567234
research-article2014
TDEXXX10.1177/0145721714567234Provider Exercise and Diet Advice in Adults With Serious Psychological DistressXiang et al
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 185
Provider Advice on Exercise and Diet Among Adults With Comorbid Serious Psychological Distress and Diabetes or Diabetes Risk Factors Purpose
Xiaoling Xiang, MPhil Rosalba Hernandez, PhD
To examine the lifetime prevalence and correlates of provider advice to increase exercise and reduce dietary fat intake among adults with comorbid serious psychological distress (SPD) and diabetes or diabetes risk factors.
Christopher R. Larrison, PhD From University of Illinois at Urbana-Champaign, Urbana, Illinois (Ms Xiang, Dr Hernandez, Dr Larrison). Correspondence to Xiaoling Xiang, M.Phil, School of Social Work, University of Illinois at Urbana-Champaign, 1010 W. Nevada, Urbana, IL 61801, USA ([email protected]).
Methods Study sample (n = 5942) was selected from the Medical Expenditure Panel Survey Household Component (MEPS-HC) series of 2007-2011. SPD was defined as a score of ≥13 on the Kessler Psychological Distress Scale (K6). Multivariate logistic regression was used to examine correlates of lifetime provider advice.
Conflict of interest: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. DOI: 10.1177/0145721714567234
Results
© 2015 The Author(s)
Less than half of adults with SPD had been advised to increase exercise (49.4%) or reduce dietary fat intake (45.6%). The prevalence of receiving provider advice increased in a linear fashion as the number of diabetes risk factors increased and was the highest among those with diabetes. Provision of provider advice was strongly associated with clinical factors rather than individuals’ sociodemographic characteristics and current health behaviors.
Xiang et al Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
The Diabetes EDUCATOR 186
Conclusions Health care providers are missing opportunities to provide exercise and low-fat dietary advice to patients with SPD before they manifest clinical risk factors associated with diabetes. It is important that providers counsel them as early as possible about exercise and nutritional changes that reduce the risks associated with diabetes.
P
ersons with mental illness such as depression and anxiety have high risk for diabetes and other preventable chronic diseases and suffer from excessive premature mortality.1 Diabetes and mental illness individually and collectively contribute to the substantial burden of diseases in the United States. Diabetes affected an estimated 29.1 million Americans in 2012 and cost $245 billion in direct medical costs and reduced productivity.2 Mental illness, on the other hand, accounts for nearly one-third of total US years lived with disability.3 The comorbidity of mental illness and diabetes is associated with poor adherence to diabetes treatment and metabolic control, increase in health care cost and disability days, and decrease in quality of life and life expectancy.1,4,5 Several biological pathways between mental illness and poor outcomes in diabetes and related conditions have been investigated, including shared genetic susceptibility,6 dysfunction in the hypothalamicpituitary-adrenocortical (HPA) axis,7 impaired glucose tolerance,8 excessive visceral fat due to stress, and inflammation.9 In addition, there is substantial empirical evidence documenting the high prevalence of unhealthy behaviors among persons with mental illness,10-13 suggesting behavioral mechanisms between mental illness and diabetes-related outcomes. These studies highlight the importance of targeted lifestyle interventions in reducing the risks for diabetes and its complications and improving life expectancy among people with mental illness. National guidelines, including objectives outlined in Healthy People 2020, call on health care providers to reduce the burden of diabetes and other preventive chronic diseases by increasing counseling or education related to physical activity and nutrition during patients’ office visits.14,15 In-office health counseling is an evidence-based practice as existing evidence suggests that even brief advice by health care providers could promote positive
behavior changes.16-18 Despite the potential benefits of provider advice, previous studies have documented missed opportunities for healthy lifestyle advice in the general population with or without diabetes.19-22 To date, however, little is known about how often the recommended exercise and nutrition counseling guidelines are implemented among individuals with mental illness. In an attempt to begin filling this gap in knowledge, this study examines the prevalence and correlates of provider advice among a nationally representative sample of adults with serious psychological distress (SPD). SPD is a nonspecific indicator of past year mental health problems, such as anxiety and depression.23 Previous studies have shown that people with SPD experience significant individual, financial, and system barriers to general medical care.24 There is concern that the recommended exercise and nutrition counseling may not be consistently provided to individuals with SPD partially because of providers’ distrust of patients’ ability to make positive lifestyle changes due to the stigma of mental illness that is sometimes found in the health care setting.25 The objectives of the study were to determine the lifetime prevalence of health care providers’ advice to increase exercise and reduce dietary fat intake and examine correlates for the provision of provider advice among adults with comorbid SPD and diabetes or diabetes risk factors.
