Diabetes Learning in Virtual Environments: Testing the Efficacy of Self-Management Training and Support in Virtual Environments (Randomized Controlled Trial Protocol). Addressing the needs of patients with multiple chronic illnesses: the case of diabetes and depression. Design and methods for a pilot randomized clinical trial involving exercise and behavioral activation to treat comorbid type 2 diabetes and major depressive disorder. Impact of Distress Reduction on Behavioral Correlates and A1C in African American Women with Uncontrolled Type 2 Diabetes: Results from EMPOWER. Behavioral health coaching for rural veterans with diabetes and depression: a patient randomized effectiveness implementation trial Integrating depression and chronic disease care among patients with diabetes and/or coronary heart disease: the design of the TEAMcare study. Heart Failure 2012 Improving Confidence for Self Care in Patients with Depression and Chronic Illnesses Effect of case management on glycemic control and behavioral outcomes for chinese people with type 2 diabetes: A 2-year study. An Ecological Perspective on Diabetes Self-care Support, Self-management Behaviors, and Hemoglobin A1C Among Latinos Synopsis of the 2017 U.S. Department of Veterans Affairs/U.S. Department of Defense Clinical Practice Guideline: Management of Type 2 Diabetes Mellitus A self-management approach using self-initiated action plans for symptoms with ongoing nurse support in patients with Chronic Obstructive Pulmonary Disease (COPD) and comorbidities: the COPE-III study protocol. Aerobic physical activity and resistance training: an application of the theory of planned behavior among adults with type 2 diabetes in a random, national sample of Canadians
BACKGROUND Ongoing self-management improves outcomes for those with Type 2 diabetes ( T2D ) ; however , there are many barriers to patients receiving assistance in this from the healthcare system and peers . Findings from our pilot study showed that a virtual diabetes community on the Internet with real-time interaction among peers with T2D- and with healthcare professionals-is feasible and has the potential to influence clinical and psychosocial outcomes . OBJECTIVE The purpose of this article is to present the protocol for the Diabetes Learning in Virtual Environments ( LIVE ) trial . PROTOCOL Diabetes LIVE is a two-group , r and omized controlled trial to compare effects of a virtual environment and traditional Web site on diet and physical activity . Our secondary aims will determine the effects on metabolic outcomes ; effects of level of engagement and social network formation in LIVE on behavioral outcomes ; potential mediating effects of changes in self-efficacy ; and diabetes knowledge , diabetes-related distress , and social support on behavior change and metabolic outcomes . We will enroll 300 subjects at two sites ( Duke University/Raleigh-Durham , NC and New York University/New York , NY ) who have T2D and do not have serious complications or comorbidities . Those r and omly assigned to the intervention group have access to the LIVE site where they can find information , synchronous classes with diabetes educators , and peer support to enhance self-management . Those in the control group have access to the same informational and educational content in a traditional asynchronous Web format . Measures of self-management , clinical outcomes , and psychosocial outcomes are assessed at baseline and 3 , 6 , 12 , and 18 months . DISCUSSION Should LIVE prove effective in improved self-management of diabetes , similar interventions could be applied to other prevalent chronic diseases . Innovative programs such as LIVE have potential for improving healthcare access in an easily disseminated alternative model of care that potentially improves the reach of self-management training and support OBJECTIVES To review the literature on comorbid depression and diabetes ( DM/D ) and present a conceptual framework for integrating depression management with diabetes care in a managed care environment . STUDY DESIGN Literature review . RESULTS Depression affects diabetes management by 1 ) directly affecting patients ' health-related quality of life , 2 ) reducing physical activity levels , 3 ) limiting adherence to self-care regimens , and 4 ) impairing patients ' ability to communicate effectively with clinicians . Small r and omized trials suggest that both antidepressant medication and cognitive behavioral therapies ( CBTs ) or related approaches may improve not only DM/D patients ' depressive symptoms , but their physical health as well . CONCLUSIONS An effective DM/D management strategy should include the following elements : 1 ) systematic identification of DM/D patients and quality -of-care review s , 2 ) proactive patient monitoring between outpatient encounters , 3 ) intensive efforts to coordinate treatment across providers , 4 ) increased access to CBT or related therapies addressing patients ' depressive symptoms and diabetes self care , and 5 ) an emphasis on promoting physical activity to address both depressive symptoms and physiologic dysregulation . The conceptual framework developed for the care of DM/D patients offers general insights into the management of patients with multiple chronic medical BACKGROUND : The comorbidity of type 2 diabetes mellitus ( T2DM ) and depression is associated with poor glycemic control .  