Robin Nwankwo

Nutrition Therapy Recommendations for the Management of Adults With Diabetes

There is no standard meal plan or eating pattern that works universally for all people with diabetes. In order to be effective, nutrition therapy should be individualized for each patient/client based on his or her individual health goals; personal and cultural preferences; health literacy and numeracy; access to healthful choices; and readiness, willingness, and ability to change. Nutrition interventions should emphasize a variety of minimally processed nutrient dense foods in appropriate portion sizes as part of a healthful eating pattern and provide the individual with diabetes with practical tools for day-to-day food plan and behavior change that can be maintained over the long term.

The prevention or delay of type 2 diabetes: American Diabetes Association and National Institute of Diabetes, Digestive and Kidney Diseases

D iabetes is one of the most costly and burdensome chronic diseases of our time and is a condition that is increasing in epidemic proportions in the U.S. and throughout the world (1). The complications resulting from the disease are a significant cause of morbidity and mortality and are associated with the damage or failure of various organs such as the eyes, kidneys, and nerves. Individuals with type 2 diabetes are also at a significantly higher risk for coronary heart disease, peripheral vascular disease, and stroke, and they have a greater likelihood of having hypertension, dyslipidemia, and obesity (2–6). There is also growing evidence that at glucose levels above normal but below the diabetes threshold diagnostic now referred to as pre-diabetes, there is a substantially increased risk of cardiovascular disease (CVD) and death (5,7–10). In these individuals, CVD risk factors are also more prevalent (5–7,9,11–14), which further increases the risk but is not sufficient to totally explain it. In contrast to the clear benefit of glucose lowering to prevent or retard the progression of microvascular complications associated with diabetes (15– 18,21), it is less clear whether the high rate of CVD in people with impaired glucose homeostasis, i.e., those with impaired fasting glucose (IFG), impaired glucose tolerance (IGT), or diabetes, is caused by elevated blood glucose levels or will respond to treatments that lower blood glucose. Epidemiological studies have shown a clear relationship (19,20), whereas intervention trials in people with diabetes suggest, but have not demonstrated, a clear benefit of glycemic control (15,16,21,22). Additionally, there are no studies that have investigated a benefit of glucose lowering on macrovascular disease in subjects with only pre-diabetes (IFG or IGT) but not diabetes. Although the treatment of diabetes has become increasingly sophisticated, with over a dozen pharmacological agents available to lower blood glucose, a multitude of ancillary supplies and equipment available, and a clear recognition by health care professionals and patients that diabetes is a serious disease, the normalization of blood glucose for any appreciable period of time is seldom achieved (23). In addition, in well-controlled socalled “intensively” treated patients, serious complications still occur (15–18,21), and the economic and personal burden of diabetes remains. Furthermore, microvascular disease is already present in many individuals with undiagnosed or newly diagnosed type 2 diabetes (11,24– 28). Given these facts, it is not surprising that studies have been initiated in the last decade to determine the feasibility and benefit of various strategies to prevent or delay the onset of type 2 diabetes. Two early reports (29,30) suggested that changes in lifestyle can prevent diabetes, but weaknesses in study design limited their general relevance. Recently, however, four well-designed randomized controlled trials have been reported (31–35). In the Finnish study (31), 522 middleaged (mean age 55 years) obese (mean BMI 31 kg/m) subjects with IGT were randomized to receive either brief diet and exercise counseling (control group) or intensive individualized instruction on weight reduction, food intake, and guidance on increasing physical activity (intervention group). After an average follow-up of 3.2 years, there was a 58% relative reduction in the incidence of diabetes in the intervention group compared with the control subjects. A strong correlation was also seen between the ability to stop the progression to diabetes and the degree to which subjects were able to achieve one or more of the following: lose weight (goal of 5.0% weight reduction), reduce fat intake (goal of 30% of calories), reduce saturated fat intake (goal of 10% of calories), increase fiber intake (goal of 15 g/1,000 kcal), and exercise (goal of 150 min/week). No untoward effects of the lifestyle interventions were observed. In the Diabetes Prevention Program (DPP) (32–34), the 3,234 enrolled subjects were slightly younger (mean age 51 years) and more obese (mean BMI 34 kg/m) but had nearly identical glucose intolerance compared with subjects in the Finnish study. About 45% of the participants were from minority groups (e.g, AfricanAmerican, Hispanic), and 20% were 60 years of age. Subjects were randomized to one of three intervention groups, which included the intensive nutrition and exercise counseling (“lifestyle”) group or either of two masked medication treatment groups: the biguanide metformin group or the placebo group. The latter interventions were combined with standard diet and exercise recommendations. After an average follow-up of 2.8 years (range 1.8–4.6 years), a 58% relative reduction in the progression to diabetes was observed in the lifestyle group (absolute incidence 4.8%), and a 31% relative reduction in the progression of diabetes was observed in the metformin group (absolute incidence 7.8%) compared with control subjects (absolute incidence 11.0%). ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

