UPDATES ON: DSMT, EXERCISE BARRIERS IN T1D, AND HERBS & SPICES

EDUCATOR WATCH

UPDATES ON:

DSMT, EXERCISE BARRIERS IN T1D, AND HERBS & SPICES

FOCUS ON T2D: EMERGING RESEARCH ON COFFEE; MORE ON GENETICS AND EXERCISE
In each edition of In the Know, EducatorWatch highlights some of the most interesting and relevant clinical studies from that stack of journals on your desk. Each study includes an Educator Take-Home Point with insights from a diabetes educator (DE) about what this emerging research could mean to you—and your patients.

MORE DIABETES EDUCATION & TRAINING NEEDED IN NEWLY DIAGNOSED PATIENTS

A recent large-scale analysis of private insurance claims data found that only 6.8% of adults newly diagnosed with diabetes participated in diabetes self-management education and training (DSMT) [Li et al].

The American Diabetes Association (ADA) recommends providing DSMT to people with newly diagnosed diabetes because data suggest this is the time when they are most receptive to such engagement. However, the study results indicate a gap between this recommendation and current practice.

The research, published in CDC’s Morbidity and Mortality Weekly Report (MMWR), included an analysis of claims data for more than 95,000 patients aged 18 to 64 years who were diagnosed with diabetes between 2009 and 2012 [Li et al]. Researchers tracked their participation in DSMT within 12 months of diagnosis.

FACTORS AFFECTING PARTICIPATION
The adjusted rates of participation in DSMT were slightly higher among:

  • Patients aged 45 to 64 years (compared with patients aged 18 to 44 years—7.2% versus 5.9%, P<0.001);
  • Those prescribed insulin for glycemic control versus oral agents only (14.2% versus 6.7%, P<0.001) or not prescribed any antiglycemic medication (14.2% versus 5.1%, P<0.001);
  • Those enrolled in fee-for-service health plans compared with those in capitated health plans (7.0% versus 6.0%, P<0.001);
  • Those residing in a metropolitan statistical area compared with those outside (7.1% versus 5.5%, P<0.001);
  • Those residing in the North Central region (9.2%) compared with those residing in other regions (5.7%–6.9%, P<0.001 for each).

Still, the researchers noted, adjusted DSMT participation did not exceed 14.2% even in any of the subgroups.

AN OPPORTUNITY FOR INTERVENTION
The authors emphasized both an opportunity and a need to enhance rates of DSMT participation among people newly diagnosed with diabetes. The MMWR editors called for health system-level interventions such as improving access to DSMT, along with personal-level interventions such as behavioral change strategies.

EDUCATOR TAKE-HOME POINT FROM HEATHER LECLERC, MS, RD, CDE: It was shocking to read in this study that only 6.8% of newly diagnosed, privately insured people with diabetes received DSMT. In the large healthcare system where I work, diabetes education for newly diagnosed patients is one of the quality indicators for our primary care practices. Despite this, not all patients receive diabetes education.

Based on my own observations and those of 2 seasoned primary care providers with whom I discussed this study, barriers to receiving diabetes education often include:

  • Copays may be a financial barrier. Many patients are living paycheck-to-paycheck, and even modest copays can be a hardship.
  • Getting time off from work can be difficult for some patients. Many medical offices are not open weekends or evenings, which makes it difficult for patients to attend classes.
  • Some patients consider diabetes the least of their problems. As a result, taking care of their diabetes gets put on the “back burner.”
  • Travel costs can be a barrier. Our service area is large, and patients often have to drive 1 to 4 hours to get to our office.
  • Some patients feel that they know how to manage their diabetes already because a close relative has diabetes.

As DEs, we need to find ways to break down the barriers that keep patients from getting the diabetes education they need to achieve optimal health.

SOURCE
Li R, Shrestha SS, Lipman R, Burrows NR, Kolb LE, Rutledge S. Diabetes self-management educating and training among privately insured persons with newly diagnosed diabetes—United States, 2011-2012. MMWR. 2014;63(46):1045-1049.


