rothenberger cd (2011) Journal of Nursing and Healthcare of Chronic Illness3, 77–86
Chronic Illness Self-Management in prediabetes: a concept analysis
Aim. To explore the concept of self-management in prediabetes.
Background. Type 2 diabetes is a global epidemic, resulting in significant morbidity and mortality. Effective management of prediabetes, primarily through lifestyle modification, has been demonstrated to significantly slow or prevent the onset of type 2 diabetes. A clear definition of self-management in prediabetes is needed to direct intervention and research.
Methods. Concept analysis, as outlined by Walker and Avant (2005), was used to clarify the meaning of self-management in prediabetes.
Conclusion. Defining attributes of self-management in prediabetes include setting of individualised goals, engagement in long term lifestyle modification, self-monitoring of progress, and collaboration with healthcare professionals. Antecedents, consequences and empirical referents are discussed. The concept is clarified through presentation of model, borderline, related and contrary cases.
Relevance to clinical practice. Exploring the concept of self-management in prediabetes provides a structure for evidence based practice in type 2 diabetes prevention. Healthcare providers can advocate for antecedents to self-management and develop interventions to support attributes of self-management to assist individuals in slowing down or preventing the onset of type 2 diabetes.
Approximately one fourth of adults in the United States are estimated to have prediabetes (Cowie et al. 2006), defined as impaired fasting glucose (100–126 mg/dl; 5·3–6·9 mmol/l) or impaired glucose tolerance (140–199 mg/dl; 7·8–11 mmol/l after a two hour glucose tolerance test) (Garber et al. 2008, Diabetes Prevention Program Research Group 2009). These individuals have a 5- to 15-fold increased risk of developing type 2 diabetes within five years (American Association of Diabetes Educators 2009), leading to significant risk for cardiovascular, cerebrovascular and peripheral vascular disease (Ryden et al. 2007). Similar trends have been noted in Europe (Ryden et al. 2007, Schwartz et al. 2008a) and the World Health Organization recognises diabetes as a global epidemic, affecting at least 171 million people (World Health Organization 2010). Intensive lifestyle modification has been found to substantially decrease or slow progression to type 2 diabetes (Knowler et al. 2002). Numerous professional and public health organizations support self-management of prediabetes as an effective means of decreasing the incidence of type 2 diabetes (Garber et al. 2008, Rosenzweig et al. 2008, American Diabetes Association 2010, World Health Organization 2010). A significant challenge associated with prevention of diabetes is that the affected individual is largely responsible for implementing interventions required to manage prediabetes. Although these interventions have been described, awareness and implementation remain low (Geiss et al. 2010). A clear definition of self-management in prediabetes is needed to provide a foundation for intervention with individuals and communities.
Although self-management has been examined in other contexts, it has not been defined in prediabetes. Lack of clear understanding of the concept prevents consistent implementation of effective self-management strategies, impairs communication among healthcare professionals and patients, and presents a barrier to conducting research which can be translated into practice. The purpose of this paper is to explore the meaning of the concept in order to identify tentative theoretical and operational definitions, attributes, antecedents, consequences and empirical referents of self-management in prediabetes.
Concept analysis, as outlined by Walker and Avant (2005), was used to clarify the meaning of self-management in prediabetes. After determination of the aim for the concept analysis, relevant literature was identified by searching appropriate databases including the Cumulative Index to Nursing and Allied Health Literature, PubMed, The Cochrane Database of Systematic Reviews, PsycINFO, Education Research Complete, and Business Source Complete. Self, management, self-management (both with and without the hyphen), prediabetes, impaired glucose tolerance and diabetes prevention were searched. The search focused on uses of the term after publication of the diabetes prevention program (DPP) results in 2002. Synthesis of literature led to identification of defining attributes, which were applied in model, borderline, related and contrary cases. Antecedents and consequences of self-management in prediabetes were proposed. Theoretical and operational definitions were formulated and empirical referents considered. Description of current use of the concept can provide a foundation for evidence based practice in prevention of type 2 diabetes.
