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

Comparing Continuous Glucose Monitoring and Blood Glucose Monitoring in Adults With Inadequately Controlled, Insulin-Treated Type 2 Diabetes (Steno2tech Study): A 12-Month, Single-Center, Randomized Controlled Trial

OBJECTIVE

To compare the 12-month effects of continuous glucose monitoring (CGM) versus blood glucose monitoring (BGM) in adults with insulin-treated type 2 diabetes.

RESEARCH DESIGN AND METHODS

This is a single-center, parallel, open-label, randomized controlled trial including adults with inadequately controlled, insulin-treated type 2 diabetes from the outpatient clinic at Steno Diabetes Center Copenhagen, Denmark. Inclusion criteria were ≥18 years of age, insulin-treated type 2 diabetes, and HbA1c ≥7.5% (58 mmol/mol). Participants were randomly assigned (1:1) to 12 months of either CGM or BGM. All participants received a diabetes self-management education course and were followed by their usual health care providers. Primary outcome was between-group differences in change in time in range (TIR) 3.9-10.0 mmol/L, assessed at baseline, after 6 and 12 months by blinded CGM. The prespecified secondary outcomes were differences in change in several other glycemic, metabolic, and participant-reported outcomes.

RESULTS

The 76 participants had a median baseline HbA1c of 8.3 (7.8, 9.1)% (67 [62-76] mmol/mol), and 61.8% were male. Compared with BGM, CGM usage was associated with significantly greater improvements in TIR (between-group difference 15.2%, 95% CI 4.6; 25.9), HbA1c (-0.9%, -1.4; -0.3 [-9.4 mmol/mol, -15.2; -3.5]), total daily insulin dose (-10.6 units/day, -19.9; -1.3), weight (-3.3 kg, -5.5; -1.1), and BMI (-1.1 kg/m2, -1.8; -0.3) and greater self-rated diabetes-related health, well-being, satisfaction, and health behavior.

CONCLUSIONS

In adults with inadequately controlled insulin-treated type 2 diabetes, the 12-month impact of CGM was superior to BGM in improving glucose control and other crucial health parameters. The findings support the use of CGM in the insulin-treated subgroup of type 2 diabetes.

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.

Diabetes-related distress and quality of life among people with type 2 diabetes at primary care level in Brazil

PURPOSE

Living with diabetes can be challenging, particularly when it comes to dealing with psychological distress and requiring self-care directives. Patients may feel frustrated, angry, overwhelmed, and discouraged. This study aimed to investigate the diabetes-related distress and quality of life among people with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study carried out at the Clinical Research Centre at the University of Campinas, Brazil, between September 2020 and April 2021. Patients answered data regarding demographic and clinical variables, the Brazilian version of the Diabetes Distress Scale and the Diabetes Quality of Life (QOL) Measure by telephone contact. The data were managed using the RedCap System. For statistical analysis of the data, the Mann-Whitney and Kruskal-Wallis tests were applied for comparisons, and the Chi-square test for associations. The correlations were evaluated using the Spearman correlation coefficient.

RESULTS

Out of the 302 participants we recruited, 50.33% exhibited significant diabetes-related distress. Those with elevated diabetes-related distress scores had shorter education levels (p < 0.05), lower HbA1c levels (p < 0.05), and lower total scores in Diabetes QOL Measure (p < 0.0001), particularly in the QOL impact (p < 0.0001), social/vocational worry (p < 0.05), and diabetes worry (p < 0.0001) subscales compared to the group with the lowest diabetes-related distress.

CONCLUSION

Elevated diabetes-related stress scores significantly affect patients' QOL. Therefore, early screening of individuals at risk for this condition, using well-coordinated protocols, could mitigate adverse QOL effects and enhance their overall experience during disease management.

Initial evaluation of the Optimal Health Program for people with diabetes: 12-month outcomes of a randomised controlled trial

OBJECTIVE

This study aimed to evaluate if a new Mental health IN DiabeteS Optimal Health Program (MINDS OHP) compared with usual care in adults with Type 1 and Type 2 diabetes would improve psychosocial outcomes including self-efficacy and quality of life.Design and Main Outcome Measures This initial randomised controlled trial evaluated MINDS OHP compared with usual care. Participants were recruited through outpatient clinics and community organisations. The intervention group received nine sessions with assessments over twelve months. Primary outcomes were self-efficacy and quality of life. Secondary outcomes included diabetes distress and anxiety.

RESULTS

There were 51 participants in the control group (mean age = 52) and 55 in the intervention group (mean age = 55). There were significant main effects of time in general self-efficacy, diabetes distress, diabetes self-efficacy, and illness perceptions, however no significant between-group differences in primary or secondary outcomes. Post-hoc analyses revealed MINDS OHP improved diabetes self-efficacy for participants with mild to severe depression and anxiety, with a small effect.

CONCLUSION

Initial evaluation found MINDS OHP was associated with improved diabetes self-efficacy for adults with diabetes, for people with mild to severe levels of distress, with small effect. Further research is required to explore whether this disease-specific, collaborative care-focused intervention benefits the mental health of people with diabetes.

Study protocol of translation into Spanish and cross-cultural adaptation and validation of the problem areas in diabetes-Pediatric version (PAID-Peds) survey

AIM

The metabolic and psychological management of paediatric type 1 diabetes mellitus (T1DM) can be challenging over time given that T1DM may cause a negative emotional burden and, consequently, result in poor metabolic control of the disease. The objectives of this study are to translate the Problem Area in Diabetes Survey-Pediatric version (PAID-Peds) into Spanish, adapt it culturally and validate it.

DESIGN

Multicenter cross sectional study.

METHODS

636 patients aged 8-17 years, diagnosed with T1DM, under treatment with insulin and follow-up at the Miguel Servet University Hospital in Zaragoza (Aragón, Spain), the Ramón y Cajal University Clinical Hospital in Madrid (Spain) and at the Sant Joan de Déu Hospital in Barcelona (Catalonia, Spain) between 1 January 2023 and 31 December 2024 will be included. This study will consist of two phases: (1) Translation and cultural adaptation of the original PAID-Peds® survey into Spanish following eight steps; (2) Validation of the Spanish version of the PAIS-Peds® survey. The statistical analysis will be performed using Jamovi® 2.1.23. The reliability or internal consistency will be calculated using Cronbach's alpha index (considering an index higher than 0.8 to be good) and the test-retest will be evaluated using the intraclass correlation coefficient. For validity, confirmatory factor analysis will be calculated. This study has been approved by the ethics and research committees at each centre.

RESULTS

The translation and validation into Spanish language of the Problem Area in Diabetes Survey-Pediatric version will be feasible, valid and reliable to detecting the youth-perceived burden of T1DM. Therapeutic education in diabetes-recommended by the WHO and the Diabetes Education Study Group-has shown encouraging results in glycaemia and psychosocial and behavioural factors in T1DM.

