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Review

Type 2 Diabetes Self-Management: Role of Diet Self-Efficacy

Irene Strychar EdD, RD a,b,c,*, Belinda Elisha MSc b,d, Norbert Schmitz PhD c,e, f

a Centre de Recherche du Centre Hospitalier de lUniversit de Montral (CRCHUM), Montral, Qubec, Canadab Dpartement de Nutrition, Universit de Montral, Montral, Qubec, Canadac Montreal Diabetes Research Center (MDRC), Montral, Qubec, Canadad Institut de Recherches Cliniques de Montral (IRCM), Montral, Qubec, Canadae Douglas Mental Health University Institute, Montral, Qubec, CanadafDepartment of Psychiatry, McGill University, Montral, Qubec, Canada

a r t i c l e i n f o

Article history:

Received 23 August 2012Received in revised form11 October 2012Accepted 13 October 2012

Keywords:

dietary behavioursself-efficacyself-managementsocial cognitive theorytype 2 diabetes

Mots cls:

comportements alimentairesconnaissance de ses propres capacitsprise en chargethorie sociale cognitivediabte de type 2

a b s t r a c t

The importance of self-management in diabetes cannot be underestimated. It includes a variety ofbehaviours that are affected by multiple factors. Although much attention has been given to diabetesmanagement as a whole, the purpose of this review is to focus on dietary aspects. One relevant factor inunderstanding this complex system of management is self-efficacy, defined according to the socialcognitive theory (SCT) as an individuals confidence in being able to carry out a behaviour. The primarypurpose of this review is to determine the role of self-efficacy in understanding dietary behaviours andcorresponding outcomes in type 2 diabetes mellitus. We identified 59 articles and 19 met our inclusioncriteria: studies focusing exclusively on type 2 diabetes, having a self-efficacy measure that includeda dietary component, and including self-efficacy and/or related SCT constructs in the intervention. Themajority of studies used a general diabetes self-efficacy measure that included diet as one component ofmanagement, along with exercise, medications and blood sugar control. Results of cross-sectional studiesfound that self-efficacy was associated with dietary self-care behaviours, reduced fat intake andimproved glycemic index-load; it also was found to mediate the association between body mass index(BMI) and depression. Intervention studies, that integrated the concept of self-efficacy and other

constructs of the SCT, resulted in improvements in self-efficacy, behaviours, BMI, and glycated hemo-globin (A1C) with self-efficacy mediating the effect of the intervention on A1C levels. In general,improving dietary self-efficacy has positive effects; however, the development of specific dietary self-efficacy scales seems warranted to better capture the multiple aspects of dietary management in type2 diabetes.

2012 Canadian Diabetes Association

r s u m

Limportancede la prise en chargedu diabtepar le patient ne peut pas tre sous-estime. Elle inclutdiverscomportements qui sont influencs par de multiples facteurs. Bien que beaucoup dattention ait tconsacre la prise en charge du diabtedans son ensemble, le but de cette revue est de se concentrer surles aspects alimentaires. Un facteur pertinent dans la comprhension de ce systme complexe de prise encharge est la connaissance de ses propres capacits, qui est dfinie selon la thorie sociale cognitive (TSC)commelaconfiance individuelle en sa capacit dadopterun comportement.Le butprincipalde cette revueest de dterminer le rle de la connaissance de ses propres capacits dans la comprhension des com-portements alimentaires et des rsultats correspondants au cours du diabte sucr de type 2. Nous avonsrelev 59 articles, dont 19 rpondaient nos critres dinclusion : les tudes visant exclusivement lediabte de type 2, ayant une mesure sur la connaissance de ses propres capacits qui incluait une com-posante alimentaire, et incluant la connaissance de ses propres capacits ou les concepts connexes de laTSC dans lintervention, ou les deux. La majorit des tudes utilisaient une mesure gnrale de la con-naissance de ses capacits sur le diabte qui incluait le rgime comme une composante de la prise encharge, de mme que lexercice, les mdicaments et la matrise de la glycmie. Les rsultats des tudestransversales montraientque la connaissance de sespropres capacits tait associe lautonomie dans les

* Address for correspondence: Irene Strychar, Hpital Notre-Dame du CHUM,Pavillon Mailloux, porte K-6244, Rue 1560 Sherbrooke est, Montral, Qubec H2L4M1, Canada.

E-mail address: [email protected] (I. Strychar).

