Food insecurity is associated with diabetes self-care behaviours and glycaemic control.

AIMS: Food insecurity is the 'limited or uncertain availability of nutritionally adequate and safe foods'. Our objective was to examine the association between food insecurity, diabetes self-care and glycaemic control. METHODS: We conducted a cross-sectional analysis of baseline data from adult patients with Type 2 diabetes who were enrolled in a randomized trial evaluating a health literacy-focused diabetes intervention in safety net primary care clinics in middle Tennessee. Food insecurity was assessed with three items from the U.S. Household Food Security Survey. Diabetes self-care behaviours were assessed with the Summary of Diabetes Self-Care Activities Scale, Personal Diabetes Questionnaire and Adherence to Refills and Medication Scale. Glycaemic control was assessed with HbA1c . RESULTS: The sample consisted of 401 participants, 73% of whom reported some level of food insecurity. Food insecurity was significantly associated with self-care behaviours including less adherence to a general diet [Adjusted Odds Ratio (AOR) 0.9, P = 0.02], less physical activity (AOR 0.9, P = 0.04) and with a greater occurrence of medication non-adherence (AOR 1.2, P = 0.002) and calorie restriction (AOR 1.1, P = 0.02). Food insecurity was also associated with worse glycaemic control (adjusted ß = 0.1, P = 0.03). None of the self-care behaviours were significantly associated with HbA1c , limiting the ability to test for self-care as a mechanism linking food insecurity to glycaemic control. CONCLUSIONS: There was a high rate of food insecurity in a sample of patients with Type 2 diabetes who were of low socio-economic status. Food insecurity was associated with less adherence to recommended self-care behaviours and worse glycaemic control.

Seat belt use among Hispanic ethnic subgroups of national origin.

OBJECTIVE: Findings from over a dozen studies of Hispanic/white disparities in seat belt use have been inconsistent, variably revealing that seat belt use prevalence among Hispanics is higher, lower, or comparable to use among non-Hispanics. In contrast to previous studies, this study investigates disparities in seat belt use by Hispanic subgroups of national origin. METHODS: Data from the US Fatality Analysis Reporting System were used to compare seat belt use among 60 758 non-Hispanic whites and 6879 Hispanics (Mexican American (MA), n = 5175; Central American/South American (CASA), n = 876; Puerto Rican (PR), n = 412; Cuban (CU), n = 416) killed in crashes from 1999-2003. Logistic regression was used to adjust for age, gender, seat belt law, seat position, urban/rural region, and income. RESULTS: Overall adjusted odds ratios for seat belt use among Hispanic subgroups, relative to non-Hispanic whites, were 1.04 (95% confidence interval (CI) 0.85 to 1.28) for CUs, 1.17 (95% CI 0.95 to 1.44) for PRs, 1.33 (95% CI 1.25 to 1.42) for MAs, and 1.66 (95% CI 1.44 to 1.91) for CASAs. Relative to their non-Hispanic white counterparts, odds ratios among MA and CASA Hispanics were highest for men, younger age groups, drivers, primary law states, rural areas, and lower income quartiles. CONCLUSION: Among all Hispanic subgroups, seat belt use was at least as prevalent as among non-Hispanic whites. In the CASA and MA subgroups, which have the most rapidly growing subpopulations of immigrants, seat belt use was significantly more common than among whites.

A conceptual framework for reducing risky teen driving behaviors among minority youth.

Teenage drivers, especially males, have higher rates of motor vehicle crashes and engage in riskier driving behavior than adults. Motor vehicle deaths disproportionately impact youth from poor and minority communities and in many communities there are higher rates of risky behaviors among minority youth. In this paper, the authors review the data on teens, risky driving behaviors, and morbidity and mortality. They identify areas in which known disparities exist, and examine strategies for changing teen driving behavior, identifying what has worked for improving the use of seat belts and for reducing other risky behaviors. A multifaceted, multilevel model based on ecological theory is proposed for understanding how teens make choices about driving behaviors, and to understand the array of factors that can influence these choices. The model is used to create recommendations for comprehensive intervention strategies that can be used in minority communities to reduce disparities in risk behaviors, injury, disability, and death.

