<p>Abstract</p><p>Problem: African Americans face a disparate risk for renal disease development secondary to type 2 diabetes (T2D), and African-American women have shown to be at the highest risk. Despite this, there is minimal research on African American's awareness of renal disease and existing renal disease risk perceptions, and none focused specifically on African-American women with T2D. Although the literature has shown that a portion of this disparate risk is due to modifiable social and cultural factors, there is still a significant amount of unexplained risk. Since past research has shown that risk perceptions can influence preventative behaviors, it is important to gain an in-depth understanding of renal disease beliefs and existing risk perceptions among high-risk African-American women with T2D. Once risk perceptions are better understood in this population, interventions can be developed to correct inaccurate beliefs and risk perceptions and aim to decrease renal disease risk.</p><p>Methods: Three different methods of analyses were employed in this dissertation, including: 1) a systematic review of the literature, 2) an exploratory, descriptive, qualitative study, and 3) a quantitative secondary analysis, including descriptive statistics, a cluster analysis and mixed modeling. The Common Sense Model guided all three studies and these three methods of evaluation helped us to gain a more complete understanding of renal disease risk perceptions in African Americans, particularly African-American women with T2D, and provided guidance for future intervention research in this population. </p><p>Conclusions: The findings of this dissertation illustrated there is a significant gap in the literature on African American's renal disease awareness and risk perceptions, yet the available research was used to guide the in-depth interviews with African-American women with T2D. Overall, African Americans underestimate their renal disease risk and lack an understanding of the disease, even in the presence of risk factors. African-American women, in particular, related renal disease directly to the end-stages of the disease, perceived a greater risk for other complications of diabetes, and exhibited significant fear related to their perceived consequences of the disease. This fear frequently initiated maladaptive coping mechanisms, which influenced risk perceptions negatively and hindered preventative behaviors. This study also found that health care providers rarely discussed the disease and often exhibited provider control. Therefore, these findings suggest an urgent need for clinical practice suggestions and intervention research aimed at correcting inaccurate risk perceptions. The secondary analysis findings showed that a culturally relevant intervention with coping skills training resulted in significant improvements in renal disease risk factors among high-risk African-American women with T2D; however, we cannot be sure which facets of the intervention or control care for equal attention may have influenced these outcomes, and renal disease beliefs and risk perceptions were not assessed in the parent study. Therefore, the knowledge gained from this dissertation can be used to guide intervention research that evaluates change over time in renal disease risk representations, risk perceptions, coping procedures and outcomes among participants at high-risk for renal disease.</p> / Dissertation

Type 2 diabetes mellitus is a metabolic disease that affects one in ten people in the United States. It is caused by a combination of genetics and lifestyle factors. Disease progression begins with insulin resistance in peripheral tissues followed by pancreatic beta-cell failure. The mechanisms behind disease progression are not completely understood. PH domain leucine rich repeat protein phosphatase 1 (PHLPP1) is a known regulator of Akt and other members of the AGC kinase family. Akt has been established to play a role in numerous metabolic signaling pathways, including insulin action. It is hypothesized that as a regulator of Akt, PHLPP1 would have an important function in glucose homeostasis. Glucose tolerance tests performed on 8-week old Phlpp1-/- mice revealed no significant difference in glucose tolerance compared to wild type, however these mice did exhibit increased fasting blood glucose levels. Glucose tolerance tests were repeated at 20 weeks on the same mice and, interestingly, they displayed impaired glucose tolerance compared to wild type. Insulin tolerance tests showed that 8-week old mice have increased insulin sensitivity, however, the 20-week old mice were insulin-resistant compared to control animals. The 20-week old knockout mice also had significantly higher fasting blood glucose levels compared to 8-week old mice. To determine if the increased fasting blood glucose levels are due to increased hepatic glucose output, pyruvate tolerance tests were performed on both the 8 & 20 week old mice. Old mice displayed significantly increased hepatic glucose production compared to wild type. EchoMRI done on 24-week old mice showed significantly increased fat mass and decreased lean mass in the Phlpp1-/- mice compared to wild type littermates. Western blot analysis of liver samples from 32 week old Phlpp1-/- mice indicates loss of Akt signaling accompanied by a decrease in IRS2 protein levels, a common indicator of insulin resistance. These data suggest that Phlpp1-/- mice mimic the development of type 2 diabetes in humans, and provide a unique animal model to study the progression of type 2 diabetes and diabetes-associated complications.