Exercise has been shown to improve mood and glycemic control , but individuals with comorbid T2DM and depression are disproportionately sedentary compared to the general population and report more difficulty with exercise . Behavioral activation , an evidence -based depression psychotherapy , was design ed to help people with depression make gradual behavior changes , and may be helpful to build exercise adherence in sedentary population s. This pilot r and omized clinical trial will test the feasibility of a group exercise program enhanced with behavioral activation strategies among women with comorbid T2DM and depression . METHODS / DESIGN : Sedentary women with inadequately controlled T2DM and depression ( N=60 ) will be r and omly assigned to one of two conditions : exercise or usual care .  Participants r and omized to the exercise condition will attend 38 behavioral activation-enhanced group exercise classes over 24 weeks in addition to usual care . Participants r and omized to the  usual care condition will receive depression treatment referrals and print information on diabetes management via diet and physical activity . Assessment s will occur at baseline and 3- , 6- , and 9-months following r and omization . The goals of this pilot study are to demonstrate feasibility and intervention acceptability , estimate the re sources and costs required to deliver the intervention and to estimate the st and ard deviation of continuous outcomes ( e.g. , depressive symptoms and glycosylated hemoglobin ) in preparation for a fully-powered r and omized clinical trial . DISCUSSION : A novel intervention that combines exercise and behavioral activation strategies could potentially improve glycemic control and mood in women with comorbid type 2 diabetes and depression . TRIAL REGISTRATION : NCT01024790 OBJECTIVE Symptoms of emotional distress related to diabetes have been associated with inadequate self-care behaviors , medication non-adherence , and poor glycemic control that may predispose patients to premature death . African American women , in whom diabetes is more common and social support is often insufficient , may be at particularly high risk . The objective of this study was to examine the impact of lowering diabetes-related emotional distress on glycemic control and associated behavioral correlates in rural African American women with uncontrolled type 2 diabetes ( T2D ) . DESIGN Post-hoc analysis of prospect i ve , r and omized , controlled trial . SETTING Rural communities in the southeastern United States . PATIENTS 129 rural middle-aged African American women with uncontrolled type 2 diabetes (T2D)(A1C ≥ 7.0 ) . PRIMARY INDEPENDENT VARIABLE Diabetes-related distress . MAIN OUTCOME MEASURES Changes from baseline to 12-month follow-up in diabetes-related distress , and associated changes in medication adherence , self-care activities , self-efficacy , and glycemic control ( A1C ) . RESULTS Patients with a reduction in diabetes-related distress ( n=79 ) had significantly greater improvement in A1C , medication adherence , self-care activities , and self-efficacy compared with those in whom diabetes distress worsened or was unchanged ( n=50 ) . Changes in distress were also significantly and inversely correlated with improvements in medication adherence , self-care activities , and self-efficacy . CONCLUSIONS Among rural African American women , reductions in diabetes-related distress may be associated with lower A1C and improvements in self-efficacy , self-care behaviors , and medication adherence Background Depression and diabetes cause significant burden for patients and the healthcare system and , when co-occurring , result in poorer self-care behaviors and worse glycemic control than for either condition alone . However , the clinical management of these comorbid conditions is complicated by a host of patient , provider , and system-level barriers that are especially problematic for patients in rural locations . Patient-centered medical homes provide an opportunity to integrate mental and physical health care to address the multifaceted needs of complex comorbid conditions . Presently , there is a need to not only develop robust clinical interventions for complex medically ill patients but also to find feasible ways to embed these interventions into the frontlines of existing primary care practice s. Methods / design This r and omized controlled trial uses a hybrid effectiveness-implementation design to evaluate the Healthy Outcomes through Patient