Virtual reality's impact on children with type 1 diabetes: a proof-of-concept randomized cross-over trial on anxiety, pain, adherence, and glycemic control

AIMS

 Assess the effectiveness of virtual reality (VR) technology, in reducing pain and anxiety, and improving adherence and glycemic control among children with type 1 diabetes (T1D).

METHODS

Children with T1D, managed with continuous glucose monitoring and insulin pumps, were recruited for a randomized cross-over trial. Children were randomized to one of two interventions for diabetes management: group 1 used VR glasses first and group 2 listened to vocal-guided affective imagery first (audio). After 1 month, the interventions were crossed over. The outcome measures included pain and anxiety assessment, adherence, glycemic control, and patient-reported outcome measures (PROMs) of VR satisfaction and effectiveness.

RESULTS

 Forty children, mean age 11.4 ± 1.8 years, were participated. During the VR part, the monthly mean pain score compared to the baseline improved in both groups by 30% (p = 0.03). A 14% reduction in the state anxiety score was observed from baseline to 1 month in both groups (p = 0.009). Glycemic control measures including time in range, time above range, and glucose management indicator improved in both groups during VR part (p < 0.004 for all), compared to audio part. After one month, the patient-reported outcome measure (PROM) of satisfaction and effectiveness was sixfold higher after 1 month in group 1 compared to group 2 (p = 0.002). Adherence improved for both groups.

CONCLUSIONS

VR was shown to be effective in reducing pain and anxiety, improving adherence, PROM, and glycemic control among children with T1D. We suggest incorporating VR technology in pediatric diabetes clinics to facilitate and improve coping and management of diabetes.

TRIAL REGISTRATION

Trial registration number and date of registration for prospectively registered trials:ClinicalTrials.gov Identifier: NCT05883267, May 10th, 2023.

The prevalence of diabetes distress among patients with type 2 diabetes in Jordan

Objectives

Diabetes distress (DD) is a state of emotional distress that evolves from living with chronic disease and the burden of daily adjustments of medications and lifestyle. This study investigated the prevalence of DD in patients with type 2 diabetes mellitus (T2DM) in Jordan and the related sociodemographic and medical factors.

Methods

We conducted a cross-sectional study in 608 patients with T2DM in Jordan, ranging from ages 15 to 80 years. The participants filled out a questionnaire where they were asked to self-assess their DD using the Diabetes Distress Scale. In all, 32 participants were excluded according to the exclusion criteria, which resulted in 576 people being included in this study.

Results

The overall prevalence of DD was 53% (25% had moderate distress and 28% had high distress). Emotional distress had the highest prevalence among the DD subscales, with a total prevalence of 58.8%. The data showed a significant association of DD with different factors including age, the presence of diabetic complications, the type of medication used, and medication adherence.

Conclusion

This study showed a high prevalence of DD (53%). This finding should raise awareness to healthcare providers about the importance of screening for DD as part of the treatment guidelines, especially in patients who are on multiple medication regimens for DM; patients who have previous medical complications related to DM; and those who exhibit poor adherence to medications, which was found to be a risk factor of DD in this study.

Efficacy and safety of a telemedicine system in subjects with gestational diabetes mellitus (TELEGLAM): Study protocol for a randomized controlled trial

Background

Strict glycemic control is important to prevent perinatal complications in patients with gestational diabetes mellitus (GDM). Patients often require insulin injection, and frequent hospital visits are necessary to adjust the dose of insulin, which is considered burdensome for pregnant patients. Telemedicine may reduce the burden of hospital visits, and previous studies have reported its safety in GDM patients. This study aimed to evaluate the efficacy of telemedicine in GDM patients, focusing on patient satisfaction and health economic indicators.

Methods

This is a single-center, two-arm, randomized, open-label parallel-group study. Subjects will be selected from the patient population attending the Department of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Japan. Patients diagnosed with GDM by an oral glucose tolerance test (OGTT) by 29 weeks and 6 days of gestation who have undergone self-monitoring of blood glucose (SMBG) and insulin injection are eligible for inclusion. In the intervention group, telemedicine will be administered using the MeDaCa telemedicine system developed by the Medical Data Card, Inc., Tokyo, Japan. Subjects in the control group will be examined face-to-face every 2-3 weeks, as usual. We set health economic indicators and patient satisfaction as the primary endpoints, and will perform a cost-consequence analysis. Glycemic control indicators and perinatal outcomes will be evaluated as secondary endpoints.

Conclusions

Eligible patients are currently being recruited. Recruitment will be completed when the expected number of patients are enrolled.

Microbiome composition and central serotonergic activity in patients with depression and type 1 diabetes

The role of gut-brain axis functioning gains growing attention in research on the pathophysiology of major depressive disorders. Here, especially consequences of altered microbiota composition on tryptophan metabolism resulting in altered serotonergic neurotransmission in the central nervous system (CNS) have reached a central position. Previous research, however, mainly focused on either microbiota and peripheral serotonin levels or central serotonergic neurotransmission. The present study aimed to combine the analysis of microbiota composition and central serotonergic activity using a valid neurophysiological indicator. We recruited 19 adult patients with type 1 diabetes and depression (D + D; 7 males), 19 patients with type 1 diabetes (D-; 7 male), and 20 healthy participants (HC; 7 males). Next to the analysis of fecal microbiota regarding α- and β-diversity, the loudness dependence of auditory evoked potential (LDAEP) was investigated, a non-invasive measurement of central serotonergic activity. High α-diversity was associated with high LDAEP, i.e., low serotonergic activity, in patients with diabetes and additional depression. Furthermore, relative abundances of bacterial families belonging to Bacteroidetes, Proteobacteria and Firmicutes were shown to have an impact on central serotonergic activity. This finding was supported by a tendency indicating an association of central serotonergic activity with the Bacteroidetes-Firmicutes ratio in both patients' groups. Together, this data suggests that the guts' microbiota composition might play an important role in regulating the central serotonergic activity in the brain.

Diabetes Distress in Uninsured Patients with Diabetes During COVID-19 Pandemic: A Longitudinal Observational Study

This study assessed diabetes distress (DD) and glycemic control levels through three time periods during the COVID-19 pandemic in uninsured patients with diabetes. Diabetes Distress Screening Scales 2 and 17 were utilized to identify the prevalence of DD among uninsured patients during multiple stages of the COVID-19 pandemic at the Providing Access to Healthcare (PATH) diabetes clinic at the University of Alabama at Birmingham. For the 328 uninsured diabetic patients who were screened for DD at least once, the mean age was 46 years old with a majority being Black (55.5%), male (56.1%), and non-Hispanic (89.9%). Mean scores reflecting patients' level of DD initially increased in the first 6 months of the pandemic, from 2.86 to 3.44, and then decreased after 12 months of the COVID-19 pandemic to 3.09, while their mean hemoglobin A1c (HbA1c) followed a similar pattern of initial increase (from 11.31 to 12.13) followed by a decline (to 10.79). Addressing patient concerns quickly through early interventions to provide alternative means of care through telehealth and accommodating safe pick-up of diabetes supplies and medications, including insulin, can reduce DD and contribute to better management of glycemic control. Understanding the potential direct correlation of DD with HbA1c in uninsured patients with diabetes is an important factor for clinicians when providing care to this vulnerable population.

