569078

research-article2015

TDEXXX10.1177/0145721715569078Diabetes Support, A1C, and Self-management BehaviorsSoto et al

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214

An Ecological Perspective on
Diabetes Self-care Support,
Self-management
Behaviors, and Hemoglobin
A1C Among Latinos
Purpose

Sandra C. Soto, MPH

Sabrina Y. Louie, MPH
Andrea L. Cherrington, MD, MPH
Humberto Parada, MPH
Lucy A. Horton, MPH, MS
Guadalupe X. Ayala, PhD, MPH
From San Diego State University/University of California, San Diego Joint
Doctoral Program in Public Health (Health Behavior) and the Institute for
Behavioral and Community Health, San Diego, California (Ms Soto);
Cedars-Sinai Medical Center, Los Angeles, California (Ms Louie); University
of Alabama at Birmingham, School of Medicine, Division of Preventive
Medicine, Birmingham, Alabama (Dr Cherrington); University of North
Carolina, Chapel Hill, Gillings School of Global Public Health, Chapel Hill,
North Carolina (Mr Parada); Institute for Behavioral and Community
Health, San Diego, California (Ms Horton); and San Diego State University,
Graduate School of Public Health, Division of Health Promotion and
Behavioral Science, and the Institute for Behavioral and Community
Health, San Diego, California (Dr Ayala).
Correspondence to Sandra Soto, MPH, San Diego State University/
University of California, San Diego Joint Doctoral Program in Public Health
(Health Behavior) and the Institute for Behavioral and Community Health,
9245 Sky Park Court, Suite 221, San Diego, CA 92123, USA (Sandra.
soto@mail.sdsu.edu).
Financial Support: Puentes hacia una mejor vida (Bridges to a better life)
was funded by the Peers for Progress network and sponsored by the
American Academy of Family Physicians Foundation (SOOOII24OIGEL).
The authors have no relevant conflict of interest to disclose.
DOI: 10.1177/0145721715569078
2015 The Author(s)

The purpose of this study was to examine the role of self,

interpersonal (ie, family/friend), and organizational (ie,
health care) support in performing diabetes-related selfmanagement behaviors and hemoglobin A1C (A1C)
levels among rural Latinos with type 2 diabetes.

Methods
Cross-sectional data from baseline interviews and medical records were used from a randomized controlled trial
conducted in rural Southern California involving a clinic
sample of Latinos with type 2 diabetes (N = 317). Selfmanagement behaviors included fruit and vegetable
intake, fat intake, physical activity, glucose monitoring,
daily examination of feet, and medication adherence.
Multivariate linear and logistic regression models were
used to assess the relationships of sources of support
with self-management behaviors and A1C.

Results
Higher levels of self-support were significantly associated with eating fruits and vegetables most days/week,
eating high-fat foods few days/week, engaging in physical activity most days/week, daily feet examinations, and
self-reported medication adherence. Self-support was
also related to A1C. Family/friend support was significantly associated with eating fruits and vegetables and
engaging in physical activity most days/week. Health
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215

care support was significantly associated with consuming fats most days/week.

Conclusions
Health care practitioners and future interventions should
focus on improving individuals diabetes management
behaviors, with the ultimate goal of promoting glycemic
control. Eliciting family/friend support should be encouraged to promote fruit and vegetable consumption and
physical activity.

ype 2 diabetes is widespread in the US, with

an estimated 25.8 million people living with
diabetes and an additional 79 million living
with prediabetes.1 Diabetes disproportionately affects Latinos, who are nearly 2 times
more likely to have diabetes compared to non-Latino
whites.2 Moreover, Latinos tend to be diagnosed with diabetes at younger ages than non-Latino whites, indicating a
greater risk of developing diabetes-related complications
earlier in life (median age of 49 vs 55, respectively).3 A
meta-analysis revealed that compared with non-Latino
whites with diabetes, Latinos with diabetes have approximately 0.5% higher A1C levels.4 Self-management behaviors including consuming a healthy diet and engaging in
regular physical activity, among others, can improve glycemic control and reduce the risk of diabetes-related complications.5 However, Latinos with diabetes generally
report lower rates of self-management behaviors than
non-Latino whites with diabetes.6 Hence, an investigation
into the factors that influence self-management behaviors
in Latinos is warranted.
The social ecological framework (SEF) depicts multiples sources of influence on self-management behaviors (see Figure 1).5 These sources of support range from
the individual to the media each exerting their direct and
indirect influence on a persons ability to engage in diabetes-related self-management behaviors.7,8 According to
the SEF, sources of support for diabetes-related selfmanagement behaviors include the individual with diabetes, interpersonal support (eg, family and friends),
health care professionals, the neighborhood, community
organizations, the workplace, health insurance, and the
media (Figure 1).9 For instance, those with diabetes can

