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Citation: Park, K.; Song, Y.
Multimodal Diabetes Empowerment
for Older Adults with Diabetes. Int. J.
Environ. Res. Public Health 2022,19,
11299. https://doi.org/10.3390/
ijerph191811299
Academic Editor: Omorogieva Ojo
Received: 5 August 2022
Accepted: 7 September 2022
Published: 8 September 2022
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International Journal of
Environmental Research
and Public Health
Article
Multimodal Diabetes Empowerment for Older Adults
with Diabetes
Keumok Park 1and Youngshin Song 2,*
1Department of Nursing, College of Health and Welfare, Woosong University, Daejeon 34606, Korea
2Department of Nursing, College of Nursing, Chungnam National University, Daejeon 35015, Korea
*Correspondence: yssong87@cnu.ac.kr; Tel.: +82-42-580-8334
Abstract:
Systematically improving empowerment is not easy when operating a diabetes program
for older adults. This study aimed to develop and test the feasibility of the diabetes empowerment
(Dia-Empower) program for older adults with type 2 diabetes. A non-randomized controlled study
with a matched sampling design was conducted. Community-dwelling older adults with diabetes
were allocated to either the Dia-Empower program group or a control group. Changes in the primary
(diabetes self-care and empowerment) and secondary outcomes (body composition and physical
function) were compared between the groups. The scores for diabetes self-care and empowerment
were significantly higher in the experimental group than in the control group. Changes in skeletal
muscle mass and body fat ratio were significantly different between the groups. Handgrip strength
and shoulder flexibility positively changed in the experimental group. The Dia-Empower program
was feasible for older adults with diabetes in the community. In the future, it is necessary to study
the long-term effects of the program and its effects on blood sugar control.
Keywords: diabetes mellitus; older adults; empowerment; self-care; physical function
1. Introduction
The prevalence and mortality of type 2 diabetes mellitus (T2DM) are increasing world-
wide. With the recent spread of the coronavirus worldwide, diabetes reportedly has a
higher risk of infection and more than double the severity of the disease compared to the
general population, requiring special management [
1
]. Meanwhile, the burden of diseases
that impede socioeconomic development is also increasing [
2
]. As of 2014, 8.3% of the
world’s population, 7.3% of the Korean population, and 22.6% of the Korean population
over the age of 65 years had diabetes [
3
,
4
]. Individuals with T2DM require a healthy lifestyle
through self-management efforts, leading to optimal blood sugar levels [
5
]. To this end,
many studies have successfully applied programs based on various theories to promote
diabetes self-management [
6
,
7
]. Despite the high prevalence of diabetes in older adults,
some studies and active care targets have excluded older adults owing to the presence of
multiple comorbidities and high risk [
8
]. As the American Diabetes Association (ADA) has
been providing guidelines for diabetes management to older adults for more than a decade,
the need for scientific evidence from diabetes research for older adults is gaining increasing
importance.
Several diabetes self-care programs, such as motivational interviewing, coaching, cog-
nitive behavioral therapy, and technology-based interventions, have contributed to the pro-
motion of diabetes self-care and improvements in glycemic control, but not consistently [
9
].
Application of a single model, the program being expert oriented (led by experts), and am-
biguity in the intervention have been noted as possible causes [
9
]. Patient-oriented multi-
modal approaches and precise protocols have been recommended as alternatives [9,10].
Empowerment theory, a patient-centered theory, advocates that the role of the health-
care provider is to present the vision, not act as an expert, when educating or running a
Int. J. Environ. Res. Public Health 2022,19, 11299. https://doi.org/10.3390/ijerph191811299 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2022,19, 11299 2 of 12
program [
11
]. Diabetes empowerment can help develop the decision-maker ’s capacity for
one to be responsible for one’s own life using a collaborative approach tailored to match
the fundamental realities of diabetes care [
11
–
13
]. However, although some studies have
applied education interventions based on empowerment theory [
14
,
15
], studies imple-
menting complex intervention strategies, including exercise and education, are lacking [
9
].
In previous studies, the concept of empowerment was measured only as an outcome vari-
able, without a diabetes empowerment intervention [
16
,
17
]. Moreover, the major outcomes
of most programs involved psychological factors, such as self-efficacy, and physiologi-
cal factors, such as weight, waist circumference, and body mass index, have also been
reported [9].
Meanwhile, it is well known that physical activity is essential for diabetes self-care
and that it improves physical functions. The “Be Happy and Strong” (BeHaS) exercise
was developed to improve physical functions (such as grip strength and shoulder flexi-
bility), pain relief, and self-efficacy and to reduce depression in individuals with arthritis,
involving exercises that can be easily performed by older adults [
18
,
19
]. The BeHaS ex-
ercise program has been applied to patients with knee arthritis [
18
], women with breast
cancer [
20
], older women [
21
], and patients with hypertension [
22
]; however, to our knowl-
edge, it has not been applied to older adults with T2DM. Moreover, no studies have applied
BeHaS exercise combined with the principles of diabetes empowerment to older adults.
