Nancy A. Allen

Social Cognitive Theory in Diabetes Exercise Research: An Integrative Literature Review

PURPOSE This integrative review critically examined the literature on diabetes research using Social Cognitive Theory (SCT) to determine its predictive ability in explaining exercise behavior and to identify key interventions that enhance exercise initiation and maintenance. METHODS Literature published between 1985 and 2002 was searched using the following keywords: SCT, self-efficacy, diabetes mellitus, non-insulin-dependent diabetes mellitus, insulin-dependent diabetes mellitus, physical activity, and exercise. The databases searched were CINAHL, Medline, and PsychInfo. Of the 38 articles retrieved from databases, 13 were reviewed. RESULTS A statistically significant relationship between self-efficacy and exercise behavior was found in correlational studies. Results from the predictive study support the predictability of self-efficacy for exercise behavior. Mixed results were found for the predictive ability of outcome expectancies for exercise behavior. Self-efficacy was predictive of exercise initiation and maintenance over time. The evidence for successful interventions to increase self-efficacy and exercise behavior over time was inconclusive. CONCLUSIONS To better understand exercise behavior and to develop effective exercise interventions, a microanalytic, theory-driven approach to studying exercise behavior is needed. Several suggestions are offered to strengthen exercise self-efficacy.

Continuous glucose monitoring counseling improves physical activity behaviors of individuals with type 2 diabetes: A randomized clinical trial

AIMS Despite the known benefits, 60% of individuals with diabetes do not engage in regular physical activity (PA). This pilot study tested the effects of a counseling intervention using continuous glucose monitoring system (CGMS) feedback on PA self-efficacy, PA levels, and physiological variables. METHODS Adults (N=52) with type 2 diabetes (non-insulin requiring, inactive) were randomized to intervention (n=27) or control (n=25) groups. Both groups received 90min of diabetes education with a follow-up phone call 4 weeks later. The intervention group also received counseling derived from self-efficacy theory. This intervention included feedback on each participants CGMS graph and used role model CGMS graphs to clearly depict glucose reductions in response to PA. Outcomes were assessed at baseline and 8 weeks. RESULTS Participants receiving the intervention had higher self-efficacy scores than the control group for sticking to activity/resisting relapse at 8 weeks (p<0.05), indicating more confidence in maintaining a PA program. Intervention group participants light/sedentary activity minutes decreased significantly (p<0.05), moderate activity minutes increased significantly (p<0.05), and, HbA1c and BMI decreased significantly (p<0.05). CONCLUSIONS These data suggest that PA counseling interventions using CGMS feedback for individuals with type 2 diabetes may improve PA levels and reduce risk factors for diabetes-related complications.

Transitional care programs improve outcomes for heart failure patients: an integrative review.

Background:Individuals with heart failure are frequently rehospitalized owing to a lack of knowledge concerning how to perform their self-care and when to inform their healthcare provider of worsening symptoms. Because there are an overwhelming number of hospital readmissions for individuals with heart failure, efforts are underway to discover how they can be supported and educated during their hospitalization and subsequently followed by a nurse after discharge for continued education and support. Purpose:The purpose of this integrative review was to critically examine the interventions, quality of life, and readmission rates of individuals with heart failure who are enrolled in a transitional care program. The second aim was to examine the cost-effectiveness of nurse-led transitional care programs. Conclusions:The results of this integrative review (n = 20) showed that transitional care programs for individuals with heart failure can increase a patient’s quality of life and decrease the number of readmissions and the overall cost of care. The types of interventions that were most successful in decreasing readmissions used home visits alone or in combination with telephone calls. There is a need for nurse researchers to address gaps in transitional care for heart failure patients by performing studies with larger randomized clinical trials and measuring outcomes such as readmissions at regular intervals over the study period. Clinical Implications:The Patient Protection and Affordable Care Act will change reimbursement for heart failure readmissions and presents opportunities for healthcare teams to build transitional care programs for patients with conditions such as heart failure. This integrative review can be used to determine effective intervention strategies for transitional care programs and highlights the gaps in research. Healthcare teams that use these programs within their practice may increase continuity of care and quality of life and decrease readmissions and healthcare costs for individuals with heart failure.