Figure 1. Socio ecological framework of sources of support for diabetes

self-care.

engage in goal setting, a form of self-management support.10 Interpersonal support has also been found to promote self-management behaviors. For example, Fisher et
al11 found that family cohesion was more strongly related
to healthier diet intake and exercise among Latinos than
non-Latino whites with diabetes. Higher levels of support from friends12 and health care professionals13 have
also been associated with improved diabetes management and glycemic control in Latinos and non-Latinos.
The literature also supports the important role that environmental and community sources of support have on
self-management behaviors.14 Individuals with diabetes
who live in neighborhoods with suitable environments
for physical activity and healthy food options are more
likely to engage in physical activity and consume healthier foods.15 Community organizations that provide health
education and promote disease management have also
been linked to improved self-management behaviors
among those with diabetes.16,17 While the literature suggests relationships of various sources of support with
self-management behaviors and A1C, there is limited
evidence for which sources of support are most influential in specific self-management behaviors.
The purpose of this study was to examine the role of
self, interpersonal (ie, family/friend), and organizational
(ie, health care) support in performing diabetes-related
self-management behaviors and A1C levels among rural
Latinos with type 2 diabetes.

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Methods

Measures

Study Design

Diabetes Self-management Behaviors

This cross-sectional study used baseline data from a

randomized controlled trial in rural southern California
that included 336 clinic patients with diabetes.18 Data
came from Puentes hacia una mejor vida (Puentes;
Bridges to a Better Life), 1 of 8 international studies testing models of peer support for diabetes control (ie, Peers
for Progress). Puentes was conducted in Imperial County,
the southeastern most county in California along the
US-Mexico border, where 81% of county residents are
Latino and 32% are foreign-born.19

Fruit and vegetable intake, fat intake, physical activity,

glucose monitoring, and foot examinations were measured
using the Summary of Diabetes Self-care Activities scale
previously used with Latino populations.20-22 These behaviors are recommended by the American Association of
Diabetes Educators and the American Diabetes Association
and are the standard of care for self-management education.5 Self-management behaviors were analyzed separately given the low inter-item correlations seen among the
behaviors20 and each behaviors potentially distinct associations with sources of support. Each self-management
behavior was assessed by a single item as follows: On
how many of the last 7 days did you (a) eat 5 or more servings of fruits and vegetables, (b) eat high-fat foods, such as
red meat or full-fat dairy products, (c) participate in at least
30 minutes of physical activity (do not count physical
activity as part of your work), (d) test your blood sugar,
and (e) check your feet? Because there are no firm recommendations for fruit, vegetable, or fat intake related to diabetes control,23 these variables were dichotomized into
whether participants reported consuming these foods a few
days a week (0-3 days) versus most days of the week (4-7
days). Physical activity was dichotomized based on recommendations from the Centers for Disease Control and
Prevention to exercise 5+ days per week versus fewer.24
The blood sugar testing and feet exam items were dichotomized as 7 days per week versus <7 days per week.

Sample and Setting

Between April 2010 and January 2011, participants

were randomly sampled using the medical charts from 3
of 9 clinics that are part of Clnicas de Salud del Pueblo,
Inc, a federally qualified health center with clinic sites
located in Imperial and Riverside counties. All patients
who met these criteria were sampled: (a) a diagnosis of
type 1 or type 2 diabetes, (b) at least 18 years of age, (c)
a recent (within 3 months) A1C value over 7.0%, and (d)
seen at 1 of the 3 clinics within the past 3 months. Fifty
percent of the patients on this list were randomly sampled
and mailed letters of invitation followed by a telephone
call from a research staff member. Patients who agreed
were then screened for eligibility confirming the aforementioned criteria, the patients ability to read in English
or Spanish, and their intention to reside in the study area
for the duration of the study (12 months). Patients were
excluded if they had participated in an intensive diabetes
education program in the past 6 months or if they had a
significant physical or developmental disorder that would
limit participation. All eligible participants signed an
informed consent form and a medical chart release form.
Study instruments and protocols were approved by the
Institutional Review Board of San Diego State University.
Following enrollment and consenting procedures, a
research assistant administered a questionnaire in Spanish
or English based on the patients preference. A research
staff member abstracted the most recent values of A1C
from the patients medical chart.
Fifteen participants were excluded because they did
not self-identify as Latino. Four participants with type 1
diabetes were excluded given differences in the regimens
required for managing these 2 types. The final sample
size for this study was 317.

