study was conducted in the investigator’s laboratory located in Miami, Florida. Demographic, dietary, anthropometric and laboratory data were collected. Arterial pulse pressure was calculated by the formula systolic minus the diastolic blood pressure. Glycemic load, fructose, sucrose, percent of average daily calories from carbohydrate, fat and protein, grams of fiber and micronutrient intakes were calculated from a validated food frequency questionnaire. Results: The mean arterial pulse pressure was significantly higher in participants with (52.9 ± 12.4) than without (48.6 ± 13.4) type 2 diabetes. The odds of persons with diabetes having high arterial pulse pressure (>40) was 1.85 (95% CI =1.09, 3.13); p=0.023. For persons with type 2 diabetes higher glycemic load was associated with lower arterial pulse pressure. Conclusions: Arterial pulse pressure and diet are modifiable risk factors of cardiovascular disease. Arterial pulse pressure may be associated with carbohydrate intake differently considering diabetes status. Results may be due to individuals with diabetes following dietary recommendations. The findings of this study suggest clinicians take into consideration how medical condition, ethnicity and diet are associated with arterial pulse pressure before developing a medical nutrition therapy plan in collaboration with the client.

Obesity and Serum High Sensitivity C-Reactive Protein Levels Among Elderly Turkish Immigrants in the Netherlands with Type 2 Diabetes

The study examined the associations of anthropometric measures of obesity with high sensitivity C-reactive protein (hs-CRP) levels in Turkish immigrants with type 2 diabetes (T2D) living in the Netherlands. A total of 110 participants, physician-diagnosed with T2D, aged 30 years and older were recruited from multiple sources from The Hague, Netherlands. Serum hs-CRP levels were measured with immunoturbidimetric assay. Glycated hemoglobin (A1C) was determined by high-pressure liquid chromatography. Measures of obesity: body weight, body mass index (BMI), waist circumference (WC), hip circumference (HC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHtR) were determined. Statistical analysis included descriptive statistics, Pearson’s correlations and multiple linear regressions (MLR) stratified by gender. Hs-CRP was log transformed to achieve normality. Subjects with hs-CRP levels >10 mg/L (n = 17) were excluded from the analysis. Females had a higher BMI (p = 0.007), HC (p < 0.001), and WHtR (p = 0.011) as compared to males. Conversely, males had a higher weight (p = 0.007), and WHR (p < 0.001) than females. MLR showed that after controlling for covariates, log hs-CRP was positively associated with BMI (B = 0.039, SE = 0.019, β = 0.287, p < 0.05), WC (B = 0.025, SE = 0.011, β = 0.332, p < 0.05) and WHtR (B = 4.015, SE = 1.464, β = 0.376, p < 0.01) in females only. Gender-specific associations between obesity measures and hs-CRP level need to be further investigated in the Turkish immigrant population. Hs-CRP assessment may be added as a standard of care for T2D treatment within this population.

Gender Differences in Medical Advice and Health Behavior of Obese African Americans With and Without Type 2 Diabetes

This study examined gender differences in medical advice related to diet and physical activity for obese African American adults (N = 470) with and without diabetes. Data from the 2007-2008 National Health and Nutrition Examination Survey were analyzed using logistic regression analyses. Even after sociodemographic adjustments, men were less likely to report receiving medical advice as compared with women. Both men and women given dietary and physical activity advice were more likely to follow it. Men were less likely to report currently reducing fat or calories, yet men withdiabetes were 5 times more likely to state that they were reducing fat and calories as compared with women with diabetes. Gender- and disease state-specific interventions are needed comparing standard care with enhanced patient education. Moreover, these findings necessitate studies that characterize the role of the health care professional in the diagnosis and treatment of obesity and underscore patient-provider relationships.

Inadequacy of Micronutrients, Fat, and Fiber Consumption in the Diets of Haitian-, African- and Cuban-Americans with and without Type 2 Diabetes

Micronutrient insufficiency, low dietary fiber, and high saturated fat intake have been associated with chronic diseases. Micronutrient insufficiencies may exacerbate poor health outcomes for persons with type 2 diabetes and minority status. We examined dietary intakes using the Recommended Dietary Allowances (RDAs) of micronutrients, and Adequate Intakes (AIs) of fiber, and Dietary Guidelines for Americans (DGA) for saturated fat in Haitian-, African-, and Cuban- Americans (n = 868), approximately half of each group with type 2 diabetes. Insufficient intakes of vitamins D and E and calcium were found in over 40 % of the participants. Over 50 % of African- and Cuban- Americans consumed over 10 % of calories from saturated fat. Haitian-Americans were more likely to have insufficiencies in iron, B-vitamins, and vitamins D and E, and less likely to have inadequate intake of saturated fat as compared to Cuban-Americans. Vitamin D insufficiency was more likely for Haitian-Americans as compared to African- Americans. Diabetes status alone did not predict micronutrient insufficiencies; however, Haitian-Americans with no diabetes were more likely to be insufficient in calcium. Adjusting for age, gender, energy, smoking, physical activity, access to health care, and education negated the majority of micronutrient insufficiency differences by ethnicity. These findings suggest that policies are needed to ensure that low-cost, quality produce can be accessed regardless of neighborhood and socioeconomic status.

Dietary Intake Of Flavonoids And HDL- And LDL- Cholesterol In Two Black Ethnicities With And Without Type 2 Diabetes

Flavonoids are a class of over 6,500 plant metabolites that have been associated with reduced mortality from cardiovascular disease. A cross-sectional analysis of dietary flavonoids and serum cholesterol in 507 Blacks with and without type 2 diabetes (258 Haitian-Americans and 249 African-Americans) showed differences by ethnicity and diabetes status. Haitian-Americans consumed more of most flavonoids as compared to African-Americans. Individuals with type 2 diabetes consumed less of most flavonoids as compared to those without diabetes. Flavonoids were differentially associated with low-density lipoprotein cholesterol (LDL) and high-density lipoprotein cholesterol (HDL) by diabetes status. Flavanones were associated with lower LDL for participants without diabetes and higher LDL for those with diabetes, independent of ethnicity and adjusted for age, gender, cholesterol medications, daily energy, dietary fat, body mass index (BMI), and smoking. Flavan-3-ols were positively related to LDL while polyflavonoids (theaflavin and polymers, proanthocyanidins) were inversely related to LDL for the group without diabetes only. Higher anthocyanidins and flavan-3-ols and lower polyflavonoids were associated with higher HDL (same adjustments) for those without diabetes, whereas no flavonoids were associated with HDL for individuals with type 2 diabetes.