Short-form measures of diabetes-related emotional distress: the Problem Areas in Diabetes Scale (PAID)-5 and PAID-1

Psychometric validation of the hyperglycaemia avoidance scale UK (HAS-UK)

AIMS

Hyperglycaemia aversion in type 1 diabetes can be associated with severe hypoglycaemia and impaired awareness of hypoglycaemia but is not routinely assessed clinically. This study aimed to undertake the first psychometric validation of the UK version of the Hyperglycaemia Avoidance Scale (HAS-UK).

METHODS

The HAS-UK was completed by adults with type 1 diabetes in three separate research studies. Psychometric properties were evaluated, using exploratory factor analysis, internal consistency, and convergent validity.

RESULTS

Of the 431 participants who completed the HAS-UK in the three studies, mean age was 49.5 years, and 58.0% were women. Mean duration of diabetes was 29 years, with 192 (44.5%) using multiple daily injections and 229 (53.1%) using an insulin pump. Five participants were excluded from analyses due to incomplete HAS-UK responses. Exploratory factor analysis revealed a 3-factor solution, with acceptable internal consistency for 'worry' and 'blood glucose decisions' factors. HAS-UK total score was higher in those using insulin pumps versus multiple daily injections, and 'blood glucose decisions' score was higher in those using a continuous blood glucose sensor versus a meter.

CONCLUSIONS

The HAS-UK is a reliable measure with acceptable structural validity and is likely to be useful for evaluating hyperglycaemia aversion in people with type 1 diabetes. Future research would benefit from investigating further psychometric properties including test-retest reliability, sensitivity to change, and clinical significance of scores.

Network of doctors for multimorbidity and diabetes - the NOMAD intervention: protocol for feasibility trial of multidisciplinary team conferences for people with diabetes and multimorbidity

BACKGROUND

The prevalence of diabetes and coexisting multimorbidity rises worldwide. Treatment of this patient group can be complex. Providing an evidence-based, coherent, and patient-centred treatment of patients with multimorbidity poses a challenge in healthcare systems, which are typically designed to deliver disease-specific care. We propose an intervention comprising multidisciplinary team conferences (MDTs) to address this issue. The MDT consists of medical specialists in five different specialities meeting to discuss multimorbid diabetes patients. This protocol describes a feasibility test of MDTs designed to coordinate care and improve quality of life for people with diabetes and multimorbidity.

METHODS

A mixed-methods one-arm feasibility test of the MDT. Feasibility will be assessed through prospectively collected data. We will explore patient perspectives through patient-reported outcomes (PROs) and assess the feasibility of electronic questionnaires. Feasibility outcomes are recruitment, PRO completion, technical difficulties, impact of MDT, and doctor preparation time. During 17 months, up to 112 participants will be recruited. We will report results narratively and by the use of descriptive statistics. The collected data will form the basis for a future large-scale randomised trial.

DISCUSSION

A multidisciplinary approach focusing on better management of diabetic patients suffering from multimorbidity may improve functional status, quality of life, and health outcomes. Multimorbidity and diabetes are highly prevalent in our healthcare system, but we lack a solid evidence-based approach to patient-centred care for these patients. This study represents the initial steps towards building such evidence. The concept can be efficiency tested in a randomised setting, if found feasible to intervention providers and receivers. If not, we will have gained experience on how to manage diabetes and multimorbidity as well as organisational aspects, which together may generate hypotheses for research on how to handle multimorbidity in the future.

ADMINISTRATIVE INFORMATION

Protocol version: 01 TRIAL REGISTRATION: NCT05913726 - registration date: 21 June 2023.

Preferences of people with diabetes for diabetes care in Germany: a discrete choice experiment

OBJECTIVES

The objective of this study is to elicit health care preferences of people with diabetes and identify classes of people with different preferences.

METHODS

A discrete choice experiment was conducted among people with diabetes in Germany comprising attributes of role division in daily diabetes care planning, type of lifestyle education, support for correct medication intake, consultation frequency, emotional support, and time spent on self-management. A conditional logit model and a latent class model were used to elicit preferences toward diabetes care and analyze preference heterogeneity.

RESULTS

A total of 76 people with diabetes, recruited in two specialized diabetes care centers in Germany (mean age 51.9 years, 37.3% women, 49.1% type 2 diabetes mellitus, 50.9% type 1 diabetes mellitus), completed the discrete choice experiment. The most important attributes were consultation frequency, division in daily diabetes care planning, and correct medication intake. The latent class model detected preference heterogeneity by identifying two latent classes which differ mainly with respect to lifestyle education and medication intake.

CONCLUSION

While the majority of people with diabetes showed preferences in line with current health care provision in Germany, a relevant subgroup wished to strengthen lifestyle education and medication intake support with an aid or website.

Healthy food delivery for type 2 diabetes management in rural clinics' patients: A comparative effectiveness randomized controlled trial protocol

BACKGROUND

Rural populations experience a higher prevalence of both food insecurity and type 2 diabetes mellitus (T2DM) than metropolitan populations and face many challenges in accessing resources essential to optimal T2DM self-management. This study aims to address these challenges by delivering a T2DM-appropriate food box and recipes directly to rural participants' homes.

METHODS

This is a comparative effectiveness randomized controlled trial including 400 English- or Spanish-speaking rural adult participants with T2DM (HbA1c ≥6.5%) experiencing food insecurity. Participants are randomly assigned to a 3-month Healthy Food Delivery Intervention (HFDI) plus one 60-min virtual consultation with a diabetes educator or consultation only. The HFDI includes a weekly food box delivery with recipes. Data are collected at pre-intervention, 3-months (post-intervention), 9-months, and 15-months. The primary outcome is change in HbA1c, with secondary measures including diet quality (Healthy Eating Index-2015, calculated from one 24-h dietary recall at each data collection time point), cardio-metabolic risk factors (i.e., blood pressure, lipids, body mass index, glucose), and patient-centered outcomes (e.g., T2DM self-efficacy, T2DM-related distress). Process evaluation data (e.g., successful food box deliveries, diabetes educator consultation attendance, intervention satisfaction) are collected during and post-intervention (3-months). A cost-effectiveness analysis based on traditional cost per quality-adjusted life year gain thresholds will be conducted to estimate the incremental cost-effectiveness between HFDI plus consultation and consultation alone.

CONCLUSION

Findings from this study will provide evidence regarding the effectiveness of an intervention that promotes participant adherence and improves access to healthy food.

CLINICAL TRIAL REGISTRATION

NCT04876053.

Psychometric properties of the Diabetes Eating Problem Survey-Revised among Dutch adults with type 1 diabetes and implications for clinical use

AIMS

Disordered eating behaviour (DEB) in people with type 1 diabetes (T1D) can be screened with the Diabetes Eating Problem Survey-Revised (DEPS-R). This study aimed to investigate the psychometric properties of the DEPS-R among Dutch adults with T1D and to explore the individual items alongside the standard cut-off score of ≥20 for clinical use.

METHODS

The construct validity of the DEPS-R was assessed with an exploratory factor analysis, through principal axis factoring and with Spearman correlations between clinical variables and the DEPS-R. Backward logistic regression identified clinical predictors for DEPS-R scores above the cut-off. DEPS-R item responses were summarized with frequencies, means and standard deviations.

RESULTS

Participants were 145 adults with T1D, of whom 79.3% were women and 35.9% presented with DEB based on the cut-off. A single-factor solution of the DEPS-R showed good internal consistency, while a three-factor solution showed acceptable to good internal consistency within the factors. A younger age, a higher BMI and more diabetes distress were predictors for a DEPS-R cut-off score of ≥20. Clinically relevant items were identified that contributed minimally to the DEPS-R score.

CONCLUSIONS

This study supports a single-factor and a three-factor structure of the DEPS-R while also suggesting an item-specific or factor-specific approach in clinical practice.

Diabetes-related stress in older adults with type 2 diabetes and chronic complication: Multiple effects of social-ecological support on self-management behavior

This study aims to explore the relationship among diabetes-related distress, social-ecological support, and self-management behavior in older adults with type 2 diabetes mellitus (T2DM) and chronic complications. This cross-sectional study included older adults with T2DM in Shanghai, China, between January and July 2022. The problem areas in diabetes scale (PAID), the chronic illness resource survey (CIRS), and the diabetes self-management behavior for older (DSMB-O) were employed. A total of 264 participants (157 [59.47%] males, aged 71.07 ± 6.47 years) were included; their T2DM duration ranged from 5 to 30 years, with an average of 11.19 ± 6.96 years. The DSMB-O scores were negatively correlated with the PAID scores and positively correlated with CIRS scores. The CIRS scores were negatively correlated with the PAID scores. CIRS had a positive direct effect on DSMB-O, and CIRS had an indirect effect on DSMB-O through PAID. CIRS had a total effect on DSMB-O through PAID. The mediating effect made up 28.89% of the total effect. In older adults with T2DM and chronic complications, chronic illness resources were correlated with diabetes-related distress and self-management behavior. Chronic illness resources had both a direct effect on self-management behavior and an indirect effect through diabetes-related distress.

Improving mental health in chronic care in general practice: study protocol for a cluster-randomised controlled trial of the Healthy Mind intervention

BACKGROUND

Mental health issues are common among patients with chronic physical conditions, affecting approximately one in five patients. Poor mental health is associated with worse disease outcomes and increased mortality. Problem-solving therapy (PST) may be a suitable treatment for targeting poor mental health in these patients. This study protocol describes a randomised controlled trial of the Healthy Mind intervention, a general practice-based intervention offering PST to patients with type 2 diabetes and/or ischaemic heart disease and poor mental well-being.

METHODS

A stepped-wedge cluster-randomised controlled trial with 1-year follow-up will be conducted in Danish general practice. At the annual chronic care consultation, patients with type 2 diabetes and/or chronic ischaemic heart disease will be screened for poor mental well-being. Patients in the control group will be offered usual care while patients in the intervention group will be offered treatment with PST provided by general practitioners (GPs) or general practice staff, such as nurses, who will undergo a 2-day PST course before transitioning from the control to the intervention group. The primary outcome is change in depressive symptoms after 6 and 12 months. Secondary outcomes include change in mental well-being, anxiety, and diabetes distress (patients with type 2 diabetes) after 6 and 12 months as well as change in total cholesterol levels, low-density lipoprotein (LDL) levels, and blood glucose levels (patients with diabetes) after 12 months. Process outcomes include measures of implementation and mechanisms of impact. We aim to include a total of 188 patients, corresponding to approximately 14 average-sized general practices.

