Tim McClintock of 'Be Encouraged!'

Last week, I posted an open invitation for anyone who might be interested in guest blogging while I travel this summer. Much to my delight, I got way more responses than I expected! I have a couple of posts queued already, and hopefully, more will be filling my in-box

Tim McClintock of Be Encouraged! kindly offered to write a post about emotions - and as we all know, there are plenty of those that come with diabetes! Tim started blogging fairly recently, so if you haven’t seen his blog, check it out. Maybe I’m not catching the right blogs, but it’s seemed to me that there are fewer male D-bloggers than females, so it’s been cool to see a few more guys join the D-blogosphere recently. Time is also an active D-twitterer so be sure to follow him if you’re on twitter.

Real Emotion

What is it about the big D. that gives it the ability to play with our emotions so well? Recently, I found myself in a situation, which gave me an opportunity to help a very close friend of mine. Within a 24-hour period, I found myself going from feeling elated, grateful, and awestruck to feeling like a complete and utter failure. I felt all the former things from simply having been given an opportunity to try and help, and then felt even more of the same after finding a way to actually make it happen. All of my BG tests during this timeframe were pretty much in what I would consider a normal range for me, which would be anywhere from 100 to 150.

On the other hand, about three hours ago, I came home after having run some errands. I exercised for a short while, and then took a restroom break. My brain must’ve been in slow motion, because it seemed like it took a long time to register that the thing hanging down by my foot was the obviously less than durable medical device formally attached to my thigh. I immediately reached for my meter, did a quick test, and upon seeing a most less than awesome 320,000 (it might just as well have been, from the way it made me feel), [okay it was more like 320] I immediately began to feel a rage welling up inside. For those of you that know me even a little bit, you know that this is not normal Tim territory. I tend to stay fairly even most of the time. “cha mon man! Not now!” All I knew was that I didn’t want to deal with this at that particular moment (can you say NEVER!?!?), nor did I want to have any memory of it later. Where’s my brain bleach anyway?

What is it about the big D. that gives it the ability to mess with my mind so easily, especially when I am high or experiencing a low? And the larger question for me is, knowing that it can and does mess with me if I let it, what can I do about that? I may never know the answer to the first question, and I’m okay with that. As to what I can do, and what I often end up doing, is sharing those emotions and feelings with people I care about, people that care about me, and people that understand because they have been there. Some of those people are in my family. They love me, and I love them. They care about me. I care about them. It works. I tell them how I feel, physically, mentally, and diabetically (btw, if I just made up a word, I SO own it, but hereby officially give it to the DOC) but the ability of my family to completely and totally understand is a bit limited, because try as they might, which they do, they haven’t been inside of my head, my body, my emotions, etc.

So in addition to my family, it is usually during these times that I am drawn to run to the DOC. Sometimes I post, but often during these times of highs or lows I simply read some of the twitter posts or a blog without commenting. I will sometimes withhold comment simply out of fear that what will come out will not be interpreted as I meant it because of what the high or the low is doing to me. Other times I withhold comment because I know that it WILL be interpreted exactly as I meant it, and because of the altered state my brain is in during those moments what I might say and even think is 180° the opposite of what I would ever say or even think when my numbers are in the normal range. The point here is that simply being around those that I know will understand helps. Because they’ve been there. Because they are there. And until the day the cure comes for all of us, unfortunately we will all continue to be there. But the absolutely cool thing is we are all there.

Together. Listening. Learning. Challenging and encouraging each other. Leaning on each other. Standing back-to-back, swords drawn, ready to slay the lame poser of a sucky dragon called diabetes. How cool is that? Not only is it wicked sweet, it’s approaching dope/badass territory. Just sayin’. And oh yeah, thanks DOC. I owe you big. And just know, when and if you need, I got your six. citas: mamacitas

Thanks so much for the blog post, Tim - and thanks for expressing a sentiment that I think most of us feel.