Empowerment ( HOPE ) intervention , which seeks to simultaneously address diabetes and depression for rural veterans in Southeast Texas . A total of 242 Veterans with uncontrolled diabetes and comorbid symptoms of depression will be recruited and r and omized to either the HOPE intervention or to a usual-care arm . Participants will be evaluated on a host of diabetes and depression-related measures at baseline and 6- and 12-month follow-up . The trial has two primary goals : 1 ) to examine the effectiveness of the intervention on both physical ( diabetes ) and emotional health ( depression ) outcomes and 2 ) to simultaneously pilot test a multifaceted implementation strategy design ed to increase fidelity and utilization of the intervention by coaches interfacing within the primary care setting . Discussion This ongoing blended effectiveness-implementation design holds the potential to advance the science and practice of caring for complex medically ill patients within the constraints of a busy patient-centered medical home . Trial registration Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression : NCT01572389 Diabetes and coronary heart disease ( CHD ) are two of the most prevalent medical illnesses in the US population and comorbid depression occurs in up to 20 % of these patients . Guidelines for management of diabetes and CHD overlap for healthy lifestyle and disease-control recommendations . However , the majority of patients with these medical illnesses have been shown to have inadequate control of key risk factors such as blood pressure , LDL cholesterol , or blood sugar . Comorbid depression has been shown to adversely affect self-care of diabetes and CHD , and is associated with an increased risk of complications and mortality . Interventions that have improved quality and outcomes of depression care alone in patients with diabetes and CHD have not demonstrated benefits in self-care , improved disease control or morbidity and mortality . This paper describes the design and development of a new biopsychosocial intervention ( TEAMcare ) aim ed at improving both medical disease control and depression in patients with poor control of diabetes and /or CHD who met the criteria for comorbid depression . A team approach is used with a nurse interventionist who receives weekly psychiatric and primary care physician caseload supervision in order to enhance treatment by the primary care physician . This intervention is being tested in an NIMH-funded r and omized controlled trial in a large integrated health plan Heart failure has been named “ the growing epidemic . ” Over the last decade , the annual number of heart failure hospitalizations has almost doubled with approximately 50 % of patients being rehospitalized within 6 months of discharge [ 1 ] . The complex array of physiologic , psychological , social , and health care delivery issues makes it a challenging chronic disease to manage . Underst and ing the epidemiology and pathophysiology of the syndrome , identifying the predictors and their strength of association with outcomes , and using the available diagnostic modalities cost-effectively are essential in order to devise effective prevention interventions and implement novel therapeutic approaches to curb this epidemic . In this special issue , we have invited a few papers that address such issues and explain why despite the emergence of novel therapeutic approaches , that promise life prolongation and hospital length reduction , this patient population will still be needing rehospitalization and will often have a poor prognosis . This special issue is the extension of an effort that was initiated in 2011 with the first heart-failure-focused issue [ 2 ] . In the pathophysiology section , S. M. R. Kazemi-Bajestani et al. describe the opportunities and challenges of targeting the angiotensin converting enzyme 2 (ACE2)/Ang II/Ang1–7 and apelin/APJ pathways as novel therapeutic modalities in heart failure [ 3 ] . ACE2 and the apelin/APJ are two important peptide systems which exert diverse effects on the cardiovascular system . Dysregulation of such systems may be involved in the predisposition to cardiovascular diseases whereas enhancing their action may have important therapeutic effects . In the same section , D. Lindner et al. provide a comprehensive review on the protective function of signal transducer and activator of transcription 3 ( STAT3 ) in CVB3-induced myocarditis [ 4 ] . The transcription factor ( STAT3 ) is an important mediator of the inflammatory process , and in this original research the investigators examine the role of STAT3 in viral myocarditis and its possible role in the development to dilated cardiomyopathy . Considering the high mortality rate and the availability of life-saving therapies like transplantation and left ventricular assist devices , accurate prognosis determination in HF is clinical ly important . Taking into account the mediocre performance of