Contents lists available at SciVerse ScienceDirect

Canadian Journal of Diabetesj o u r n a l h o m e p a g e :

w w w . c a n a d i a n j o u r n a l o f d i a b e t e s . c o m

1499-2671/$ e see front matter 2012 Canadian Diabetes Associationhttp://dx.doi.org/10.1016/j.jcjd.2012.10.005

Can J Diabetes 36 (2012) 337e344
mailto:[email protected]://www.sciencedirect.com/science/journal/14992671http://www.canadianjournalofdiabetes.com/http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://dx.doi.org/10.1016/j.jcjd.2012.10.005http://www.canadianjournalofdiabetes.com/http://www.sciencedirect.com/science/journal/14992671mailto:[email protected]


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comportements alimentaires, la rduction de lapport en matires grasses, et lamlioration de lindiceet de la charge glycmique; il tait galement montr quelle influenait le lien entre lindice de massecorporelle (IMC) et la dpression. Les tudes dinterventions qui intgraient le concept de la connaissancede ses propres capacits et les autres concepts de la TSC entranaient lamlioration de la connaissance deses propres capacits, des comportements, de lIMC et de lhmoglobine glyque (HbA1C) dont la con-naissance de sespropres capacits influenant leffetdelinterventionsur lesconcentrations de lHbA1C. Engnral, lamlioration de la connaissance de ses propres capacits sur le plan alimentaire a des effetspositifs. Cependant, le dveloppement dchelles spcifiques sur la connaissance de ses propres capacitssur le plan alimentaire semble justifier une meilleure comprhension des multiples aspects de la prise encharge alimentaire au cours du diabte de type 2.

2012 Canadian Diabetes Association

Introduction

Diabetes care is complex and requires life-long learning andsupport (1). Individuals with diabetes face the daily challenge ofmaking decisions that affect their diabetes management and ulti-mately metabolic outcomes. Self-management education andsupport programs are recognized by numerous diabetes organiza-tions as integral components of care (2e5). As outlined in theposition statement of the International Diabetes Federation, thegoal of self-management education is to prepare individuals withdiabetes to change their behaviour to support improved outcomes

(5). Several reviews and recent publications have identified thebenefits of self-management interventions (6e10) and of psycho-logical interventions (11) on self-management behaviours andglycemic control, although the effects of these interventions onmetabolic outcomes were variable.

The components of self-management (i.e. healthy eating,increased physicalactivity, optimal glucose control and appropriatemedication use) are as multifaceted as the psychosocial andcognitive factors (i.e. self-efficacy, social support, problem-solvingskills) associated with self-management behaviours (12). Self-efficacy is but one factor associated with self-management behav-iours. It is nevertheless a central component of Social CognitiveTheory (SCT) and is defined as an individuals confidence in beingable to carry outa behaviour (13e16). Self-efficacycan beshaped bypeer modelling, skill development, goal setting, previous perfor-mance accomplishments, observational learning and social support(13e16), related constructs of SCT. Planning interventions thatintegrate these elements into program activities/content aredesigned to increase a persons confidence in performing behav-iours, including confidence in overcoming barriers to performthose behaviours (15). In diabetes, it can play a role in assistingindividuals to carry out daily tasks to take control of their condition(17). Self-efficacy is also a construct that is part of the Health BeliefModel (18) and the Transtheoretical Model, Stages of Change (19).

Self-efficacy has been used to predict behaviours and to planinterventions, yet what is the evidence for its use in type 2 diabetesmellitus? More specifically, how does self-efficacy relate to themultiple facets of diet-related behaviours (i.e. diet plan andnutrient intakes) and corresponding outcomes (i.e. glycemic andweight control)? Therefore, the primary objective of this review isto determine the role of self-efficacy in understanding adherencetodiet, weight management, and metabolic parameters in type 2diabetes. A better understanding of how self-efficacy and relatedSCT constructs are integrated into planning self-managementprograms and a better understanding of the factors associatedwith dietary self-management will better equip clinicians to facil-itate patient empowerment for improved diabetes-related behav-iours and outcomes (20).

Methods

Studies retained in this review were those that focus exclusivelyon type 2 diabetes and have a self-efficacy measure that includes

dietary aspects. Interventions that target self-efficacy and/or goalsetting associated with SCT were also retained. A PubMed searchwas conducted using the following key words: self-efficacy, dietand diabetes (n 214 articles). Other sources of articles included:1) additional PubMed searches using the words: diabetes self-management, nutrition, interventions and/or obesity, 2) identifi-cation of relevant articles cited in these publications, and 3)targeted searches for authors working in the area. Approximately300 articles were identified and 59 were deemed to be relevant tothe review: 40 did not meet inclusion criteria and 19 were retained.Article inclusion criteria: patients with type 2 diabetes, measures

of self-efficacy that included questions on diet self-efficacy andinterventions that integrated self-efficacy and related SCTconstructs in their programs.

