According to 2010 data from the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States. It is assumed that various diabetes interventions are available to help individuals manage this chronic disease, but that is not the case. The literature is scant regarding interventions focused on people with disabilities who have diabetes. The purpose of this article is to review interventions specifically focused on people with disabilities who have diabetes and to discuss the effect of these interventions on this population.
Approximately 20% of the adult U.S. noninstitutionalized population has some type of physical, mental, or cognitive disability (Miller, Kirk, Kaiser, & Glos, 2014). Children with disabilities make up approximately 9.2% of the U.S. population. Individuals with disabilities are not always able to access the care that they need, and as a result, often develop secondary conditions such as diabetes (Diab & Johnston, 2004). According to 2010 data from the Centers for Disease Control and Prevention (CDC), diabetes is the seventh leading cause of death in the United States.
Due to limitations in people with disabilities, this population is more likely to be overweight or obese than are people without disabilities, both of which are risk factors for developing diabetes (Centers for Disease Control and Prevention, n.d.). In fact, adults and children with disabilities have increased obesity rates upwards of 58% and 38%, respectively higher than adults and children without disabilities in the general population (Centers for Disease Control and Prevention, n.d.). Individuals with disabilities are more likely to have stated developing a chronic disease such as diabetes or cardiovascular disease (Reichard, Stolzle, & Fox, 2011); and adults with developmental related disabilities are especially more likely to have diabetes (Havercamp, Scandlin, & Roth, 2004). Healthcare costs for people with disabilities can be astronomical. In 2006, expenditures for health care related to disabilities were nearly $398 billion (Anderson, W., Armour, Finkelstein, & Wiener, 2010).
Empirical studies have indicated an association between disabilities and diabetes (Dixon-Ibarra & Horner-Johnson, 2014; Gregg et al., 2000, 2002). In addition, a multitude of interventions and self-management programs exist for people with diabetes (Kanaya et al., 2012; Schulz et al., 2005) and many interventions are directly geared toward people with disabilities (Heller, McCubbin, Drum, & Peterson, 2011; Kosma, Cardinal, & McCubbin, 2005; Spanos, Melville, & Hankey, 2013). However, information is limited on the availability of interventions specifically directed toward people with disabilities who have diabetes. With the growing subpopulation of people with disabilities who have diabetes and diabetes being one of the leading chronic illnesses in the United States, it is imperative that we identify interventions for this population.
Our study purpose was to review the literature on community-based interventions that were collectively directed toward this subpopulation. Our study purpose is imperative as identifying interventions for people with disabilities who have diabetes is one way to help understand the incidence of diabetes, as well as analyze the prevention and explore strategies/interventions available to improve the quality of life for people in this population. For this review we did not distinguish between the type of disability that an individual had so that it could be inclusive of all disabilities (physical, mental, or cognitive). This review looks at studies that were published from January 2004 through August 2014.
Identification of Interventions
The literature search for community interventions for people with disabilities and who have diabetes in the United States was conducted using the electronic databases ABI Inform, Academic Search Premier, CINAHL, and PubMed. Other databases that were used initially, but were determined unnecessary due to article duplication, were Google Scholar, EBSCO, and ProQuest. The key words used to locate articles were “disabilities,” “diabetes,” “interventions,” “disabilities and diabetes,” and “disabilities and diabetes interventions.”
We collected a total of 41 articles, of which 23 articles were duplicates and, thus, subsequently removed. Of the remaining 18 articles, 17 were removed because they did not meet our inclusion criteria. We were looking for articles that specifically addressed diabetes interventions for people with disabilities who had diabetes; thus, we excluded articles on interventions that did not directly address diabetes that affects people with disabilities such as articles that concentrated on obesity, physical activity, or weight loss. As a result our final sample consisted of 1 article.
The lone article that met the inclusion criteria was published in 2009 (Bazzano et al., 2009). The intervention was health promotion related and designed to educate about diabetes, obesity, and fitness. The target population was 431 individuals, 18–65 years of age, with developmental disabilities (mental retardation, autism, epilepsy, cerebral palsy) living in Western Los Angeles county. To be eligible, individuals had to have a BMI greater than 25 and one other risk factor for developing diabetes, or already be diagnosed with diabetes. The intervention program was designed by a team of researchers, health practitioners, and people with developmental disabilities living within the community. The program included client-peer mentoring, health education, supervised physical activity, behavior change, individual health education and advocacy training, clinical maintenance, and an encouraging social network (Bazzano et al., 2009). The intervention used a single group pre-posttest design conducted from December 2005 to June 2006.