Materials and Methods Participants
This study analyzed data from the Household Component of Medical Expenditure Panel Survey (MEPS-HC). Conducted by the Agency for Healthcare Research and Quality (AHRQ), the MPES is a large-scale nationally representative survey of health services and expenditures for US civilian, noninstitutionalized population. The MEPS-HC collects data from a sample of families and individuals in selected communities across the US, following a multistage area probability design. MEPS collects detailed information through in-person interviews for each person in the selected households on demographic characteristics, health conditions, health status, access and use of medical services, charges and source of payment, and satisfaction with care. MEPS adopts an overlapping panel design, where a new panel of sample households is selected each year, and each panel of households is followed for 2 calendar years. During
Volume 41, Number 2, April 2015 Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 187
the 2-year follow-up period for each panel, a total of 5 rounds of interviews take place to collect data from each participant. The MEPS is designed in a way that data for each calendar year, covering rounds 3, 4, and 5 interviews of the panel in its second year and rounds 1, 2, and 3 interviews of the panel in its first year, is representative of the US population in that year. As a result, overlapping panels can be combined to obtain estimate for each calendar year. More detailed information on MEPS survey design, questionnaires, and relevant data are available at its web portal (http://meps.ahrq.gov/mepsweb/). This study did a cross-sectional analysis of full-year MEPS-HC data files from 2007 through 2011. Multiple years of data were pooled to obtain adequate sample size for participants with SPD and diabetes. The combined overall response rates for the 2007-2011 surveys ranged from 53.5% to 59.3%.26 Detailed information about the MEPS methodology are described elsewhere.27 During 2007-2011, 110 351 adult participants (≥18 years old) responded to the Kessler Psychological Distress Scale (K6)—a validated scale to assess symptoms of psychological distress. After excluding those with missing data on the K6 (n = 7788 or 7.1%) and those without elevated level of psychological distress (n = 97 071), the final study sample consisted of 5492 adults who met the criteria for SPD (ie, a score ≥13 on the K6). Measures Provider Advice
Receipt of provider advice was ascertained from answers of yes to the question, “Has a doctor or other health professional ever advised you to eat fewer high-fat or high-cholesterol foods?” and “ . . . to exercise more?”
more severe psychological distress. SPD is defined as a score of 13 or higher on the K6. Selected based on the results from receiver operating characteristic (ROC) analysis, this cut-off point had a sensitivity of 0.36 and a specificity of 0.96 in predicting past-year serious mental illness.29 Although the instrument is not intended to diagnose specific mental disorders, it can identify persons with mental health problems that are severe enough to cause functioning impairment and require treatment.12 Detailed information on the psychometric property and validation of K6 can be found elsewhere.28,29 Assessment of Diabetes and Diabetes Risk Factors
Information on diabetes and diabetes risk factors was from self-report. Respondents were asked if a health care provider had ever diagnosed them with diabetes. For those without a current diabetes diagnosis, the authors followed the most recent American Diabetes Association (ADA) guidelines14 and included 7 diabetes risk factors that were available in the MPES-HC data. These risk factors included (1) age ≥45 years, (2) non-Caucasian race/ ethnicity, (3) body mass index (BMI) ≥25.0 kg/m2, (4) physical inactivity, (5) hypertension (diagnosed with high blood pressure on 2 or more different medical visits), (6) hyperlipidemia (ever diagnosed with high cholesterol), and (7) history of cardiovascular disease (CVD) (ever diagnosed with coronary heart disease, angina, heart attack, stroke, and other heart disease). Physical inactivity was ascertained by a negative response to the question, “Do you spend half an hour or more in moderate or vigorous physical activity at least 3 times a week?” Additional Individual Characteristics
Serious Psychological Distress
The K6 was developed as a brief screening scale for nonspecific psychological distress in adults and has been shown to be strongly predictive of serious mental illness.28,29 The K6 asks participants to rate the frequency of 6 symptoms of psychological distress over the past 30 days on a 5-point Likert scale—none of the time (0), a little of the time (1), some of the time (2), most of the time (3), and all of the time (4). These symptoms include feeling (a) nervous, (b) hopeless, (c) restless or fidgety, (d) so depressed that nothing could cheer you up, (e) that everything was an effort, and (f) worthless. The total score for K6 ranges from 0 to 24, with higher scores indicating
In addition to the aforementioned diabetes risk factors, the following individual characteristics were included to assess systematic differences on provision of provider advice: sex, household income as percentage of the federal poverty level (FPL) (≤100% FPL, 101%-200% FPL, 201%-400% FPL, and >400% FPL), education (less than high school, high school, and college degree or higher), health insurance coverage (any private insurance, public only, and uninsured), census region (Northeast, South, Midwest, and West), and current smoking status (current smoker yes or no). Current smoking status was ascertained by a positive response to the question, “Do you currently smoke?”