DISCUSSION

The Healthy Mind trial investigates the impact of PST treatment for patients with chronic disease and poor mental well-being in general practice. This will be the first randomised controlled trial determining the effect of PST treatment for patients with chronic diseases in general practice. The results of this study will provide relevant insights to aid GPs, and general practice staff manage patients with poor mental well-being.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05611112. Registered on October 28, 2022.

Type 1 diabetes-related distress: Current implications in care

Type 1 diabetes (T1D) is a complex chronic disease associated with major health and economic consequences, also involving important issues in the psychosocial sphere. In this regard, T1D-related distress, defined as the emotional burden of living with T1D, has emerged as a specific entity related to the disease. Diabetes distress (DD) is an overlooked but prevalent condition in people living with T1D, and has significant implications in both glycemic control and mental health in this population. Although overlapping symptoms may be found between DD and mental health disorders, specific approaches should be performed for the diagnosis of this problem. In recent years, different DD-targeted interventions have been postulated, including behavioral and psychosocial strategies. Moreover, new technologies in this field may be helpful to address DD in people living with T1D. In this article, we summarize the current knowledge on T1D-related distress, and we also discuss the current approaches and future perspectives in its management.

The role of peer social relationships in psychological distress and quality of life among adolescents with type 1 diabetes mellitus: a longitudinal study

BACKGROUND

Adolescents with type 1 diabetes mellitus suffer from diabetes distress and poor health-related quality of life (HRQOL) since living with the condition that differentiates them from their peers. The present study investigated the effects of peer support and stress on diabetes distress and HRQOL and whether positive coping mediated the effects.

METHODS

We used a prospective study design. A total of 201 adolescents with type 1 diabetes mellitus from 20 cities in 4 provinces were recruited.Participants complete two separate surveys at approximately 18-month intervals. The scales employed at both Time 1 and Time 2 included the Diabetes-Specific Peer Support Measure, Diabetes Stress Questionnaire for Youths, Simplified Coping Style Questionnaire, 5-item Problem Areas in Diabetes Scale, and the Diabetes Quality of Life for Youth scale.

RESULTS

Baseline peer stress directly predicted diabetes distress and HRQOL at 18 months, even controlling for age, gender, and peer support. However, the direct effect of baseline peer support on 18-month diabetes distress and HRQOL was insignificant. Baseline peer support indirectly affected diabetes distress and HRQOL at 18 months through positive coping, indicating that positive coping plays a mediating role.

CONCLUSION

The findings suggest that peer social relationships, especially peer stress, and positive coping are promising intervention targets for adolescents facing challenges in psychosocial adaptation.

Reliability and validity of the Turkish version of the problem areas in diabetes (PAID) survey: Results from diabetes MILES - Turkey

BACKGROUND AND AIMS

To 1) assess the reliability and validity of the Turkish version of the Problem Areas in Diabetes (PAID), PAID-5 and PAID-1 survey among Turkish adults with type 1 or type 2 diabetes, 2) estimate the level of elevated diabetes-specific distress (DD), and 3) determine the demographic and clinical correlates of DD-symptom severity.

METHODS AND RESULTS

From 2017-2019, 252 adults with type 1(n = 80) (T1DM) or type 2 diabetes (n = 172) (T2DM) self-reported demographic factors, DD(PAID) and related psychological and clinical questionnaires. We examined PAID internal consistency, structural and convergent validity. Associations of measures with DD were explored with hierarchical linear regression analysis. PCA yielded a 3-factor solution for PAID-20 and a 2-factor solution for PAID-5. Cronbach's α for PAID/PAID-5 subscales ranged from 0.63-0.90. All PAID versions correlated most strongly to BIPQ and HFS. The prevalence of elevated distress (PAID-20 ≥33) was 40% in T1DM and 15% in T2DM. DD severity was significantly positively associated (p < 0.01) with more negative diabetes perceptions (BIPQ) and type 1 diabetes.

CONCLUSIONS

The Turkish translation of the PAID and its short forms appeared to have satisfactory psychometric properties. Elevated diabetes distress was more common in T1DM.

Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with poor glycemic control and early onset of complications. Identification of psychosocial factors associated with poor glycemic control is needed to inform efficacious interventions.

Objective

To identify psychosocial factors associated with glycated hemoglobin (HbA1c) levels in young adults with youth-onset type 2 diabetes.

Design, Setting, and Participants

For the iCount cohort study, HbA1c levels were measured twice (at baseline [T1] and at 1 year [T2]) during the last years (2017-2019) of the observational phase of the multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study. Participants were young adults who had been diagnosed with type 2 diabetes during childhood or adolescence. Data were analyzed from December 2021 to September 2023.

Main Outcomes and Measures

Glycemic control was examined categorically (high [≥8.0%] vs low [<8.0%] HbA1c), continuously (HbA1c level), and over time (change in HbA1c: decreased ≥0.5%, remained stable, or increased ≥0.5%). Psychosocial measures included beliefs about medicines, depression and anxiety symptoms, diabetes distress, diabetes self-efficacy, self-management support, and unmet material needs. Multivariable logistic and linear regression models evaluated the association of each psychosocial factor with the probability of T2 HbA1c of 8.0% or greater, T2 HbA1c level, and change in HbA1c.

Results

Of the 411 TODAY2 participants approached, 381 enrolled in the iCount study, and 348 with T1 and T2 HbA1c data comprised the analysis group. The 348 participants had a mean (SD) age of 26.1 (2.5) years and a mean (SD) HbA1c of 9.4% (2.8%). Most participants (229 [65.8%]) were women. In adjusted multivariable regressions, greater beliefs that diabetes medicines are necessary (odds ratio [OR], 1.19 [95% CI, 1.03-1.37]; P = .02), concerns about medicines (OR, 1.20 [95% CI, 1.00-1.45]; P = .049), diabetes distress (OR, 1.08 [95% CI, 1.02-1.15]; P = .006), and high distress (OR, 2.18 [95% CI, 1.15-4.13]; P = .02) increased the odds of high HbA1c at T2. Greater support (OR, 0.67 [95% CI, 0.46-0.97]; P = .04) and diabetes self-efficacy (OR, 0.91 [95% CI, 0.84-0.99]; P = .02) decreased the odds of high HbA1c at T2. Diabetes distress was associated with higher HbA1c level at T2 (coefficient, 0.08 [95% CI, 0.02-0.13]; P = .01). Beliefs that diabetes medicines are necessary (OR, 1.20 [95% CI, 1.03-1.39]; P = .02) and concerns about medicines (OR, 1.22 [95% CI, 1.00-1.47]; P = .048) increased the odds of an HbA1c decrease of at least 0.5% over 1 year.

Conclusions and Relevance

In this cohort study of young adults with youth-onset type 2 diabetes, beliefs about medicines, high diabetes distress, low diabetes self-efficacy, and self-management support were associated with high HbA1c over time. Future research should assess whether interventions that address these factors result in improved glycemic control in this at-risk group.

A Three-Arm Randomized Controlled Study Comparing Patient-Reported Outcomes in People With Type 1 Diabetes Using Continuous Subcutaneous Insulin Infusion or Multiple Daily Injections

BACKGROUND

The aim of this study was to compare patient-reported outcomes (PROs) in people with type 1 diabetes using either continuous subcutaneous insulin infusion (CSII) with two different insulin patch pumps or multiple daily injections (MDIs).

MATERIALS AND METHODS

In this randomized three-arm study, people with type 1 diabetes on MDI therapy were included and used either MDI, the Accu-Chek Solo micropump system (Solo) or Omnipod for 26 weeks. From weeks 26 to 39, all participants used CSII with Solo. Patient-reported outcomes were assessed using the diabetes technology questionnaire (DTQ); in addition, HbA1c values were measured.

RESULTS

Overall, 181 participants were randomized (61 MDI arm, 62 Solo arm, 58 Omnipod arm) and 142 completed the study. After 26 weeks in the study, the DTQ "change" score in the Solo group (105.9 [100.6-111.2]; baseline-adjusted mean [95% confidence interval]) was significantly higher than in the MDI group (94.8 [89.6-100.0]) (P = .001). The comparison between the Solo group (105.1 [99.1-111.1]) and the Omnipod group (108.7 [103.1-114.4]) showed no significant differences (P = .382). HbA1c increased by 0.2% ± 0.7% in the MDI group and decreased in both pump groups (Solo group -0.2% ± 0.8% and Omnipod group -0.1% ± 0.8%). Differences in HbA1c between the Solo group and the MDI group were significant (P = .009), but not between the Solo group and the Omnipod group (P = .896).

CONCLUSIONS

This study showed that switching from MDI to CSII improves both psychosocial well-being and physiological outcomes. Furthermore, there were no substantial differences between the established and the recently released patch pump. Trial registration at www.clinicaltrials.gov is NCT03478969.

Pilot trial results of D-HOMES: a behavioral-activation based intervention for diabetes medication adherence and psychological wellness among people who have been homeless

Introduction

People living with type 2 diabetes who experience homelessness face a myriad of barriers to engaging in diabetes self-care behaviors that lead to premature complications and death. This is exacerbated by high rates of comorbid mental illness, substance use disorder, and other physical health problems. Despite strong evidence to support lay health coach and behavioral activation, little research has effectively engaged people living with type 2 diabetes who had experienced homelessness (DH).

Methods

We used community engaged research and incremental behavioral treatment development to design the Diabetes HOmeless MEdication Support (D-HOMES) program, a one-on-one, 3 month, coaching intervention to improve medication adherence and psychological wellness for DH. We present results of our pilot randomized trial (with baseline, 3 mo., 6 mo. assessments) comparing D-HOMES to enhanced usual care (EUC; brief diabetes education session and routine care; NCT05258630). Participants were English-speaking adults with type 2 diabetes, current/recent (<24 mo.) homelessness, and an HbA1c‗7.5%. We focused on feasibility (recruitment, retention, engagement) and acceptability (Client Satisfaction Questionnaire, CSQ-8). Our primary clinical outcome was glycemic control (HbA1c) and primary behavioral outcome was medication adherence. Secondary outcomes included psychological wellness and diabetes self-care.

Results

Thirty-six eligible participants enrolled, 18 in each arm. Most participants identified as Black males, had high rates of co-morbidities, and lived in subsidized housing. We retained 100% of participants at 3-months, and 94% at 6-months. Participants reported high satisfaction (mean CSQ-8 scores=28.64 [SD 3.94] of 32). HbA1c reduced to clinically significant levels in both groups, but we found no between group differences. Mean blood pressure improved more in D-HOMES than EUC between baseline and 6 mo. with between group mean differences of systolic -19.5 mmHg (p=0.030) and diastolic blood pressure -11.1 mmHg (p=0.049). We found no significant between group differences in other secondary outcomes.

