Impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy

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.

Association of Personality Traits and Self-Care Behaviors in People With Type 2 Diabetes Mellitus: A Systematic Review and Meta-Analysis

Diabetes self-care is critical for individuals with type 2 diabetes mellitus (T2DM), and exploring the impact of personality traits on this domain remains pivotal. This study aimed to investigate the association between personality traits and various dimensions of self-care in people with T2DM. A Preferred Reporting Items for Systematic Reviews and Meta Analyses (PRISMA)-guided systematic review with meta-analysis was conducted. Two reviewers independently screened articles, extracted data, and assessed the risk of bias. Estimates were pooled using random-effects meta-analysis. Twenty-three studies, that met our inclusion criteria, revealed distinct associations between certain personality traits and various aspects of self-care. Notably, traits such as openness, conscientiousness, and agreeableness showed associations with improved foot care compliance (odds ratio (OR) = 2.53, 95% CI = 1.49-4.28; OR = 1.84, 95% CI = 1.10-3.08; and OR = 2.07, 95% CI = 1.23-3.48, respectively). Openness was also linked to better overall self-care behaviors (OR = 2.00, 95% CI = 1.17-3.41), while conscientiousness correlated with reduced smoking (OR = 0.96, 95% CI = 0.93-0.99), and agreeableness was associated with improved medication adherence (OR = 1.68, 95% CI = 1.34-2.31). Conversely, traits like extraversion and neuroticism showed associations with decreased medication adherence (OR = 0.77, 95% CI = 0.61-0.96 and OR = 0.51, 95% CI = 0.40-0.65, respectively), with neuroticism additionally linked to lower overall self-care behaviors (OR = 0.67, 95% CI: 0.55-0.81). This study emphasizes the intricate role of personality traits in shaping self-care practices in individuals with T2DM, underscoring the significance of factoring these traits into tailoring and improving diabetes self-care strategies. Nevertheless, establishing definitive causal relationships mandates further in-depth longitudinal investigations and broader meta-analyses to achieve a more conclusive understanding.

Which diabetes specific patient reported outcomes should be measured in routine care? A systematic review to inform a core outcome set for adults with Type 1 and 2 diabetes mellitus: The European Health Outcomes Observatory (H2O) programme

OBJECTIVES

The objective was to identify candidate patient reported outcomes with potential to inform individual patient care and service development for inclusion in a digital outcome set to be collected in routine care, as part of an international project to enhance care outcomes for people with diabetes.

METHODS

PubMed, COSMIN and COMET databases were searched. Published studies were included if they recommended patient reported outcomes that were clinically useful and/or important to people with diabetes. To aid selection decisions, recommended outcomes were considered in terms of the evidence endorsing them and their importance to people with diabetes.

RESULTS

Twenty-seven studies recommending 53 diabetes specific outcomes, and patient reported outcome measures, were included. The outcomes reflected the experience of living with diabetes (e.g. psychological well-being, symptom experience, health beliefs and stigma) and behaviours (e.g. self-management). Diabetes distress and self-management behaviours were most endorsed by the evidence.

CONCLUSIONS

The review provides a comprehensive list of candidate outcomes endorsed by international evidence and informed by existing outcome sets, and suggestions for measures.

PRACTICE IMPLICATIONS

The review offers evidence to guide clinical application. Integrated measurement of these outcomes in care settings holds enormous potential to improve provision of care and outcomes in diabetes.

Diabetes distress in a Medicaid sample: The role of psychosocial and health-related factors

AIMS

Diabetes-related distress can negatively affect disease management leading to worse complications, especially among marginalized populations. Prior studies mostly focus on distress' impact on diabetes outcomes, with few examining distress predictors. The current study examined the impact of social needs on distress on its own and after controlling for other socio-demographic, psychosocial, and health factors.

METHODS

Adult Medicaid beneficiaries with type 2 diabetes and a recent HbA1c test documented in claims data (<120 days) were recruited for a 12-month social needs intervention trial. Baseline survey data assessed diabetes distress, social needs, psychosocial factors and health factors. Descriptive statistics were obtained, and bivariate and multivariable logistic regression analyses were used to identify predictors of moderate to severe distress.

RESULTS

Bivariate analyses revealed social needs, stress, depression, comorbidity and comorbidity burden, poor self-rated health, insulin use, a self-reported HbA1c ≥ 9.0, and difficulty remembering to take diabetes medications were all positively associated with greater odds of diabetes distress; greater social support, diabetes self-efficacy, and age were negatively associated. Four variables remained significant in the multivariate model: depression, diabetes self-efficacy, self-reported HbA1c ≥ 9.0, and younger age.

CONCLUSIONS

Targeted distress screening efforts might prioritize people with HbA1c values >9.0, greater depression, and worse diabetes self-efficacy.

Personality and weight management in adults with type 2 diabetes: A systematic review

Aims

Managing weight in the context of type 2 diabetes presents unique hormonal, medicinal, behavioural and psychological challenges. The relationship between weight management and personality has previously been reviewed for general and cardiovascular disease populations but is less well understood in diabetes. This systematic review investigated the relationship between personality constructs and weight management outcomes and behaviours among adults with type 2 diabetes.

Methods

Medline, PubMed, Embase, PsycINFO and SPORTDiscus databases were searched to July 2021. Eligibility: empirical quantitative studies; English language; adults with type 2 diabetes; investigation of personality-weight management association. Search terms included variants of: diabetes, physical activity, diet, body mass index (BMI), adiposity, personality constructs and validated scales. A narrative synthesis, with quality assessment, was conducted.

