Further Examination of a Structured Adherence Interview of Diabetes for Children,Adolescents, and Parents

This study evaluated the factor structure of the Diabetes Self-Management Profile (DSMP), a structured interview for diabetes regimen adherence for children with type 1 diabetes. Study aims included a detailed examination of parent-child agreement in ratings of adherence. The DSMP was administered to 121 children and their parents during routine visits to a tertiary care diabetes clinic. Confirmatory factor analysis of the rationally derived five subscales yielded poor fit indexes. Subsequent exploratory factor analysis supported a two-factor solution for both the parent and child DSMP adherence ratings with factors named Food and Insulin Schedule Adherence and Adherence to Blood Sugar Testing and Adjustments. The internal consistency of the factors was acceptable, and predictive validity was supported vis-a-vis positive correlations with metabolic control (HbA1c). This factor structure appears to provide a brief yet reliable and valid framework for assessing adherence and predicting metabolic control in children. In addition, parent-child agreement varied as a function of age. However, poor metabolic control did not relate to higher parent-child disagreement.     

Further Examination of a Structured Adherence Interview of Diabetes for Children, Adolescents, and Parents

This study evaluated the factor structure of the Diabetes Self-Management Profile (DSMP), a structured interview for diabetes regimen adherence for children with type 1 diabetes. Study aims included a detailed examination of parent-child agreement in ratings of adherence. The DSMP was administered to 121 children and their parents during routine visits to a tertiary care diabetes clinic. Confirmatory factor analysis of the rationally derived five subscales yielded poor fit indexes. Subsequent exploratory factor analysis supported a two-factor solution for both the parent and child DSMP adherence ratings with factors named Food and Insulin Schedule Adherence and Adherence to Blood Sugar Testing and Adjustments. The internal consistency of the factors was acceptable, and predictive validity was supported vis-a-vis positive correlations with metabolic control (HbA1c). This factor structure appears to provide a brief yet reliable and valid framework for assessing adherence and predicting metabolic control in children. In addition, parent-child agreement varied as a function of age. However, poor metabolic control did not relate to higher parent-child disagreement.     

Development of the Diabetes Family Adherence Measure (D–FAM)

The objective of this research was to develop and validate the Diabetes Family Adherence Measure (D–FAM), a comprehensive and up-to-date tool designed for the assessment of adherence-related parenting behaviors for youth with type 1 diabetes (T1D). Further, this article outlines an empirical approach for scale design. First, experts reviewed a battery of potential items to create a preliminary version of the D–FAM. Subsequently, 165 youth with T1D and their families completed an initial administration. A parsimonious measure resulted, consisting of 19 items with 4 additional validity items. Factor analysis identified supportive, coercive, control, and monitoring subscales. D–FAM factors were generally associated with both adherence and health status (HbA1c [glycosolated hemoglobin]), as well as with extant scales of family functioning. Strong internal consistency, test–retest reliability, and construct-convergent reliability were obtained. This initial evaluation of the D–FAM suggests utility for efficient evaluation of family functioning related to adherence and glycemic control for research and clinical purposes.     

Intrinsic motivation in ethnic minority youth with type 1 diabetes

Increasing intrinsic motivation (IM) may be an effective way to improve regimen adherence and glycemic control in youth with type 1 diabetes (T1D). This preliminary study evaluated the reliability and validity of a new measure of intrinsic motivation for diabetes management for ethnic minority youth with T1D. The 12-item Intrinsic Motivation Inventory for Diabetes Management (IMI-DM) was developed to assess perceptions of confidence in and the importance of engaging in self-care behaviors for diabetes management. Participants included 51 11–16 year-old minority adolescents (mean age = 13.5 years) with T1D and their parents. The IMI-DM demonstrated excellent internal consistency (α = 0.92). Higher IM was associated with better diabetes self-management behaviors and glycemic control, better youth self-concept, less depression and family conflict, and greater youth responsibilities for diabetes management. These findings provide preliminary support for the reliability and validity of a new diabetes-specific IM measure for youth with T1D, and identified some key individual and family factors that may be important to consider in interventions to improve regimen adherence and glycemic control in minority youth with T1D.     

Intensive telephone follow-up to a hospital-based disease management model for patients with diabetes mellitus.