Results

Self-efficacy has been studied in different contexts: 1) inter-vention studies that have applied/integrated notions of self-efficacyand related SCT constructs into the program content-activities andintervention studies that have included self-efficacy as a primary orsecondary outcome, and 2) cross-sectional analyses and longitu-dinal studies that examined psychosocial-behavioural-metaboliccorrelates of self-efficacy or analyses that determined their medi-ating or predictive role. The studies in this review consist of anarray of different interventions, measures and outcomes. Theprincipal intervention studies presented in this review aresummarized in Table 1.

Measures

There are important differences in how the construct of self-efficacy is applied. It can range from general applications(i.e. confidence in following diabetes treatments including diet,exercise, medication use and blood glucose monitoring) to specificapplications (i.e. confidence in following the eating plan, confi-dence in reducing fat intake) and to specific situations(i.e. following the diet when eating at a restaurant, following thediet when feeling stressed). Themes from self-efficacy measures

used in selected studies reported in this review are outlined inTable 2.

Description of intervention studies integrating self-efficacy and

related SCT constructs

A randomized controlled trial (RCT) comparing a Self-EfficacyProgram (n 72) with routine care (n 73) was conductedamong individuals with type 2 diabetes recruited from outpatientclinics inTaiwan (21). The program was based on SCT and included:a 10 minute DVD consisting of a success story of an individual withtype 2 diabetes (SCT construct of observational learning). Partici-pants also received a booklet containing information related to diet,physical activity, blood glucose testing, adherence to medicationand foot care as well as goal setting sheets to permit patients to

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monitor their diabetes control. The sheets formed the basisfor discussion at group counselling sessions, held weekly (each60 minutes in duration) for four weeks. During the follow-upperiod, group leaders contacted each participant by phone (10 to15 minutes) at 8 and 16 weeks after baseline to encourage main-tenance of accomplishments. The control group received routinecare that included a 15 minute session with a nurse and another15 minutes with a dietitian. Assessments were done at baseline andat the3- and 6-month follow-ups. Self-efficacy was measured using

the Chinese version of the Diabetes Management Self-Efficacy Scale(DMSES) (22) focusing on confidence in being able to manage bloodglucose levels, diet and level of exercise. Reported self-care activi-ties assessing diet and exercise behaviours were measured usinga 12 item Chinese version of the Summary of Diabetes Self-CareActivities (SDSCA) measure by Toobert et al (23). Diabetes self-efficacy and behaviours were significantly higher in the interven-tion group at 3 and 6 months when compared to the usual caregroup. The intervention was associated with significant

Table 1

Characteristics of selected intervention studies on the role of diet self-efficacy

Study(reference no.)

Population Design Measures Outcomes

21 n 14530e81 yrNo major complicationsRecruited from outpatientclinic and hospital in Taiwan

RCTn 72Self-efficacy program: DVD,booklet, goal-setting sheets,4 group sessions held weeklyand 2 follow-up phone contacts

n 73Control group (routine care:1 visit with a nurse and 1 witha dietitian)

DMSES: 20 items(22)SDSCATooberts et al measure (23)

[ Self-efficacy scores and[ SDSDA behaviour scores inintervention group compared tothe usual care group at 3 and 6 months

24 n 8750e90 yrA1C !7.5%Recruited from a VeteransAffairs Medical Centerin Texas

Randomized studyn 45EPIC program: four 1-hr groupsessions, 3 weeks apart, designedto improve self-efficacyn 42Traditional education: one 2-hrgroup session with a nurse andone 2-hr group session witha dietitian and 1 consultationwith the primary care provider

Self-efficacy for diabetesLorig et als 8-itemmeasure (25,26)A1CNo behaviours assessed

[ Self-efficacy scores in EPIC groupcompared to traditional educationgroup at 3-months but not maintainedat 12 months andY A1C levels at 3 and 12 months;self-efficacy mediates A1C

27,28 n 1665 subjects!55 yrMedicare recipientNo major comorbiditiesRecruited from primary careproviders in underservedareas in New York state

RCT

n 844IDEATel Telemedicine program:30e60 min video consultationsevery 4e6 weeks during 2 yrn 821Usual care group

Diabetes self-efficacy

Measure was similar to that usedin Wu et al (21)A1C, LDL-C, blood pressureNo behaviours assessed