Conclusion

We effectively recruited and retained DH over 6 months. Data support that the D-HOMES intervention was acceptable and feasible. We observe preliminary blood pressure improvement favoring D-HOMES that were statistically and clinically significant. D-HOMES warrants testing in a fully powered trial which could inform future high quality behavioral trials to promote health equity.

Clinical trial registration

https://clinicaltrials.gov/study/NCT05258630?term=D-HOMES&rank=1, identifier NCT05258630.

A Pilot Trial of Continuous Glucose Monitoring Upon Emergency Department Discharge Among People With Diabetes Mellitus

OBJECTIVE

People with diabetes mellitus, particularly those with limited access to longitudinal care, frequently present to the emergency department (ED). Continuous glucose monitoring (CGM) has been shown to improve outcomes in ambulatory settings, so we hypothesized that it would be beneficial if initiated upon ED discharge.

METHODS

We randomized adults with diabetes who were seen in the ED for hypo- or hyperglycemia to either 14 days of flash CGM or care coordination alone. All participants were scheduled to follow up in our diabetes specialty clinic. Outcomes included clinic attendance, the 3-month change in hemoglobin A1c, and repeat ED utilization.

RESULTS

We recruited 30 participants, including 13 with newly diagnosed diabetes. All but one (97%) had type 2 diabetes. We found no significant difference between the CGM (n = 16) and control (n = 14) groups in terms of clinic attendance (75 vs 64%, P = .61) or repeat ED utilization (31 vs 50%, P = .35), although our power was low. The absolute reduction in A1c was greater in the CGM group (5.2 vs 2.4%, P = .08). Among newly diagnosed participants for whom we had data, 7 out of 7 in the CGM group had a follow-up A1c under 7% compared to 1 out of 3 in the control group (P = .03). Over 90% of patients and providers found the CGM useful.

CONCLUSIONS

Our data demonstrate the feasibility of starting CGM in the ED, a valuable setting for engaging difficult-to-reach patients. Our pilot study was limited by its small sample size, however, as recruitment in the ED can be challenging.

Validation and Cultural Adaptation of the Problem Areas in Diabetes-5 (PAID-5) Scale to European Portuguese

INTRODUCTION

Diabetes distress syndrome (DDS) can lead to poor outcomes and should be assessed with adapted and validated tools. One of these tools is the Problem Areas in Diabetes (PAID) scale, which assesses diabetes distress in people suffering from diabetes (PsD). A short five-item form, PAID-5, is an easier and quicker alternative to be used in clinical and research practices, than the previous one with 20-items and has been validated by the original authors. This study intended to perform the cultural adaptation and validation of the PAID-5 scale in European Portuguese.

METHODS

To create the Portuguese version of PAID-5, translation-back translation, a clinical review, and a cognitive debriefing panel were performed. A convenience sample of 90 PsD was studied in three primary healthcare units for reliability and validity tests. Reliability was studied by the internal consistency (Cronbach's alpha) and the interval coefficient correlation (ICC) under a test-retest design. Structural validity was studied by principal component analysis. The construct validity was tested by the sensitivity of the PAID-5 total score with age, most recent HbA1c test, and socioeconomic class by the Socio-Economic Deprivation Index (SEDI). Criterion validity was tested by correlating the PAID-5 total score with the psychological distress questions of the Diabetes Health Profile 18 Questions (DHP-PDQ).

RESULTS

A Cronbach's alpha coefficient value of 0.905 and an ICC of 0.905 were computed. In a sample of n = 90 PsD, 55.6% were males, 63.3% aged 65 years or more, SEDI was 5.2 ± 0.8 [3 to 6], 44.4% studied for less than 4 years, and 18.9% were living alone. The Spearman correlation between PAID-5 and DHP-PDQ total scores was ρ = 0.382, p < 0.001, between PAID-5 total score and age was ρ = -0.207, p = 0.050 and between PAID-5 total score and most recent HbA1c knowledge was ρ = 0.275, p = 0.040. There was no significant relationship between PAID-5 total score and SEDI ρ = 0.080, p = 0.452.

CONCLUSION

DDS can now be assessed in the Portuguese context, accounting for better intervention by primary care teams. PAID-5 has good psychometric properties and is a reliable scale to identify diabetes-specific distress in the Portuguese diabetic population.

The Effect of Diabetes Management Shared Care Clinic on Glycated Hemoglobin A1c Compliance and Self-Management Abilities in Patients with Type 2 Diabetes Mellitus

Objective

We aim to evaluate the impact of diabetes management shared care clinic (DMSCC) on glycated hemoglobin A1c (HbA1c) compliance and self-management abilities in patients with type 2 diabetes mellitus (T2DM).

Methods

This study was a prospective cohort study of patients with T2DM participating in the DMSCC. At baseline and after management, the HbA1c levels were measured, the HbA1c compliance rate were calculated, and the Summary of Diabetes Self-Care Activities-6 (SDSCA-6), Diabetes Empowerment Scale-DAWN Short Form (DES-DSF), and Problem Areas in Diabetes Scale-Five-item Short Form (PAID-5) were completed. These pre- and post-management data were compared.

Results

A total of 124 eligible patients were enrolled. After the diabetes management of DMSCC, the average HbA1c decreased and the HbA1c compliance rate increased significantly (P < 0.01). SDSCA-6 showed significant improvement in physical activity, glycemic monitoring, smoking (P < 0.01), and taking medication (P < 0.05). DES-DSF suggested a greater willingness to try to effectively treat diabetes (P < 0.05). PAID-5 indicated significant improvement in diabetes-related emotional distress.

Conclusion

DMSCC can help patients with T2DM reduce HbA1c, increase HbA1c compliance, improve diabetes self-management behaviors, empowerment, and diabetes-related emotional distress and serve as an effective exploration and practice of diabetes self-management education and support.

The Clinical Relevance of Diabetes Distress versus Major Depression in Type 2 Diabetes: A Latent Class Analysis from the Fremantle Diabetes Study Phase II

BACKGROUND

The nosological position and clinical relevance of the concept of diabetes distress (DD) are uncertain. The aim of this study was to use latent class analysis (LCA) to categorise classes of people with type 2 diabetes and to compare their characteristics.

METHODS

Data from 662 participants in the longitudinal observational Fremantle Diabetes Study Phase II were analysed. LCA identified latent subgroups based on individual responses to the Patient Health Questionnaire-9, the Generalised Anxiety Disorder Scale, and the 5-item Problem Areas in Diabetes Scale.

RESULTS

Four classes were identified: Class 1 (65.7%, no symptoms), Class 2 (14.0%, DD), Class 3 (12.6%, subsyndromal depression (SSD)), and Class 4 (7.6%, major depression (MD)). Multinomial regression analysis with Class 1 as reference showed significant associations between the DD class and Southern European and Asian ethnic background, HbA1c, and BMI. The SSD class was significantly associated with HbA1c, cerebrovascular disease, and coronary heart disease (CHD). The MD class had significant associations with age (inversely), Southern European ethnic background, HbA1c, BMI, and CHD. In conclusion, LCA identified a pure DD group comprising 14.0% of participants. The only variable uniquely associated with the DD class was Asian ethnic background.

CONCLUSION

Although identification of DD may have some utility in assessing the psychological wellbeing of individuals with type 2 diabetes, it adds little to the assessment of depressive disorder and its significant clinical sequalae.

Use of Voice-Based Conversational Artificial Intelligence for Basal Insulin Prescription Management Among Patients With Type 2 Diabetes: A Randomized Clinical Trial

Importance

Optimizing insulin therapy for patients with type 2 diabetes can be challenging given the need for frequent dose adjustments. Most patients receive suboptimal doses and do not achieve glycemic control.

Objective

To examine whether a voice-based conversational artificial intelligence (AI) application can help patients with type 2 diabetes titrate basal insulin at home to achieve rapid glycemic control.

Design, Setting, and Participants

In this randomized clinical trial conducted at 4 primary care clinics at an academic medical center from March 1, 2021, to December 31, 2022, 32 adults with type 2 diabetes requiring initiation or adjustment of once-daily basal insulin were followed up for 8 weeks. Statistical analysis was performed from January to February 2023.

Interventions

Participants were randomized in a 1:1 ratio to receive basal insulin management with a voice-based conversational AI application or standard of care.

Main Outcomes and Measures

Primary outcomes were time to optimal insulin dose (number of days needed to achieve glycemic control), insulin adherence, and change in composite survey scores measuring diabetes-related emotional distress and attitudes toward health technology and medication adherence. Secondary outcomes were glycemic control and glycemic improvement. Analysis was performed on an intent-to-treat basis.

Results

The study population included 32 patients (mean [SD] age, 55.1 [12.7] years; 19 women [59.4%]). Participants in the voice-based conversational AI group more quickly achieved optimal insulin dosing compared with the standard of care group (median, 15 days [IQR, 6-27 days] vs >56 days [IQR, >29.5 to >56 days]; a significant difference in time-to-event curves; P = .006) and had better insulin adherence (mean [SD], 82.9% [20.6%] vs 50.2% [43.0%]; difference, 32.7% [95% CI, 8.0%-57.4%]; P = .01). Participants in the voice-based conversational AI group were also more likely than those in the standard of care group to achieve glycemic control (13 of 16 [81.3%; 95% CI, 53.7%-95.0%] vs 4 of 16 [25.0%; 95% CI, 8.3%-52.6%]; difference, 56.3% [95% CI, 21.4%-91.1%]; P = .005) and glycemic improvement, as measured by change in mean (SD) fasting blood glucose level (-45.9 [45.9] mg/dL [95% CI, -70.4 to -21.5 mg/dL] vs 23.0 [54.7] mg/dL [95% CI, -8.6 to 54.6 mg/dL]; difference, -68.9 mg/dL [95% CI, -107.1 to -30.7 mg/dL]; P = .001). There was a significant difference between the voice-based conversational AI group and the standard of care group in change in composite survey scores measuring diabetes-related emotional distress (-1.9 points vs 1.7 points; difference, -3.6 points [95% CI, -6.8 to -0.4 points]; P = .03).

Conclusions and Relevance

In this randomized clinical trial of a voice-based conversational AI application that provided autonomous basal insulin management for adults with type 2 diabetes, participants in the AI group had significantly improved time to optimal insulin dose, insulin adherence, glycemic control, and diabetes-related emotional distress compared with those in the standard of care group. These findings suggest that voice-based digital health solutions can be useful for medication titration.

Trial Registration

ClinicalTrials.gov Identifier: NCT05081011.