Patient-reported outcomes for people with diabetes: what and how to measure? A narrative review

Patient-reported outcomes (PROs) are valuable for shared decision making and research. Patient-reported outcome measures (PROMs) are questionnaires used to measure PROs, such as health-related quality of life (HRQL). Although core outcome sets for trials and clinical practice have been developed separately, they, as well as other initiatives, recommend different PROs and PROMs. In research and clinical practice, different PROMs are used (some generic, some disease-specific), which measure many different things. This is a threat to the validity of research and clinical findings in the field of diabetes. In this narrative review, we aim to provide recommendations for the selection of relevant PROs and psychometrically sound PROMs for people with diabetes for use in clinical practice and research. Based on a general conceptual framework of PROs, we suggest that relevant PROs to measure in people with diabetes are: disease-specific symptoms (e.g. worries about hypoglycaemia and diabetes distress), general symptoms (e.g. fatigue and depression), functional status, general health perceptions and overall quality of life. Generic PROMs such as the 36-Item Short Form Health Survey (SF-36), WHO Disability Assessment Schedule (WHODAS 2.0), or Patient-Reported Outcomes Measurement Information System (PROMIS) measures could be considered to measure commonly relevant PROs, supplemented with disease-specific PROMs where needed. However, none of the existing diabetes-specific PROM scales has been sufficiently validated, although the Diabetes Symptom Self-Care Inventory (DSSCI) for measuring diabetes-specific symptoms and the Diabetes Distress Scale (DDS) and Problem Areas in Diabetes (PAID) for measuring distress showed sufficient content validity. Standardisation and use of relevant PROs and psychometrically sound PROMs can help inform people with diabetes about the expected course of disease and treatment, for shared decision making, to monitor outcomes and to improve healthcare. We recommend further validation studies of diabetes-specific PROMs that have sufficient content validity for measuring disease-specific symptoms and consider generic item banks developed based on item response theory for measuring commonly relevant PROs.

Development and Validation of a Distress Measurement Related to Glucose Monitoring of Diabetes Patients

INTRODUCTION

Glucose monitoring-related problems affect the social and psychological distress experienced by patients with diabetes, and this distress leads to low compliance. Consequently, it is important to be able to comprehensively assess distress due to glucose monitoring in these patients. We have developed and validated a distress of self-glucose monitoring (DSGM) scale instrument to assess patient distress from glucose monitoring.

METHODS

Following an extensive literature review and qualitative study, we selected 21 items for assessing the DSGM, including physical, psychosocial, and process domains. We conducted a cross-sectional study in patients with insulin-treated diabetes aged 10-40 years at Samsung Medical Center, Seoul, Korea, from April 2021 to September 2021. Exploratory and confirmatory factor analyses (CFA) were performed to confirm the structural validity of the DSGM scale. To confirm construct and criterion validity, we assumed that the Korean version of the Problem Areas in Diabetes (PAID-K) instrument, life interference, and stress due to glucose monitoring might moderately correlate with the total score and scores of all domains of the DSGM scale except for the physical domain.

RESULTS

Cronbach's alpha coefficients for the DSGM scale were 0.92, and Cronbach's alpha coefficients of the three subscales ranged from 0.69 to 0.92, indicating satisfactory internal consistency. The DSGM scale was evaluated using CFA, and the fit indices for this model were good. The PAID-K total score, life interference, and stress due to glucose monitoring were moderately correlated with the total score of the DSGM scale and with the scores of the psychosocial and process domains, and were weakly correlated with the score of the physical domain of the DSGM scale.

CONCLUSION

The DSGM scale is a valid and reliable tool to evaluate distress due to glucose monitoring in adults, adolescents, and children with diabetes.

Validation of the type 1 diabetes distress scale (T1-DDS) in a large Danish cohort: Content validation and psychometric properties

Aim

To validate the Type 1 Diabetes Distress Scale (T1-DDS) in a large sample of adults with Type 1 diabetes (T1D) from diabetes clinics in Denmark.

Methods

Altogether 40 adults with T1D were interviewed to explore the content of T1-DDS in a Danish setting and to validate the translation of the T1-DDS into Danish. Subsequently, a survey including T1-DDS, the Problem Areas In Diabetes scale (PAID-20), fear of hypoglycemia, social support, and diabetes duration was answered by 2201 people with T1D. Other person characteristics were collected from the National Patient Register. HbA1c was obtained from the Clinical Laboratory Information System. Data distribution, internal consistency, convergent and construct validity, factor structure, three weeks retest, and cut-points were explored.

Results

Interview data supported the relevance of all T1-DDS items for the assessment of diabetes distress among adults with T1D. The T1-DDS showed good content and acceptable construct validity, and the ability to detect high diabetes distress levels. A high correlation between T1-DDS and PAID-20 (rho = 0.91) was found. The retest scores showed a good reliability (all rho ≥0.68) with the highest variability in the Friends/Family Distress and Physician Distress subscales and the lowest variability in the Powerlessness and Eating Distress subscales of the T1-DDS. Qualitative findings pointed out relevant concerns of people with T1D, which were not included in the T1-DDS.

Conclusion

The study supports the use of the Danish T1-DDS, but also highlights that existing diabetes distress questionnaires including T1-DDS do not cover all potential diabetes stressors and worries.

A data-driven approach to manage type 2 diabetes mellitus through digital health: The Klivo Intervention Program protocol (KIPDM)

BACKGROUND

Digital therapeutics, an emerging type of medical approach, is defined as evidence-based therapeutic interventions through qualified software programs that help prevent, manage, or treat chronic diseases such as type 2 diabetes mellitus (T2DM), which has high social and economic burden. Klivo, a startup certified by the Brazilian Society of Diabetes, developed the first digital therapeutic product for managing T2DM in Brazil, reaching 21 of 24 states. Klivo has continuously been improving its model of behavior change on the basis of an intensive lifestyle intervention method that addresses individuals' needs-the Klivo Intervention Program for T2DM (KIPDM). To test the most recent version of the KIPDM, we will evaluate the ongoing management of daily life habits in patients with T2DM by measuring clinically significant outcomes. To improve the transparency of further results, here we will present the study protocol and detail the plan for the research project, including the study design and the analysis strategies.

