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Supplemental Material for Yarning about pain: Evaluating communication training for health professionals at persistent pain services in Queensland, Australia by Christina M Bernardes, Stuart Ekberg, Stephen Birch, Andrew Claus, Matthew Bryant, Renata Meuter, Jermaine Isua, Paul Gray, Joseph P Kluver, Eva Malacova, Corey Jones, Kushla Houkamau, Marayah Taylor, Ivan Lin and Gregory Pratt in British Journal of Pain

Medication nonadherence and suboptimal glycemia are common among adults with T2D, particularly minorities and people with low SES. Text messaging is used ubiquitously without disparities. REACH (Rapid Education/Encouragement And Communications for Health) is a theory-based text messaging intervention that iteratively personalizes content to participants’ diabetes medicines and barriers to adherence. All participants have completed 6-month follow-up of a 15-month pragmatic RCT evaluating REACH. Adults (N=512) with T2D were recruited from community health centers and medical center primary care clinics. All participants received educational newsletters, completed A1c tests (venipuncture or mail-in kit) and surveys every 3 months; those assigned to REACH received daily texts. Surveys included a barriers assessment and the Summary of Diabetes Self-Care Activities medications subscale. Regression models examined change in barriers, adherence, and A1c (adjusted for test type) relative to controls. Participants were predominantly non-white (53%) and low SES (56% annual incomes REACH engaged a diverse and high-risk group with daily texts, reduced barriers to adherence, improved adherence, and substantively improved A1c among patients with elevated glycemia at baseline. Disclosure L.S. Mayberry: None. L.A. Nelson: None. R.A. Greevy: None. K. Wallston: None. S. Kripalani: None. C.Y. Osborn: Employee; Self; One Drop. E.M. Bergner: None. L. LeStourgeon: None. S.E. Williamson: None. A.J. Spieker: None. C. Gentry: None. A.W. Brown: None. B.P. Gregory: None. S. Acuff: None. T. Elasy: None. Funding National Institutes of Health (R01DK100694)

Portion-size estimation is an important component of weight management. Literacy and numeracy skills may be important for accurate portion-size estimation. It was hypothesized that low literacy and numeracy would be associated with decreased accuracy in portion estimation.A cross-sectional study of primary care patients was performed from July 2006 to August 2007; analyses were performed from January 2008 to October 2008. Literacy and numeracy were assessed with validated measures (the Rapid Estimate of Adult Literacy in Medicine and the Wide Range Achievement Test, third edition). For three solid-food items and one liquid item, participants were asked to serve both a single serving and a specified weight or volume amount representing a single serving. Portion-size estimation was considered accurate if it fell within +/-25% of a single standard serving.Of 164 participants, 71% were women, 64% were white, and mean (SD) BMI was 30.6 (8.3) kg/m(2). While 91% reported completing high school, 24% had9th-grade literacy skills and 67% had9th-grade numeracy skills. When all items were combined, 65% of participants were accurate when asked to serve a single serving, and 62% were accurate when asked to serve a specified amount. In unadjusted analyses, both literacy and numeracy were associated with inaccurate estimation. In multivariate analyses, only lower literacy was associated with inaccuracy in serving a single serving (OR=2.54; 95% CI=1.11, 5.81).In this study, many participants had poor portion-size estimation skills. Lower literacy skills were associated with less accuracy when participants were asked to serve a single serving. Opportunities may exist to improve portion-size estimation by addressing literacy.

Purpose Diabetes self-management education is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care. Methods To address this potential barrier to successful diabetes teaching and counseling, the authors developed the Diabetes Literacy and Numeracy Education Toolkit (DLNET). Conclusion The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and used by all members of the multidisciplinary diabetes care team. The material's content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. Although designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Nurses increasingly use telephonic assessment and counseling to manage clients with a variety of chronic illnesses. This article describes a study designed to assess a group of telephonic nurse disease managers' teaching and adherence promotion skills during actual patient interactions. Nurse care managers showed improvements after training in four main counseling skills categories, with a decrease in time spent.