The Effect of a Patient Activation Tailored Intervention on Type 2 Diabetes Self-Management and Clinical Outcomes: A Study from Saudi Arabian Primary Care Settings

Background

Type 2 diabetes mellitus (T2DM) is a global public health challenge. T2DM self-management, including diet, physical activity, blood glucose self-monitoring, foot care, and adherence to medication, is considered a primary tool for managing diabetes. Patient activation, an individual's knowledge, skill, and confidence in managing their health and healthcare, was recognized to be associated with better T2DM self-management and clinical outcomes. Patient activation intervention has been described as a potential approach for enhancing chronic disease self-management. This study is aimed at examining the effect of a patient activation-tailored intervention on T2DM self-management and clinical outcomes in primary care settings in Saudi Arabia.

Method

A pre- and postintervention study was conducted among ≥18 years old T2DM patients attending primary healthcare centers in Saudi Arabia. Collected data included demographics, clinical data, the Patient Activation Measure (PAM), the Summary of Diabetes Self-Care Activities (SDSCA), the diabetes knowledge test (DKT2), the problem area in diabetes test (PAID-5), and the diabetes quality of life test (DQOL). The intervention was tailored based on the participants' patient activation level. The intervention consisted of monthly face-to-face sessions for three months and a telephone follow-up per month for three months postintervention. Descriptive statistics, a paired sample t-test for scale variables, and Wilcoxon's signed-rank test for categorical variables were used for data analysis.

Results

A total of 82 patients, mostly female (61%) with a mean age of 51.3 ± 9.9 years old, completed baseline and postintervention surveys. After six months of intervention, there was a significant change in patient activation score from 54.74 to 61.58 (p < 0.001), hemoglobin A1c (HbA1c) from 8.38 to 7.55 (p < 0.001), and body mass index (BMI) from 30.90 to 29.16 (p < 0.001). Also, there was a significant change in SDSCA scores (diet from 3.12 to 3.67, exercise from 2.54 to 3.49, and blood glucose self-testing from 2.37 to 3.24) (p < 0.001) and DKT from 6.29 to 7.22 (p = 0.01).

Conclusion

Our findings suggested that tailoring interventions based on patients' activation levels is more likely to yield promising T2DM self-management and clinical outcomes.

Evaluation of an interprofessional follow-up intervention among people with type 2 diabetes in primary care-A randomized controlled trial with embedded qualitative interviews

With an ageing population and improved treatments people live longer with their chronic diseases, and primary care clinics face more costly and difficult-to-treat multimorbid patients. To meet these challenges, current guidelines for the management of type 2 diabetes suggest that an interprofessional team should collaborate to enhance the delivery of worthwhile self-management support interventions. In this study, we aimed to evaluate the effects of an empowerment-based interprofessional follow-up intervention in people with type 2 diabetes in primary care on patient-reported outcomes, biomarkers and weight, and to explore the experiences of patients attending the intervention. We invited patients during regular visits to their general practitioners. The 12-month intervention included 1) empowerment-based counselling; 2) a standardized medical report. The control group received consultations with physicians only. The primary outcome was the Patient Activation Measure, a patient-reported measure assessing individual knowledge, skills, and confidence integral to managing one's health and healthcare. After the trial we conducted qualitative interviews. We observed no difference in the primary outcome scores. On secondary outcomes we found a significant between-group intervention effect in favor of the intervention group, with mean differences in glycemic control after 12 months (B [95% CI] = -8.6 [-17.1, -0.1] mmol/l; p = 0.045), and significant within-group changes of weight (B [95% CI] = -1.8 kg [-3.3, -0.3]; p = 0.02) and waist circumference (B [95% CI] = -3.9 cm [-7.3, -0.6]; p = 0.02). The qualitative data showed that the intervention opened patients' eyes for reflections and greater awareness, but they needed time to take on actions. The patients emphasized that the intervention gave rise to other insights and a greater understanding of their health challenges. We suggest testing the intervention among patients with larger disease burden and a more expressed motivation for change.

Psychosocial Factors Predicting Healthcare Usage in Young Adults with Youth-Onset Type 2 Diabetes: The TODAY2 iCount Observational Study

BACKGROUND

Established diabetes care ("diabetes home") and regular healthcare visits are important to achieve optimal health. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes, at risk for early complications.

OBJECTIVE

To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

DESIGN

Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for potential confounders, identified predictors of sub-optimal HCU (defined as no diabetes home, 0 visits for routine care, or  ≥ 1 urgent care visit in prior 6 months).

PARTICIPANTS

N = 366 TODAY2 participants with T1 and T2 data (381 consented). Mean age = 26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, 6.3% "other," mean HbA1c = 9.4%.

MAIN MEASURES

HCU survey; reliable and valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities, self-management support.

KEY RESULTS

25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had  ≥ 1 urgent care visit (prior 6 months). Beliefs in the necessity of (adjusted odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.12, 1.46, p < 0.001), and concerns about (OR = 1.29;CI = 1.08,1.54, p = 0.004), diabetes medicines, and its negative psychosocial impacts (OR = 1.57;CI = 1.04, 2.38, p = 0.03), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of a diabetes home (OR = 0.56;CI = 0.37,0.85, p = 0.006). Necessity beliefs (OR = 1.2;CI = 1.06,1.36, p = 0.004), and self-management support (OR = 1.5;CI = 1.08,2.07, p = 0.01) predicted higher odds of having  ≥ 1 diabetes care visit, harm beliefs predicted lower odds (OR = 0.6;CI = 0.41,0.88, p = 0.01).

CONCLUSIONS

Sub-optimal healthcare usage, common in young adults with youth-onset type 2 diabetes, is predicted by beliefs about medicines, diabetes impact, and self-management support. We must address these factors to help this vulnerable group establish stable diabetes care.

Family Typology for Adults With Type 2 Diabetes: Longitudinal Stability and Validity for Diabetes Management and Well-being

OBJECTIVE

We validated longitudinally a typology of diabetes-specific family functioning (named Collaborative and Helpful, Satisfied with Low Involvement, Want More Involvement, and Critically Involved) in adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted k-means cluster analyses with nine dimensions to determine if the typology replicated in a diverse sample and if type assignment was robust to variations in sampling and included dimensions. In a subsample with repeated assessments over 9 months, we examined the stability and validity of the typology. We also applied a multinomial logistic regression approach to make the typology usable at the individual level, like a diagnostic tool.

RESULTS

Participants (N = 717) were 51% male, more than one-third reported minority race or ethnicity, mean age was 57 years, and mean hemoglobin A1c (HbA1c) was 7.9% (63 mmol/mol; 8.7% [72 mmol/mol] for the longitudinal subsample). The typology was replicated with respect to the number of types and dimension patterns. Type assignment was robust to sampling variations (97% consistent across simulations). Type had an average 52% stability over time within participants; instability was not explained by measurement error. Over 9 months, type was independently associated with HbA1c, diabetes self-efficacy, diabetes medication adherence, diabetes distress, and depressive symptoms (all P < 0.05).

CONCLUSIONS

The typology of diabetes-specific family functioning was replicated, and longitudinal analyses suggest type is more of a dynamic state than a stable trait. However, type varies with diabetes self-management and well-being over time as a consistent independent indicator of outcomes. The typology is ready to be applied to further precision medicine approaches to behavioral and psychosocial diabetes research and care.

Community-based type 2 diabetes care by lay village health workers in rural Lesotho: protocol for a cluster-randomized trial within the ComBaCaL cohort study (ComBaCaL T2D TwiC)

BACKGROUND

Type 2 diabetes (T2D) poses a growing public health burden, especially in low- and middle-income countries (LMICs). Task-shifting to lay village health workers (VHWs) and the use of digital clinical decision support systems (CDSS) are promising approaches to tackle the current T2D care gap in LMICs. However, evidence on the effectiveness of lay worker-led T2D care models, in which VHWs initiate and monitor drug treatment in addition to community-based screening and referral services, is lacking.

METHODS

We are conducting a cluster-randomized trial nested within the Community-Based Chronic Disease Care Lesotho (ComBaCaL) cohort study (NCT05596773) using the trial within cohort (TwiC) design to assess the effectiveness of a VHW-led, CDSS-assisted T2D care model in rural Lesotho. Participants are non-pregnant members of the ComBaCaL cohort study with T2D. The ComBaCaL cohort study is conducted in approximately 100 villages in two rural districts in Lesotho and is managed by trained and supervised VHWs. In intervention villages, VHWs offer a community-based T2D care package including lifestyle counselling, first-line oral antidiabetic, lipid-lowering, and antiplatelet treatment guided by a tablet-based CDSS to participants who are clinically eligible, as well as treatment support to participants who prefer or clinically require facility-based T2D care. In control clusters, all participants will be referred to a health facility for T2D management. The primary endpoint is the mean glycosylated haemoglobin (HbA1c) 12 months after enrolment. Secondary endpoints include the 10-year risk for cardiovascular events estimated using the World Health Organization risk prediction tool.

DISCUSSION

The trial was launched on May 13, 2023, and has enrolled 226 participants at the date of submission (October 6, 2023). To our knowledge, the trial is the first to assess task-shifting of T2D care to VHWs at the community level, including the prescription of first-line antidiabetic, lipid-lowering, and antiplatelet medication in sub-Saharan Africa, and will thus provide the missing evidence on the effectiveness of such a T2D care model in this setting. The study is operating within the established Lesotho VHW programme. Similar community health worker programmes which exist across sub-Saharan Africa may benefit from the findings.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05743387. Registered on February 24 2023.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes.

Objective

To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia.

Design, Setting, and Participants

This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023.

Main Outcomes and Measures

The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey.

Results

Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence.

Conclusions and Relevance

These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

Effectiveness of a Digital Health Application for the Treatment of Diabetes Type II-A Pilot Study

(1) Background: This study aimed at providing preliminary evidence for mebix, an app-based treatment program for patients with diabetes mellitus type II. The main target was to show a positive healthcare impact as defined by improved blood glucose control, i.e., reduced HbA1c values. (2) Methods: For this, a 3-month, prospective, open-label trial with an intraindividual control group was conducted. Participants received the mebix intervention for 3 months. HbA1c values were observed every 3 months: retrospectively, at baseline, and 3 months after the start of using the app. Additionally, weight and patients' reported outcomes (well-being, diabetes-related distress, and self-management) were assessed. Data generated within the app were summarized and analyzed (steps, physical activity, fulfilled tasks, and food logs). (3) Results: After the usage of mebix for 3 months, participants significantly reduced their HbA1c levels (-1.0 ± 0.8%). Moreover, improvements in weight, well-being, and self-management as well as a reduction in diabetes-related distress were observed. App-generated data mainly supported the other main finding, that higher baseline HbA1c values lead to higher reductions. Overall, the study provided preliminary evidence that mebix can help patients improve metabolic and psychological health outcomes.