Therefore, a multimodal study with the addition of BeHaS exercise for T2DM based on
the diabetes empowerment principle is necessary to test its effect on physical function and
empowerment in older adults with T2DM. The purpose of this study was to apply the
multimodal diabetes empowerment program (Dia-Empower program) and evaluate its
effects on diabetes self-care, empowerment, body composition, and physical function in
older adults with T2DM. Specifically, we tested the following hypotheses.
First, we hypothesized that a greater change would be noted in the experimental
group compared to the control group in the primary outcome (diabetes self-care and
empowerment) scores following the intervention. Second, we hypothesized that a greater
change would be noted in the experimental group compared to the control group in
the secondary outcome (body composition and physical function) scores following the
intervention.
2. Materials and Methods
2.1. Design
A non-randomized control study design was employed to evaluate the effectiveness
of the Dia-Empower program on physical function, diabetes self-care, and empowerment
in older adults with T2DM.
2.2. Sample and Setting
Participants aged 65 years or older with hemoglobin A1c (HbA1c) of 6.5% or higher
(diabetic) were recruited among the residents visiting the S City Public Health Center.
A recruitment flyer was posted at the public health center. Individuals who voluntarily
wished to participate were enrolled in the study after screening for cognitive function.
The sample size was calculated using the G*Power program 3.1 version (Heinrich Heine
Universität Düsseldorf, Düsseldorf, Germany). A significance level of 0.05, a power (1-
β
) of
0.80, and an effect size of 0.8 per a previous study were entered into the program [
23
], and a
sample size of 26 was found to be appropriate for each group. Considering the dropout rate
(20%), 32 participants were assigned to the experimental group and 31 to the control group
using the matching sampling method. We included individuals who could understand the
aims of the study with cognitive integrity, were literate, and could perform the program.
Those with restricted physical activity or problems performing activities of daily living,
those who had participated in other similar exercise programs or had participated in the
BeHaS program in the past, and those with cognitive disorders were excluded.
Int. J. Environ. Res. Public Health 2022,19, 11299 3 of 12
The study was conducted at the Diabetes Education Center of the S-city Public Health
Center. To ensure eligibility, participants were screened for HbA1c levels > 6.5% using a
portable analyzer in advance. The primary outcomes were surveyed when the criteria for
participant selection were met. Primary and secondary data were collected at baseline and
at week 8.
A matched sampling design was used to assign 32 participants to the experimental
and control groups without randomization or blinding. The participants in the two groups
were matched for age, sex, and HbA1c levels. A total of 63 participants were recruited
and allocated to either the intervention (n= 32) or control (n= 31) groups in public health
centers. The final number of participants was 31 in the experimental group and 31 in the
control group because one participant in the experimental group dropped out due to health
problems (falling injury at home). The dropout rate in the experimental group was 3.2%.
Compliance with the group sessions for the Dia-Empower program was satisfactory, and no
harmful effects were observed during the study.
The recruitment flow for this study is presented in Figure 1.
Int. J. Environ. Res. Public Health 2022, 19, x FOR PEER REVIEW 3 of 12
daily living, those who had participated in other similar exercise programs or had partic-
ipated in the BeHaS program in the past, and those with cognitive disorders were ex-
cluded.
The study was conducted at the Diabetes Education Center of the S-city Public Health
Center. To ensure eligibility, participants were screened for HbA1c levels > 6.5% using a
portable analyzer in advance. The primary outcomes were surveyed when the criteria for
participant selection were met. Primary and secondary data were collected at baseline and
at week 8.
A matched sampling design was used to assign 32 participants to the experimental
and control groups without randomization or blinding. The participants in the two groups
were matched for age, sex, and HbA1c levels. A total of 63 participants were recruited and
allocated to either the intervention (n = 32) or control (n = 31) groups in public health cen-
ters. The final number of participants was 31 in the experimental group and 31 in the con-
trol group because one participant in the experimental group dropped out due to health
problems (falling injury at home). The dropout rate in the experimental group was 3.2%.
Compliance with the group sessions for the Dia-Empower program was satisfactory, and
no harmful effects were observed during the study.
The recruitment flow for this study is presented in Figure 1.
Figure 1. Participant flow diagram.
2.3. Primary and Secondary Outcomes
The primary outcomes included diabetes self-care and diabetes empowerment. The
secondary outcomes comprised anthropometric measures, such as body weight (BW),
body index mass (BMI), skeletal muscle mass (SMM), and body fat ratio (BFR). Physical
functions, such as handgrip strength and shoulder flexibility, were also used as secondary
outcomes.