The objective of this study was to evaluate the value of an intensive telephone follow-up as an additional component of a diabetes disease management program already shown to be effective in improving glycemic control, adherence with American Diabetes Association (ADA) standards of care, and health-related quality of life (HRQOL). The study involved a randomized controlled trial. The intervention group received a series of 12 weekly phone calls reinforcing base education and self-management skills. Five hundred and seven consenting patients, age 18 years or older, with type 1 or type 2 diabetes mellitus referred to the hospital- based disease management program who had telephones and were able to complete surveys in English or Spanish were enrolled. Outcomes were evaluated at 3 and 12 months follow- up. Adherence to ADA standards of care, specifically annual eye exams, physician foot exams, foot self-exams, and pneumonia vaccination were significantly better with the added telephone intervention, but there were no differences between the groups on glycemic control, HRQOL, or patient satisfaction. The effectiveness of the disease management program was replicated with sustained improvement in glycemic control, HRQOL, and adherence to ADA standards. The additional telephone intervention further improved adherence to ADA guidelines for self-care and medical care but did not affect glycemic control or HRQOL.     

Low Reported Adherence to the 2019 American Diabetes Association Nutrition Recommendations among Patients with Type 2 Diabetes Mellitus,Indicating the Need for Improved Nutrition Education and Diet Care

Patient adherence to guidelines is important for improved outcomes and prognosis. Nevertheless, many patients with type 2 diabetes mellitus (T2DM) do not comply with the recommendations regarding medication, physical activity, diet or self-care. The present cross-sectional study aimed to assess the level of adherence to the dietary recommendations issued by the American Diabetes Association (ADA) among patients with T2DM in Komotini, Greece. A total of 162 adults with T2DM (64.7 ± 10.6 years old), of which 41.4% were men, were recruited from the Sismanoglio Hospital and participated in the study. The level of adherence to individual recommendations issued by the ADA was assessed using yes/no questions. The overall adherence rate to the guidelines was low (41.2%). According to the multivariable analysis, age and medication therapy were identified as contributors to the compliance rate. No differences were noted in the total compliance rate between patients of different religious denominations (Muslims/Christians). Patients on oral antidiabetic agents (OAA) were more adherent compared with those on insulin therapy. A mere 3.7% of the participants had received nutrition education by a registered dietitian, 9.9% were following an individualized diet plan to improve glycemia, and 3.1% had set specific energy goals to reduce body weight. These findings are indicative of the need for the delivery of improved nutrition education.     

Decreases in dietary glycemic index are related to weight loss among individuals following therapeutic diets for type 2 diabetes

This study assessed the effect of changes in glycemic index (GI) and load (GL) on weight loss and glycated hemoglobin (HbA1c) among individuals with type 2 diabetes beginning a vegan diet or diet following the 2003 American Diabetes Association (ADA) recommendations. The study was a 22-wk, randomized trial of 99 participants with type 2 diabetes who were counseled to follow 1 of 2 diet treatments. GI and GL changes were assessed based on 3-d dietary records. The relationships between GI/GL and changes in weight and HbA1C were calculated. In an intention-to-treat analysis (n = 99), the vegan group reduced GI to a greater extent than the ADA group (P < 0.05), but GL was reduced further in the ADA than the vegan group (P < 0.001). GI predicted changes in weight (P = 0.001), adjusting for changes in fiber, carbohydrate, fat, alcohol, energy intake, steps per day, group, and demographics, such that for every point decrease in GI, participants lost ~0.2 kg (0.44 lb). GI was not a predictor for changes in HbA1C after controlling for weight loss (P = 0.33). Weight loss was a predictor of changes in HbA1C (P = 0.047). GL was not related to weight loss or changes in HbA1C. A low-GI diet appears to be one of the determinants of success of a vegan or ADA diet in reducing body weight among people with type 2 diabetes. The reduction of body weight, in turn, was predictive of decreasing HbA1C.     

A Pilot Study on the Metabolic Impact of Mediterranean Diet in Type 2 Diabetes: Is Gut Microbiota the Key?