Results

Seventeen studies were identified: nine cross-sectional, six cohort and two randomised controlled trials (N=6,672 participants, range: 30-1,553). Three studies had a low risk of bias. Personality measurement varied. The Big Five and Type D personality constructs were the most common measures. Higher emotional instability (neuroticism, negative affect, anxiety, unmitigated communion and external locus of control) was negatively associated with healthy diet and physical activity, and positively associated with BMI. Conscientiousness had positive associations with healthy diet and physical activity and negative associations with BMI and anthropometric indices.

Conclusions

Among adults with type 2 diabetes, evidence exists of a relationship between weight management and personality, specifically, negative emotionality and conscientiousness. Consideration of personality may be important for optimising weight management and further research is warranted.

Systematic review registration

www.crd.york.ac.uk/prospero/, identifier CRD42019111002.

The impact of enhancing self-management support for diabetes in Community Health Centers through patient engagement and relationship building: a primary care pragmatic cluster-randomized trial

Type 2 diabetes (T2DM) self-management support (SMS) programs can yield improved clinical outcomes but may be limited in application or impact without considering individuals' unique social and personal challenges that may impede successful diabetes outcomes. The current study compares an evidence-based SMS program with an enhanced version that adds a patient engagement protocol, to elicit and address unique patient-level challenges to support improved SMS and diabetes outcomes. Staff from 12 Community Health Center (CHC) clinical sites were trained on and delivered: Connection to Health (CTH; 6 sites), including a health survey and collaborative action planning, or Enhanced Engagement CTH (EE-CTH; 6 sites), including additional relationship building training/support. Impact of CTH and EE-CTH on behavioral self-management, psychological outcomes, and modifiable social risks was examined using general linear mixed effects. Clinics enrolled 734 individuals with T2DM (CTH = 408; EE-CTH = 326). At 6- to 12-month postenrollment, individuals in both programs reported significant improvements in self-management behaviors (sugary beverages, missed medications), psychological outcomes (stress, health-related distress), and social risks (food security, utilities; all p < .05). Compared with CTH, individuals in EE-CTH reported greater decreases in high fat foods, salt, stress and health-related distress; and depression symptoms improved within EE-CTH (all p < .05). CTH and EE-CTH demonstrated positive behavioral, psychological, and social risk impacts for T2DM in CHCs delivered within existing clinical work flows and a range of clinical roles. Given the greater improvements in psychological outcomes and behavioral self-management in EE-CTH, increased attention to relationship building strategies within SMS programs is warranted.

Self-efficacy mediates the associations of diabetes distress and depressive symptoms with type 2 diabetes management and glycemic control

BACKGROUND

Adults with type 2 diabetes (T2D) often experience two common diabetes-related psychological distress: diabetes distress and depressive symptoms. Both are associated with adverse diabetes outcomes including poor self-management and glycemic control. However, diabetes distress and depressive symptoms differ in their associations with diabetes outcomes in T2D patients.

OBJECTIVE

This study proposes a hypothetical model to examine whether self-efficacy mediates the adverse effects of depressive symptoms and/or diabetes distress on self-care behaviors and glycemic control. Additionally, we examined the bi-directional relationships between diabetes distress and depressive symptoms to identify potential underlying mechanisms.

METHODS

This study conducted in 15 rural health clinics in Jiangsu province China. 900 adults with T2D participated in the prospective cohort study. The data Diabetes distress (the 17-item Diabetes Distress Scale, DDS17), depressive symptoms(the 10-item Center for Epidemiologic Studies Depression Scale, CESD-10), self-efficacy, self-care behaviors (diet and physical activity), metabolic variables (fasting plasma glucose, FPG) and demographic characteristics were assessed at baseline. Subsequent 12-month Hemoglobin A1C (HbA1c) were measured after baseline. Hierarchical multiple regression and bootstrap mediation analysis were used to test the effects and pathways among these associations.

RESULTS

Of 843 participants (93.67%) of total cohort with available subsequent 12-month HbA1c levels, mean age was 66.08 years and 66.55% were women, 25.15% of them had depressive symptoms (CES-D ≥ 10), 12.20% had moderate diabetes distress (mean DDS ≥2) and 4.98% had the both two psychological distress. Hierarchical multiple regression showed higher DDS score significantly predicted unhealthy diet(β = -1.10, P < 0.001) but not physical activities, while CESD score was negatively associated with physical activity (β = -0.06, P < 0.001) but not diet. No independent effects of the two psychological distress variables on subsequent 12-month HbA₁c were observed. Mediation analysis supported that elevated self-efficacy solely mediated the negative effect of both diabetes distress and depressive symptoms on diet (DDS score: β = -0.238, 95 BCE% CI [-0.350, -0.141]; CESD score: β = -0.010, 95 BCE% CI [-0.016, -0.005]), physical activities (DDS score: β = -0.446, 95 BCE% CI [-0.630, -0.283]; CESD score: β = -0.019, 95 BCE% CI [-0.030, -0.010]) and subsequent 12-month HbA1c (DDS score: β = 0.105, 95 BCE% CI [0.030,0.189]; CESD score: β = 0.004, 95 BCE% CI [0.001,0.009])_. Additionally, the interplay of diabetes distress and depressive symptoms exerts their effects on diabetes outcomes directly and indirectly via self-efficacy.

CONCLUSIONS

Self-efficacy may contribute to better diabetes outcomes and ameliorate negative effects of diabetes distress and depressive symptoms.