Implementing an Empowerment-Based Diabetes Self-management Education Program

Diabetes educators are challenged to develop culturally appropriate, integrated, behaviorally based, effective education programs. This article describes the intervention used in a problem-based educational program for urban African Americans with diabetes. The intervention consisted of six 2-hour, weekly group educational and data collection sessions. No lectures were used, and the content was determined by participants’ questions and concerns. Culturally tailored written educational materials were also provided.

Healthy Eating and Exercising to Reduce Diabetes: Exploring the Potential of Social Determinants of Health Frameworks Within the Context of Community-Based Participatory Diabetes Prevention

OBJECTIVES We examined a community-based participatory diabetes intervention to identify facilitators of and barriers to sustained community efforts to address social factors that contribute to health. METHODS We conducted a case study description and analysis of the Healthy Eating and Exercising to Reduce Diabetes project in the theoretical context of a conceptual model of social determinants of health. RESULTS We identified several barriers to and facilitators of analysis of social determinants of a community-identified disease priority (in this case, diabetes). Barriers included prevailing conceptual models, which emphasize health behavioral and biomedical paradigms that exclude social determinants of health. Facilitating factors included (1) opportunities to link individual health concerns to social contexts and (2) availability of support from diverse partners with a range of complementary resources. CONCLUSIONS Partnerships that offer community members tangible resources with which to manage existing health concerns and that integrate an analysis of social determinants of health can facilitate sustained engagement of community members and health professionals in multilevel efforts to address health disparities.

Twenty-First Century Behavioral Medicine: A Context for Empowering Clinicians and Patients With Diabetes A consensus report

In the past decades, the sophistication of treatments for diabetes has increased dramatically, and evidence for effective interventions has proliferated. As a result, it is now possible to achieve excellent glucose control and reduce the risk of many of the complications associated with the disease. Despite these advances, however, many people with diabetes have less than optimal metabolic control and continue to suffer from preventable complications. The gap between optimal evidence-based medicine and actual practice can be great, dependent not only on the ability of the clinician to make changes in practice patterns but also on the central role of the patient in implementing optimal management plans in daily life. With recognition of the centrality of patients’ actions to achieve optimal outcomes must come awareness that those actions reflect much more than simple “self-control.” In addition to individual characteristics, the environment in which behaviors are enacted has great influence, from family eating patterns to the design of neighborhoods to workplace and national health policies. For patients and clinicians, these factors create the context or environment in which behaviors are enacted. Diabetes provides a prime example of this fundamental interaction of individual characteristics with the ecological or contextual factors. For example, Pima Indians living in the U.S. have the highest prevalence of type 2 diabetes of any population in the world, yet Pimas living traditional lifestyles in Mexico have relatively low levels of diabetes. Ample evidence links genetics to diabetes within the Pima population, but exposure to an obesogenic environment is critical to expression of this very strong genetic propensity (1). This interplay between the individual and the context in which he or she behaves is commonly cited in discussions of personal health choices and health and social policies. These perspectives have shifted in …

Developing a New Generation of Ongoing Diabetes Self-management Support Interventions A Preliminary Report

Purpose The study examined the feasibility, acceptability, and potential impact of an innovative, community-based, ongoing self-management intervention aimed at enhancing and sustaining self-care behaviors over the long term among urban African Americans with type 2 diabetes. Methods Sixty-two African American men and women completed the study. Participants were invited to attend 24 weekly, consecutive, diabetes self-management support/ education groups. The flow of the weekly group sessions was guided by questions and concerns of the patients. Baseline and 6-month follow-up metabolic functioning, lipid profiles, cardiovascular functioning, and self-care behaviors were assessed. Results Ninety percent (n = 56) of the sample attended at least 1 session; 40% attended at least 12 or more sessions. Paired t tests found significant improvements in body mass index (P< .001), total cholesterol (P< .01), high density lipoprotein (P< .05), and low-density lipoprotein (P< .001). Significant increases were also found for self-care behaviors (P< .05). Conclusions Preliminary evidence suggests that participation in this weekly problem-based, self-management support intervention can yield diabetes-related health benefits.