Diabetes self-care was measured using the Korean version of the Summary of Diabe-
tes Self-care Activities (SDSCA), and diabetes self-care activities in five areas, including
diet, exercise, blood sugar testing, smoking, and foot care, were assessed over the last 7
days. The SDSCA reliability at the time of development was determined at Cronbach’s α
= 0.78–0.77. In this study, the total Cronbach’s α for the SDSCA was 0.71.
Figure 1. Participant flow diagram.
2.3. Primary and Secondary Outcomes
The primary outcomes included diabetes self-care and diabetes empowerment. The sec-
ondary outcomes comprised anthropometric measures, such as body weight (BW), body
index mass (BMI), skeletal muscle mass (SMM), and body fat ratio (BFR). Physical functions,
such as handgrip strength and shoulder flexibility, were also used as secondary outcomes.
Diabetes self-care was measured using the Korean version of the Summary of Dia-
betes Self-care Activities (SDSCA), and diabetes self-care activities in five areas, including
diet, exercise, blood sugar testing, smoking, and foot care, were assessed over the last
7 days. The SDSCA reliability at the time of development was determined at Cronbach’s
α= 0.78–0.77. In this study, the total Cronbach’s αfor the SDSCA was 0.71.
Diabetes empowerment was measured using the Diabetes Empowerment Scale-Short
Form (DES-SF), developed by Anderson et al. In 2003, the Korean version was used to
measure diabetes empowerment [
24
]. The reliability of the DES-SF in this study was the
same as that at the time of development, with Cronbach’s α= 0.84.
Anthropometrics included BW, BMI, SMM, and BFR without shoes measured using a
stadiometer BSM370
®
(InBody Co., Seoul, Korea) and body composition analyzer Inbody
Int. J. Environ. Res. Public Health 2022,19, 11299 4 of 12
770
®
(InBody Co.) with simultaneous multi-frequency impedance, systolic blood pressure,
and diastolic blood pressure measurements with an electronic blood pressure monitor
Omron HEM7121
®
(Omron, Kyoto, Japan). Blood glucose levels were measured with a
glucose meter Accu-Chek
®
(Roche, Indianapolis, IN, USA), and HbA1c was measured
using a portable analyzer-type glycated hemoglobin analyzer SD A1cCare
™
(Ethitech,
Midrand, South Africa).
The handgrip strength of both hands was measured with an electronic hand dy-
namometer CAMRY EH101
®
(CAMRY Scales, Zhongshan, China), and the flexibility of
both shoulders was measured using a measuring tape. Shoulder flexibility was measured
by placing the patient’s hands behind their back and measuring the distance in cm between
the middle fingers using a tape measure.
2.4. Process of Dia-Empower Program Development
The Dia-Empower program was developed in four steps:
(a)
Reviewing the literature and preparing the instructors: Social cognitive and empow-
erment theory accepted [
14
,
25
,
26
]. Researchers acquired certification through BeHaS
instructors and diabetes educators.
(b)
Designing the program: Program designed for 8 weeks and 8 sessions.
(c)
Reviewing feasibility and safety based on expert opinions: Feasibility and content
validity were reviewed by experts.
(d)
Evaluating the program: Applied and tested the program.
2.5. Intervention (the Dia-Empower Program)
For the intervention group, the Dia-Empower program consisted of diabetes empow-
erment (10 min), diabetes education (10 min), and exercise (40 min) and was administered
by the researcher, Dia-Empower program instructor, and research assistant for 8 weeks
(8 sessions), once a week, 60 min per session in class. The content of diabetes education was
guided by the Korea Centers for Disease Control and Prevention and the Korean Diabetes
Association, and eight topics were instructed and discussed.
The BeHaS exercise was developed based on the Korean traditional “Shimmudo”
exercise (low-to-median intensity) (see Supplement Figure S1) [
18
]. This exercise does not
require special equipment or facilities for the community, and studies have shown that it
can lead to health improvements [
18
]. Physical exercise consisted of an open mind-body
warm-up, warm-up exercise, main exercise, and final exercise to improve muscle strength
and joint flexibility that lasted approximately 40 min via a facilitator’s guidance in class;
an individual guidebook was also provided. However, no materials were prepared in the
empowerment class.
For educational methods applying social cognitive theory, it is necessary to strengthen
competence based on the expectation of efficacy and outcome of diabetes self-management.
Through small-group (10–11 people) interaction and inclusive education, community-
dwelling older adults with diabetes can understand their body, mind, and intrinsic motiva-
tion; strengthen their knowledge and competency for disease management; and improve
self-management behaviors for diabetes.