Development of a culturally sensitive food frequency questionnaire for use in the Southern Community Cohort Study.

A food frequency questionnaire (FFQ) was developed to assess long-term habitual dietary intake in a cohort of approximately 100,000 40 to 79 year-old men and women living in the Southeastern US. Using the NHANES-III database for the southem region for specific race and sex subgroups, a list of 262 food categories was developed, coded and reduced to 102 food items that could discriminate between racial groups and account for large portions of cancer-relevant nutrients. The developed FFQ was tested in a pilot study in three southeastern states involving 239 African Americans and Whites, aged 56.9 +/- 12.2 years. The frequencies of consumption and portion sizes of the 102 foods were determined and intakes of various nutrients were estimated and compared with the NHANES-III data. African Americans reported higher total energy intakes and higher consumption of macronutrients and several micronutrients, compared to Whites. Estimated nutrient indices were higher among pilot study than among NHANES-III participants, although adjustment for total energy essentially eliminated the differences. Analysis of the frequency distribution of individual foods shows that the questionnaire includes commonly eaten foods that can discriminate between African Americans and Whites. The FFQ is currently being calibrated within the cohort study population.

A taxonomy of obstacles to breast examinations in African American women.

The purpose of this study was to describe and classify the barriers to breast self-examinations (BSE) and mammography in African American women. A total of 125 African American women were recruited from historically black colleges, churches and community organizations in Nashville, Tennessee. Their responses to a comprehensive open- and closed-ended questionnaire about barriers to BSE and mammography were coded using a hierarchical coding system and analyzed according to participants' stage of behavior change assignment. On the average, each woman reported 3.1 barriers to BSE (2.5 psychological and 0.6 environmental) and 2.5 barriers to mammography (1.5 psychological and 1.0 environmental). Barriers cited included fear of finding cancer, forgetting, lack of time, lack of knowledge, competing demands, costs, pain, emotional consequences, cultural attitudes towards medicine, uncertainty about benefits and laziness. For BSE, the number of psychological barriers exceeded environmental barriers, while for mammography, the number of psychological and environmental barriers was similar. For BSE, but not mammography, psychological barriers appeared most important for women in the precontemplation, contemplation and preparation stages of behavior change. Overcoming barriers to BSE and mammography could increase early detection rates in African American women. Interventions based on stage of change theory may be especially applicable.

Evaluation of the insulin resistance syndrome in 5- to 10-year-old overweight/obese African-American children.

OBJECTIVE: To characterize the insulin sensitivity of overweight and obese 5- to 10-year-old (Tanner stage 1-3) African-American children screened for participation in a diabetes prevention study and to identify the association of insulin sensitivity with obesity, hyperlipidemia, and hypertension. RESEARCH DESIGN AND METHODS: Measures of insulin resistance (homeostasis model assessment) and insulin sensitivity (Matsuda and DeFronzo's whole-body insulin sensitivity) were calculated from a 2-h oral glucose tolerance test in 137 African-American children recruited into a diabetes prevention study. Measures of lipids (LDL, HDL, total cholesterol, and triglycerides), blood pressure, and body composition were obtained for a subset of the children. RESULTS: In response to a glucose challenge, girls and older and heavier children produced significantly more insulin. As BMI increased, there was a statistically significant decrease in insulin sensitivity, particularly in girls. Insulin sensitivity was inversely correlated with increases in blood pressure, triglycerides, subcutaneous fat, the percentage of total body fat, and Tanner stage, but it was not correlated with LDL and HDL. CONCLUSIONS: Reduced insulin sensitivity and the cluster of risk factors known as the insulin resistance syndrome (IRS) are already apparent in these overweight African-American children. Young African-American girls, in particular, already show evidence of hyperinsulinemia in response to a glucose load, suggesting that the early stages of metabolic decompensation that lead to type 2 diabetes are already occurring. Monitoring of those risk factors known to be part of IRS should become part of routine medical care for overweight or obese African-American children.

Use of innovative technologies in the evaluation of Nashville's REACH 2010 community action plan: reducing disparities in cardiovascular disease and diabetes in the African American community.