METHODS

The KIPDM will be sponsored by health plans and healthcare provider organizations and will be free for patients (adults aged ≥ 18 years and <65 years; and glycated hemoglobin ≥ 7%). The program will be based on a 6-month management process that will supervise patients remotely. The program will include educational classes via the Klivo app, text messages, or e-mails. Evaluation will include objectively assessing clinical, laboratory, and behavioral outcomes such as health-related quality of life, mental health, medication adherence, and healthcare utilization. For this, validated electronic questionnaires will be available through the Klivo app. The primary outcome will be glycated hemoglobin (HbA1c) values. The secondary outcome will be time in target blood glucose range (TIR) estimated by capillary glycemia. Other outcomes of interest will be evaluated at baseline and stipulated time points (3 and 6 months after the start of the program).

EXPECTED OUTCOMES

KIPDM patients should present improved HbA1c and TIR along the intervention as compared to baseline values. Findings from this study will provide insights into the health improvement of T2DM and other cardiometabolic conditions such as hypertension, dyslipidemia, and obesity by using a digital therapeutic strategy. By analyzing the patient's health over time, this study will also contribute to understanding comorbidities associated with this chronic condition in the Brazilian population.

Technology-Enabled Collaborative Care for Concurrent Diabetes and Distress Management During the COVID-19 Pandemic: Protocol for a Mixed Methods Feasibility Study

BACKGROUND

The COVID-19 pandemic disrupted the delivery of diabetes care and worsened mental health among many patients with type 2 diabetes (T2D). This disruption puts patients with T2D at risk for poor diabetes outcomes, especially those who experience social disadvantage due to socioeconomic class, rurality, or ethnicity. The appropriate use of communication technology could reduce these gaps in diabetes care created by the pandemic and also provide support for psychological distress.

OBJECTIVE

The purpose of this study is to test the feasibility of an innovative co-designed Technology-Enabled Collaborative Care (TECC) model for diabetes management and mental health support among adults with T2D.

METHODS

We will recruit 30 adults with T2D residing in Ontario, Canada, to participate in our sequential explanatory mixed methods study. They will participate in 8 weekly web-based health coaching sessions with a registered nurse, who is a certified diabetes educator, who will be supported by a digital care team (ie, a peer mentor, an addictions specialist, a dietitian, a psychiatrist, and a psychotherapist). Assessments will be completed at baseline, 4 weeks, and 8 weeks, with a 12-week follow-up. Our primary outcome is the feasibility and acceptability of the intervention, as evident by the participant recruitment and retention rates. Key secondary outcomes include assessment completion and delivery of the intervention. Exploratory outcomes consist of changes in mental health, substance use, and physical health behaviors. Stakeholder experience and satisfaction will be explored through a qualitative descriptive study using one-on-one interviews.

RESULTS

This paper describes the protocol of the study. The recruitment commenced in June 2021. This study was registered on October 29, 2020, on ClinicalTrials.gov (Registry ID: NCT04607915). As of June 2022, all participants have been recruited. It is anticipated that data analysis will be complete by the end of 2022, with study findings available by the end of 2023.

CONCLUSIONS

The development of an innovative, technology-enabled model will provide necessary support for individuals living with T2D and mental health challenges. This TECC program will determine the feasibility of TECC for patients with T2D and mental health issues.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04607915; https://clinicaltrials.gov/ct2/show/NCT04607915.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/39724.

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.

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.

Diabetes Distress Among Type 1 Diabetic Adolescents in a Tertiary Care Hospital in Pakistan

BACKGROUND AND AIM

 Diabetes distress, a term used to describe negative emotions associated with diabetes, is the key factor responsible for the elevated risk of psychological burden and compromised self-management. The aim of this study is to determine the prevalence of diabetes-related distress among adolescent patients with type 1 diabetes (T1D) and to ascertain various factors associated with it.

METHODOLOGY

In this cross-sectional study, 117 T1D patients with age 12-20 years visiting a diabetic clinic in the Department of Endocrinology and Metabolism, Services Hospital Lahore from February 2022 to August 2022 were enrolled. The patient's demographic and clinical details were noted in a pre-designed proforma. T1D distress scale (T1DDS) was utilized as the tool for measuring diabetes distress and distress was classified as severe, moderate, and no/little distress.

RESULTS

Of the total 117 T1D patients, 34.2% (n=40) had diabetes-related distress, out of which 31.6% had moderate and 2.6% had severe distress. The average total distress score was 1.73 ± 0.52 and higher mean scores were of powerlessness, negative social perception, and eating distress. Distress was higher among females, in those with the onset of diabetes in teens rather than in childhood. There is a significant impact of glycated hemoglobin (HbA1c) on the severity of diabetes distress as demonstrated by Pearson's correlation (r=.570, n= 117, p = <.001) Conclusion: The present study highlights the association of diabetes distress in adolescents with various factors, most significantly poor glycemic control, and therefore emphasizes the need for developing psychological interventional strategies in routine diabetes care to improve the mental well-being and self-management of diabetic patients.

Diabetes distress in adult patients with type 1 and type 2 diabetes

Background: Diabetes is a chronic and demanding condition, exposing patients to complex physical and mental challenges, and making them particularly vulnerable to distress. Diabetes distress related to disease in diabetic patients is a term encompassing challenges associated with the psychosocial adaptation required of these individuals. Aim of the study: To assess distress in patients with diabetes mellitus. Material and methods: This study was conducted among 107 patients with type 1 and 2 diabetes mellitus reporting for follow-up at a diabetes clinic. The Diabetes Distress Scale (DDS) was used for data collection. Results: Moderate and severe diabetes distress was found in 36.4% and 15% of respondents in the study group, respectively. The total mean score for the DDS was 2.19. The largest percentages of respondents with high levels of distress were observed in patients with a financial situation rated lower than good (30.6%), those having less than secondary education (28.0%), and those under 30 years of age (27.8%). Patients with type 1 diabetes (26.9%), a disease duration > 30 years (30.8%), those using insulin pump therapy (30%) or CGM (Continuous Glucose Monitoring) and FGM (Flash Glucose Monitoring) systems (50%), and those showing ≥ 3 chronic diabetic complications (37.5%) experienced severe distress. Conclusions: Overall, diabetic patients showed a moderate level of distress. The greatest inconveniences caused by the disorder were associated with regimen-related distress and emotional burden. Rural patients with a lower level of education and a lower financial status showed higher levels of distress. Patients experiencing chronic complications from diabetes and those with higher levels of glycated hemoglobin also presented with more severe distress.

Test–retest reliability and measurement error of the WHO-5 Well-being Index and the Problem Areas in Diabetes questionnaire (PAID) used in telehealth among patients with type 1 diabetes

Background

Patient-reported outcome (PRO) measures may be used in telehealth for the clinical assessment of mental health and diabetes distress, which are important aspects in diabetes care, but valid and reliable instruments on these topics are necessary. We aimed to evaluate the test–retest reliability and measurement error of the Danish versions of the WHO-Five Well-being Index (WHO-5) and Problem Areas in Diabetes (PAID) questionnaires used in a PRO-based telehealth intervention among patients with type 1 diabetes. A further aim was to evaluate the test–retest reliability of single items concerning patients’ symptom burden and general health status.