To achieve empowerment for diabetes self-care, the “Stages of Behavioral Change
in the Diabetes Empowerment Approach” was used to organize the Dia-Empower pro-
gram [
14
]. According to Funnell and Anderson’s behavioral change protocol, divided into
past–present–future [
14
], participants used pens and papers to organize their experiences
by topic for the conversations and presentations. In the first phase of this Dia-Empower
program (1st and 2nd week), the patient develops a degree of self-belief in their change.
Participants had time to make autonomous decisions to acquire the knowledge and skills
needed to perform self-care. In this stage, the education content consists of diabetes causes,
blood sugar management, and its difficulty. The second step (3–5 weeks) was to identify
long-term goals for the patient to help the patient choose and commit to action and to sup-
port their long-term goals. In the third step, the patient’s efforts were assessed and what the
Int. J. Environ. Res. Public Health 2022,19, 11299 5 of 12
participants had learned in the process was confirmed, through which the empowerment of
the patients with diabetes is established. In this phase, participants explored their strengths,
discovered resources, and shared their plans. At this point, a sense of responsibility was
emphasized. Medication, foot care, and health behaviors were discussed in the education
sessions. Finally (6–8 weeks), problem-solving strategies and self-management perfor-
mance were encouraged, and the participants set long-term goals. There was a process
of announcing one’s decision-making and receiving exercise and education certificates.
During the educational class for each diabetes management topic, educational materials
(one each for 8 weeks) were provided, and the participants shared their experiences with
the difficulties in maintaining a healthy diet and with diabetic complications. Table 1shows
the stages and contents of the Dia-Empower program.
Table 1. Contents of the Dia-Empower program.
Stages Week Empowerment
(10 min)
Education
(10 min)
Exercise
(40 min) Remarks
Dialog
1st
Understand my body
Overview of diabetes
Body relaxation,
Preparation of exercise,
Main exercise,
(see Supplementary
Materials)
Final exercise
Pre-test
Opening ceremony
2nd Who is the owner of
my body?
Blood sugar
management/Exercise
Practice and group
discussion and sharing
experiences
Diabetes self-care
guidebook provided.
Practical tasks at home and
self-care checklist provided.
Capacity building Action
task used.
Discovery
3rd Find my strengths
How to
medicate/manage with
stress
4th Explain my worth Foot care
5th My good habits Smoking/Drinking
Development
6th Find my resources Diabetes diet
7th Become a self-health
motivator
Prevention of
complications
8th Express hope for the
future Risk notification mark Post- test &
Closing ceremony
For the control group, the usual diabetes education of the public health centers was
provided by the staff. The usual diabetes education program, which takes place in class,
provides group education to those with diabetes in the community with a basic (2 h) and
intensive (2 h) disease education programed by the Korea Centers for Disease Control.
2.6. Ethical Consideration
This study was conducted with the approval of the bioethics committee of the uni-
versity (201711-SB-078-01), and the survey was conducted only for those who voluntarily
signed the study participation agreement. If the participants in the control group wanted,
an intervention program brochure and a 1-day diabetes camp were provided after the
intervention. The participants in the experimental group received compensation of USD 25.
2.7. Statistical Analysis
Descriptive statistics, independent t-tests, and the chi-squared test were used to test
homogeneity according to the demographics and outcome variables between the groups.
The unit of analysis was the group because the data entered into the analysis were the
average itself, and no missing data were found. An independent t-test was used for statis-
tical differences in outcome variables between the baseline and post-intervention points
between groups. Implementation fidelity to this program was evaluated by calculating
attrition and assessing the self-reported process log in terms of content, frequency, duration,
and intervention dose by a research assistant [
26
]. The reliability of the SDSCA and DES-SF
was calculated using Cronbach’s
α
. Data were analyzed using the IBM SPSS 24.0 program
(IBM Corp., Armonk, NY, USA), and the significance level of all statistical analyses was set
at p= 0.05, two-sided.
Int. J. Environ. Res. Public Health 2022,19, 11299 6 of 12
3. Results
3.1. Homogeneity Test between the Groups
A homogeneity test was performed for the demographics and primary and secondary
outcomes, and the results are shown in Table 2. There was no significant difference between
the groups in terms of demographics or primary and secondary outcomes.
Table 2. Homogeneity tests.