Medication Adherence

This self-management behavior was assessed using

the 4-item Morisky Medication Adherence scale.25 The
scale has yes/no response options to items such as, Do
you ever forget to take your diabetes medicine?
Consistent with a previous study with this sample,18 medication adherence was dichotomized into adherent (no
report of nonadherence to any item) versus nonadherent
(affirmative response to at least 1 item). Internal consistency with the current sample was .52 compared with .61
previously reported by Morisky and colleagues.25
Hemoglobin A1C

This continuous measure of percentage value for A1C

was obtained from the most recent lab result in the participants medical record within the previous 3 months.
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Sources of Support for Diabetes Self-care

Demographic Characteristics

Frequency of support received was assessed using the

Chronic Illness Resource Survey (CIRS),9 previously
translated and validated in a Spanish-speaking sample
with at least 1 chronic disease by Eakin et al.26 The
22-item CIRS assesses the frequency of support from 7
sources in the past 3 months ranging from those closest to
the individual to more distal sources of support: (a) self
(3 items), (b) family/friends (3 items), (c) health care (3
items), (d) neighborhood (4 items), (e) community organizations (3 items), (f) workplace (3 items), and (g) health
insurance/media (3 items; see Table 1). Participants were
asked to respond to items using the following stem: In
the past 3 months..., and response options were on a
5-point Likert scale ranging from none of the time to
all of the time.
To determine whether the sources of support assessed
by the CIRS accurately assessed the sources of support of
the study sample, a factor analysis was conducted using
the samples responses to the CIRS. Principal components analysis using varimax rotation was used to explore
the factors. The variance accounted for by the solution,
the variance accounted for by each individual factor, and
the interpretability of the factors were all evaluated to
initially determine the factor structure. To further confirm
the factor structure, a parallel analysis was used. Based on
a factor analysis in this sample, several changes were
made to the scoring of the CIRS. First, workplace support
was omitted because only 24% of our sample was
employed. Second, the distal sources of support were
removed because of poor factor loadings. As a result, the
following 3 sources of support were examined in this
study: (a) self, (b) family/friends, and (c) health care.
Third, 2 items from the neighborhood support subscale
had high factor loadings on the family/friends subscale
and were therefore included with this subscale (Did you
go to parks for picnics, walks, or other outings? and Did
you eat at a restaurant that had low-fat food choices?).
This is consistent with previous research showing that
park use and going out to eat are social behaviors that
occur most frequently with family and friends.27,28 The
self and health care subscales remained as originally proposed by Eakin and colleagues.26 Mean subscale scores
were obtained, ranging from 1 to 5, with higher scores
indicating more frequent support. Internal consistency for
the self, family/friend, and health care support subscales
were .81, .62, and .62, respectively.

These included age (< 50, 51-57, 58-64, and 65),

gender, marital status (married or living with a partner vs
single, divorced, widowed, or separated), employment
status (employed vs not employed, retired, homemaker,
student), education level (less than high school education
vs high school graduate or greater), and monthly household income (less than $1000 vs $1000 or greater).
Country of birth (Mexico or other country vs US) was
used as a proxy for acculturation. Finally, duration of diabetes diagnosis was included due to its potential influence on self-management behaviors and A1C.29
Data Analyses

