Although near normal glycemic control (HbA1c <7 percent) is important for the prevention and delayed progression of serious microvascular compilations of diabetes, many patients struggle with diabetes self- care and glycemic control. The Breaking Down Barriers (BDB) study found that a cognitive behavioral- based educational intervention taught by an experienced nurse and dietitian was successful in helping 61 percent of poorly controlled patients improve self-care and glycemia. However, approximately 40 percent of patients in the experimental arm and 54 percent of patients overall (including the control arms) were not able to improve glycemia three months post intervention. Further, 21 percent of those who improved, including experimental and control conditions, did not maintain that improvement over an extended time frame (12 months). We found that self-reported organizational and time management problems were associated with poor glycemic control and decreased frequency of diabetes self-care. Pilot data from this cohort on 55 type 1 patients shows that 41 percent used disorganized approaches on the Rey Osterrieth Complex Figure, and of these, 9 out of 10 in the structured BDB intervention improved glycemia by at least 0.5 percent, while only 2 out of 11 in the two control groups improved glycemia. This suggests that executive function may be an important determinant of clinical approach, i.e. how much of a structured intervention is required in the care of individual patients. We hypothesize that organization, planning, and resultant time management issues are important abilities for integrating diabetes self-care into one's lifestyle. Thus, we propose a comprehensive investigation of the factors leading to the ability and inability to self-manage diabetes and benefit from diabetes education. This information could help develop clinical strategies for individual clinicians to use with their patients, including referral to structured programs such as Breaking Down Barriers that focus on patients'diabetes specific organization and planning skills. We plan to assess patients from the BDB study (initially had A1c levels >7.6 percent) and compare them to (newly recruited) patients who currently have an A1c level of <7 percent and who have maintained that level for 4-5 years, using both a qualitative and quantitative component. Qualitative interviews will examine patients'perceptions of barriers and supports (some of which may be previously unrecognized) that impacted their successes and failures in achieving glycemic targets. The quantitative component will evaluate executive functioning (the ability to plan, organize, and complete complex tasks) among people with diabetes and its relationship with diabetes self-care (and for BDB patients, its relationship with the response to the educational interventions);this component involves physiologic, psychosocial, intelligence, and neuropsychological measures, as well as measures of self-care via both self-report and record keeping tasks.
As the number of people with diabetes increases to almost epidemic proportions in the United States and across the world, poor control of diabetes is a serious public health concern and puts diabetes patients at risk for serious complications and comorbidities including blindness, kidney failure, foot sores and amputations, and cardiovascular disease. Many patients are at risk for such complications because they struggle with their self-care behaviors and thus are unable to achieve glycemic targets. Much effort and many resources have addressed barriers to adherence with little progress. Yet, little is known about mechanisms related to this struggle, thus once the underlying mechanisms of diabetes self-care are better-characterized, more effective clinical approaches and interventions can be developed.
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