Available online at www.sciencedirect.com

Research in Social and

Administrative Pharmacy 7 (2011) 151–161

Original Research

Relationship between diet, exercise habits, and healthstatus among patients with diabetes

Heather M. Campbell, Pharm.D.a,b, Nasreen Khan, Ph.D.b,*,Catherine Cone, Pharm.D., B.C.P.S.b, Dennis W. Raisch, Ph.D.a,b

aVA Cooperative Studies Program Clinical Research Pharmacy Coordinating Center, Albuquerque, NM 87106, USAbDepartment of Pharmacy Practice, University of New Mexico College of Pharmacy, Albuquerque, NM 87131, USA

Abstract

Background: The American Diabetes Association recommends that people with diabetes should engage inphysical activity and healthy eating. Similarly, diets rich in fruits or vegetables (5-13 servings) have beenfound to lower the risk of stroke, cardiovascular conditions, cancer, and diabetes.Objectives: To examine the associations between eating fruits and vegetables and exercising on physical/

mental health among diabetes patients. A secondary objective was to describe the relationship betweensocioeconomic status and physical/mental health. Finally, we used the Health Belief Model (HBM) to helpproviders understand how they can work best with their patients to implement healthy lifestyle.

Methods: The 2005 Centers for Disease Control’s Behavioral Risk Factor Surveillance System was used todetermine the relationship between eating fruits/vegetables and exercise on physical and mental health. Thesample was restricted to individuals who self-reported being diagnosed with diabetes (N¼ 33,320) in 2005.

Eating fruits and vegetables was categorized by the number of fruit and vegetable servings consumed daily(0, 1-2, 3-4, and R5). Poisson regression was used to assess these associations.Results: Only 26% of individuals ate 5 or more servings of fruits and vegetables, whereas only 33% met

exercise recommendations. Individuals who ate 5 or more servings of fruits and vegetables reported bettermental health but poor physical health. Compared with meeting exercise recommendations, no exercisewas associated with more days of poor physical/mental health.Conclusions: Reinforcement of daily exercise is helpful to patients with diabetes (PWDS); meeting exercise

recommendations was associated with better outcomes of physical and mental health. Pharmacists andother public health providers should focus on interventions that incorporate the promotion of healthy life-styles. The HBM can be used to improve health behavior among PWDS. Pharmacists are in a unique po-

sition to advocate change with consistent access to care.� 2011 Elsevier Inc. All rights reserved.

Keywords: Diabetes mellitus; Health behavior; Fruit; Vegetables; Exercise

* Corresponding author. Tel.: þ1 505 272 5294; fax: þ1 505 272 6749.

E-mail address: nkhan@salud.unm.edu (N. Khan).

1551-7411/$ - see front matter � 2011 Elsevier Inc. All rights reserved.

doi:10.1016/j.sapharm.2010.03.002

152 Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

Background

In 2007, an estimated 23.5 million (10%) per-sons aged 20 and older had either diagnosed or

undiagnosed diabetes with higher rates of diabetesamong African American and Hispanic personsthan Caucasian.1 Diabetes causes substantial mor-tality andmorbidity in theUnited States, where it is

the seventh leading cause of death.1 Microvascularcomplications from diabetes may include blind-ness, renal disease, and peripheral neuropathy.

Diabetes is the leading cause of blindness amongadults. Approximately half of end-stage renal dis-ease patients have diabetes.Macrovascular compli-

cations include morbidity and mortality related tocardiovascular disease. Patients with diabetes(PWDS) are 2-4 times more likely to develop car-diovascular disease comparedwith the general pop-

ulation.2,3 PWDS also have higher mortalitycompared with nondiabetic patients with about65% of deaths from resultant heart disease and

stroke.4,5

PWDS report worse health-related quality oflife including more problems with physical func-

tions, such as walking and performing householdtasks. PWDS also report more mental healthproblems and worse self-reported general health.6

Furthermore, lower health-related quality of lifeand worse self-reported health have been foundto be associated with higher all cause, cardiovas-cular, and noncardiovascular mortality among

PWDS.7,8

In an effort to avoid such complications,HealthyPeople 20109 recommends diabetic preven-

tion programs to reduce the disease and economicburden and to improve individuals quality of life.TheAmericanDiabetesAssociation (ADA) recom-

mends that PWDS should regularly engage in phys-ical activity and healthy eating.10 The ADArecommends at least 150 minutes/week ofmoderate-intensity aerobic physical activity dis-

tributed over minimally 3 days per week.11 This issimilar to at least 30 minutes of moderate exercisemost days of the week as recommended by the

U.S. Surgeon General Report.10,12 Similarly, dietsrich in fruits or vegetables (5-13 servings) havebeen found to lower the risk of stroke, cardiovascu-

lar conditions, cancer, and diabetes.13

Clinical trials with interventions of 2-12months indicate that higher levels of consumption

of healthy foods and exercise lead to reducedweight, blood pressure, hyperglycemia, insulinresistance, and low-density lipoprotein levelsamong PWDS.14,15 Clinical trials, however, have

limited generalizability because of their strict ex-clusion criteria and limited intervention durations.Therefore, the effectiveness of eating healthy and

exercising is unclear among the diabetes popula-tion who incorporate these activities as dailyhabits.