I arrived at my friend’s house in Fort Worth last night after 13 hours in the car and only two pit-stops. I had planned on being a little more leisurely about it, but once I was going, I just wanted to get here, thus there was no stopping to soak up a little wi-fi time. Starting tomorrow, I have a couple of guest blogs queued up so far, and some offers to guest blog so hopefully there will be more to follow.

Today is Thesis Thursday though, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, you read the first part of my review of some research on psychosocial intervention research, specifically research focusing on medical office-based treatment. Today I offer a discussion of a research study on the application of cognitive-behavior treatment.

Psychosocial Interventions for Diabetes (continued)

Cognitive-Behavioural group training (CBGT) was examined by van der Ven, Chatrou, and Snoek (2000).

Central to cognitive therapy is the assumption that behaviour and emotions are in constant interaction with cognitions. These cognitions or beliefs may be inaccurate, leading to excessive emotional reactions and a failure to cope effectively. The aim of cognitive therapy is to help make patients identify their dysfunctionsl cognitions, test them against reality and alter them, thereby modifying emotional disturbances and improving coping behaviour. (van der Ven, Chatrou & Snoek, 2000, p. 209)

In CBGT, cognitive and behavioral techniques such as cognitive restructuring, stress-management, and cueing are implemented “to help patients to diminish diabetes-related distress, to reduce perceived barriers to various aspects of self-management and to enhance coping skills” (van der Ven, Chatrou & Snoek, 2000, p. 213). The goal of Cognitive-Behavioural group training “is to help patients cope more effectively with their diabetes regimen, in order to improve glycaemic control, without compromising, and possibly enhancing, psychological well-being” (van der Ven, Chatrou & Snoek, 2000, p. 213).

A psychologist and diabetes educator facilitated the CBGT in four consecutive two hour weekly meetings to groups of five to eight participants. A different theme was addressed each week. These themes were:

(a) the way cognitions affect emotions and behavior—developing a different view on diabetes and self-care; (b) stress and metabolic control—ways to cope with stressful situations; (c) diabetes, complications and the future—ways to cope with worries and insecurity; and (d) diabetes and social relationships—ways to obtain support from your environment. (van der Ven, Chatrou & Snoek, 2000, p. 214)

The 24 participants in this study were not adolescent, but all had type 1 diabetes for a mean duration of 17.62 (±9.35) years. The mean age of the participants was 35.17 (±11.13); two were on conventional (two injection) insulin therapy, seventeen were on intensive (> three injections) insulin therapy, and five were on insulin pump therapy; and the mean HbA1c was 9.22 (±1.19) at baseline (van der Ven, Chatrou & Snoek, 2000, p. 219).

Van der Ven, Chatrou and Snoek (2000) concluded that after the course of CBGT, there were improvements in diabetes-related distress, measured with the Dutch version of the Problem Areas In Diabetes (PAID) questionnaire (p. 222). Using the Perceived Barriers in Diabetes Self-care scale (BDQ), they saw a slight decrease compared to baseline (p. 223). The barriers considered most serious by the participants were items concerning SMBG, difficulties maintaining normal blood-glucose levels in special situations (i.e. weekends, when under increased stress), and items relating to hypoglycemia (p. 222).

The Hypoglycaemia Fear Survey (HFS) measured changes in fear of hypoglycemia as a barrier to good diabetes control. Van der Ven, Chatrou and Snoek (2000) found that fear of hypoglycemia was not a problem to the group as a whole at baseline. Two of the twenty-four participants scored high at baseline however, indicating that this was a significant barrier for them. Again, at three months follow-up, fear of hypoglycemia was not a problem for the group as a whole.