In order to fully understand self-management in prediabetes, the definition of the term must be examined (Walker & Avant 2005). The Oxford English Dictionary Online (1989) defines self- as a prefix ‘with reflexive meaning …in various relations with the second element of the compound’. (Self 1989). In this case, it is paired with a noun of action (-management), meaning management by oneself or by ones power. Self- was first used in the 16th century as an imitation of a Greek compound. Compound uses of self- increased greatly after the 17th century, and are not individually defined by the dictionary.
The Oxford English Dictionary Online defines the noun management as ‘organization, supervision, or direction; the application of skill or care in the manipulation, use, treatment, or control (of a thing or person)’ (Management 1989). This word was initially used in the 16th century. First used in a medical context in 1860, management can also be defined as ‘the care of a patient or treatment of a disease or condition; the coordinated course of action determined for this purpose’ (Management 1989).
A more complete understanding of self-management can be gained by exploring use of the term in a variety of disciplines (Walker & Avant 2005). In business, self-management is used to describe an individual’s strategic regulation of their own career (Abele & Wiese 2008, Kaplan 2008). The term also refers to a management style in which a group of employees has the autonomy, flexibility and decision-making ability to structure their personnel and work processes to achieve common goals (Tata & Prasad 2004, Langfred 2007). In information technology, self-management is a characteristic of a computing system which functions with minimal human intervention in order to decrease human workload and error (Huebscher & McCann 2008, Noirie et al. 2009). The term is used in the field of education to describe the ability of a student to control their own classroom behaviour, and avoid engaging in disruptive conduct (O’Reilly et al. 2005, Gureasko-Moore et al. 2007, Briesch & Chafouleas 2009).
Self-management is used similarly in nursing, psychology and medicine. Glasgow and Anderson (1999) define self-management as the ‘cluster of daily behaviours that patients perform to manage their diabetes’ (p. 2090). Grey et al. (2006) add that self-management is more than compliance with a set of instructions, but is a dynamic process of maintaining health in the setting of a chronic illness. Lorig and Holman (2003) state that self-management involves day-to-day responsibility for a chronic disease and is a lifelong task. Self-management can be enhanced by providing education and emotional support to teach skills required to manage a health care regimen and change behaviour. Key components include active engagement of the client and collaboration between the client and healthcare providers (SMART Center n.d.). The American Diabetes Association identifies client empowerment, collaboration with healthcare team members, goal setting, self-care activities, and ongoing support as critical aspects of self-management of diabetes (Funnel et al. 2010).
The concept of self-management began to be widely discussed in relation to prediabetes after publication of results of the DPP in 2002. In this landmark study, 3234 non-diabetic individuals with elevated fasting or postload blood glucose levels were randomised to one of three treatment groups: metformin and standard lifestyle recommendations, placebo and standard lifestyle recommendations, or intensive lifestyle modification. The primary goals for participants in the intensive lifestyle modification arm were 7% weight loss and engagement in at least 150 minutes of moderately intense physical activity per week. Although goals were similar for all subjects, strategies for meeting goals were personalised. Sixteen weeks of individual lifestyle modification education focused on exercise, nutrition and behavioural strategies. Bimonthly individual and/or group follow-up with case managers was provided. Participants self-monitored their weight, calorie and/or fat intake and exercise. When compared with the placebo arm, the incidence of type 2 diabetes was 58% lower in the intensive lifestyle modification group and 31% lower in the metformin group. Weight loss was the primary predictor of diabetes prevention. The Diabetes Prevention Program Research Group (DPPRG) concluded that engagement in intensive lifestyle modification can prevent or delay the onset of type 2 diabetes in individuals with prediabetes (Knowler et al. 2002). A later analysis of DPP data concluded that lifestyle modification is a cost-effective approach to diabetes prevention (Ratner and Diabetes Prevention Program Research 2006). Ten year follow-up revealed that the intensive lifestyle modification group demonstrated the lowest cumulative incidence of type 2 diabetes (Diabetes Prevention Program Research Group 2009). Similar trends have been noted with lifestyle modification interventions in Europe (Lindstrom et al. 2006) and Japan (Imai et al. 2008).
