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1.  Consumption of Sugar- and Fat-Modified Foods among Rural Older Adults: The Rural Nutrition and Health (RUN) Study 
This study examines the levels of and factors associated with consumption of sugar- and fat-reduced foods in a sample of rural, ethnically diverse older adults. Data were collected from 122 older adults, including demographic and health characteristics and six 24-hour recalls over a 16 month period. About one-quarter of sweetened foods were modified, while intake of fat-modified foods ranged from 4.4–76.1%. Few differences in intake of modified foods were observed by gender, and ethnic group. Diabetes status was associated with higher use of sugar-modified foods. This study shows a high level of acceptance of sugar- and fat-modified foods among rural older adults across a variety of demographic and health characteristics.
PMCID: PMC3097384  PMID: 18032214
Nutrition; Elderly; African Americans; Native Americans; Dietary Modification; Low Socioeconomic Status; Dietary Modification
2.  Complementary and Alternative Medicine Use and Diabetes Self-Management Among Rural Older Adults 
Complementary and alternative medicine (CAM) is a growing form of self-care and is related to other healthy behaviors. This study examines the relationship between CAM use and diabetes self-management. A survey of rural older African American, Native American, and White adults with diabetes was conducted. Data were collected on diabetes self-management domains and general and diabetes-specific CAM use. Some associations were observed, particularly for CAM use and following a healthy eating plan. CAM is part of the health maintenance strategy of rural older adults with diabetes. Further research should examine the health trajectory associated with CAM use in this population.
doi:10.1177/1533210106292461
PMCID: PMC2743492  PMID: 19756166
complementary and alternative medicine; diabetes mellitus; self-management; African Americans; Native Americans
3.  Predictors of Falls in a Multiethnic Population of Older Rural Adults With Diabetes 
Background
Falls are a recognized danger for older adults with diabetes. Persons in rural communities with diabetes may face additional risks from falling due to environmental and activity differences.
Methods
Data were obtained in a cross-sectional survey of a stratified random sample of 691 community-dwelling adults (42.7% white, 31.4% African American, and 25.9% Native American) at least 65 years old with two or more Medicare claims for diabetes in 1998–2000, living in two rural counties in North Carolina. Falls data were self-reported for the previous year. Demographic data, foot-related symptoms, diabetes medications, and other health characteristics were reported.
Results
Three hundred two persons (43.7%) reported falling at least once, including 171 (26.2%) who experienced two or more (frequent) falls. Frequent fallers were more likely to be male (odds ratio [OR] = 1.76; 95% confidence interval [CI] = 1.17, 2.66), report tingling or numbness in feet (OR = 1.75; 95% CI = 1.13, 2.70), have had a stroke (OR = 1.81; 95% CI = 1.19, 2.76), have longer duration of diabetes (OR = 1.21; 95% CI = 1.00, 1.47), have lower physical functioning (OR = 0.97; 95% CI = 0.96, 0.99) and mobility (OR = 0.89; 95% CI = 0.82, 0.96), and take a greater number of prescription medications (OR = 1.07; 95% CI = 1.01, 1.13).
Conclusions
For rural older adults with diabetes, falls history should be screened to identify those at risk. Further research should investigate unique environmental factors contributing to falls for rural elderly persons.
PMCID: PMC1592639  PMID: 16611707
4.  Complementary and Alternative Medicine Use as Health Self-Management: Rural Older Adults With Diabetes 
Objectives
This study describes complementary and alternative medicine (CAM) use among rural older adults with diabetes, delineates the relationship of health self-management predictors to CAM therapy use, and furthers conceptual development of CAM use within a health self-management framework.
Methods
Survey interview data were collected from a random sample of 701 community dwelling African American, Native American, and White elders residing in two rural North Carolina counties. We summarize CAM use for general use and for diabetes care and use multiple logistic modeling to estimate the effects of health self-management predictors on use of CAM therapies.
Results
The majority of respondents used some form of CAM for general purpose, whereas far fewer used CAM for diabetes care. The most widely used CAM categories were food home remedies, other home remedies, and vitamins. The following health self-management predictors were related to the use of different categories of CAM therapies: personal characteristics (ethnicity), health status (number of health conditions), personal resources (education), and financial resources (economic status).