current established prediction models , such as the Seattle Heart Failure Model [ 5–7 ] , the work by H. Fukuta et al. [ 8 ] on the prognostic value of left ventricular diastolic dysfunction in patients undergoing cardiac catheterization for coronary artery disease sheds light on this extremely important topic . A shared underst and ing of medical conditions between patients and their health care providers has been shown to improve self-care and outcomes [ 9 ] . In the comorbidity section , we demonstrate how certain comorbid conditions may affect patients ' decision-making capacity and interfere with their ability to comply with treatment requirements , recognize and self-manage disease worsening symptoms . Among others , cognitive impairment is increasingly recognized as a common adverse consequence of HF , whereby phenomena such as microembolism , chronic or intermittent cerebral hypoperfusion , and /or impaired cerebral vessel reactivity may lead to cerebral hypoxia and ischemic brain damage . Cognitive decline in HF is characterized by deficits in one or more cognition domains , including attention , memory , executive function , and psychomotor speed . E. Dardiotis et al. [ 10 ] , in a comprehensive review , underscore the importance for healthcare professionals to become familiar with assessment of cognitive performance using st and ardized screening instruments in their routine evaluations of HF patients . Another comorbidity gaining increasing attention in HF patients is depression . There are several pathophysiological mechanisms as well as behavioral processes linking depression and HF . Equally important is screening for depression and there are several valid and reliable screening tools to identify patients at greater risk . Consultation should be provided by a multidisciplinary team , consisting of cardiologists , psychiatrists , and hospital or community nurses so as to carefully plan , execute , and evaluate medical intervention and implement lifestyle changes . D. Mastrogiannis et al. [ 11 ] systematic ally review the existing knowledge regarding current definitions , prognostic implication s , pathophysiological mechanisms , and current and future treatment options in patients with depression and HF . Evidence from the literature supports the possibility of a pathophysiological relationship between cognitive impairment , depression , and HF . Yet , very few studies have sought to investigate this relationship . The paper by Z. N. Sohani and Z. Samaan review s current literature on the association between depression and cognitive impairment  in persons with HF and explores possible mechanisms explaining this complex triad [ 12 ] . Heart failure through neurohumoral activation induces alterations of cardiac metabolism , such as insulin resistance , and promotes increased utilization of noncarbohydrate substrates for energy production [ 13 , 14 ] . Fasting blood ketone bodies as well as fat oxidation have been shown to be increased in this patient population . The result is depletion of myocardial ATP , phosphocreatine , and creatine kinase , leading to decreased efficiency of mechanical work . A direct approach to manipulate cardiac energy metabolism consists in modifying substrate utilization by the failing heart . Trimetazidine , perhexiline , and ranolazine directly inhibit fatty acid oxidation and have been used to increase the ischemic threshold in patients with effort angina . Current research is supporting the concept that shifting the energy substrate preference away from fatty acid metabolism and toward glucose metabolism could be an effective adjunctive treatment in patients with HF . These agents have been shown to improve both glucose metabolism and left ventricular function in diabetic patients with left ventricular dysfunction . In the pharmacotherapy section , we provide a systematic review , in which N. Signoretta et al. [ 15 ] discuss the beneficial therapeutic effects of modulation of cardiac metabolic substrates utilization in patients with HF . In the advanced heart failure section , we provide a thorough review on the current status of mechanical circulatory support in patients with advanced HF . Management of the advanced HF patients with the numerous comorbidities [ 16 , 17 ] requires a significant amount of health care re sources and is becoming a major public health problem . As therapeutical strategies for HF have been refined , the number of patients suffering from the end-stage disease has exp and ed dramatically . Although heart transplantation still represents the gold st and ard therapeutical approach , the shortage of donors universally has made the implantation of mechanical circulatory support devices a well-established management for this disease . The systematic review by K. Spiliopoulos et al. [ 18 ] , outlines the current status of mechanical circulatory support in this patient population . In the chronic follow-up section , we deal with telemonitoring , a novel diagnostic modality that has been suggested to be beneficial for HF patients , targeting optimization of their chronic followup . Telemonitoring is viewed as a means of recording physiological data ( such as body weight , heart rate , arterial blood pressure electrocardiogram recordings , and other data ) by portable devices and transmitting these data remotely ( via a telephone line , a mobile phone , or a computer ) to a server where they can be stored , review ed , and analyzed by the research team . In a systematic review of all r and omized clinical trials evaluating telemonitoring in chronic HF , G. Giamouzis et al. [ 19 ] assess whether telemonitoring provides any substantial benefit in this patient population . We hope that the readers of the journal will find the topics as interesting and important as we did . Gregory Giamouzis George Giannakoulas Javed Butler John A. Elefteriades Carsten Tschope Filippos The aim of this study was to examine whether patients who received a multicondition collaborative care intervention for chronic illnesses and depression had greater improvement in self-care knowledge and efficacy , and whether greater knowledge and self-efficacy was positively associated with improved target outcomes . A r and omized controlled trial with 214 patients with comorbid depression and poorly controlled diabetes and /or coronary heart disease tested a 12-month team-based intervention that combined self-management support and collaborative care management . At 6 and 12 month outcomes the intervention group showed significant improvements over the usual care group in confidence in ability to follow through with medical regimens important to managing their conditions and to maintain lifestyle changes even during times of stress . Improvements in self care-efficacy were significantly related to improvements in depression , and early improvements in confidence to maintain lifestyle changes even during times of stress explained part of the observed subsequent improvements in depression OBJECTIVE To examine the effect of case management on glycemic control and behavioral outcomes in adults with Type 2 diabetes in China . METHODS Participants were r and omly assigned to a 1-year case management ( CM ) group ( n=60 ) or control group ( n=60 ) . Monthly case management visits included identifying individuals ' diabetes-related problems , setting goals , planning self-care , and evaluating progress . During a 1-year follow-up , all participants attended visits every 3 months without intervention . RESULTS In the CM vs. the control group , HbA1c was reduced at 6 months compared to baseline ( P=0.034 ) , with trends at 12 and 24 months , and empowerment ability improved ( P<0.05 ) . Also in the CM vs. controls , total self-care behaviors , the frequency of exercise , blood glucose testing , and foot care were higher ( P<0.001 ) at 12 months , and the percentage of individuals with HbA1c ≤7.0 % was higher ( P=0.035 ) at 24 months . CONCLUSION The case management intervention in China was effective at 6 months and , based on trends in HbA1c at 12 and 24 months and results for behavioral outcomes , the intervention shows promise and warrants more research . PRACTICE IMPLICATION S A case management approach can enhance behavior change and glycemic control in Chinese with diabetes Purpose The purpose of this study was to examine the role of self , interpersonal ( ie , family/friend ) , and organizational ( ie , health care ) support in performing diabetes-related self-management behaviors and hemoglobin A1C ( A1C ) levels among rural Latinos with type 2 diabetes . Methods Cross-sectional data from baseline interviews and medical records were used from a r and omized controlled trial conducted in rural Southern California involving a clinic sample of Latinos with type 2 diabetes ( N = 317 ) .  Self-management behaviors included  fruit and vegetable intake , fat intake , physical activity , glucose monitoring , daily examination of feet , and medication adherence . Multivariate linear and logistic regression models were used to assess the relationships of sources of support with self-management behaviors and A1C . Results Higher levels of self-support were significantly associated with eating fruits and vegetables most days/week , eating high-fat foods few days/week , engaging in physical activity most days/week , daily feet examinations , and self-reported medication adherence . Self-support was also related to A1C . Family/friend support was significantly associated with eating fruits and vegetables and engaging in physical activity most days/week . Health care support was significantly associated with consuming fats most days/week . Conclusions Health care practitioners and future interventions should focus on improving individuals ’ diabetes management behaviors , with the ultimate goal of promoting glycemic control . Eliciting family/friend support should be encouraged to promote