[ Self-efficacy scoresY A1C levelsin telemedicine groupSelf-efficacy mediated the effects ofthe intervention on A1C levels

29,33 n 46325e75 yrBMI !25 kg/m2

One other risk factor(but not heart disease)Access to InternetRecruited from 5 primarycare clinics at KaiserPermanente Colorado

RCTn 169CASMInternet website: identificationof behaviours goals with strategieson how to achieve these goals.n 162CASMplus: same as CASM plus3 120-min group sessionsn 132

EUC: possibility to attend theregular programs offeredat Kaiser Permanente Colorado

Self-efficacy for diabetes: (Loriget als 8 items diabetes measureplus 8 additional items, includingdiet) (25)Start The Conversation, generaleating behaviours (31)NCI Fat Screener (32)A1CTC/HDL-CBlood pressure

BMI

All 3 groups improved self-efficacy,behaviours, and metabolic parameters (29)No differences between 3 groupsfor self-efficacy or metabolic parameters,except improved diet behaviours inthe CASM and plus groups comparedto EUC (29)Improvements in dietary behavioursexplained by: self-efficacy, problemsolving, and social environmental

support (33)

34,35 n 824!18 yrNewly diagnosed recruitedfrom 13 primary care clinicsin England and Scotland

RCTn 437DESMOND TrialSelf management educationprogram; one 6-hr group sessionn 387Usual care

No measure of self-efficacySDSCA Questionnaire (23)A1C, lipids, blood pressure,weight-height

1-yr results (35)Significant Yweight 2.98 kg vs. 1.86 kg3-yr results (34)Differences not maintained 1.75 kgvs. 1.44 kgNo differences in A1C

42 n 10340e70 yrDiabetes !1 yrNo major complicationsRecruited from clinics,newspaper and television

advertisements

n 55Intervention group9 weeks of group session, each2 hr in duration designed toimprove diet glycemic indexand glycemic load and

self-efficacyn 48Delayed intervention group

DES-SF (43,44)Self-efficacy for glycemicindex and diet

Improvements in participants dietglycemic index and load, and glycemicindex self-efficacy after the interventionand at the 18 week follow-up

BMI, Body mass index;CASM, Computer-Assisted Self-Management; DES-SF, DiabetesEmpowerment Scale-Short Form;DMSES, DiabetesManagement Self-Efficacy Scale;EPIC,Empowering Patient in Care; EUC, Enhanced Usual Care; HDL-C, high-density lipoprotein cholesterol; LDL-C, low-density lipoprotein cholesterol; RCT, randomized controlledtrial, SDSCA, Summary of Diabetes Self-Care Activities; TC, total cholesterol.

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improvements in both self-efficacy scores and self-care behaviours;no measure of glycemic control was provided.

A randomized study was conducted to compare 2 interventions,the Empowering Patient in Care (EPIC) program vs. the TraditionalEducation program, among 87 patients with type 2 diabetesrecruited from a Veterans Affair Medical Center registry in theUnited States (24). The 3-month EPIC program was based on prin-ciples of the SCT and included concepts of goal setting, feedback,self-management goals and corresponding action plans, alldesigned to enhance the persons self-efficacy in being able to carryout the behaviours. It consisted of four 1-hour group sessions held

3 weeks apart. Each group session was followed by a 10 minuteindividual session with a clinician, during which the other partic-ipants had the opportunity to interact with their peers. The themesaddressed in the group sessions were as follows: 1) ABC s of dia-betes and 3 risk factors: glycated hemoglobin (A1C), blood pres-sure, cholesterol levels, 2) principles of goal setting were reviewedpermitting individuals to determine their own diabetes goals andaction plans related to diet, exercise, blood glucose monitoring andmedication usage, 3) principles of enhancing patient-physicianinteraction so as to obtain feedback on goals and action plans,and 4) feedback on participants performances. Each session wasdivided into 3 components: clinician led discussion regardinginformation provided in a manual given to each participant,discussion of problem-based exercises in the manual and peer-suggested practical applications related to the session theme. The

