Heather E. Cuevas

Depression and Adherence to Lifestyle Changes in Type 2 Diabetes A Systematic Review

Purpose Depression affects millions of people worldwide and is prevalent among those with diabetes. The purpose of this review was to synthesize recent research on depression and adherence to dietary and physical activity recommendations in persons with type 2 diabetes (T2DM). Methods This systematic review is a subanalysis of an NIH-funded model-testing meta-analysis. Thirteen electronic databases were searched using terms: depression, adherence, T2DM, diabetes. Selected studies: were reported in English between 2000 and 2012, focused on adults with T2DM, and measured depression and dietary and/or physical activity adherence. Results Twenty-seven studies involving 7266 participants were selected; participants were 54% female and 62 years of age, on average. When reported, depression prevalence in study samples ranged from 4.5% to 74%. Six intervention studies targeted diabetes treatment, with or without depression treatment; no studies focused solely on treating depression. Twenty-one descriptive studies examined relationships between depression and diet/physical activity adherence, finding a negative association. Only 2 of the 6 intervention studies examined this relationship; findings were inconsistent. Conclusion Depression was associated with lower adherence to diabetes self-care, as evidenced primarily by descriptive studies; results of intervention studies were conflicting. Future research should focus on the effects of treating depression on diabetes health outcomes.

Biobehavioral determinants of glycemic control in type 2 diabetes: A systematic review and meta-analysis.

OBJECTIVES To conduct a model-driven meta-analysis of correlational research on psychological and motivational predictors of diabetes outcomes, with adherence factors as mediators. METHODS A comprehensive literature search of published and unpublished studies located a sample of 775 individual correlational or predictive studies reported across 739 research reports. RESULTS Results varied according to the outcome variable included in the regression models. Depression had a larger negative effect on adherence to physical activity than on dietary adherence. Coping and self-efficacy were strongly related to dietary adherence, which was strongly related to improved glycemic control. Medication adherence was related to glycosylated hemoglobin, whereas medications and self-monitoring were related to fasting blood glucose. Adding appointment keeping to the models did not significantly alter the results. CONCLUSION Self-efficacy was the most consistent predictor of all adherence behaviors and dietary adherence was the most significant predictor of HbA1c. Physical activity was the most predictive factor of BMI and glucose self-monitoring the most predictive of FBG. PRACTICE IMPLICATIONS Metabolic control is a primary goal in T2DM, so the best pathway to attaining that goal appears to be an emphasis on self-efficacy and dietary adherence.

Perceived cognitive deficits are associated with diabetes self-management in a multiethnic sample

BackgroundPeople with diabetes have almost twice the risk of developing cognitive impairment or dementia as do those without diabetes, and about half of older adults with diabetes will become functionally disabled or cognitively impaired. But diabetes requires complex self-management: patients must learn about the implications of their disease; manage their diets, physical activity, and medication; and monitor their blood glucose. Difficulties with cognition can hinder these activities.MethodsThe purpose of this study was to explore perceptions of cognitive ability in a multiethnic sample of persons with type 2 diabetes (T2DM). One hundred twenty participants completed surveys assessing perceived memory, executive function, diabetes self-management, and quality of life. Scores on the surveys were examined along with hemoglobin A1C levels and demographics.ResultsScores for executive function were positively associated with self-reports of dietary adherence and blood glucose monitoring. Perceived memory ability was a significant predictor of quality of life, and executive function was a significant predictor of A1C.ConclusionsPatients’ perceptions of their cognitive difficulties may assist health care providers in detection of patients’ deficiencies in performing diabetes self-management tasks. The relationships between cognitive difficulties and self-management found in this descriptive study suggest that research on the processes leading to cognitive changes in T2DM is needed, as are studies on how those processes affect diabetes self-management.

Managing complex research datasets using electronic tools: A meta-analysis exemplar

Meta-analyses of broad scope and complexity require investigators to organize many study documents and manage communication among several research staff. Commercially available electronic tools, for example, EndNote, Adobe Acrobat Pro, Blackboard, Excel, and IBM SPSS Statistics (SPSS), are useful for organizing and tracking the meta-analytic process as well as enhancing communication among research team members. The purpose of this article is to describe the electronic processes designed, using commercially available software, for an extensive, quantitative model-testing meta-analysis. Specific electronic tools improved the efficiency of (a) locating and screening studies, (b) screening and organizing studies and other project documents, (c) extracting data from primary studies, (d) checking data accuracy and analyses, and (e) communication among team members. The major limitation in designing and implementing a fully electronic system for meta-analysis was the requisite upfront time to decide on which electronic tools to use, determine how these tools would be used, develop clear guidelines for their use, and train members of the research team. The electronic process described here has been useful in streamlining the process of conducting this complex meta-analysis and enhancing communication and sharing documents among research team members.

Self-Management Decision Making of Cuban Americans With Type 2 Diabetes

Purpose: Although researchers have studied how individuals manage type 2 diabetes, none have examined how Cuban Americans do so. This article explores how Cuban Americans make self-management choices and examines whether an empowerment framework is viable for informing interventions. Design: A qualitative descriptive study was conducted (n = 20) with Cuban Americans with type 2 diabetes. Individual interviews were analyzed with content analysis. Results: Motivation and temporal factors, such as knowledge of symptoms and the ability to plan ahead, positively affect self-management. Cultural factors, such as access to cultural foods, negatively affect self-management. Empowerment formed a comprehensive lens through which self-management decisions were acted on. Conclusion: Given the cultural context, empowerment and unique barriers and facilitators can affect diabetes self-management in this population. Strategies to promote healthy decisions must take into account the strengths of this community as well as its challenges.