Ethnic minorities in the United States suffer disproportionately from chronic diseases such as cancer, heart disease, AIDS, and diabetes. A nationally-funded initiative known as Racial and Ethnic Approaches to Community Health (REACH) has designated 26 communities to implement demonstration projects to reduce health disparities in targeted minority populations. This article presents two methods of integrating innovative technologies into the program's evaluation plan: (1) a Web-based data entry system for recording project activity and (2) geographic information systems (GISs) for developing visual maps of project targets. These technologies can assist other programs in managing and measuring community-based public health initiatives.

Impact of moods and social context on eating behavior.

The relationship of moods and social context to energy and nutrient intakes was examined to ascertain if these variables interact or function independently. The subjects were 78 predominantly white, obese women participating in weight-loss studies. Mean age was 36.7 (SD=7.6) and mean Body Mass Index was 32.1 (SD=3.6). Subjects completed 2-week baseline food diaries recording everything they ate, including moods and people present during the meals. Meals eaten in positive and negative moods were significantly larger than meals eaten in a neutral mood. Meals eaten with other people were significantly larger than meals eaten alone. There were no significant moods by social context interactions for total energy intake. Moods and social context functioned additively to increase the risk of over-eating. Macro nutrient analysis revealed only a main effect for social context. Percentage of calories from fat and protein were greater, whereas the percentage of carbohydrate was less in social context meals compared to meals eaten alone. Clinicians should conduct a functional analysis to assess exposure to the frequency and types of risky situations. Teaching people to cope more effectively with social situations and moods may increase the efficacy of weight loss and maintenance programs.

Care giver perception of children's obesity-related health risk: a study of African American families.

OBJECTIVE: To examine care giver perception of children's weight-related health risk in African American families. RESEARCH METHODS AND PROCEDURES: One-hundred and eleven families (representing 48 boys and 63 girls) screened for participation in a diabetes prevention study participated. Care givers completed a health awareness questionnaire that assessed their perception of the child's weight, eating habits, appearance, exercise habits, and health risk. The care givers also reported each subject's family history of obesity, diabetes, and other chronic diseases. After a physical examination, height and weight were used to compute an age- and sex-adjusted body mass index for each child. RESULTS: Despite the fact that a substantial number of children were obese (57%) and super-obese (12%), only 44% of the care givers perceived the child's weight to be a potential health problem. Regression analysis showed that 21% of the variance in parental perception of obesity-related health risk could be predicted by child age, body mass index, perception of frame size, and perception of exercise habits. DISCUSSION: A number of reasons for the apparent minimization of child health risk are discussed, including cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity and future health risk, and an optimistic bias in the perception of personal health risk.

Diabetes training for dietitians: needs assessment, program description, and effects on knowledge and problem solving.

Recent changes in management and medical nutrition therapy for diabetes mellitus have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 2 1/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (+/- standard deviation) scores on pre- and postests of knowledge and problem solving were 69 +/- 13% and 86 +/- 9%, respectively (P < 0.01). The SNAP program needs assessment, training methods, and knowledge problem-solving test are relevant to all types of education programs in clinical dietetics.

Stages of change and the intake of dietary fat in African-American women: improving stage assignment using the Eating Styles Questionnaire.

OBJECTIVE: To develop an algorithm for determining the stage of change for dietary fat intake in African-American women. DESIGN: We examined the relationships between stage of change, dietary fat intake, and associated eating behaviors and developed an assessment tool for placing subjects in their appropriate stage of change. SUBJECTS: Working class and middle-income African-American women in Nashville, Tenn; 174 in study 1 and 208 in study 2. STATISTICAL ANALYSES: Fat and fiber intake by stage of change was examined using multivariate analysis of variance. Hierarchical cluster analysis was performed using Ward's method. RESULTS: A significant difference in fat intake was noted between women trying to change their intake and those not trying to change in study 1 (P < .001) and study 2 (P < .03). Of those trying to change, only 34% (study 1) and 9% (study 2) of subjects reported fat intakes below the Healthy People 2000 goal of 30% of energy from fat. In study 1, cluster analysis identified 14 groups of foods that significantly separated subjects into not trying, noncompliant, and compliant categories. Compliant subjects ate out less; ate fewer snack foods and less chicken, meat, and fat; and ate more fruits, vegetables, breakfast foods, and low-fat products. These results led to development of the Eating Styles Questionnaire (study 2), which facilitated more appropriate placement of the noncompliant group in stages of change for dietary fat intake. APPLICATIONS/CONCLUSIONS: These data support the stage construct of the Transtheoretical Model for dietary fat reduction in African-American women. Moreover, the Eating Styles Questionnaire (ESQ) can improve determination of stage of change for this group of women. The ESQ can be used to diagnose the eating styles that contribute to a high-fat intake and help in the design of interventions to lower fat intakes.