In total, 85 of the 431 eligible individuals signed up for the intervention. Approximately 66% of the individuals either lost or maintained their weight, with an average weight loss of 2.6 pounds. The average body mass index (BMI) decreased for all individuals who participated. Thirty-nine individuals had pre-post measurements of their waist circumference, and 74% decreased their waist line by an average of 1.9 inches. In 61% of the individuals, the amount of physical activity rose, with individuals exercising an average of four times per week. Eating habits also improved, as well as daily water consumption. Additionally, individuals felt more comfortable accessing the medical care that they needed; and overall satisfaction with life was enhanced (Bazzano et al., 2009).
Our review showed a gap in the literature as it relates to community-based interventions for people with disabilities who have diabetes. One reason for this gap could be the role that culture plays in more specific interventions targeting people with disabilities who have diabetes. People with disabilities may realize that they stand out among individuals without disabilities, and there is often judgment and shame associated with using specialized services (Jahoda & Markova, 2004). Another reason for this gap in the literature could be that people with disabilities who have diabetes may already be included in several interventions that target people with diabetes, but these studies did not consider individuals with disabilities as a special group. It may also be the case that people with disabilities do not have the opportunity to participate in interventions, whether it be because they have physical or cognitive barriers that prevent them from doing so, or there is a lack of exposure or knowledge to participation in interventions. For instance, in Bazzano et al.'s (2009) intervention, only about 20% of eligible individuals with a disability signed up for the intervention. As a result, a variety of health disparities exists among people with disabilities due to health promotion and disease prevention programming barriers (Piotrowski & Snell, 2007).
Further, there may be some interventions targeted toward this population that have not been published. If that is the case, we are unable to capture that literature in our review. This would result in an incomplete review of any studies conducted on interventions for people with disabilities who have diabetes.
People with a chronic disease require a lot of medical care. They are more likely to make emergency room visits and to be hospitalized, which are expensive, and over time, become cumbersome. Seventy-eight percent of all medical care expenses come from individuals with a chronic disease (Anderson, G., & Horvath, 2004). Diabetes as a chronic disease is unduly burdensome because it is more difficult to manage than other chronic diseases (Larme & Pugh, 1998). In 2012, approximately 9.3% of the U.S. population (29.1 million) had diabetes (Centers for Disease Control and Prevention, 2012). The cost of this chronic disease in 2012 was estimated to be $245 billion, which equates to about $1 in every $5 in health care being spent directly on diabetes (Centers for Disease Control and Prevention, 2012). This denotes a 41% increase from the figure presented in 2007.
If people with disabilities are more likely to report having diabetes, then it is particularly important to address this condition within this population (Dixon-Ibarra & Horner-Johnson, 2014). Thus, interventions for people with disabilities who have diabetes have the potential to manage diabetes, improve quality of life, and avoid related adverse health outcomes by educating this population about the importance of diabetes management. Further, this is in line with one of the goals of Healthy People 2020, which is to improve the participation rate of people with disabilities in activities that promote health (Dixon-Ibarra et al., 2014).
Although not community-based, it is worth mentioning interventions geared toward individuals with diabetes who have health literacy challenges. Close to 90 million people suffer from health literacy difficulties (Shue, O'Hara, Marini, McKenzie & Schreiner, 2010). Among individuals with diabetes, low health literacy is common (Cavanaugh et al., 2009). The term health literacy refers to human capital that individuals have acquired over time which allows them to understand, assess, and apply health information in a manner that will be beneficial to them (Long & Gambling, 2011).
