The impact of cognitive impairment in dementia on self‐care domains in diabetes: A systematic search and narrative review

Self‐management is integral to effective chronic disease management. Cognitive impairments (CogImp) associated with dementia have not previously been reviewed in diabetes mellitus (DM) self‐care. The aims of this study are to know (1) whether CogImp associated with dementia impact self‐care and (2) whether specific CogImp affects key DM self‐care processes. A systematic literature search with a narrative review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. This review examined studies published from January, 2000 to February, 2016 describing the relationship between cognition and DM self‐care domains in community dwelling older adults with dementia/CogImp. Eight studies met inclusion criteria. Decrements in all self‐care domains were associated with CogImp. Problem solving was related to reduced disease knowledge (OR 0.87, 95% CI = 0.49‐1.55), resulting in poorer glycemic control. Decision‐making impairments manifested as difficulties in adjusting insulin doses, leading to more hospital admissions. People without CogImp were better able to find/utilize resources by adhering to recommended management (OR 1.03, 95% CI = 1.02‐1.05). A lack of interaction with health care providers was demonstrated through reduced receipt of important routine investigation including eye examinations (ARR = 0.85, 95% CI = 0.85‐0.86), HbA1c testing (ARR = 0.96, 95% CI = 0.96‐0.97), and LDL‐C testing (ARR = 0.91, 95% CI = 0.901‐0.914). People without CogImp had better clinic attendance (OR 2.17, 95% CI = 1.30‐3.70). Action taking deficits were apparent through less self‐testing of blood sugar levels (20.2% vs 24.4%, P = 0.1) resulting in poorer glycemic control, self‐care, and more frequent micro/macrovascular complications. Persons with diabetes and CogImp, particularly in domains of learning, memory and executive function, were significantly impaired in all self‐care tasks.     

Emotional distress is associated with poor self care in type 2 diabetes mellitus

Background: The aim of the present study was to evaluate possible clinical and psychosocial variables that influence diabetes self‐care management in patients with type 2 diabetes mellitus (T2DM). Methods: A total of 150 individuals with T2DM who had had diabetes for at least 6 months were recruited to this cross‐sectional study. Levels of self‐care and psychosocial status were determined using the Self‐Care Inventory (SCI) and Problem Areas in Diabetes (PAID) scale. The PAID scores were calculated using a five‐point Likert scale with options ranging from 0 (not a problem) to 4 (serious problem). Data were evaluated using non‐parametric and parametric tests as appropriate. Results: The mean age of the study participants was 69.97 ± 8.68 years. Cronbach’s α for SCI and PAID scores was 0.85 and 0.98, respectively. People with poor glycemic control had significantly higher mean (±SD) total PAID scores than individuals with good glycemic control (29.5 ± 30.9 vs 16.7 ± 26.9, respectively; P = 0.012). There was a significant relationship between PAID scores and glycemic control (r = 0.2; P = 0.012). Conclusions: The present study demonstrates that psychosocial factors directly influence glycemic control and diabetes self‐care habits. In addition, diabetes‐specific distress in study population was unrelated to the duration of diabetes, the age of the patients and anthropometric indices.     

Patient–provider perceptions of diabetes and its impact on self‐management: a comparison of African‐American and White patients

Aims To compare patient–provider differences in diabetes‐related perceptions between African‐American and White patients and to examine its association with self‐care behaviours. Methods One hundred and thirty patient–provider pairs were recruited from the greater Detroit area. Patients and providers completed a survey assessing perceptions about diabetes‐related concepts and demographic background. The Diabetes Semantic Differential Scale was used to measure diabetes‐related perceptions. Patients also reported the frequency of performing self‐care behaviours, including following a healthy eating plan, engaging in physical activity, blood glucose monitoring, and taking medication and/or insulin. Results There were a greater number of patient–provider differences in diabetes‐related perceptions for the African‐American patients (nine of 18 concepts) compared with the White patients (four of 18 concepts). Stepwise regression analyses found patients’ semantic differential scores to be significantly associated with five self‐care behaviours for African‐American patients and two self‐care behaviours for White patients. Providers’ semantic differential scores emerged as predictors of self‐care behaviours for African‐American patients, but not for White patients. Conclusions Our findings suggest that compared with White patients, African‐Americans differ in a greater number of diabetes‐related perceptions than their providers. Patients’ and providers’ perceptions of diabetes care concepts have a significant impact on a greater number of self‐care behaviours for African‐American patients than White patients.     

