Lifestyle Education in Diabetes Care Bonnie L. Hinds

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1 Lifestyle Education in Diabetes Care Bonnie L. Hinds RHAT Annual Conference November 2018

2 2 Diabetes Facts -- Diabetes rates have tripled over the last 20 years. -- Diabetes is the seventh leading cause of death in the United States. The highest diabetes rates in the U.S. are in the south. -- Tennessee has the seventh highest rate of diabetes in the nation. *2016 data

3 3 Research Project -- Funded by the Humana Foundation (July 2017-June 2018) --Research team a partnership between UT Extension and UT s Department of Public Health --To understand the self-management challenges and educational needs of individuals with Type 2 diabetes in Appalachian east Tennessee -- To determine preferred content and delivery methods for educational programming.

4 4 Focus Groups Recruited and conducted six focus groups: Three Knox County Three rural East TN counties

5 5

6 6 Focus Group Participants -- Individuals with Type 2 diabetes -- Duration of 12 months or longer -- Not Type I, pre, at risk, or borderline -- Pre-registration required total participants 27 female, 15 male (23 rural/19 Knox County) 3 husband/wife pairs 1 father/daughter pair

7 7 Provider Interviews As a counterbalance to the focus groups, conducted eight personal interviews from among providers working with individuals with diabetes. Questions for both focus groups and provider interviews developed by the research team and vetted and revised by a group of nine consultants working in varying aspects of diabetes.

8 8 Focus Groups: Major Themes -- Prevalence within families and communities: It just seems like there are so many people have diabetes that it s accepted almost.... Those who know about diabetes typically try to make some helpful concessions. Likelihood that earlier generations of families had diabetes and didn t know it. Flip Side: Stigma/Blaming Lack of control with food

9 9 The Social Perspective In the south, we eat a lot just about every time we get together. When we get together, it s always birthday parties. And you ve got to have cupcakes and cake and ice cream. Our church... always has food. But s it always spaghetti and cake and cookies, and [foods] like that.

10 10 Family Influences... may be helpful or may be detrimental. I m lucky because my wife is so good and she monitors me like a warden. If I get out of bounds, which I tend to do, she s all over it. Broken record. Thank you for your concern. I know you love me, but I m in charge of my eating and exercise.... sometimes he ll say, Here, have a bite. It won t hurt you. [The difficulties of] fix[ing] two meals two versions. My youngest, you know, he s a sweet addict like me, and he would just....buys me candy when I can t deny it. She came to the table and said, Half of that s mine, right? That s five bites. And so, we cut the piece of pie in half and she ate half and I ate half.

11 11 Time, Money, and Temptation [We live in] kind of a fast food culture. A lot of times, it s just easier to stop at McDonald s and get something to eat, because you don t have time once you get home to actually cook something healthy. Just walk in the grocery store, and what is the first thing you see? Baked goods and candy. The first thing that you see. They [vegetables] are so expensive, too, in the grocery store.

12 12 Regarding Exercise... My challenge is my wife and I do everything together. And when she hurt her back, she couldn t exercise. So, I didn t exercise. One thing for me, for exercise, I despise busy work. It s like a cycle with me. If I don t eat right and exercise, my blood sugar goes up, and then I don t feel like exercising or doing anything else, for that matter. "He s [My husband] real good about that, because I mean I wouldn t go walk by myself where I go.... And he walks with me.

13 13 They said, You need to pick up your meter up front. It ll explain itself to you. Informational Needs They [diabetes educators) really don t know the answers....they will beat around the bush, but they can t give you the answers you need to know about diabetes. Even my own doctors cannot answer the questions about diabetes. I see a lot of people running diabetes classes that don t understand diabetes. So I went to the dietitian, and she says: I don t make menus, you know. You just have to read and figure out what you can do. A lot of times, your doctor doesn t tell you how it [diabetes] affects your body. They talk about your eyes and your feet. They don t talk about how diabetes will affect your weight, stress levels, or how to deal with, you know, your food management. You trust your doctor to tell you you know, what you re supposed to be doing. And it isn t always reliable.... When I was told I had it, they said, don t eat sugar; don t eat sweet stuff; don t eat starches. But we need a list of what nots and what tos, you know?