Traditional Education program consisted of two 2-hour sessions,one with a nurse (discussing disease aspects and medications) andone with a dietitian (knowledge of diabetes, food labels, mealpreparations and portion control), and a 20 to 30 minute visit withtheir primary care provided to discuss self-management anda treatment plan. Participants were assessed for self-efficacy andA1C levels at baseline, at 3 months (after the intervention) and at12 months (1-year follow-up). Lorig et als (25,26) measure wasused to assess diabetes self-efficacy that consists of 8 items relatedto confidence in eating meals on a regular basis, in following thediet, in choosing appropriate foods to eat when hungry, in exer-

cising, in preventing blood sugar levels from dropping whenexercising, in knowing what to do when blood sugar levels arehigher or lower than they should be, in judging when illnessnecessitates a visit to the doctor and in controlling diabetes so thatit does not interfere with daily activities. Results indicated thatself-efficacy scores were higher in the EPIC intervention group at3 months when compared to the Traditional Education program,however these increases were not sustained at the 1-year follow-up. A1C levels significantly decreased in the intervention group at3-months, compared to the Traditional Education program, andwere maintained at the 1-year follow-up, with self-efficacy scorespartially mediating this effect. Changes in dietary or exercisebehaviours were not reported.

A randomized trial compared a home telemedicine program,entitled the Informatics for Diabetes Education and Telemedicine

Table 2

Themes of self-efficacy measures

Reference no. General themes Confidence to

22,25,26,29,45,51,52,54 Diet, eating, weight control,fat, glycemic index, carbohydrates

Follow my diet on a regular basisFollow my diet when eating with people without diabetesFollow my diet when preparing food for othersFollow my diet when eating at a restaurantStick to my diet most of the timeStick to my diet when away from homeStick to my diet when on vacation

Stick to my diet at a partyAdjust my diet when away from homeAdjust my diet when illAdjust my diet in case of stressAdjust my diet for extra physical exerciseEat my meals every 4e5 hr every dayControl my body weightKeep my weight under controlResist food temptationsChoose the appropriate foods to eat when I am hungryControl the amount of food I eat by measuring portion sizeLimit eating high-fat foodsPurchase lower fat foodsUse lower fat cooking methodsPrepare foods with a low glycemic indexSelect foods with a low glycemic index at the supermarketMake choices based on the glycemic index value of foods

Choose low glycemic index foods when I eat outSubstitute a low glycemic index food for a high glycemic index foodUse glycemic index recommendations to plan mealsAdjust carbohydrate intake based on my blood glucoseMake healthy food choices by reading the amount of total carbohydrateon the food labelControl the amount of carbohydrate I eat

22,25,26,54 Exercise Exercise regularlyExercise 15e30 min, 4e5 times a weekDo extra exercise on doctors advicePrevent blood sugar levels from dropping during exercise

22,25,26,45,54 Blood glucose Test my blood sugar at the recommended frequencyMonitor blood glucose at homeKnow what to do when my blood sugar levels are too highKnow what to do when my blood sugar levels are too low

22,25,26 Medications, treatment Take my medications according to prescriptionAdjust my medications when ill

Consult my doctor for diabetes controlJudge when the changes in illness needs a visit to the doctor



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(IDEATel) project, with usual care among 1665 individuals withtype 2 diabetes !55 years of age to underserved areas in New Yorkstate (27,28). The intervention incorporated principles of the SCTand was designed to increase self-efficacy. Videoconferences (tel-evisits with a nurse or dietitian case manager) were held for 30 to60 minutes every 4 to 6 weeks during the entire 2-year interven-tion period. A web-computer program permitted the uploading ofsubjects blood glucose and blood pressure readings and resultswere discussed during the televisits. Other issues covered during

the televisits included discussions about diabetes, nutrition andexercise as well as diabetes management goals. An endocrinologistreceived the summary of each televisit. A general self-efficacymeasure of diabetes, similar to the one used in the Wu et al study(21,22), was administeredat 3 time points (baseline, year 1 and year2). Results indicated that baseline self-efficacy scores were signif-icantly inversely correlated with baseline A1C, blood pressure andlow-density lipoprotein cholesterol (LDL-C) levels. The interventionwas associated with improved self-efficacy scores and A1C levelsover time; self-efficacy also mediated the effect of the interventionon A1C levels. Finally, changes in self-efficacy were significantlyrelated to changes in A1C levels, but not to changes in bloodpressure or LDL-C. No measures of behaviours were reported.