However, one participant had an increased worry score (29-42), without an increase in hypoglycaemic episodes, while two others had considerably lower scores (drops from 26 to 17 and from 61 to 54). Although this last change may be an important improvement clinically, it still indicates a high level of fear. (van der Ven, Chatrou & Snoek, 2000, p. 223)

Emotional well-being was measured using the short form of the Well-Being Questionnaire (WBQ-12). Following treatment, mean total score increased slightly, indicating some overall improvement and positive well-being increased significantly, “indicating that improvement of HbA1c did not occur at the cost of well-being” (van der Ven, Chatrou & Snoek, 2000, p. 223).

A short form of the Diabetes Self-Care Inventory-1 (DSC-1) was used to assess self-care behaviors.

Self-reported self-care behaviour varied greatly among participants … The degree of non-adherence varied from participants not inspecting their feet to not performing SMBG at all. Given this large inter-individual variation, the effects of CBGT are likely to be differential: every participant has his/her own areas of potential improvement. (van der Ven, Chatrou & Snoek, 2000, pp. 223-224)

The researchers found that for SMBG, only one of seven non-adherers improved; they had expected greater improvement at follow-up (p. 224). When taking diabetes into account when eating or drinking, seven reported this to be the case some of the time, while five never or rarely did this; at follow-up only one of these participants had improved (p. 224).

In analyzing glycemic control of the participants, nine were in moderately poor control (HbA1c 8-9%), nine were in poor control (HbA1c 9-10%), and four were in very poor control (HbA1c > 10%) at baseline. At three months follow-up, mean HbA1c improved from 9.57 (±1.22) to 8.86 (±1.38), with all participants in very poor control at baseline showing improvement, some significant, and participants in the poor control and moderately poor control groups showing varied results. At six months follow-up, some participants in poor control at baseline who did not show improvement at three months follow-up, did eventually show improvement in HbA1c levels (van der Ven, Chatrou & Snoek, 2000, p. 225).

Hypoglycemic episodes, noted as an item of concern for the participants using the Perceived Barriers in Diabetes Self-care scale, were measured at baseline and at follow-up. The mean number of hypoglycemic episodes per week doubled from 2.07 (±1.32) to 4.17 (±3.47). According to the researchers, “the increase of hypos may be directly related to the observed improvement in glycaemic control. Also, it is likely that participants have become more aware of hypoglycaemia” (van der Ven, Chatrou & Snoek, 2000, p. 226).

The authors conclude that “CBGT appears to be successful in improving HbA1c while reducing diabetes-related distress and preserving well-being” (van der Ven, Chatrou & Snoek, 2000, p. 227). However, they point out that there was not consistent improvement in diabetes-related self-care behavior, although some participants showed significant improvement. Patients in poor control who do not experience correlating distress might not benefit from CBGT due to decreased levels of “readiness to change” (van der Ven, Chatrou & Snoek, 2000, p. 227).

At the conclusion of the study, the researchers decided to add two classes, going from four to six sessions. The first additional session will be based on the theme of goal setting in order to increase focus on self-management behavior and assist patients in setting individual and realistic self-care goals. The theme of the second additional setting will be how to be a patient, focusing on “adopting an assertive, active attitude, to get the most out of contacts with health care providers” (van der Ven, Chatrou & Snoek, 2000, p. 227). While an increased number of sessions will likely impact attendance levels negatively, van der Ven, Chatrou and Snoek (2000) believe that the longer course will ultimately have a positive impact on glycemic levels and emotional well-being (p. 228).

Check back next Thursday for continued discussion of Psychosocial Interventions for Diabetes.

Last Monday, Kerri posted that she would be in Philly later in the week, and there was going to be a meet-up while she was in town. She asked that anyone who was interested in joining, let her know. She had mentioned that she would be here earlier in June, and I had filed that away in my brain, only to forget, so I was glad that she posted the reminder/invitation to join.

However, somewhere between reading that and writing a response that I’d like to get in on the meet-up action, I saw something shiny – and never responded. On Thursday, I was checking twitter, and by sheer luck, just happened to catch a tweet from her that the meet-up would be later. I messaged her, asking about the when and where details, and inquired if T3’s were invited, to which she happily told me to bring Jason, and so it was set.

