COUPLED: Changing our Understanding of People Living Everyday with Diabetes

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COUPLED Changing our Understanding of People
Living Everyday with Diabetes

• Linda A. Wray, PhD
• Department of Biobehavioral Health
• The Pennsylvania State University
• Presented to
• Health Services Research Colloquium
• April 7, 2006

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Acknowledgements

• Thanks to my collaborators at Penn State
• Duane Alwin
• Latrica Best
• Elizabeth Beverly
• Rachael Clauser
• Carla Miller
• Sherry Willis

• This research was supported by
• NIA Grant No. AG15437-04 for Socioeconomic
  Status, Psychological Resources, and Health
  (D.F. Alwin, PI L.A. Wray, Co-PI)
• NIA Grant No. P30 AG024395 for Spousal Support
  Diabetes-Related Behavior Change in Middle-Aged
  and Older Adults (L.A. Wray, PI C.K. Miller and
  S.L. Willis, Co-Is)

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Outline

• Background
• Recent studies
• Social status and diabetes
• Diabetes diagnosis and weight loss

• Current study
• Spousal support and diabetes management
• Findings
• Implications and future directions

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Background

• Decades of studies show links between
• Social status and health
• Social support and health
• Current research on social status ? health link
  moves in three directions to
• Examine roles of ascribed, early-life, and
  achieved social status
• Understand role of mediators and moderators
• Consider processes in specific health problems
• Social support ? health research focuses on
  moderating role of social support in health

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Background

• Health-care providers and policy-makers are
  concerned about how rapidly diabetes prevalence
  is increasing
• In middle-aged and older adults
• And in younger people as well

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Prevalence of diagnosed diabetes by age, U.S.,
19802004 (CDC, 2005)
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Background

• Recent studies on diabetes examined
• Role of social status and risky health behaviors
• Link between diagnosis and behavior changes
• Current study on diabetes explores
• Role of social support in behavior changes

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Study 1 Social status, risky health behaviors,
and diabetes

• Wray, Alwin, McCammon, Manning, Best, under
  review, 2006 Wray, Alwin, McCammon, 2006
• Used large longitudinal data set
• Health and Retirement Study (HRS)
• Nationally representative panel study of
  community-dwelling U.S. adults age 51-61 and 70
  in 1992
• Since 1996, representative of adults 51
• Black and Latino Americans over-sampled
• Rich source of data on health, household
  composition, and economic outcomes

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Study 1 Social status, risky health behaviors,
and diabetes

• Investigated
• Role of ascribed, early-life, and achieved social
  status on diabetes prevalence and incidence
• Whether effects of risky health behaviors mediate
  social status-health link
• Whether effects differ by age group
• Figure 1 graphically presents relationships among
  key constructs

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Study 1 Social status, risky health behaviors,
and diabetes

• Figures 2-4 show probabilities of reporting
  selected risky behaviors by gender,
  race-ethnicity, and age group
• Probabilities vary widely across groups
• Risky behaviors are associated with diabetes
  onset

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Study 1 Conclusions

• Social status predict prevalent and incident
  diabetes in midlife and older age
• Risky health behaviors (particularly obesity and
  smoking behavior) strongly predict incidence,
  independent of achieved social status
• High incidence of diabetes persists for Black and
  Latino adults, independent of achieved social
  status and risky health behaviors
• Challenges remain to discern
• Reasons why adults participate in both risky and
  protective health behaviors
• Social, psychological, and/or physiological
  mechanisms underlying persistent gender and
  race-ethnicity disparities

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Study 2 Diabetes diagnosis and behavior changes
in middle-aged adults

• Wray, Blaum, Ofstedal, Herzog (2004)
• Using HRS data, investigated
• If self-reported DX of diabetes prior to 1994
  predicts weight loss between 1994-1996
• If achieved social status influences relationship
• Study samples restricted to relatively healthy
  but overweight adults in 1992 (those at-risk for
  losing weight)

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Study 2 Conclusions

• Diabetes DX resulted in 50 increased odds of
  reporting loss of 10 lbs of excess weight
• Achieved social status (education and net worth)
• Did not predict weight loss
• Did not explain DX ? weight loss links

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Study 3 Spousal support and diabetes-related
behavior changein middle-aged and older adults

• Wray (PI), Miller Willis (co-PIs)
• Two necessary but difficult behavior changes
• Adhering to healthful diet
• Increasing physical activity
• Spousal support linked to glycemic control and
  other diabetes-related health outcomes
• What spousal support represents is unclear
• Study informed by
• Social Cognitive Theory (reinforcement,
  self-efficacy)
• Social support literature

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Questions

• How is spousal relationship associated with links
  between diagnosis and diet changes and, in turn,
  health outcomes?
• Do men or women benefit more from spousal support?

