Diet and exercise in the prevention of diabetes.

BACKGROUND: Individuals with impaired fasting glucose or impaired glucose tolerance are at high risk of progression to type 2 diabetes. Lifestyle modification through change to diet and exercise habit has considerable potential to prevent or delay the onset of this disease. METHODS: A systematic literature search was undertaken of Medline, EMBASE, the Cochrane library and the Cumulative Index to Nursing and Allied Health Literature for journal articles relevant to the question of whether type 2 diabetes can be prevented by lifestyle change. RESULTS: Four cohort studies in a total of 4864 high risk individuals followed for a period of 2.5-6 years were identified. These showed that lifestyle change may reduce the incidence of type 2 diabetes by 28-59%. Moreover, follow-up studies also indicate that diabetes incidence rates continue to be depressed many years after the discontinuation of a lifestyle intervention. Evidence from a meta-analysis confirms this evidence and suggests that it would be necessary to treat 6.4 (95% confidence interval 5.0-8.4) individuals to prevent or delay one case of diabetes through lifestyle intervention. An examination of weight loss diets (low fat, high protein or Mediterranean) suggests each may be effective but each has limitations requiring care in food selection. Evidence also suggests that the maintenance of weight loss also requires regular exercise with an additional expenditure of approximately 8.4 MJ week(-1) (2000 kcal week(-1)). CONCLUSIONS: Diabetes can be prevented by lifestyle change. The challenge is to develop public health approaches to support individuals with respect to incorporating the lifestyle changes needed to reduce the risk of diabetes into their everyday life.

Are current psychometric tools suitable for measuring outcomes of diabetes education?

AIMS: To critically appraise the suitability, validity, reliability, feasibility and sensitivity to change of available psychometric tools for measuring the education outcomes identified in the (Australian) National Consensus on Outcomes and Indicators for Diabetes Patient Education. METHODS: Potentially suitable psychometric measurement tools were identified through a two-step process. Step 1: a structured semi-systematic literature review and consultation with experts; step 2: development of inclusion criteria and a formal, purpose-designed, systematically derived Appraisal Checklist-from the literature and with expert psychometric advice-to critically appraise the identified tools for relevance, validity, reliability, responsiveness to change, burden, feasibility and acceptability. RESULTS: Searching medline, PubMed, PsycINFO and cinhal yielded 37 diabetes-specific and generic measurement tools. Eleven of these did not address the research questions, leaving 26 tools. Of these, 11 assessed indicators of psychological adjustment; seven assessed various domains of self-determination; five measured self-management behaviours, for example, foot care, blood glucose testing and lifestyle domains; and three measured diabetes knowledge und understanding, respectively. When the Appraisal Checklist was applied, only three tools met all criteria, namely the Problem Areas in Diabetes (PAID) scale, the Summary of Diabetes Self-Care Activities (SDSCA) scale and the Appraisal of Diabetes Scale (ADS). However, a number of other suitable tools [i.e. the Diabetes Integration Scale (ATT19), the Diabetes Health Profile (DHP-1/18), the Self-Care Inventory-Revised (SCI-R), the Diabetes Management Self Efficacy Scale Australian/English version (DMSES-A/E), the Diabetes Empowerment Scale-Short Form (DES-SF)] met all except one criteria, that is, either no formal test-retest or no responsiveness to change data. CONCLUSIONS: Although numerous tools were identified, few met rigorous psychometric appraisal criteria. Issues of suitability, adequate psychometric testing for the intended purpose, burden and feasibility need to be considered before adopting tools for measuring diabetes education outcomes.

A national consensus on outcomes and indicators for diabetes patient education.

AIM: To develop a national evidence and consensus position on the desired goals, outcomes and indicators of diabetes patient education (DPE). METHODS: A mixture of qualitative and quantitative methods were used including: (i) literature reviews to identify existing definitions, issues and work in the area; (ii) interviews with key opinion leaders; (iii) focus groups with people with diabetes; (iv) a national survey of diabetes education service providers; (v) a systematic consultation process culminating in a national stakeholder forum. RESULTS: Three overarching goals were identified as the main purpose of diabetes patient education: (i) optimal adjustment to living with diabetes, (ii) optimal health outcomes and (iii) optimal cost-effectiveness (for the individual and for society). Given the difficulty in attributing cause and effect between education and clinical or cost outcomes and that mechanisms already exist for collecting data on clinical endpoints and surrogate indicators, the development of education indicators concentrated on the goal of optimal adjustment to living with diabetes. Four key outcomes for this goal were listed in order as either directly attributable to DPE or in which DPE plays a discernable role: knowledge and understanding, self-determination, self-management and psychological adjustment. CONCLUSIONS: The consensus position represents a sound evidence-informed platform on which diabetes education policy, programmes, data collection and research can be based. However, further work was required to test and make recommendations about applying potentially relevant psychometric tools to measure changes in the identified indicators.