Evaluation of Clinical Outcomes for Gastric Bypass Surgery: Results from a Comprehensive Follow-up Study

BackgroundLaparoscopic gastric bypass (LGB) surgery markedly increases percent excess weight loss (%EWL) and obesity-related co-morbidities. However, poor study quality and minimal exploration of clinical, behavioral, and psychosocial mechanisms of weight loss have characterized research to date.MethodsWe conducted a comprehensive assessment of n=100 LGB patients surveyed 2–3 years following surgery using standardized measures.ResultsMean %EWL at follow-up was 59.1±17.2%. This high level of weight loss was associated with a low rate of metabolic syndrome (10.6%), although medications were commonly used to achieve control. Mean adherence to daily vitamin and mineral supplements important to the management of LGB was only 57.6%, and suboptimal blood chemistry levels were found for ferritin (32% of patients), hematocrit (27%), thiamine (25%), and vitamin D (19%). Aerobic exercise level (R2=0.08) and pre-surgical weight (R2=0.04) were significantly associated with %EWL, but recommended eating style, fluid intake, clinic follow-up, and support group attendance were not. Psychosocial adjustment results showed an absence of symptomatic depression (0%), common use of antidepressant medications (32.0%), low emotional distress related to the post-surgical lifestyle (19.8±14.0; scale range 0–100), a high level of perceived benefit from weight loss in terms of functioning and emotional well-being (82.7±17.9; scale range 0–100), and a change in marital status for 26% of patients.ConclusionsAt 2–3 years following LGB surgery aerobic exercise, but not diet, fluid intake, or attendance at clinic visits or support groups, is associated with %EWL. Depression is symptomatically controlled by medications, lifestyle related distress is low, and marital status is significantly impacted.

Comprehensive Diabetes Management Program for Poorly Controlled Hispanic Type 2 Patients at a Community Health Center

Technology and improved care coordination models can help diabetes educators and providers meet national care standards and provide culturally sensitive diabetes education that may improve diabetes outcomes. The purpose of the study was to evaluate the clinical usefulness of a nurse-led diabetes care program (Comprehensive Diabetes Management Program, CDMP) for poorly controlled Hispanic type 2 diabetes (T2DM) patients in an urban community health center setting. Patients were randomized to the intervention condition (IC; n = 21) or an attention control condition (AC; n = 18). IC and AC conditions were compared on rates of adherence to national clinical practice guidelines (blood glucose, blood pressure, foot exam, eye exam), and levels of diabetes distress, depression, and treatment satisfaction. IC patients had a significant improvement in A1C from baseline to 12-month follow-up compared with AC (−1.6% ± 1.4% versus −0.6% ± 1.1%; P = .01). The proportion of IC patients meeting clinical goals at follow-up tended to be higher than AC for A1c (IC = 45%; AC = 28%), systolic blood pressure (IC = 55%; AC = 28%), eye screening (IC = 91%; AC = 78%), and foot screening, (IC = 86%; AC = 72%). Diabetes distress and treatment satisfaction also showed greater improvement for IC than AC (P = .05 and P = .06, respectively), with no differences for depression. The CDMP intervention was more effective than an attention control condition in helping patients meet evidence-based guidelines for diabetes care.

Depression, depression treatment, and insulin sensitivity in adults at risk for type 2 diabetes.

AIMS To compare insulin sensitivity (Si) in adults at risk for type 2 diabetes (T2DM) who were categorized as non-depressed, treated for depression and untreated depression after controlling for physical activity (PA). METHODS Baseline data was analyzed from individuals enrolled in a diabetes prevention program (n=56). Si was calculated using the whole-body insulin sensitivity method. The Centers for Epidemiologic Studies Depression Scale (CESD) was used to assess depressive symptoms and depressed cases were identified using a cutoff of >or=16. Depression treatment was identified using a self-report form validated by medical chart review. The PA subscale of the Health Promoting Lifestyle Profile was used to determine PA levels. RESULTS One third of participants had elevated depressive symptoms; 19% were taking antidepressant medication. Mean Si was 3.1 (+/-1.9). In ANOVA, depressed individuals showed significantly lower Si (M=1.8+/-0.9) than non-depressed individuals (M=3.4+/-1.8). However, individuals taking antidepressant medications had Si similar to non-depressed individuals (M=3.7+/-2.3: p=.63). In ANCOVA this association remained after controlling for PA. CONCLUSIONS These data suggest that in adults at high risk for T2DM, depression treatment may improve insulin resistance observed in depression. Healthcare practitioners are encouraged to screen, treat, or refer their patients with depression for treatment.

A Continuous Glucose Monitoring and Problem-Solving Intervention to Change Physical Activity Behavior in Women with Type 2 Diabetes: A Pilot Study

BACKGROUND Diabetes technology has the potential to provide useful data for theory-based behavioral counseling. The aims of this study are to evaluate the feasibility, acceptability, and preliminary efficacy of a continuous glucose monitoring and problem-solving counseling intervention to change physical activity (PA) behavior in women with type 2 diabetes. METHODS Women (n=29) with type 2 diabetes were randomly assigned to one of two treatment conditions: continuous glucose counseling and problem-solving skills or continuous glucose monitoring counseling and general diabetes education. Feasibility data were obtained on intervention dose, implementation, and satisfaction. Preliminary efficacy data were collected at baseline and 12 weeks on the following measures: PA amount and intensity, diet, problem-solving skills, self-efficacy for PA, depression, hemogoloin A1c, weight, and blood pressure. Demographic and implementation variables were described using frequency distributions and summary statistics. Satisfaction data were analyzed using Wilcoxon rank. Differences between groups were analyzed using linear mixed-modeling. RESULTS Women were mostly white/non-Latina with a mean age of 53 years, a 6.5-year history of diabetes, and suboptimal glycemic control. Continuous glucose monitoring plus problem-solving group participants had significantly greater problem-solving skills and had greater, although not statistically significant, dietary adherence, moderate activity minutes, weight loss, and higher intervention satisfaction pre- to post-intervention than did participants in the continuous glucose monitoring plus education group. CONCLUSION A continuous glucose monitoring plus problem-solving intervention was feasible and acceptable, and participants had greater problem-solving skills than continuous glucose monitoring plus education group participants.