There are interventions that have shown success in addressing the needs of individuals with diabetes who also have health literacy issues. Five interventions, three digital (video and internet) and two in-person, were geared toward educating individuals about literacy, numeracy, empowerment and behavior change, goal setting, and the importance of communication skills with the provider. The video intervention was a qualitative study and intervention satisfaction was perceived well among the individuals (Shue et al., 2010). The two in-person interventions improved self-efficacy and glycemic control, and significantly improved HbA1c and cost savings via the reduction of hospital visits, respectively (Cavanaugh et al., 2009; Micklethwaite, Brownson, O'Toole, & Kilpatrick, 2012). The two Internet interventions were successful in increased confidence and empowerment in individuals to make their own decisions based on knowledge they received, and the ability to use knowledge gained in a way that was beneficial based on their own choices (Long & Gambling, 2011; Rowsell et al., 2015).
It is also important to briefly mention interventions geared toward individuals with diabetes who take atypical antipsychotic drugs. For many people, taking atypical antipsychotics, such as olanzapine and clozapine, leads to extreme weight gain, which in turn is a risk factor for diabetes development (Jean & Pajonk, 2003; Robson & Gray, 2007).
There are interventions that have shown success in addressing the needs of individuals with diabetes who take atypical antipsychotics. Four interventions geared toward overall lifestyle changes that affect health in a positive manner for individuals taking atypical antipsychotics were identified. Interventions that focus on lifestyle have shown more weight loss among this population of individuals, as opposed to interventions that focus on pharmacologic drugs (Park, Usher, & Foster, 2011).
Some key ideas of the interventions focused on weight loss, diabetes, and nutritional education, physical activity, and positive social support (Cimo, Stergiopoulos, Cheng, Bonato, & Dewa, 2012; McKibbin et al., 2006; Park et al., 2011; Weber & Wyne, 2006). One intervention exhibited weight loss in this population using a cognitive/behavioral intervention (Weber & Wyne, 2006). Another demonstrated a higher level of confidence in the individual management of diabetes and understanding related to knowledge and education received during the intervention (McKibbin et al., 2006). Two additional interventions showed positive results related to weight prevention by incorporating several approaches (exercise, nutrition education, motivational interviewing) and positive encouragement, meal planning, and actual cooking of meals, respectively (Cimo et al., 2012; Park et al., 2011).
This review has some limitations. We only reviewed published literature on community interventions for people with disabilities who have diabetes. Based on the lone published article that meets our inclusion criteria, the intervention was implemented at the community level, so generalization is only possible toward the community in which the intervention was implemented. That includes the fact that the target population was individuals with specific developmental disabilities (mental retardation, autism, epilepsy, cerebral palsy) and did not include other developmental disabilities. More community-based interventions are needed to address the health care needs of people with disabilities who have diabetes.
In addition, future research should focus on health disparities that are experienced by disability type and severity of disability. Because all disabilities are different, they cannot be addressed in the same manner. Therefore, it is important to determine which interventions are appropriate, according to the type of disability that an individual has. Future research should also target the composition of financial arrangements and financing systems that are in place to help assist and support people with disabilities who have diabetes.
Chronic diseases include cancer, diabetes, and cardiovascular system abnormalities, which are costly, widespread, and in some cases preventable. Annually, more than 1.7 million people in the United States die from chronic disease (Centers for Disease Control and Prevention, 2004). Because chronic disease is arduous, it is important to manage these diseases efficiently.
Diabetes is a difficult disease to combat for people without disabilities, but it is more difficult to manage among people with disabilities. About 54 million people in the United States suffer some type of disability (Froehlich-Grobe, Lee, & Washburn, 2013). Individuals with disabilities have more and higher health care expenses than individuals without disabilities, especially as it relates to diabetes (Anderson, L., et al., 2009). Medicaid and Medicare comprise about 70% of the almost $400 billion healthcare cost dollars spent on individuals with disabilities (Anderson, W., et al., 2010). More interventions aimed at diabetes management for people with disabilities who have diabetes must be conducted to help this population self-manage this chronic disease.
Manuscript presented orally at 2015 Business and Health Administration Association annual meeting in Chicago, Illinois.
DeLawnia Comer-HaGans, Health Administration, Governors State University, University Park, Illinois;
Shamly Austin, Gateway Health, Research & Development Solutions, Pittsburgh, Pennsylvania; and
Zo Ramamonjiarivelo, Health Administration, Governors State University, University Park, Illinois.
Manuscript presented orally at 2015 Business and Health Administration Association annual meeting in Chicago, Illinois.