Using Behavioral Risk Factor Surveillance

System (BRFSS) data for years 1996, 1998, and2000, Smith and McFall16 found that diet did notreduce the gap between physical and mental out-

comes among patients with and without diabetesbut exercise had a beneficial effect.

The effect of exercise on physical health among

PWDS is well documented. Exercise reducesglycosylated hemoglobin, resulting in decreasedincidence of stroke, cardiovascular disease, uri-nary albumin excretion, retinopathy, and all-cause

mortality.17 However, most studies that have ana-lyzed the association between exercise and mentalhealth are restricted to either healthy people or

psychiatric patients.18 We identified 2 studiesexamining exercise and mental health amongpatients with chronic illness.18,19 The first of these

studies was qualitative; the researchers foundexercise provided a helpful way to perceive lifeand health with a sense of revitalization.18 The

second study revealed a positive relationshipbetween exercise and physical and mental healthamong PWDS.19

To the authors’ knowledge, this is the second

analysis of fruit and vegetable consumption’srelationship with physical or mental health amongPWDS. The first study used the 2005 BRFSS to

examine if PWDS who ate 5 or more servings offruits and vegetables were less likely to havefrequent mental or physical distress, defined as

at least 14 days of mentally or physically un-healthy days in the last 30.19 They found there wasno difference between diet and frequent mental orphysical distress.19 Clearly, more studies that

examine this relationship are needed.The objective of this study was to determine if

PWDS who ate more fruits and vegetables or

exercised reported better physical or mental healthcompared with those who did not. The secondaryobjective was to describe the relationship between

socioeconomic status (SES) and physical andmental health.

Methods

The analysis used data from the 2005 BRFSS.The Centers for Disease Control and Prevention20

153Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

oversees administration of this national cross-sectional survey in which individuals are selectedrandomly. Annually, 350,000 Americans are inter-viewed in the world’s largest telephone survey for

preventable disease states, risk factors, and pre-ventive practices. The survey collects detailedinformation on demographics; health conditions;

use of preventive services; and preventive behav-iors, for example, fruit and vegetable consump-tion and exercise; among others. Information is

self-reported; however, prior research indicatesthat the survey is valid and reliable to study eatingand exercising activities.21 Studies have also indi-

cated that self-reported measures have strongagreement (80%) with actual levels of exercise.22

Indeed, BRFSS has been used by researchersand policymakers to monitor health behavior,

develop policy, and assess health trends.20 Thesample was limited to individuals who reportedbeing diagnosed with diabetes.

Measures

The dependent variables were number of daysof poor physical health based on the question,‘‘How many days during the past 30 days was

your physical health not good?’’ and number ofdays of poor mental health based on the question,‘‘How many days during the past 30 days was

your mental health not good?’’The primary independent variables were eating

fruits and vegetables and exercising. The number

of servings of fruits and vegetables consumeddaily was categorized into 0, 1-2, 3-4, or 5 ormore servings. Exercise level was categorized as

(1) Meeting recommendations: moderate (atleast 30 minutes on 5 or more days per

week, leading to small increases in heartrate) and/or vigorous (at least 20 minuteson 3 or more days per week, leading to sub-

stantial increases in heart rate) physicalactivity,

(2) Less than recommendations: lower levels of

physical activity than (1), or(3) Not exercising: reporting no exercise.

Statistical analysis

Chi-squares or independent sample t tests wereused to assess bivariate comparisons between thosewho did and did not eat 5 or more servings of fruits

and vegetables or met recommendations for exer-cise using STATA� software (Stata� Version 9from StataCorp LP, Texas) that adjusts for

complex survey design. A 2-tailed P-value of .05was considered significant.This relationshipwas as-sessed further usingmultivariate regressionmodels.

Two multivariate models were developed for

each dependent variable. Both models includedcovariates representing SES (education and annualhousehold income) because of health disparities

associated with these factors.23-26 In the secondmodel, number of comorbidities, diabetes compli-cations (retinopathy and peripheral neuropathy),

insulin use, and bodymass index (BMI) were addedbecause these have been shown to impact healthoutcomes.16,27-29 Separation into 2 differentmodels

facilitated the ability to observe whether the addi-tional factors are possible confounders in the re-gression models and also assess their independentassociations. Comorbidities are self-reported and

included presence of coronary heart disease or an-gina, hypertension, myocardial infarction, stroke,asthma, osteoporosis, and arthritis.

Because the dependent variables are in theform of counts (number of days), Poisson re-gression, which uses the maximum likelihood

estimation method, was used. The standard errorswere adjusted for likely overdispersion that iscommon with count data. To account for complex

survey design, the regression models were adjustedusing BRFSS sample weights.

Results

The sample was restricted to individuals whoself-reported being diagnosed with diabetes(N¼ 33,320). Table 1 describes characteristics

for the entire sample. Most were non-Hispanicwhite and urban. Mean age was 62 years. Only26% of individuals ate 5 or more servings of fruits

and vegetables, whereas only 33% met exerciserecommendations. Of note, those who met exer-cise recommendations had fewer complications

but more comorbidities. In contrast, those whoate 5 or more servings of fruit and vegetableshad similar rates of complications and comorbi-dites as those who did not. Individuals with higher

education or income more frequently exercised orhad more servings of fruits/vegetables.