Once Jason was home from work, we drove down the road to the commuter rail station. As we stood waiting for the train, I used my last test strip to confirm my suspicion that my BG was high - 305mg/dL – due to having stuffed my face with carbs all afternoon trying to treat a rather persistent low. I bolused, and cursed myself for not bringing extra strips. Of course, there is no better time to run out of strips than on one’s way to a D meet-up, so I hoped I could bum a strip or two off of someone at the restaurant.

We hopped on the commuter train, and 25 minutes later, emerged from the train stop into the middle of Center City Philadelphia, only a block from the Black Sheep Pub. Once inside, we told the hostess we were looking for a group, and as we were trying to hear what the heck she was saying over the blasting music, Kelly showed up on our coattails. I hugged her and introduced Jason to her before we squeezed past crowd at the bar, and soon spotted Kerri sitting with some unfamiliar faces – and Manny! I couldn’t have been more surprised to see Manny there – and equally delighted since the last time Jason and I had seen him was last September after an amazing day of sightseeing with him, Andreina and Santiago in San Francisco.

We got comfortable at an adjacent table, ordered drinks and inspected our dinner options on the menu. Kelly graciously spotted me some extra test strips to carry me through the evening, and I didn’t even have to re-code my meter because her strips were coded as 17, same as my empty bottle! I was happy to see that my BG was under 200mg/dL by the time we ordered our food too. We talked about Michael Jackson’s untimely death, concurring that he hadn’t done his body any favors by putting it through the wringer with countless plastic surgeries. Soon enough, we were yelling over some of his older hits, blaring over the bar’s speakers, and I was getting my groove on. Luckily, I didn’t have any alcohol because otherwise I might have been on the table dancing because seriously, if you don’t feel like dancing when Rock with You starts playing, then someone needs to check your pulse to make sure you’re still alive. What can I say? I love to dance to 70’s and 80’s music!

I got an update from Kelly about how her mom’s been doing, and we talked about her experience speaking at the diabetes camp last week. Manny and I talked about his latest projects for the Diabetes Hands Foundation, his experience writing and now promoting Ning for Dummies, and how sales have been. I also got to yell across the table at Kerri about how the conference she and Manny were attending was going – and we shared some laughs about the pharma folks’ response to the presence of D-bloggers in their midst. We also briefly talked about our expectations for the Roche event in a few short weeks. Dorkabetic Hannah showed up a little late, but she made it into Philly despite the ridiculous traffic she had to endure, and I was super thrilled to finally meet her.

As you probably read elsewhere it was hot as… well, it was unbelievably hot in that bar, but it was an awesome time. I didn’t get a chance to talk with everyone, but it seemed like everyone else had an equally great time. I got to meet a familiar face for the first time in person, see “old” friends, and meet some entirely new people. Once we stepped out onto the street to relish the fresh air, we snapped a bunch of pictures before bidding farewell. There’s nothing like a D meet-up to put a smile on your face, and in this case, a little moonwalk in your step.

I don’t buy that many sugar-free products. While it’s my cynical impression that food manufacturers would like people to think that sugar-free is magically synonymous with carb-free, that’s not the case by any stretch of the imagination. Just because something doesn’t have sugar or has less sugar, does not mean it isn’t sweetened with sugar alcohols or loaded with some other kind of carbs since we all know carbs come from countless other sources besides sugar. If I have to give a comparable amount of insulin to eat the sugar-free version of any given food, I’d rather just have the sugarful version because chances are, it’s going to taste better.

However, there are a handful of products of which I prefer the SF variety. I’ve never been a big fan of pudding, but Jason really likes pudding so I’ve always gotten that for him for lunches and snacks, with the hope that he’ll occasionally opt for that over eating potato chips straight from the bag. Because I buy pudding for him, I now peruse the pudding section of the supermarket, and I found myself eyeing the SF varieties. Once upon a time, when SF pudding was introduced, there was vanilla and chocolate, but now there’s a fairly decent selection of flavors beyond that. They’re not so SF that you can eat them without bolusing, but with my insulin to carb ratio of 1:15, things I can eat that requires less than 1 unit, are the next best thing, so I’ve been trying different kinds of pudding.