Evaluation of an Internet-based diabetes self-management

program was conducted among 463 subjects with type 2 diabetesrecruited from 5 primary care clinics in KaiserPermanente Colorado(29). Subjects were randomized to 3 groups: 1) computer-assistedself-management (CASM) program (n 169), 2) computer-assisted self-management program with social support (CASM-plus) (n 162)and 3) enhanced usual care (n 132). Participants ofthe CASM program identified 3 achievable goals for medicationtaking, healthy eating and exercise, and subsequently monitoredtheir progress on the website, with feedback. Six weeks later,subjects developed action plans and identified barriers to achievingthese goals and identified problem solving strategies to addressthese barriers. The site also included additional resources such ashandouts for healthy lifestyles, quizzes and motivational tips.Subjects received calls encouraging them to use the computer-

based program. Participants of the CASMplus program receivedthe same interventionas CASM butalso received 2 additional phonecalls between weeks 2 and 8 and were invited to attend three120-minute group sessions. The enhanced usual care group couldparticipatein the traditional programs offered to Kaiser PermanenteColorado members that included education classes, weight lossgroups and case management (30). Assessments were conducted atbaseline and at 4 and 12 months. Self-efficacy was measured using2 scales: 1) Lorig et als (25,26) 8-item measure of general diabetesself-efficacy and 2) eight additional items regarding taking medi-cations, exercising and limiting high-fat foods. Dietary behaviourswere evaluated using Start The Conversation measure (31) and theNational Cancer Institute Fat Screener (32). Metabolic parametersassessed included A1C, total cholesterol/high-density lipoprotein

cholesterol ratio, bloodpressureand body massindex (BMI).Resultsat the12-month follow-upindicated that all3 groupsimproved self-efficacy, improved dietary behaviours and improved metabolicparameters, with larger effect sizes observed at the 4-monthassessment than at the 12-month assessment. However, no signif-icant differences between the 3 groups were detected, except forbehaviours whereby improvements in the CASM and the CASMplusgroups were higher than the enhanced usual care group. Further-more, cross-sectional analyses indicated the psychosocial variablesexplaining dietary behaviours were self-efficacy, problem solving,and social environmental support (33).

One trial applied and integrated the concepts of self-efficacyinto a structured group education program but changes in self-efficacy were not evaluated as a primary outcome. In the DiabetesEducation and Self Management of Ongoing and Newly Diagnosed

(DESMOND) trial, 824 individuals from 13 primary care sites inEngland and Scotland were randomized to either a one-time6-hour education program (1-day or 2 half-day sessions) (n 437) or usual care within approximately 6 to 12 weeks of diagnosis(n 387) (34,35). The education program was based on 3 theo-retical frameworks: Leventhal`s common sense theory, dual pro-cessing theory and social learning theory (renamed Social CognitiveTheory by Bandura). It focused on food choices, physical activityand cardiovascular risk factors. Participants were encouraged to

select achievable goals for behaviour change that were based onpersonal risk factors. Assessments were conducted at baseline andat the 1 and 3-year follow-ups. Results at 1-year indicated that theeducation group lost significantly more weight (2.98 kg)compared to the usual care group (1.86 kg) (35), but this differ-ence was not maintained at year 3 (1.75 vs. 1.44, respectively)(34). No significant differences between groups were found for A1Clevels (after adjusting for baseline values and clustering for primarycare sites), for depression or for quality of life scores.

Another intervention that did not evaluate self-efficacy wasthe Look AHEAD (Action for Health in Diabetes) trial (36e39).The authors also did not explicitly refer to the construct of self-efficacy in describing their weight loss program; however, theydid integrate constructs of SCT (goal setting and monitoring

activitiesmeans of increasing self-efficacy) into the intervention;therefore this trail was retained in this review. Look AHEAD isa multicentered randomized trial in 16 sites in the United Stateswith 5145 overweight and obese individuals with type 2 diabetes. Itwas designed to compare the effects of two programs (IntensiveLifestyle Intervention [ILI] vs. Diabetes Support and Education[DSE]) on weight loss and incidence of major cardiovascular diseaseevents over a period ofw12 years (36e39). The ILI is a goal-basedbehaviour oriented program (36) that was adapted from thecurriculum of the Diabetes Prevention Program (40). In the ILIprogram, during year 1, participants had frequent contacts (groupand individual sessions): weekly in the first 6 months (3 groupsessions and 1 individual session) and 3 times per month in thefollowing 6 months (2 group sessions and 1 individual session). The

goals were provided by the program:!7% weight loss during year 1and maintenance of this weight loss, exercising !175 minutes perweek, reducing fat intake to


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Diabetes Empowerment Scale-Short Form (DES-SF) that does nothave specific questions related to diet (43,44) and 2) a 20-itemquestionnaire of dietary self-efficacy designed to evaluate confi-dence in using the glycemic index to make healthy food choices,control portion size of food, control of carbohydrate intake andself-monitoring for optimal glycemic control (45). Food intake wasassessed using a 3-day dietary recall. Results indicated that partic-ipants in the intervention group (n 55), compared to the delayedintervention group (n 48), significantly improved their glycemic

index self-efficacy scores, their diets glycemic index and glycemicloadimmediately afterthe 9 weekintervention; thesechangesweremaintained at the 18-week follow-up. Interestingly, improvementsin the scores of the general self-efficacy measure, without a dietcomponent, were not maintained at the 18-week follow-up.