The sample reported an average of 9.0 days of

poor physical health and 4.6 days of poor mentalhealth in the previous month. Among those whoate 5 or more servings of fruits and vegetables

compared with those who did not, days of poorphysical health was not statistically significant,but these individuals had 0.7 fewer days of poor

Table 1

Bivariate comparisons between meeting recommendations for exercise and eating fruits and vegetables

Variable Description Sample Exercisea Eating Fruits and

Vegetablesb

Yes No Yes No

Mean age, years 61.91 59.92 62.51h 63.11 61.43h

Female, % 59 53 62h 62 68h

Non-Hispanic White, % 72 74 71h 73 72g

African American, % 12 10 13h 12 12

Other racec, % 16 16 16 15 16g

Did not complete high school, % 19 14 21h 14 20h

High school graduate, % 35 33 35h 31 36h

Some college, % 25 27 25g 28 25h

College graduate, % 21 26 19h 27 19h

Income $0-$14,999, % 20 15 22h 18 21h

Income $15,000-$24,999, % 21 20 22h 20 22i

Income $25,000-$34,999, % 12 14 12g 13 13

Income $35,000-$49,999, % 12 14 11h 12 12

Income $50,000 or more, % 19 26 17h 21 18h

Never married, % 8 9 8 8 9i

Unmarriedd, % 42 36 44h 43 42

Married, % 50 55 48h 49 50

Insured, % 91 91 91 93 90h

Rural, % 35 35 35 35 35

Number of comorbiditiese 1.28 1.14 1.36h 1.30 1.28

Diabetes complicationsf 0.21 0.18 0.22h 0.21 0.20

Insulin use, % 19 16 20h 20 18h

Eats recommended fruit/vegetable servings daily, % 26 33 23h 100 0h

Meets exercise recommendations, % 33 100 0h 42 30h

Mean days of poor physical health 9.0 6.2 10.5h 8.8 9.1

Mean days of poor mental health 4.6 3.7 5.1h 4.1 4.8h

Number of observations 33,320 10,065 20,617 8,453 24,214

Notes:a Meeting recommendations for exercise is defined as meeting recommendations for moderate and/or vigorous exer-

cise. Moderate exercise is defined as exercise leading to small increases in heart rate for at least 30 minutes per day for 5

or more days a week. Vigorous exercise is defined as exercise leading to substantial increases in heart rate for at least 20

minutes per day for 3 or more days per week.b Eating fruits and vegetables is defined as eating 5 or more servings daily.c Other race is defined as Asian, Native Hawaiian or other Pacific Islander, American Indian or Alaskan Native,

Hispanic, or multiracial.d Unmarried is defined as divorced, separated, widowed, or a member of an unmarried couple.e Comorbidities is defined as coronary heart disease OR angina, hypertension, myocardial infarction, stroke, asthma,

osteoporosis, and arthritis. No other comorbidities are captured in the BRFSS data.f Diabetes complications is defined as retinopathy and peripheral neuropathy. No other complications are captured

in BRFSS data.g significant at p ¼ 0.05.h significant at p ¼ 0.01.i significant at p ¼ 0.000.

154 Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

mental health. Those who met recommendationsfor exercise had 4.3 and 1.4 fewer days of poor

physical and mental health, respectively, resultingin significant differences between those who didnot meet recommendations.

Table 2 displays results from the multivariateregression models. A negative coefficient indicates

fewer days of poor physical or mental health.Model 1 indicates consuming 0 servings of fruits

and vegetables daily is associated with 15.0%fewer days of poor physical health comparedwith eating 5 or more servings. Similarly, eating

1-2 servings and 3-4 servings decreased the num-ber of poor physical days by 9.3% and 6.8%,

Table 2

Relationship between eating fruits and vegetables and regular exercise on number of days of poor physical health or mental health (estimate (95% confidence interval)

Independent variable Days of Poor Physical Health Days of Poor Mental Health

Model 1 Model 2 Model 1 Model 2

0 servings of fruits/vegetables daily �0.163c (�0.241, �0.085) �0.006 (�0.142, 0.017) 0.252c (0.154, 0.350) 0.297c (0.195, 0.399)

1-2 servings of fruits/vegetables daily �0.098c (�0.139, �0.057) �0.067b (�0.109, � 0.025) 0.074b (0.014, 0.134) 0.070a (0.008, 0.131)

3-4 servings of fruits/vegetables daily �0.070b (�0.109, �0.030) �0.050a (�0.090, �0.010) �0.038 (�0.097, 0.022) �0.040 (�0.010, 0.021)Eats recommended servings fruits/vegetables Reference Reference Reference Reference

Not exercising 0.653c (0.612, 0.694) 0.577c (0.535, 0.619) 0.486c (0.427, 0.545) 0.414c (0.352, 0.475)

Exercises less than recommendations 0.231c (0.190, 0.271) 0.198c (0.157, 0.240) 0.159c (0.102, 0.216) 0.140c (0.081, 0.198)

Meets exercise recommendations Reference Reference Reference Reference

Age R65 years �0.128c (�0.173, �0.083) �0.257c (�0.304, �0.210) �0.956c (�1.021, �0.891) �1.076c (�1.145, �1.007)Age 50-64 years 0.069c (0.028, 0.111) �0.066b (�0.109, � 0.023) �0.254c (�0.306, �0.201) �0.385c (�0.440, �0.330)Age 30-49 Reference Reference Reference Reference