Work in diabetes prevention since 2002 has frequently incorporated most aspects of the DPP protocol, with modifications to facilitate translation into practice. Education about prediabetes, the risk of progression to type 2 diabetes, and lifestyle modification strategies has generally been provided in a group setting and in a condensed format (Imai et al. 2008, Seidel et al. 2008, Amundson et al. 2009, Kulzer et al. 2009, Whittemore et al. 2009). Content in education programs closely mirrored information included in the DPP, focusing on decreased calorie and/or fat intake, weight loss of 5–10% of body weight, and 150 minutes/week of moderate physical activity (Imai et al. 2008, Seidel et al. 2008, Amundson et al. 2009, Kulzer et al. 2009, Whittemore et al. 2009). One program focused primarily on daily exercise (Yates et al. 2008). All studies included goals which were similar to those used in the DPP. Several supported individualization of goals (Yates et al. 2008, Imai 2008, Whittemore et al. 2009). Self-monitoring of lifestyle modification activities was a component of these trials, although the parameters varied slightly. Frequency of self-monitoring correlated positively with meeting weight loss and physical activity goals in one study (Amundson et al. 2009). Follow-up contact with a healthcare provider was integral to all protocols. Ongoing contact took place in small group sessions (Seidel et al.2008, Amundson et al. 2009, Kulzer et al. 2009) or one-on-one (Yates et al. 2008, Whittemore et al. 2009), and continued for six (Seidel et al. 2008, Yates et al. 2008, Amundson et al. 2009, Whittemore et al. 2009) to 12 months (Kulzer et al. 2009). Outcome measures used in these studies varied, but all found a decrease in weight and increase in physical activity. Some also noted a decrease in fasting blood glucose and other criteria associated with metabolic syndrome (Yates et al. 2008, Kulzer et al. 2009, Whittemore et al. 2009).
Several meta-analyses of diabetes prevention literature have been published. The authors (Norris et al. 2005, Gillies et al. 2007, Madden et al. 2008) concluded that while lifestyle modification interventions are effective in preventing or slowing progression to type 2 diabetes, sustained change remains a critical and challenging factor in diabetes prevention. As a result of the body of work in type 2 diabetes prevention, several professional organizations have issued statements on this topic. The American Association of Diabetes Educators (2009) recommends that all individuals with prediabetes have access to education about risk, dietary changes, weight loss, and physical activity and engage in long-term lifestyle modification. They identify collaborative, individualised goal setting and regular follow-up as critical factors in successful self-management. The American Diabetes Association (2010) states that patients with prediabetes should be referred to an ongoing programme for education, weight loss and physical activity. In their consensus statements on prediabetes, the European Society of Cardiology, European Association for the Study of Diabetes (Ryden et al. 2007), American College of Endocrinology and American Association of Clinical Endocrinologists (Garber et al. 2008) support intensive lifestyle management as the primary treatment modality. They recommend strategies used in the DPP, and state self-monitoring, realistic incremental goal setting and ongoing support increase success in self-management for prevention of type 2 diabetes. The Endocrine Society (Rosenzweig et al. 2008) identifies long-term lifestyle modification as an individual and public health priority for prevention of type 2 diabetes.
Several terms closely related to self-management were indentified during the literature search, including self-monitoring, compliance and adherence. Self-monitoring has been described as awareness and observation of self, leading to improved self-management (Wilde & Garvin 2007). After a review of nursing literature, Ingram (2009) concluded that compliance involves obedience, adaptability and flexibility in following a prescribed plan of care. In this context, patients are passive recipients of healthcare. Adherence is defined as the degree to which an individual follows a prescribed treatment plan from a healthcare professional (Bissonnette 2008). Adherence and compliance are frequently used interchangeably (Bissonnette 2008, Shay 2008). Several authors identify adherence and compliance as concepts which may not have relevance in today’s patient-centered environment of care, as they diminish autonomy and collaboration between individuals and healthcare providers (Glasgow & Anderson 1999, Bissonnette 2008, Ingram 2009). In a qualitative study investigating perceptions of self-management, individuals with chronic illness did not necessarily associate compliance with self-management (Kralik et al. 2004). In contrast, other authors recognise compliance to recommended treatment as a component of effective self-management (Buelow & Johnson 2000, Lorig & Holman 2003, Warsi et al. 2004, Grey et al. 2006). In prediabetes, adherence to lifestyle modification recommendations has been associated with prevention or delay of type 2 diabetes (Knowler et al. 2002, Lindstrom et al. 2006, Gillies et al. 2007, Kulzer et al. 2009, Noirie et al. 2009).