Discussion
CAM is a widely used component of health self-management among rural among older adults with diabetes. Research on CAM use will benefit from theory that considers the specific behavior and cognitive characteristics of CAM therapies.
PMCID: PMC1622916  PMID: 16497962
5.  Ethnic Disparities in Glycemic Control Among Rural Older Adults with Type 2 Diabetes 
Ethnicity & disease  2005;15(4):656-663.
Glycemic control is a predictor of diabetes-related morbidity and mortality. However, little is known about how well older adults in rural communities, with limited access to self-care resources and specialty care practitioners, control their diabetes. Even less is known about whether minority, older, rural adults are at increased risk for poor glycemic control. We analyzed data from a cross-sectional survey of randomly selected older (≥65 years) adults with type 2 diabetes in rural North Carolina. Participants (N=693) were men and women from three ethnic groups: African American, Native American, and White. Capillary blood samples were collected for HbA1C analysis. HbA1C levels (<7%, 7%–<8%, and ≥8%) were compared across ethnic and gender groups. Two multiple logistic regression models (model 1: personal characteristics; model 2: personal and health characteristics) were used to evaluate potential predictors of HbA1C ≥7%. Overall, 36.4% had HbA1C ≥7%. Native Americans and African-American men had the highest proportion at levels of poor glycemic control (≥7%), and African-American women and White men had the lowest. In bivariate analysis, ethnicity, living arrangements, use of medications for diabetes, having a diabetes-related healthcare visit in the past year, and duration of diabetes were significantly associated with glycemic control. In multivariate analysis (model 1), being Native American, having low income without Medicaid, and being married were associated with poor glycemic control. Adding health characteristics (model 2), longer diabetes duration and diabetes medication therapy were significant predictors. These data indicate that older ethnic minorities in rural communities are at increased risk for diabetes complications and need diabetes management strategies to improve glycemic control.
PMCID: PMC1780265  PMID: 16259490
African Americans; Elderly; Diabetes; Ethnicity; Glycosylated Hemoglobin; Health Disparities; Native Americans; Rural
6.  Self-monitoring of Blood Glucose in a Multiethnic Population of Rural Older Adults With Diabetes 
The Diabetes educator  2005;31(1):84-90.
Purpose
The purpose of the study was to describe self-monitoring of blood glucose (SMBG) practices of 698 older adults with type 2 diabetes in the rural Southeast, to identify characteristics differentiating testers from nontesters, and to identify personal and support-related predictors of monitoring frequency.
Methods
The ELDER (Evaluating Long-term Diabetes Self-management Among Elderly Rural Adults) study was a population-based, cross-sectional survey of African American, Native American, and white Medicare recipients ≥65 years with diagnosed diabetes. Data were obtained through in-home interviews. Multiple logistic regression models were used to identify factors associated with SMBG and frequency of monitoring.
Results
Seventy-seven percent of respondents practiced SMBG in the previous week; 40% tested every day in that week. No ethnic differences were seen. Significant independent predictors of any SMBG were medication regimen (taking oral agents or insulin with or without oral agents) and health care provider (HCP) recommendation to test. Among those monitoring, significant independent predictors of SMBG frequency were medication regimen, HCP recommendation to test, duration of diabetes, and receiving help with testing, which was negatively associated with monitoring frequency.
Conclusions
Among rural older persons with diabetes, HCP recommendation significantly affected practicing SMBG and SMBG frequency. These findings suggest points of intervention by diabetes educators with this vulnerable population. Further research is needed to determine how older adults use SMBG data in their self-care regimen.
PMCID: PMC1630682  PMID: 15779249
7.  Physical Activity Among Rural Older Adults With Diabetes 
Purpose
This analysis describes physical activity levels and factors associated with physical activity in an ethnically diverse (African American, Native American, white) sample of rural older adults with diabetes.
Method
Data were collected using a population-based, cross-sectional stratified random sample survey of 701 community-dwelling elders with diabetes completed in 2 rural North Carolina counties. Outcome measures were as follows: first, physical activity in the past year, and second, days physically active in the prior week (0-7). Potential correlates included personal and health characteristics and were evaluated for statistical significance using logistic regression models.