Validity of the short-form five-item Problem Area in Diabetes questionnaire as a depression screening tool in type 2 diabetes mellitus patients

AIMS/INTRODUCTION

Depression is prevalent in diabetes patients and associated with poor outcomes, but is currently underdiagnosed, with no firm consensus on screening methods. We evaluated the validity of the short-form five-item Problem Areas in Diabetes (PAID-5) questionnaire as a screening tool for depression, comparing it with the Beck Depression Inventory-II (BDI-II) and nine-item Patient Health Questionnaire (PHQ-9).

MATERIALS AND METHODS

A total of 208 English-speaking adults with type 2 diabetes, recruited from outpatient clinics, completed the BDI-II, PHQ-9 and PAID-5 questionnaires in English. Cronbach's α was used for internal reliability. Convergent validity was examined with BDI-II and PHQ-9. Receiver operating characteristics analyses were used to identify optimal PAID-5 cut-offs for the diagnosis of depression.

RESULTS

All three screening tools were highly reliable, with BDI-II, PHQ-9 and PAID-5 having a Cronbach's α of 0.910, 0.870 and 0.940, respectively. There was a good correlation between BDI-II and PHQ-9, with a correlation co-efficient (r) of 0.73; and a moderate correlation between PAID-5 and PHQ-9, and PAID-5 and BDI-II, with r of 0.55 and 0.55 respectively (P values <0.01). An optimal PAID-5 cut-off ≥9 corresponded to both a BDI-II cut-off >14 (sensitivity 72%, specificity 784%, area under the curve 0.809) and a PHQ-9 cut-off >10 (sensitivity 84%, specificity 74%, area under the curve 0.806). Using a PAID-5 cut-off ≥9, the prevalence of depressive symptoms was 36.1%.

CONCLUSIONS

Depressive symptoms are prevalent in people with type 2 diabetes, with the degree of distress significantly related to the severity of depressive symptoms. PAID-5 is a valid and reliable screening tool, and a score ≥9 could prompt further confirmation for depression.

A Short-Form Measure of Diabetes Distress Among Adults With Type 1 Diabetes for Use in Clinical Practice: Development and Validation of the T1-DDS-7

OBJECTIVE

Valid and reliable diabetes distress assessment is essential for identifying adults with elevated levels of concern and to guide targeted support. However, assessing diabetes distress must also be feasible in time-limited settings. We aimed to identify a short-form measure of the 28-item Type 1 Diabetes Distress Scale (T1-DDS-28) representing seven sources of type 1 diabetes distress that would be convenient for use in clinical practice.

RESEARCH DESIGN AND METHODS

Based on the evaluation of influence and importance by 14 experts in diabetes care and research, we identified the best-performing item within each of seven sources of diabetes distress included in the T1-DDS-28. To further validate the proposed short-form measure, we used survey data from 2,016 adults living with type 1 diabetes. Validity was examined by exploratory factor analysis, Cronbach's α, test-retest reliability analysis, and correlations with other psychosocial measures.

RESULTS

We identified a short-form measure of the T1-DDS-28 consisting of seven items, each representing a source of diabetes distress. These items showed satisfactory reliability (factor loadings > 0.45; α = 0.82; test-retest correlation, r = 0.90) and validity (correlation with T1-DDS-28, r = 0.95; area under the curve = 0.91; sensitivity 93%; specificity 89%) when combined in the short-form scale (T1-DDS-7).

CONCLUSIONS

We propose the T1-DDS-7 as a valid and reliable measure for routine screening of diabetes distress among adults with type 1 diabetes. In case of elevated levels of diabetes distress, we recommend that a full-scale assessment and open dialogue follow the short-form measure before determining further treatment.

High diabetes-specific distress among adults with type 1 diabetes and impaired awareness of hypoglycaemia despite widespread use of sensor technology

AIMS

Impaired awareness of hypoglycaemia (IAH) has been associated with increased diabetes distress and use of sensor technology can reduce diabetes distress. The aim of this study was to examine diabetes-specific distress (emotions, cognitions, behaviours) in relation to IAH status and use of glucose sensors in people with type 1 diabetes.

METHODS

Individuals with type 1 diabetes from an academic diabetes outpatient clinic completed the Clarke questionnaire (to assess hypoglycaemic awareness), Problem Areas in Diabetes (PAID-5), Hypoglycaemia Fear Survey-II (HFS-II), Attitudes to Awareness of Hypoglycaemia Survey (A2A), Nijmegen Clinical Screening Instrument Survey (NCSI) and Hyperglycaemia Avoidance Scale (HAS).

RESULTS

Of the 422 participants (51.9% male, diabetes duration 30 [16-40] years, HbA1c 60 ± 11 mmol/mol [7.6 ± 1.0%], 351 [88.2%] used a glucose sensor; 82 [19.4%]) had IAH. Compared to individuals with normal awareness, those with IAH more often had PAID-5 scores ≥8 (35.4% vs. 21.5%, p = 0.008) and higher scores on all HFS-II subscores (total [40.2 ± 21.5 vs. 27.9 ± 17.2, p < 0.001]), HFS-II behaviour (18.5 ± 10.0 vs. 15.1 ± 8.0, p = 0.005), HFS-II worry (21.8 ± 13.5 vs. 12.7 ± 10.9, p < 0.001), HAS worries (17.5 ± 7.3 vs. 14.3 ± 7.0, p < 0.001) and NCSI hypoglycaemia items. HAS behaviour, A2A and NCSI hyperglycaemia scores did not differ between individuals with or without IAH. Restricting the analyses to individuals using a glucose sensor did not materially change the results.

CONCLUSIONS

Diabetes-specific distress remains a major problem among individuals with type 1 diabetes, particularly those with IAH, despite the widespread use of (intermittently scanned) sensor technology. Further studies are needed to examine strategies to lower diabetes-specific distress in individuals with IAH.

The impact of real-time sensor technology on quality of life for adults with type 1 diabetes: A Dutch national survey

AIMS

To examine the impact of real-time continuous glucose monitoring (RT-CGM) on quality of life in Dutch adults with type 1 diabetes, inside/outside automated insulin delivery (AID) systems.

METHODS

In this cross-sectional retrospective observational study, RT-CGM users completed an online survey including (adapted) validated questionnaires, study-specific items and open-ended questions.

RESULTS

Of 893 participating adults, 69% used the RT-CGM as part of AID. The overall sample reported improvements in quality of life related to RT-CGM use (irrespective of initial indication), particularly with respect to physical health, emotional wellbeing and energy. Merits for sleep, intimacy and cognitive diabetes load lagged somewhat behind, mostly when RT-CGM was not integrated in AID. Users of AID had significantly larger improvements in overall quality of life, fatigue and diabetes-specific distress than users of sensor-augmented pump or Open Loop treatment. In regression analyses, user evaluations were associated with perceptions of benefit and burden. In qualitative content analysis, benefits (e.g. life 'normalization', increased perceptions of control) outweighed burdens (e.g. technology frustrations, confrontation with diabetes).

CONCLUSIONS

RT-CGM positively impacted the quality of life of adults with type 1 diabetes. This justifies a (re-)consideration of broader access. Increased support to maximize device benefits and minimize burdens is also warranted.

Diabetes distress and disordered eating behaviors in youth with type 1 diabetes: the mediating role of self-regulatory fatigue and the moderating role of resilience

BACKGROUND

Despite previous research on the association between diabetes distress and disordered eating behaviors (DEBs) among youth with type 1 diabetes (T1D), there is a lack of understanding regarding the underlying mechanisms. This study aimed to investigate the relationships between diabetes distress and DEBs, specifically examining whether self-regulatory fatigue mediated the relationship and whether resilience moderated this mediation.

METHODS

A cross-sectional study was performed among youth with T1D recruited from two diabetes centers in Nanjing, China. Measurement instruments included the problem areas in the diabetes-5 scale, the diabetes strengths and resilience measure for adolescents, the self-regulatory fatigue scale, and the Chinese version of diabetes eating problem survey-revised. Mediation and moderated mediation analyses were conducted.

RESULTS

A total of 185 youths with T1D were involved in the current study. The results indicated that diabetes distress positively predicted DEBs. Self-regulatory fatigue partially mediated the association between diabetes distress and DEBs, accounting for 50.88% of the overall effect. Additionally, the pathway from self-regulatory fatigue to DEBs was moderated by resilience.

CONCLUSION

The current study examined whether self-regulatory fatigue mediated the relationship between diabetes distress and DEBs and whether resilience moderated the connection between self-regulatory fatigue and DEBs. These findings add to the theoretical basis of how diabetes distress influences DEBs and help guide the incorporation of diabetes distress, self-regulatory fatigue, and resilience into DEBs reduction programs for youth with T1D.

Family involvement and diabetes distress across dyads for adults with type 2 diabetes

OBJECTIVE

Family/friend involvement and diabetes distress are associated with outcomes for persons with type 2 diabetes (PWDs), but little is known about how they relate to each other. We aim to (1) describe associations between PWD and support person (SP) distress; (2) describe associations between involvement and diabetes distress for PWDs, for SPs, and across the dyad; and (3) explore whether associations differ by PWD-SP cohabitation.

METHODS

PWDs and SPs co-enrolled in a study evaluating the effects of a self-care support intervention and completed self-report measures at baseline.

RESULTS

PWDs and SPs (N = 297 dyads) were, on average, in their mid-50s and around one-third identified as racial or ethnic minorities. The association between PWD and SP diabetes distress was small (Spearman's ρ = 0.25, p < 0.01). For PWDs, experienced harmful involvement from family/friends was associated with more diabetes distress (standardized β = 0.23, p < 0.001) independent of helpful involvement in adjusted models. Separately, SPs' self-reported harmful involvement was associated with their own diabetes distress (standardized β = 0.35, p < 0.001) and with PWDs' diabetes distress (standardized β = 0.25, p = 0.002), independent of SPs' self-reported helpful involvement.

CONCLUSION AND PRACTICE IMPLICATIONS

Findings suggest dyadic interventions may need to address both SP harmful involvement and SP diabetes distress, in addition to PWD distress.

Validity and Reliability of the Occupational Balance Questionnaire (OBQ11) in a U.S. Sample of Adults With Type 1 Diabetes

IMPORTANCE

Although occupational balance (OB) is a construct of importance to occupational therapy, existing OB assessments have not been validated in clinical populations.

OBJECTIVE

To examine the validity and reliability of the 11-item version of the Occupational Balance Questionnaire (OBQ11) in U.S. adults with Type 1 diabetes.