Methods

Outpatients with type 1 diabetes from the Steno Diabetes Center Aarhus, Aarhus University Hospital, Denmark, were enrolled from April 2019 to June 2020. Patients aged ≥ 18 who had type 1 diabetes for > 1 year, internet access, and the ability to understand, read, and write Danish were included. Intraclass correlation coefficients (ICC) and weighted Kappa values were used to assess test–retest reliability, and measurement error was assessed by estimating the minimal detectable change (MDC).

Results

A total of 146/255 (57%) patients completed the web questionnaire twice. The median response time between the two-time points was five days. The ICC of the WHO-5 scale was 0.87 (95% CI 0.82–0.90), and MDC was 18.56 points (95% CI 16.65–20.99). The ICC of the PAID scale was 0.89 (95% CI 0.84–0.92), and MDC was 11.86 points (95% CI 10.46–13.70). Overall, test–retest reliability of single symptoms and general health status items was substantial.

Conclusions

The WHO-5 and PAID questionnaires, and single symptoms and general health status items showed substantial test–retest reliability among patients with type 1 diabetes. Measurement error of the PAID questionnaire was considered acceptable; however, a larger measurement error of the WHO-5 questionnaire was observed. Further research is recommended to explore these findings.

Prevalence and predictors of diabetes-related distress in adults with type 1 diabetes

Type 1 diabetes (T1DM) is a chronic disease requiring lifelong insulin therapy and rigorous self-management. As it negatively impacts the affected individuals’ quality of life, it may eventually lead to diabetes-related distress. This study evaluated the prevalence and identified the predictors of diabetes-related distress in a representative sample of adults with T1DM treated at secondary and tertiary levels in Croatia. A multicenter, cross-sectional study was conducted in adults with T1DM in Croatia (N = 100). Data were collected between January 2018 and December 2018 from medical records and interviews during a single clinical visit, when participants completed a 20-item Problem Area in Diabetes (PAID) Questionnaire. The proportion of participants with a total PAID score ≥ 40 indicating high diabetes-related distress was calculated, and binary logistic regression was run to determine predictors. High diabetes-related distress was found in 36% of participants, with a mean PAID total score of 31.9 (21.1). The predictors of diabetes-related distress were higher HbA1c level (OR = 1.491, p = 0.037, CI = 1.025–2.169) and the presence of microvascular complications (OR = 4.611, p = 0.005; 95%CI 1.546–13.754). Worrying about the future and chronic complications and feeling guilty when off-track with diabetes management were identified as items that contribute the most to distress. Diabetes-related distress is a frequent condition in adults with T1DM in Croatia. Special attention should be given to patients with suboptimal glycemic control and microvascular complications. Given the high prevalence and impact of psychosocial problems in diabetes, psychological care should be integrated into routine care for adults with type 1 diabetes.

Disordered eating behaviours and eating disorders in adults with type 1 diabetes (DEBBI): rational and design of an observational longitudinal online study

INTRODUCTION

Disordered eating behaviours (DEB) and eating disorders (ED) are among the most common mental health comorbidities of type 1 diabetes. However, research on diabetes-specific risk and protective factors is limited. To this end, comprehensive characterisations of DEB and ED in type 1 diabetes, as well as longitudinal research on the course of DEB and ED, are needed to gain more insight. The 'Disordered eating behaviours and eating disorders in diabetes type I' (DEBBI) study aims to describe DEB/ED and their correlates in people with type 1 diabetes, to identify key diabetes-specific, psychosocial risk and protective factors, and to describe the course of DEB over time.

METHODS AND ANALYSIS

The DEBBI study is a longitudinal online survey with follow-up assessments after 6, 12 and 18 months, targeted at adults who have been diagnosed with type 1 diabetes for at least 12 months. The survey covers data on diabetes diagnosis and self-management (eg, diabetes treatment and complications), lifestyle (eg, eating habits, physical activity), psychosocial well-being (eg, anxiety, depressive symptoms) and demographic and medical information. It includes validated instruments and self-generated items. One key aspect of the data analysis will be latent profile analyses to determine latent subtypes of DEB manifestation in people with type 1 diabetes and their courses over time, including data on the clinical picture and symptoms, behaviours and diabetes-specific complications.

ETHICS AND DISSEMINATION

The study protocol was approved by the Ethics Committee of the State Medical Chamber of Rhineland-Palatine, Germany (ID 2021-16040). Participants give informed written consent before starting the survey. The DEBBI study will provide more clarity in the so far inconsistent empirical evidence base and will help to inform research on prevention and intervention strategies that are tailored to diabetes-specific needs.

TRIAL REGISTRATION NUMBER

The study is registered with DRKS German Clinical Trials Register (DRKS00028833).

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

Diabetes Distress, Depressive Symptoms, and Anxiety Symptoms in People With Type 2 Diabetes: A Network Analysis Approach to Understanding Comorbidity

OBJECTIVE

In this study, we aimed to explore interactions between individual items that assess diabetes distress, depressive symptoms, and anxiety symptoms in a cohort of adults with type 2 diabetes using network analysis.

RESEARCH DESIGN AND METHODS

Participants (N = 1,796) were from the Montreal Evaluation of Diabetes Treatment (EDIT) study from Quebec, Canada. A network of diabetes distress was estimated using the 17 items of the Diabetes Distress Scale (DDS-17). A second network was estimated using the DDS-17 items, the nine items of the Patient Health Questionnaire (PHQ-9), and the seven items of the Generalized Anxiety Disorder Assessment (GAD-7). Network analysis was used to identify central items, clusters of items, and items that may act as bridges between diabetes distress, depressive symptoms, and anxiety symptoms.

RESULTS

Regimen-related and physician-related problems were among the most central (highly connected) and influential (most positive connections) in the diabetes distress network. The depressive symptom of failure was found to be a potential bridge between depression and diabetes distress, being highly connected to diabetes distress items. The anxiety symptoms of worrying too much, uncontrollable worry, and trouble relaxing were identified as bridges linking both anxiety and depressive items and anxiety and diabetes distress items, respectively.

CONCLUSIONS

Regimen-related and physician-related diabetes-specific problems may be important in contributing to the development and maintenance of diabetes distress. Feelings of failure and worry are potentially strong candidates for explaining comorbidity. These individual diabetes-specific problems and mental health symptoms could hold promise for targeted interventions for people with type 2 diabetes.