Diabetes Self-Management and the Associated Factors Among Adult Omanis with Type 1 Diabetes

Objectives

This study aimed to assess and explore factors affecting diabetes self-management (DSM) among Omani adults with type one diabetes mellitus (T1DM).

Methods

This cross-sectional study was conducted from May to November 2018. Convenience sampling was used to recruit participants from three referral hospitals in Oman. Data were collected using the Diabetes Self-Management Questionnaire, Empowerment Scale (short form), Medical Outcome Study Social Support Scale, Diabetes Knowledge Test and glycosylated haemoglobin test results. Linear multiple regression analysis was used to explore possible predictors of DSM.

Results

A total of 210 people participated in the study (response rate: 87.5%). The majority of participants were female (70.5%) with a mean age of 26.82 ± 8.25 years. The mean score for DSM was 6.8 ± 1.4, which represents 68% of the total maximum score. More than one-third (36.2%) of the participants had poor glycaemic control. The predictors of high levels of DSM were being employed (P = 0.049), earning a low monthly income of less than 300 Omani rials (P = 0.014), having other chronic diseases (P = 0.029), a high diabetes self-efficacy (DSE; P = 0.003) and high social support (SS; P = 0.006).

Conclusion

According to the findings of this study, Omanis with T1DM have suboptimal DSM levels. Factors such as diabetes knowledge, DSE and SS are modifiable factors that can be targeted by interventions from different healthcare professionals to enhance DSM.

Predicting Perceived Stress Related to the Covid-19 Outbreak through Stable Psychological Traits and Machine Learning Models

The global SARS-CoV-2 outbreak and subsequent lockdown had a significant impact on people's daily lives, with strong implications for stress levels due to the threat of contagion and restrictions to freedom. Given the link between high stress levels and adverse physical and mental consequences, the COVID-19 pandemic is certainly a global public health issue. In the present study, we assessed the effect of the pandemic on stress levels in N = 2053 Italian adults, and characterized more vulnerable individuals on the basis of sociodemographic features and stable psychological traits. A set of 18 psycho-social variables, generalized regressions, and predictive machine learning approaches were leveraged. We identified higher levels of perceived stress in the study sample relative to Italian normative values. Higher levels of distress were found in women, participants with lower income, and participants living with others. Higher rates of emotional stability and self-control, as well as a positive coping style and internal locus of control, emerged as protective factors. Predictive learning models identified participants with high perceived stress, with a sensitivity greater than 76%. The results suggest a characterization of people who are more vulnerable to experiencing high levels of stress during the COVID-19 pandemic. This characterization may contribute to early and targeted intervention strategies.

Effectiveness of Social Cognitive Theory-Based Interventions for Glycemic Control in Adults With Type 2 Diabetes Mellitus: Protocol for a Systematic Review and Meta-Analysis

BACKGROUND

For those living with type 2 diabetes mellitus (T2DM), failing to engage in self-management behaviors leads to poor glycemic control. Social cognitive theory (SCT) has been shown to improve health behaviors by altering cognitive processes and increasing an individual's belief in their ability to accomplish a task.

OBJECTIVE

We aim to present a protocol for a systematic review and meta-analysis to systematically identify, evaluate, and analyze the effect of SCT-based interventions to improve glycemic control in adults with T2DM.

METHODS

This protocol follows the 2009 Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Data sources will include PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsychINFO, Cochrane Library, and Web of Science, and data will be reviewed with the use of customized text mining software. Studies examining SCT-based behavioral interventions for adults diagnosed with T2DM in randomized controlled trials located in the outpatient setting will be included. Intervention effectiveness will be compared with routine care. Screening and data collection will be performed in multiple stages with three reviewers as follows: (1) an independent review of titles/abstracts, (2) a full review, and (3) data collection with alternating teams of two reviewers for disputes to be resolved by a third reviewer. Study quality and risk of bias will be assessed by three reviewers using the Cochrane risk of bias tool. Standardized mean differences will be used to describe the intervention effect sizes with regard to self-efficacy and diabetes knowledge. The raw mean difference of HbA1c will be provided in a random effects model and presented in a forest plot. The expected limitations of this study are incomplete data, the need to contact authors, and analysis of various types of glycemic control measures accurately within the same data set.

RESULTS

This protocol was granted institutional review board exemption on October 7, 2019. PROSPERO registration (ID: CRD42020147105) was received on April 28, 2020. The review began on April 29, 2020. The results of the review will be disseminated through conference presentations, peer-reviewed journals, and meetings.

CONCLUSIONS

This systematic review will appraise the effectiveness of SCT-based interventions for adults diagnosed with T2DM and provide the most effective interventions for improving health behaviors in these patients.

TRIAL REGISTRATION

PROSPERO CRD42020147105; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=147105.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/17148.

The Big Six Personality Traits and Mental Distress: Dynamic Modeling in a Population Panel Study Reveals Bidirectional Relationships Involving Neuroticism, Extraversion, and Conscientiousness

In a single comprehensive model, using a large nationally representative sample, we investigate longitudinal relationships between mental distress and "Big Six" personality using an analysis approach sensitive to dynamic effects (i.e., to effects of deviations from individual trajectories). We find that, consistent with a mechanism involving scarring by distress, upward deviations (flare-ups) in distress predict flare-ups in Neuroticism 12 months later. Among younger adults (n = 4,775), distress flare-ups predict dips in Conscientiousness. Consistent with a dynamic precursor model, (a) flare-ups in Neuroticism and Extraversion predict subsequent flare-ups in distress among older adults (n = 11,167), and (b) slopes of distress correlate with slopes of a number of traits (e.g., positively for Neuroticism, and, among older adults, negatively for Extraversion). While demonstrating these scarring and dynamic precursor effects, we draw attention to a nuanced direction of dynamic effect for Extraversion, a newly discovered dynamic effect of Conscientiousness, and previously undocumented dynamic effects of traits on each other.