Female 0.027 (�0.005, 0.059) �0.004 (�0.0378, 0.0029) 0.227c (0.180, 0.273) 0.212c (0.163, 0.261)

Male Reference Reference Reference Reference

Income $0-$14,999 0.829c (0.771, 0.888) 0.678c (0.619, 0.738) 0.872c (0.735, 0.900) 0.703c (0.618, 0.525)

Income $15,000-$24,999 0.579c (0.522, 0.636) 0.461c (0.403, 0.518) 0.520c (0.440, 0.601) 0.442c (0.360, 0.525)

Income $25,000-$34,999 0.346c (0.283, 0.410) 0.271c (0.207, 0.335) 0.385c (0.297, 0.474) 0.366c (0.275, 0.456)

Income $35,000-$49,999 0.220c (0.156, 0.285) 0.158c (0.093, 0.223) 0.157c (0.065, 0.247) 0.116a (0.021, 0.210)

Income $50,000 or more Reference Reference Reference Reference

Insured 0.105c (0.054, 0.155) 0.032 (�0.020, 0.084) 0.096b (0.030, 0.163) 0.013 (�0.055, 0.082)Uninsured Reference Reference Reference Reference

Never been married �0.026 (�0.084, 0.032) �0.014 (�0.073, 0.046) 0.173c (0.099, 0.247) 0.146b (0.069, 0.223)

Unmarried �0.033 (�0.069, 0.002) �0.035 (�0.072, 0.002) 0.114c (0.062, 0.167) 0.104b (0.050, 0.159)

Married Reference Reference Reference Reference

Did not complete high school 0.225c (0.169, 0.280) 0.142c (0.086, 0.199) 0.201c (0.119, 0.282) 0.153b (0.070, 0.237)

Completed high school 0.148c (0.098, 0.197) 0.119c (0.068, 0.169) 0.131b (0.059, 0.203) 0.098b (0.023, 0.172)

Attended some college 0.171c (0.121, 0.222) 0.136c (0.085, 0.187) 0.220c (0.148, 0.292) 0.179c (0.106, 0.253)

College graduate Reference Reference Reference Reference

African American �0.166c (�0.212, �0.120) �0.176c (�0.223, �0.129) �0.113b (�0.176, �0.051) �0.112b (�0.177, �0.047)Other race �0.143c (�0.183, �0.102) �0.024 (�0.065, 0.017) �0.194c (�0.253, �0.136) �0.118c (�0.179, �0.037)Non-Hispanic White Reference Reference Reference Reference

Rural 0.059b (0.022, 0.096) 0.026 (�0.012, 0.065) �0.095b (�0.151, �0.039) �0.136c (�0.195, �0.077)Urban/Suburban Reference Reference Reference Reference

1 comorbidity – 0.381c (0.316, 0.446) – 0.425c (0.341, 0.510)

2 or more comorbidities – 0.838c (0.777, 0.900) – 0.671c (0.590, 0.753)

No comorbidities – Reference – Reference

(Continued) 155

Campbell

etal./Resea

rchin

Socia

landAdministra

tivePharm

acy7(2011)151–161

Table

2(C

ontinued

)

Independentvariable

DaysofPoorPhysicalHealth

DaysofPoorMentalHealth

Model

1Model

2Model

1Model

2

Diabetes

complications

–0.246c

(0.210,0.282)

–0.179c(0.126,0.233)

Nodiabetes

complications

–Reference

–Reference

Insulinuse

–0.276c(0.239,0.314)

–0.130c(0.074,0.186)

Noinsulinuse

–Reference

–Reference

Bodymass

index

(BMI)

indicatesobesity

–0.011(�

0.037,0.059)

–0.163c(0.090,0.236)

BMIindicatesoverweight

–�0.004(�

0.054,0.017)

–�0.058(�

0.188,0.072)

MissingBMI

–�0.149b(�

0.239,�0.060)

–�0.020(�

0.114,0.073)

BMIindicatesnorm

alweight

–Reference

–Reference

Number

ofobservations

29,319

27,786

29,728

28,166

Notes:

asignificantatp¼

0.05.

bsignificantatp¼

0.01.

csignificantatp¼

0.000.

156 Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

respectively. However, when controlled for diabe-tes complications, comorbidities, and insulin use(model 2), coefficients on all fruit and vegetable

consumption variables decreased, and thecoefficient on 0 servings was no longer significant.

The relationships between consumption offruits and vegetables and days of poor mental

health were as expected. Eating 5 or more servingswas associated with significant decreases com-pared with eating 0 or 1-2 but not 3-4 servings

per day. For instance, individuals consuming0 servings had approximately 31.6% more daysof poor mental health compared with those who

ate 5 or more servings. Those who ate 1-2 servingshad approximately 7.5% more days of poormental health compared with those who ate 5 ormore servings conditional on covariates.