Objective: The primary treatment for adults with risk factors for metabolic syndrome is lifestyle change, though adoption of traditional lifestyle programs is often limited. This pilot study tested the feasibility of conducting a randomized clinical trial comparing a novel targeted yoga program coupled to lifestyle education versus lifestyle education alone among adults with metabolic syndrome risk factors. Design and methods: Patients from primary care clinic were pre-screened electronically and further screened for metabolic syndrome. Consented participants were randomized to either a 12-week yoga program with lifestyle education or lifestyle education alone. Participants in the yoga arm received weekly 30 to 45 min of face-to-face yoga instruction, followed by 30 to 45 min of lifestyle education, and written instructions for home yoga practice and lifestyle changes. The lifestyle education was based on (EDU) the Group Lifestyle Balance Program that is adapted from the Diabetes Prevention Program. Participants in EDU only group received a weekly standardized curriculum matched in attention and time to the yoga with EDU arm. The primary outcome was to assess the feasibility of conducting a randomized trial by assessing recruitment rate and adherence to the protocol. Secondly, we aimed to collect preliminary data on changes in cardiometabolic factors including insulin resistance (IR) as measured by Homeostatic Model Assessment of Insulin Resistance (HOMA-IR), blood pressure, fasting lipids, body weight and composition, habitual physical activity, and dietary intake from baseline to 12-week intervention. Results: We identified 238 adults at high risk for metabolic syndrome medical records review utilizing an electronic recruitment tool. Among eligible individuals, 67 (28%) were enrolled and 56 (84%) completed the 12-week assessment. The median attendance was 8 of 12 sessions for the yoga with EDU and 9 of 12 sessions for the EDU arm. Self-reported median frequency of home practice was 2.8 (IQR 1.4) times per week among the yoga with EDU group and 3.3 (IQR 1.1) times per week among the EDU group. Participants in the yoga with EDU arm versus EDU alone demonstrated a non-significant decrease in HOMA-IR (-0.21 (S.D. 0.99) versus 0.02 (S.D. 0.74), p=0.29). Both groups had similar changes in blood pressure, lipids, weight, body composition, energy intake, and physical activity from baseline to 12 weeks. Conclusions: It is feasible to implement yoga combined with EDU and conduct a prospective trial to assess effectiveness on cardiometabolic risk reduction in adults with metabolic syndrome.

Background Comprehension of food labels can be important for patients, including those with chronic illness, to help follow dietary recommendations. Patient comprehension of food labels was examined, along with the relationship of comprehension to their underlying literacy and numeracy skills. Methods From June 2004 to April 2005, a cross-sectional study of 200 primary care patients was performed. A 24-item measure of food label comprehension was administered. Literacy was measured with the Rapid Estimate of Adult Literacy in Medicine (REALM), and numeracy with the Wide Range Achievement Test, third edition (WRAT-3). Results Most patients (89%) reported using food labels. While 75% of patients reported at least a high school education and 77% had 9th-grade literacy skills, only 37% had 9th-grade math skills. On average, patients answered 69% (standard deviation, 21%) of the food-label questions correctly. Common reasons for incorrect responses included misapplication of the serving size, confusion due to extraneous material on the food label, and incorrect calculations. For example, only 37% of patients could calculate the number of carbohydrates consumed from a 20-ounce bottle of soda that contained 2.5 servings. Higher comprehension of food labels was significantly correlated (all p values were less than 0.001) with higher income (rho=0.39), education (rho=0.49), literacy (rho=0.52), and numeracy (rho=0.67). Conclusions Patients demonstrated deficits in understanding nutrition labels. Poor label comprehension was highly correlated with low-level literacy and numeracy skills, but even patients with higher literacy could have difficulties interpreting labels. Providers need to consider patients' literacy and numeracy when providing dietary recommendations. Opportunities may exist for the U.S. Food and Drug Administration to promote changes to make food labels more comprehensible.

To compare practice patterns of the American College of Obstetrician and Gynecologists (ACOG) Fellows for the diagnosis and treatment of gestational diabetes mellitus (GDM) and type 1 diabetes mellitus with current ACOG recommendations and prior published series.We sent a questionnaire to 1,398 practicing ACOG Fellows and Junior Fellows, 398 of whom comprise the Collaborative Ambulatory Research Network. Responses were evaluated by age and sex to assess differences in practice.Younger physicians were more likely to treat pregnant patients. Ninety-six percent of obstetricians routinely screen for GDM, nearly all by using a 50-g glucose 1-hour oral test. Nearly 60% of respondents establish the diagnosis of GDM using the National Diabetes Data Group criteria. In addition to medical nutrition therapy, almost 75% of respondents recommend exercise for patients with GDM. Approximately 60% of respondents reported that all of their patients with GDM self-monitor their blood glucose. When medical nutrition therapy is ineffective for their patients with GDM, 82% of respondents initially prescribe insulin, whereas 13% begin with glyburide. Nearly 75% of respondents routinely perform a postpartum evaluation of glucose tolerance in the patient with GDM. Most obstetricians manage the glucose control of their patients with type 1 diabetes mellitus themselves.Practicing obstetrician-gynecologists have incorporated recent recommendations into their practice patterns for both GDM and type 1 diabetes mellitus, including patients' self-monitoring of blood glucose, exercise, and postpartum testing in GDM.III