Characteristics Categories Exp. (n= 31) Cont. (n= 31)
tor χ2p
n(%) or Mean (±SD) n(%) or Mean (±SD)
Age (years) 71.03 (±4.11) 71.45 (±4.76) 0.37 0.712
Sex Woman 12 (38.7) 16 (51.6) 1.04 0.444
Man 19 (61.3) 15 (48.4)
Diabetic Complication Yes 17 (54.8) 14 (45.2) 0.58 0.446
No 14 (45.2) 17 (54.8)
HbA1c (%) 7.59 (±0.93) 7.25 (±0.61) −1.75 0.085
Education level
≤Elementary school 13 (41.95) 8 (25.8)
7.48 0.113
Middle High school 12 (38.7) 16 (51.6)
≤College 6 (19.35) 7 (22.6)
Having Religion Yes 21 (67.7) 13 (41.9) 4.17 0.073
No 10 (32.3) 18 (58.1)
Having a job Yes 11 (35.5) 9 (29.0) 0.30 0.786
No 20 (64.5) 22 (71.0)
Subjective Economic state
Stable 10 (32.2) 11 (35.5)
5.62 0.229
Moderate 10 (32.3) 15 (48.4)
Unstable 11 (35.5) 5 (16.1)
Alcohol Drinking No 19 (61.3) 16 (51.7) 9.76 0.534
Yes 12 (38.7) 15 (48.3)
Smoking Yes 3 (9.7) 2 (6.5) 0.22 1.000
No 28 (90.3) 29 (93.5)
Duration of DM (years) 15.35 (±10.91) 13.71 (±9.26) −0.64 0.524
Cognitive function (MMSE KC) 27.99 (±1.11) 27.75 (±1.24) −0.82 0.415
Perceived Health Status
Good 6 (19.3) 7 (22.6)
3.06 0.548
Fair 11 (35.5) 16 (51.6)
Poor 14 (45.2) 8 (25.8)
Health index
FBS (mg/dL) 145.45 (±40.28) 138.23 (±25.16) −0.85 0.400
HbA1c (%) 7.59 (±0.93) 7.25 (±0.61) −1.75 0.086
SBP (mmHg) 133.45 (±19.15) 140.58 (±18.93) 1.47 0.146
DBP (mmHg) 75.68 (±12.61) 79.94 (±9.69) 1.49 0.141
Anthropometrics
Body weight (kg) 63.84 (±9.39) 64.69 (±8.18) 0.38 0.712
BMI 25.24 (±3.47) 24.71 (±2.70) −0.66 0.511
Skeletal muscle mass (kg) 21.75 (±6.22) 24.22 (±4.31) 1.82 0.074
Body fat rate (%) 34.07 (±8.45) 31.30 (±6.39) −1.45 0.151
Physical Function
Handgrip strength (Rt.) (kg) 24.17 (±7.00) 24.79 (±5.49) 0.39 0.698
Handgrip strength (Lt.) (kg) 22.49 (±6.33) 24.04 (±5.93) 0.99 0.327
Shoulder flexibility (Rt.) (cm) 17.03 (±12.28) 21.39 (±12.13) 1.40 0.165
Shoulder flexibility (Lt.) (cm) 20.29 (±9.86) 24.16 (±11.45) 1.43 0.159
SDSCA
Total 27.84 (±13.85) 25.90 (±4.97) 0.17 0.864
Diet 13.94 (±5.82) 12.65 (±5.81) −0.87 0.386
Exercise 5.29 (±4.58) 6.35 (±4.79) 0.89 0.375
Glucose monitoring 4.06 (±4.73) 2.93 (±3.08) −1.11 0.270
Foot care 4.55 (±4.23) 6.55 (±4.86) 1.73 0.089
DES Total 24.68 (±6.71) 25.90 (±4.97) 0.82 0.417
SD, standard deviation; HbA1c, hemoglobin A1c; MMSE KC, Korean version of Mini-Mental State Examination;
FBS, fasting blood sugar; DBP, diastolic blood pressure; SBP, systolic blood pressure; BMI, blood pressure; Rt, right;
Lt, left; SDSCA, Summary of Diabetes Self-Care Activities; DES, Diabetes Empowerment Scale; Exp., Experiment
group; Cont., Control group; DM, Diabetes Mellitus.
Int. J. Environ. Res. Public Health 2022,19, 11299 7 of 12
3.2. Hypothesis 1: A Greater Change Would Be Found in the Experimental Group Compared to the
Control Group in the Primary Outcome (Diabetes Self-Care and Empowerment) Scores Following
the Intervention
The change in the scores of the primary outcomes (diabetes self-care and empow-
erment) before and after the program was higher in the experimental group than in the
control group. Therefore, Hypothesis 1 was supported (Table 3).
Table 3. Changes in the primary outcomes between the groups (Exp. = 31, Cont. = 31).
Variables Categories Group Baseline Posttest Changes in Score (Post-Baseline)
Mean (±SD) Mean (±SD) Diff-Mean (±SD) t(p)
SDSCA
Total Exp.
27.84 (
±
13.85)
57.45 (±7.71) 29.61 (±14.30) −8.16
(<0.001)
Cont.