Cross‐cultural comparison of predictors for self‐care behaviors in patients with type 2 diabetes

The aim of the present study was to evaluate how culture moderates the behavioral and psychosocial predictors of diabetes self‐care activities. Patients with type 2 diabetes were recruited in the outpatient department at two sites: Kyoto University hospital in Japan and the Christiana Care Health System in the USA. The data were collected by survey using questionnaires including questions on the frequency of self‐care activities, behavioral and psychosocial predictors, and other background information from 149 Japanese patients and 48 American patients. The cultural impact was observed by multiple regression analyses with interaction terms on the association between emotional support and self‐care activities in diet in female patients. The findings of the present study serve as an example of how cultural context can affect patients with diabetes, and lead to a better understanding of culturally sensitive behavioral intervention.     

Type 1 diabetes and body composition in youth: A systematic review

An increasing prevalence of overweight and obesity was reported in youth with type 1 diabetes, likely due to the intensive insulin treatment and/or an unhealthy lifestyle. Analyses of body composition may help describe the real increase in fat mass, which contributes to the diabetes‐related cardio‐metabolic risk. This systematic review evaluated the current literature on body composition assessments in youth with type 1 diabetes and the potential association with cardio‐metabolic, functional, or behavioural risk factors. A systematic search of literature studies reporting assessments of body composition in youth with type 1 diabetes published until April 2018 was performed following the Preferred Reporting Items for Systematic Reviews and Meta‐Analyses guidelines. Twenty‐three articles with different study designs reported assessments of body composition. The following methods were used to assess body composition: computerized dual energy X‐ray absorptiometry (n = 10), bioelectrical impedance analysis (n = 8), skinfold thickness measurement (n = 4), and air displacement plethysmography (n = 1). Higher fat mass values were found in youth with type 1 diabetes in seven of the 13 studies that included a healthy control group. Most studies investigating the association between body composition and cardio‐metabolic risk factors showed that youth with higher fat mass levels had poor glycaemic control, dyslipidaemia, or higher blood pressure. Assessments of body composition may represent a useful clinical procedure to support decision‐making in type 1 diabetes management. Further research is needed to standardize the assessment of body composition and develop a consensus guideline.     

The global challenge of type 2 diabetes and the strategies for response in ethnic minority groups

Ethnic minorities living in high‐income countries usually exhibit a greater risk of developing diabetes along with higher morbidity and mortality rates. We evaluated the effectiveness of interventions to improve glycaemic control in ethnic minority groups. Results of major controlled trials, systematic reviews and meta‐analyses were included in the review. Only 1/47 studies addressing diet and exercise interventions reported details on the ethnicity of the studied population. Self‐management education was successful if associated with increased self‐efficacy; delivered over a longer period; of high intensity; culturally tailored; and when using community educators. Strategies adopted in community‐gathering places, family‐based, multifaceted, and those tackling the social context were likely to be more effective. A positive relationship was found between social support and self‐management behaviour as well as quality of life, but there is little evidence about the impact of organizational changes within health‐care services on diabetes control. More research is needed to strengthen the evidence on effective strategies for response to diabetes in ethnic minorities. Also, there is a need to take into account diabetes beliefs and communication difficulties, as well as potential protective factors. Globally, many health‐care systems are inadequately equipped to improve diabetes prevention and disease outcomes in these communities. Copyright © 2010 John Wiley & Sons, Ltd.     