Xiang et al Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
The Diabetes EDUCATOR 188
Statistical Analyses
A series of chi-square tests were conducted to compare the characteristics of adults with SPD to those without SPD to provide contextual information on the study sample. In the main analyses that were restricted to adults with SPD, chi-square tests were conducted to compare the prevalence of provider advice across selected subgroups of adults with SPD. Logistic regression was used to examine the relationship between individual characteristics and the receipt of provider advice among adults with SPD. The MEPS complex survey design was incorporated in all estimates. Statistical analyses were conducted using Stata 11.0 SE version.30
Results Approximately 5.1% (n = 5942) of the participants had a score of 13 or higher on the K6. The prevalence of diabetes was 15.6% among participants with SPD, compared to 7.9% among those without SPD. Among participants without an existing diagnosis of diabetes, adults with SPD had an average of 3.1 diabetes risk factors compared with an average of 2.4 diabetes risk factors among those without SPD. Compared with participants without SPD, participants with SPD were more likely to be female (58.1% vs 51.6%), racial and ethnic minorities (33.7% vs 31.4%), have household income ≤100% FPL (28.3% vs 10.9%), have less than a college degree (80.3% vs 62.8%), covered by public insurance only (38.8% vs 15.23) or uninsured (17.6% vs 15.0%), current smoker (37.6% vs 18.0%), and physically inactive (63.1% vs 42.1%). In addition, rates for all the clinical conditions were higher among participants with SPD compared with those without SPD, including BMI ≥25.0 kg/m2 (70.2% vs 64.3%), hypertension (42.1% vs 25.6%), hyperlipidemia (42.0% vs 30.6%), and a history of CVD (29.7% vs 14.7%). All comparisons were significant at P < .05 (results not shown in tables). As shown in Table 1, less than half of adults with SPD had ever been advised to exercise more (49.4%) or reduce dietary fat intake (45.6%). In bivariate analyses, a higher proportion of individuals who reported ever receiving exercise and low-fat dietary advice were female, insured, overweight or obese, physically inactive, or nonsmoker. Those who had a diagnosis of hypertension, CVD history, hyperlipidemia, or diabetes were also more likely to have received exercise and low-fat dietary advice from a provider. The proportion receiving provider advice for exercise and diet increased with age up to 69 years, after
which it declined. There were no significant differences in the prevalence of provider advice by education, household income, race/ethnicity, or census region. As shown in Table 2, over 73% of adults with comorbid SPD and diabetes received advice to exercise more or reduce dietary fat intake whereas less than half received advice for lifestyle modification if they had SPD alone. The prevalence of receiving provider advice increased monotonically with the number of diabetes risk factors, eventually reaching similar levels to the rates among those with diabetes. As shown in Table 3, clinical factors remained strong correlates of provision of provider advice in multivariate analyses. Diabetes and hypertension were associated with 30% to 80% increased odds of receiving provider advice while controlling for covariates. Hyperlipidemia diagnosis and being overweight or obese were associated with 2- to 4-fold increase in the odds of receiving provider advice. However, having CVD history was no longer significantly associated with the provision of provider advice after controlling for other covariates. Several sociodemographic differences in receipt of provider advice remained significant in multivariate analyses. Male sex was negatively associated with provider exercise advice (OR = 0.70; 95% CI, 0.60-0.82) but not low-fat dietary advice. Lack of health insurance coverage was associated with lower odds of receiving exercise (OR = 0.70; 95% CI, 0.57-0.87) and low-fat dietary advice (OR = 0.65; 95% CI, 0.50-0.84). The provision of provider advice was not significantly associated with current smoking status or physical inactivity.