Outcome variables included self-management behaviors (treated as categorical) and A1C (treated as continuous). Self-management behaviors were dichotomized as
follows: fruit and vegetable intake and fat intake were
dichotomized into consuming these foods a few days a
week (0-3 days) versus most days of the week (4-7 days),
physical activity was dichotomized into 5 or more days
per week versus <5 days per week, blood glucose monitoring and foot examinations were dichotomized as
7days per week versus <7 days per week, and medication
adherence was dichotomized into adherent versus nonadherent. Because daily glucose monitoring is recommended for those who are prescribed insulin but not
always for those who are not taking insulin,30,31 analyses
with glucose testing as the outcome variable were only
conducted using participants who were prescribed insulin
(n = 91).
Univariate logistic regression models were used to
calculate unadjusted odds ratios and 95% confidence
intervals of the self-management behaviors with self,
family/friend, and health care sources of support.
Univariate linear regression was used to calculate unadjusted parameter estimates and P values for the association of A1C with self, family/friend, and health care
sources of support and covariates. Because HbA1C was
not normally distributed, it was log-transformed for
analyses. The only variables included in the unadjusted
models were the outcome variables and the sources of
support, without the inclusion of any demographic characteristics (e.g., covariates). Covariates associated with
self-management behaviors and A1C at P < .20 were
included in multivariate models.

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Item

Did you think about good things you did to take care of your diabetes?
Did you make time to take care of your diabetes?
Did you think about the goals you set for yourself to take care of your
diabetes?
Did your family/friends exercise with you?
Did your family/friends make food for you that was healthy?
Did you share healthy low-fat recipes with family/friends?
Did your doctor/health care provider involve you in making decisions about
your diabetes?
Did your doctor/health care provider listen to what you had to say about your
diabetes?
Did your doctor/health care provider tell you the results of any tests in a way
you could understand?
Did you go to parks for picnics, walks, or other outings?
Did you eat at a restaurant that had low-fat food choices?
Did you walk/exercise outdoors in your neighborhood?
Did you walk/exercise with your neighbors?
Did you go to a local health program or health club?
Did you go to free or low-cost meetings about your diabetes, such as church
groups or community programs?
Did you volunteer at a local organization or for an interest/cause?
Did you have a work schedule that you could change to meet your health
needs?
Were there rules/policies at work that made it easier for you to take care of
your diabetes?
Did you have control over your job duties so that you could still take care of
your diabetes?
Did you have health insurance that covered most of the costs of your medical
care and medicines?
Did you read articles in newspapers/magazines about taking care of your
diabetes?
Have you seen ads about not smoking, eating low-fat foods or getting regular
exercise?

Eakin et al.26
Factor scores not reported if less than .250.

Health insurance/
media

Workplace

Community
organizations

Neighborhood

Health care (HC)

Family/friend (FF)

Self

CIRS Subscalesa

Chronic Illness Resource Survey (CIRS) Factor Analysis Results

Table 1

.753
.430
.392

.792
.677
.597

.313

.262

.258

.843
.837
.817

.456

.705

.714

.753

.296

.718
.575

.323

.804
.760

.740

.293

.296

Factorb

.302

.784

.470
.333

.300

.353

.599

.277

.765

.302

.288

.660

.416

.275

.556

FF
FF

HC

HC

FF
FF
FF
HC

Self
Self
Self

Scales

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Separate multivariate logistic and linear regression

models examined whether sources of support were associated with self-management behaviors and A1C, respectively, after adjusting for covariates. Each multivariate
model controlled for other sources of support. For
example, the model assessing the association between
self-support and physical activity controlled for both
family/friend and health care support. Statistical significance was established at P < .05. Statistical analyses
were performed using SAS Version 9.2 (Cary, North
Carolina, USA).

Results
Participants were, on average, 57 years old (12), primarily female (64%), married (61%), and foreign-born
(79%). Only 24% were currently employed, most had
less than a high school education (70%), and almost half
reported a monthly household income of less than $1000.
The average (SD) A1C in this sample was 8.53% (70
mmol/mol) (1.63% [17.8 mmol/mol]). Half of all participants reported consuming 5 or more servings of fruits
and vegetables on most days of the week. Most participants reported consuming high-fat foods on few days of
the week. One-third reported engaging in at least 30 minutes of physical activity at least 5 days per week. Over
70% of individuals prescribed insulin tested their blood
glucose daily, and of all participants, nearly 70% examined their feet daily. Forty percent of participants were
adherent to their medication regimen. Mean scores for
support were highest for self, followed by health care and
family/friend support (Table 2).
Table 3 provides the logistic regression findings on
the association of sources of support with self-management behaviors. Self-support was consistently and
strongly associated with most self-management behaviors. For example, higher levels of self-support were
associated with 87% higher odds of being adherent to
diabetes medications, 55% higher odds of consuming
fats less frequently, 30% to 40% higher odds of eating
fruits and vegetables on 4 or more days/week, engaging
in physical activity on 5 or more days/week, and conducting daily foot examinations, after adjusting for relevant covariates. Family/friend support was significantly
associated with 70% higher odds of physical activity on
5 or more days/week and eating fruits and vegetables on
4 or more days/week. Health care support was only associated with fat intake. Specifically, after adjusting for