DESIGN

Data were analyzed from adults with Type 1 diabetes enrolled in a larger longitudinal study examining the relationships among blood glucose, emotion, and functioning. Dimensionality of the OBQ11 was assessed with item response theory (IRT); convergent validity was tested by examining whether associations between the OBQ11 and other constructs were consistent with a priori hypotheses.

SETTING

Three outpatient clinical sites in the United States.

PARTICIPANTS

Data from 208 U.S. adults with Type 1 diabetes were included in the analyses (42% Latino, 29% White, 14% African American, 7% multiethnic, and 8% other).

OUTCOMES AND MEASURES

Assessments administered include the OBQ11, Patient Health Questionnaire (depression), and Diabetes Self-Management Questionnaire.

RESULTS

Overall, results from IRT models and correlational tests supported the reliability and validity of the OBQ11. For instance, higher scores on the OBQ11 were significantly associated with better self-ratings of diabetes management behaviors (r = .28, p < .001), lower depression symptoms (r = -.53, p < .001), and greater positive affect (r = .32, p < .001). A single-factor generalized partial credit model fit the OBQ11 acceptably well, supporting its unidimensionality.

CONCLUSIONS AND RELEVANCE

The OBQ11 may be a reliable and valid measure of OB appropriate for use in clinical populations such as adults with diabetes. What This Article Adds: OB is not often formally assessed by occupational therapists in the United States, even though the contributions of OB to health and well-being are core components of the philosophy of occupational therapy. The current evidence supports the validity of the OBQ11 in a clinical population of adults with Type 1 diabetes and demonstrates significant associations between OB and health management behaviors. Study results may encourage greater consideration and assessment of OB in occupational therapy clinical practice in the United States.

Diabetes distress in a Barbadian population with type 2 diabetes: A pilot test

One in five Barbadians has diabetes, suggesting that there is a severe burden of the disease.

Objective

To assess the psychometric properties of the Diabetes Distress Scale, in order to determine the feasibility, practicality, internal consistency and criterion validity of the instrument when used with Barbadians living with Type 2 Diabetes.

Methods

Patients with type 2 diabetes, (n = 106. 60% females, 40% males; mean age = 65.2, 11.3 years) attending a private clinic in Barbados were assessed for diabetes distress, depression, glycated hemoglobin (HbA1C) and blood pressure (BP).A self-report questionnaire that included: clinical and demographic questions; the Diabetes Distress Scale (DDS); the Patient Health Questionnaire (PHQ-9); and the Problem Areas In Diabetes (PAID-5) scale. Glycated haemaglobin (HbA1C) and Blood pressure (BP) were also measured.

Results

Of the 110 persons who participated, 106 persons completed the questionnaire. The Cronbach alpha coefficient of the PAID was 0.92 and the DDS was 0.92. Concurrent validity was demonstrated in a strong consistent relationship between the scores on the DDS and PAID-5, with a strong positive correlation, r = 0.70, n = 86, p < 0.001. There was a significant difference in the DDS scores between males (M = 1.26, SD = 0.37) and females (M = 1.50, SD = 0.73), t(73.31) = -1.99, p = 0.05 two tailed.

Conclusion

The DDS is shown to be a valid and reliable measure within this Caribbean context. Thus, researchers and clinicians desirous of a tool to assess Diabetes Distress may be assured of the strong psychometric properties demonstrated thus far.

Identification of Core Outcome Domains and Design of a Survey Questionnaire to Evaluate Impacts of Digital Health Solutions That Matter to People With Diabetes

BACKGROUND

Digital health solutions (DHS) are increasingly used to support people with diabetes (PwD) to help manage their diabetes and to gather and manage health and treatment data. There is a need for scientifically reliable and valid methods to measure the value and impact of DHS on outcomes that matter to PwD. Here, we describe the development of a survey questionnaire designed to assess the perceptions of PwD toward DHS and their prioritized outcomes for DHS evaluation.

METHOD

We applied a structured process for engagement of a total of nine PwD and representatives of diabetes advocacy organizations. Questionnaire development consisted of a scoping literature review, individual interviews, workshops, asynchronous virtual collaboration, and cognitive debriefing interviews.

RESULTS

We identified three overarching categories of DHS, which were meaningful to PwD and crucial for the identification of relevant outcomes: (1) online/digital tools for information, education, support, motivation; (2) personal health monitoring to support self-management; (3) digital and telehealth solutions for engaging with health professionals. Overall outcome domains identified to be important were diabetes-related quality of life, distress, treatment burden, and confidence in self-management. Additional positive and negative outcomes specific to DHS were identified and corresponding questions were incorporated into the survey questionnaire.

CONCLUSION

We identified the need for self-reporting of quality of life, diabetes distress, treatment burden, and confidence in self-management, as well as specific positive and negative impacts of DHS. We designed a survey questionnaire to further assess the perceptions and perspectives of people with type 1 and 2 diabetes on outcomes relevant for DHS evaluations.

An integrated approach to address diabetes in the context of food insecurity: Delivering health study protocol

Background

Diabetes self-management education and support (DSMES) interventions among food insecure individuals with type 2 diabetes (T2D) have found modest improvements in nutrition and health outcomes but are limited by barriers to attendance and retention. This study applies a community-based participatory research approach, engaging community members at all levels of intervention planning, development, implementation, and dissemination, to deliver a plain-language DSMES curriculum to food insecure community members with T2D.

Methods

This is a single-arm, pre-post design assessing the efficacy of a 12-week home-delivered DSMES curriculum and T2D-appropriate food box intervention to improve the nutrition and health outcomes of food insecure individuals with T2D. The intervention consists of a weekly food box delivery and handout with video links on key DSMES topics, developed and refined using community advisor feedback. Up to 100 English-, Spanish-, or Marshallese-speaking adult participants with T2D (HbA1c ≥ 7%) and food insecurity are being recruited from food pantries in northwest Arkansas. Data is collected at pre-intervention and immediately post-intervention. The primary study outcome is change in HbA1c. Secondary measures include diet quality (Healthy Eating Index-2015, calculated from 3 24-h dietary recall interviews via phone), body mass index, blood pressure, skin carotenoids, food security, T2D self-management behaviors, T2D self-efficacy, and T2D-related distress.

Results

Recruitment began in August 2021 and enrollment is anticipated to be complete in March 2023.

Conclusion

Findings from this study will provide a rich understanding of diabetes-related health outcomes and dietary patterns of individuals with food insecurity and T2D and inform future food-focused DSMES interventions in this setting.

Assessing attitudes towards insulin pump therapy in adults with type 1 diabetes: Italian validation of the Insulin Pump Attitudes Questionnaire (IT-IPA questionnaire)

AIMS

The aim of the study was to adapt the German version of the insulin pump therapy (IPA) questionnaire to Italian (IT-IPA) and to evaluate its psychometric properties in adults with type 1 diabetes.

METHODS

We conducted a cross-sectional study, data were collected through an online survey. In addition to IT-IPA, questionnaires evaluating depression, anxiety, diabetes distress, self-efficacy, and treatment satisfaction were administered. The six factors identified in the IPA German version were assessed using confirmatory factor analysis; psychometric testing included construct validity and internal consistency.

RESULTS

The online survey was compiled by 182 individuals with type 1 diabetes: 45.6% continuous subcutaneous insulin infusion (CSII) users and 54.4% multiple daily insulin injection users. The six-factor model had a very good fit in our sample. The internal consistency was acceptable (Cronbach's α = 0.75; 95% IC [0.65-0.81]). Diabetes treatment satisfaction was positively correlated with a positive attitude towards CSII therapy (Spearman's rho = 0.31; p < 0.01), less Technology Dependency, higher Ease of Use, and less Impaired Body Image. Furthermore, less Technology Dependency was associated with lower diabetes distress and depressive symptoms.

CONCLUSIONS

The IT-IPA is a valid and reliable questionnaire evaluating attitudes towards insulin pump therapy. The questionnaire can be used for clinical practice during consultations for shared decision-making to CSII therapy.

Effectiveness of a Digitally Delivered Continuous Care Intervention (Defeat Diabetes) on Type 2 Diabetes Outcomes: A 12-Month Single-Arm, Pre-Post Intervention Study

Low-carbohydrate dietary approaches can lead to improvements in blood glucose levels and weight loss, as well as a reduction and/or cessation in medication use in people with type 2 diabetes (T2D). Recent technological advances have led to the development of health-related applications (apps), including a high proportion dedicated to the management of diabetes. The Defeat Diabetes Program is a smartphone- and web-based app that provides guidance on a low-carbohydrate dietary approach for T2D and was designed to be used in conjunction with standard care in the medical management of T2D. The primary aim of this protocol is to provide the rationale and design of a single-arm 12-month pre-post intervention clinical trial using the Defeat Diabetes Program in an Australian community-based cohort of people with T2D who were referred by their general practitioner (GP). The study seeks to engage the GP community to help demonstrate whether the results of using a low-carbohydrate dietary approach for T2D can be achieved by the Defeat Diabetes Program in their patients. This protocol describes (1) the rationale for the selection of primary and secondary outcome measures, (2) the sampling procedures and methodological steps used to identify eligible participants and collect data, and (3) the approach followed to involve and educate GPs to support the trial.

Sustained Impact of Intermittently Scanned Continuous Glucose Monitoring on Treatment Satisfaction and Severe Hypoglycemia in Adults with Type 1 Diabetes (FUTURE): An Analysis in People with Normal and Impaired Awareness of Hypoglycemia

Objective: Nationwide reimbursement of intermittently scanned continuous glucose monitoring (isCGM) was introduced in Belgium (2016). This real-world observational study investigates the impact of isCGM over 24 months on adults with type 1 diabetes with impaired or normal awareness of hypoglycemia (IAH or NAH). Methods: We included 1905 people who started first-generation 14-day FreeStyle Libre (without alerts). Sixteen percent had IAH. Primary endpoint was evolution of quality of life (QOL); secondary endpoints were evolution of severe hypoglycemia, work absenteeism, glycated hemoglobin (HbA1c), and sensor-measured outcomes. Results: At baseline, people with IAH (n = 308) had significantly worse QOL than people with NAH (n = 1594). Only people with IAH improved on the hypoglycemia fear survey-worry subscale after 24 months (22.8 [95% confidence interval: 21.4-24.2] at baseline; 20.6 [19.0-22.1] at 24 months, P = 0.002). For both groups, Diabetes Treatment Satisfaction Scale improved over 24 months (IAH: +3.1 [2.1-4.1], P < 0.001; NAH: +2.3 [1.9-2.7], P < 0.001), whereas general QOL, diabetes distress, and HbA1c remained stable. People with IAH showed the strongest decline in work absenteeism and severe hypoglycemia (36.4% having an event 6 months before isCGM initiation; 16.0% having an event during last 6 months of follow-up, P < 0.001), with similar observations for hypoglycemia hospitalization and hypoglycemia coma. Over 24 months, people with IAH spent more time in hypoglycemia, but less time in hyperglycemia than people with NAH. Conclusion: These data show sustained improvement of severe hypoglycemia, work absenteeism, and hypoglycemia fear after isCGM reimbursement, mostly driven by people with IAH. Together with improved treatment satisfaction, irrespective of hypoglycemia awareness level, isCGM without alerts is a valuable tool under long-term real-world conditions. Clinical Trial Registration number: NCT02898714.