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Hypotheses

• Greater perceived spousal support? greater
  diet-related self-efficacy
• Greater self-efficacy?greater adherence to diet
  changes
• Men will benefit more from spousal support than
  will women

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Figure 5. Relationship between personal,
behavioral, and environmental factors and
diabetes management in middle-aged and older
married couples
Personal Non-health Schooling, Marriage duration
Behavioral Outcomes Diet self-efficacy
Other Health Outcomes Diet adherence Glycemic
control Quality of life
Personal Background Age, gender, ethnicity
Personal Health Physical health,
Psychological functioning
Environmental Spousal support, marital quality
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Methods

• Recruit 60 married or cohabiting
  community-dwelling couples living in Central
  Pennsylvania
• Both adults age 50 and relatively healthy
• One adults diagnosed by a physician with type 2
  diabetes at least one year previously
• Recruit through Penn State Diabetes Center
  registry, with recruitment letters signed by
  physician group, and other media
• Participants
• Completed survey questionnaires, provided HbA1c
• Participated in focus groups
• Couples received 50 honorarium and
  newly-released diabetes management tips book

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Preliminary findingsFocus groups

• To date, 51 couples completed questionnaires
• 30 couples also attended focus groups
• Held at GCRC and Hershey Medical Center
• Adults separated into two groups
• Persons with diabetes (PWD)
• Spouses of persons with diabetes (SPWD)
• In seven couples, both adults had diabetes
• Adult with longest diagnosis assigned PWD group
• Adults with shorter diagnosis assigned SPWD group
• Focus groups conducted using well-established
  techniques
• Each group included 5-10 people
• Trained moderators, co-moderators, protocols
• Data recorded, transcribed, and analyzed to
  develop themes until saturation (consensus) was
  reached

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Preliminary findingsFocus groups

• Average focus group participant Age 65, married
  38 years, some college, overweight
• Average PWD 67 year old obese man, diagnosed 10
  years ago, taking oral medications
• Average SPWD 63 year old overweight woman, fewer
  comorbid conditions compared to PWD

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Spousal supportthis?
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Spousal supportor this?
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Focus group findings

• Analyses revealed five core themes around
  adopting and maintaining food-related behavior
  change
• Commitment
• Communication
• Coping
• Competence
• Control
• Themes can be categorized within two key
  theoretical constructs
• Reinforcement (commitment, communication, coping)
• Self-efficacy (competence, control)

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Focus group findings Commitment

• Commitment to marriage links to better spousal
  support and adoption of healthful eating
  patterns
• Here I am a diabetic anda year or so later she
  was diagnosed She gave support when I was
  diagnosed and then later on when she needed it, I
  tried to give all the support I could.
• We committed at the marriage vows. It was until
  death do us part I think we are in it for the
  long haul.
• Lack of commitment to marriage links to low
  spousal support and negative health behaviors
• I think pushing is an interesting question
  because I am sure it is a function of peoples
  personality I do not like it at all It feels
  like criticism to me the strength and will power
  to take care of myself is going to come from me
  He cant change me.
• There is that silent resistance. You do not want
  to have diabetes and you do not want someone to
  remind you that you have diabetes.

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Focus group findings Communication

• Good communication between spouses can validate
  experience and, in turn, improve diet-related
  adherence
• It diabetes is an excuse to talk about your
  health I do not remember her ever expressing
  concern about my health particularly, except
  about this so I support what that really
  translates to is she is concerned about it.
• We talk about almost everything, but about the
  diabetes, we have very little communication at
  all.
• You learn after 50 years a lot of stuff is no
  longer important. It is not worth the energy. You
  learn to pick your battles, you learn to walk
  away, you learn to think about your spouse too.
• If you cant communicate, you cant have a
  compromise.