After a literature review of self-management in prediabetes, defining attributes can be identified. These characteristics are frequently discussed in relation to prediabetes and provide an understanding of self-management in this context (Walker & Avant 2005).
Engagement in intensive lifestyle modification activities is foundational to self-management in prediabetes. Weight loss and regular moderate exercise were primary interventions in the intensive lifestyle modification arm of the DPP and resulted in a significant decrease in progression to type 2 diabetes (Knowler et al. 2002). Work in diabetes prevention since 2002 has consistently included these interventions (Kelly et al. 2004, Biuso et al. 2007, Garber et al. 2008, Madden et al. 2008, Seidel et al. 2008, Yates et al. 2008, American Association of Diabetes Educators 2009, Amundson et al. 2009, Kulzer et al. 2009, American Diabetes Association 2010). Activities specific to self-management in prediabetes include weight loss of approximately 5–10%, a decrease in calorie and/or fat intake, and moderate physical activity for 150 minutes/week. Long-term lifestyle modification is necessary (Madden et al. 2008, American Association of Diabetes Educators 2009).
Setting realistic, individualised goals for lifestyle modification is also an attribute of self-management in prediabetes. Goals consistently identified in literature are based on those used in the DPP (Knowler et al. 2002). The ADA (Funnell et al. 2010) identifies goal setting as a guiding principle in self-management education. Other professional organizations have specifically recommended setting incremental goals which are tailored to each client’s needs (Garber et al. 2008, American Association of Diabetes Educators 2009).
Self-monitoring is an additional attribute of self-management in prediabetes. Self-monitoring of pertinent parameters (weight, caloric and/or fat intake, exercise) can assist the client and healthcare provider in assessing progress toward desired outcomes (Knowler et al. 2002), and serve as a motivator for change (Bandura 2004). Frequency of self-monitoring is positively associated with the achievement of weight loss and activity goals (Knowler et al. 2002, Amundson et al. 2009).
Ongoing support from health care professionals is the final attribute of self-management in prediabetes. Frequent interaction with a health care provider assists in maintaining accountability in goal achievement (Garber et al. 2008, American Association of Diabetes Educators 2009) and facilitates development of problem solving skills (American Association of Diabetes Educators 2009). A review of weight loss interventions for prevention of diabetes found that frequency of contact with health care providers positively correlated with weight loss (Noirie et al. 2009). The American Diabetes Association (2010) cites ongoing counselling as a critical factor in the success of diabetes prevention.
Although not found in this review of literature, several other attributes are likely to be present in self-management in prediabetes. Problem solving (Lorig 2003, Lorig & Holman 2003, Newman et al. 2004) and decision making (Buelow & Johnson 2000, Kralik et al. 2004, Lorig & Holman 2003) have been frequently identified as attributes of self-management among individuals with chronic illness. Reports of interventions to facilitate self-management in prediabetes do not consistently include a description of strategies to support problem solving and decision making, although these are likely to be integral parts of lifestyle modification education and counselling. The fluctuating trajectory of chronic illness and multiple demands of daily life require that individuals make frequent adjustments in order to maintain balance (Buelow & Johnson 2000, Holman & Lorig 2004, Kralik et al. 2004). Successful adaptation contributes to a sense of control (Lorig & Holman 2003, Kralik et al. 2004, Newman et al. 2004, Grey et al. 2006) within the context of the illness. The presence of these widely recognised attributes of self-management should be validated through future work in this specific population.
When analyzing a concept, it is helpful to consider a model case which includes all attributes of the concept (Walker & Avant 2005). The following is a model case for self-management in prediabetes.