Closed-loop insulin delivery in pregnant women with type 1 diabetes (CRISTAL): a multicentre randomized controlled trial - study protocol

BACKGROUND

Despite increasing use of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII, insulin pumps) in type 1 diabetes (T1D) in pregnancy, achieving recommended pregnancy glycaemic targets (3.5-7.8 mmol/L or 63-140 mg/dL) remains challenging. Consequently, the risk of adverse pregnancy outcomes remains high. Outside pregnancy, hybrid closed-loop (HCL) insulin delivery systems have led to a paradigm shift in the management of T1D, with 12% higher time in glucose target range (TIR) compared to conventional CSII. However, most commercially available HCL systems are currently not approved for use in pregnancy. This study aims to evaluate the efficacy, safety and cost-effectiveness of the MiniMed™ 780G HCL system (Medtronic) in T1D in pregnancy.

METHODS

In this international, open-label, randomized controlled trial (RCT), we will compare the MiniMed™ 780G HCL system to standard of care (SoC) in T1D in pregnancy. Women aged 18-45 years with T1D diagnosis of at least one year, HbA1c ≤ 86 mmol/mol (≤ 10%), and confirmed singleton pregnancy up to 11 weeks 6 days will be eligible. After providing written informed consent, all participants will wear a similar CGM system (Guardian™ 3 or Guardian™ 4 CGM) during a 10-day run-in phase. After the run-in phase, participants will be randomised 1:1 to 780G HCL (intervention) or SoC [control, continuation of current T1D treatment with multiple daily injections (MDI) or CSII and any type of CGM] stratified according to centre, baseline HbA1c (< 53 vs. ≥ 53 mmol/mol or < 7 vs. ≥ 7%), and method of insulin delivery (MDI or CSII). The primary outcome will be the time spent within the pregnancy glucose target range, as measured by the CGM at four time points in pregnancy: 14-17, 20-23, 26-29, and 33-36 weeks. Prespecified secondary outcomes will be overnight TIR, time below range (TBR: <3.5 mmol/L or < 63 mg/dL), and overnight TBR. Other outcomes will be exploratory. The planned sample size is 92 participants. The study will end after postpartum discharge from hospital. Analyses will be performed according to intention-to-treat as well as per protocol.

DISCUSSION

This large RCT will evaluate a widely used commercially available HCL system in T1D in pregnancy. Recruitment began in January 2021 and was completed in October 2022. Study completion is expected in May 2023.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04520971. Registration date: August 20, 2020. https://clinicaltrials.gov/ct2/show/NCT04520971.

360° Diagnostic Tool to Personalize Lifestyle Advice in Primary Care for People With Type 2 Diabetes: Development and Usability Study

BACKGROUND

Various multifaceted factors need to be addressed to improve the health and quality of life of people with type 2 diabetes (T2D). Therefore, we developed a web-based decision support tool that comprises a more holistic diagnosis (including 4 domains: body, thinking and feeling, behavior, and environment) and personalized advice. This 360° diagnostic tool enables people with T2D and health care professionals at the general practice to obtain an overview of the most important T2D-related issues and, subsequently, determine the most suitable intervention for the person with T2D.

OBJECTIVE

This study aimed to describe the systematic and iterative development and evaluation of the web-based 360° diagnostic tool.

METHODS

We defined the requirements for the web-based 360° diagnostic tool based on previously developed tools, a literature review, and inputs from a multidisciplinary team of experts. As part of the conceptualization, we defined 3 requirements: diagnostics; feedback; and advice, consultation, and follow-up. Next, we developed and designed the content for each of these requirements. We evaluated the diagnostic part of the tool (ie, measurement instruments and visualization) with a qualitative design, in a usability study with a think-aloud strategy and interview questions, among 8 people with T2D at a Dutch general practice.

RESULTS

For each of the 4 domains, specific parameters and underlying elements were selected, and measurement instruments (including clinical data and questionnaires) were chosen. Cutoff values were defined to identify high-, middle-, and low-ranking scores, and decision rules were developed and implemented using R scripts and algorithms. A traffic light color visual design was created (profile wheel) to provide an overview of the scores per domain. We mapped the interventions that could be added to the tool and developed a protocol designed as a card deck with motivational interview steps. Furthermore, the usability study showed that people with T2D perceived the tool as easy to use, useful, easy to understand, and insightful.

CONCLUSIONS

Preliminary evaluation of the 360° diagnostic tool by experts, health care professionals, and people with T2D showed that the tool was considered relevant, clear, and practical. The iterative process provided insights into the areas of improvement, which were implemented. The strengths, shortcomings, future use, and challenges are also discussed.

Simplifying carb counting: A randomized controlled study - Feasibility and efficacy of an individualized, simple, patient-centred carb counting tool

INTRODUCTION

The purpose of this study was to introduce and test a simple, individualized carbohydrate counting tool designed for persons with Type 1 Diabetes Mellitus (T1DM) in order to determine whether the tool improved A1C levels for participants with age, education or language barriers.

METHODS

In a randomized controlled trial, 85 participants were offered six diabetes instructional sessions free of charge over a six-month period. Forty-one received guidance using the regular carbohydrate counting (RCC) method. Forty-four received guidance using an individualized 'Simple Carb Counting' (SCC), involving two customized tables prepared for participants.

RESULTS

The simple, individualized SCC tool for carbohydrate counting was non-inferior to the standard method of RCC. The SCC tool was more effective among participants aged 40 and older, while no differences were found when comparing participants by education level. Irrespective of intervention group, all participants improved their A1C level (9.9% = 13.2 mmol/L vs 8.6% = 11.1 mmol/L, p = .001). A greater improvement in A1C level was seen in newly diagnosed participants (-6.1 vs -0.7, p = .005, -3.4 vs 0.9, p = .032) in both the RCC and SCC groups. All participants expressed improved emotional level per their PAID5 questionnaires (Problem Areas in Diabetes Scale-PAID), (10.6 (±5.7) vs 9.5 (±5.7), p = .023), with women reporting greater improvement than men.

CONCLUSIONS

SCC is a simple, individualized, feasible, low-tech tool for carbohydrate counting, which promotes and enables accurate insulin dosing in people with T1DM. It was found more effective among participants aged 40 and older. Additional studies are needed to corroborate these findings.

Factors associated with continuity of care in hypertension and type 2 diabetes among forcibly displaced persons in the Bidibidi refugee settlement in Uganda: Protocol for a cross-sectional, mixed-methods study

BACKGROUND

Non-communicable diseases in humanitarian settings are generally under-researched, particularly in Africa and have been called a neglected crisis. Little is known about factors affecting access to and (dis)continuity of care for chronic conditions, such as hypertension (HTN) and type 2 diabetes among forcibly displaced persons (FDPs) in Uganda.

AIM

To investigate factors affecting access to and (dis)continuity of HTN and/or type 2 diabetes care among FDPs in the Bidibidi refugee settlement, Uganda.

METHODS

A sequential explanatory mixed-methods design incorporating methodological and investigator triangulation will be conducted. The study aims to employ a community-based participatory research approach to equitably engage community members, researchers, and other stakeholders in the research process, recognising and maximising their diverse contributions. In phase 1, the quantitative arm of the study, 960 FDPs with HTN and/or type 2 diabetes will be interviewed about their sociodemographic characteristics, health status, migration experiences, social capital, and awareness, treatment, and control of these diseases. Participants will be purposively recruited from phase 1 as well as village health teams, healthcare providers, and policymakers to participate in phase 2, the qualitative study, in order to gain more insight into how mobility and social factors affect (dis)continuity of care among FDPs with HTN and/or type 2 diabetes.

DISCUSSION

The findings from phase 1 and phase 2 of the study will be integrated through a triangulation process to provide a more holistic and comprehensive insight into the factors affecting access to and (dis)continuity for HTN and/or type 2 diabetes care among FDPs. Understanding these factors is expected to pave the way for conceptualizing health-enabling environments and strengthening health systems for FDPs with chronic conditions. It is anticipated that the study will generate baseline evidence that might be beneficial in developing and implementing HTN and diabetes care models for FDPs in the region.

Psychosocial factors predict medication adherence in young adults with youth-onset type 2 diabetes: Longitudinal results from the TODAY2 iCount study

AIM

To identify psychosocial predictors of medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

METHODS

Participants (mean age: 26 years) completed validated psychosocial measures. Unannounced telephone pill counts were completed at T1 (baseline) and T2 (follow-up, approximately 1 year later) to assess adherence to oral hypoglycaemia agents (OHAs). Adherence to insulin was assessed by self-report. Logistic and linear regressions identified factors that predicted 'low adherence' (<80% of pills/insulin) and per cent adherence, adjusted for potential confounders.

RESULTS

Of 171 participants with OHA adherence scores at T1 and T2 (65% women, 43% Hispanic and 35% non-Hispanic Black), 65.4% were low adherent. After adjustment (including T1 adherence), concerns about diabetes medicines (adverse effects, dependence) at T1 predicted higher odds of being low adherent (categorical) at T2 (p = 0.019). Housing insecurity (p = 0.045) and reporting ≥2 need insecurities (p = 0.027) at T1 predicted lower per cent adherence (continuous) at T2. Of 157 participants with insulin adherence scores at T1 and T2 (69% women, 38% Hispanic and 38% non-Hispanic Black), 36.3% were low adherent. After adjustment (including T1 adherence), beliefs that medicines are overused predicted higher odds of insulin low adherence at T2 (p = 0.013), and beliefs that medicines are harmful (p = 0.004) and overused (p = 0.010) predicted lower per cent insulin adherence at T2.

CONCLUSIONS

Suboptimal medication adherence, common in young adults with youth-onset type 2 diabetes, is predicted by interfering beliefs about medicines and social factors. We must address these beliefs and unmet needs to develop tailored interventions for this vulnerable group.

Exploring the Needs of Adults Living With Type 1 or Type 2 Diabetes Distress Using the Problem Areas in Diabetes 5 Tool

OBJECTIVES

This study investigated the feasibility and acceptability of implementing a screening tool as a part of routine care and the subsequent screening experiences of patients and clinicians. Additionally, potential sources of diabetes distress (DD) were identified in this clinical population.