28.39 (
±
11.00) 32.00 (
±
10.25)
3.61 (±10.49)
Diet Exp. 13.94 (±5.82) 22.52 (±3.15) 8.58 (±5.52) 4.48
(<0.001)
Cont. 12.65 (±5.81) 14.19 (±4.93) 1.55 (±5.92)
Exercise Exp. 5.29 (±4.58) 11.32 (±2.8) 6.03 (±5.39) 4.63
(<0.001)
Cont. 6.35 (±4.79) 6.77 (±3.48) 0.42 (±4.06)
Glucose monitoring Exp. 4.06 (±4.73) 10.52 (±3.66) 6.45 (±4.65) 6.13
(<0.001)
Cont. 2.93 (±3.08) 3.26 (±2.72) 0.32 (±3.05)
Foot care Exp. 4.55 (±4.23) 13.09 (±1.72) 8.55 (±4.33) 5.82
(<0.001)
Cont. 6.55 (±4.86) 7.77 (±4.74) 1.26 (±5.50)
DES Exp. 24.68 (±6.71) 37.74 (±2.77) 13.06 (±7.00) −9.03
(<0.001)
Cont. 25.90 (±4.97) 25.26 (±4.40) 0.65 (±4.72)
SD, standard deviation; SDSCA, Summary of Diabetes Self-Care Activities; Exp., Experimental; Cont., Control;
DES, Diabetes Empowerment Scale.
The primary outcomes, diabetes self-care and empowerment, were measured using
the SDSCA and DES-SF. The changes in the SDSCA and DES-SF scores were significantly
different between the groups. The SDSCA scores were significantly higher in the exper-
imental group than in the control group (t=
−
8.16, p< 0.001). The total SDSCA score of
the experimental group increased by 29.60 (
±
14.30), whereas that of the control group
increased by 3.61 (
±
10.49). The score changes in the DES-SF were also significantly different
between the groups (t=
−
9.04, p< 0.001). In the experimental group, the DES-SF score
increased by 13.06 (±7.00), while in the control group, it increased by 0.65 (±4.72).
Table 3presents the changes in the primary outcomes.
3.3. Hypothesis 2: A Greater Change Would Be Found in the Experimental Group Compared to the
Control Group in the Secondary Outcome (Body Composition and Physical Function) Scores
Following the Intervention
The change in the scores of the secondary outcomes (body composition and physical
function) before and after the intervention was greater in the experimental group than in
the control group but not for all variables. Therefore, Hypothesis 2 was partially supported
(Table 4).
The secondary outcomes measured were anthropometric (BW, BMI, SMM, and BFR)
and physical functions (handgrip strength and shoulder flexibility on both upper arms).
The results showed that changes in SMM (t= 2.32, p= 0.024) and BFR (t= 3.32, p= 0.002)
were significantly different between the groups. In the experimental group, SMM increased,
while BFR decreased to a greater degree than in the control group. The handgrip strength
and shoulder flexibility scores positively changed in the experimental group, but no changes
were found in the control group. Table 4presents the changes in the scores of the secondary
outcomes between the groups.
Int. J. Environ. Res. Public Health 2022,19, 11299 8 of 12
Table 4. Changes in the secondary outcomes between the groups (Exp. = 31, Cont. = 31).
Variables Categories Group Baseline Posttest Changes in Score
(Post-Baseline)
Mean (±SD) Mean (±SD) Diff-Mean (±SD) t(p)
Anthropometrics
Body weight (kg) Exp. 63.84 (±9.39) 62.94 (±9.41) −0.90 (±1.59) 0.75
(0.454)
Cont. 64.69 (±8.18) 64.20 (±7.98) −0.49 (±1.14)
BMI Exp. 25.24 (±3.47) 24.84 (±3.51) −0.33 (±0.62) 1.29
(0.201)
Cont. 24.71 (±2.70) 24.56 (±2.58) −0.14 (±0.46)
Skeletal muscle mass (kg)
Exp. 21.75 (±6.22) 23.64 (±4.94) 1.88 (±5.25) 2.32
(0.024)
Cont. 24.22 (±4.31) 23.84 (±4.32) −0.38 (±1.38)
Body fat rate (%) Exp. 34.07 (±8.45) 31.19 (±8.46) −2.87 (±2.84) 3.32
(0.002)
Cont. 31.30 (±6.39) 31.21 (±6.52) −0.08 (±3.70)
Physical Function
Handgrip strength (Rt.)
(kg)
Exp. 24.17 (±7.00) 26.46 (±6.16) 2.29 (±1.96) −3.96
(<0.001)
Cont. 24.79 (±5.49) 25.13 (±5.15) 0.34 (±1.93)
Handgrip strength (Lt.)
(kg)
Exp. 22.49 (±6.33) 24.96 (±6.07) 2.45 (±1.94) −4.76
(<0.001)
Cont. 24.04 (±5.93) 24.11 (±5.86) 0.08 (±1.97)
Shoulder flexibility (Rt.)
