Optimizing Diabetes Self-Management Outcomes in Low-Income Ethnic Minority Patients in the United States

Purpose: In 2013, approximately 382 million people over the age of 20 years were diagnosed with type 2 diabetes, and it is estimated that by 2035 that number will increase to 592 million worldwide (1). The majority of patients diagnosed with type 2 diabetes do not receive consistent medical care and education about the disease process and do not maintain good glycemic control (2,3). Poor glycemic control leads to microvascular and macrovascular complications (2).  The purpose of this randomized controlled pilot study was to develop and test an interdisciplinary approach to diabetes self-management in a community-based health center serving underserved and uninsured minority patients.

Methods: The primary outcome was glycated hemoglobin from baseline to 15 months. Secondary outcomes included lipids and blood pressure and diabetes self-management.  A randomized repeated measures design was used with 40 patients in the experimental group and 40 patients in the control group. The patients in the experimental group were provided with a diabetes group visit which consisted of individualized sessions with a physician or nurse practitioner to review medications and conduct a medical examination and group sessions to deliver diabetes self-management education. The control group received usual care.  All 5 classes were delivered to each patient in the experimental group in the same order every 3 months for 15 months. Classes included understanding foot care, blood glucose monitoring, blood pressure and cholesterol, nutrition and exercise, and complications of diabetes. Data collected included clinical data and questionnaires every 3 months for 15 months. Data analysis was completed using ANOVA comparing Time 1 (baseline) data and Time 5 (15 month) data. 

Results: The patients ranged in age from 32 to 65 years (mean ± SD years, 51.4 ± 8.5). A total of 89.3% were women and 10.7% men. The sample was 77.4% non-Hispanic Black, 17.9% non-Hispanic White, 2.4% bilingual Hispanic, 1.2% Asian Pacific, and 1.2% American Indian. A total of 54.2% had finished high school; 25.2% had finished 4 years of college; and 3.6% had finished graduate school. At the completion of Time 5 data, the experimental group retained 35 patients (88% retention rate), and the control group retained 33 patients (83% retention rate). The experimental group significantly decreased glycated hemoglobin (F = 12.8; p = .001) and triglycerides (F = 11.0; p = .002), increased high-density lipoprotein (F = 4.8; p = .033), and decreased resting heart rate (F = 4.9; p = .031) compared to the control group patients.  The patients in the experimental group felt their general health (F= 11.4; p = .001) was significantly better than the control group. In addition, the patients in the experimental group felt that they could do significantly more stretching and strengthening exercises each week (F = 10.4; p = .002) and felt significantly more confident (F = 4.7; p = .034) that they could exercise 15 to 20 minutes, 4-5 times a week. The patients in the experimental group also felt significantly more confident (F= 4.9; p = 0.03) that they could do something to prevent their blood sugar from dropping when they exercised.

Conclusion: Diabetes group visits imbedded in a community health center improved metabolic control, high-density lipoproteins, triglycerides and some diabetes self-management behaviors.