Time With Diabetes Distress and Glycemia-Specific Distress: New Patient-Reported Outcome Measures for the Psychosocial Burden of Diabetes Using Ecological Momentary Assessment in an Observational Study

OBJECTIVE

To estimate time with diabetes distress using ecological momentary assessment (EMA) in people with type 1 diabetes and analyze its associations with glycemic management based on continuous glucose monitoring (CGM).

RESEARCH DESIGN AND METHODS

We used EMA to assess diabetes distress in a sample of recently hospitalized adults with type 1 diabetes once a day for 17 consecutive days in an ambulatory setting. Additionally, participants were asked daily about hypoglycemia distress (<70 mg/dL [3.9 mmol/L]), hyperglycemia distress (>180 mg/dL [10 mmol/L]), and variability distress (glucose fluctuations). Per person, the percentage of days with elevated distress was calculated (time with distress). Multilevel regression was used to analyze daily associations of distress ratings with CGM-derived parameters. EMA-derived associations between diabetes distress and glycemic outcomes were compared with questionnaire-derived associations.

RESULTS

Data of 178 participants were analyzed. Participants spent a mean (SD) of days in a state of diabetes distress, 54.6 ± 26.0% in hyperglycemia distress, 45.2 ± 27.5% in variability distress, and 23.0 ± 19.3% in hypoglycemia distress. In multilevel analyses, higher daily ratings of diabetes distress were significantly associated with hyperglycemia (β = 0.41). Results showed high between-person variability as explanation of variance of the models ranged between 22.2 and 98.8%. EMA-derived diabetes distress showed a significant association with mean glucose (r = 0.25), while questionnaire-based diabetes distress did not (r = 0.10). Prospectively, time with diabetes distress was associated with HbA1c at the 3-month follow-up (r = 0.27), while questionnaire-based distress showed no association (r = 0.11).

CONCLUSIONS

Time with distress as assessed with EMA showed a comparative advantage over distress as determined by questionnaire-based assessment of diabetes distress regarding associations with glycemic management.

Psychosocial Impact of the COVID-19 Pandemic on People With Type 1 Diabetes: Results of an Ecological Momentary Assessment Study

Aims

Psychological distress due to living with diabetes, demanding self-management tasks, impacts on life, and risks of complications is common among people living with diabetes. COVID-19 could pose a new additional risk factor for psychological distress in this group. This study aimed to analyze levels of COVID-19-related burdens and fears, variables explaining these levels, and associations with the concurrent 7-day COVID-19 incidence in people with type 1 diabetes (T1D).

Methods

A total of 113 people with T1D (58% women; age: 42.3 ± 9.9 years) participated in an ecological momentary assessment (EMA) study between December 2020 and March 2021. The participants reported daily levels of COVID-19-related burdens and fears over 10 consecutive days. Global ratings of COVID-19-related burdens and fears were assessed using questionnaires, as were current and previous levels of diabetes distress (PAID), acceptance (DAS), fear of complications (FCQ), depressive symptoms (CES-D), and diabetes self-management (DSMQ). Current levels of diabetes distress and depressive symptoms were compared with pre-pandemic ratings gained during an earlier study phase. Associations between burdens and fears, psychosocial and somatic aspects, and the concurrent 7-day incidence rate were analyzed using multilevel regression.

Results

Diabetes distress and depressive symptoms reported during the pandemic were comparable to pre-pandemic levels (PAID: p = .89; CES-D: p = .38). Daily EMA ratings reflected relatively low mean COVID-19-related burdens and fears in everyday life. However, there was substantial day-to-day variation per person indicating higher burdens on specific days. Multilevel analyses showed that daily COVID-19-related burdens and fears were significantly predicted by pre-pandemic levels of diabetes distress and diabetes acceptance but were not associated with the concurrent 7-day incidence rate nor with demographic and medical variables.

Conclusions

This study observed no increase in diabetes distress and depressive symptoms during the pandemic in people with T1D. The participants reported low to moderate levels of COVID-19-related burdens. COVID-19-related burdens and fears could be explained by pre-pandemic levels of diabetes distress and acceptance but not by demographic and clinical risk variables. The findings suggest that mental factors may constitute stronger predictors of COVID-19-related burdens and fears than objective somatic conditions and risks in middle-aged adults with T1D.

Supporting the emotional well-being of patients with diabetes mellitus in primary care

Diabetes mellitus is a condition characterised by elevated blood glucose levels that can lead to significant acute and long-term complications. Alongside these physical complications, the condition can have substantial effects on people's emotional well-being, potentially resulting in diabetes distress and/or major depressive disorder. Therefore, timely assessment and referral of patients with diabetes who display signs and symptoms of diabetes distress or other mental health conditions are essential. This article discusses emotional well-being in patients with diabetes, and outlines some diabetes-specific validated assessment tools that can be used in practice. It also discusses the management and appropriate onward referral of people with diabetes who require support.

Evaluation of a Stepped Care Approach to Manage Depression and Diabetes Distress in Patients with Type 1 Diabetes and Type 2 Diabetes: Results of a Randomized Controlled Trial (ECCE HOMO Study)

INTRODUCTION

Depression is a common and serious complication of diabetes. Treatment approaches addressing the specific demands of affected patients are scarce.

OBJECTIVE

The aim of this work was to test whether a stepped care approach for patients with diabetes and depression and/or diabetes distress yields greater depression reduction than treatment-as-usual.

METHODS

Two-hundred and sixty patients with diabetes and elevated depressive symptoms (CES-D ≥16) and/or elevated diabetes distress (PAID ≥40) were randomized to stepped care for depression or diabetes treatment-as-usual. The primary outcome was the rate of meaningful depression reduction at the 12-month follow-up according to the HAMD (score <9 or reduction by ≥50%). Secondary outcomes were changes in depression scores (HAMD/CES-D), diabetes distress (PAID), diabetes acceptance (AADQ), well-being (WHO-5), quality of life (EQ-5D/SF-36), self-care behavior (SDSCA/DSMQ), HbA1c, and biomarkers of inflammation.

RESULTS

One-hundred and thirty-one individuals were assigned to stepped care and 129 to treatment-as-usual. Overall, 15.4% were lost to follow-up. Meaningful depression reduction was observed in 80.2 versus 51.2% in stepped care versus treatment-as-usual (p < 0.001, intention-to-treat analysis). Of the secondary measures, the HAMD (∆ -3.2, p < 0.001), WHO-5 (∆ 1.5, p = 0.007), and AADQ (∆ -1.0, p = 0.008) displayed significant treatment effects, while effects on CES-D (∆ -2.3, p = 0.065), PAID (∆ -3.5, p = 0.109), and SDSCA (∆ 0.20, p = 0.081) were not significantly different. Both groups showed comparable changes in EQ-5D/SF-36, DSMQ, HbA1c, and biomarkers of inflammation (all p ≥ 0.19).

CONCLUSIONS

The stepped care approach improved depression, well-being, and acceptance. The results support that increasing treatment intensity on demand is effective and can help provide more optimal treatment. The inclusion of diabetes-specific interventions may be beneficial for patients with diabetes and elevated depression.