Factors associated with self-efficacy

Recent cross-sectional studies were conducted among patientswith type 2 diabetes in Malaysia (n 388) (46), in Jordan (n 223)(47) and in India (n 507) (48). The Malaysian and Jordanianstudies used the 20-item Diabetes Management Self-Efficacy Scale(DMSES) (22); in India, a 4-item questionnaire was used wherebysubjects were asked whether they were able to keep blood sugar in

good control, keep weight under control, do things needed fordiabetes and handle feelings about diabetes. In 2 studies thatmeasured diabetes self-care behaviours (Toobert et als SDSCAmeasure [23]), a significant association between diabetes self-carebehaviours and self-efficacy (46,47) was reported. All 3 studies alsoshowed a significant association between self-efficacy scores andglycemic control (A1C).

In a similar study in Alabama (n 50), Hunt et al (12) also foundthat diabetes self-care behaviours (SDSCA measure) (27) weresignificantly correlated with self-efficacy (DMSES) (28), socialsupport and social problem solving. Self-efficacy was notassociatedwith demographic characteristics, except for higher education.Sharoni and Wu (46) also reported that higher self-efficacy wasassociated with higher levels of education.

In the San Francisco Bay area, Skaff et al (49) studied self-efficacyamong individuals with type 2 diabetes of Latino and Europeandescent. Diabetes self-efficacy (measured by 4 items: confidence tomake and to maintain changes in their diet and exercise program)was found to be associated with adherence to recommendedcalories (amount consumed/amount required, from a 3-day foodrecord) and with adherence to exercise behaviours for EuropeanAmericans (n 115) but no significant association was found forLatino participants (n 74). The authors concluded that theseresults should be interpreted with caution because factors nottaken into consideration included: language barriers, resources,social responsibilities and level of autonomy. In contrast, Sarkaret al (50) reported that diabetes self-efficacy scores did not differacross 4 groups of individuals living in the San Francisco area:

Asian/Pacific Islander, African American, Latino or white race/ethnicity (n 408).

Nouwen et al (51) examined the association between dietaryself-reported behaviours (measured by the 5 diet questions in theSDSCA questionnaire) (23) and dietary self-efficacy (questionsmeasuring confidence in following the diet on a regular basis, whenpreparingfood for others, when eating at a restaurant, etc) at 5 timepoints over an 18-month period, among individuals with type 2diabetes recruited through hospital registries in rural counties inEngland (n 237). Results of univariate analysis indicated thatdietary self-efficacy was significantly associated with dietary self-care behaviours. In multivariate analyses, dietary self-efficacyalong with autonomy support, autonomous motivation, andself-evaluation remained significantly associated with dietaryself-care behaviours, even after controlling for age, sex, BMI and

diabetes knowledge. Furthermore, changes in dietary self-efficacywere also significantly associated with changes in dietary self-care behaviours, but dietary self-care behaviours did not predictdiabetes control (A1C levels).

Ledermann and Sheeshka (52) examined whether self-efficacyfor reducing dietary fat intake was associated with stages ofchange of the Transtheoretical Model among 186 participants ofdiabetes education centers in Southern Ontario. The self-efficacymeasure included 21 questions related to confidence in

purchasing lower fat foods, using lower fat cooking methodsand reducing portion size of meat. No significant differences inself-efficacy scores were found across the 5 stages of change(precontemplation, contemplation, preparation, action and main-tenance); contrary to the hypothesis that the lowest scores ofself-efficacy would be found among individuals in the pre-contemplation stage, the authors suggest that the lack of significantdifferences may have been due to the small sample size of indi-viduals in the precontemplation, contemplation and preparationstages of change.

Sacco et al (53) examined the mediating role of self-efficacy ina small sample of 56 English speaking subjects with type 2 diabetesrecruited from a Florida Diabetes Center. They found thatself-efficacy (measured using 4-items related to diet, exercise and

weight control of the Multidimensional Diabetes QuestionnaireSelf-efficacy questionnaire) (54) was found to mediate the rela-tionship between BMI and depression and between self-carebehaviours (SDSCA measure) (22) and depression. Diabetesself-efficacy hasalso been found to mediate theassociationbetweenself-care behaviours (SDSCA) (22) and lifelong history of majordepression among women with type 2 diabetes (55). However, ina Korean population of women with type 2 diabetes (56), the asso-ciation between self-efficacy and depression was not significant.