other sources of support and covariates, health care support was associated with more frequent fat intake.
Sources of support were not statistically related to glucose monitoring in participants who were prescribed
insulin in adjusted models.
Self-support was the only source of support that was
significantly associated with lower A1C levels before
and after controlling for covariates ( = 0.16; P = .01)
(Table 4). The exponentiated coefficient for the adjusted
relationship between self-support and A1C was 1.17,
indicating that for a 1-unit increase in self-support, there
was a 17% decrease in A1C.

Discussion
Results indicated that higher levels of self-support
were related to more frequent fruit and vegetable intake,
less frequent fat intake, physical activity on most days of
the week, daily feet examination, improved medication
adherence, and lower A1C in a clinical sample of Latinos
with diabetes. These findings are consistent with previous research indicating that higher self-support for diabetes self-management is associated with a healthier
diet,32,33 physical activity,32-34 and lower A1C.35 However,
most previous research has been conducted with nonLatino populations.32,34,35 Findings for glucose monitoring showed no relationship with sources of support in
multivariate models, though it is possible that the sample
size of 91 was too small to detect significance.
Higher levels of family/friend support were related to
more frequent fruit and vegetable intake and physical
activity. In previous studies with older Mexican
Americans33 and in a mixed-ethnicity sample,14 family
support was also related to improved diet and physical
activity. However, other studies have demonstrated
mixed results. For instance, in a multi-ethnic sample,
Shaw et al36 did not find an association between family
support and fruit, vegetable, and fat intake using the
same measures and cutoff scores used in this study.
Moreover, in an Australian sample, the association of
family support with diet and physical activity was no
longer significant when self-efficacy, an indicator of selfsupport according to the authors, was included in the
model.32 It is notable that fruit and vegetable intake and
physical activity tend to be more socially bound than
other self-management behaviors assessed in this study,
such as daily feet examinations and medication adherence.37 As Sherbourne and colleagues37 observed, social

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Table 2

Participant Characteristics (N = 317).

Demographics

% (n) or Mean (SD or lower-upper quartiles)

Female
Age in years
Marital status
Married/living with partner
Single, divorced, windowed, or separated
Employment status
Employed
Unemployed, retired, student, or homemaker
Education
< High school/GED
High school/GED
Household monthly income
<$1,000
$1,000
Country of birth
Mexico or other
US
Diabetes-related
Years with diabetes diagnosis
Hemoglobin A1C% (mmol/mol)
Self-management behaviors
Fruit and vegetable intake (4-7 days/week)
Fat intake (0-3 days/week)
Physical activity (30 min 5 days/week)
Glucose monitoring (7 days/week)a
Daily feet examinations (7 days/week)
Medication adherence (adherent)
Sources of supportb
Self
Family/friend
Health care

64 (202)
57 (12)
61 (192)
39 (125)
24 (76)
76 (240)
70 (222)
30 (94)
47 (144)
53 (160)
79 (249)
21 (67)
13 (11)
8.53 (1.63) (70 [17.8])
50 (158)
80 (252)
33 (104)
74 (67)
69 (219)
39 (123)
3.52 (2.67-4.67)
1.98 (1.25-2.50)
3.28 (2.33-4.00)

Glucose testing among those prescribed insulin (n = 91).

Scores range from 1 to 5, with higher scores indicating more support.

behaviors including those that are diet related impact the

entire family and therefore require their support for
change. Our findings appear to support the idea that
interpersonal support is important for social behaviors.
In this sample, higher levels of health care support
were related to more frequent fat intake. King et al14
found the same counterintuitive result in a Colorado
sample comprised of 21% Latino participants (N = 463).
In a separate study with 695 Norwegian adults with
diabetes, greater health care support was associated with
poor diet management, although the measure of diet did
not include fat intake.38 The authors suggested that more

supportive health care providers perhaps do not exert

sufficient external pressure to consume a healthful diet.
In the current study, the health care support subscale
contained items reflecting shared decision making and
patient-centered care. It may be that patients who are
active participants in their health care choose not to focus
on fat consumption in their discussions on self-management behaviors with their health care providers. It also
may be the case that health care providers focus on
carbohydrates, specifically, fruit, vegetable, and fiber
intake, and exclude fat intake in their patient counseling.
Given that this is a reoccurring finding, future studies

