David G. Schlundt

Reduced Awareness of Hypoglycemia in Adults With IDDM: A prospective study of hypoglycemic frequency and associated symptoms

OBJECTIVE To prospectively evaluate the frequency and severity of hypoglycemic episodes in IDDM subjects who declare themselves to have reduced awareness of hypoglycemia, to validate their self-designations in their natural environment, and to determine objectively the presence or absence of autonomic and neuroglycopenic symptoms associated with their low blood glucose (BG) levels. RESEARCH DESIGN AND METHODS A total of 78 insulin-dependent diabetes mellitus (IDDM) subjects (mean age 38.3 ± 9.2 years; duration of diabetes 19.3 ± 10.4 years) completed two sets of assessments separated by 6 months. The assessments included reports of frequency and severity of low BG, symptoms associated with low BG, and a BG symptom/estimation trial using a hand-held computer (HHC). Diaries of hypoglycemic episodes were kept for the intervening 6 months. HbA1 levels were determined at each assessment. RESULTS Of the subjects, 39 declared themselves as having reduced awareness of hypoglycemia (reduced-awareness subjects). There were no differences between these reduced-awareness subjects and aware subjects with regard to age, sex, disease duration, insulin dose, or HbA1. During the HHC trials, reduced-awareness subjects were significantly less accurate in detecting BG < 3.9 mmol/l (33.2 ± 47 vs. 47.6 ± 50% detection, P = 0.001) and had significantly fewer autonomic (0.41 ± 0.82 vs. 1.08 ± 1.22, P = 0.006, reduced-awareness vs. aware) and neuroglycopenic (0.44 ± 0.85 vs. 1.18 ± 1.32, P = 0.004, reduced-awareness vs. aware) symptoms per subject. Prospective diary records revealed that reduced-awareness subjects experienced more moderate (351 vs. 238, P = 0.026) and severe (50 vs. 17, P = 0.0062) hypoglycemic events. The second assessment results were similar to the first and verified the reliability of the data. CONCLUSIONS IDDM subjects who believe they have reduced awareness of hypoglycemia are generally correct. They have a history of more moderate and severe hypoglycemia, are less accurate at detecting BG < 3.9 mmol/l, and prospectively experience more moderate and severe hypoglycemia than do aware subjects. Neither disease duration nor level of glucose control explains their reduced awareness of hypoglycemia. Reduced-awareness individuals may benefit from interventions designed to teach them to recognize all of their potential early warning symptoms.

Comparing Diabetes Prevalence Between African Americans and Whites of Similar Socioeconomic Status

OBJECTIVES We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors. METHODS We analyzed data from 34331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension. RESULTS Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR]=1.07; 95% confidence interval [CI]=0.95, 1.20); women: OR=1.13, 95% CI=1.04, 1.22). CONCLUSIONS Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race.

Validation of self-ideal body size discrepancy as a measure of body dissatisfaction

Recently, body dissatisfaction has been conceptualized as the discrepancy between self and ideal body size estimates. This study evaluated the validity of this conceptualization using three methods for estimating actual and ideal body size: (a) the Body Image Assessment, (b) the Body Image Testing System, and (c) the Body Image Detection Device. The three body image assessment procedures were concurrently administered to a sample of 110 women diagnosed: bulimia nervosa (n=18),obese (n=34),and non-eating disorder (n=58).The Eating Disorder Inventory Body Dissatisfaction scale was also used to measure body dissatisfaction. Measures of self-ideal body size discrepancy were found to correlate more highly with measures of body dissatisfaction than were measures of current body size perception, ideal body size, body size estimation accuracy, or indices based on actual body size. Estimation of both current and ideal body size were found to significantly predict overall body dissatisfaction; thus, both self and ideal body size measures were found to be significant components in determining body size dissatisfaction. These data were interpreted as supportive of the conceptualization of body dissatisfaction as the discrepancy between self and ideal body size estimates.

Literacy, numeracy, and portion-size estimation skills.

BACKGROUND Portion-size estimation is an important component of weight management. Literacy and numeracy skills may be important for accurate portion-size estimation. It was hypothesized that low literacy and numeracy would be associated with decreased accuracy in portion estimation. METHODS A cross-sectional study of primary care patients was performed from July 2006 to August 2007; analyses were performed from January 2008 to October 2008. Literacy and numeracy were assessed with validated measures (the Rapid Estimate of Adult Literacy in Medicine and the Wide Range Achievement Test, third edition). For three solid-food items and one liquid item, participants were asked to serve both a single serving and a specified weight or volume amount representing a single serving. Portion-size estimation was considered accurate if it fell within +/-25% of a single standard serving. RESULTS Of 164 participants, 71% were women, 64% were white, and mean (SD) BMI was 30.6 (8.3) kg/m(2). While 91% reported completing high school, 24% had <9th-grade literacy skills and 67% had <9th-grade numeracy skills. When all items were combined, 65% of participants were accurate when asked to serve a single serving, and 62% were accurate when asked to serve a specified amount. In unadjusted analyses, both literacy and numeracy were associated with inaccurate estimation. In multivariate analyses, only lower literacy was associated with inaccuracy in serving a single serving (OR=2.54; 95% CI=1.11, 5.81). CONCLUSIONS In this study, many participants had poor portion-size estimation skills. Lower literacy skills were associated with less accuracy when participants were asked to serve a single serving. Opportunities may exist to improve portion-size estimation by addressing literacy.