14 14 Provider Interviews: Major Patient Challenges Time, Money, and Temptation Fast foods are really easy. They re cheap. And they re convenient. And it going to be hard to break those. I ve had so many patients talk to me about they want to buy healthy things, but it s very expensive and they can t afford it with a fixed income. What I would love to do is to follow somebody around for a day and see what they eat and watch how they live. Their biggest challenges sometimes, I think, can also be time restraints. They re so busy with their lives that they don t want to take the time to go grocery shop, meal plan, and be proactive. They just want to be very reactive and eat out every night.

15 15 Lifestyle Issues I tell people: You did not get this because of genetics. You have this because of your lifestyle. The depression has been our big obstacle. Mentioned six times: --Soda --Sweet Tea --Lemonade Pop is a big deal. And sweet tea at McDonald s is big, big deal. I think it s a family disease. Like I think that the whole family needs to be educated about what s going on and understand, you know, everything about it, instead of just the patient themselves. Mentioned four times: Stress When people are taking care of sick family members, a lot of times they ll not focus on their own health as much. Breads and potatoes are really a problem for people in this area.

16 16 Patients and Exercise I think the mainstay is we ve got to change. We ve got to change concepts. We ve got to get and I don t mean that you have to be an Olympic athlete. But you ve got to get some moving around. You ve got to get up out of the... the chair at home and do something. I don t use that word, exercise [with my patients]. As far as planned exercise, they ve worked all day long, they don t they don t want to exercise. People are just really not motivated to try to get the exercise. They re willing to change their diet or they say that they are, but the exercise component of it is not something that people tend to want to take on as much. I talk to some people who just have no idea how to be more physically active or what to do or where to start.

17 17 Attitudes and Education If they don t have desire and selfmotivation, they re not going to utilize the knowledge. And then, you know, there s the psychosocial aspect of people, you know, feeling like a failure. I feel confident in my ability to manage people medically, but I think that we re not doing everything we could possibly be doing to have people be educated and manage these things on their own. In primary care, there s not enough time. [Regarding exercise] You can tell me yes or no. And I d rather you d tell me if you re not going to. Just be honest, and just tell me.... They want easy fixes. Because when patients come to the office, they present the best of themselves. And so, you know, trying to understand what their daily life is like.

18 18 Community Advisory Board -- Seven members, representing the focus groups (Composition: 4 females, 3 males 4 Knox County, 3 rural residents) -- Objective: Distill community preferences for a onesession educational offering. Evaluate the session for its reflection of their needs. -- Commitment: Three meetings over the course of eight weeks

19 19 Prioritizing Content Rating Seriousness of Topic Community View Personal Importance 9 or 10 Very serious Very strong Very important 7 or 8 Relatively serious Strong Important 5 or 6 Serious Somewhat strong Somewhat important 3 or 4 Moderately serious Moderately strong Moderately important 1 or 2 Relatively not serious Relatively not strong Relatively not important 0 Not serious Not strong Not important Guiding Considerations Does it require immediate attention? Is there public demand? What is the impact on quality of life? Are there programs that currently address the topic? Level of community Interest Level of community acceptance Personal challenge? Lacking personal resources to address?

20 20 Prioritizing Delivery Mode High Personal and Low Community High Personal and High Community Low Personal and High Community Low Personal and Low Community

21 21 Patients Educational Preferences -- Knowledgeable leader -- Practical and direct information -- Latest research -- Interactive approach -- Notebook for organizing handouts -- Tiered content (to accommodate experience of learners) -- Inclusion of support person(s) and pre-diabetics -- Exclusion of individuals with Type 1 diabetes -- Group capped at 7-12 people with diabetes plus support person -- Travel limitation of 30 minutes each way -- Class length of minutes

22 22 Content for Single Session Educational Offering After an initial dead heat, dietary considerations nosed out medication as the pilot topic. The trial session included only Community Advisory Board members.

23 23 Evaluation: How well did we meet participants needs? On a scale of 5: Highest scores: 5 I would recommend this session to others... The session offers useable, practical information. Lowest score: 4 The format and activities are engaging for support members (spouse, friend, etc.).

24 24 Many thanks to the Humana Foundation, the University of Tennessee research team, and the focus group and interview participants. Dr. Soghra Jarvandi, P.I. Dr. Laurie L. Meschke Aubrey Ray (DrPH student) C.J. Whitfield (MPH Candidate)

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