Evaluation of a multicomponent, behaviorally oriented, problem-based "summer school" program for adolescents with diabetes.

A 2-week summer school program, combining problem-based learning with behavior therapy, was developed to help adolescents with insulin-dependent diabetes improve their ability to cope with obstacles to dietary management. Ten students participated in a first session, and 9 participated in a second session, serving as a waiting list control group. Outcomes were evaluated pre- and postsession and at a 4-month follow-up using 3-day food diaries, blood glucose data, and paper-and-pencil tests of diabetes-related knowledge, self-efficacy, coping strategies, and general problem solving. Improvements were observed in self-efficacy, problem-solving skills, and self-reported coping strategies. No significant changes were observed in daily intake of fat, cholesterol, calories, mean blood glucose levels or blood glucose variability, and diabetes knowledge. Comparisons between the first group and the waiting list control group do not allow the significant pre-post changes to be clearly attributed to the summer school program.

What are the eating cognitions of children whose chronic diseases do and do not require attention to diet?

Nutrition therapy is essential to the management of several chronic diseases affecting adolescents. Unfortunately, dietary impositions may evoke pathological eating-related cognitions. This pilot study examined eating- and weight-related cognitions of 55 adolescents attending a summer camp for youngsters with a heterogeneous variety of chronic diseases. Campers completed the Eating Cognitions Questionnaire and the Situational Obstacles to Dietary Adherence questionnaire. Campers whose medical regimens included special dietary recommendations (n = 24) were expected to have more cognitions associated with eating disorders than those without dietary restrictions (n = 31). Girls were significantly more concerned than boys about weight and restrictive dietary rules. Cognitions of youngsters with special dietary recommendations showed greater flexibility, less eating pathology and less weight concern than campers without recommended diets. Contrary to previous reports, dietary restrictions were associated with more appropriate eating cognitions, suggesting that adolescents with chronic illnesses requiring nutrition therapy may not necessarily bear greater risk of eating disorders.

Assessing and overcoming situational obstacles to dietary adherence in adolescents with IDDM.

PURPOSE: To develop and evaluate a tool for assessing selected aspects of dietary adherence in adolescents with diabetes mellitus (IDDM). METHODS: The Situational Obstacles to Dietary Adherence Questionnaire (SODA) is a 30-item inventory that yields a total self-efficacy score and scales that measure cognitive and behavioral coping strategies. Alternative forms of the SODA were administered at the beginning and end of a summer camp for youngsters with IDDM in order to obtain evidence for its reliability and validity, and to evaluate the impact of an educational intervention. The program consisted of two 50-minute small group sessions intended to help adolescents with IDDM improve their ability to cope with challenging dietary situations. Using the method of anchored instruction, the campers first viewed a video about a teenager with diabetes who faces common situations that make diabetes self-management difficult. Group problem-solving sessions led by a registered dietitian were used to help campers learn more effective ways to solve dietary problems. RESULTS AND CONCLUSIONS: Results suggested that the SODA has reasonable reliability and validity. In addition, anchored instruction improved dietary self-efficacy and changed young adolescents' estimates of how often they would use selected cognitive and behavioral strategies to solve dietary problems.

Evaluation of a patient teaching skills course disseminated through staff developers.