Background: Type 2 diabetes is among the fastest growing diseases in the world, especially in India where the prevalence is 9 percent and expected to rise significantly. Managing diabetes involves a substantial portion of self-care and lifestyle changes for the patient. Hence, the nursing care to patients needs to be focused on promoting self-care and empowerment. Objective: To describe the nursing care, focusing on self-care and empowerment, provided to patients with type 2 diabetes at a private diabetes clinic in India. Method: Eleven diabetes educators with specialist training were interviewed individually. Data was analysed using qualitative contents analysis. Results: One core category called Comprehensive approach was found. Additionally, the data was sorted into four main categories: Nursing care interventions, Counselling, Health education and Health protection. Conclusion: The participants had a comprehensive view of the patients, the disease and the role of health personnel involved in the care. This holistic approach permeated the nursing care performed by the participants, facilitated empowerment and the promotion of self-care to the patients. Clinical relevance: The study provides a widened perspective and understanding of the concepts of self-care and empowerment to patients with type 2 diabetes in different cultural contexts. The results can serve as an inspiration to new ways of promoting self-care and empowerment to patients with other health problems. / Bakgrund: Diabetes typ 2 är en av de snabbast ökande sjukdomarna i världen, särskilt i Indien. Där är prevalensen 9 procent och den befaras stiga betydligt. För att hantera sjukdomen behöver patienten genomföra livsstilsförändringar och behärska egenvård. Därför bör omvårdnaden inriktas på empowerment och att främja patientens förmåga till egenvård. Syfte: Att beskriva den omvårdnad, med fokus på egenvård och empowerment, som ges till patienter med diabetes typ 2 på en specialistklinik i Indien. Metod: Elva diabetesutbildare med specialistutbildning intervjuades individuellt. Materialet analyserades med hjälp av kvalitativ innehållsanalys. Resultat: En kärnkategori, kallad Helhetsperspektiv, hittades. Därutöver sorterades materialet in i fyra huvudkategorier: Omvårdnadsåtgärder, Rådgivning, Hälsoutbildning och Hälsoskyddande åtgärder. Slutsats: Respondenterna hade en helhetssyn på patienterna och sjukdomen, samt på den roll all hälsopersonal som var inblandad i vården hade. Denna helhetssyn genomsyrade omvårdnaden, hur respondenterna arbetade med empowerment till patienterna samt hur de stärkte patienternas kapacitet att utföra egenvård. Klinisk betydelse: Studien bidrar till en vidgad syn på och ökad förståelse för begreppen egenvård och empowerment när det gäller patienter med diabetes typ 2 i olika kulturella kontexter. Resultatet kan även inspirera till nya sätt att arbeta med empowerment och att främja egenvård bland andra patientgrupper.

Bakgrund: Människors sätt att leva har under det senaste århundrandet förändrats.Detta har lett till att diabetes typ 2 har ökat runt om i världen. Diabetes typ 2 är enkronisk sjukdom som leder till höga blodsockervärden. Det går att fördröjasjukdomsförloppet och undvika komplikationer om man genomför livsstilsförändringar.Förändringarna kan leda till tankar och känslor hos individerna kring deras situation.Det är viktigt för sjuksköterskor med ökad kunskap om hur personer med diabetes typ 2upplever genomförandet av livsstilsförändringar. Ökad kunskap inom detta område kange personer med diabetes typ 2 förbättrade förutsättningar vid genomförandet avlivsstilsförändringar.Syfte: Syftet med litteraturstudien var att öka kunskapen om hur personer med diabetestyp 2 upplever livsstilsförändringar. Metod: Allmän litteraturstudie baserad på tolv kvalitativa vetenskapliga artiklar. Resultat: I resultatet framkom fem huvudkategorier; upplevda känslor, hinder ochmöjligheter, upplevelse av motivation, betydelse av stöd samt vikten av information. Diskussion: Utifrån resultatet framkom tre centrala fynd som diskuterades; hinder ochmöjligheter, upplevelse av motivation och betydelse av stöd. / Background: The way people live has changed over the last century. This has led to aworldwide increase of type 2 diabetes. Type 2 diabetes is a chronic disease that leads tohigh blood sugar levels. It is possible to delay the disease progression and preventcomplications if lifestyle changes are implemented. These changes can lead to thoughtsand feelings with the individuals regarding their situation. It is important for nurses tohave a better understanding of how people with type 2 diabetes experience theimplementation of lifestyle changes. Increased knowledge in this area can providepeople with type 2 diabetes improved conditions in the implementation of lifestylechanges. Aim: The Aim of the literature review was to increase the knowledge about how peoplewith type 2 diabetes experience lifestyle changes. Method: A general literature review based on twelve qualitative scientific articles. Results: The results revealed five major categories; perceived emotions, obstacles andopportunities, experience of motivation, the importance of support and the importanceof information. Discussion: Based on the results three key findings were revealed and discussed; Obstacles and opportunities, experience of motivation and the importance of support.

