Family Support and Diet Barriers Among Older Hispanic Adults With Type

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423 Vol. 36, No. 6 Type 2 diabetes disproportionately burdens the elderly and minority groups in the United States.

1,2 Mexican Americans, the largest Hispanic/Latino subgroup, are almost twice as likely to have diabetes as non-Hispanic whites of similar age. 3 Diet plays an important role in the management of blood glucose control in diabetes, and inadequate diet is a commonly identified problem of diabetes management. 4-9 Research has indicated that several barriers exist to adherence to a diabetic prudent diet.

8,10-12 Barriers to self-care refer to the environmental and cognitive factors that interfere with following the rec- ommended treatment regimen. For older adults, family support may be important in overcoming barriers to self- care. The characteristics of the patient 9s family envi- ronment in which diabetes management takes place have been associated with self-management behav- iors.

13,14 Among Hispanics, the extended family is con- sidered a primary support group. 15,16 Although most would agree that family function and perceived and actual family support would influence a patient 9s adherence to diet, surprisingly little research has been conducted on this matter in adults with diabe- tes and even less among older Hispanics with diabetes. Instead, most of the research on the families 9 ... more. less.

influences on diabetes management has focused on children, ado- lescents, and young adults. 17-19 The implications of these findings for older Hispanics are unknown. Fisher et al found that family structure and organi- zation were associated with good diet and exercise among non-elderly Hispanic patients with diabetes. 13 In another study of predominantly older African Ameri- can adults with diabetes, researchers reported that fam- ily support was related to the pattern of diet self-care behaviors. 11 We hypothesized that perceived family function and family support are associated with barri- ers to diet self-care among older Hispanic adults with type 2 diabetes. This study examined how family function, family support, selected demographic variables, and disease characteristics are related to the older Hispanic adult 9s perception of barriers to diet self-care. The specific objectives of the study included: (1) to determine the level of perceived barriers to diet among older Hispan- F a m il y S u ppo rt a n d D i e t B a rr i e rs A m o n g O l d e r H i s p a n i c A d u l ts W i t h T y p e 2 D i a b e t e s L o nni e K . W e n, PhD; Mi c h ae l L . P a r c h m a n, MD, MPH; M a rvin D. Sh e p h e r d , PhD From VERDICT, South Texas Veterans Health Care System, San Antonio, Tex (Drs Wen and Parchman); the Department of Family and Community Medicine, University of Texas Health Science Center at San Antonio (Dr Parchman); and the College of Pharmacy, University of Texas at Austin (Dr Shepherd). B a c k g r o u n d a n d O b j e c t i v e s : Diet plays an important role in the management of diabetes, and a subop- timal diet is a commonly identified problem. Family support may be important in overcoming barriers to good diet. We conducted this study to examine the role of the family in overcoming barriers to diet self-care among older Hispanic patients with diabetes. M e t h o d s : We performed a cross-sectional sur- vey of 138 older Hispanic adults seeking care at an outpatient university clinic. Patients reported on their perception of family functioning, family support for diet, and barriers to diet self-care. R e s u l t s : Level of family functioning was related to family support for diet self-care, and family support for diet was related to perceived barriers to diet self-care. Scores for family support were higher for those who perceived their family as functional compared to those who perceived their family as mildly dysfunc- tional or dysfunctional. As family support for diet increased, perceived barriers to diet self-care de- creased. C o n c l u s i o n s : To fully understand difficulties encountered by older Hispanic adults with ad- herence to a diabetic diet, primary care physicians should explore the role of family support and family functioning. For those with poorly functioning families or low levels of family support, family-level interventions may need to be considered. (Fam Med 2004;36(6):423-30.) Clinical Research and Methods 424 June 2004Family Medicine ics who have diabetes, (2) to evaluate the level of per- ceived family support specific to diet and level of fam- ily function, and (3) to examine the relationship be- tween perceived family support and demographic and disease characteristics with perceived barriers to diet. Methods Participants Older patients at an ambulatory care center, within a tax-supported county health care system in the South- west, were approached as they presented for care in the clinic reception