Discussion The current study estimated lifetime prevalence of provider advice on exercise and low-fat diet among adults with SPD. The study found that the majority of adults with comorbid SPD and diabetes received healthy lifestyle advice from a health care provider. The likelihood of receiving advice increased monotonically with the number of diabetes risk factors, indicating providers’ awareness of the importance of promoting healthy lifestyle changes among people with diabetes or diabetes risk factors. However, nearly one-third of adults with comorbid SPD and diabetes and over half of all adults with SPD had never been told to exercise more or reduce dietary fat intake, suggesting missed opportunities for providing lifestyle counseling. The ADA recommends
Volume 41, Number 2, April 2015 Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 189
Table 1
Unadjusted Lifetime Prevalence of Receiving Provider Advice on Exercise and Low-Fat Diet Among Adults With Serious Psychological Distress by Selected Characteristics Advised to Exercise More Characteristics Total Age groups 18-29 30-39 40-49 50-59 60-69 ≥70 Sex Female Male Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other Poverty level ≤100% FPL 101%-200% FPL 201%-400% FPL >400% FPL Education levels Less than high school High school College degree or higher Insurance status Any private Public only Uninsured Census region Northeast South Midwest West Current smoker Yes No BMI (kg/m2)
research-article2014
TDEXXX10.1177/0145721714567234Provider Exercise and Diet Advice in Adults With Serious Psychological DistressXiang et al
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 185
Provider Advice on Exercise and Diet Among Adults With Comorbid Serious Psychological Distress and Diabetes or Diabetes Risk Factors Purpose
Xiaoling Xiang, MPhil Rosalba Hernandez, PhD
To examine the lifetime prevalence and correlates of provider advice to increase exercise and reduce dietary fat intake among adults with comorbid serious psychological distress (SPD) and diabetes or diabetes risk factors.
Christopher R. Larrison, PhD From University of Illinois at Urbana-Champaign, Urbana, Illinois (Ms Xiang, Dr Hernandez, Dr Larrison). Correspondence to Xiaoling Xiang, M.Phil, School of Social Work, University of Illinois at Urbana-Champaign, 1010 W. Nevada, Urbana, IL 61801, USA ([email protected]).
Methods Study sample (n = 5942) was selected from the Medical Expenditure Panel Survey Household Component (MEPS-HC) series of 2007-2011. SPD was defined as a score of ≥13 on the Kessler Psychological Distress Scale (K6). Multivariate logistic regression was used to examine correlates of lifetime provider advice.
Conflict of interest: We wish to confirm that there are no known conflicts of interest associated with this publication and there has been no significant financial support for this work that could have influenced its outcome. DOI: 10.1177/0145721714567234
Results
© 2015 The Author(s)
Less than half of adults with SPD had been advised to increase exercise (49.4%) or reduce dietary fat intake (45.6%). The prevalence of receiving provider advice increased in a linear fashion as the number of diabetes risk factors increased and was the highest among those with diabetes. Provision of provider advice was strongly associated with clinical factors rather than individuals’ sociodemographic characteristics and current health behaviors.
Xiang et al Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
The Diabetes EDUCATOR 186
Conclusions Health care providers are missing opportunities to provide exercise and low-fat dietary advice to patients with SPD before they manifest clinical risk factors associated with diabetes. It is important that providers counsel them as early as possible about exercise and nutritional changes that reduce the risks associated with diabetes.