A longitudinal study on perceived health in cardiovascular patients: The role of conscientiousness, subjective wellbeing and cardiac self-efficacy

Cardiovascular disease (CVD) is the world’s most prevalent chronic disease and the leading chronic cause of morbidity. There are several psychosocial factors associated with quality of life during CVD. Our main objectives were to analyze the roles of conscientiousness, subjective wellbeing and self-efficacy beliefs. The sample comprised 514 patients (mean age 63.57 years) who were assessed twice over a nine-month interval. At Time 1, participants answered a questionnaire assessing conscientiousness, perceived subjective wellbeing (positive and negative affect, life satisfaction), cardiac self-efficacy and health-related quality of life (HRQoL). The same variables (except for conscientiousness) were re-assessed at Time 2. Results showed that conscientiousness had a positive relation with subjective wellbeing, cardiac self-efficacy, and HRQoL at Time 1. Moreover, cardiac self-efficacy at Time 1 had a positive longitudinal effect on HRQoL at Time 2, while controlling for autoregressive effects. Mediation analyses indicated that the relationship between conscientiousness and HRQoL was mediated by positive affect and cardiac self-efficacy. These results suggest the usefulness of psychosocial interventions aimed at promoting positive affect and self-efficacy beliefs among CVD patients.

Toward effective interventions to reduce diabetes distress among adults with type 1 diabetes: Enhancing Emotion regulation and cognitive skills

OBJECTIVE

We tested three models to determine how improvements in emotion regulation (ER) and cognitive skills (CS) as a result of intervention operate to affect reductions in diabetes distress DD.

METHODS

Change data were drawn from the baseline and 9-month T1-REDEEM trial. Adults with type 1 diabetes were recruited from several U.S. states and Toronto, Canada. A primary and two alternative structural equation models were tested to explore the directionality of effect: primary model - changes in ER and CS drive changes in DD; reverse model - changes in DD drive changes in ER and CS; and bidirectional model - changes in ER, CS and DD occur together with no directionality.

RESULTS

All three models displayed a good fit to the data. The primary model indicated 7 significant directional pathways: improvements in ER and CS operate together to drive reductions in DD. The reverse model only indicated that reductions in DD affected changes in one CS variable; and the bidirectional model indicated only that these results were bidirectional. Reductions in all tested domains of DD occurred together.

CONCLUSIONS

Improvements in ER and CS drive reductions in DD.

PRACTICE IMPLICATIONS

Interventions to reduce high DD should focus on improving ER and CS.

Health beliefs and medication adherence in patients with hypertension: A systematic review of quantitative studies

OBJECTIVE

This review synthesizes findings of quantitative studies examining the relationship between health beliefs and medication adherence in hypertension.

METHODS

This review included published studies in PubMed, CINHAL, EMBASE, and PsycINFO databases. Studies were included if they examined beliefs of patients with hypertension. Quality of the studies was evaluated using the Quality Assessment Tool for Systematic Review of Observational Studies.

RESULTS

Of the 1558 articles searched, 30 articles were included in the analysis. Most beliefs examined by studies of this review in relation to medication adherence were beliefs related to hypertension severity and susceptibility to its consequences, medication effectiveness or necessity, and barriers to medication adherence. Higher medication adherence was significantly related to fewer perceived barriers to adherence (e.g, side-effects) was fairly consistent across studies. Higher self-efficacy was related to higher medication adherence. Patients' beliefs and their relationship to medication adherence appear to vary unpredictably across and within countries.

CONCLUSION

Clinicians should assess beliefs for individual patients. When individual beliefs appear likely to undermine adherence, it may be useful to undertake educational interventions to try to modify them.

PRACTICAL IMPLICATIONS

Clinicians should explore individual patients' beliefs about hypertension and blood pressure medications, discuss their implications for medication adherence, and try to modify counterproductive beliefs.

Comparison of self-care in non-cardiac diabetic patients

BACKGROUND

In general, the majority of diabetic patients suffering from a lack of capability in controlling different aspects of self-care have likely been prone to cardiovascular disease. To reduce the economic burden in societies and the rate of death on one hand, and improve life expectancy, on the other hand, it seems necessary to emphasize self-care training in diabetic patients. The purpose of this study was to determine comparison of self-care in cardiac and non-cardiac diabetic patients.

METHODS

This descriptive-analytic study was carried out with 136 diabetic participants selected using random sampling and divided into two groups of 68 non-cardiac diabetic patients. Data were collected using a demographic and diabetic patient's self-management questionnaire (DSMQ). For the analysis of the data, SPSS16 was employed to check the significance test at the level of P<0.05.

RESULTS

In this study, twenty-eight (41.2%) and forty (58.8%) of the participants in each group were male and female, respectively. Their ages spanned from (61.35±13.34) in non-cardiac diabetic group to (65.94±8.74) in cardiac diabetic participants. There were significant differences between two groups, specifically in patients with cardiac diabetic disease in different aspects, for instance, including glucose monitoring (F=4.977, P=0.027, η²=0.036), diet control (F=9.125, P=0.003, η²=0.064), physical activity (F=22.954, P=0.0001, η²=0.146) and health care awareness (F=31.366, P=0.0001, η²=0.19).