Health care effects and medical benefits of a smartphone-based diabetes self-management application: study protocol for a randomized controlled trial

Background

Diabetes self-management is a mainstay of diabetes care, but the implementation of self-management regimens into daily life is complex and often results in discouragement and distress. Modern approaches such as smartphone-based self-management applications are therefore needed to support people with diabetes. Since reimbursability would increase the availability of such digital applications to people with diabetes, we designed a study that meets all scientific and methodological requirements set by the German Digital Healthcare Act to allow reimbursement for a specific application (mySugr PRO). Here, we report the protocol of this study that aims at evaluating the efficacy of the digital self-management application with regard to patient-reported outcomes and medical benefits.

Methods/design

This multicenter, open-label, randomized, parallel-group, controlled trial will evaluate the health care effects and medical benefits of mySugr PRO. A total of 466 people with diabetes will be randomly allocated (2:1 randomization) to the interventional group (n = 311) that will use the digital self-management application during the 12-week study period or the control group (n = 155; no usage of the application). Baseline and follow-up examinations will assess diabetes distress as the primary endpoint as well as empowerment, HbA1c, blood glucose data, self-management, general well-being, and treatment satisfaction as secondary endpoints. Statistical analyses will use an intention-to-treat procedure (using multiple imputation for missing values) as well as a per-protocol approach for sensitivity analysis.

Discussion

To the best of our knowledge, this study will be one of the largest diabetes-specific evaluations of a digital health application supporting people with diabetes in their diabetes self-management that follow the requirements of the German Digital Healthcare Act.

Trial registration

German Clinical Trial Register DRKS00022923. Registered on 22 October 2020.

Exploring and Developing a New Culturally-Appropriate Diabetes Distress Scale in Taiwan

Introduction

The aim of this study was to develop and validate a new diabetes distress scale suitable for Chinese and Taiwanese culture.

Methods

This study collected the current diabetes distress measurement tools, re-organized current definitions about the domains of diabetes distress, and then developed a new tool. Three hundred and ninety-five participants from four hospitals in northern Taiwan were recruited by cluster randomized sampling for validity test.

Results

We found the new diabetes distress scale had appropriate reliability and validity, including an acceptable model fit for the 12-item scale.

Conclusions

This new diabetes distress scale might be more directly related to emotional distress issues blood glucose control, improve the clinical conspicuity of diabetes distress, and even benefit the overall care of diabetic patients in Taiwan. Further studies about the validity and reliability of this new tool in a nationwide setting are needed.

How to identify clinically significant diabetes distress using the Problem Areas in Diabetes (PAID) scale in adults with diabetes treated in primary or secondary care? Evidence for new cut points based on latent class analyses

INTRODUCTION

The Problem Areas of Diabetes (PAID) questionnaire is a frequently used measure to assess diabetes-distress. The aim of this study was to identify clinically meaningful levels of diabetes-distress, using latent class analyses (LCA), and to determine which groups were at increased risk of elevated diabetes-distress in terms of sex, age, type of diabetes and glycaemic control.

METHODS

Data were derived from four studies (total N=2966, 49% female, age range 18-95 years, 43% type 1 diabetes, diabetes duration range 0-79 years). LCAs were performed to examine possible latent groups in the distribution of answers on the individual PAID items. Demographic and diabetes-related characteristics were added to the model to estimate their effects on latent class membership and receiver operating curves curves to determine cut-offs.

RESULTS

Three levels of diabetes distress were distinguished with defined cut-off scores and labelled as: low, moderate and high diabetes distress. Levels of distress did not associate with distinct clusters of items. Older people were more likely to be part of the low distress class; women and people with high HbA_1c were more likely to be part of the high distress class. Sensitivity and specificity of the commonly used cut-off of 40 for high distress are 0.95 and 0.97, respectively. To distinguish the moderate distress group, cut-off scores of 17 and 39 are optimal with a sensitivity of 0.93 and a specificity of 0.94.

CONCLUSION

Three levels of diabetes-distress can be distinguished: low, moderate and high diabetes distress. Younger people, women and people with poor glycaemic control are at an increased risk for high levels of distress. A cut-off of 40 is satisfactory to detect people with high levels of diabetes-distress; a score of 0-16 indicates low diabetes distress and a score of 17-39 moderate diabetes distress.

The Chinese version of the revised Diabetes Distress Scale for adults with type 2 diabetes: Translation and validation study

Objectives

This study aimed to translate the revised 17-item Diabetes Distress Scale (DDS17, 2017) into mandarin (simplified) Chinese and validate the Chinese version of DDS17 (C-DDS17, 2021) among adult patients with type 2 diabetes in China.

Methods

A scale translation and cross-sectional validation study was conducted. The DDS17 was translated into mandarin (simplified) Chinese through a five-step process: authorization, forward translation, synthesis, back translation, and amendment. During this session, 59 patients assessed the understandability and readability of the translated scale. From June 7 to September 4, 2021, a cross-sectional study that adhered to the COSMIN checklist was conducted with 400 individuals with type 2 diabetes from three Class A tertiary comprehensive hospitals in Beijing, China. The content, construct, convergent, discriminant validity, and reliability (Cronbach’s α coefficient and item-total correlation coefficients) of the C-DDS17 were evaluated. This study was a part of a project registered in the Chinese Clinical Trial Registry (no. ChiCTR2100047071).

Results

Among the participants, 33.3% (133/400) of them experienced moderate to high diabetes distress. The content validity indices of the C-DDS17 equaled 1.00. The scale yielded a four-factor structure. The average variances extracted were 0.42–0.57, which was lower than squared correlations. Cronbach’s α coefficient was 0.88 for the overall scale and ranged from 0.76 to 0.81 for sub-scales. Corrected item-total correlation coefficients ranged from 0.42 to 0.61. The eighth item (“Feeling that I am often failing with my diabetes routine”) was better fit to physician distress than regimen distress but had little influence on the validation results.

Conclusions

The C-DDS17 is a reliable and valid instrument for assessing diabetes distress in patients with type 2 diabetes. It is a promising instrument for early identification and management of diabetes distress in clinical practice and trials.

Psychrometric Properties of the Arabic Version of the Problem Areas in Diabetes Scale in Primary Care

Background

The Problem Areas in Diabetes (PAID) scale is a reliable and valid tool that is widely used for diabetes-distress screening, but the Arabic version of the scale lacks validity and reliability analysis in primary healthcare (PHC) patients. Our study aimed to evaluate the psychometric properties of the Arabic version of the PAID (AR-PAID) scale among Egyptian patients with type 2 diabetes mellitus (T2DM) in PHC settings.