The process of developing and validating national core competencies for diabetes educators.

The National Core Competencies for Diabetes Educators were developed on behalf of the Australian Diabetes Educators Association between July 1994 and November 1995. This paper traces the development of the competencies including the rationale for undertaking the project, the process involved and the measures taken to ensure their relevance and validity. The limitations of applying the competency concept to health professionals are discussed. The paper also explores issues affecting professional bodies which attempt to define and document competencies and describes some of the obstacles which may be encountered during the process.

Can patients set their own educational priorities?

This study aimed to determine if patients can set their own educational priorities accurately and if the impact of diabetes education on knowledge differed between patients who did and did not set their own priorities. Forty patients referred for individual education were randomly assigned to one of two groups. Prior to education with a diabetes specialist nurse (DSN) patients ranked 10 diabetes care topics in order of perceived importance and relevance to their needs and completed a knowledge questionnaire. Group 1 set their own priorities and the DSN directed education according to the patients stated priorities. In Group 2 the DSN set the educational priorities without seeing the patients priority list. The priority ranking by the two groups of the 10 topics and their pre-education knowledge score were not significantly different. Post-education knowledge scores improved equally and significantly in both groups (Group 1 from 23 to 87%; Group 2 from 21 to 79%); P < 0.0001). In both groups, knowledge scores for the top three priorities were significantly higher than for the three lowest ranked topics. Knowledge is neither dependent on, nor a good discriminator of, patient-selected priorities. There may be reasons why it is important for patients to set their own priorities, but education directed solely at those priorities may leave knowledge deficits which could compromise diabetes care.

Quality management for a health education unit.

Specialty health education units are unique in the health care system. Quality Assurance (QA) protocols developed for general ward and hospital department use are not always able to accommodate the unique organizational and functional elements found in such units. In addition, QA measures are all too infrequently applied in the area of health education. The Diabetes Centre at the Prince of Wales Hospital, Randwick is staffed by a multi-disciplinary team which provides in excess of 800 clinical and/or educational occasions of service per month. This paper describes the development and implementation of a Quality Management Plan, specific to the unit's needs, that was introduced in stages over a number of years.

Quality assurance of individual diabetes patient education.

Individual patient education is the most common means of communicating diabetes information and teaching self-care skills. Despite a considerable amount of literature regarding the outcome of group patient education, there is limited reference to the outcome of individual diabetes patient education or to quality assurance of the health messages delivered during this type of education. This study was designed to develop standardized educational messages for individual patient education delivered by diabetes nurse educators, test the immediate impact of these educational messages on patient knowledge, and identify any differences between diabetes nurse educators in their ability to influence patient knowledge. Overall, subjects demonstrated a significant improvement in knowledge immediately following an individual education session. The topic with the least improvement was diet. Significant differences in the patients' posteducation knowledge scores were observed between the three nurse educators in this study. No apparent patient factors accounted for this difference.

Sensori-motor function in older persons with diabetes.

Twenty-five persons with diabetes (aged 55-83 years) who were living independently in the community, and 40 age- and sex-matched non-diabetic controls were assessed for tactile sensitivity, vibration sense, proprioception, quadriceps strength and body sway. In both men and women, those with diabetes performed significantly worse in tests of body sway on firm and compliant surfaces compared with the control subjects after controlling for weight and body mass index. The female diabetic subjects also performed significantly worse in tests of peripheral sensation and strength compared with controls. Age-related declines in sensori-motor function were greater in the diabetic group (r = 0.55-0.75) than in the controls (r < 0.44), while within the diabetic group, duration of diabetes and vibration sense were significantly correlated with sway on a compliant (foam rubber) surface with the eyes open (partial r = 0.52, p < 0.01 and r = 0.55, p < 0.01, respectively). The study findings provide evidence that older people with diabetes have problems with stability and related sensori-motor factors which may place them at increased risk of falls.

The quality of self-monitoring of blood glucose.

The accuracy of self-monitoring of blood glucose (SBGM) was assessed by a quality control programme. Ninety diabetic patients who were routinely performing SBGM were supplied with a series of quality control solutions which they tested with their usual meter and reagent strip. The overall error rate (a result outside the range of the mean +/- 3SD for each quality control solution) was 39% for users of the Ames system and 33% in Boehringer Mannheim system users. The clinical relevance of these errors was determined by examining the effect on the clinical decision which would have been based on the erroneous result, either in taking inappropriate action or in failing to take appropriate action. In 30% of all patients, 25% or more of the errors were of such a degree as to be clinically misleading. The most common error was an underestimation of the result, which gave the impression of better than actual blood glucose control. The main reason for these errors was the failure of patients to take sufficient care in following the manufacturers' instructions when performing the test. Clinically relevant erroneous results are common among patients performing SBGM.