METHODS

Our investigation was a cross-sectional, mixed-methods, convenience sample of 203 patients living with type 1 or type 2 diabetes from 2 Canadian tertiary hospital-based clinics. The Problem Areas in Diabetes 5 (PAID5) scale was used to assess DD. Structured telephone interviews of patients with high DD scores and care provider focus group transcriptions were analyzed using a deductive thematic content analysis.

RESULTS

The prevalence of DD was 45%. Lack of medication coverage (p=0.02) and presence of neuropathy (p=0.04) were approximately 5- and 2-fold more likely to be predictors of high DD, respectively. Patient interviews identified DD screening as an opportunity to share and feel supported but demonstrated their fear of discussing mental health concerns. Patients found discussion about mental health helpful and often did not require a referral to a mental health specialist. Staff focus groups discussed screening as a feasible tool, but also acknowledged barriers and knowledge gaps that preclude DD screening integration in routine clinical practice. Specialized training for clinicians may help increase confidence and improve uptake of DD screening into routine clinical practice.

CONCLUSIONS

The prevalence of DD in outpatient care settings is high. Findings suggest that integrating the PAID5 screening tool into regular clinical practice is feasible by patients and care providers.

Improving Health and Diabetes Self-Management in Immigrants with Type 2 Diabetes Through a Co-Created Diabetes Self-Management Education and Support Intervention

To examine the impact of a co-created culturally sensitive diabetes self-management education and support (DSMES) intervention on the physical and mental health of immigrants with type 2 diabetes (T2D). Pre- and post-test among people with T2D whose primary language was Urdu, Arabic or Turkish (n = 97). Participants were offered a six-week intervention based on a person-centred approach using research-based dialogue tools to facilitate learning and reflection, which was developed in co-creation with immigrants and healthcare professionals. Data were collected at baseline, post-intervention and after 6 months and analysed using paired t-tests, Wilcoxon signed-rank tests, chi-square tests and regression models when appropriate. Several clinical outcomes were improved post-intervention, including HbA1c (P < 0.001), body fat percentage (P = 0.002), self-rated general health (P = 0.05), well-being (P = 0.004) and several self-management behaviours, e.g., physical activity (P < 0.001). Most outcomes remained improved after 6 months, but the effect on HbA1c was no longer statistically significant. Some outcomes were improved only at 6 months, including waist circumference (P < 0.001) and diabetes-related emotional distress (P < 0.001). Fatigue did not change. Attendance at more programme sessions was associated with better outcomes. The DSMES intervention developed in a co-creation process was highly effective in improving the health of immigrants with T2D.

Comprehensive Diabetes Assessment Instrument for Patients With Type 2 Diabetes

AIMS

There is a paucity of efficient processes for collecting information in a primary care setting to connect patients afflicted with type 2 diabetes to valuable resources. The objective of this research project was to develop a Comprehensive Diabetes Assessment (CDA) instrument which could be used to assess patients' barriers to best outcomes.

METHODS

We reviewed published literature and online compilations for validated tools assessing threats to optimal diabetes self-management. We conducted focus groups with patients, clinicians, and service providers who provided feedback on the tools' appropriateness and feasibility. We aggregated the favored tools and did cognitive testing with patients to assess understanding and affective response to the instrument.

RESULTS

Five focus groups involved varied stakeholders in Baltimore, MD and Honolulu, HI. We presented 2 tools assessing knowledge barriers, 3 tools assessing psychological barriers, 4 tools assessing literacy, and 1 numeracy. The final instrument included 6 multi-part items and takes 3 minutes to complete. Cognitive interviewing with 8 patients in Baltimore and 8 in Hawaii confirmed that the instrument is understandable, quick to complete, and is acceptable to patients.

CONCLUSIONS

Because of the complexity of self-management of diabetes, we suggest that this CDA instrument, plus a social needs assessment, should be administered at least annually and at times of clinical deterioration. We anticipate the instrument will be proven valuable in connecting patients to services from which they will benefit.

Improved Effectiveness of Immediate Continuous Glucose Monitoring in Hypoglycemia-Prone People with Type 1 Diabetes Compared with Hypoglycemia-Focused Psychoeducation Following a Previous Structured Education: A Randomized Controlled Trial

Objective: Stepped-care has been suggested in the management of patients with problematic hypoglycemia and impaired awareness of hypoglycemia (IAH), initially with psychoeducational programs based on blood glucose awareness training, progressing to diabetes technology in those with persisting need. We examined the clinical effectiveness of stepped-care starting with HypoAware and adding continuous glucose monitoring (CGM) as needed, versus immediate CGM in type 1 diabetes patients with problematic hypoglycemia despite previous structured education in insulin adjustment. Research Design and Methods: A randomized controlled trial (N = 52, mean age 53, 56% females). The stepped-care group attended HypoAware. If a severe hypoglycemic event (SHE) had occurred or IAH was still present after 6 months, CGM was initiated. The control group started immediate CGM. Primary endpoint was the number of participants with self-reported SHE. Secondary outcomes, evaluated at 6 and 12 months, were glycated hemoglobin (HbA1c), the number of participants with IAH time below range (TBR; <54 mg/dL), and patient-reported outcomes (PROs). Results: At 6 months, the number of patients reporting SHE had decreased significantly more in the CGM group: -39% (P < 0.05). HbA1c decreased more in the CGM group (-0.47 percentage-points, P < 0.05). IAH was restored in 31% of patients in both groups. TBR (<54 mg/dL) was lower in the CGM group (-2.4 percentage-points, P < 0.05). In the stepped-care group, 93% started CGM/intermittently scanned CGM. At 12 months, the number of patients reporting SHE was still higher in the stepped-care group. No differences were found in PROs. Conclusions: Immediate start of CGM is more effective than a hypoglycemia-focused reeducation program in reducing SHE risk and attaining glycemic targets in individuals with problematic hypoglycemia and IAH despite previous education in insulin dose adjustment. Trial registration: Netherlands Trial Register, NL64474.029.18.

Diabetes-related distress and associated factors among adults with diabetes in Germany: Results of the nationwide study "Disease knowledge and information needs - Diabetes mellitus 2017"

BACKGROUND

Diabetes-related distress (DRD) can affect diabetes management adversely. In lack of population-based data, the frequency and determinants of DRD among adults with diabetes in Germany remain controversial.

METHODS

This study included 1367 adults with diabetes who participated in a nationwide health telephone survey conducted among German adults aged 18 years and older in 2017. The short form of the Problem Areas in Diabetes (PAID-5) scale was used to assess DRD. The associations of high DRD (PAID-5 sum score ≥ 8) with socio-demographics, diabetes-related risk factors, diabetes clinical characteristics as well as quality of self-care and chronic illness care assessed by patients were tested in multivariable logistic regression models.

RESULTS

The overall DRD prevalence was 15.1% (95% confidence intervals, 95% CIs, 12.5-18.0%) with no significant difference between men (14.7%, 95% CIs 11.2-19.1%) and women (15.4%, 11.9-19.8%). In multivariable analyses, DRD was significantly associated with younger age (odds ratio 0.96, 95% CIs 0.94-0.98, per year), immigration background (2.26, 1.16-4.42), current smoking (2.06, 1.14-3.70), insulin use (2.57, 1.45-4.56), and the presence of diabetes-specific complications (1.80, 1.10-2.94) or depressive symptoms (5.34, 3.24-8.81). Among those with depressive symptoms (18,4% of the study population), 38.3% also had DRD, which accounted for 7.0% (95% CIs 5.3-9.3%) of the study population.

CONCLUSION

DRD is a common health problem among adults with diabetes in Germany, and highly correlates with depressive symptoms, current smoking, immigration background, and insulin use. Addressing DRD needs to become an integrative part of ambulatory diabetes care.

Psychosocial Assessment Tools for Youth with Type 1 Diabetes: a 10-Year Review

PURPOSE OF REVIEW

There is a notable lack of consistency in the measurement of psychosocial factors affecting youth with type 1 diabetes, resulting in a need for increased measurement standardization and establishment of measures tailored to capture unique experiences faced by youth. This review sought to assess 10 years of extant literature (2011 to 2020) to identify which established measurement tools are commonly used and to evaluate new measurement tools that were introduced during this period.

RECENT FINDINGS

There are a variety of psychosocial factors affecting youth, and assessment of these measures has shown substantial variability. Our review found that most frequently cited scales were those pertaining to self-efficacy, diabetes distress, family conflict, autonomy, and fear of hypoglycemia. During our review period, experts developed and validated 21 new scales, the majority of which sought to evaluate areas pertaining to diabetes distress. Of the common scales and newly developed scales identified in this review, psychometric properties showcase high reliability and validity, and items are becoming increasingly specific to youth but still lack assessment of how youth perceive technology's impact on diabetes management. The field would benefit from measures employing more nuanced age specificity and addressing technology usage.

Diabetes-related shame among people with type 2 diabetes: an internet-based cross-sectional study

INTRODUCTION

Emerging evidence suggests that diabetes stigma and negative emotions associated with it may impair the quality of life of people with diabetes. Among these psychological distresses, shame is considered the most distressing of all human emotional experiences and may be a condition to which diabetes clinicians should pay attention. This epidemiological study focused on diabetes-related shame and aimed to determine the prevalence of diabetes-related shame, its factors, and its association with psychological indicators.

RESEARCH DESIGN AND METHODS

A cross-sectional online survey was conducted among people with type 2 diabetes preregistered with a research firm. The questionnaire included experience of diabetes-related shame and demographic data such as age, clinical characteristic measures such as hemoglobin A1c (HbA1c), and psychological indicators, including the WHO Five Well-Being Index (WHO-5) and Problem Areas In Diabetes-5 (PAID-5). Differences in each indicator between people with diabetes who experienced shame and those who did not were analyzed with the unpaired t-test. As supplemental analysis, binomial logistic regression analysis was used to identify factors associated with the prevalence of diabetes-related shame.

RESULTS

Of the 510 participants, 32.9% experienced diabetes-related shame and 17.5% concealed their disease from colleagues or friends. Those who had experienced diabetes-related shame showed significantly lower WHO-5 and higher PAID-5 scores (p<0.001). However, no significant difference was found in HbA1c (p=0.36). Binomial logistic regression revealed that women, young adults, those without a college degree, those with low self-efficacy, and those with a strong sense of financial burden or external pressure were at higher risk of experiencing diabetes-related shame.

CONCLUSIONS

Among people with type 2 diabetes mellitus, diabetes-related shame was associated with diabetes-specific emotional distress and low psychological well-being. Further research and care development are needed to address diabetes-related shame and improve the quality of life of people with diabetes.