The Mediterranean diet (MD) has been recommended for type 2 diabetes (T2D) treatment. The impact of diet in shaping the gut microbiota is well known, particularly for MD. However, the link between MD and diabetes outcome improvement is not completely clear. This study aims to evaluate the role of microbiota modulation by a nonpharmacological intervention in patients with T2D. In this 12-week single-arm pilot study, nine participants received individual nutritional counseling sessions promoting MD. Gut microbiota, biochemical parameters, body composition, and blood pressure were assessed at baseline, 4 weeks, and 12 weeks after the intervention. Adherence to MD [assessed by Mediterranean Diet Adherence Screener (MEDAS) score] increased after the intervention. Bacterial richness increased after 4 weeks of intervention and was negatively correlated with fasting glucose levels and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR). Prevotella to Bacteroides ratio also increased after 4 weeks. In contrast, glycated haemoglobin (HbA1c) and HOMA-IR were only decreased at the end of study. Alkaline phosphatase activity was assessed in fecal samples and was negatively correlated with HbA1c and positively correlated with bacterial diversity. The results of this study reinforce that MD adherence results in a better glycemic control in subjects with T2D. Changes in gut bacterial richness caused by MD adherence may be relevant in mediating the metabolic impact of this dietary intervention.     

Adherence to the Mediterranean Diet Is Associated with Better Metabolic Features in Youths with Type 1 Diabetes

Our aim was to evaluate adherence to the Mediterranean diet (MedDiet) among children and adolescents with type 1 diabetes (T1D) in relation to metabolic control. Adherence to the MedDiet was assessed with the Mediterranean Diet Quality Index (KIDMED) questionnaire and physical activity by the International Physical Activity Questionnaire for Adolescent (IPAQ-A) on 65 subjects (32 males, 9–18 years) with T1D. Clinical and metabolic evaluation was performed (standardized body mass index (BMI-SDS), hemoglobin A1C (HbA1c), continuous glucose monitoring metrics when present, blood pressure, lipid profile). Parental characteristics (age, body mass index (BMI), socio-economic status) were reported. The adherence to the MedDiet was poor in 12.3%, average in 58.6%, and high in 29.1% of the subjects. Furthermore, 23.4% of patients were overweight/obese. The most impacting factors on BMI-SDS were skipping breakfast and their father’s BMI. HbA1c and time in range % were positively associated with sweets and fish intake, respectively. Additionally, the father’s socio-economic status (SES) and mother’s age were associated with glucose control. Blood pressure was associated with travelling to school in vehicles, extra-virgin olive oil intake and milk/dairy consumption at breakfast. The promotion of the MedDiet, mainly having a healthy breakfast, is a good strategy to include in the management of T1D to improve glucose and metabolic control. This research is valuable for parents to obtain the best results for their children with T1D.     

Momentary Assessment of Social Context and Glucose Monitoring Adherence in Adolescents With Type 1 Diabetes

PurposeTo investigate the associations between momentary social context and glucose monitoring adherence in adolescents with type 1diabetes (T1D).MethodsFor 14 days, patients (14–18 years old, T1D duration >1 year) of a pediatric diabetes clinic carried handheld computers that prompted them to report their location, companionship, and attitudes toward companions at the times they usually checked their glucose, and again 30 minutes later to report whether they checked their glucose and, if not, why. Associations between social context factors and checking glucose (adherence) were analyzed using logistic generalized estimating equations and adjusted for age, sex, duration of T1D, and pump use.ResultsThirty-six participants (mean age 16.6 ± 1.5 years, mean duration of T1D 8.7 ± 4.4 years) completed 971 context and 1,210 adherence reports, resulting in 805 paired reports. Median signal response rate was 63%. The odds of checking glucose was higher when participants expressed very strong desire to blend in (adjusted odds ratio [AOR] = 2.30, 95% confidence interval 1.07–4.94, p = .03). Strong desire to impress others was associated with decreased likelihood of checking glucose (AOR = .52, 95% confidence interval .28–.97, p = .04.) Location, solitude, type of companion, and attitudes toward companions were not significantly associated with checking glucose.ConclusionsDesire to blend in may support glucose monitoring adherence and desire to impress others may impede this behavior in adolescents with T1D. Other dimensions of social context were not linked to checking glucose in this study.     