Table 2 also displays the relationship betweendifferent levels of exercise and healthy days. The re-sults indicate that exercising was positively associ-

ated with physical and mental well-being. Thosewho met recommendations for exercise reportedthe lowest mean number of days of poor physical

health compared with those who did not. In addi-tion, increase in exercise intensity was related tofewer days of poor health. For instance, no exercise

was associatedwith 92.1%more days of poor phys-ical health compared with those who met recom-mendations, holding other variables constant.Similarly, exercising less than recommendations is

associated with 25.9% more days of poor physicalhealth comparedwith those whomet recommenda-tions. However, those in poor health are less likely

to exercise; as such, the number of chronic condi-tions, diabetes complications, and insulin usewere included in the second model to estimate the

relationship between health and exercise amongrespondents conditional on these covariates.Including these covariates suggests that no exercisewas associatedwith 78.0%more days of poor phys-

ical health, whereas exercising less than recommen-dations was associated with 21.9% more days ofpoor physical health. Mean days of poor physical

health for thosewhomet the recommended exerciselevel was 6.2; so, not exercising would increase thenumber of poor physical health days by almost 5

days each month.Exercise level is related to the number of days

with poor mental health. Those who did not

exercise spent, on average, 56.9% more days inpoor mental health compared with those who metrecommendation for exercise. Across bothmodels, we found those who engaged in some,

but inadequate, exercise had 16.1% more days of

157Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

poor mental health compared with those who metexercise recommendations.

Further, higher income was associated withfewer days of poor physical and mental health.

Individuals living in households with annual in-come less than $15,000 spent more days in poorphysical and mental health in the last month

compared with those living in households withmore than $50,000 in annual income. Similarly,those with less education were more likely to be in

poor physical and mental health.

Discussion

The study results indicate that only 26% ofindividuals ate 5 or more servings of fruits andvegetables, whereas only 33% exercised moder-ately or vigorously. Further, eating 5 or more

servings of fruits and vegetables was associatedwith fewer numbers of poor mental days but morenumber of days with poor physical health.

These findings extend the results of the pre-vious study of fruits and vegetables consumptionrelationship with physical or mental health among

PWDS.19 The present study reveals more detailedinformation about the quantity of fruits and veg-etables. In regard to the unexpected negative rela-

tionships between physical health and fruit andvegetable consumption, it was observed that thestrength of the coefficients became lower for phys-ical health when comorbidities, complications, in-

sulin use, and BMI were added. However, meetingrecommendations for fruit and vegetable con-sumption has a positive relationship with mental

health whether or not disease severity is includedin the model.

Physical inactivity increased the expected num-

ber of days of poor physical health by 85.1% andnumber of days with poor mental health by56.9%. Exercising at levels less than recommen-

dations versus meeting recommendations in-creased the expected number of days with poorphysical health by 23.9% and number of dayswith poor mental health by 16.1%. These

relationships were consistent with and withoutadjustments for comorbidities, complications, in-sulin use, and BMI.

A secondary objective was to describe therelationship between SES and physical and mentalhealth. People with higher income or education

reported better physical and mental health. Asimilar relationship was observed between SESand physical health in a study using 4 National

Health and Nutrition Examination Surveys.30 Thestudy revealed diabetes prevalence increased forall income groups except the highest from 1971to 2001.30 This pattern was also found across ed-

ucation levels.30

These health disparities could be because ofdifferential access to care and poor knowledge.

People with higher income and education may beseeing providers more frequently, which mayincrease exposure to the importance of eating

fruits and vegetables and exercising.23 An inter-view of Hispanic women with type 2 diabetesfound greater nutrition knowledge among those

who had seen a registered dietitian or diabeteseducator.31 A study using the Third NationalHealth and Nutrition Examination Survey,a nationally representative, cross-sectional survey

taken between 1988 and 1994, found a positiveassociation between SES and fruit and vegetableconsumption.32 Specifically, the researchers found

people who attained more than a high schooleducation consumed 1.19 more servings dailythan people who did not and people in higher-

income families consumed 0.62 more servingsdaily than people in poor families.32

To comply with Healthy People 2010 goals for

PWDS, interventions are needed to improvehealth behavior and modify lifestyle amongPWDS. Health care providers can use the theo-retical basis of the Health Belief Model (HBM) to

aid in behavior change.33 The HBM assumes thathealth behavior is a function of personal beliefs orperceptions about a disease and the strategies

available to decrease its occurrence.34 If adoptinga healthy lifestyle causes individuals’ perception ofthe seriousness or their susceptibility to illness to

be lessened, and/or their perceived benefits includeimproved health, they respond with positivehealth behavior. Health behavior is also influ-enced by cues to action, motivating factors, bar-

riers to care, and self-efficacy.Education, media, and disease symptoms can

impact perceived threat of diabetes, thus increas-

ing the likelihood of behavior change. People whoare unaware of the benefits of healthy lifestylesmay not be aware that poor eating and exercise

habits can lead to increased diabetes severity andcomplications. The commercial advertising media,by promoting fast food more than healthy food, is

a cue that reinforces poor eating habits. The U.S.population is exposed to more television commer-cials and print advertising for fast food thanpublic service announcements about the benefits

of healthy food choices.

