THE RELATIONSHIP OF EDUCATIONAL INTERVENTIONS AND RISK FACTORS ASSOCIATED WITH COMPLICATIONS OF TYPE 2 DIABETES IN AFRICAN AMERICANS LAWANNE BUCHANAN UNIVERSITY OF THE DISTRICT OF COLUMBIA NURSING RESEARCH DR. CONNIE WEBSTER

INTRODUCTION According to the CDC, diabetes affects 25.8 million people, over 18.8 million diagnosed and 7.0 million estimated to be undiagnosed. African- Americans are 1.8 times more likely to have diabetes than Caucasians… and also more likely to suffer from amputations, diabetic retinopathy, and kidney failure which are the three most serious complications of diabetes. Type 2 diabetes accounts for about 90% to 95% of all diagnosed cases of diabetes. It usually begins as insulin resistance, a disorder in which the cells do not use insulin properly. The increase in the number of individuals with diabetes has led to a continued rise in the number of individuals affected by its complications. It is often possible for individuals with diabetes to live healthy lives and delay or prevent complications through the management of blood glucose, blood lipids and blood pressure levels through lifestyle changes and medication (Public Health Agency of Canada, 2011).

Numerous studies have been published in the United States on type 2 diabetes in the African American population. Studies that looked at educational interventions, dietary approaches, and preventing risk factors showed varying degrees of success. A randomized study conducted by Samuel-Hodge et al. (2009) used 24 African American churches in central North Carolina to develop and test a culturally appropriate, churched-based intervention to improve type 2 diabetes self-management. The intervention included an 8-month intensive phase, consisting of 1 individual counseling visit, 12 group sessions, monthly phone contacts, and 3 encouragement postcards, followed by a 4-month reinforcement phase including monthly phone contacts and the control group only received a standard educational program using pamphlets by mail.

The findings from this study showed improvement in diabetes knowledge and diabetes related quality of life in the special intervention group along with a decrease in Alc levels and body mass index compared to the minimal intervention group which showed no changes. Further, a quantitative, randomized, controlled, three-group experimental design was carried out by Skelly et al, (2009), investigating the effectiveness of a symptom-focused diabetes intervention in comparison to a focus on skills training for weight management and diet. The intervention study consisted of 120 participants, control group 60 participants, and telephone booster half of the intervention group which was randomly selected.

The symptom-focused intervention involved teaching and counseling modules delivered by a nurse in the participant's home over a series of four 60-minute bimonthly visits. While the skills, or control group, taught included activities such as counting carbohydrates, reading labels, determining portion sizes, finding healthy types of fat, and reducing saturated fat in the diet. Results showed no difference between the intervention and control group but both groups made behavioral changes and improved health outcomes, symptom distress, perceived quality of life, impact of diabetes, and self-care activities also improved significantly for the whole sample, also there was a declined in Alc levels. The study findings suggest that the symptom-focused and the weight and diet approaches can be combined into a revised intervention with the potential for a greater effect on outcomes.

Another study investigated by Clark (2012) revealed that those who used the DASH (dietary approaches to stop hypertension) eating plan saw reductions in fasting blood glucose levels, HbA1c, body weight, and waist circumference compared to those who followed a reduced calorie diet. Clark concluded that the DASH eating plan pattern may reduce cardio-metabolic risk in patients with type 2 diabetes, but longer- term studies are needed.

Lastly, according to Salanitro et al. (2010) hypertension and diabetes are two common diseases. Increasing age, the presence of obesity, and worsening renal function all contribute to an increased likelihood of hypertension in people with diabetes. The findings from their study showed that patients who managed their blood pressure with the use of an anti-hypertensive reduced their risk of neuropathy by 22% compared to those that received a placebo. Control of blood pressure among patients with diabetes can affect important cardiovascular disease (CVD) outcomes because the relationship between blood pressure and risk of CVD events is continuous, consistent, and independent of other risk factors.