Self-efficacy is often studied as a predictor of professional practice behaviors or as an outcome of clinical training, using brief scales with little validation. This study examines the utility of a brief self-efficacy scale in the evaluation of a clinical training program. Subjects were 119 registered dietitians who participated in diabetes training. Hypothesized relationships between self-efficacy ratings and indices of skill mastery, participation in training, and subsequent practice change were examined. Self-efficacy ratings after training correlated significantly with relevant prior experience (r = .4 and .29, p < .01) but not total experience and with knowledge post-test score (r = .21, p < .02). Self-efficacy for all 12 program objectives increased significantly after training. Post-training self-efficacy for two program objectives correlated significantly with self-reported successful practice changes related to those objectives (r = .4, p < .04 and r = .51, p < .01). The data suggest that brief self-efficacy assessments can contribute meaningfully to clinical training program evaluation.

Recent changes in management and medical nutrition therapy for diabetes mellitus. have produced a need to retrain many practicing dietitians. To meet this need, a multidisciplinary group experienced in medical nutrition therapy and educational methods used a formal needs-assessment process to design a new training program. Sugar is Not a Poison (SNAP): The Dietitian's New Role in Diabetes Management is a 21/2-day program that uses written text, didactic presentation, and exercises that simulate patient encounters to accomplish 12 learning objectives. Program evaluations show high levels of participant satisfaction. Mean (±standard deviation) scores on pre- and posttests of knowledge and problem solving were 69±13% and 86±9%, respectively ( P J Am Diet Assoc. 2000; 100:225-228.

A lthough benefits of medical nutrition therapy (MNT) in the management of diabetes have been well established, lack of time to address nutrition or the many other diabetes self-management tasks is an obstacle for most physicians. This article offers some simple strategies for physicians to use to address nutrition with both type 1 and type 2 diabetes patients before they are able to see a registered dietitian (RD). Weight loss is not always enough to bring blood glucose values into target range. There are several potential reasons: 1. If loss of β-cell function is severe, weight loss is unlikely to compensate. 2. Weight loss does not address postprandial blood glucose excursions. 3. Many patients have failed at weight loss or the maintenance of weight loss and need success to build confidence. Although weight loss is important for a variety of reasons, asking patients who have made multiple unsuccessful attempts at long-term weight loss to again attempt dieting can be frustrating for both patients and physicians. Patients with a poor weight loss track record may tune out additional weight loss advice. Changing the focus from losing weight to controlling carbohydrate intake may allow this type of patient to gain success and build confidence. Identifying and reducing excessive carbohydrate intake may reduce postprandial glucose excursions. High postprandial blood glucose has been shown to be an independent risk factor for cardiovascular disease; targeting it has been shown to improve blood glucose control. To assist patients in this goal: 1. Help patients identify large servings of juice or …

Diabetes education to improve patient self-management is an important component of comprehensive diabetes care. Patients with low health literacy and numeracy may have difficulty translating information from traditional diabetes educational programs and materials into effective self-care. To address this potential barrier to successful diabetes teaching and counseling, we describe the development of the Diabetes Literacy and Numeracy Education Toolkit (DLNET) and opportunities for its use in clinical practice. The DLNET is composed of 24 interactive modules covering standard diabetes care topics that can be customized to individual patient needs and utilized by all members of the multidisciplinary diabetes care team. The material’s content and formatting aims to improve the ease of use for diabetes patients with low literacy and numeracy by adhering to a lower text reading level, using illustrations for key concepts, and color-coding and other accommodations to guide patients through instructions for self-care. Individual sections of the DLNET may be provided to patients for initial teaching, as well as for reinforcement. While designed for lower literacy and numeracy skills, the DLNET provides unique materials to facilitate diabetes education for all patients.