fruit and vegetable consumption and physical activity Diabetes is the leading cause of major complications , such as end-stage renal disease and lower extremity amputations , and is a significant contributor to ischemic heart disease , stroke , peripheral vascular disease , and vision loss ( 1 ) . There has been increasing acceptance of the importance of individualizing glycemic management and assessment of risk for adverse events , especially hypoglycemia ( 26 ) . This is of great importance for all patients , especially older adults ( aged 65 years ) with comorbid conditions . In 2013 , 12.0 million older adults in the United States had diabetes , comprising 40 % of the 30.2 million persons with the disease ( 7 ) . Older adults account for an estimated 60 % to 70 % of the U.S. Department of Veterans Affairs ( VA ) and U.S. Department of Defense ( DoD ) diabetic population ( largely retirees ) ( VA/DoD. Unpublished data ) . These considerations make safe and effective diabetes management a policy priority for health care providers ( physicians , nurses , dietitians , and pharmacists ) and policymakers in both the VA and the DoD. The 2017 VA/DoD Clinical Practice Guideline ( CPG ) for the Management of Type 2 Diabetes Mellitus in Primary Care offers health care providers an evidence -based framework to evaluate , treat , and manage persons with type 2 diabetes  mellitus in the context of their individual needs and preferences ( 8) . The current article is a summary of key CPG recommendations , which was developed with multiple stakeholders to ensure representation by a broad spectrum of clinicians . It provides practice recommendations for the care of patients with diabetes , with an emphasis on shared decision making . Guideline Development and Review Process These recommendations were developed using methods established by the VA/DoD Evidence -Based Practice Work Group ( EBPWG ) ( 9 ) , which are aligned with st and ards for trustworthy guidelines ( 10 ) . The EBPWG and the U.S. Army Medical Comm and selected guideline panel cochairs ( 1 each from the VA and the DoD ) . The cochairs then selected a multidisciplinary panel of practicing clinician stakeholders , including primary care physicians ( family and internal medicine ) , endocrinologists , medical nutritionists , pharmacists , diabetes educators , and nurse practitioners . At the start of the CPG development process and at other key points throughout , all members were required to su bmi t disclosure statements for potential conflicts of interest in the previous 24 months . Verbal affirmations of no conflicts were used during meetings throughout the development process . The project team was also subject to r and om Web-based surveillance ( for example , ProPublica ) . The VA/DoD contracted with The Lewin Group , a third party with expertise in clinical practice guideline development , to facilitate meetings . The guideline panel , in collaboration with the ECRI Institute , developed 9 key questions using the PICOTS ( population , intervention , comparator , outcomes , timing of outcomes measurement , and setting ) format . A systematic search of the peer- review ed literature from January 2009 through March 2016 was conducted to find evidence relevant to the key questions that focused on r and omized trials , systematic review s , and meta-analyses of fair or better quality . One key question was up date d through 14 June 2016 . The search methods and results are detailed in the full guideline ( 8) . The guideline panel rated recommendations by using the GRADE ( Grading of Recommendations Assessment , Development and Evaluation ) method ( 11 ) . The guideline panel focused on developing new and up date d recommendations using the evidence review for the key questions . The panel also considered , without a complete review of the relevant evidence , the current applicability of recommendations that were included in the 2010 CPG . As part of the development process , a patient focus group was also convened to better underst and the perspectives of patients receiving diabetes treatment in the VA and the DoD. Five patients were included , consistent with the requirements of the federal Paperwork Reduction Act . All patients had type 2 diabetes and were veterans receiving care in the VA . The focus group explored knowledge of treatment options , views on the delivery of care , patients ' needs and preferences , and the effect of diabetes on their lives . Important concepts that emerged from the focus group were shared with the panel and informed guideline development . It was acknowledged that this convenience sample may not be representative of all VA and DoD patients receiving treatment for type 2 diabetes . The draft guideline was sent to more than 15 expert review ers inside and outside the federal sector . Comments were review ed and , where appropriate , were incorporated into the final guideline based on panel consensus . The VA/DoD