AIM & RESEARCH QUESTION This proposed study aims to explore the relationship of an educational intervention on risk factors associated with complications of type 2 diabetes in African Americans. The intervention will focus on nutrition and physical activity. The research question guiding this proposed study is : What impact will an educational intervention focusing on nutrition and physical activity have on African Americans with type 2 diabetes?

STUDY DESIGN This proposed study is a quantitative randomized correlational design. Prior to implementation of this study, approval from appropriate Institutional Review Board and Maryland Research Ethical Committee will be obtained. The sample size will be determined for statistical significance through power analysis. Eligibility criteria include African Americans with a physician diagnosis of type 2 diabetes between years of age. Exclusion criteria include insulin dependence, mobility health problems, and any eating disorders.

Recruitment for participants will occur at local churches and community centers for youth and the elderly. Prior to recruiting participants a meeting will be held with the health ministry and pastor to discuss significance of the study. Consent forms will be signed after participants receive a description of their role in the study, their rights to withdrawal from the study at any time, and confidentially of the information obtained. At the completion of this study, participants who complete the full study will receive a $50 Visa gift card.

OPERATIONAL DEFINITIONS For the purpose of this study: African Americans are people having origins in any of the Black racial groups of Africa. The Black or African American population includes people who self-identify as “Black, African American, or negro or Sub-Saharan African (e.g. Kenyan and Nigerian) or Afro-Caribbean such as Haitian or Jamaican, According to the US Census Bureau (2010). Educational Intervention a 12 week structured learning activity that focuses on: diabetes, nutritional and food exchanges, the impact of food groups on blood glucose levels, and the relationship of physical activity on blood pressure and weight loss. Lifestyle Changes defined as changes in nutritional intake and changes in physical activities within the 12 week intervention based on newly learned behavior. Type 2 diabetes prior physician diagnosis of type 2 diabetes.

PROCESS After recruitment and sample size determination participants will be randomly assigned to either the intervention or control group after IRB approval. The treatment group will receive the 12 week educational activity program and the control group will continue their usual self- care activities. It is hypothesized that the intervention group will show a decrease in blood pressure, cholesterol, weight, and Alc levels after 12 weeks. Data will be statically analyzed after completion of the study to determine if the hypothesis is supported or refuted.

IMPLICATIONS FOR NURSING PRACTICE Nurses are the primary health care providers that develop patient relationships and ongoing interactions; therefore, it is the nurse duty to provide information, support, and encourage. Monitoring, educating, and assessing patients’ for complications associated with diabetes decreases complications, improves the quality of life and health outcomes, increases knowledge about the disease, and the importance of self-care compliance. Nurses should assess patients’ knowledge and ability to control blood glucose through monitoring, medication administration, and dietary and exercise regimens; a clear understanding will help patients’ manage their diabetes effectively and take control.

Basic education on diabetes should be done for all patients and reinforced at every opportunity. The findings from this study will add to stores of evidence, add clinical evidence to support the success of community based diabetes interventions, assist diabetes educators with clinical issues of compliance, and also support the importance of lifestyle changes to control complications associated with diabetes.

REFERENCES Center for Disease Control and Prevention. (2011). What is diabetes? Retrieved from Clark, A. (2012). Use of the dietary approaches to stop hypertension (DASH) eating plan for diabetes management. Diabetes spectrum. 25 (4), Retrieved from Public Health Agency of Canada. (2011). The health impact of diabetes on Canadians. Retrieved from Salanitro, A. & Roumie, C. (2010). Blood pressure management in patients with diabetes. Clinical diabetes, 28 (3), Retrieved from Samuel-Hodge, C. et al. (2009). A randomized trial of a church-based diabetes self-management program for African Americans with type 2 diabetes. The diabetes educator, 35 (3), dio: / Skelly, A. Carlson, J. Leeman, J. Soward, A. & Burns, D. (2009). Controlled trail of nursing interventions to improve health outcomes of older African American women with type 2 diabetes. Nursing Research, 58 (6),

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