Mrs. M is a 54 year old woman with a past medical history of hypertension and obesity (weight = 106·4 kg or 234 lb). During a routine medical exam she learns her fasting blood glucose is 6·3 mmol/l (114 mg/dl). Her physician discusses her increased risk for diabetes and tells her that lifestyle changes are effective in slowing down or preventing the development of diabetes. He refers her to a Diabetes Center for prediabetes education classes. Mrs. M and the Certified Diabetes Educator (CDE) agree that her goals will be to walk at a moderate intensity for 30 minutes 5–6 days/week, and lose 7·3 kg (16 lb) over the next year. Mrs. M uses a daily food and exercise diary to track her weight, calorie intake and physical activity. Mrs. M returns to her physician in three months, and reports that she walks for 30 minutes in a local park every day, has consistently followed a 1400 calorie/day diet and has lost 5·5 kg (12 lb). She continues to return for medical exams every three months, and frequently calls the CDE when she has questions or concerns. One year after her diagnosis, Mrs. M has lost 8·2 kg (18 lb) and her fasting blood glucose is 4·8 mmol/l (86 mg/dl). She tells her physician, ‘I’m relieved that I have decreased my chances of getting diabetes. These changes have become a part of my life, and I intend to continue them!’
This model case contains all the attributes of self-management in prediabetes. Appropriate individualised goals are set in collaboration with a CDE. Mrs. M engages in lifestyle modification by walking regularly, decreasing her caloric intake and losing weight. She monitors her progress daily, continues to see her physician regularly and seeks support and information from a CDE. Mrs. M reports that she is committed to long-term lifestyle modification.
The following borderline case contains some, but not all, attributes of self-management in prediabetes (Walker & Avant 2005).
Mrs. B is a 54 year old woman with a past medical history of hypertension and obesity (weight = 106·4 kg or 234 lb). During a routine medical exam she learns her fasting blood glucose is 6·3 mmol/l (114 mg/dl). Mrs. B is referred to a prediabetes education program, but decides that she will not attend the classes, as she prefers to learn independently. She gathers information about diabetes prevention during an internet search, learning that she should lose about 7% of her body weight and walk for 30 minutes five days per week. Mrs. B begins a walking programme and follows a reduced calorie diet. She does not use a food/exercise diary. Mrs. B struggles with maintaining her lifestyle changes, and stops exercising during the winter. One year later she has lost 2·3 kg (5 lbs) and her blood glucose is 6·2 mmol/l (112 mg/dl).
In this borderline case of self-management, Mrs. B receives information about prediabetes and intensive lifestyle modification, and sets appropriate goals. She does not monitor her progress, or have ongoing contact with a healthcare provider. She inconsistently engages in lifestyle modification activities. After one year she achieves a small weight loss, but her blood glucose remains elevated in the prediabetic range. Mrs. B has not demonstrated all attributes of self-management in prediabetes.
A related case uses a concept that is similar to, but not the same as, the concept being studied (Walker & Avant 2005). The following case demonstrates adherence, not self-management, in prediabetes.
Mrs. R is a 54 year old woman with a past medical history of hypertension and obesity (weight = 106·4 kg or 234 l). During a routine medical exam she learns her fasting blood glucose is 6·3 mmol/l (114 mg/dl). She is diagnosed with prediabetes, and her physician tells her she needs to lose 11·4 kg (25 lbs). He gives her a pamphlet with instructions for weight loss, including a 1200 calorie/day diet and 30 minutes of exercise five days per week. He instructs her to follow the plan. Mrs. R reads the pamphlet in detail, and begins the diet and exercise plan. She weighs herself daily, and is successful in following the diet. Six months later, she has lost the recommended weight and her blood glucose is 5·2 mmol/l (94 mg/dl). Mrs. R tells her physician, ‘I followed your instructions, and I am relieved that I have decreased my risk for diabetes. This diet was hard, and I’m glad to be done following it!’
In this related case, Mrs. R is successful in decreasing her blood glucose level, but demonstrates adherence rather than self-management. She follows her physician’s instructions, self-monitors her weight and engages in recommended lifestyle modification activities in order to meet the prescribed weight loss goal. She does not intend to continue her diet or exercise changes. Mrs. R has not demonstrated the self-management attributes of collaboration with a healthcare provider or long-term lifestyle modification.