The importance of health belief models in determining self‐care behaviour in diabetes

Patients’ self‐care behaviours have a major role in diabetes management. Diabetes education provides the required knowledge, but despite this, self‐care is often suboptimal. The degree to which patients follow advice as regards the various self‐care behaviours is determined by their health beliefs (Illness Representations or Personal Models) of diabetes. Psychometric studies have tried to categorize and measure the beliefs about illness that influence patients to adhere to treatment recommendations in diabetes. Various models have been proposed to explain the relationship between beliefs and behaviour. Leventhal's Self‐Regulatory Model, which takes account of the emotional as well as the objective rational response to illness, currently seems to offer the best system for identifying the determinants of patient self‐care behaviour. A review of interventions indicates those based on psychological theory offer professionals the best chance of maximizing their patients’ contribution to diabetes self‐management and achieving improved outcomes, both glycaemic and psychosocial. Studies designed specifically to modify illness representations are now being undertaken. This brief review aims to summarize developments in this area of psychological theory over the last 20 years and the implications for promoting better self‐care behaviour in diabetes.     

Glycaemic control and microvascular complication among patients with youth onset diabetes in India using differing types of insulin and methods of glucose monitoring

We assessed whether insulin types and monitoring methods were relevant to glycaemic control, microvascular complications as well as costs of management in 208 patients with youth onset diabetes in India. The type of insulin and monitoring method used made no difference to the glycaemic and complication status. Cost considerations support bovine insulin use along with urine glucose monitoring as an appropriate approach to diabetes self care in developing countries.     

Predicting the ability of elderly diabetes patients to acquire the insulin self‐injection technique based on the number of animal names recalled

Aims/Introduction

To our knowledge, no studies have reported that cognitive tests can be used to evaluate whether or not patients can acquire the insulin self‐injection technique. We investigated whether or not the number of animal names recalled in 1 min by elderly diabetes patients could be used as a predictor of the patients’ ability to acquire the insulin self‐injection technique within 1 week.

Materials and Methods

We enrolled 57 inpatients with type 2 diabetes aged >60 years who were starting insulin therapy. We carried out the Mini‐Mental State Examination and verbal fluency tests, which included recalling animal names and common nouns starting with the letters ‘a,’ ‘ka’ and ‘shi’ (Japanese letters). We used 12 checkpoints for insulin self‐injection to judge the patients’ levels of acquisition of the technique. The most predictive cognitive test was determined by multivariate logistic regression analysis.

Results

In the present study, multivariate logistic analysis showed that the number of animal names recalled was the most reliable predictor of the ability to acquire the insulin self‐injection technique within 1 week. A figure of 11 animal names predicted a successful acquisition, with a sensitivity of 73% and a specificity of 91% being observed (area under the curve 0.87, 95% confidence interval 0.76–0.97, P < 0.01).

Conclusions

The number of animal names recalled in 1 min was the most useful indicator of the ability of elderly diabetes patients to learn to manage insulin self‐injection therapy within 1 week. The cut‐off value was 11 animal names.     

Glucose control in non‐critically ill inpatients with diabetes: towards closed‐loop

Inpatient glycaemic control remains an important issue due to the increasing number of patients with diabetes admitted to hospital. Morbidity and mortality in hospital are associated with poor glucose control, and cost of hospitalization is higher compared to non‐diabetes patients. Guidelines for inpatient glycaemic control in the non‐critical care setting have been published. Current recommendations include basal‐bolus insulin therapy, regular glucose monitoring, as well as enhancing healthcare provider's role and knowledge. In spite of growing focus, implementation in practice is limited, mainly due to increasing workload burden on staff and fear of hypoglycaemia. Advances in healthcare technology may contribute to an improvement of inpatient diabetes care. Integration of glucose measurements with healthcare records and computerized glycaemic control protocols are currently being used in some institutions. Recent interests in continuous glucose monitoring have led to studies assessing its utilization in inpatients. Automation of glucose monitoring and insulin delivery may provide a safe and efficacious tool for hospital staff to manage inpatient hyperglycaemia, whilst reducing staff workload. This review summarizes the evidence on current approaches to managing inpatient glycaemic control; its utility and limitations. We conclude by discussing the evidence from feasibility studies to date, on the potential use of closed loop in the non‐critical care setting and its implication for future studies.     