Purpose The purpose of this feasibility study was to examine primary care pediatricians and a diabetes specialty team sharing the care of children with type 1 diabetes in a structured network. Methods A diabetes specialty team and 3 pediatric practice groups participated in training and shared care of patients with type 1 diabetes. The diabetes team-consisting of 1 pediatric endocrinologist, 2 nurses in advanced practice, and 1 master's-prepared registered dietitian-initiated therapy and self-management training for families; pediatricians implemented maintenance therapy. Role definitions, specially developed records, and a communication framework guided the interaction of providers. Satisfaction of families and pediatricians was assessed by questionnaire. The A1C level was used to assess patients' metabolic control. Results Twenty-nine patients accepted pediatrician referral, 25 kept initial training sessions, and 20 completed at least 1 year in the network. All 24 invited pediatricians participated, and 17 enrolled patients. All families who completed satisfaction surveys were highly satisfied with the network. Nineteen pediatricians completed end-of-study questions and were also highly positive about sharing care with the specialty team. The mean A1C value was near target levels or better the first year, and it rose during the second year. Conclusions The study supports the feasibility of integrating general pediatrician and diabetes specialty services for children with type 1 diabetes. Larger studies are justified to assess the efficacy and effectiveness of shared care.

women with pregestational diabetes Etoi Garrison, Cornelia Graves, Rebecca Gregory, Russell Rothman, James Slaughter, Sarah Fletcher, Kelly A. Bennett Vanderbilt University School of Medicine, Obstetrics and Gynecology, Nashville, TN, St. Thomas Health-Baptist Hospital, Obstetrics and Gynecology, Nashville, TN, Vanderbilt University Medical Center, Eskind Diabetes Center, Nashville, TN, Vanderbilt University School of Medicine, Medicine, Nashville, TN, Vanderbilt University School of Medicine, Biostatistics, Nashville, TN, Vanderbilt University School of Medicine, Obstetrics and Gynecology, Nashville, TN OBJECTIVE: Numeracy is defined as the ability to use numbers and math in daily life. Diabetes-related numeracy skills may be used to perform diabetes-related tasks for self-management of Type 1 and Type 2 diabetes. Inadequate health literacy and poor diabetes-related numeracy have been found to be independently associated with poor glycemic control among nonpregnant adult diabetics. This association in diabetes during pregnancy has not been well studied. We investigated this association in a defined pregnant diabetic population. STUDY DESIGN: Subjects were prospectively enrolled and administered validated measures of literacy (REALM), diabetes-related numeracy (DNT), and perceived self-efficacy (PDSMS). Glucose meter readings and A1C data were collected at baseline enrollment and prior to delivery. Univariate analyses were conducted. RESULTS: Fifty-eight subjects were recruited, 52% (n 30) with Type 1 and 48 % (n 28) with Type 2 diabetes. Subjects were high school educated, but 8% had less than 9th grade literacy skills. Mean baseline A1C was 7.0%, mean DNT score was 84 out of 100. Thirty-three percent could not use a food label to determine caloric content based upon serving size. Seventy-one percent of the Type 2 diabetics and 41 % of the Type 1 diabetics were unable to use a nutrition label to calculate carbohydrate grams based upon serving size. Eighteen percent of the Type 2 diabetics could not use numerical hierarchy to determine which glucose values were above or below a normal reference range. Health literacy and DNT scores were negatively and significantly associated with HgBA1C (r2 0.08 p 0.04; r2 0.11, p 0.01), respectively. Every 14% increase in DNT score was associated with a 0.35 (Type I) and 0.52 (Type II) decrease in HgBA1C (p 0.04). CONCLUSION: In this defined group, health literacy and numeracy-dependent diabetes self-management skills were significantly associated with better glycemic control. This data may be useful in the development of targeted diabetes education tools in pregnancy. 252 TNF alpha has a direct inhibitory effect on Ca2 responses necessary for eNOS activation in primary HUVEC Heather Bankowski, Fu Xian Yi, Derek Boeldt, Dinesh Shah, Ian Bird University of Wisconsin, Obstetrics and Gynecology, Maternal Fetal Medicine, Madison, WI, University of Wisconsin, Obstetrics and Gynecology, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology, Maternal Fetal Medicine, Madison, WI, University of WI School of Medicine and Public Health, Obstetrics and Gynecology & Pediatrics, Madison, WI OBJECTIVE: Evidence suggests that the pathologic metabolic state of diabetes mellitus(DM)results in oxidative stress. Tumor necrosis factor alpha (TNF ) has been shown to induce intracellular reactive oxygen species formation and is proposed to be a significant perpetrator of insulin resistance in gestational diabetes mellitus (GDM). Previously we have shown in DM HUVEC in vivo ROS damage to eNOS protein. Even in GDM patients, there is a overall decrease in NO production consistent with ROS damage of functional eNOS protein, despite maintenance of eNOS protein levels. It is known that sustained Ca2 elevation is also required for eNOS activity. Could TNF also inhibit NO production at the level of Ca2 signaling? Hypothesis: The decrease in agonist stimulated NO production due to TNF stimulated ROS production may not only occur through damage to eNOS protein in DM HUVEC but may also involve direct impairment of Ca2 signaling mechanisms necessary for eNOS activation. STUDY DESIGN: HUVEC cells from a combined pool of control patients were prepared at a density of 95%. HUVEC underwent acute (30 minutes)and chronic (16 hours) treatments with 50, 10 or 1 ng/ml TNF prior to imaging using Fura-2 to detect Ca2 in real time in response to 30 minute stimulation with ATP (100 uM). RESULTS: There were statistically significant reductions (P 0.05) in burst numbers in cells in the acute and chronic TNF treatment groups (Fig. 1). The decrease in Ca2 bursts was dose dependent in each case. In addition to the damaged eNOS protein itself, there is an acute, direct effect of TNF to directly inhibit eNOS activation by also impairing sustained Ca2 signaling in the form of repetitive bursts. These in vitro findings compliment our prior observations on in vivo ROS damage to eNOS in DM HUVEC. CONCLUSION: Ultimately, such improved understanding of the inhibitory role of TNF and other inflammatory cytokines will lead to a therapeutic strategy to reduce oxidative stress and development of macro and micro-vascular complications in pregnancies complicated by DM. www.AJOG.org Diabetes, Labor, Medical-Surgical-Disease, Obstetric Quality & Safety, Prematurity, Ultrasound-Imaging Poster Session II