HOW TO ADDRESS EXERCISE BARRIERS IN PATIENTS WITH TYPE 1 DIABETES

While most patients with type 1 diabetes (T1D) recognize the health benefits of regular exercise, a significant number still do not participate in physical activity at recommended levels [Lascar et al].

A recent study of 26 male and female T1D patients aged 21 to 64 years used interviews to identify patients’ exercise levels as well as barriers and motivators in initiating and maintaining a regular regimen. This formal qualitative research builds on previous quantitative, questionnaire-based studies.

BARRIERS TO EXERCISE
Researchers identified 6 main barriers to exercise in people with T1D, including:

  • Lack of time and work-related factors;
  • Access to facilities;
  • Lack of motivation;
  • Concerns about body image;
  • Weather issues;
  • Diabetes-specific barriers.

The diabetes-specific barriers related to low levels of knowledge about managing diabetes and its complications around exercise.

GETTING MOTIVATED
Researchers also identified benefits of exercise that motivated people with T1D:

  • Physical benefits;
  • Improvements in body image;
  • Enjoyment derived from the physical activity;
  • Social interaction from group or gym work-outs.

Overall, those participating in the study said they preferred one-to-one support rather than group support.

Researchers also identified benefits of exercise that motivated people with T1D:

  • Free or reduced admission to gyms and pools;
  • Help with time management;
  • Advice and encouragement around managing diabetes for exercise.

CLINICAL RELEVANCE
Researchers observed that people with T1D experience many of the same barriers to exercise as people without diabetes. In addition, T1D patients have the additional need of specific education surrounding the effects of exercise on diabetes control and its complications. The study authors concluded that increased education in this area and one-to-one techniques with a proven track record in increasing activity in the general public and in patients with other chronic diseases also should be beneficial for people with T1D.

EDUCATOR TAKE-HOME POINT FROM KENDALL L. SMITH, MPH, RD/LD, CDE: Unlike most clinical research examining exercise and diabetes, which frequently focuses on patients with T2D, this study centered on the T1D population. The results of the study provide valuable qualitative data to help address and overcome the barriers to physical activity in patients with T1D. While the study was small, it included a good sampling of patients gender- and age-wise.

The study results provide immediate clinical implications that can be addressed by DEs. Identifying barriers to physical activity enables a better understanding of individual challenges so that we can create a plan to address and overcome these hurdles.

While many barriers to exercise are the same for people with diabetes and those without, a primary difference is that people with diabetes require education regarding the impact of physical activity on overall diabetes control. This makes an excellent case for the critical role that DEs—especially those with an exercise physiology and fitness background—can play in providing one-to-one education about physical activity.

SOURCE
Lascar N, Kennedy A, Hancock B, et al. Attitudes and barriers to exercise in adults with type 1 diabetes (T1DM) and how best to address them: a qualitative study. PLoS One. 2014;9(9):e108019.


COULD HERBS AND SPICES IMPROVE CARDIOVASCULAR RISK FACTORS?

It has been well-demonstrated in the evidence-based literature that diabetes—along with high low-density lipoprotein (LDL), hypertension, and smoking—remains a significant risk factor for cardiovascular disease (CVD).

As a DE who makes dietary recommendations to patients, you may occasionally receive questions about the role that herbs and spices such as cinnamon might play in managing diabetes and potentially preventing or managing CVD. A study published recently in Nutrition Today offers some additional insights in this area [West et al].

Because herbs and spices are rich in potentially bioactive compounds, a number of clinical studies have examined their effects on blood insulin, blood lipids, and inflammation. The newly published research includes an analysis of previously published studies on cinnamon and blood lipids, with some of the studies specifically focused on people with type 2 diabetes (T2D). The researchers also conducted their own pilot study of overweight men aged 30 to 65 years to determine whether a single, large dose (14 g) of a high-antioxidant spice blend incorporated into a test meal caused postprandial blood changes.

CINNAMON WORTH A CLOSER LOOK
The study authors’ analysis of a number of studies focused on the effects of cinnamon (Cinnamomum verum J. Presl, Lauraceae) on blood lipids identified variable results, with the studies in patients with T2D showing more positive outcomes.