A case which is clearly not an example of the concept being analyzed can assist in clarifying attributes (Walker & Avant 2005). The following is a contrary case of self-management in prediabetes.
Mrs. C is a 54 year old woman with a past medical history of hypertension and obesity (weight = 106·4 kg or 234 lb). During a routine medical exam she learns her fasting blood glucose is 6·3 mmol/l (114 mg/dl). She is referred to a prediabetes education program. Mrs. C considers her physician’s advice, but decides she is too busy to attend a class or lose weight. One year later, when her medical office calls to schedule a routine exam, she declines an appointment. Two years later she is hospitalised for chest pain. She is surprised to learn that she has gained 6·8 kg (15 lbs) and her fasting blood glucose is 14·9 mmol/l (268 mg/dl). Mrs. C is diagnosed with type 2 diabetes.
This case includes factors which are contrary to the defining attributes of self-management in prediabetes. Mrs. C decides not to engage in lifestyle modification activities or self-monitoring, and does not set any goals. She declines collaboration with and ongoing support from her healthcare provider. Mrs. C has not engaged in self-management.
In order for self-management in prediabetes to occur, several events, or antecedents, must first be present (Walker & Avant 2005). An individual must be screened for and receive a diagnosis of prediabetes. Criteria for screening and diagnosis of individuals who are high risk for diabetes and prediabetes have been developed (Kelly et al. 2004, Garber et al. 2008, Madden et al. 2008, Schwartz et al. 2008a, b, American Diabetes Association 2010).
Knowledge about health risks and benefits of change are a necessary precursor to change. Information about the outcome of behaviour modification may determine health behaviour (Bandura 2004). Educational needs in prediabetes include information about specific lifestyle modification strategies (weight loss, caloric and fat intake restriction and regular exercise), and should be individualised to the client’s needs (American Association of Diabetes Educators 2009). The ADA supports the role of education in self-management, stating that education is related to improvement in outcomes and quality of life (2010). Patients with prediabetes have also identified a need for clear information about the disease process and prevention strategies (Evans et al. 2007).
Self-efficacy, an individual’s belief that they can successfully complete a behaviour (Champion & Skinner 2008, p. 49), is an antecedent to self-management. Bandura (2004) identifies self-efficacy as a significant factor influencing engagement in healthcare behaviours. ‘The stronger the perceived self-efficacy, the higher the goals people set for themselves and the firmer their commitment to them’ (Bandura 2004, p. 145). Enhancement of self-efficacy through education and support focusing on mastery of skills, modelling, symptom interpretation and social persuasion has been identified as a means of improving self-management (Lorig 2003, Lorig & Holman 2003). Increased self-efficacy has also been cited as an outcome of successful self-management (Grey et al. 2006). Self-efficacy was measured in only one study on prediabetes self-management (Yates et al. 2008). Because self-efficacy appears to play a pivotal role in numerous aspects of self-management, it should be further explored in this population.
It is also necessary for the health care system to include a means for providing prediabetes education and support, ideally via a multidisciplinary team. Lack of availability of these services has been identified as a significant barrier to prevention of diabetes on both an individual and community level (Kelly et al. 2004, Evans et al. 2007, Garber et al. 2008, Schwartz et al. 2008a, Schwatrz et al. 2008b, Yates et al. 2008, American Diabetes Association 2010). In addition, financial resources or reimbursement for appropriate care must be available. Although interventions aimed at preventing diabetes have been found to be cost effective, current healthcare systems do not consistently provide adequate compensation for disease prevention services (Garber et al. 2008). Crandall et al. (2008) identified availability of and funding for diabetes prevention services as a significant barrier to type 2 diabetes prevention.
Consequences are outcomes of a concept (Walker & Avant 2005). The primary outcome of self-management in prediabetes is normoglycaemia or slowed progression to diabetes. Because the DPPRG found that weight loss was the primary predictor of diabetes prevention (Knowler et al. 2002), some researchers have instead measured weight loss as the outcome of self-management (Seidel et al. 2008, Amundson et al. 2009).
Self-management in prediabetes is setting of individualised goals, engagement in long-term lifestyle modification, and self-monitoring of progress, in collaboration with healthcare professionals.