area by the principal investigator or trained bilingual research assistant. The patients were asked to participate in a survey about their family and factors related to diabetes self-care. The inclusion cri- teria included: (1) adults ages 55 or older, (2) diagnosed with diabetes (type 2) for at least 1 year, (3) prescribed diabetes medication, (4) living in a family environment, and (5) able to provide informed consent. Living in a family environment was defined as (1) living with a spouse/significant other, (2) living with spouse/significant other and children, (3) living with children, or (4) living with family or friends. Inclusion criteria included patients who were prescribed medi- cations, because this study is part of a larger study that examined the relationship between the family environ- ment and diabetes self-care in the four regimen areas 4 diet, exercise, medications, and self-monitoring of blood glucose. 12 The exclusion criteria included (1) treatment for major psychiatric problems within the previous 6 months, because patients who received treatment for major psychiatric problems such as schizophrenia may not provide valid responses to questions about their diabetes self-care behaviors, (2) scoring of 15 or higher on the Patient Health Questionnaire depression screen, 20 because depression might affect their perception of barriers to self-care and perception of family function- ing, or (3) insulin therapy initiated during the 6-month period preceding the study, since this would represent a major modification in medication management that would require adjustment from both patient and family member(s) and may not accurately reflect the perceived support or barriers to self-care. Other exclusions in- cluded (4) presence of major complications that may affect performance of diabetes self-management activi- ties such as cognitive impairment, end-stage renal dis- ease, and blindness or (5) a requirement for nursing care, such as home health nurse assisting with diabetes management. Procedures The interviewer briefly explained the purpose of the study to patients during their clinic visit and screened for eligibility for the study. Patients were asked if they were age 55 or older, if they have been diagnosed with diabetes for more than a year, and if they live with fam- ily. Those who met the inclusion criteria were given more information about the purpose of the study and were asked to participate. The survey was available in English and in Spanish and was completed either be- fore or after the physician visit. Each participant was given a book on diabetes (either in English or in Span- ish) as a token of appreciation for participating in the study. Family members who accompanied patients were asked to leave the area so the participant could com- plete the survey. Approval from our Institutional Re- view Board was obtained. Measures Barriers to Diet Self-care. Barriers to diet self-care were measured with the diet subscale of the Barriers to Self-care Scale developed by Glasgow and associates. 21 The seven-item scale measures the frequency of both environmental and cognitive factors that interfere with following a recommended diet. The scale has been vali- dated on adults with type 2 diabetes. The internal con- sistency for the diet subscale ranges from 0.55 to 0.92 (Cronbach 9s alpha). 8,21 The instrument asks respondents to rate how fre- quently they experience various barriers to diet self- care using a 7-point frequency of occurrence scale from 1 (very rarely or never) to 7 (daily). The scale was scored by averaging the responses across the items. Higher scores indicate a higher frequency of barriers. Family Support. Perceived family support for diet was assessed with the diet subscale from the Diabetes Fam- ily Behavior Checklist II (DFBC-II). 4 There were two items that measure positive and two items that mea- sure negative support specific to diet. For example, participants were asked to rate how often a particular family member will cpraise you for following your diet d (positive support) and will ceat foods that are not part of your diabetic diet d (negative support). The response format is a 5-point scale from 1 (never) to 5 (at least once a day). The diet component scores for the DFBC-II were calculated by adding the positive items and subtracting the ratings of the negative items. 4 A high component score indicates a strong perception of positive interac- tions with the rated family members. To complete the DFBC-II, respondents were asked to think about one family member with whom they generally have the most contact. Family Function. Family function was measured us- ing the Family APGAR Scale. 22 The Family APGAR is a validated scale of family function. The scale was de- veloped as a tool to measure a family member 9s per- ception of five dimensions of family function: adapt- ability, partnership, growth, affection, and resolution. 