CONCLUSION

According to DSMQ questionnaire in the present study, glucose monitoring, diet control, physical activity, and health care awareness in diabetic patients with heart disease were significantly reported to have been better than the other group with no cardiac problem. Due to insufficient self-care in diabetic patients and some consequences such as poor health, heart disease as one of the complications of diabetes, hospital re-admission and heavy costs, the therapeutic team should be alerted to self-care training.

Association of Depressive Symptoms and Diabetes Distress With Severe Hypoglycemia in Adults With Type 2 Diabetes

OBJECTIVES

To examine the association of depressive symptoms (DS) and diabetes-related distress (DD) with severe hypoglycemia (SH) in adults with type 2 diabetes.

METHODS

Baseline data from a cohort study of adults with type 2 diabetes (N=2,040) were used. The Patient Health Questionnaire 8-items and Problem Areas in Diabetes 5-items questionnaires were used to assess DS and DD, respectively. SH was defined as a positive report of "calling an ambulance or visiting an emergency department because of hypoglycemia in the past year." Composite dummy variables for the 2 stratification levels of DS and DD were computed and used in multivariable logistic regression analyses.

RESULTS

Participants had a mean (± SD) age of 64±11 years, and 45% were female. The average duration of diabetes was 12±9 years; 3% had moderate to severe DS, 8% had moderate to severe DD and 5% had moderate to severe levels of both symptoms. Only 4.2% of participants reported experiencing SH in the past year. The presence of any level of DD (adjusted OR 2.3; 95% CI 1.3, 3.9) or moderate to severe DD (2.2; 1.1, 4.2) was associated with increased risk for SH. Combinations of any levels of DD and DS (4.3; 2.5, 7.3) and moderate to severe DD and DS (2.3; 1.1, 4.8) were associated with increased risk for SH. The presence of any level of DS alone (1.2; 0.3, 4.9) or moderate to severe DS (1.7; 0.6, 5.1) was not associated with increased risk for SH.

CONCLUSIONS

Patients with type 2 diabetes and symptoms of depression, but not diabetes-related distress alone, were more likely to experience SH than those without either of these symptoms.

High Diabetes Distress Among Ethnic Minorities Is Not Explained by Metabolic, Cardiovascular, or Lifestyle Factors: Findings From the Dutch Diabetes Pearl Cohort

OBJECTIVE

Diabetes distress among patients from ethnic minorities is still poorly understood. We investigated the association between ethnicity and diabetes distress among ethnic minority groups of people with type 2 diabetes in the Netherlands, focusing on the possible effects of glycemic control, lifestyle factors, cardiovascular risk factors, and diabetes complications.

RESEARCH DESIGN AND METHODS

Cross-sectional data from the Dutch Diabetes Pearl cohort included people with type 2 diabetes from primary, secondary, and tertiary diabetes care programs. We used the 20-item Problem Areas in Diabetes Survey (PAID) scale to assess diabetes distress; a score ≥40 is considered to represent high distress. Ethnicity was estimated on the basis of country of birth. Sociodemographic and lifestyle data were self-reported; cardiovascular and metabolic data were retrieved from medical charts. Logistic regression analysis determined the association between ethnicity and diabetes distress, with Caucasians as the reference group.

RESULTS

Diabetes distress scores and ethnicity were available for 4,191 people with type 2 diabetes: 3,684 were Caucasian, 83 were Asian, 51 were Moroccan, 92 were African, 134 were Latin American, 46 were Turkish, and 101 were Hindustani-Surinamese. Overall, participants in minority groups had worse health outcomes than those of Caucasian descent, and diabetes distress was more prevalent (ranging from 9.6 to 31.7%, compared with 5.8% among Caucasians), even after adjusting for age, sex, education level, alcohol use, smoking, BMI, lipid profile, HbA_1c, medication use, and the presence of diabetes complications.

CONCLUSIONS

Among people with type 2 diabetes in the Netherlands, ethnicity is independently associated with high diabetes distress. Further research is warranted to explain the higher prevalence of diabetes distress in minority groups and to develop effective interventions.

Psychological interventions for diabetes-related distress in adults with type 2 diabetes mellitus

BACKGROUND

Many adults with type 2 diabetes mellitus (T2DM) experience a psychosocial burden and mental health problems associated with the disease. Diabetes-related distress (DRD) has distinct effects on self-care behaviours and disease control. Improving DRD in adults with T2DM could enhance psychological well-being, health-related quality of life, self-care abilities and disease control, also reducing depressive symptoms.

OBJECTIVES

To assess the effects of psychological interventions for diabetes-related distress in adults with T2DM.

SEARCH METHODS

We searched the Cochrane Library, MEDLINE, Embase, PsycINFO, CINAHL, BASE, WHO ICTRP Search Portal and ClinicalTrials.gov. The date of the last search was December 2014 for BASE and 21 September 2016 for all other databases.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) on the effects of psychological interventions for DRD in adults (18 years and older) with T2DM. We included trials if they compared different psychological interventions or compared a psychological intervention with usual care. Primary outcomes were DRD, health-related quality of life (HRQoL) and adverse events. Secondary outcomes were self-efficacy, glycosylated haemoglobin A1c (HbA1c), blood pressure, diabetes-related complications, all-cause mortality and socioeconomic effects.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified publications for inclusion and extracted data. We classified interventions according to their focus on emotion, cognition or emotion-cognition. We performed random-effects meta-analyses to compute overall estimates.