The application of root mean square electrocardiography (RMS ECG) for the detection of acquired and congenital long QT syndrome.

Background Precise measurement of the QT interval is often hampered by difficulty determining the end of the low amplitude T wave. Root mean square electrocardiography (RMS ECG) provides a novel alternative measure of ventricular repolarization. Experimental data have shown that the interval between the RMS ECG QRS and T wave peaks (RTPK) closely reflects the mean ventricular action potential duration while the RMS T wave width (TW) tracks the dispersion of repolarization timing. Here, we tested the precision of RMS ECG to assess ventricular repolarization in humans in the setting of drug-induced and congenital Long QT Syndrome (LQTS). Methods RMS ECG signals were derived from high-resolution 24 hour Holter monitor recordings from 68 subjects after receiving placebo and moxifloxacin and from standard 12 lead ECGs obtained in 97 subjects with LQTS and 97 age- and sex-matched controls. RTPK, QTRMS and RMS TW intervals were automatically measured using custom software and compared to traditional QT measures using lead II. Results All measures of repolarization were prolonged during moxifloxacin administration and in LQTS subjects, but the variance of RMS intervals was significantly smaller than traditional lead II measurements. TW was prolonged during moxifloxacin and in subjects with LQT-2, but not LQT-1 or LQT-3. Conclusion These data validate the application of RMS ECG for the detection of drug-induced and congenital LQTS. RMS ECG measurements are more precise than the current standard of care lead II measurements.

Real-Time Continuous Glucose Monitoring Facilitates Feelings of Safety in Older Adults With Type 1 Diabetes: A Qualitative Study:

Background: Older adults with long-standing type 1 diabetes (T1D) have a higher risk for hypoglycemia and hypoglycemia unawareness. Hypoglycemia can be dangerous, even fatal. Real-time continuous glucose monitoring (RT-CGM) effectively supports diabetes management and well-being in adult and pediatric populations. Little is known about older adults and RT-CGM use. The purpose of this study was to identify why RT-CGM was important for diabetes management in individuals with T1D 65 years of age. Methods: A convenience sample of older adults with T1D participated in one of two online surveys about RT-CGM. Categorical data were analyzed using descriptive statistics. A qualitative content analysis was conducted for open-ended responses. Results: Participants (N = 22) included in this study were those using RT-CGM (n = 11) and those who were not using RT-CGM, but desired to do so (n = 11). Those using RT-CGM were less likely to experience severe hypoglycemia (P = .02) or hypoglycemia resulting in a fall or inability to operate a motor vehicle (P = .01) Three major themes were identified: (1) RT-CGM facilitates feelings of safety by preventing hypoglycemia, (2) RT-CGM improves well-being, and (3) access is a barrier to RT-CGM use. Conclusions: RT-CGM improves safety and well-being in older adults with T1D by preventing hypoglycemia and associated injury and worry. Older adults without access to RT-CGM experience more severe hypoglycemia events that negatively affect their safety and well-being. Improving access to RT-CGM in older adults is critical to improving health and safety, and demands more attention from stakeholders in diabetes care.

Physiological and Behavioral Factors Related to Physical Activity in Black Women With Type 2 Diabetes Mellitus

Purpose: To describe relationships among physical activity (PA), physiological factors, and psychological factors in Black women with type 2 diabetes mellitus (T2DM). Methods: A cross-sectional design was used (N = 109). Data were collected on PA (activity/inactivity, TV hours, bed confinement), physiology (blood pressure, lipids, hemoglobin A1c), psychology (anxiety, emotional distress, physical functioning, bodily pain, vitality), and health care provider (HCP) support. Results: Walking was the preferred PA; TV viewing averaged 3.7 hours/day, and 24% reported confinement to bed >1 week in the last year. Inactive women had greater physiological and psychological problems than active women. Women watching TV >2 hours/day had more physiological problems than women watching TV <2 hours/day. Women reporting >1 week of confinement to bed in the last year had more physiological and psychological problems than those confined to bed <1 week. Conclusions: PA interventions in Black women with T2DM should promote walking, address TV viewing time, incorporate HCP’s role of PA counseling/support, and address several psychological factors.