P
ersons with mental illness such as depression and anxiety have high risk for diabetes and other preventable chronic diseases and suffer from excessive premature mortality.1 Diabetes and mental illness individually and collectively contribute to the substantial burden of diseases in the United States. Diabetes affected an estimated 29.1 million Americans in 2012 and cost $245 billion in direct medical costs and reduced productivity.2 Mental illness, on the other hand, accounts for nearly one-third of total US years lived with disability.3 The comorbidity of mental illness and diabetes is associated with poor adherence to diabetes treatment and metabolic control, increase in health care cost and disability days, and decrease in quality of life and life expectancy.1,4,5 Several biological pathways between mental illness and poor outcomes in diabetes and related conditions have been investigated, including shared genetic susceptibility,6 dysfunction in the hypothalamicpituitary-adrenocortical (HPA) axis,7 impaired glucose tolerance,8 excessive visceral fat due to stress, and inflammation.9 In addition, there is substantial empirical evidence documenting the high prevalence of unhealthy behaviors among persons with mental illness,10-13 suggesting behavioral mechanisms between mental illness and diabetes-related outcomes. These studies highlight the importance of targeted lifestyle interventions in reducing the risks for diabetes and its complications and improving life expectancy among people with mental illness. National guidelines, including objectives outlined in Healthy People 2020, call on health care providers to reduce the burden of diabetes and other preventive chronic diseases by increasing counseling or education related to physical activity and nutrition during patients’ office visits.14,15 In-office health counseling is an evidence-based practice as existing evidence suggests that even brief advice by health care providers could promote positive
behavior changes.16-18 Despite the potential benefits of provider advice, previous studies have documented missed opportunities for healthy lifestyle advice in the general population with or without diabetes.19-22 To date, however, little is known about how often the recommended exercise and nutrition counseling guidelines are implemented among individuals with mental illness. In an attempt to begin filling this gap in knowledge, this study examines the prevalence and correlates of provider advice among a nationally representative sample of adults with serious psychological distress (SPD). SPD is a nonspecific indicator of past year mental health problems, such as anxiety and depression.23 Previous studies have shown that people with SPD experience significant individual, financial, and system barriers to general medical care.24 There is concern that the recommended exercise and nutrition counseling may not be consistently provided to individuals with SPD partially because of providers’ distrust of patients’ ability to make positive lifestyle changes due to the stigma of mental illness that is sometimes found in the health care setting.25 The objectives of the study were to determine the lifetime prevalence of health care providers’ advice to increase exercise and reduce dietary fat intake and examine correlates for the provision of provider advice among adults with comorbid SPD and diabetes or diabetes risk factors.
Materials and Methods Participants
This study analyzed data from the Household Component of Medical Expenditure Panel Survey (MEPS-HC). Conducted by the Agency for Healthcare Research and Quality (AHRQ), the MPES is a large-scale nationally representative survey of health services and expenditures for US civilian, noninstitutionalized population. The MEPS-HC collects data from a sample of families and individuals in selected communities across the US, following a multistage area probability design. MEPS collects detailed information through in-person interviews for each person in the selected households on demographic characteristics, health conditions, health status, access and use of medical services, charges and source of payment, and satisfaction with care. MEPS adopts an overlapping panel design, where a new panel of sample households is selected each year, and each panel of households is followed for 2 calendar years. During
Volume 41, Number 2, April 2015 Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 187
the 2-year follow-up period for each panel, a total of 5 rounds of interviews take place to collect data from each participant. The MEPS is designed in a way that data for each calendar year, covering rounds 3, 4, and 5 interviews of the panel in its second year and rounds 1, 2, and 3 interviews of the panel in its first year, is representative of the US population in that year. As a result, overlapping panels can be combined to obtain estimate for each calendar year. More detailed information on MEPS survey design, questionnaires, and relevant data are available at its web portal (http://meps.ahrq.gov/mepsweb/). This study did a cross-sectional analysis of full-year MEPS-HC data files from 2007 through 2011. Multiple years of data were pooled to obtain adequate sample size for participants with SPD and diabetes. The combined overall response rates for the 2007-2011 surveys ranged from 53.5% to 59.3%.26 Detailed information about the MEPS methodology are described elsewhere.27 During 2007-2011, 110 351 adult participants (≥18 years old) responded to the Kessler Psychological Distress Scale (K6)—a validated scale to assess symptoms of psychological distress. After excluding those with missing data on the K6 (n = 7788 or 7.1%) and those without elevated level of psychological distress (n = 97 071), the final study sample consisted of 5492 adults who met the criteria for SPD (ie, a score ≥13 on the K6). Measures Provider Advice
Receipt of provider advice was ascertained from answers of yes to the question, “Has a doctor or other health professional ever advised you to eat fewer high-fat or high-cholesterol foods?” and “ . . . to exercise more?”