Findings
About half (52.5%) of the participants stated that they had engaged in physical activity in the past year. Among those, 42.5% stated that they had no days with at least 30 minutes of continuous physical activity in the prior week, while 21.5% reported daily physical activity. Common activities were walking and housework. Correlates of physical activity in the past year and days active in the prior week included measures of physical health and mobility.
Conclusions
Physical activity in this ethnically diverse sample of rural elders with diabetes is limited. Effort must be invested to increase physical activity in these groups.
doi:10.1111/j.1748-0361.2006.00026.x
PMCID: PMC1613260  PMID: 16606429
8.  Diabetes Foot Self-care Practices in a Rural, Triethnic Population 
The Diabetes educator  2005;31(1):75-83.
Purpose
The purposes of this study were to assess the level of foot self-care performed in a rural, multiethnic population of older adults and to identify factors associated with foot self-care.
Methods
The Evaluating Long-term Diabetes Self-management Among Elder Rural Adults study included a random sample of 701 African American, Native American, and white adults from 2 rural North Carolina counties. Participants completed in-home interviews, 5 foot self-care practices from the Summary of Diabetes Self-Care Activities (SDSCA), functional status measures, and measures of education and support for foot care.
Results
Foot care practices/behaviors reported at least 6 days/week ranged from 35.6% for inspecting shoes to 79.2% for not soaking feet. Four independent predictors of the SDSCA summary foot care index score were observed: having been shown how to care for feet (P < .0001), female gender (P = .03), having had a doctor check nerves in feet in past year (P = .02), and not receiving support caring for feet (P = .0425).
Conclusions
These findings indicate that educating patients about foot self-care may encourage routine foot care but that those dependent on either formal or informal support to perform foot care do so less frequently than those who perform it independently.
PMCID: PMC1613259  PMID: 15779248
9.  Prevalence and Correlates of Depressive Symptoms Among Rural Older African Americans, Native Americans, and Whites With Diabetes 
Diabetes care  2005;28(4):823-829.
OBJECTIVE
Depression is associated with morbidity, mortality, and decreased quality of life and is a well-established complication among people with diabetes. Little is known about the prevalence and correlates of depressive symptoms among older adults living in rural communities, particularly among ethnic minority groups, who are at increased risk of developing diabetes and complications.
RESEARCH DESIGN AND METHODS
Data were analyzed from the ELDER (Evaluating Long-term Diabetes Self-management Among Elder Rural Adults) diabetes study in which face-to-face interviews were conducted with 696 older (≥65 years of age) African-American, Native American, and white men and women in two rural counties in central North Carolina.
RESULTS
Using a criterion of ≥9 on a modified CES-D (Center for Epidemiologic Study of Depression) scale, 15.8% of the sample had depressive symptoms. In bivariate analyses, depressive symptomatology was more common among women and individuals who were unmarried and had less than a high school education, fewer financial resources, more chronic conditions, more prescription medications, and lower physical functioning. In multivariate analyses, sex, education, living arrangement, BMI, number of prescription medications, number of chronic conditions, and physical functioning remained significant.
CONCLUSIONS
These results show that older rural adults with diabetes are at high risk for depressive symptoms, regardless of their ethnic group, and that certain demographic and health characteristics are important factors in this association. These findings add to the limited body of knowledge of comorbid depression in this population. Greater attention should be paid to diagnosing and treating this condition by those who provide care to these populations.
PMCID: PMC1592640  PMID: 15793180
10.  Primary and Specialty Medical Care Among Ethnically Diverse, Older Rural Adults With Type 2 Diabetes: The ELDER Diabetes Study 
Purpose
Residents in rural communities in the United States, especially ethnic minority group members, have limited access to primary and specialty health care that is critical for diabetes management. This study examines primary and specialty medical care utilization among a rural, ethnically diverse, older adult population with diabetes.