Effective Patient Teaching (EPT), a course designed to improve health professionals' and health professions students' teaching skills, reliably produces gains in participants' skills when presented by its developers. The objective of this dissemination research study was to investigate whether, using a 'training of trainers' approach, seven nurses with staff development responsibilities in five different sites could teach EPT with similar effectiveness. The evaluation included pre- and post-course analysis of audiotaped patient education sessions conducted by 48 health professional participants who took EPT from one of the trainers in their home institutions. Post-course participant satisfaction surveys were also administered. EPT resulted in teaching skill improvements in four of five sites, and overall teaching skills scores improved significantly (P < 0.01). EPT can improve participants' teaching skills when taught by health professional trainers with staff development responsibilities who have recently received EPT training.

Frequency of severe hypoglycemia in insulin-dependent diabetes mellitus can be predicted from self-monitoring blood glucose data.

Severe hypoglycemia is associated with insulin-dependent diabetes mellitus and may occur more frequently as metabolic control approaches normal. The goal of this study was to determine whether the frequency of severe hypoglycemia could be predicted by the following predictor variables: 1) frequency and degree of low blood glucose (BG) readings, 2) degree of BG variability during routine self-monitoring blood glucose (SMBG) readings, and 3) level of glycemic control measured by glycosylated hemoglobin-A1 (HbA1). Seventy-eight insulin-dependent diabetes mellitus subjects from 3 different sites had their glycosylated HbA1 assayed and then performed 50 SMBG recordings during the next 2-3 weeks. Over the following 6 months, subjects recorded their severe hypoglycemic episodes (stupor or unconsciousness). There was no difference in the number of severe hypoglycemic episodes between subjects in good vs. poor metabolic control. A higher frequency of severe hypoglycemia during the subsequent 6 months was predicted by frequent and extreme low SMBG readings and variability in day to day SMBG readings. Regression analysis indicated that 44% of the variance in severe hypoglycemic episodes could be accounted for by initial measures of BG variance and the extent of low BG readings. Patients who recorded variable and frequent very low BG readings during routine SMBG were at higher risk for subsequent severe hypoglycemia. Individuals who had lower glycosylated Hb levels were not at higher risk of severe hypoglycemic episodes.

Evaluation of a training program for improving adherence promotion skills.

A workshop for improving the adherence counseling skills of health professionals was developed and evaluated. Target audiences have included medical students, nursing students, dietetic interns, and practising nurses and dietitians. Four categories of skills are taught: relationship building, interviewing, problem diagnosis, and behavioral intervention. Teaching methods include faculty demonstration, participant rehearsal, and group and individual feedback. The Adherence Promotion Training (APT) workshop has been offered as a 3- to 5-day intensive course and as a semester-long elective. A reliable coding system was developed to assess these skills from videotaped provider-patient interactions. A standardized patient task was given to 60 subjects before and after participation in the adherence counseling skills workshop. Videotapes were coded by trained raters, who were masked to whether the tape came from before or after the workshop. Significant short-term improvements were observed in all four core skills. This uncontrolled evaluation suggests that the Adherence Promotion Training program is a promising way to enhance the ability of health professionals to care for nonadherent patients.

Situational obstacles to dietary adherence for adults with diabetes.

OBJECTIVE: To develop a taxonomy of everyday situations that create obstacles for adherence to dietary management in patients with diabetes. SUBJECTS: Twenty-six adults with diabetes (12 with insulin-dependent diabetes mellitus and 14 with non-insulin-dependent diabetes mellitus) were recruited from an outpatient diabetes clinic. MAIN OUTCOME MEASURES: Subjects were interviewed to identify problem situations that create obstacles for dietary adherence. The resulting 69 situations were judged for the presence or absence of 32 environmental features using a reliable coding system. STATISTICAL ANALYSIS: A hierarchical cluster analysis was used to identify homogeneous groups of dietary adherence obstacles. RESULTS: Twelve types of problem situations were identified: negative emotions, resisting temptation, eating out, feeling deprived, time pressure, tempted to relapse, planning, competing priorities, social events, family support, food refusal, and friends' support. CONCLUSIONS: The resulting taxonomy provides an outline for the detailed assessment of obstacles to dietary adherence. An individual's ability to cope with this array of obstacles to dietary adherence should be assessed so treatment can be individualized.