more severe psychological distress. SPD is defined as a score of 13 or higher on the K6. Selected based on the results from receiver operating characteristic (ROC) analysis, this cut-off point had a sensitivity of 0.36 and a specificity of 0.96 in predicting past-year serious mental illness.29 Although the instrument is not intended to diagnose specific mental disorders, it can identify persons with mental health problems that are severe enough to cause functioning impairment and require treatment.12 Detailed information on the psychometric property and validation of K6 can be found elsewhere.28,29 Assessment of Diabetes and Diabetes Risk Factors
Information on diabetes and diabetes risk factors was from self-report. Respondents were asked if a health care provider had ever diagnosed them with diabetes. For those without a current diabetes diagnosis, the authors followed the most recent American Diabetes Association (ADA) guidelines14 and included 7 diabetes risk factors that were available in the MPES-HC data. These risk factors included (1) age ≥45 years, (2) non-Caucasian race/ ethnicity, (3) body mass index (BMI) ≥25.0 kg/m2, (4) physical inactivity, (5) hypertension (diagnosed with high blood pressure on 2 or more different medical visits), (6) hyperlipidemia (ever diagnosed with high cholesterol), and (7) history of cardiovascular disease (CVD) (ever diagnosed with coronary heart disease, angina, heart attack, stroke, and other heart disease). Physical inactivity was ascertained by a negative response to the question, “Do you spend half an hour or more in moderate or vigorous physical activity at least 3 times a week?” Additional Individual Characteristics
Serious Psychological Distress
The K6 was developed as a brief screening scale for nonspecific psychological distress in adults and has been shown to be strongly predictive of serious mental illness.28,29 The K6 asks participants to rate the frequency of 6 symptoms of psychological distress over the past 30 days on a 5-point Likert scale—none of the time (0), a little of the time (1), some of the time (2), most of the time (3), and all of the time (4). These symptoms include feeling (a) nervous, (b) hopeless, (c) restless or fidgety, (d) so depressed that nothing could cheer you up, (e) that everything was an effort, and (f) worthless. The total score for K6 ranges from 0 to 24, with higher scores indicating
In addition to the aforementioned diabetes risk factors, the following individual characteristics were included to assess systematic differences on provision of provider advice: sex, household income as percentage of the federal poverty level (FPL) (≤100% FPL, 101%-200% FPL, 201%-400% FPL, and >400% FPL), education (less than high school, high school, and college degree or higher), health insurance coverage (any private insurance, public only, and uninsured), census region (Northeast, South, Midwest, and West), and current smoking status (current smoker yes or no). Current smoking status was ascertained by a positive response to the question, “Do you currently smoke?”