Training peers to provide ongoing diabetes self-management support (DSMS): Results from a pilot study

OBJECTIVE This study determined the feasibility of training adults with diabetes to lead diabetes self-management support (DSMS) interventions, examined whether participants can achieve the criteria required for successful graduation, and assessed perceived efficacy of and satisfaction with the peer leader training (PLT) program. METHODS We recruited nine African-American adults with diabetes for a 46-h PLT pilot program conducted over 12 weeks. The program utilized multiple instructional methods, reviewed key diabetes education content areas, and provided communication, facilitation, and behavior change skills training. Participants were given three attempts to achieve the pre-established competency criteria for diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy. RESULTS On the first attempt 75%, 75%, 63%, and 75% passed diabetes knowledge, empowerment-based facilitation, active listening, and self-efficacy, respectively. Those participants who did not pass on first attempt passed on the second attempt. Participants were highly satisfied with the program length, balance between content and skills development, and preparation for leading support activities. CONCLUSION Findings suggest that it is feasible to train and graduate peer leaders with the necessary knowledge and skills to facilitate DSMS interventions. PRACTICAL IMPLICATIONS With proper training, peer support may be a viable model for translating and sustaining DSMS interventions into community-based settings.

The Development of a Pilot Training Program for Peer Leaders in Diabetes Process and Content

Purpose The goal of this study is to describe the process of developing a program that trains peers to facilitate an empowerment-based diabetes self-management support intervention. Methods To guide and advise the development process, the authors formed a peer leader training action committee. The committee was an interdisciplinary group (principal investigator, nurse—certified diabetes educators, dietitian— certified diabetes educators, nutritionist, physician, and 3 community members) that met every 3 months over a 1-year period for continuous quality improvement meetings. During meetings, the committee reviewed and supervised the curriculum development, provided feedback, and informed modifications and improvements. Results The resulting peer leader training program is a 46-hour program with 2 training sessions conducted per week over a 12-week period. The competency-based training program is based on the theory of experiential learning, and it consists of 3 major components—namely, building a diabetes-related knowledge base, developing skills (communication, facilitation, and behavior change), and applying skills in experiential settings. All components are integrated within each training session using a range of instructional methods, including group brainstorming, group sharing, role-play, peer leader simulations, and group facilitation simulations. Conclusion Through the process described above, the authors developed a training program that equips peer leaders with the knowledge and skills to facilitate empowerment-based diabetes self-management support interventions. Future directions include conducting and evaluating the peer training program.

A study of certified diabetes educators: influences and barriers.

Purpose There were 2 related goals for this study. The first purpose was to describe the structure (type, staffing, and number of educational sessions provided), process (preferred learning approaches), and outcome measures commonly used to provide patient education. The second purpose was to identify the influences, resources, and constraints that affect and alter the attitudes and practices of diabetes educators. Methods A 30-item questionnaire that addressed 4 areas— demographics, practice characteristics, education program structure, and educational processes—was mailed to a sample of American Association of Diabetes Educators members. Three hundred sixty-one registered nurse and registered dietician certified diabetes educators completed the questionnaire and were included in the final analysis. Results This survey indicated that this group of certified diabetes educators has incorporated new research findings and innovative teaching methods into their practices. They experience few barriers and tend to make changes in their attitudes and practices based on scientific and experiential evidence. The 3 most highly rated influences on these changes were related to patient responses to their teaching, followed by continuing education conferences and new research findings. Conclusions Based on these findings, providing continuing education that first and foremost incorporates experience-based examples of effective strategies supported by research published in professional journals appears to have the most influence on the practice of educators.

Outcomes of a Church-based Diabetes Prevention Program Delivered by Peers A Feasibility Study

Purpose This purpose of this study was to investigate the feasibility and potential health impact of a church-based diabetes prevention program delivered by peers. Methods Thirteen at-risk African American adults were recruited to a peer-led diabetes prevention program adapted from the National Diabetes Education Program’s Power to Prevent curriculum. The program consisted of 6 core education sessions followed by 6 biweekly telephone support calls. Components of feasibility examined included recruitment, attendance, and retention. Baseline, 8-week, and 20-week assessments measured clinical outcomes (percentage body weight change, waist circumference, lipid panel, blood pressure) and lifestyle behaviors (eg, physical activity and diet). Results Of the 13 participants enrolled at baseline, 11 completed the intervention. Mean attendance across 6 core sessions was 5.2 classes (87%). At 8 weeks, significant improvements were found for physical activity (P = .031), waist circumference (P = .049), serum cholesterol (P = .036), systolic blood pressure (P = .013), and fat intake (P = .006). At 20 weeks, not only did participants sustain the improvements made following the core intervention, but they also demonstrated additional improvements for HDL (P = .002) and diastolic blood pressure (P = .004). Conclusion Findings suggest that it is feasible to conduct a peer-led diabetes prevention program in a church-based setting that has a potentially positive impact on health-related outcomes.