425 Vol. 36, No. 6 Scores on the Family APGAR assess the overall satis- faction with family life and provide a composite mea- sure of perceived family functioning. In diabetes, the Family APGAR has been used in several studies ex- amining family function and the relationship to glyce- mic control 23,24 and the relationship between family function and quality of life in adults with type 2 diabe- tes. 25 This instrument can be used with either a 3- or 5- point scale. For research purposes, the authors of the Family APGAR recommended that the 5-point scale be used because this improves the instrument 9s reliabil- ity. 26 Each question has five possible responses: cal- ways d (4 points), calmost always d (3 points), csome of the time d (2 points), chardly ever d (1 point), and cnever d (0 points). The participants answer questions dealing with the level of satisfaction with each one of the five aspects of family life as they apply to each family mem- ber. For example, participants rated how satisfied they were with cthe help that I receive from family member when something is troubling me. d The APGAR score for each family member was calculated by summing the scores of the five items in the scale. The overall APGAR score for each participant was calculated by summing the APGAR scores for the participant and dividing by the number of family members rated. The total score ranges from 0 to 20. The higher the score, the higher the level of perceived family function. The 5-point scale was interpreted as functional (15 320), mildly dysfunctional (9 314), and dysfunctional (0 38). The interpretation of the scores is based on previous work by other researchers with the Family APGAR. 24,27-29 The internal consistency for the tool with a five-choice response format has been reported to be 0.86 (Cronbach 9s alpha). 22 The instrument has been cor- related with the Pless-Satterwhite measure of family function and with clinicians 9 rating of family. 30 Demographic and Health Variables. In addition to the above scales, there were items on the survey regarding age, gender, education, income, acculturation (language based), duration of diabetes, and number of diabetes- related comorbidities. Education, income, and duration of diabetes were self-reported. The comorbidities were obtained from the clinical chart. The comorbidities re- lated to diabetes included microvascular and macrovascular disorders. Microvascular disorders in- cluded retinopathy, nephropathy, neuropathy, and foot problems. Macrovascular disorders included cardiovas- cular disease, cerebral vascular disease, and peripheral vascular disease. The scale developed by Deyo and associates is a simple scale for quantifying English use among Mexi- can Americans. 31 The scale consists of four brief ques- tions regarding language. Language has been found to be an important behavioral indicator of acculturation. 32 The language scale appears to be reliable and valid. Scale scores were found to have significant associa- tions with major demographic characteristics that were considered to be correlated with acculturation. 31 Each patient in our study was given a total score by assign- ing 1 point for each response favoring English and zero points for each response favoring Spanish. The patient has a score ranging from zero to 4, with higher scores reflecting higher levels of acculturation. Spanish Translation of Instrument A Spanish version of the instrument was developed by translating the English version of the instrument into Spanish and then back translating it into English. Lin- guistics professionals experienced with health surveys translated and back translated the instrument. Any dis- crepancies were corrected using the consensus of three bilingual experts. The bilingual experts included two linguistic professionals and a bilingual staff member with the Institutional Review Board, whose responsi- bility is to review surveys. Statistical Analysis Descriptive statistics provided information on all variables. For the analyses, marital status categories were collapsed into two categories 4married and not married. Married include living with a significant other. Not married included being divorced, separated, wid- owed, or never married. Household status was also col- lapsed into two categories for the analysis 4lives with spouse/significant other only (couple only) or lives with family (included spouse/significant other and children; children and or other family members). In addition, educational level was collapsed into two response lev- els: (1) 8 or less years of schooling and (2) some high school or high school graduate/some college or col- lege graduate. Non-parametric test (Mann-Whitney U) was used with variables with non-normal distributions. Paramet- ric tests were used when appropriate. Univariate analy- ses were used to examine the relationship between the initial set of predictors and barriers to diet. A regres- sion model was used, and the variables included in the model were those that showed a significance level of 0.25 in the univariate analysis. 