Lifestyle Therapy for the Treatment of Youth with Type 2 Diabetes

Type 2 diabetes (T2D) in youth is a relatively novel condition facing paediatric health care providers. Few experimental trials exist to guide clinical management in this population. Supporting and prescribing modifiable lifestyle behaviours is cornerstone in the management of T2D in adults. Clinical trials in obese adolescents suggest that intensive lifestyle interventions that include both dietary changes and increased physical activity elicit clinically meaningful reductions in weight and improve cardiovascular risk profiles. Observational studies in youth with T2D suggest that better diet quality and increased physical activity are associated with better metabolic control; however, the limited experimental data available does not support these observations. Trials evaluating lifestyle monotherapy for the treatment of hyperglycaemia in youth with T2D do not exist, and the only study evaluating combined lifestyle and pharmacologic therapy did not show additional benefit over pharmacologic treatment with metformin alone. Physiological and psychosocial differences between youth and adults with T2D likely contribute to the differences in the effectiveness of lifestyle therapy for improving glycaemic control. The current review describes these topics in detail and provides recommendations for paediatric health care providers for the promotion of lifestyle therapy for the management of hyperglycaemia and cardiovascular risk factors for youth with T2DM.     

Inhaled insulin and insulin antibodies: a new twist to an old debate

The recent development of inhaled insulin for the treatment of diabetes has the potential to significantly improve patient compliance and diabetes control. Preliminary studies have shown inhaled insulin to be effective in lowering blood glucose and HbA(1c) levels. However, inhaled insulin may stimulate insulin antibody production more than is commonly observed with highly purified human insulin administered subcutaneously. The significance of insulin antibodies in patient care has been a topic of frequent debate and has been studied extensively. This review will discuss the potential implications of elevated insulin antibody levels, the role insulin antibodies play in the metabolic control of diabetes and the effect inhaled insulin may have on the immune system.     

Options for prandial glucose management in type 2 diabetes patients using basal insulin: addition of a short‐acting GLP‐1 analogue versus progression to basal‐bolus therapy

Integrating patient‐centered diabetes care and algorithmic medicine poses particular challenges when optimized basal insulin fails to maintain glycaemic control in patients with type 2 diabetes. Multiple entwined physiological, psychosocial and systems barriers to insulin adherence are not easily studied and are not adequately considered in most treatment algorithms. Moreover, the limited number of alternatives to add‐on prandial insulin therapy has hindered shared decision‐making, a central feature of patient‐centered care. This article considers how the addition of a glucagon‐like peptide 1 (GLP‐1) analogue to basal insulin may provide new opportunities at this stage of treatment, especially for patients concerned about weight gain and risk of hypoglycaemia. A flexible framework for patient–clinician discussions is presented to encourage development of decision‐support tools applicable to both specialty and primary care practice.     

Guidelines on the prevention of foot ulcers in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the prevention of foot ulceration in persons with diabetes and updates the 2015 IWGDF prevention guideline. We followed the GRADE methodology to devise clinical questions and critically important outcomes in the PICO format, to conduct a systematic review of the medical‐scientific literature, and to write recommendations and their rationale. The recommendations are based on the quality of evidence found in the systematic review, expert opinion where evidence was not available, and a weighing of the benefits and harms, patient preferences, feasibility and applicability, and costs related to the intervention. We recommend to screen a person at very low risk for ulceration annually for loss of protective sensation and peripheral artery disease and persons at higher risk at higher frequencies for additional risk factors. For preventing a foot ulcer, educate the at‐risk patient about appropriate foot self‐care and treat any pre‐ulcerative sign on the foot. Instruct moderate‐to‐high risk patients to wear accommodative properly fitting therapeutic footwear, and consider instructing them to monitor foot skin temperature. Prescribe therapeutic footwear that has a demonstrated plantar pressure relieving effect during walking to prevent plantar foot ulcer recurrence. In patients that fail non‐surgical treatment for an active or imminent ulcer, consider surgical intervention; we suggest not to use a nerve decompression procedure. Provide integrated foot care for high‐risk patients to prevent ulcer recurrence. Following these recommendations will help health care professionals to provide better care for persons with diabetes at risk of foot ulceration, to increase the number of ulcer‐free days, and to reduce the patient and health care burden of diabetic foot disease.     