Self-management in prediabetes is characterised by collaboration with healthcare providers in setting goals for lifestyle modification activities based on an individual’s unique needs. Long-term engagement in lifestyle modification is based on these goals, and generally includes a decrease in caloric intake, weight loss of 5–10% of body weight, and participation in moderate physical activity for 150 minutes/week. Self-monitoring of progress toward established goals takes place daily, through use of a diet, weight, and/or exercise log. Collaboration with healthcare providers with expertise in diabetes self-management is ongoing as needed to meet individualised goals.
Phenomena demonstrating the presence of the concept are empirical referents (Walker & Avant 2005). Measurement of self-management in prediabetes involves the use of a number of empirical referents. Goal setting can be measured by a client’s self-report of their personalised goals. The unit of measurement is presence or absence of the client’s ability to accurately state lifestyle modification goals (yes/no). Review of a diet, weight and/or exercise diary can facilitate measurement of long-term participation in lifestyle modification activities and self-monitoring. Engagement in lifestyle modification can be measured by collecting data from a diary about risk reduction activities. This data would be based on the individual’s personalised goals, and might include calorie intake per day, fat gramme intake per day, weight and/or minutes of physical activity per week. Weight is measured in pounds and/or percent change in body weight. Self-monitoring can be measured by calculating how frequently the diary is completed. Collaboration with healthcare professionals could be measured by totaling the number of contacts with designated caregivers (e.g. primary care physician, endocrinologist, CDE, etc.) in a predetermined period of time (e.g. contacts per year). Collaboration with healthcare providers can also be measured by evaluating patient satisfaction. Valid and reliable instruments for measurement of satisfaction with disease management services are not widely available, and are frequently proprietary (Sen et al. 2005). The Diabetes Management Evaluation Tool addresses satisfaction with the structure, process and outcomes of diabetes self-management programmes (Paddock et al. 2000). This instrument could be modified to be appropriate for use in clients with prediabetes. Although modification of this instrument would provide an optimal means for evaluation of client satisfaction, instruments that are currently used in a setting may provide an alternate means of evaluation. Consequences of self-management can be evaluated through routine blood glucose measurements. Ongoing monitoring of empirical referents can ensure that all attributes of self-monitoring are present.
Relevance to clinical practice
In addition to moving toward a definition of self-management in prediabetes, results of this concept analysis can provide a foundation for evidence based practice (Walker & Avant 2005). Extensive research supports self-management of prediabetes as an effective strategy for slowing or preventing onset of type 2 diabetes. Antecedents and attributes of self-management should be advocated for and available to all individuals with prediabetes. Although screening guidelines have been developed (Kelly et al. 2004, Garber et al. 2008, Madden et al. 2008, Schwartz et al. 2008a, Schwatrz et al. 2008b, American Diabetes Association 2010), recent research found that less than one third of adults in the United States with prediabetes were aware they had the disorder (Geiss et al. 2010). Knowledge, another antecedent to self-management, is also lacking. Geiss et al. (2010) found that only one third of adults with prediabetes were informed about lifestyle modification by a healthcare provider. While physician advice has been associated with increased engagement in lifestyle modification, a multidisciplinary and community approach is recommended for increased effectiveness (Geiss et al. 2010). Advocacy for healthcare system changes to increase availability of lifestyle modification services is also necessary. The need is particularly great in underserved areas (World Health Organization 2010). Engagement in long-term lifestyle modification, goal-setting, self-monitoring and ongoing support are all features of a coordinated system of care for chronic illness. Supporting self-management of prediabetes based on a common definition has potential for a significant positive impact on health of individuals and communities. Clearly defining the attributes of self-management in prediabetes can allow healthcare providers to move toward incorporating research findings for diabetes prevention into everyday practice.
Exploring current use of the concept of self-management in prediabetes has resulted in identification of tentative definitions, antecedents, attributes, and consequences. Ongoing analysis is required as the concept evolves. Clarification of the meaning of self-management in prediabetes can allow for further theory development and research. The ultimate goal is improvement in health outcomes through implementation of research based interventions which assist individuals in preventing type 2 diabetes.