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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)

Background: Women diagnosed with gestational diabetes mellitus (GDM) substantially modify their diets during pregnancy to control hyperglycemia. These changes could also affect maternal weight management. Materials and Methods: From July 2014 to December 2015 we enrolled women with and without GDM in a prospective cohort study to compare their mean rates of (1) weight gain before GDM screening, (2) weight gain after GDM screening, and (3) postpartum weight loss. All GDM-affected women were referred to Medical Nutrition Therapy and asked to self-monitor blood glucose until delivery. Rate comparisons were conducted separately for each interval using weighted t-tests and inverse probability of treatment weighting (IPTW) to account for age and prepregnancy body mass index (BMI). Linear regression models were developed to characterize the association of GDM status and rate of weight change. Results: The study included 40 women with GDM and 49 women without GDM. The IPTW analysis found that (1) women with and without GDM had similar mean rates of gestational weight gain before GDM screening (0.41 ± 0.26 kg/week vs. 0.45 ± 0.35 kg/week, respectively, p = 0.86), (2) women with GDM gained weight at a significantly lower mean rate than women without GDM following GDM screening (0.30 ± 0.28 kg/week vs. 0.53 ± 0.28 kg/week, respectively, p = 0.001), and (3) women with and without GDM had similar mean rates of postpartum weight loss (−1.37 ± 0.58 kg/week vs. −1.28 ± 0.46 kg/week, respectively, p = 0.73). The linear regression model (adjusted for age and prepregnancy BMI) demonstrated that women with GDM gained 0.19 kg/week less than women without GDM (p = 0.004) during pregnancy after GDM screening. Conclusions: In the postpartum period, women with GDM lose weight at similar rates to women without GDM despite gaining weight at significantly lower rates following GDM screening. Diagnosis and treatment of GDM may improve maternal weight management, but this benefit is limited to late pregnancy.

To compare the effectiveness of different approaches to nutrition education in diabetes self-management education and support (DSME/S).We randomized 150 adults with type 2 diabetes to either certified diabetes educator (CDE)-delivered DSME/S with carbohydrate gram counting or the modified plate method versus general health education. The primary outcome was change in HbA1C over 6 months.At 6 months, HbA1C improved within the plate method [-0.83% (-1.29, -0.33), P0.001] and carbohydrate counting [-0.63% (-1.03, -0.18), P=0.04] groups but not the control group [P=0.34]. Change in HbA1C from baseline between the control and intervention groups was not significant at 6 months (carbohydrate counting, P=0.36; modified plate method, P=0.08). In a pre-specified subgroup analysis of patients with a baseline HbA1C 7-10%, change in HbA1C from baseline improved in the carbohydrate counting [-0.86% (-1.47, -0.26), P=0.006] and plate method groups [-0.76% (-1.33, -0.19), P=0.01] compared to controls.CDE-delivered DSME/S focused on carbohydrate counting or the modified plate method improved glycemic control in patients with an initial HbA1C between 7 and 10%.Both carbohydrate counting and the modified plate method improve glycemic control as part of DSME/S.

Purpose Patients with low literacy, low numeracy, and/or linguistic needs can experience challenges understanding diabetes information and applying concepts to their self-management. The authors designed a toolkit of education materials that are sensitive to patients’ literacy and numeracy levels, language preferences, and cultural norms and that encourage shared goal setting to improve diabetes self-management and health outcomes. The Partnership to Improve Diabetes Education (PRIDE) toolkit was developed to facilitate diabetes self-management education and support. Methods The PRIDE toolkit includes a comprehensive set of 30 interactive education modules in English and Spanish to support diabetes self-management activities. The toolkit builds upon the authors’ previously validated Diabetes Literacy and Numeracy Education Toolkit (DLNET) by adding a focus on shared goal setting, addressing the needs of Spanish-speaking patients, and including a broader range of diabetes management topics. Each PRIDE module was evaluated using the Suitability Assessment of Materials (SAM) instrument to determine the material’s cultural appropriateness and its sensitivity to the needs of patients with low literacy and low numeracy. Reading grade level was also assessed using the Automated Readability Index (ARI), Coleman-Liau, Flesch-Kincaid, Fry, and SMOG formulas. Conclusions The average reading grade level of the materials was 5.3 (SD 1.0), with a mean SAM of 91.2 (SD 5.4). All of the 30 modules received a “superior” score (SAM >70%) when evaluated by 2 independent raters. The PRIDE toolkit modules can be used by all members of a multidisciplinary team to assist patients with low literacy and low numeracy in managing their diabetes.

OBJECTIVE Diabetic patients with lower literacy or numeracy skills are at greater risk for poor diabetes outcomes. This study evaluated the impact of providing literacy- and numeracy-sensitive diabetes care within an enhanced diabetes care program on A1C and other diabetes outcomes. RESEARCH DESIGN AND METHODS In two randomized controlled trials, we enrolled 198 adult diabetic patients with most recent A1C ≥7.0%, referred for participation in an enhanced diabetes care program. For 3 months, control patients received care from existing enhanced diabetes care programs, whereas intervention patients received enhanced programs that also addressed literacy and numeracy at each institution. Intervention providers received health communication training and used the interactive Diabetes Literacy and Numeracy Education Toolkit with patients. A1C was measured at 3 and 6 months follow-up. Secondary outcomes included self-efficacy, self-management behaviors, and treatment satisfaction. RESULTS At 3 months, both intervention and control patients had significant improvements in A1C from baseline (intervention −1.50 [95% CI −1.80 to −1.02]; control −0.80 [−1.10 to −0.30]). In adjusted analysis, there was greater improvement in A1C in the intervention group than in the control group (P = 0.03). At 6 months, there were no differences in A1C between intervention and control groups. Self-efficacy improved from baseline for both groups. No significant differences were found for self-management behaviors or satisfaction. CONCLUSIONS A literacy- and numeracy-focused diabetes care program modestly improved self-efficacy and glycemic control compared with standard enhanced diabetes care, but the difference attenuated after conclusion of the intervention.

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.

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.

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 …