A naturalistic functional analysis of binge eating

A naturalistic functional analysis of self-monitoring records was used to investigate the time of day, day of week, social context, physical context, hunger, and mood prior to eating as antecedent conditions to binge eating in binge eating disordered (BED) individuals, non-clinical binge eaters (NCB), and normal control subjects (NRM). An analysis of reported binge episodes found that BED subjects reported 36.2% of their food intakes as binges, compared to 23.2% for NCB subjects, and 12.1% for NRM subjects. Important similarities as well as differences in the overall eating and binging patterns of the three groups of subjects were identified. The frequency and pattern of meals were very similar and binging occurred primarily in the evening at supper or at later snacks. All three groups also displayed a pattern of binge eating in response to negative emotions, with NRM subjects also binging in response to positive emotions. Furthermore, the abstinence violation effect was observed in all three groups.

Self-Management Behaviors, Racial Disparities, and Glycemic Control Among Adolescents With Type 2 Diabetes

OBJECTIVE. Type 2 diabetes is a growing problem among adolescents, but little is known about self-management behaviors in this population. Our aim was to examine self-management behaviors and glycemic control among adolescents with type 2 diabetes. METHODS. From 2003 to 2005, a telephone survey of adolescents with type 2 diabetes was performed. Chart review obtained most recent glycated hemoglobin and clinical characteristics. Analyses compared patient characteristics and self-management behaviors to recent glycated hemoglobin levels. RESULTS. Of 139 patients contacted, 103 (74%) completed the study. The mean age was 15.4 years: 69% were girls, 47% were white, and 46% were black. Mean glycated hemoglobin was 7.7%, and the average duration of diabetes was 2.0 years. More than 80% of patients reported ≥75% medication compliance, and 59% monitored blood glucose >2 times daily. However, patients reported frequent episodes of overeating, drinking sugary drinks, and eating fast food. More than 70% of patients reported exercising ≥2 times a week, but 68% reported watching ≥2 hours of television daily. Nonwhite patients had higher glycated hemoglobin and hospitalizations per year compared with white patients. In multivariable analyses, nonwhite race remained significantly associated with higher glycated hemoglobin even after adjusting for age, gender, BMI, insurance status, and other factors. Nonwhite patients were more likely to watch ≥2 hours of television per day (78% vs 56%), to report exercising ≤1 time per week (35% vs 21%), and to drink ≥1 sugary drink daily (27% vs 13%). CONCLUSION. Although patients reported good medication and monitoring adherence, they also reported poor diet and exercise habits and multiple barriers. Nonwhite race was significantly associated with poorer glycemic control even after adjusting for covariates. This may, in part, be related to disparities in lifestyle behaviors. Additional studies are indicated to further assess self-management behaviors and potential racial disparities in adolescents with type 2 diabetes.

Changing Behavior: Practical lessons from the Diabetes Control and Complications Trial

The recently completed Diabetes Control and Complications Trial (DCCT) has elicited renewed interest in behavior change strategies, because intensive therapy of 1DDM in the DCCT was a comprehensive behavioral change program with unequivocal health benefits (1,2). Intensive therapy lowered blood glucose levels and slowed the appearance and progression of microvascular and neuropathic complications because participants changed many behaviors, including testing blood glucose and administering insulin more frequently, quantifying and regulating dietary intake, and modifying diet, insulin, and physical activity to balance their effects on blood glucose levels. It is natural to ask what can be learned from the DCCT about changing behavior that is pertinent to diabetes management in clinical practice. The DCCT compared two treatment programs that differed in many ways. Among the differences between the two treatments was the more frequent use of behavioral change strategies in the intensive therapy group. Use of specific behavior change strategies depended on the needs of individual patients. In addition, while the framework of intensive therapy was dictated by the study protocol, the detailed application of behavioral change strategies is presumed to have varied with the skills and preferences of each Clinical Center staff, as was also true of other elements of treatment such as insulin management and the choice of pump or multiple injection therapy. Consequently, there were uncontrolled differences across clinics and individuals in the use of behavioral interventions. Therefore, the DCCT Study Group has not attempted to draw systematic conclusions about the effectiveness of specific behavioral change strategies or other elements of the intensive therapy program. Nevertheless, it is possible to offer opinions on the behavioral strategies that seemed most helpful. To generate a broad synthesis of practical lessons from the DCCT, the first author recruited collaborators from several DCCT Clinics and disciplines, including nursing, nutrition, clinical psychology, psychiatry, and social work. The practical lessons we offer here were not discovered or used for the first time in the DCCT, but are well grounded in a large body of literature, examples of which we cite. A short list of additional reading is also included. The point emphasized here is that the DCCT has demonstrated that these strategies are truly effective in achieving longterm behavioral changes and health benefits in subjects with IDDM. Before discussing specific behavioral change strategies, we wish to articulate a general principle suggested by the DCCT: ordinary people can adopt and maintain substantial behavioral changes. Because of the extraordinary adherence of the DCCT volunteers to the protocol, it has been implied that they were so well