MAIN RESULTS

We identified 30 RCTs with 9177 participants. Sixteen trials were parallel two-arm RCTs, and seven were three-arm parallel trials. There were also seven cluster-randomised trials: two had four arms, and the remaining five had two arms. The median duration of the intervention was six months (range 1 week to 24 months), and the median follow-up period was 12 months (range 0 to 12 months). The trials included a wide spectrum of interventions and were both individual- and group-based.A meta-analysis of all psychological interventions combined versus usual care showed no firm effect on DRD (standardised mean difference (SMD) -0.07; 95% CI -0.16 to 0.03; P = 0.17; 3315 participants; 12 trials; low-quality evidence), HRQoL (SMD 0.01; 95% CI -0.09 to 0.11; P = 0.87; 1932 participants; 5 trials; low-quality evidence), all-cause mortality (11 per 1000 versus 11 per 1000; risk ratio (RR) 1.01; 95% CI 0.17 to 6.03; P = 0.99; 1376 participants; 3 trials; low-quality evidence) or adverse events (17 per 1000 versus 41 per 1000; RR 2.40; 95% CI 0.78 to 7.39; P = 0.13; 438 participants; 3 trials; low-quality evidence). We saw small beneficial effects on self-efficacy and HbA1c at medium-term follow-up (6 to 12 months): on self-efficacy the SMD was 0.15 (95% CI 0.00 to 0.30; P = 0.05; 2675 participants; 6 trials; low-quality evidence) in favour of psychological interventions; on HbA1c there was a mean difference (MD) of -0.14% (95% CI -0.27 to 0.00; P = 0.05; 3165 participants; 11 trials; low-quality evidence) in favour of psychological interventions. Our included trials did not report diabetes-related complications or socioeconomic effects.Many trials were small and were at high risk of bias for incomplete outcome data as well as possible performance and detection biases in the subjective questionnaire-based outcomes assessment, and some appeared to be at risk of selective reporting. There are four trials awaiting further classification. These are parallel RCTs with cognition-focused and emotion-cognition focused interventions. There are another 18 ongoing trials, likely focusing on emotion-cognition or cognition, assessing interventions such as diabetes self-management support, telephone-based cognitive behavioural therapy, stress management and a web application for problem solving in diabetes management. Most of these trials have a community setting and are based in the USA.

AUTHORS' CONCLUSIONS

Low-quality evidence showed that none of the psychological interventions would improve DRD more than usual care. Low-quality evidence is available for improved self-efficacy and HbA1c after psychological interventions. This means that we are uncertain about the effects of psychological interventions on these outcomes. However, psychological interventions probably have no substantial adverse events compared to usual care. More high-quality research with emotion-focused programmes, in non-US and non-European settings and in low- and middle-income countries, is needed.

The influence of diabetes distress on digital interventions for diabetes management in vulnerable people with type 2 diabetes: A qualitative study of patient perspectives

BACKGROUND

Digital interventions for improving diabetes management in Type 2 diabetes mellitus (T2DM) are used universally. Digital interventions are defined as any intervention accessed and taking input from people with T2DM in the form of a web-based or mobile phone-based app to improve diabetes self-management. However, the current confidence in digital interventions threatens to augment social inequalities in health, also known as the "digital divide". To counteract dissemination of the digital divide, we aimed to assess the potential of a tailored digital intervention for improving diabetes management in vulnerable people with T2DM.

METHODS

A qualitative design using semi-structured in-depth interviews to explore the perspectives of 12 vulnerable people with T2DM. Interviews were analyzed using inductive content analysis. Vulnerability was defined by the presence of one or more comorbidities, one or more lifestyle risk factors, poor diabetes management, low educational level and low health literacy.

RESULTS

The main themes identified were: "Dealing with diabetes distress" characterized by psychological avoidance mechanisms; "Suffering informational confusion" dealing with inconsistent information; "Experiencing digital alienation" dealing with loss of freedom when technology invades the private sphere; and "Missing the human touch" preferring human interaction over digital contact.

CONCLUSION

Vulnerable people with T2DM are unprepared for digital interventions for disease management. Experiencing diabetes distress may be an intermediate mechanism leading to nonadherence to digital interventions and the preference for human interaction in vulnerable people with T2DM. Future interventions could include a designated caregiver and an allocated buddy to provide support and assist uptake of digital interventions for diabetes management.

The ACHRU-CPP versus usual care for older adults with type-2 diabetes and multiple chronic conditions and their family caregivers: study protocol for a randomized controlled trial

BACKGROUND

Many community-based self-management programs have been developed for older adults with type-2 diabetes mellitus (T2DM), bolstered by evidence from randomized controlled trials (RCTs) that T2DM can be prevented and managed through lifestyle modifications. However, the evidence for their effectiveness is contradictory and weakened by reliance on single-group designs and/or small samples. Additionally, older adults with multiple chronic conditions (MCC) are often excluded because of recruiting and retention challenges. This paper presents a protocol for a two-armed, multisite, pragmatic, mixed-methods RCT examining the effectiveness and implementation of the Aging, Community and Health Research Unit-Community Partnership Program (ACHRU-CPP), a new 6-month interprofessional, nurse-led program to promote self-management in older adults (aged 65 years or older) with T2DM and MCC and support their caregivers (including family and friends).