158 Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

Food and exercise choices are also related toacculturation, environment, and SES. Personswith lower incomes may not be able to afford

the relatively higher costs of fruits and vegetablesversus less expensive, less healthy food that con-tains added fats, sugars, and/or refined grains.35

Furthermore, grocery stores and convenience

stores in lower income neighborhoods may notoffer healthy food options.36 Similarly, theremay be a lack of access to exercise facilities and

few safe places to exercise among those with lowerSES.37,38 Even if people feel safe in their commu-nities, lack of sidewalks or bike trails has been

associated with lower exercise rates; their subse-quent availability increases exercise by communitymembers.39,40 In fact, it has been documented thatlack of available facilities, lack of knowledge

about exercise benefits, lack of clear counselingfrom providers regarding exercise, lack of motiva-tion to exercise, and presence of certain comorbid-

ities (obesity, neuropathy) are barriers to exerciseamong PWDS.41-44

Health care providers, such as pharmacists,

can help patients adopt healthy lifestyles bymodifying their patients’ perceived seriousnessand susceptibility to disease as well as focusing

on the benefits of exercise and healthy eating.Indeed, published reports and studies on diabetesmanagement by pharmacists show improvementin outcomes, such as glycosylated hemoglobin

(HbA1c), lipids, and blood pressure, comparedwith usual care. Also in the literature, evaluationof measures such as adherence to medications and

patient understanding of diabetes have shownsimilar results.45-48 Pharmacist participation inpatient health and well-being was explored

recently in a study that was developed to screenfor metabolic syndrome in a community phar-macy setting.49 It was determined that pharma-cists have an important role in screening patients

for risk factors associated with metabolic syn-drome, and that by providing education on life-style modifications, pharmacists can increase the

likelihood that patients with metabolic syndromeimplement lifestyle changes.49

Education and re-enforcement of lifestyle rec-

ommendations can occur in multiple forms and innumerous settings to improve the health and well-being of our patients. The pharmacy can be an

ideal setting for this education because pamphletscan be added to patients’ prescription bags andpharmacies could engage patients through coun-seling techniques as they fill and refill their

diabetes medications. Demonstrating the

relationships between exercise and number ofphysical and mental healthy days may helpmotivate PWDS to change their behavior, espe-

cially among those who are concerned aboutdiabetes and its complications, and can makethem aware of the perceived susceptibility, sever-ity, and benefits associated with lifestyle modifi-

cations. Supplemental materials about fruit andvegetable consumption’s effect on cardiovascularhealth may augment behavioral change. In addi-

tion, explaining that 2 in every 3 PWDS die fromcardiovascular disease or stroke could increasepatients’ awareness of risk, and thus, the need to

change to more healthy behavior, eating fruits andvegetables, and exercising.

The spectrum of pharmacist-provided patientcare can range from becoming certified diabetes

educators (CDEs) to ensuring that patients receivethe counseling they need. As cognitive servicesbecome reimbursable, pharmacists should see

a resurgence of counseling. Numerous areas ofresearch could be pursued including interventionsas complicated as randomized controlled trials of

CDEs to simple interventions, such as counselingon lifestyle on discharge from a hospital orincluding patient information brochures regarding

lifestyle recommendations along with patient’smedications. Lifestyle modifications, such as dietand exercise, have been compared with medica-tion therapy in diabetes as well as in the pre-

vention of diabetes.50,51 Pharmacists are, in idealsettings, to provide equity in provision of healthservices and should be explored for new opportu-

nities to improve patient outcomes. In addition,because our results indicate that people with lowerSES reported poorer physical and mental health,

pharmacists need to preferentially aid this popula-tion by means of improved patient access toservices.

Limitations

A limitation of this study is that it was notpossible to establish the direction of the relation-ships using observational, cross-sectional data.

For example, patients who report better physicaland mental health may be more likely to exerciserather than exercise resulting in better physical

and mental health. Nevertheless, previous studieshave confirmed that exercise is associated withimproved mental and physical health.17,52

Because BRFSS relies on self-report, it issubject to recall and social acceptability biases.However, a random sample of ambulatory

159Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

geriatric patients asked to report their diseasesdemonstrated a 98%, 98%, 94%, 86%, and 85%agreement in medical charts for diabetes, stroke,myocardial infarction, hypertension, and angina,

respectively.53 Similarly, previous studies havedemonstrated moderate to strong reliability andvalidity with these measures.21,22

It also is acknowledged that diet and exerciseguidelines recommended for PWDS are far moredetailed compared with the definition of diet and

exercise used in the analysis. For instance, theADA provides specific recommendation for fatand carbohydrate intake.

Conclusions

Reinforcement of daily exercise is helpful toPWDS; meeting exercise recommendations wasassociated with better outcomes of physical andmental health. Health care professionals should

focus on interventions that incorporate promo-tion of healthy lifestyles. Pharmacists havea unique opportunity to provide these interven-

tions by means of greater patient access through-out all health care settings. Future studies shouldexamine fruit and vegetable consumption and

exercise in a prospective, controlled environment.

Acknowledgments

There are no conflicts of interest; no fundingwas received.

References

1. National Institutes of Diabetes and Digestive and

Kidney Diseases. National Diabetes Statistics Fact

Sheet: General Information and National Estimates

on Diabetes in the United States, 2005. Bethesda,

MD:USDepartment of Health andHuman Services,

National Institutes of Health; 2005.

2. HuxleyR, Barzi F,WoodwardM. Excess risk of fatal

coronary heart disease associated with diabetes in

men and women: meta-analysis of 37 prospective co-

hort studies. BMJ 2006;332:73–78.