Within the last month, I found Jello brand cinnamon roll flavored pudding. That intrigued me so I got some. It’s pretty good, definitely reminiscent of a cinnamon roll without the fat and carbs of a cinnamon roll - it’s only 12g carbs per cup. Since I wasn’t a huge fan of pudding to start though, I wasn’t astounded by it enough to get it again. It was an interesting snack to try though. A couple of weeks after finding the cinnamon roll flavor, I found boston cream pie flavored also by Jello brand. I haven’t been terribly impressed with this one. I guess I was hoping it would remind me of a boston cream donut, much like the cinnamon roll flavor reminded me of cinnamon rolls, because boston cream donuts are one of my favorite kinds of donuts. Alas, it didn’t really do that for me. It’s OK, but it just kind of tastes like regular chocolate pudding to me for the most part. I’ve eaten them, but I’m not sure I would get that flavor again either. Like the cinnamon roll flavor, the boston cream pie comes in at 12g carbs.

A few months ago, I found myself digging Kozy Shack brand SF tapioca pudding. I don’t think I ever had tapioca pudding as a kid, but Jason likes it, so somehow I ended up tasting some within the last few years, and I liked it. When I saw the SF Kozy Shack tapioca on sale one day, I figured I’d get some and check it out, and lo and behold, I liked it far more than I imagined liking pudding. I liked it so much that when I go to the supermarket and they don’t have it, I’m disappointed. This one comes in at 11g carbs, so for a dessert, it’s relatively low in carbs. I do like my desserts, so especially on days when my BG is running high or I’ve had more carbs than usual, I don’t feel guilty about having this.

Now, my absolute favorite pudding is banana flavored. When I was a kid at camp, the banana pudding dessert they had was one of my favorites, so to this day, I have a weak spot for it. At camp they layered bananas and vanilla wafers in it, which is really what made the dessert. Back then, we were all on exchange diets, and I don’t recall what the exchanges were, but they worked it into our diets.

So I have the special fondness for banana pudding, but I can’t remember ever finding pre-made packaged SF banana pudding. When I was at the supermarket a couple of nights ago, I started thinking about banana pudding. I checked both the refrigerated pudding section and the pudding section of the grocery shelves. I found some regular banana pudding, but I passed on that. I was certain that Jello makes banana pudding mix though, so I looked, found it, and grabbed a box off the shelf. I had already decided to get it, regardless of the nutrition information, but I had a look at the label anyway – and my instant pudding instantly annoyed me.

When you read nutrition labels, which I know we all study like our lives depended on it, since, you know, they do, have you ever noticed that some foods that have to be prepared in some way or another have the nutrition data listed “as packaged”? I’ve seen this on rice and pasta mixes, baked good mixes, and I’m sure all kinds of other products that aren’t coming to mind at the moment, and I can’t help but wonder what the point of that is.

As amusing as the image in my head of someone licking brownie mix batter out of the bag is, I find it a little unlikely that anyone would do that - and if they did, I find it even more unlikely that they’d concern themselves with serving sizes. I need to know what the nutrition info is when something is prepared as the directions say – after the milk or eggs or oil or whatever has been added and the food has been cooked. Telling me that 8g of dry pudding mix is a serving doesn’t really help me understand how much prepared pudding I should scoop into my cup once it’s ready to eat. Telling me that there are 6g of carbs in a serving of pudding powder doesn’t help me understand how many carbs I need to bolus when I eat it once it’s mixed with milk.

So I called Kraft Foods, the makers of Jello brand products.

Lee Ann: I have a question on nutrition information on one of your foods.

Kraft Rep: Sure. What are you inquiring about?