METHODS/DESIGN

The study will enroll 160 participants in two Canadian provinces, Ontario and Alberta. Participants will be randomly assigned to the control (usual care) or program study arm. The program will be delivered by registered nurses (RNs) and registered dietitians (RDs) from participating diabetes education centers (Ontario) or primary care networks (Alberta) and program coordinators from partnering community-based organizations. The 6-month program includes three in-home visits, monthly group sessions, monthly team meetings for providers, and nurse-led care coordination. The primary outcome is the change in physical functioning as measured by the Physical Component Summary (PCS-12) score from the short form-12v2 health survey (SF-12). Secondary client outcomes include changes in mental functioning, depressive symptoms, anxiety, and self-efficacy. Caregiver outcomes include health-related quality of life and depressive symptoms. The study includes a comparison of health care service costs for the intervention and control groups, and a subgroup analysis to determine which clients benefit the most from the program. Descriptive and qualitative data will be collected to examine implementation of the program and effects on interprofessional/team collaboration.

DISCUSSION

This study will provide evidence of the effectiveness of a community-based self-management program for a complex target population. By studying both implementation and effectiveness, we hope to improve the uptake of the program within the existing community-based structures, and reduce the research-to-practice gap.

TRIAL REGISTRATION

ClinicalTrials.gov, Identifier: NCT02158741 . Registered on 3 June 2014.

Evaluating Digital Health Interventions: Key Questions and Approaches

Digital health interventions have enormous potential as scalable tools to improve health and healthcare delivery by improving effectiveness, efficiency, accessibility, safety, and personalization. Achieving these improvements requires a cumulative knowledge base to inform development and deployment of digital health interventions. However, evaluations of digital health interventions present special challenges. This paper aims to examine these challenges and outline an evaluation strategy in terms of the research questions needed to appraise such interventions. As they are at the intersection of biomedical, behavioral, computing, and engineering research, methods drawn from all of these disciplines are required. Relevant research questions include defining the problem and the likely benefit of the digital health intervention, which in turn requires establishing the likely reach and uptake of the intervention, the causal model describing how the intervention will achieve its intended benefit, key components, and how they interact with one another, and estimating overall benefit in terms of effectiveness, cost effectiveness, and harms. Although RCTs are important for evaluation of effectiveness and cost effectiveness, they are best undertaken only when: (1) the intervention and its delivery package are stable; (2) these can be implemented with high fidelity; and (3) there is a reasonable likelihood that the overall benefits will be clinically meaningful (improved outcomes or equivalent outcomes at lower cost). Broadening the portfolio of research questions and evaluation methods will help with developing the necessary knowledge base to inform decisions on policy, practice, and research.

Stress and A1c Among People with Diabetes Across the Lifespan

Stress is known to negatively affect health and is a potentially serious barrier to diabetes-related health outcomes. This paper synthesizes what is known about stress and glycemic control among people with type 1 and type 2 diabetes across the lifespan. Chronic stress-especially in relation to living with diabetes-was most strongly associated with A1c, particularly among subgroups that face disproportionate stress, such as minority groups or adolescents/young adults. Mechanisms of the stress-A1c association include physiological, psychological, behavioral, and environmental links. Understanding the dimensions of stress as they relate to health in diabetes can be of significant clinical importance, and interventions targeting mechanisms that either exacerbate or buffer stress have reported modest improvements in A1c.

Impact of Personality on Cognitive Aging: A Prospective Cohort Study

OBJECTIVES

The aim of this study was to assess the association between personality factors and age-related longitudinal cognitive performance, and explore interactions of stress-proneness with apolipoprotein E (APOE) ɛ4, a prevalent risk factor for Alzheimer's disease (AD).

METHODS

A total of 510 neuropsychiatrically healthy residents of Maricopa County recruited through media ads (mean age 57.6±10.6 years; 70% women; mean education 15.8±2.4 years; 213 APOE ɛ4 carriers) had neuropsychological testing every 2 years (mean duration follow-up 9.1±4.4 years), and the complete Neuroticism Extraversion Openness Personality Inventory-Revised. Several tests were administered within each of the following cognitive domains: memory, executive skills, language, visuospatial skills, and general cognition. Primary effects on cognitive trajectories and APOE ɛ4 interactions were ascertained with quadratic models.

RESULTS

With personality factors treated as continuous variables, Neuroticism was associated with greater decline, and Conscientiousness associated with reduced decline consistently across tests in memory and executive domains. With personality factors trichotomized, the associations of Neuroticism and Conscientiousness were again highly consistent across tests within memory and to a lesser degree executive domains. While age-related memory decline was greater in APOE ɛ4 carriers as a group than ɛ4 noncarriers, verbal memory decline was mitigated in ɛ4 carriers with higher Conscientiousness, and visuospatial perception and memory decline was mitigated in ɛ4 carriers with higher Openness.

CONCLUSIONS

Neuroticism and Conscientiousness were associated with changes in longitudinal performances on tests sensitive to memory and executive skills. APOE interactions were less consistent. Our findings are consistent with previous studies that have suggested that personality factors, particularly Neuroticism and Conscientiousness are associated with cognitive aging patterns. (JINS, 2016, 22, 765-776).

How to assess diabetes distress: comparison of the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS)

AIMS

To compare the properties of the two most commonly used assessment tools for diabetes distress, the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), in order to discriminate their psychometric capabilities and functions.

METHODS

Six hundred and twenty-eight people with diabetes (67% Type 1, 33% Type 2) were cross-sectionally assessed with the PAID, the DDS and further self-report scales regarding coping, quality of life, depressive symptoms and self-care, and medical data were gained. We analysed the PAID and DDS for areas of contentual/psychometric divergence in assessing diabetes distress and compared their associations with criteria of interest.