33,34 All other analyses were established a priori at P <.05 for acceptance. The Statistical Package for the Social Sciences (SPSS) for Windows ® Version 11.5 was used for all statistical analyses. Results Of the 186 patients who were approached for par- ticipation, 170 agreed to participate, and of those, 138 were self-identified as Mexican Americans and met the inclusion criteria for the study. Demographic and fam- Clinical Research and Methods 426 June 2004Family Medicine ily characteristics of the participating subjects are pre- sented in Table 1. The mean scores for the diet barrier scale are shown in Table 2. The most frequent barrier reported was cbe- ing around people who are eating or drinking things that I shouldn 9t. d Results of the family support scale (DFBC-II), on which respondents were asked to select one family member with whom they generally have the most contact, are shown in Table 1. Almost half of the sample (44.2%) reported that the family member selected ate foods that were not a part of their diet cat least once a day. d The overall median score for diet family support was 1.00 (interquartile range=3.0), which indicates a moderate level of positive support. The range for the scale is -8 to 8, with higher numbers indicating more perceived positive support. The maximum number of family members rated by a single participant with the Family APGAR scale was five. The median APGAR score for the sample was 18 (interquartile range=6), which indicates a high level of family function (range=0 to 20). The scores for the Family APGAR were skewed so that the scores were collapsed to categories for the analyses. A score of 15 or above was categorized as cfunctional. d A score of 14 or less was categorized as cmildly dysfunctional d or cdysfunctional. d Approximately 72% were catego- rized as cfunctional, d and 28% were cmoderately dys- functional d or cdysfunctional. d Table 3 presents the average rank scores for diet fam- ily support and the mean diet barriers scores by family function (APGAR) and gender. The average rank for diet support score was significantly higher in the func- tional group. There were no significant differences in the diet barrier scores among the functional and dys- functional groups or by gender. Additionally, there were no significant differences in family function scores among men and women (chi square=0.820, P =.365). The initial set of independent variables selected for the univariate analyses included age, gender, educa- tion, income, duration of diabetes, number of diabe- tes-related comorbidities, marital status, household sta- tus, family APGAR, and diet family support. Table 4 presents the results of the analyses. Univariate analy- ses were used to condense the pool of initial variables entered into the final multiple regression model. Vari- ables that were significant at the 0.25 level were se- lected for the final model, and these included age, gen- der, marital status, diabetes comorbidities, duration of diabetes, and diet family support. A multiple regres- sion analysis was conducted to examine the relation- ship between these variables and barriers to diet (Table 5). The final model explained 14.4% of the variance for barriers to diet self-care. The linear combination of the predictor variables was significantly related to bar- riers to diet (F=3.62; df =6, 135; P =.002). In the final model, age and diet family support were the only two Table 1 Demographic and Family Characteristics Characteristic n Mean (SD) Age (years)13864.1(6.84) Duration of diabetes (years)13813.4(9.46) Number of diabetes-related comorbidities137 1 1.9(1.15) Acculturation score (range from 0 to 4) 2 1381.8(0.98) Gender Percentage Females9266.7 Total138100.0 Marital status Married7554.3 Widowed3223.2 Divorced or separated2719.6 Never married42.9 Total138100.0 Household status Lives with spouse or significant other5439.1 Lives with children4431.9 Lives with spouse or significant other and children2215.9 Lives with relatives and friends1813.0 Total13899.9 3 Educational level Grade school or less (0 38)6648.2 Some high school (9 311)2619.0 High school graduate or GED3122.6 Some college or college degree1410.2 Total137 4 100.0 Total family monthly income Less than $5002116.9 $501 to $1,0004737.9 $1,001 to $1,5004334.7 $1,501 or greater1310.5 Total124 5 100.0 Employment status Employed2216.1 Not employed/retired11583.9 Total137 5 100.0 Family member with most contact Son or daughter4633.3 Husband4230.4 Wife3023.9 Other (siblings, nephews, aunts, housemate)2012.3 Total13899.9 3 Mean (SD) Average time spent with family member (waking hours) in hours per day7.6(4.69) 1 One chart not available 2 Acculturation scale ranges from 0 to 4 (higher numbers indicate more acculturation.) 3 Does not equal 100% due to rounding error. 4 One respondent did not provide a response. 