3. Stamler J, Vaccaro O, Neaton JD, Wentworth D.

Diabetes, other risk factors, and 12-yr cardiovascular

mortality for men screened in the Multiple Risk Fac-

tor Intervention Trial. Diabetes Care 1993;16:

434–444.

4. Gu K, Cowie CC, Harris MI. Mortality in adults

with and without diabetes in a national cohort of

the U.S. population, 1971-1993. Diabetes Care

1998;21:1138–1145.

5. National Diabetes Fact Sheet: General Information

and National Estimates on Diabetes in the United

States, 2005. Atlanta, GA: Department of Health

and Human Services, Centers for Disease Control

and Prevention; 2005.

6. Stewart AL,Greenfield S,HaysRD, et al. Functional

status and well-being of patients with chronic condi-

tions. Results from the Medical Outcomes Study.

JAMA 1989;262:907–913.

7. Kleefstra N, Landman GW, Houweling ST, et al.

Prediction of mortality in type 2 diabetes from

health-related quality of life (ZODIAC-4). Diabetes

Care 2008;31:932–933.

8. McEwen LN, Kim C, Haan MN, et al. Are health-

related quality-of-life and self-rated health associated

with mortality? Insights from Translating Research

Into Action for Diabetes (TRIAD). Prim Care Dia-

betes 2009;3:37–42.

9. Office of Disease Prevention and Health Promotion,

U.S. Department of Health and Human Services.

Healthy People 2010: Understanding and Improving

Health. Washington, DC: U.S. Government Printing

Office; 2000.

10. American Diabetes Association, Standards of medi-

cal care in diabetes-2007. Diabetes Care 2007;30:

S4–S41.

11. American Diabetes Association, Standards of medi-

cal care in diabetes-2010. Diabetes Care 2010;33:

S11–S61.

12. U.S. Department of Health and Human Services.

Centers for Disease Control and Prevention,

National Center for Chronic Disease Prevention

and Health Promotion. Physical Activity and Health:

A Report of the Surgeon General. Atlanta, GA: Cen-

ters for Disease Control and Prevention; 1996.

13. U.S. Department of Health and Human Services, U.

S. Department of Agriculture. Dietary Guidelines for

Americans, 2005. 6th ed.Washington, DC:U.S. Gov-

ernment Printing Office; 2005.

14. Nield L, Moore HJ, Hooper L, et al. Dietary advice

for treatment of type 2 diabetes mellitus in adults.

Cochrane Database Syst Rev 2007;(3). CD004097.

15. Thomas DE, Elliott EJ, Naughton GA. Exercise for

type 2 diabetesmellitus.CochraneDatabase Syst Rev.

2006;(3). CD002968.

16. Smith DW, McFall SL. The relationship of diet and

exercise for weight control and the quality of life

gap associated with diabetes. J Psychosom Res

2005;59:385–392.

17. Tight blood pressure control and risk of macrovascu-

lar and microvascular complications in type 2 diabe-

tes: UKPDS 38. UK Prospective Diabetes Study

Group. BMJ 1998;317:703–713.

18. Graham R, Kremer J, Wheeler G. Physical exercise

and psychological well-being among people with

chronic illness and disability: a grounded approach.

J Health Psychol 2008;13:447–458.

19. Li C, Ford ES, Mokdad AH, Jiles R, Giles WH.

Clustering of multiple healthy lifestyle habits and

160 Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

health-related quality of life among U.S. adults with

diabetes. Diabetes Care 2007;30:1770–1776.

20. Centers for Disease Control and Prevention. BRFSS

Operational and Users Guide Version 3.0. Available

at: http://www.cdc.gov/nccdphp/shared/pdfinfo.htm;

2007. Accessed 29.09.06.

21. Nelson DE, Holtzman D, Bolen J, Stanwyck CA,

Mack KA. Reliability and validity of measures

from the Behavioral Risk Factor Surveillance

System (BRFSS). Soz Praventivmed 2001;46:

S3–S42.

22. Strath SJ, Bassett DR Jr, Ham SA, Swartz AM.

Assessment of physical activity by telephone inter-

view versus objective monitoring. Med Sci Sports

Exerc 2003;35:2112–2118.

23. Burge M, Lucero S, Rassam AG, Schade DS. What

are the barriers to medical care for patients with

newly diagnosed diabetes mellitus? Diabetes Obes

Metab 2000;2:351–354.

24. Dammann KW, Smith C. Factors affecting low-

income women’s food choices and the perceived

impact of dietary intake and socioeconomic status

on their health and weight. J Nutr Educ Behav

2009;41:242–253.

25. Diez-Roux AV, Nieto FJ, Muntaner C, et al. Neigh-

borhood environments and coronary heart disease:

a multilevel analysis. Am J Epidemiol 1997;146:

48–63.

26. Nordstrom CK, Diez Roux AV, Jackson SA,

Gardin JM. The association of personal and neigh-

borhood socioeconomic indicators with subclinical

cardiovascular disease in an elderly cohort. The car-

diovascular health study. Soc Sci Med 2004;59:

2139–2147.

27. Glasgow RE, Ruggiero L, Eakin EG, Dryfoos J,

Chobanian L. Quality of life and associated charac-

teristics in a large national sample of adults with dia-

betes. Diabetes Care 1997;20:562–567.