Xiang et al Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
The Diabetes EDUCATOR 188
Statistical Analyses
A series of chi-square tests were conducted to compare the characteristics of adults with SPD to those without SPD to provide contextual information on the study sample. In the main analyses that were restricted to adults with SPD, chi-square tests were conducted to compare the prevalence of provider advice across selected subgroups of adults with SPD. Logistic regression was used to examine the relationship between individual characteristics and the receipt of provider advice among adults with SPD. The MEPS complex survey design was incorporated in all estimates. Statistical analyses were conducted using Stata 11.0 SE version.30
Results Approximately 5.1% (n = 5942) of the participants had a score of 13 or higher on the K6. The prevalence of diabetes was 15.6% among participants with SPD, compared to 7.9% among those without SPD. Among participants without an existing diagnosis of diabetes, adults with SPD had an average of 3.1 diabetes risk factors compared with an average of 2.4 diabetes risk factors among those without SPD. Compared with participants without SPD, participants with SPD were more likely to be female (58.1% vs 51.6%), racial and ethnic minorities (33.7% vs 31.4%), have household income ≤100% FPL (28.3% vs 10.9%), have less than a college degree (80.3% vs 62.8%), covered by public insurance only (38.8% vs 15.23) or uninsured (17.6% vs 15.0%), current smoker (37.6% vs 18.0%), and physically inactive (63.1% vs 42.1%). In addition, rates for all the clinical conditions were higher among participants with SPD compared with those without SPD, including BMI ≥25.0 kg/m2 (70.2% vs 64.3%), hypertension (42.1% vs 25.6%), hyperlipidemia (42.0% vs 30.6%), and a history of CVD (29.7% vs 14.7%). All comparisons were significant at P < .05 (results not shown in tables). As shown in Table 1, less than half of adults with SPD had ever been advised to exercise more (49.4%) or reduce dietary fat intake (45.6%). In bivariate analyses, a higher proportion of individuals who reported ever receiving exercise and low-fat dietary advice were female, insured, overweight or obese, physically inactive, or nonsmoker. Those who had a diagnosis of hypertension, CVD history, hyperlipidemia, or diabetes were also more likely to have received exercise and low-fat dietary advice from a provider. The proportion receiving provider advice for exercise and diet increased with age up to 69 years, after
which it declined. There were no significant differences in the prevalence of provider advice by education, household income, race/ethnicity, or census region. As shown in Table 2, over 73% of adults with comorbid SPD and diabetes received advice to exercise more or reduce dietary fat intake whereas less than half received advice for lifestyle modification if they had SPD alone. The prevalence of receiving provider advice increased monotonically with the number of diabetes risk factors, eventually reaching similar levels to the rates among those with diabetes. As shown in Table 3, clinical factors remained strong correlates of provision of provider advice in multivariate analyses. Diabetes and hypertension were associated with 30% to 80% increased odds of receiving provider advice while controlling for covariates. Hyperlipidemia diagnosis and being overweight or obese were associated with 2- to 4-fold increase in the odds of receiving provider advice. However, having CVD history was no longer significantly associated with the provision of provider advice after controlling for other covariates. Several sociodemographic differences in receipt of provider advice remained significant in multivariate analyses. Male sex was negatively associated with provider exercise advice (OR = 0.70; 95% CI, 0.60-0.82) but not low-fat dietary advice. Lack of health insurance coverage was associated with lower odds of receiving exercise (OR = 0.70; 95% CI, 0.57-0.87) and low-fat dietary advice (OR = 0.65; 95% CI, 0.50-0.84). The provision of provider advice was not significantly associated with current smoking status or physical inactivity.
Discussion The current study estimated lifetime prevalence of provider advice on exercise and low-fat diet among adults with SPD. The study found that the majority of adults with comorbid SPD and diabetes received healthy lifestyle advice from a health care provider. The likelihood of receiving advice increased monotonically with the number of diabetes risk factors, indicating providers’ awareness of the importance of promoting healthy lifestyle changes among people with diabetes or diabetes risk factors. However, nearly one-third of adults with comorbid SPD and diabetes and over half of all adults with SPD had never been told to exercise more or reduce dietary fat intake, suggesting missed opportunities for providing lifestyle counseling. The ADA recommends
Volume 41, Number 2, April 2015 Downloaded from tde.sagepub.com at PENNSYLVANIA STATE UNIV on November 14, 2015
Provider Exercise and Diet Advice in Adults With Serious Psychological Distress 189
Table 1
Unadjusted Lifetime Prevalence of Receiving Provider Advice on Exercise and Low-Fat Diet Among Adults With Serious Psychological Distress by Selected Characteristics Advised to Exercise More Characteristics Total Age groups 18-29 30-39 40-49 50-59 60-69 ≥70 Sex Female Male Race/ethnicity White, non-Hispanic Black, non-Hispanic Hispanic Other Poverty level ≤100% FPL 101%-200% FPL 201%-400% FPL >400% FPL Education levels Less than high school High school College degree or higher Insurance status Any private Public only Uninsured Census region Northeast South Midwest West Current smoker Yes No BMI (kg/m2)