5 Fourteen respondents did not provide responses. SD 4standard deviation GED 4general equivalency diploma 427 Vol. 36, No. 6 of family support for diet were also more likely to re- port living in a functional family setting. Why should level of family support be inversely re- lated to perceived barriers for diet self-care? Barriers to care that have been associated with the management of diabetes are based primarily within the family set- ting. 35 The most frequent diet barrier reported in this study was cbeing around people who are eating or drink- ing things that I shouldn 9t. d This may be a problem for Hispanic older adults because the Hispanic family household size is larger than those of non-Hispanic whites. 36 In 2000, almost one third of family house- holds in which a Hispanic person was a member con- sisted of five or more people. 37 Only 11.8% of non- Hispanic white family households were this large. More than 40% of our subjects reported that the family mem- ber they spend the most time with eats foods that are not part of their diet cat least once a day. d Participants in other studies have reported that it can be difficult to adhere to a diet regimen if the rest of the family was not willing to eat the same foods that the participants were eating, and preparing two different types of meals may be difficult for most families. 11,38 The level of perceived family support specific to dia- betes was moderate. There were not any gender differ- ences on perceived family support for diet. Brown et al reported that males expressed stronger perceptions of social support for diet than did women. 39 This may be due to the gender role differences in this culture where women are responsible for cooking and preparing meals. The sample in the Brown study was younger (mean age=54 years) than the present study. There may Table 2 Mean Scores for Barrier to Diet Self-care Scale ItemnMean (SD) How often do each of the following happen to you? Around people who are eating and drinking things I shouldn 9t1384.83 (2.42) Not home for meals1383.85 (2.12) Think about costs of foods1373.20 (2.12) Unsure about foods1373.12 (2.17) Still feel hungry1372.93 (2.06) Don 9t have time to prepare foods1362.43 (2.04) Won 9t matter if don 9t follow diet1382.23 (1.91) Overall scale score1373.22 (1.07) Scale: 1=very rarely or never, 2=once per month, 3=twice per month, 4= once per week, 5=twice per week, 6=more than twice weekly, and 7=daily Table 3 Mean Diet Barriers and Diet DFBC Scores by Family Function and Gender Diet Barriers* Diet DFBC** Family functionnMean SDt dfP Value n Mean Rank z P Value Functional ( e 15)993.171.07-0.95134.3469974.64-2.728.006 Mildly dysfunctional/ dysfunctional ( d 14)373.361.08 4 4 43854.30 4 4 Gender Males463.020.94-1.541350.1264667.47-0.429.668 Females913.311.12 4 4 49270.52 4 4 Scale: Diet barriers: 1 (never or rarely ) to 7 (daily); Diet DFBC: range from -8 to 8 with higher scores indicating more perce ived support *Parametric test used 4diet barriers variable displays characteristics of normal distribution as tested by Shapiro-Wilk 9s statis tic = 0.982; P >.05 ** Non-parametric test (Mann-Whitney U) used for non-normally distributed variable DFBC 4Diabetes Family Behavior Checklist significant predictors of barriers to diet. Table 6 pre- sents the bivariate correlations among the variables in the model. Discussion Older Hispanic adults with higher levels of family support for diet self-care reported fewer barriers to diet self-care. Moreover, those who reported higher levels Clinical Research and Methods 428 June 2004Family Medicine not have been any gender differences in our study be- cause our sample was older, and participants may have depended on the support from their children or other family members. The structural function theory may be used to ex- plain the second question of why family functioning is related to the level of family support for diabetes. The theory provides a framework for assessing families and health. The structural functional framework defines the family as a social system. 40 Illness of a family member results in changes of the family structure and function. The theory focuses on the family structure and func- tion and how well the family structure performs its func- tion. The concept of structure refers to how the family is organized, the manner in which the units are arranged, and how these units relate to each other. 40 The concept of function refers to what the family does and why it exists. Structure is assessed by the Family APGAR, and function is as- sessed by the family support specific to diabetes. Family function serves as a resource for social support for the patient. 