(cm)
Exp.
17.03 (
±
12.28) 11.16 (
±
10.56)
−5.87 (±5.43) 5.20
(<0.001)
Cont.
21.39 (
±
12.13) 21.35 (
±
11.39)
−0.03 (±3.09)
Shoulder flexibility (Lt.)
(cm)
Exp. 20.29 (±9.86) 14.87 (±8.06) −5.42 (±5.71) 4.51
(0.001)
Cont.
24.16 (
±
11.45) 23.68 (
±
11.13)
−0.48 (±2.13)
SD, standard deviation; Exp., Experimental Group; Cont., Control Group; BMI, Body Mass Index; Rt., right; Lt., left.
4. Discussion
The Dia-Empower program for older adults with T2DM was feasible for diabetes
self-care, empowerment, body composition, and physical function. The program focused
on strengthening physical exercise and helped improve self-care through diabetes empow-
erment and education. To achieve the goal of the primary outcomes, such as diabetes
empowerment and self-care, diabetes empowerment strategies and education were in-
cluded for 10 min each before and after exercise in the program. Diabetes empowerment in
this program emphasized exploring self-discovery, identifying diabetes problems, making
plans, solving problems, expressing future hope, and evaluating goal achievement [
10
,
27
].
The empowerment strategy for diabetes self-care was of a question-and-answer format
in which the participants spoke of their experience and decision-making process as the
center [
10
,
27
]. Moreover, the education mainly consisted of practices such as meal making,
blood sugar and blood pressure monitoring, and foot-care methods to increase interest
and efficiency in this program through empowerment steps. Based on these processes,
the levels of diabetes empowerment and self-care were significantly improved in the
experimental group.
In contrast, the control group followed the diabetes management program developed
by the Korea Centers for Disease Control and participated in regular hospital visits, tele-
phone counseling, and basic and intensive diabetes education in Korea [
28
]. The diabetes
management program applied by the Korea Centers for Disease Control was developed
based on the chronic disease model (CDM), which is known as an effective model for
managing various chronic diseases, including diabetes. However, a systematic review
indicated that CDM does not always improve intermediate- or long-term outcomes in
chronic conditions [
29
]. To achieve a successful CDM outcome for participants with T2DM,
the program should be brief, in line with the flow of the participants’ needs, and focus on
participant–provider interaction [
29
]. The Dia-Empower program can be an alternative to
complement the weaknesses of interventions based on the CDM.
Int. J. Environ. Res. Public Health 2022,19, 11299 9 of 12
According to ADA standards for diabetes care in older adults, physical exercise should
include aerobic activity, weight-bearing exercise, and/or resistance training for all older
adults who can safely engage in such activities [
30
]. To develop the Dia-Empower program,
various diabetes management programs were reviewed, and as a result, the BeHaS exercise
was selected. Exercise in the BeHaS program is based on traditional Korean exercise, and its
composition includes aerobic activity, balance, and weight-bearing exercises. Moreover,
it is easy to follow and promotes intimacy, as it contains components for strengthening
relationships (eye contact, hugging, etc.) during exercise [
26
]. To reflect the characteristics
of diabetes, the Dia-Empower exercise program (low to moderate intensity, once a week for
2 months) was less demanding and shorter in terms of intensity and operation time than
the conventional program.
After 8 weeks, grip strength and shoulder flexibility in both arms of the experimental
group positively changed in this study. Moreover, muscle mass and BFR in the experimental
group significantly changed, but body weight and BMI did not. There was no change
in body weight and BMI because the frequency of exercise was once a week and the
application time was 40 min, which did not follow the ADA recommendation of exercising
2–3 times a week for 150 min. Similar to this study, in a prior study, structured exercise
interventions of at least 8-week duration changed HbA1c in people with T2DM without a
significant change in BMI [
31
]. Although previous studies have reported positive physical
and emotional changes during exercise [
19
,
21
,
22
,
32
,
33
], it is necessary to have a step-by-step
goal in consideration of safety when applying exercise. During the program, participants’
safety, such as avoiding falls, hypoglycemia, and orthostatic hypotension, was ensured by
placing a chair close to the participants so that they could rest at any time. No adverse
events occurred during the study.
Several studies have applied empowerment strategies to chronic diseases, such as
chronic renal failure and rheumatoid arthritis, and have succeeded in self-care and symp-
tom management [
5
,
34
–
37
]. According to ADA guidelines, diabetes self-management
education and support should be patient-centered and provided in group or personalized
settings [
30
]. The diabetes empowerment strategy can satisfy ADA guidelines because
diabetes empowerment should be operated by considering the needs, goals, and life ex-
periences of patients [
5
,
10
]. In Korea, an effective diabetes program should secure access
to providers for decision support facilitated through evidence-based guidelines [
5
,
38
],
but older adults with T2DM in the community still do not participate in preventive health-
care services, such as education, and tailored care services are rarely available [
34
,
39
].