Discussion

In this review of dietary self-efficacy in type 2 diabetes,we foundthat self-efficacy has been found to be associated with numerous

factors, including diverse diabetes management behaviours,selected nutrients and some metabolic parameters. The majority ofthe studies used a self-efficacy measure that included diet as onecomponent of self-management along with exercise, medicationsand blood sugar control (12,21,24,27,29,41,42,46e50,53,55,56) andonly a few self-efficacy measures focused specifically on diet, fat orglycemic index (51,52). All studies that examined the associationbetween self-efficacy and self-care behaviours found significantassociations (12,46e48,51), except for one study in a Latino pop-ulation in San Francisco (49). However, another study in the samearea found no differences in self-efficacy scores across diverseethnicities, including the Latino population (50). Some studies havefound that self-efficacy was associated with A1C levels (27,46,48),others found that self-efficacy was associated with problem solving

and social environment support (12), with diet including overalleating patterns and reduced fat intake (29). One study found thatself-efficacy mediated the association between self-carebehavioursand depression and between BMI and depression (53).

Intervention studies integrated self-efficacy and related SCTconstructs into their programs in a variety of formats. Mostprograms included group sessions (21,24,34,36,41,42) and one ofthese added individual sessions (24), one used telemedicine visits(27) and one used an Internet format (29). Duration of theprograms varied from a one-time group session (34) to a 2-yearintervention (27); follow-ups ranged from several weeks (21,42)to 4 years (36). Therefore, it is not possible to decipher to whatextent program success can be attributed to self-efficacy itself or itsinteraction with other theoretical constructs, to its content, activi-ties or delivery mode. According to the SCT, behaviours are the



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result of a constant interaction between behavioural, personaland environmental factors that are primarily influenced by confi-dence in performing the behaviour, expected outcomes of thebehaviour and values associated with expected outcomes (13e15).Behavioural capacities can be facilitated by setting goals andself-regulation/monitoring. Self-efficacy is therefore but onecomponent of the SCT. Further research is needed because identi-fying which individual components of interventions are the mosteffective still has yet to be determined (8).

The majority of the intervention studies reported that programsdesigned to improve self-efficacy did so at the follow-up assess-ment when compared to the usual care (that varied in intensity)(21,27,29,42), although one study reported that improvementswere not maintained at the 1-year follow-up (24) and anotherstudy found no increases in self-efficacy (41). Two interventionstudies did not include self-efficacy as a primary or secondaryoutcome (34,36) and 2 studies reported that improvements in self-efficacy scores were associated with improved self-managementbehaviours (21,29). Two intervention studies reported that self-efficacy mediates the effect on A1C levels (24,27) and one cross-sectional study reported that it mediates the relationshipbetween BMI and depression (53). Overall, integrating self-efficacyinto program designs has positive benefits on outcomes.

Only 3 studies specifically focused on dietary self-efficacy; onefor glycemic index (42) and 2 for reducing fat intake (29,52).Comparison between studies is difficult because it is well docu-mented that dietary behaviours in diabetes treatment plans aremultifaceted (2,4). The questions used in general self-efficacymeasures do not capture the multiple aspects of dietary self-management (57) nor do they capture the management of behav-iours over time. Furthermore, to our knowledge, no studies haveused weight loss self-efficacy measures in research with type 2diabetes populations (58,59) and no one has fully addressed thecomplexities of appetite in daily diabetes management. Otherlimits of the studies reported in this review include: 1) absence ofa definition of an optimal degree of self-efficacy to achieveimprovements in diabetes management and 2) absence of detailed

clinical assessment and reliance on self-reported behaviourassessments. Furthermore, only a few measures identified in thisreview include a description of their psychometric properties(22,23). Some studies included new questions that were developedfor their specific study objectives and outcome behavioursaccording to the principles of the SCT (13e15). Development ofstandardized diet self-efficacy questionnaires seems warranted tofacilitate comparisons between studies. There is a need to pursuethis area of research, because many adults with type 2 diabetes donot adhere to their treatment plans (60e62). The challenge forclinicians is to ensure that treatment plans for patients integratetheir physiological, behavioural, psychological, cultural and socialenvironmental realities.

Author Disclosures

The authors have no disclosures to declare.

Authors Contributions

IS conducted the PubMed search and identified the articles forthe review; input was provided by BE and NS. All authors wereinvolved in the writing and the critique of the manuscript andapproved the final version submitted.

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