Symptoms of depression prospectively predict poorer self‐care in patients with Type 2 diabetes

Aims To examine prospectively the association of depression symptoms with subsequent self‐care and medication adherence in patients with Type 2 diabetes mellitus. Methods Two hundred and eight primary care patients with Type 2 diabetes completed the Harvard Department of Psychiatry/National Depression Screening Day Scale (HANDS) and the Summary of Diabetes Self‐Care Activities (SDSCA) at baseline and at follow‐up, an average of 9 months later. They also self‐reported medication adherence at baseline and at a follow‐up. Results Baseline HANDS scores ranged from 0 to 27, with a mean score of 5.15 ± 4.99. In separate linear regression models that adjusted for baseline self‐care, patients with higher levels of depressive symptoms at baseline reported significantly lower adherence to general diet recommendations and specific recommendations for consumption of fruits and vegetables and spacing of carbohydrates; less exercise; and poorer foot care at follow‐up (β ranging from ?0.12 to ?0.23; P < 0.05). Similarly, each one‐point increase in baseline HANDS score was associated with a 1.08‐fold increase in the odds of non‐adherence to prescribed medication at follow‐up (95% confidence interval 1.001, 1.158, P = 0.047). Increases in depression scores over time also predicted poorer adherence to aspects of diet and exercise. Conclusions Depressive symptoms predict subsequent non‐adherence to important aspects of self‐care in patients with Type 2 diabetes, even after controlling for baseline self‐care. Although the relationship between symptoms of depression and poorer diabetes self‐care is consistent, it is not large, and interventions may need to address depression and self‐care skills simultaneously in order to maximize effects on diabetes outcomes.     

Preparing for adulthood: Health care transition counseling for youth with arthritis

Objective

To determine the proportion of adolescents with arthritis who receive health care transition services and to compare the rates with those reported for adolescents with other special health care needs and adolescents with diabetes.

Methods

We used data from the 2005–2006 National Survey of Children with Special Health Care Needs. A parent/guardian identified youth ages 12–17 years with arthritis (n = 1,052), diabetes (n = 389), and special health care needs (n = 18,189). Four questions examined the extent to which providers discussed health care transition issues, including 1) transfer of care to adult providers, 2) health care needs of adults, 3) acquiring health insurance, and 4) encouraging self‐care responsibility. Bivariate comparisons assessed the associations between sociodemographic characteristics and health care transition services, and multivariate regression models compared outcomes between conditions.

Results

Many adolescents with arthritis are being encouraged to assume self‐care responsibilities (74.8%); fewer discussed how health needs will change in adulthood (52.1%), acquiring insurance (22.5%), or transferring care to a provider who sees adults (19.0%). These results are similar to youth with other special health care needs, but behind youth with diabetes.

Conclusion

Among this sample of US adolescents, many report discussions about health care needs and self‐management, but few are addressing critical aspects of the transition to adult‐oriented health care.     

Diabetes stigma is associated with negative treatment appraisals among adults with insulin‐treated Type 2 diabetes: results from the second Diabetes MILES – Australia (MILES‐2) survey

Aim

To explore factors associated with negative insulin appraisals among adults with Type 2 diabetes, including perceived and experienced diabetes stigma.

Methods

The second Diabetes MILES – Australia study (MILES‐2) is a national survey of adults with diabetes, focused on behavioural and psychosocial issues. Subgroup analyses were conducted on the responses of 456 adults with insulin‐treated Type 2 diabetes (38% women; mean ± sd age: 61.2 ± 8.8 years; diabetes duration: 14.5 ± 7.5 years; years using insulin: 6.4 ± 5.5). Participants completed validated measures of perceived and experienced diabetes stigma (Type 2 Diabetes Stigma Assessment Scale), insulin appraisals [Insulin Treatment Appraisal Scale (ITAS)] and known correlates of insulin appraisals: diabetes‐specific distress (Problem Areas In Diabetes scale) and diabetes‐specific self‐efficacy (Confidence in Diabetes Self‐care scale). A multiple linear regression was conducted (N = 279) to determine the contribution of those variables found to be associated with ITAS Negative scores.