28. Rejeski WJ, Lang W, Neiberg RH, et al. Correlates

of health-related quality of life in overweight and

obese adults with type 2 diabetes. Obesity (Silver

Spring) 2006;14:870–883.

29. Lloyd A, Sawyer W, Hopkinson P. Impact of long-

term complications on quality of life in patients

with type 2 diabetes not using insulin. Value Health

2001;4:392–400.

30. Kanjilal S, Gregg EW, Cheng YJ, et al. Socioeco-

nomic status and trends in disparities in 4 major

risk factors for cardiovascular disease among US

adults, 1971-2002. Arch Intern Med 2006;166:

2348–2355.

31. Fitzgerald N, Damio G, Segura-Perez S, Perez-

Escamilla R. Nutrition knowledge, food label use,

and food intake patterns among Latinas with and

without type 2 diabetes. J Am Diet Assoc 2008;108:

960–967.

32. Dubowitz T, HeronM, Bird CE, et al. Neighborhood

socioeconomic status and fruit and vegetable intake

among whites, blacks, and Mexican Americans in

the United States. Am J Clin Nutr 2008;87:

1883–1891.

33. Janz N, Champion V, Strecher V. The health belief

model. In: Glanz K, Rimer B, Lewis F, eds. Health

Behavior and Health Education. 3rd ed. San Francis-

co, CA: Jossey-Bass; 2002. p. 45–66.

34. Hochbaum GM. Public Participation in Medical

Screening Programs. A Sociopsychological Study.

PHS Publication No. 572. Washington, DC: U.S.

Government Printing Office; 1958.

35. Drewnowski A. Obesity and the food environment:

dietary energy density and diet costs. Am J Prev

Med 2004;27:154–162.

36. Sallis J, Nader PR,Rupp JW,AtkinsCJ,WilsonWC.

SanDiego surveyed for heart-healthy foods and exer-

cise facilities. Public Health Rep 1986;101:216–219.

37. Centers for Disease Control and Prevention. Neigh-

borhood safety and the prevalence of physical

inactivity-selected states. MMWR Morb Mortal

Wkly Rep 1999;38:143–146.

38. KingWC, Belle SH, Brach JS, Simkin-SilvermanLR,

Soska T, Kriska AM. Objective measures of neigh-

borhood environment and physical activity in older

women. Am J Prev Med 2005;28:461–469.

39. Heroux J. Lessons Learned: Promoting Physical Ac-

tivity at the Community Level. Grant Results Special

Report. Princeton, NJ: The Robert Wood Johnson

Foundation; 2005:1–38.

40. Frank L, Engelke P. How land use and transporta-

tion systems impact public health: a literature review

of the relationship between physical activity and built

form. ACES: Active Community Environments Ini-

tiative working paper #1. 2000.

41. Hays LM, Clark DO. Correlates of physical activity

in a sample of older adults with type 2 diabetes. Dia-

betes Care 1999;22:706–712.

42. Stolarczyk LM, Gilliland SS, LiumDJ, et al. Knowl-

edge, attitudes and behaviors related to physical

activity among Native Americans with diabetes.

Ethn Dis 1999;9:59–69.

43. Thomas N, Alder E, Leese GP. Barriers to physical

activity in patients with diabetes. Postgrad Med J

2004;80:287–291.

44. KrugLM,Haire-JoshuD,Heady SA. Exercise habits

and exercise relapse in persons with non-insulin-

dependent diabetes mellitus. Diabetes Educ 1991;17:

185–188.

45. Berringer R, Shibley MC, Cary CC, Pugh CB,

Powers PA, Rafi JA. Outcomes of a community

pharmacy-based diabetes monitoring program.

J Am Pharm Assoc (Wash) 1999;39:791–797.

46. Coast-Senior EA, Kroner BA, Kelley CL, Trilli LE.

Management of patients with type 2 diabetes by

pharmacists in primary care clinics. Ann Pharmac-

other 1998;32:636–641.

47. Jaber LA, Halapy H, Fernet M, Tummalapalli S,

Diwakaran H. Evaluation of a pharmaceutical care

model on diabetes management. Ann Pharmacother

1996;30:238–243.

161Campbell et al. / Research in Social and Administrative Pharmacy 7 (2011) 151–161

48. NauD, Ponte C. Effects of a community pharmacist-

based diabetes patient-management program on

intermediate clinical outcome measures. J Manag

Care Pharm 2001;30. 48–53.

49. Olenak JL, Calpin M. Establishing a cardiovascular

health and wellness program in a community phar-

macy: screening for metabolic syndrome. J Am

Pharm Assoc 2003;50:32–36.

50. Wadden TA, Berkowitz RI, Womble LG, et al. Ran-

domized trial of lifestyle modification and pharmaco-

therapy forobesity.NEnglJMed2005;353:2111–2120.

51. Knowler WC, Barrett-Connor E, Fowler SE, et al.

Reduction in the incidence of type 2 diabetes with

lifestyle intervention or metformin. N Engl J Med

2002;346:393–403.

52. American Diabetes Association. Position statement.

Diabetes mellitus and exercise. Diabetes Care 2002;

25:S64–S68.

53. Bush TL, Miller SR, Golden AL, Hale WE. Self-

report and medical record report agreement of

selected medical conditions in the elderly. Am J Pub-

lic Health 1989;79:1554–1556.