The Dieter's Inventory of Eating Temptations: a measure of weight control competence.

This research reports the development and initial investigation of the reliability and validity of the Dieters Inventory of Eating Temptations (DIET), a self-report inventory designed to assess behavioral competence in six types of situations related to weight control: (a) overeating, (b) negative emotions, (c) exercise, (d) resisting temptation, (e) positive social, and (f) food choice. The scales were shown to have adequate test-retest reliability and internal consistency. A comparison of 193 normal weight and 168 overweight subjects showed that overweights rated themselves as less competent in the overeating, negative emotions, and exercise situations. As a further validation, DIET scores were compared with measures of eating style derived from self-monitoring records. All of the DIET scales were significantly associated with specific parameters of eating behavior. In order to identify subtypes of overweight and normal weight individuals, cluster analyses were performed. Normal weight and overweight subjects could be grouped into interpretable clusters based on their profile of DIET scores. These data suggest that there is a relationship between eating patterns and body weight, and that there may be several types of problem behavior patterns. Treatment programs should combined assessment of behavioral competency in energy balance situations with intensive skill training in areas where situation specific competency deficits are found.

A sequential behavioral analysis of cravings sweets in obese women

This study compared 40 female participants in a behavioral weight loss program who frequently reported craving sweets to 40 who rarely reported craving sweets using 2-week behavioral eating diaries. The two groups were compared on physiological, demographic, and questionnaire measures and no significant differences were found. There were no significant differences in macronutrient intake either overall or in a wide range of specific situations. The relative proportions of carbohydrate, protein, and fat consumed in association with craving sweets differed only slightly from the composition of other meals and snacks. Carbohydrate and protein intake when craving sweets was similar to breakfasts while the relative amount of fat consumed when craving sweets was comparable to episodes of overeating. The two groups differed in their reporting of moods with the high-craving group reporting more boredom and less stress than the low-craving group. The relationship between situational and mood variables and reports of craving sweets did not differ between the two groups. Craving sweets was negatively associated with hunger and was not associated with meal skipping. A sequential analysis demonstrated that eating in response to craving sweets triggers an abstinence violation effect. These data are not consistent with the hypothesis that sweet cravers consume high-carbohydrate, low-protein meals and snacks in order to self-medicate depression caused by serotonin depletion. Instead, the data suggest that we should further explore the role of food palatability and food-related cognitions in order to understand craving sweets.

Stages of change and the intake of dietary fat in African-American women: improving stage assignment using the Eating Styles Questionnaire.

OBJECTIVE To develop an algorithm for determining the stage of change for dietary fat intake in African-American women. DESIGN We examined the relationships between stage of change, dietary fat intake, and associated eating behaviors and developed an assessment tool for placing subjects in their appropriate stage of change. SUBJECTS Working class and middle-income African-American women in Nashville, Tenn; 174 in study 1 and 208 in study 2. STATISTICAL ANALYSES Fat and fiber intake by stage of change was examined using multivariate analysis of variance. Hierarchical cluster analysis was performed using Wards method. RESULTS A significant difference in fat intake was noted between women trying to change their intake and those not trying to change in study 1 (P < .001) and study 2 (P < .03). Of those trying to change, only 34% (study 1) and 9% (study 2) of subjects reported fat intakes below the Healthy People 2000 goal of 30% of energy from fat. In study 1, cluster analysis identified 14 groups of foods that significantly separated subjects into not trying, noncompliant, and compliant categories. Compliant subjects ate out less; ate fewer snack foods and less chicken, meat, and fat; and ate more fruits, vegetables, breakfast foods, and low-fat products. These results led to development of the Eating Styles Questionnaire (study 2), which facilitated more appropriate placement of the noncompliant group in stages of change for dietary fat intake. APPLICATIONS/CONCLUSIONS These data support the stage construct of the Transtheoretical Model for dietary fat reduction in African-American women. Moreover, the Eating Styles Questionnaire (ESQ) can improve determination of stage of change for this group of women. The ESQ can be used to diagnose the eating styles that contribute to a high-fat intake and help in the design of interventions to lower fat intakes.