In particular, older adults with diabetes who are vulnerable to COVID-19 owing to the
spread of infectious diseases are highly likely to reduce their amount of exercise by social
distancing and refrain from social activities due to fear of infection, which could result in
the deterioration of blood sugar control [
1
]. The Dia-Empower program, which includes
empowerment strategies, education, and exercise, can be used as a safe program that meets
all the requirements of an effective program for older adults with diabetes. Furthermore,
in previous studies, there was a limitation in evaluating the effect after applying the dia-
betes self-care program because self-reporting of self-care improvement, such as physical
activity, was used. However, this study attempted to overcome this limitation by measuring
various body functions to increase the participants’ confidence in the program.
A weakness of this study is that there were no follow-up data after 8-week intervention;
thus, it cannot be known how long the effect of the Dia-Empower program lasted. The initial
improvement in physiological and behavioral outcomes decreased after approximately
6 months owing to lack of self-management, and knowledge was reduced by approximately
50% [
40
]. Follow-up after an intervention is important for determining the continuity of
program effectiveness. Nevertheless, according to the results of a review study, only
approximately 25% of studies reported that post-intervention was provided [
40
]. As such,
this study has some limitations. First, as this program was conducted in the short term,
there can be a limit to extrapolating long-term effects, such as HbA1c. We did not monitor
HbA1c in this study because HbA1c is measured once every 3 months according to the
Int. J. Environ. Res. Public Health 2022,19, 11299 10 of 12
regulations for the healthcare setting. Second, although matched sampling was used
in this study, sampling bias remained. The possibility that this sample bias may have
influenced the results cannot be excluded. In the future, it may be necessary to reconfirm
the Dia-Empower program through random sampling and blinding. Finally, only trained
facilitators, not general healthcare providers, can operate the BeHaS program. Because of
its need for expertise, this program can be limited in its dissemination and extension.
However, the low dropout rate (3%) might be a point in favor of the Dia-Empower
program compared to the conventional BeHaS program and existing diabetes self-care
education programs [
22
,
23
]. The reason for the low dropout rate is presumed to be the effect
of emphasizing interaction within the group, whereas the BeHaS program composition
is tailored to the individual. When specifically assessing the fidelity of other research
interventions with respect to the dropout rates, in the exercise session, 31 participants
completed the exercise once a week for 8 weeks; however, 25 of them participated in
the entire exercise session lasting 40 min, and five participated only in the warm-up and
finishing exercises. In the education session, eight education materials were prepared as
planned, and 10–12 minutes’ education sessions once a week for 8 weeks were delivered
to 29 participants. Two participants attended six of the eight education sessions. Overall,
the participation rates were high, and all planned studies were conducted to ensure fidelity.
This study found that the Dia-Empower program, including the empowerment strategy,
participatory education, and BeHaS exercise, can be applied to older adults with diabetes
in the community.
5. Conclusions
The Dia-Empower program led to positive results regarding diabetes empowerment,
diabetes self-care, and physical functions, such as muscle strength and flexibility, in older
adults with diabetes. In practice, the structured and planned Dia-Empower program can
be applied to the community and contribute to enhancing diabetes self-care. Additionally,
participant-centered education can be disseminated as an educational method for older
adults with diabetes. In future studies, it will be necessary to examine whether this program
retains its long-term effects using a longitudinal design.
Supplementary Materials:
The following supporting information can be downloaded at: https:
//www.mdpi.com/article/10.3390/ijerph191811299/s1, Figure S1: The pictures of BeHaS exercise of
this Dia-Empower program.
Author Contributions:
Conceptualization, K.P. and Y.S.; methodology, K.P. and Y.S.; validation, K.P.;
formal analysis, K.P.; investigation, K.P.; resources, K.P.; data curation, K.P and Y.S.; writing—original
draft preparation, K.P.; writing—review and editing, Y.S.; supervision, Y.S.; funding acquisition, Y.S.
All authors have read and agreed to the published version of the manuscript.
Funding:
This work was supported by the National Research Foundation of Korea [Y Song; grant
number 2019R1A2C1006016].
Institutional Review Board Statement:
The study was conducted in accordance with the Declaration
of Helsinki and approved by the Institutional Review Board (or Ethics Committee) of Chungnam
National University (201711-SB-078-01).
Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Not applicable.
Conflicts of Interest:
The authors declare no conflict of interest. The funders had no role in the design
of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or
in the decision to publish the results.
Int. J. Environ. Res. Public Health 2022,19, 11299 11 of 12
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