Thinking About Cognitive Function: Perceptions of Cognitive Changes in People With Type 2 Diabetes:

Purpose The purpose of this study is 2-fold: (1) to explore how people with diabetes view diabetes-related cognitive problems and (2) to examine participants’ ideas on a cognitive rehabilitation intervention to adapt it for persons diagnosed with type 2 diabetes (T2DM). Methods A qualitative descriptive study based on narrative interviews was conducted with adults (n = 10) with T2DM. The interview data were analyzed using content analysis. Results The interviews reflected 4 major themes: search for advice regarding cognitive complaints, cognitive symptoms, impact of perceived cognitive dysfunction on diabetes self-management, and maintenance of cognitive health. Specific areas of interest for an intervention included the following: understanding how cognitive function relates to diabetes, dealing with cognitive barriers to self-management, and learning how to incorporate a “brain healthy” lifestyle into daily activities. Conclusions Findings showed that perceived cognitive impairment impacted self-management and suggested that cognitive rehabilitation interventions have potential utility for people with T2DM. Existing successful interventions can be tailored to meet the needs of those whose diabetes self-management is impacted by cognitive problems.

Blood Glucose Self-Monitoring Patterns in Mexican Americans: Further Lessons from the Starr County Border Health Initiative

BACKGROUND The purpose was to describe patterns of home self-monitoring of blood glucose (SMBG) in Mexican Americans with type 2 diabetes mellitus enrolled in a diabetes self-management education protocol. Research questions were as follows: (1) What were the patterns and rates of home glucose self-monitoring over the 6-month course of the study? (2) What were the differences in monitoring rates between experimental and control groups? (3) What were the relationships between rates of monitoring and glycosylated hemoglobin (A1C), gender, and years with diabetes? SUBJECTS AND METHODS We used a randomized (by group) repeated-measures pretest/posttest control group design. Glucometer data from an experimental group (diabetes self-management education plus nurse case management) and a comparison group (diabetes self-management education only) were analyzed. Data were collected at baseline and at 3 and 6 months. RESULTS Overall average SMBG rates were low. Experimental and control group monitoring levels were not significantly different. More females than males never monitored glucose values, but more females than males checked at least one time per week. Those participants who checked their glucose levels more than once per week had diabetes for a longer period of time. Rates of monitoring were not strongly associated with A1C levels at 3 and 6 months, but at 6 months A1C levels were statistically significantly different based on whether or not individuals monitored their glucose levels (P=0.03, n=71). CONCLUSIONS SMBG rates were low in this study despite SMBG education and access to free glucometers and test strips. The lower rates of SMBG may reflect the effects of unexpected environmental challenges, but exact causes remain unclear. Reasons for low rates of SMBG need to be explored further, especially in underserved communities.

The Starr County Border Health Initiative: Focus Groups on Diabetes Prevention in Mexican Americans

Purpose The purpose of the study was to conduct focus groups with Mexican Americans in an impoverished rural community on the Texas-Mexico border to identify current barriers to adopting healthier lifestyles and to obtain recommendations for diabetes prevention. Methods Three separate 2-hour focus groups were led by an experienced bilingual Mexican American moderator. Interviews included questions about cultural factors and barriers that influence lifestyle behaviors, aspects of previous diabetes self-management interventions that were helpful for motivating behavioral change, and recommendations for diabetes prevention. Results Twenty-seven participants attended a focus group session; each session involved 7 to 12 informants. Individuals were diagnosed with prediabetes or type 2 diabetes mellitus; most were female, foreign born, and Spanish speaking. Interviews documented the cultural importance of food. Informants raised priority issues for diabetes prevention, including the need to learn how to prepare healthier foods and track caloric intake. Major barriers to healthier lifestyles included high costs of healthy foods, fatigue from busy schedules and working multiple jobs, a cultural view that exercise is a waste of valuable time, and fear of deportation. Conclusions Cultural influences and barriers to implementing healthy lifestyles should be assessed regularly and strategies implemented to overcome them. Such factors may change as environmental, sociocultural, and political environments change.

Participant Perspectives of Cognitive Rehabilitation for Type 2 Diabetes: Expectations and Impact

Purpose To describe the experiences of people with type 2 diabetes who have completed a comprehensive cognitive rehabilitation intervention. Method Nineteen participants with type 2 diabetes enrolled in an 8-week intervention consisting of 4 educational classes to learn strategies to improve cognitive function and an online training program at home to practice cognitively stimulating activities. Two focus groups were conducted as part of a study designed to assess the feasibility of the comprehensive cognitive rehabilitation intervention. Results Three main themes were identified in the qualitative data: (1) expectations of cognitive change; (2) use of cognitive strategies; and (3) effect on diabetes self-management. Participants shared valuable insight into how their experiences with the intervention changed and how they viewed diabetes. Conclusions While the participants did not initially tie their cognitive complaints to diabetes, they were able to show how and why they might use cognitive strategies to improve diabetes self-management activities. By adapting those strategies for diabetes, quality of life can improve as well as potentially glycemic control.

Cuban Americans (CAs) and Type 2 Diabetes: An Integrative Review of the Literature

Type 2 diabetes is associated with increased morbidity and mortality in Hispanics but few studies have been done to differentiate diabetes effects in Hispanic subgroups, such as Cuban Americans. The purpose of this review was to characterize the studies conducted on Cuban Americans with type 2 diabetes with the aim of updating knowledge related to physiologic factors, psychologic factors, and diabetes selfmanagement. An extensive literature search located 18 studies that met the inclusion criteria for this review. Previous studies provided consistent evidence demonstrating the influence of lifestyle, metabolic, and psychosocial risk factors that lead to poorer outcomes for CAs. No intervention studies were found examining the effect of treatment and education on diabetes control. Future research is needed to determine how these factors associated with diabetes can be used in lowering risks and improving health outcomes for Cuban Americans.