EBPWG approved the final document on 3 April 2017 and released it on 17 April 2017 . Recommendations are presented in the Table , and an algorithm for establishing a personalized glycemic goal and treatment plan is presented in the Figure . Key recommendations are review ed in this article . Table . Summary of Recommendations From the 2017 VA/DoD CPG on the Management of Type 2 Diabetes Mellitus Figure . Algorithmic approach to evaluating glycemic control risk factors , setting a personalized glycemic control target range , providing self-management ( including lifestyle and nutrition ) education , and initiating or reevaluating medication therapy . Recommendations Provide Patient-Centered Care and Incorporate Shared Decision Making The CPG strongly encourages clinicians to incorporate shared decision making and partner with their patients . Shared decision making is the process by which the patient and family , in conjunction with the care provider , reach an agreement about a plan of care and treatment . Key principles include readiness of the patient and family , tools with underst and able information about the benefits and harms of all options , and strategies to identify and incorporate patient preferences . Patients can not effectively participate in care and shared decision making unless they underst and diabetes and how they can be involved in planning and carrying out the jointly developed care plan . Shared decision making reinforces a trusted therapeutic relationship and increases patient satisfaction and treatment buy-in with regard to the methods used to reach a particular goal or treatment plan ( 1214 ) . It should be used not only for patients with stable glycemic control but also to assist those who are not able or willing to make lifestyle changes and decisions that affect their diabetes at any time during the course of treatment . At a minimum , shared decision making should be included at the time of diagnosis , during difficulties with management , and at times of transition or development of complications ( 14 ) . Benefits include greater knowledge of medications ( 13 ) and underst and ing of risks ( 14 ) . In addition , patient-centered care and shared decision making together may decrease patient anxiety , increase trust in clinicians ( 15 ) , and improve treatment adherence ( 16 ) . Family involvement should be considered if appropriate , especially in older adults ( 17 ) . Patient information should be culturally appropriate ; underst and able and actionable by people with limited literacy skills ; and accessible to those with physical , sensory , or learning needs ( 18 ) . As part of the patient-centered care approach to diabetes management , clinicians should explore with the patient the outcomes of previous opportunities for shared decision making , their ability to self-manage , prior efforts to change health behaviors , past treatment experiences ( including reasons for discontinuing treatment ) , and relevant clinical outcomes . In actively sharing decisions , they should involve the patient in prioritizing problems to be addressed and setting specific goals regardless of the setting or level of care . Assess Patient Characteristics and Nonglycemic Factors When Interpreting Results of Hemoglobin A1c , Fructosamine , and Other Glycemic Biomarker Testing Many factors affect measurement of hemoglobin A1c ( HbA1c ) besides the level of glycemia ( 19 ) . Because HbA1c level depends on the duration of erythrocyte exposure to glucose , conditions that alter erythrocyte life span affect the measured level of HbA1c ( 20 , 21 ) . Iron deficiency anemia , which prolongs erythrocyte life span and exposes the cell to glucose for a longer period , is associated with falsely elevated HbA1c levels ( 22 ) . In contrast , conditions that shorten erythrocyte life span ( such as hemolytic anemia ) may result in falsely low HbA1c levels . Various other conditions , such as chronic kidney disease , may alter HbA1c measurement . Hemoglobin variants can result in falsely elevated or falsely lowered HbA1c levels , depending on the assay used ( 2325 ) . In addition , oral hypoglycemic agents ( metformin or sulfonylureas ) may alter the relationship between blood glucose and HbA1c levels , although the clinical significance is unclear ( 26 ) . There are also racial/ethnic differences in HbA1c levels for a given level of glycemia . A previous study found that African Americans with prediabetes ( 27 ) had HbA1c values that were 0.4 % higher than among white persons ; those who were within 3 years of diagnosis ( 28 ) also had higher HbA1c values than white persons for any measure of glycemia . This difference can not be explained by measured differences in glycemia , clinical factors known to affect HbA1c measurement , or sociodemographic factors ( 27 , 28 ) . Therefore , it is recommended that a new diagnosis of diabetes be based on a confirmatory fasting blood glucose level of at least 7.0 mmol/L ( 126 mg/dL ) if the initial HbA1c value is 6.5 % to 6.9 % . How and where the HbA1c level is measured can also affect results because of intralaboratory variation ( variation in test accuracy and precision ) and interlaboratory variation ( variation related to use of different test methods ) . A single HbA1c measurement , even from a BACKGROUND Chronic Obstructive Pulmonary Disease ( COPD ) frequently coexists with other diseases . Whereas COPD action plans are currently part of usual care , they are less suitable and potentially unsafe for use in the presence of comorbidities . This study evaluates whether an innovative treatment approach directed towards COPD and frequently existing comorbidities can reduce COPD exacerbation days . We hypothesise that this approach , which combines self-initiated action plans and nurse support , will accelerate proper treatment actions and lead to better control of deteriorating symptoms . METHODS In this multicenter r and omised controlled trial we aim to include 300 patients with COPD ( GOLD II-IV ) , and with at least one comorbidity ( cardiovascular disease , diabetes , anxiety and /or depression ) . Patients will be recruited from hospitals in the Netherl and s ( n = 150 ) and Australia ( n = 150 ) and will be assigned to an  intervention or control group .  All patients will learn to complete daily symptom diaries for 12-months . Intervention group patients will participate in self-management training sessions to learn the use of individualised action plans for COPD and comorbidities , linked to the diary . The primary outcome is the number of COPD exacerbation days . Secondary outcomes include hospitalisations , quality of life , self-efficacy , adherence , patient 's satisfaction and confidence , health care use and cost data . ANALYSES Intention-to-treat analyses ( r and om effect negative binomial regression and r and om effect mixed models ) and cost-effectiveness analyses will be performed . DISCUSSION Prudence should be employed before extrapolating the use of COPD specific action plans in patients with comorbidities . This study evaluates the efficacy of tailored action plans for both COPD and common comorbidities Background Aerobic physical activity ( PA ) and resistance training are paramount in the treatment and management of type 2 diabetes ( T2D ) , but few studies have examined the determinants of both types of exercise in the same sample . Objective The primary purpose was to investigate the utility of the Theory of Planned Behavior ( TPB ) in explaining aerobic PA and resistance training in a population sample of T2D adults . Methods A total of 244 individuals were recruited through a r and om national sample which was created by generating a r and om list of household phone numbers . The list was proportionate to the actual number of household telephone numbers for each Canadian province ( with the exception of Quebec ) . These individuals completed self-report TPB constructs of attitude , subjective norm , perceived behavioral control and intention , and a 3-month follow-up that assessed aerobic PA and resistance training . Results TPB explained 10 % and 8 % of the variance respectively for aerobic PA  and resistance training ;  and accounted for 39 % and 45 % of the variance respectively for aerobic PA and resistance training intentions . Conclusion These results may guide the development of appropriate PA interventions for aerobic PA and resistance training based on the TPB
The most common concordant comorbidity was hypertension while depression was the most common discordant condition .
Adherence to medications was the most frequent diabetes self-care behavior reported and tended to be higher among concordant comorbidities .
The findings showed mixed results concerning the effect of some concordant comorbidities such as hypertension , hyperlipidemia , retinopathy , and heart failure on diabetes self-care behaviors .
But , there is agreement across studies that diabetes-discordant comorbidities have a more detrimental effect on self-care behaviors .
Conclusions : Concordant comorbidities may improve diabetes self-care , but the evidence is inconclusive .
Background : Most patients with Type 2 diabetes ( T2D ) have high number of comorbid chronic conditions that can affect their self-care abilities .
Guidelines for diabetes self-care behaviors are disease specific with little attention given to managing T2D with other comorbidities .
Identifying comorbidities that either improve or potentially diminish the individual 's capacity to perform effective self-care behaviors is essential to enhance clinical outcomes .
One such framework conceptualizes comorbidities as concordant or discordant with diabetes pathophysiological pathways and care goals .
Objective : The purpose of this systematic review was to examine the role of diabetes-concordant and discordant chronic conditions on the performance of self-care behaviors in adults with T2D .