The studies that included patients with T2D reported some beneficial findings:

  • Khan et al reported that mean fasting serum total cholesterol, LDL cholesterol, and triglyceride levels decreased 7% to 30% among adults with T2D who consumed 1, 3, or 6 g of cinnamon daily for 40 days compared with those who were given a placebo (all P<.05).
  • A systematic review and meta-analysis of 10 randomized controlled trials of cinnamon use in people with T2D also found significant (P<.05) reductions in total cholesterol (-15.6 mg/dL), LDL cholesterol (-9.42 mg/dL), and triglycerides (-29.59 mg/dL) and an increase in HDL cholesterol (1.66 mg/dL) when the cinnamon dose ranged from 120 mg to 6 g a day.

However, in healthy adults and people with prediabetes, researchers did not report the same types of benefits:

  • Markey et al reported no differences in postprandial plasma blood lipids among healthy adults who ate a high-fat meal containing 3 g of cinnamon.
  • Ziegenfuss and colleagues found no differences in total cholesterol, LDL, HDL, very-low-density lipoprotein, and triglyceride concentrations between prediabetic adults who supplemented their diet with a cinnamon extract (500 mg a day for 12 weeks) and those who took a placebo for 12 weeks.

PILOT STUDY TESTS SPICE BLEND
The researchers also conducted a pilot study designed to assess whether a single, large dose (14 g) of a high-antioxidant herb and spice blend incorporated into a test meal caused postprandial blood changes. While the study only included 6 overweight men aged 30 to 65 years, initial results were encouraging, the authors wrote.

Researchers found that the herb and spice blend may help improve levels of postprandial insulin and triglyceride concentrations after a high-fat meal, while also enhancing the antioxidative capacity of blood. The blend included black pepper, cinnamon, cloves, garlic powder, ginger, oregano (Mediterranean), paprika, rosemary, and turmeric.

The patients were randomized to 2 test conditions: a control meal consisting of a dessert biscuit, coconut chicken, and cheese bread, or the same meal with the spice blend added. Researchers took postprandial blood samples immediately after the meal and then every 30 minutes until 8 samples were collected. They also measured blood lipids, glucose, and insulin.

The addition of the spice blend to the test meal significantly decreased postprandial insulin area under the curve (AUC) by 21% (P=.004) and triglycerides AUC by 31% (P=.048). Total blood cholesterol, HDL cholesterol, and glucose levels were not affected by meal condition.

EDUCATOR TAKE-HOME POINT FROM KELLI BARNARD, RD, CD, CDE: In recent years, there has been an increased focus on both herbs and spices, especially cinnamon, and their effect on diabetes. At minimum, herbs and spices are a good way for people with diabetes to flavor food without adding calories and without any type of significant adverse effect on blood glucose levels.

The study findings on the use of cinnamon in people with T2D are encouraging. Certainly, most patients with T2D should be able to add cinnamon to their diets with little or no adverse effects while potentially positively impacting their blood lipid levels. The study on the spice blend also looks promising, although it was a small study. More research is needed before further conclusions can be drawn.

SOURCES
West SG, Skulas-Ray AC. Spices and herbs may improve cardiovascular risk factors. Nutrition Today. 2014;49(5):S8-S9.
Khan A, Safdar M, Ali Khan MM, Khattak KN, Anderson RA. Cinnamon improves glucose and lipids of people with type 2 diabetes. Diabetes Care. 2003;26(12):3215–3218.
Markey O, McClean CM, Medlow P, et al. Effect of cinnamon on gastric emptying, arterial stiffness, postprandial lipemia, glycemia, and appetite responses to high-fat breakfast. Cardiovasc Diabetol. 2011;10:78.
Ziegenfuss TN, Hofheins JE, Mendel RW, Landis J, Anderson RA. Effects of a water-soluble cinnamon extract on body composition and features of the metabolic syndrome in pre-diabetic men and women. J Intl Soc Sports Nutr. 2006;3(2):45–53.