Food systems and health systems are interdependent. Historically, however, strategies that focused on the development of these systems evolved in isolation from one another. Non-communicable diseases such as type 2 diabetes have an etiology that is strongly linked to food systems. Type 2 diabetes is taking an ever-increasing toll on health, and health systems, globally, and in Canada. In response, health professional organizations propose an advocacy approach to improve food system characteristics linked to the development of diabetes. Opportunities for, and barriers to, such initiatives have not yet been examined in the health geography literature. The primary objective of this dissertation is to contribute to the development of a framework for action for nutrition educators working in rural areas to use to promote local sustainable food systems. The ultimate objective is to improve the diet, and by extension, the health of those suffering from type 2 diabetes. As part of the research approach, a gendered analysis was employed for the following reasons: First, labour around food production, food procurement and food preparation and health care work is provided predominantly by women. Second, there is a gendered profile of pattern of illness and access to care for people with type 2 diabetes. The research methodology was comprised of a case study and mixed methods approach. Nineteen communities in southwestern Ontario were selected for inclusion in the case study using criteria based on the Rurality Index of Ontario. Data were collected through extensive literature reviews, 34 semi-structured interviews with health professionals, a survey of 24 people afflicted with type 2 diabetes and ‘in situ’ observations. Analysis of the findings using grounded theory techniques, such as iterative coding, revealed barriers to, and opportunities for, supporting local sustainable food systems by area health professionals working at local, regional and national scales. This thesis provides important information about gender roles, community capacity, sense of community, and health professional training that should be considered in the development of policies to promote local sustainable food systems.

Prevention and treatment of type 2 diabetes mellitus (T2DM), relies heavily on self-care behaviours such as dietary modification, physical activity, and medication adherence. Ability to perform these self-care behaviours depends, at least in part, on executive function (EF). Recent evidence suggests a correlation between T2DM and impaired cognitive function, including EF. Given the importance of EF for regulation of behaviours, and the importance of self-care in diabetes management, attenuated EF would represent a potential barrier to proper disease management. Thus the objective of Study 1 was to examine the association between T2DM and EF through meta-analytic techniques. Medline, PsychoInfo, and Scopus, as well as article references, were used to identify studies comparing individuals with T2DM to a control population. Effect size was calculated using cohen’s d and random effects modeling, and the potential impact of moderators (age, sex, and T2DM duration) were examined. Review of 60 studies (59 articles), revealed a significant, small-to-moderate effect size (d=-0.249, p<0.001) such that those with T2DM have lower EF. This finding was consistent across all aspects of EF examined (verbal fluency, mental flexibility, inhibition, working memory, and attention), and the association was stronger for those with shorter disease duration. The findings of study 1 illustrate that although individuals with T2DM have a great need for EF, as evidenced by the reliance of self-care behaviours on EF, this population has lower EF upon which to draw to perform these behaviours. Thus, strategies that improve EF, such as aerobic exercise, may be particularly relevant to this population. Acute aerobic exercise has been shown to improve EF in young and older adults; however this effect had not yet been examined in individuals with T2DM. Thus the objective of Study 2 was to examine the effects of acute aerobic exercise on EF in adults with T2DM. A within-subject design was used to compare the change in EF task performance following moderate and minimal intensity aerobic exercise, using Stroop and GNG to measure EF. Analysis revealed a significant effect of moderate exercise in women (but not men) and recently active (but not inactive) individuals, such that moderate exercise mitigated the self-regulatory fatigue effect observed following exercise. This study provides preliminary evidence of a significant beneficial effect of moderate aerobic exercise on EF in female and recently active adults with T2DM.

Thesis (Ph.D. (Dietetics))--North-West University, Potchefstroom Campus, 2010.

Background: Physical activity (PA) is an important component of type 2 diabetes management, yet the amount and type of PA support provided by different types of health care providers (HCPs) is largely unknown. Purpose: This study identified differences in the amount and type of PA supports provided by HCPs, and determined whether HCPs use the Canadian Diabetes Association (CDA) PA guidelines or Canada’s Physical Activity Guide (CPAG) in practice. Methods: Eight of 14 Winnipeg Regional Health Authority primary care clinics specializing in diabetes education agreed to participate in the study. In-person interviews were conducted with health care providers (n=48) and patients with type 2 diabetes (n=26). HCPs were given a total PA support score based on scores in three subcategories behaviour change support (BC), assessment/prescription support (AP) and information/referral/community resources support (IRCR), as reported by HCPs themselves and patients. Results: There was no difference in PA support between the 3 HCP types, but there was a significant difference between HCP report and patient report of PA support. Just over one half of HCPs report using the CDA guidelines unprompted or prompted. Conclusions: HCPs recognize the importance of PA in type 2 diabetes management, but implementing strategies to increase certain types of PA support and facilitate understanding between HCPs and patients would allow for optimal PA counseling in primary care.

Objectives: The incidence of type 2 diabetes mellitus (DM2) is on the rise worldwide. The primary objective was to determine the prevalence of nutrient inadequacy and excessiveness in persons with DM2 with and without diabetic peripheral neuropathy (DPN). Study Design: A validated semi-quantitative food frequency questionnaire was used to determine the prevalence of inadequacy of nutrients with an estimated average requirement; the mean intake of nutrients with an adequate intake; and the proportion of persons not meeting the recommendations for the acceptable macronutrient distribution range (AMDR). Results: Differences were observed in the prevalence of inadequacy of vitamin A and the proportion of persons not meeting the AMDR for total fat, linoleic acid and carbohydrate. Conclusion: The aforementioned nutrients may have a significant role in the progression/development of DPN and should be studied in further detail. We recommend a balanced diet and use of a multi-vitamin for persons with DM2.

Thesis (Ph.D. (Dietetics))--North-West University, Potchefstroom Campus, 2010.