Methods
Data were drawn from a cross-sectional face-to-face survey of randomly selected African American (n = 220), Native American (n = 181), and white (n = 297) Medicare beneficiaries ≥65 years old with diabetes in 2 rural counties in central North Carolina. Participants were asked about utilization of a primary care doctor and of specialists (nutritionist, diabetes specialist, eye doctor, bladder specialist, kidney specialist, heart specialist, foot specialist) in the past year.
Findings
Virtually all respondents (99.0%) reported having a primary care doctor and seeing that doctor in the past year. About 42% reported seeing a doctor for diabetes-related care. On average, participants reported seeing 2 specialists in the past year, and 54% reported seeing >1 specialist. Few reported seeing a diabetes specialist (5.7%), nutritionist (10.9%), or kidney specialist (17.5%). African Americans were more likely than others to report seeing a foot specialist (P<.01), while men were more likely than women to have seen a bladder specialist (P =.02), kidney specialist (P =.001), and heart specialist (P =.004), after adjusting for potential confounders. Predictors of the number of specialists seen include gender, education, poverty status, diabetes medication use, and self-rated health.
Conclusions
These data indicate low utilization of specialty diabetes care providers across ethnic groups and reflect the importance of primary care providers in diabetes care in rural areas.
PMCID: PMC1586168  PMID: 16092292
11.  Behavioral Interventions to Improve Performance in Collegiate Football 
Using a multitreatment withdrawal design, this study evaluated the differential effects of publicly posted plus verbal feedback, goal setting plus verbal feedback, and publicly posted feedback, verbal feedback, and goal setting together on the performance of 3 collegiate football players in practice scrimmages. Also assessed was whether the changes in practice behavior generalized to games. The dependent variables were performances on three wide receiver skills. The results show that public posting with verbal feedback, goal setting, and public posting with verbal feedback and goal setting were effective in improving player performance to a 90% criterion level during practice, and these changes generalized to game performance.
doi:10.1901/jaba.2006.5-06
PMCID: PMC1702400  PMID: 17020220
coaching interventions; sports
12.  Knowledge and Perceptions of Diabetes in an Appalachian Population 
Preventing Chronic Disease  2005;2(2):A13.
Introduction
Qualitative research on knowledge and perceptions of diabetes is limited in the Appalachian region, where social, economic, and behavioral risk factors put many individuals at high risk for diabetes. The aim of this study was to gain a culturally informed understanding of diabetes in the Appalachian region by 1) determining cultural knowledge, beliefs, and attitudes of diabetes among those who live in the region; 2) identifying concerns and barriers to care for those with diabetes; and 3) determining the barriers and facilitators to developing interventions for the prevention and early detection of diabetes in Appalachia.
Methods
Thirteen focus groups were conducted in 16 counties in West Virginia in 1999. Seven of the groups were composed of persons with diabetes (n = 61), and six were composed of community members without diabetes (n = 40). Participants included 73 women and 28 men (n = 101).
Results
Findings show that among this population there is lack of knowledge about diabetes before and after diagnosis and little perception that a risk of diabetes exists (unless there is a family history of diabetes). Social interactions are negatively affected by having diabetes, and cultural and economic barriers to early detection and care create obstacles to the early detection of diabetes and education of those diagnosed.
Conclusion
Public health education and community-level interventions for primary prevention of diabetes in addition to behavior change to improve the management of diabetes are needed to reduce the health disparities related to diabetes in West Virginia.
PMCID: PMC1327707  PMID: 15888224
13.  Ethnic Differences in Elders' Home Remedy Use: Sociostructural Explanations 
Objective: To determine if ethnic differences in elders' use of home remedies are explained by structured inequalities. Method: Dichotomous indicators of “food” and “other” home remedies were obtained from a randomly selected cohort of older adults with diabetes (N=701). Analyses evaluated if differences in availability of care, economic hardship, and health status explained ethnic differences in home remedy use. Results: Differences in residential location, discretionary money, and health partially explained greater home remedy use among Black and Native American elders relative to whites. Conclusions: Ethnic differences in elders' use of home remedies are not largely attributed to socially structured inequalities.
doi:10.5555/ajhb.2006.30.1.39
PMCID: PMC1613261  PMID: 16430319
home remedies; older adults; health maintenance; ethnicity; culture

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