Prevalence of Cardiovascular Disease Risk Factors Among Older Puerto Rican Adults Living in Massachusetts

There remains limited research on cardiovascular disease (CVD) risk factors in Puerto Rican adults. We compared lifestyle and CVD risk factors in Puerto Rican men and women with normal fasting glucose (NFG), impaired fasting glucose (IFG), or type 2 diabetes (T2D), and investigated achievement of American Diabetes Association (ADA) treatment goals in those with T2D. Baseline data from the Boston Puerto Rican Health Study were analyzed, which included 1,287 adults aged 45–75 years. Obesity, hyperglycemia, and dyslipidemia were prevalent and increased from NFG to IFG and T2D. In individuals without T2D, fasting insulin correlated significantly with body mass index. Achievement of ADA goals was poor; LDL cholesterol was most achieved (59.4%), followed by blood pressure (27.2%) and glycosylated hemoglobin (27.0%). Poverty, female sex, current alcohol use, and diabetes or anti-hypertensive medication use were associated with not meeting goals. Puerto Rican adults living in the Boston area showed several metabolic abnormalities and high CVD risk, likely due to pervasive obesity and socio-economic disparities.     

Adherence to Chronic Disease Medications among New York City Medicaid Participants

Medication adherence is critical for cardiovascular disease prevention and control. Local health departments are well positioned to address adherence issues, however relevant baseline data and a mechanism for monitoring impact of interventions are lacking. We performed a retrospective analysis using New York State Medicaid claims from 2008 to 2009 to describe rates and predictors of adherence among New York City Medicaid participants with dyslipidemia, diabetes, or hypertension. Adherence was measured using the medication possession ratio, and multivariable logistic regression was used to assess factors related to adherence. Medication regimen adherence was 63%. Greater adherence was observed in those who were older, male, and taking medications from ≥3 drug classes. Compared with whites, blacks and Hispanics were less likely to be adherent (adjusted odds ratio [OR]=0.67, 95% confidence interval [CI]: 0.65–0.70 and adjusted OR=0.76, 95% CI: 0.73–0.78, respectively), while Asians were as likely. Medication adherence was inadequate and racial disparities were identified in NYC Medicaid participants on stable medication regimens for chronic disease. This study demonstrates a claims-based model that may be used by local health departments to monitor and evaluate efforts to improve adherence and reduce disparities.     

Diabetes stigma,parent depressive symptoms and Type-1 diabetes glycemic control in India

ABSTRACT

Diabetes distress and stigma have been associated with worse patient outcomes in developed countries. However, diabetes stigma has not been studied in low and middle-income countries where clinical practices differ, diabetes awareness is lower, and families face different challenges for supporting children with Type 1 Diabetes (T1D). This study assessed the relationship between parental depression and diabetes stigma with a child’s glycemic control in a clinic-based survey in Nagpur, India. The association between self-reported T1D stigma, depressive symptoms, and child’s measured glycemic control (HbA1C) was assessed with data from 165 of the parents of school-aged (aged 5+) children receiving clinical T1D care at an urban nonprofit organization that provides free clinical care to children with Type-1 Diabetes (T1D) in India. Parents with moderate/severe depressive symptoms who experience stigma associated with their child’s diabetes had children with significantly worse glycemic control than parents with no/mild depressive symptoms who experience the same amount of stigma. Higher reports of stigma were associated with an average of 0.65 points higher HbA1C (β = 0.65, 95% Confidence Interval (CI): 0.18, 1.13) for parents with moderate/severe than parents with mild/no depressive symptoms. Indian parents with depressive symptoms who face social stigma associated with their child’s diabetes have children with worse T1D outcomes.     

Adherence to a Healthy Nordic Food Index Is Associated with a Lower Risk of Type-2 Diabetes—The Danish Diet,Cancer and Health Cohort Study