Certain questions often arise regarding carbohydrate counting, such as: Why use carbohydrate counting ? Where does one start? How much carbolrydrate is prescribed? How does one balance the diet? How is carbohydrate counting taught to patients? Which patients are the best candidates for carbohydrate counting? This article provides possible answers to these questions based on clinical experience at the Vanderbilt University Medical Center Diabetes Research and Training Center, and the Diabetes Control and Complications Trial.

This paper describes a nutrition education experiment in which traditional direct instruction was compared with a problem-solving method called anchored instruction (AI). Participants were 69 children ages 9 to 15 years, with insulin-dependent diabetes mellitus (IDDM), who attended a diabetes camp. Following pretesting, campers were assigned to AI or direct instruction control classes. Posttests involved evaluating diabetes knowledge, personal meal plan knowledge, ability to choose an appropriate meal from a buffet line, and ability to pack appropriate meals for an overnight campout. AI and direct instruction both produced significant knowledge gains in this study. However, because the scores for the two groups did not differ, this study was unsuccessful in replicating results of other studies or extending the findings to selected measures of actual behavior.

The influence of a patient's quantitative skills (numeracy) on the management of diabetes is only partially understood.To examine the association between diabetes-related numeracy and glycemic control and other diabetes measurements.Cross-sectional survey.2 primary care and 2 diabetes clinics at 3 medical centers.398 adult patients with type 1 or type 2 diabetes mellitus enrolled between March 2004 and November 2005.Health literacy, general numeracy, and diabetes-related numeracy assessed by using the Rapid Estimate of Adult Literacy in Medicine; the Wide Range Achievement Test, 3rd edition; and the Diabetes Numeracy Test (DNT), respectively. The primary outcome was most recent level of hemoglobin A1c. Additional measurements were diabetes knowledge, perceived self-efficacy of diabetes self-management, and self-management behaviors.The median DNT score was 65% (interquartile range, 42% to 81%). Common errors included misinterpreting glucose meter readings and miscalculating carbohydrate intake and medication dosages. Lower DNT scores were associated with older age, nonwhite race, fewer years of education, lower reported income, lower literacy and general numeracy skills, lower perceived self-efficacy, and selected self-management behaviors. Patients scoring in the lowest DNT quartile (score42%) had a median hemoglobin A1c level of 7.6% (interquartile range, 6.5% to 9.0%) compared with 7.1% (interquartile range, 6.3% to 8.1%) in those scoring in the highest quartile (P = 0.119 for trend). A regression analysis adjusted for age, sex, race, income, and other factors found a modest association between DNT score and hemoglobin A1c level.Causality cannot be determined in this cross-sectional study, especially with its risk for unmeasured confounding variables.Poor numeracy skills were common in patients with diabetes. Low diabetes-related numeracy skills were associated with worse perceived self-efficacy, fewer self-management behaviors, and possibly poorer glycemic control.