41 To examine the factors associated with perceived barriers to diet self- care, a regression analysis resulted in a model that explained a modest 14% of the variance in perceived barriers. Family support specific to diet and age were significant predictors of barriers to diet. The greater the family support for diet, the less the perceived barri- ers. Age had an inverse relationship with perceived barriers. This finding is consistent with other studies exam- ining the relationship between age and perceived barri- ers. 8,42 Limitations The results of this study should be interpreted cau- tiously since there are several important limitations. One limitation is that the study was cross-sectional, and cau- sality cannot be determined. Perhaps those who per- ceive their families as being more supportive also per- ceive fewer barriers to self-care, because they gener- ally have a positive outlook. Longitudinal studies are needed to assess the relationship between family sup- port and barriers to self-care over time. Further, the fam- ily interactions were self-reported. Also, the sample was limited to those adults living in a family environment and with lower income. Finally, the results of the study are not generalizable to all older Hispanic adults. The findings from this study have important impli- cations for primary care physicians, dieticians, and dia- betes educators. Previous research has shown that bar- riers to self-care play an important role in adherence to Table 4 Univariate Analyses Between the Initial Set of Independent Variables and the Dependent Variable 4Perceived Barriers to Diet Self-Care VariableFn P Value Age10.38136.002 Gender2.37136.126 Diabetes-related comorbidities1.80135.182 Duration of diabetes2.11136.149 Marital status2.02136.157 Household status0.02136.900 Diet DFBC4.92136.028 Family APGAR0.89135.346 Education1.18135.280 Income 4monthly0.02121.886 DFBC 4Diabetes Family Behavior Checklist Table 5 Multiple Linear Regression Analysis of Barriers to Diet Self-care VariablesBetaSE tSignificance Age-0.040.02-2.410.02 Gender0.370.201.880.06 Diet DFBC-0.090.04-2.510.01 Diabetes comorbidities-0.040.08-0.480.63 Duration of diabetes-0.010.01-0.710.48 Marital status-0.260.20-1.440.15 SE 4standard error DFBC 4Diabetes Family Behavior Checklist Table 6 Bivariate Correlations of Variables in Final Regression Model Diet DietMarital VariablesBarrierAgeGenderDFBCComorbidDurationStatus Diet Barrier1 Age-0.27**1 Gender0.13-0.061 Diet DFBC-0.20*0.020.071 Comorbid-0.110.13*0.07.0101 Duration-0.110.39**0.04-0.130.121 Marital status-0.110.42*0.22**-0.01-0.0090.041 DFBC 4Diabetes Family Behavior Checklist *Correlation is significant at the 0.05 level. **Correlation is significant at the 0.01 level. 429 Vol. 36, No. 6 diet recommendations. 4,6-9 Diet self-care behaviors are deeply rooted in culture and lifestyle. Educational pro- grams that take into consideration the culture and lifestyle of patients and family are needed. For example, for patients with poorly controlled diabetes and poor adherence to diet, consideration should be given to in- cluding the family in office visits and other interven- tions. Further research should be conducted to see if including family in office visits does, in fact, improve adherence. Family functioning is associated with diet family support, thus health care providers might consider as- sessing family functioning when low levels of family support for diet are present and refer for family coun- seling if indicated. Improving family support is impor- tant not only because it is associated with lower levels of perceived barriers to diet self-care, but family sup- port specific to diabetes has also been shown to be re- lated to diabetes self-management activities. 12,18 The greater the perceived support, the greater the self- reported adherence with the diabetes regimen. Conclusions The findings from this study indicate that family functioning is related to family support for diet self- care and that such support is inversely related to per- ceived barriers to following the diet regimen. Knowl- edge of family function and perceived support may be useful to health care providers in the care of older His- panic adults with diabetes. Acknowledgments: The authors are indebted to the patients who generously volunteered their time in participating in the survey. We also thank the fac- ulty and staff at the Family Practice Clinic of the University Health Sys- tem-Downtown Clinic, San Antonio, Tex, for their support in this study. At the time of the study, Dr Wen was a doctoral candidate at the College of Pharmacy, University of Texas at Austin. This material is the result of work supported with resources and the use of facilities at the South Texas Veterans Health Care System. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Corresponding Author: Address correspondence to Dr Parchman, VER- DICT, South Texas Veterans Health Care System, Ambulatory Care 11C-6, 7400 Merton Minter Blvd, San Antonio, TX 78229-4404. 210-617-5300, ext. 4028. Fax: 210-567-4423. parchman@uthscsa.edu. R EFERENCES 1.Anderson LA, Halter JB. Diabetes care in older adults: current issues in management and research. 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