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221

OR
95% CI
aOR
95% CI
OR
95% CI
aOR
95% CI
OR
95% CI
aOR
95% CI

1.31**
1.08-1.59
1.26*
1.02-1.57
1.61*
1.21-2.13
1.66**
1.21-2.29
1.10
0.91-1.33
1.00
0.81-1.23

1.43**
1.13-1.81
1.55*
1.17-2.06
1.07
0.77-1.50
1.07
0.73-1.57
0.76*
0.60-0.98
0.71*
0.54-0.94

Fat Intake
0-3 Days/Week
(Reference =
4-7 days)b
1.52***
1.22-1.89
1.29*
1.02-1.63
1.92***
1.43-2.59
1.74***
1.26-2.41
1.2
0.98-1.48
1.14
0.91-1.44

Physical activity
30 Minutes 5
Days/Week
(Reference = 0-4
Days)c
1.71*
1.06-2.94
1.27
0.69-2.34
1.57
0.80-3.06
1.81
0.78-4.21
0.85
0.54-1.33
0.88
0.53-1.44

Glucose
Monitoring 7
Days/Week
(Reference = <7
Days)d

Abbreviations: 95% CI, 95% confidence interval; aOR, adjusted odds ratio; OR, odds ratio.
a
Adjusted model controlling for other sources of support, gender, and country of birth.
b
Adjusted model controlling for other sources of support, age, education, and gender.
c
Adjusted model controlling for other sources of support and education.
d
Adjusted model controlling for other sources of support and age. Glucose testing analysis only conducted with those who were prescribed insulin (n = 91).
e
Adjusted model controlling for other sources of support, age, and country of birth.
f
Adjusted model controlling for other sources of support and gender.
*P < .05. **P < .01. ***P < .001.

Health care support

Family/friend support

Self support

Fruit and
Vegetable Intake
4-7 Days/Week
(Reference = 0-3
days)a
1.45***
1.18-1.78
1.36*
1.07-1.72
1.48*
1.08-2.02
1.34
0.95-1.90
1.11
0.91-1.37
1.08
0.86-1.36

Daily Feet
Examinations 7
Days/Week
(Reference = <7
Days)e

The Association Between Sources of Support and Self-management behaviors (Logistic Regression Crude and Adjusted Findings).

Table 3

1.70***
1.37-2.10
1.87***
1.47-2.38
1.13
0.86-1.49
0.89
0.65-1.23
1.06
0.87-1.28
0.95
0.76-1.18

Medication
Adherence
(Reference =
Nonadherent)f

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Table 4

The Association Between Sources of Support and the Log of Hemoglobin A1C (Linear Regression Crude and Adjusted
Findings).
Adjusted Modelsa

Crude Models

Self support
Family/friend support
Healthc are support

Standardized B (SE)

P Value

Standardized (SE)

P Value

.17 (.01)
.02 (.01)
.11 (.01)

.002
.72
.05

.16 (.01)
.04 (.01)
.08 (.01)

.01
.49
.14

Adjusted models controlling for education and age.

should explore the qualities of the patient-provider relationship and how they impact patients dietary habits.
Causal inferences cannot be made from this crosssectional study. Longitudinal studies are rare but necessary
for testing the causal path between the relationships examined here.37 Another limitation is that only 3 sources of
support were investigated in this study. Although the CIRS
has worked well in other studies involving Latinos,26,39 the
full scale performed poorly in this sample, and the low
rates of employed participants precluded us from examining workplace support. However, a strength of our study is
that sources of support and self-management behaviors
were examined separately, instead of grouping sources of
support14,39 or self-management behaviors.36,37 Creating
groups has the potential to mask relationships and inflate
others. A second strength of this study was that it involved
rural Latinos, an understudied population with one of the
highest prevalence rates of diabetes in the US.

Implications
This study is one of the first to examine the relationship of self-management behaviors and A1C with multiple sources of support among Latinos. Practitioners
should reinforce self-management behaviors to improve
A1C. However, when targeting diet and physical activity,
interpersonal support should also be promoted in both
research and clinical practice. Health care providers can
encourage these socially based behaviors by inviting and
engaging family members and friends during clinic visits
and diabetes-related counseling sessions.

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