LA: Jello sugar-free banana pudding. The nutrition information says how much carbohydrates are in it as packaged, but it doesn’t say how much is in it if it’s prepared.

The Kraft rep asked me for my name and the bar code, and then placed me on hold for minute.

KR: It’s actually just what’s in that product, not when it’s prepared, so whatever ingredients you’re going to add, like the milk, you’re going to have to add the nutrition information of that item.

LA: I understand that, but obviously no one is going to eat just the pudding powder. I guess I don’t understand why there’s not the nutrition information for it once it’s prepared.

KR: The reason is because we don’t manufacture milk and we don’t manufacture other ingredients that you could put in there, like some people like to put in other ingredients, so we just put it as the base value because that’s what we make We don’t make any other things to go in there. So since we don’t manufacture milk, we can’t put their nutrition information on our package, and also because there are other types of milk, they all have different nutritional information so we can’t really mislead like that.

I thanked her for her help, and that was that.

Just as I expected, I’ll have to figure it out myself. Because I know how much milk to use and that there are four servings, I can just divide the total carbs of milk by four and add that to the 6g carbs in the pudding mix – but seriously, I feel like a walking calculator doing constant computations already and there are times when I resent having to do advanced calculus just to eat a meal or snack.

Also, I didn’t press the issue with her, but there is information about the nutrition of “1/2 cup prepared with fat free milk”, including that a prepared serving has 70 calories, but as you can see in the photo of the nutrition label, the rest of the information is in percentages - which are obviously based on actual numbers. So while I understand her explanation and don’t dispute the logic behind it, they really aren’t abiding by their own rule.

Anyway, speaking of fond banana pudding memories of camp, the Camp Sweeney reunion is a week from tomorrow, so my banana pudding plans will likely wait until I return. I expect the reunion to be a very emotional experience for me, so when I return, I anticipate picking up some bananas and vanilla wafers to recreate the camp dessert. Whoever called pudding comfort food, didn’t even know the half of it.

It’s another addition of Thesis Thursday, a weekly series of consecutive sections from my master’s thesis, Art Therapy with Type 1 Diabetic Adolescents, Non-Adherent to Treatment: A Literature Based Study. Last week, you read the sixth section of Chapter 2: Literature Review, the first part of Psychosocial Implications of Diabetes, which included Psychosocial Issues of Adolescent Diabetes.

The next part is Psychosocial Interventions for Diabetes, a review of relevant research that had been completed prior to 2004. Until today, the lengths of sections that I’ve posted have been more or less similar to regular blog posts, but this section is considerably longer, far too lengthy to post all at once. I know reading this in weekly installments hasn’t exactly been fluid, which was one of my initial concerns when I first considered posting this. Now it’s going to be even less fluid. I’m trying to find logical transition points within the section though, so hopefully, it won’t be too difficult to follow.

Psychosocial Interventions for Diabetes

While art therapy has not been an intervention studied for use with diabetic adolescents who do not adhere to treatment, other psychosocial interventions have been applied to this population for the purpose of researching their impact on psychosocial and medical outcomes.

Glasgow and Eakin (2000) examined medical office-based interventions. They assert that there is a greater need to offer psychological care at this point of service for three primary reasons. One, many diabetic patients either do not or will not use the traditional referral system for obtaining psychological care (Glasgow & Eakin, 2000, pp. 141-142). Two, “the quality of care provided for diabetes patients in most medical settings is substantially suboptimal … The rates of preventive services, and especially lifestyle change interventions, are even lower” (Glasgow & Eakin, 2000, p. 142). Three, “patient-centered, motivational interviewing, and patient activation/empowerment approaches have consistently been found to produce beneficial effects, yet such strategies are seldom employed in either primary care or specialty endocrinological settings” (Glasgow & Eakin, 2000, p. 142).