Background: Type-2 diabetes (T2D) prevalence is rapidly increasing worldwide. Lifestyle factors, in particular obesity, diet, and physical activity play a significant role in the etiology of the disease. Of dietary patterns, particularly the Mediterranean diet has been studied, and generally a protective association has been identified. However, other regional diets are less explored. Objective: The aim of the present study was to investigate the association between adherence to a healthy Nordic food index and the risk of T2D. The index consists of six food items: fish, cabbage, rye bread, oatmeal, apples and pears, and root vegetables. Methods: Data was obtained from a prospective cohort study of 57,053 Danish men and women aged 50–64 years, at baseline, of whom 7366 developed T2D (median follow-up: 15.3 years). The Cox proportional hazards model was used to assess the association between the healthy Nordic food index and risk of T2D, adjusted for potential confounders. Results: Greater adherence to the healthy Nordic food index was significantly associated with lower risk of T2D after adjusting for potential confounders. An index score of 5−6 points (high adherence) was associated with a statistically significantly 25% lower T2D risk in women (HR: 0.75, 95%CI: 0.61–0.92) and 38% in men (HR: 0.62; 95%CI: 0.53–0.71) compared to those with an index score of 0 points (poor adherence). Conclusion: Adherence to a healthy Nordic food index was found to be inversely associated with risk of T2D, suggesting that regional diets other than the Mediterranean may also be recommended for prevention of T2D.     

Altruism as a reason for participation in clinical trials was independently associated with adherence

BACKGROUND: To determine whether altruism as reason for participation in research is independently associated with adherence to a medical regimen in a clinical trial. METHODS: Participants were 475 participants in the Women's Estrogen for Stroke Trial. Before randomization to estrogen or placebo, all women were questioned about reason for participation and baseline features that may contribute to adherence. Adherence was defined as completion of at least 80% of expected pill intake during the trial. RESULTS: Women who reported at least one altruistic reason for participation were more likely to be college educated, have a higher level of social support, and a better functional status. They were also more likely to be adherent to their study medication {155 of 212 (73%) vs. 158 of 253 (62.5%), P < .01}. On stratified analysis and multivariable regression, the relationship between altruism as reason for participation and adherence was independent of other sociodemographic, psychosocial, and clinical features (relative risk 1.17, Confidence interval 1.03-1.32). CONCLUSION: Altruism may explain a small portion of the variation in adherence among research participants. This relationship may have implications for recruitment of participants in clinical research. The possible contribution of altruism to the relationship between adherence and outcomes in clinical trials is worthy of further investigation.     

Correlates of Adherence to Prophylactic Penicillin Therapy in Children With Sickle Cell Disease

Research has found that prophylactic penicillin therapy greatly reduces the incidence of bacterial infections in children with sickle cell disease (SCD). This study describes the prevalence and assesses correlates of adherence to this medication. Thirty caregivers of children with SCD participated in this study. Adherence was obtained through caregiver reports, provider estimates, and pharmacy records. Results indicated problematic adherence, with only one third of children receiving appropriate medication according to pharmacy records. Adherence to prophylactic penicillin continues to be inadequate, with the caregivers' beliefs, reported barriers, and personal experience with SCD related to their adherence to the medication regimen.     

Physician assessments of medication adherence and decisions to intensify medications for patients with uncontrolled blood pressure: still no better than a coin toss

ABSTRACT: BACKGROUND: Many patients have uncontrolled blood pressure (BP) because they are not taking medications as prescribed. Providers may have difficulty accurately assessing adherence. Providers need to assess medication adherence to decide whether to address uncontrolled BP by improving adherence to the current prescribed regimen or by intensifying the BP treatment regimen by increasing doses or adding more medications. METHODS: We examined how provider assessments of adherence with antihypertensive medications compared with refill records, and how providers' assessments were associated with decisions to intensify medications for uncontrolled BP. We studied a cross-sectional cohort of 1169 veterans with diabetes presenting with BP [GREATER-THAN OR EQUAL TO]140/90 to 92 primary care providers at 9 Veterans Affairs (VA) facilities from February 2005 to March 2006. Using VA pharmacy records, we utilized a continuous multiple-interval measure of medication gaps (CMG) to assess the proportion of time in prior year that patient did not possess the prescribed medications; CMG [GREATER-THAN OR EQUAL TO]20 % is considered clinically significant non-adherence. Providers answered post-visit Likert-scale questions regarding their assessment of patient adherence to BP medications. The BP regimen was considered intensified if medication was added or increased without stopping or decreasing another medication. RESULTS: 1064 patients were receiving antihypertensive medication regularly from the VA; the mean CMG was 11.3 %. Adherence assessments by providers correlated poorly with refill history. 211 (20 %) patients did not have BP medication available for > =20 % of days; providers characterized 79 (37 %) of these 211 patients as having significant non-adherence, and intensified medications for 97 (46 %). Providers intensified BP medications for 451 (42 %) patients, similarly whether assessed by provider as having significant non-adherence (44 %) or not (43 %). CONCLUSIONS: Providers recognized non-adherence for less than half of patients whose pharmacy records indicated significant refill gaps, and often intensified BP medications even when suspected serious non-adherence. Making an objective measure of adherence such as the CMG available during visits may help providers recognize non-adherence to inform prescribing decisions.     