RESULTS

Content analysis: The PAID covers a greater variety of emotional concerns and shows a stronger focus on food-related problems and complications. The DDS is more reflective of physician-related distress and problems concerning diabetes self-management. Psychometric analysis: Exploratory factor analyses revealed four-factor structures of both scales, explaining 60% (PAID) and 67% (DDS) of variance. Confirmatory factor analyses confirmed that single-factor and four-factor models fit the data. Total scales proved high and subscales mostly satisfactory reliability. Associations with criteria of interest: The PAID was significantly more strongly associated with dysfunctional coping styles, quality of life and depressive symptoms. The DDS showed significantly stronger associations with diabetes self-care and metabolic outcomes.

CONCLUSION

Our results support both PAID and DDS as good self-report measures of diabetes distress. The observed contentual/psychometric differences suggest that a justified choice with regard to the intended clinical or scientific purpose can improve the acquisition of the required data.

Effect of a patient decision aid (PDA) for type 2 diabetes on knowledge, decisional self-efficacy, and decisional conflict

BACKGROUND

Patients with type 2 diabetes (T2DM) often have poor glycemic control on first-line pharmacologic therapy and require treatment intensification. Intensification decisions can be difficult because of many available options and their many benefits and risks. The American Diabetes Association recommends patient-centered, evidence-based tools supporting shared decision-making between patients and clinicians. We developed a patient decision aid (PDA) targeting decisions about treatment intensification for T2DM. Our objective was to determine the effectiveness of this PDA for patients with T2DM on metformin who require treatment intensification.

METHODS

This study was a pragmatic randomized controlled trial conducted in 27 US primary care and endocrinology clinics. Subjects were English-speaking adults with T2DM receiving metformin with persistent hyperglycemia who were recommended to consider medication intensification. Subjects were randomized to receive either the PDA or usual care (UC). Main outcome measures were change in knowledge, decisional self-efficacy, and decisional conflict.

RESULTS

Of 225 subjects enrolled, 114 were randomized to the PDA and 111 to UC. Mean [SD] age was 52 [1] years, time since T2DM diagnosis was 6 [+/-6] years, 45.3% were male, and most (55.5%) were non-Caucasian. Compared to UC, PDA users had significantly larger knowledge gains (35.0% [22.3] vs 9.9% [22.2]; P < 0.0001) and larger improvements in self-efficacy (3.7 [16.7] vs-3.9 [19.2]; P < 0.0001) and decisional conflict (-22.2 [20.6] vs-7.5 [16.6]; P < 0.0001).

CONCLUSIONS

The PDA resulted in substantial and significant improvements in knowledge, decisional conflict and decisional self-efficacy. Decisional conflict scores after PDA use were within the range that correlates with effective decision-making. This PDA has the potential to facilitate shared-decision-making for patients with T2DM.

TRIAL REGISTRATION

NCT02110979.

Sociodemographic and Clinical Predictors of Self-Management among People with Poorly Controlled Type 1 and Type 2 Diabetes: The Role of Illness Perceptions and Self-Efficacy

Self-management is critical if people with diabetes are to minimise their risk of macrovascular and microvascular complications, yet adherence to self-management recommendations is suboptimal. Understanding the predictors of optimal diabetes self-management in specific populations is needed to inform effective interventions. This study investigated the role of demographic and clinical characteristics, illness perceptions, and self-efficacy in explaining adherence to self-management recommendations among people with poorly controlled diabetes in North West of England. Illness perceptions and self-efficacy data were collected using validated questionnaires and clinical data were obtained from hospital records. Correlations were used to investigate bivariate relationships between independent variables and self-management, and multiple regression techniques were used to determine demographic and psychosocial predictors of self-management. Various demographic and clinical characteristics were associated with adherence to self-management recommendations. In particular, employment status explained 11% of the variation in adherence to foot care whilst diabetes treatment category explained 9% of exercise and 21% of the variations in SMBG recommendations. Also, 22% and 8% of the variations in overall self-management were explained by illness perceptions and self-efficacy beliefs, respectively. Illness perceptions and self-efficacy beliefs of people with poorly controlled diabetes are important predictors of their self-management behaviours and could potentially guide effective interventions.

When does personalized feedback make a difference? A narrative review of recent findings and their implications for promoting better diabetes self-care

Providing behavioral, biomarker, or disease risk feedback to patients is a key component of most behavioral interventions in diabetes, but it remains unclear what is necessary for such feedback to be truly engaging and effective. We sought to identify how personalized health-related feedback is most effectively designed and delivered, and how feedback may be tailored to meet the needs of individual patients with diabetes. To do so, we systematically reviewed recent findings concerning the effectiveness of feedback in eight health-related areas, including several specific to diabetes care (blood glucose monitoring and HbA1c) and others which touch on broader care dimensions (blood pressure, cholesterol, dietary intake, pedometer usage, self-weighing, and medical imaging). Five interdependent characteristics of health-related feedback were identified (clarity of the feedback message, personal meaningfulness of the feedback, frequency of feedback, guidance and support accompanying feedback, and interplay between feedback and patient characteristics) and applications for use in diabetes care were provided. Findings suggested that feedback will be most effective when it is easy for patients to understand and is personally meaningful, frequency of feedback is appropriate to the characteristics of the behavior/biomarker, guidance for using feedback is provided, and feedback is qualified by patient characteristics. We suggest that the effectiveness of feedback to promote better diabetes outcomes requires careful consideration of the feedback message, how it is delivered, and characteristics of the recipients.