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Focus group findings Coping

• Positive coping defined as both spouses
  understanding diabetes management rather than
  accepting disease
• Diabetes is more emotional than it is physical.
  I always feel I can cope with the physical side
  of it, but find Im overwhelmed sometimes still
  after having had diabetes for nearly 15 years.
• Diabetes is a daily disease. Today I can cope
  with it actually. Yesterday was not quite that
  good.
• Negative coping defined as behaviors that reduce
  self-efficacy and subsequent decision-making
  about food choices
• I manage diabetes on my own. We can eat
  together but I am going to prepare my own food.
• If your spouse wont work together with you,
  then it has to be done alone. I just do it.
• When it comes to managing diabetes, what I would
  like to be different is for us to work together
  with my diabetes management.

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Focus group findings Coping

• Coping further characterized by compromise and
  teamwork
• When we found out, my husband and I both said
  well, we are going to have to work at this
  together. So from the very beginning, I did not
  feel alone and scared because I knew I had the
  support of my husband.
• Like I say, if you have harmony and you have
  love big problems are handled like little
  problems and little problems take care of
  themselves. If you have contention and you have
  struggles and you have a lot of disharmony,
  little problems are handled like big problems and
  big problems are not even addressed.

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Focus group findings Competence

• Competence in making diet changes increases with
  greater knowledge and understanding about
  diabetes by both spouses
• Since we are both diabetics, it is a little
  easier. We both go grocery shopping and we both
  have the same goals. We look at the labels. We
  both try to eat healthier than we did in the
  past.
• We buy more books now and we read more. I read
  about the food. So we talk more than we did
  before the diabetes.
• I became familiar with what to observe. She
  tests a lot because she is trying to regulate her
  diet. I make it my business to know what is was
  because if she has a high, I know that is going
  to be followed by a low.
• I went to see an endocrinologist to get a little
  bit more specialized care. I think that is when
  my self-care finally turned around. I also go to
  a clinic and I see a nurse practitioner every
  three months.

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Focus group findings Control

• Control was characterized by acknowledging diet
  adherence is most difficult behavior change
• Control can be internal
• One of the problems I was faced with
  immediately was that I did not want to be come a
  nutritional bookkeeper It just did not really
  turn me on at all.
• I can get off-track with food. I usually say to
  myself, oh one more day and I will start again. I
  will go back on track tomorrow. I kind of get
  off-track for a long timethen it is hard to get
  back on.
• Control can be external
• I resent my wifes control over food and her
  nagging. She says it all adds us, so that even a
  single piece of candy is like the black plague.
• Well, my wifes control over food leads me to
  stash food in the house. Yes, and that is not
  healthy. That I realize.

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Focus group findings Control

• Spousal control over food preparation
  particularly relevant to men
• Wives responsible for food-related decisions
• Wives offered both instrumental and emotional
  support
• Men reported
• Lower self-efficacy (loss of control)
• Higher self-efficacy (collective control)
• Women reported
• Greater diet-related self-efficacy
• Lower emotional support from spouses

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Conclusions

• Adhering to healthful eating patterns was the
  most challenging self-care behavior for
  middle-aged and older adults living with diabetes
  in central Pennsylvania
• Core themes around diet adherence can be
  categorized within two Social Cognitive Theory
  constructs
• Reinforcement
• Self-efficacy
• Self-efficacy increased with positive
  reinforcement from spouse resulting from
• Commitment to marriage
• Good communication
• Positive coping skills

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Conclusions

• Gender differences were observed
• Women with diabetes
• Reported greater control over own diet than did
  men
• Wanted more emotional support from their spouses
• Offered more instrumental support because they
  were responsible for meals and food management
• Men with diabetes varied in self-efficacy
  depending on how they interpreted spousal support
• Overall, men appeared to benefit more from
  spousal support

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Practice and policy implications

• Preliminary findings suggest
• Focus on couple is key in interventions
• Opportunities to share stories with other couples
  provide needed outside social support
• Health care providers should consider role of
  spouses in diet adherence
• Participate in physician visits
• Attend diabetes education classes
• Future research should focus on role of marital
  and social contexts in behavior change adherence
• Combination of quantitative and qualitative
  research can enrich research

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Thank you! Questions?
Baby Blues (3-11-06)
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