Adherence to a Vitamin D Supplement Intervention in Urban Schoolchildren

Vitamin D supplementation is an important strategy for preventing low levels of serum 25OHD and improving bone health and consequent associated health risks, especially in children at risk of deficiency. Although vitamin D supplements are recommended, there is limited research on the factors that influence adherence to taking them. In a cross-sectional sample of 256 child (aged 9 to 15 years) and parent pairs in the Boston, MA, area during January to March 2012, analysis of covariance was used to determine associations between health beliefs about vitamin D, parental vitamin D−containing supplement use, and the individual responsible for pill administration with supplement adherence measured by pill counts. Mean and median supplement pill count adherence over 3 months were 84% and 89%, respectively. Adherence was positively associated with parents’ use of vitamin D−containing supplements (7% higher, P=0.008) and with combined child and parent responsibility for administration of the supplement compared with child only (9% higher, P=0.03). Parents’ beliefs about vitamin D neither predicted their children’s beliefs nor positively influenced children’s adherence. Adherence was higher when parents took vitamin D−containing supplements and when parents and children shared responsibility for administering the supplement. Promoting child supplement use through parent involvement and role modeling may be a practical solution for registered dietitians who are aiming to improve vitamin D adherence in at-risk youth.     

mHealth: Using Mobile Technology to Support Healthcare

Adherence to long-term therapy in outpatient setting is required to reduce the prevalence of chronic diseases such as HIV/AIDS, Diabetes, Tuberculosis and Malaria. This paper presents a mobile technology-based medical alert system for outpatient adherence in Nigeria. The system makes use of the SMS and voice features of mobile phones. The system has the potential of improving adherence to medication in outpatient setting by reminding patients of dosing schedules and attendance to scheduled appointments through SMS and voice calls. It will also inform patients of benefits and risks associated with adherence. Interventions aimed at improving adherence would provide significant positive return on investment through primary prevention (of risk factors) and secondary prevention of adverse health outcomes.     

Should we care to adhere? Guideline adherence rates,glycemic control and physician perspective on adherence for type-2 diabetes

Background and aim

Despite increasing knowledge, treatment options and funding, the number of type-2 diabetes mellitus (T2DM) patients who achieve their glycemic targets has not increased in the past 2 decades. Medical guidelines aim for favorable outcomes, but adherence to T2DM guidelines is low. Our analysis evaluates T2DM guideline adherence for Germany, its associations with glycemic target achievement and physicians’ perspectives on adherence.

Methods

In this observational study, 108 T2DM patients in diabetology specialist care, receiving initial or adjusted insulin therapy, were included in the analysis. Guideline adherence was assessed for four areas of the German national treatment guideline (NVL): (1) completing 12 disease monitoring tasks, (2) screening for 5 diabetes comorbidities and complications, (3) treatment targets in 5 dimensions and (4) adherence to the therapy algorithm along the patient pathway. Glycemic target achievement was assumed when the last HbA1c measurement was ≤ the individual HbA1c target. Physicians’ opinion on guideline adherence (importance for treatment success, ease of implementation) was gathered through a survey.

Results

Adherence rates to the four NVL areas were 44%–92%. Forty-three percent of participants achieved their HbA1c target. Participants treated adherent to 2+ or 3+ NVL areas had higher rates of target achievement than the counter groups (chi²?=?3.280/2.738, p?=?0.070/0.098). There was strong consensus between physicians about the relevance of each NVL area.

Conclusion

Patients with T2DM benefit from comprehensive guideline-adherent treatment. A study with larger sample size is required to confirm results. Digital tools can facilitate embedding of guideline information into daily clinical practice.