Glasgow and Eakin (2000) analyzed research on medical office-based interventions using the RE-AIM model. “This framework focuses attention on important applicability issues and a real world, effectiveness perspective compatible with the realities of medical office treatment of diabetics” (Glasgow & Eakin, 2000, pp. 144-145). The first component of the RE-AIM model is “Reach, or the percentage and representativeness of patients who are willing to participate in a given procedure” (Glasgow & Eakin, 2000, p. 145). The second component is “Efficacy, or the impact of an intervention on important outcomes, including behavioural, biological, quality of life, and economic outcomes” (Glasgow & Eakin, 2000, p. 145). The third component is “Adoption, or the percentage and representativeness of settings that are willing to adopt or try an office innovation” (Glasgow & Eakin, 2000, p. 145). The fourth component is “Implementation, or how consistently an intervention or procedure is delivered as intended” (Glasgow & Eakin, 2000, p. 145). The final component of the RE-AIM model is “Maintenance, or the extent to which a programme or policy becomes institutionalized or part of the routine practice of the medical settings. These five factors interact to determine the overall ‘population-based’ or public health impact of a programme” (Glasgow & Eakin, 2000, p. 145).

According to Glasgow and Eakin (2000), there have been few “behavior change interventions initiated or delivered in the office setting solely with diabetic patients” (p. 146). In summarizing the research utilizing the RE-AIM model, Glasgow and Eakin (2000) determined that the Reach of office-based interventions was fairly broad, “better than traditional education or referral” (p. 147), and the amount of research addressing Reach was moderate. The Efficacy of such interventions was variable, “better for personalized treatment” (p. 147), and the amount of research addressing Efficacy was good. The Adoption of medical office-based interventions was unknown, and there was little to no research addressing this. Implementation of office-based interventions was also unknown as there was also little research on this factor. Maintentance following office-based interventions with diabetics was poor, especially without follow-up support, and the amount of research addressing this factor was moderate at the individual level and little at the clinical level (Glasgow & Eakin, 2000, p. 147).

Glasgow and Eakins (2000) only found one study of an office-based intervention involving type 1 adolescents. Barbara Anderson, Wolf, Burkhart, Cornell, and Bacon (as cited in Glasgow & Eakin, 2000) conducted a randomized study with type 1 diabetic adolescents and their families, in which the adolescents attended five peer group meetings. The content was problem-solving and applying self-monitored blood glucose (SMBG) data. The results of this study showed that the adolescents involved in the peer group meetings had greater reductions in HbA1c and more reported using SMBG data when exercising compared to adolescents not included in the peer group meetings. Glasgow and Eakin (2000) state that further research on similar interventions with adolescents is needed (p. 147).

Additionally, they address the Diabetes Control and Complications Trial (DCCT). “Although often interpreted solely as a demonstration of the efficacy of intensive insulin management, the DCCT obtained its incredibly good adherence and low attrition rates by providing an impressive array of ongoing patient support activities” (Glasgow & Eakins, 2000, p. 149). While they did not include this research in their analysis of office-based interventions with diabetic patients,

from the RE-AIM perspective, the DCCT maximized Efficacy results, but would receive very low scores on Reach (percentage and representativeness of patients participating) and Adoption (conducted predominately in unrepresentative, specialized tertiary care centres with very high levels of clinical expertise and resources). (Glasgow & Eakins, 2000, p. 149)

Glasgow and Eakin (2000) also address the quality and applicability of current research. According to them, traditional double-blind randomized clinical trials are considered the gold standard for evaluating interventions, but these trials “often oversimplify clinical realities and emphasize internal validity … at the expense of external validity” (Glasgow & Eakin, 2000, p. 145). They assert that the medical and behavioral health fields should respond with “more research conducted on representative patient samples in representative clinical settings, conducted under ‘real-world’ conditions, to help guide important policy and resource allocations” (Glasgow & Eakin, 2000, p. 145).

Next week, Psychosocial Interventions for Diabetes will continue with a review of some cognitive-behavioral treatment research.