Results

Univariable analyses revealed negative insulin appraisals were associated with demographic and self‐care characteristics (age, employment status, BMI, years using insulin, injections per day), self‐efficacy, diabetes‐specific distress and diabetes stigma (all P < 0.01). Number of injections per day [regression coefficient [95% confidence interval]: 0.74 [0.08, 1.40]; P = 0.028], self‐efficacy [?0.12 [?0.19, ?0.06]; P < 0.001] and diabetes stigma [0.39 (0.31, 0.46); P < 0.001) significantly and independently contributed to the final multivariable model, explaining 58% of the variance in ITAS Negative scores. The independent contribution of diabetes‐specific distress was suppressed following the inclusion of diabetes stigma.

Conclusions

This study represents the first step in understanding the relationship between perceived and experienced diabetes stigma and negative insulin appraisals, and provides quantitative evidence for the strong, independent relationship between these two important constructs.     

Is diabetes‐specific health literacy associated with diabetes‐related outcomes in older adults?

Background: The present study examined the association between a measure of diabetes‐specific health literacy and three different Type 2 diabetes outcome indicators in a national sample of older adults. Methods: Data were taken from the Health and Retirement Study (HRS) 2003 Diabetes module and the HRS 2002 core wave. Analysis was performed on data from 1318 respondents aged 42–96 years [mean (±SD) 67.96 ± 8.65 years] who submitted responses on all relevant independent variable measures along with an HbA1c test kit. The index of diabetes‐specific health literacy was constructed from responses to 10 diabetes self‐care regimen items (α = 0.927). Results: Using a multivariate regression strategy to analyze weighted data, the diabetes‐specific health literacy index was significantly and positively associated with self‐graded assessment of diabetes self‐care (R² = 0.231). However, diabetes‐specific health literacy was not independently associated with the HbA1c level or the average number of days five recommended self‐management behaviors were practiced each week. Conclusions: No previous single study has focused on the relationship between diabetes‐specific health literacy and multiple diabetes‐related outcomes. The direct association of diabetes‐specific health literacy with patients’ assessment of their self‐care practice acumen is useful information for the design of effective patient intervention and/or communication strategies. Health literacy is a broad, multidimensional construct that bridges basic literacy skills and various health and illness contexts. Because it is so important to adults engaged in the self‐management of chronic illness, indicators of disease‐specific knowledge and/or understanding should be included in efforts to measure health literacy.     

Physical activity-induced improvements in markers of insulin resistance in overweight and obese children and adolescents

Childhood obesity is a significant, worldwide, public health problem. Coinciding with the increasing prevalence of obesity in youth, Type 2 diabetes has emerged as a critical health condition in this population. In the U.S. alone, approximately 215,000 U.S. youth under the age of 20 were diagnosed with diabetes, with the majority of 10-19 years old diagnosed with Type 2 diabetes. Additionally, the exact number of youth that may have Type 2 diabetes yet remain undiagnosed is unknown. Increasing physical activity to encourage weight loss among youth may reduce the incidence of Type 2 diabetes in youth; however, several recent studies reported positive associations between physical activity and components of Type 2 diabetes without weight loss in youth. These findings support previous studies in adults which observed physical activity-induced improvements in insulin dynamics without changes in body fat. The purpose of this review was to identify studies which examined the effect of physical activity without dietary intervention on markers of insulin resistance in overweight and obese youth. These studies provide strong evidence that physical activity alone, without dietary intervention, can have a positive, significant impact on insulin resistance risk and potentially prevent the development of type 2 diabetes in overweight and obese youth. The studies reviewed provide support for future interventions to shift the focus from reducing obesity to increasing physical activity for the prevention of type 2 diabetes in obese youth.