Methods

We conducted a cross-sectional study on a convenience sample of 200 patients from six rural PHC settings in the Ismailia governorate. The confirmatory factor analysis (CFA) was performed to test the goodness-of-fit to the predefined models of the PAID. Convergent construct was evaluated through correlations with the Arabic versions of the Patient Health Questionnaire 9 (PHQ-9), Generalized Anxiety Disorder Scale (GAD-7), and 5-item World Health Organization Well-Being Index (WHO-5), additionally glycated hemoglobin (HbA1c) levels. Discriminant validity was evaluated through associations with patients' sociodemographic and clinical characteristics. Reliability was evaluated through internal consistency (Cronbach's α) and test-retest reliability analysis (intraclass correlation coefficient, ICC).

Results

The CFA demonstrated the best fit for a four-factor model. The AR-PAID was significantly correlated with the following measures: PHQ-9 (rho = 0.71, p < 0.001), GAD-7 (rho = 0.50, p < 0.001), WHO-5 (rho = −0.69, p < 0.001), and HbA1c (rho = 0.36, p < 0.001), supporting sound convergent validity. Discriminant validity was satisfactory demonstrated. Internal consistency was excellent (α = 0.96) and test-retest reliability was stable (ICC = 0.97).

Conclusions

The AR-PAID scale is a valid and reliable instrument for diabetes-distress screening in primary care patients with T2DM that can be used in clinical settings and research. Further research is needed to validate short forms of the AR-PAID scale.

A Self-Report Measure of Diabetes Self-Management for Type 1 and Type 2 Diabetes: The Diabetes Self-Management Questionnaire-Revised (DSMQ-R) – Clinimetric Evidence From Five Studies

Aims

Measurement tools to evaluate self-management behavior are useful for diabetes research and clinical practice. The Diabetes Self-Management Questionnaire (DSMQ) was introduced in 2013 and has become a widely used tool. This article presents a revised and updated version, DSMQ-R, and evaluates its properties in assessing self-management practices in type 1 diabetes (T1D) and type 2 diabetes (T2D).

Methods

The DSMQ-R is a multidimensional questionnaire with 27 items regarding essential self-management practices for T1D and T2D (including diabetes-adjusted eating, glucose testing/monitoring, medication taking, physical activity and cooperation with the diabetes team). For the revised form, the original items were partially amended and the wording was updated; eleven items were newly added. The tool was applied as part of health-related surveys in five clinical studies (two cross-sectional, three prospective) including a total of 1,447 people with T1D and T2D. Using this data base, clinimetric properties were rigorously tested.

Results

The analyses showed high internal and retest reliability coefficients for the total scale and moderate to high coefficients for the subscales. Reliability coefficients for scales including the new items were consistently higher. Correlations with convergent criteria and related variables supported validity. Responsiveness was supported by significant short to medium term changes in prospective studies. Significant associations with glycemic outcomes were observed for DSMQ-R-assessed medication taking, glucose monitoring and eating behaviors.

Conclusions

The results support good clinimetric properties of the DSMQ-R. The tool can be useful for research and clinical practice and may facilitate the identification of improvable self-management practices in individuals.

Testing the Impact of a Collaborative, Goal-Setting, and Behavioral Telehealth Intervention on Diabetes Distress: A Randomized Clinical Trial

Background:Diabetes distress is underrecognized and associated with poor outcomes. This study tested whether a 12-month collaborative, goal-setting, and behavioral telehealth intervention reduced diabetes distress levels.Methods:This is a secondary analysis of the Healthy Outcomes through Patient Empowerment (HOPE) study that included individuals (N = 225) with uncontrolled diabetes and depression living at least 20 miles from a Veteran's Affairs medical center. Participants were randomized to HOPE (intervention) or Enhanced Usual Care (EUC) with education. We evaluated diabetes distress levels as measured by the Problem Areas in Diabetes (PAID) Questionnaire and its four subscales (emotional, diabetes management, social, and treatment distress) at baseline, 6, and 12 months.Results:Between-group analysis revealed greater improvements in HOPE versus EUC for: 6-month PAID total score (p = 0.04), emotional (p = 0.03), and social (p = 0.04) subscales; 12-month PAID total score (p = 0.07) and emotional subscale (p = 0.07). Within-group comparisons showed larger effect sizes for HOPE compared with EUC: 12-month PAID total scores (0.82 vs. 0.54), 6-month emotional burden (0.54 vs. 0.31), and 6-month (0.32 vs. 0.08) and 12-month (0.41 vs. 0.12) social burdens. Repeated-measures analysis evaluating treatment group and time trended toward improvement in PAID overall for HOPE compared with EUC participants, but was not statistically significant (β = 6.96; SE = 4.35; p = 0.13).Discussion:Clinically meaningful reductions in PAID overall and the emotional and social subscales were observed in HOPE compared with EUC participants.Conclusion:Further evaluation of diabetes telehealth interventions that include other facets related to diabetes distress, including treatment, diabetes management, social, and emotional burdens, is warranted. Clinical Trial Number. NCT01572389; Clinical Trial Registry. https://clinicaltrials.gov/ct2/show/NCT01572389.

Working With Type 1 Diabetes: Investigating the Associations Between Diabetes-Related Distress, Burnout, and Job Satisfaction

The present study investigates the association between diabetes-related distress (DD) and work outcomes (burnout and job satisfaction) among employed people with type 1 diabetes. Employed adults with type 1 diabetes (N = 297) completed an online survey. Measures assessed emotional, social, food- and treatment-related DD, burnout, and job satisfaction, as well as the type of insulin treatment. We conducted multiple regression analyses to test our hypotheses. Emotional DD was significantly and positively associated with burnout. Social DD was significantly and negatively associated with job satisfaction. The type of treatment (insulin pen versus insulin pump) had no significant effect on the outcomes. This study sets the stage for research on the interactions between working conditions, work outcomes and illness symptoms, and problems of people with type 1 diabetes, and, generally, employees with chronic illnesses. The findings have implications for individual health and illness management, burnout prevention, and occupational health measures.

Perceptions and correlates of distress due to the COVID-19 pandemic and stress management strategies among people with diabetes: a mixed methods study

Background

Greater risk of adverse health outcomes and public health measures have increased distress among people with diabetes during the coronavirus-2019 (COVID-19) pandemic. The objectives of this study were to explore how the experiences of people with diabetes during the COVID-19 pandemic differ according to sociodemographic characteristics and identify diabetes-related psychosocial correlates of COVID distress.

Methods

Patients with type 1 or 2 diabetes were recruited from clinics and community health centres in Toronto, Ontario, as well as patient networks. Participants were interviewed to explore the experiences of people with diabetes with varied sociodemographic and clinical identities, with respect to wellness (physical, emotional, social, financial, occupational), level of stress and management strategies. Multiple linear regression was used to assess the relationships between diabetes distress, diabetes self-efficacy and resilient coping with COVID distress.

Results

Interviews revealed that specific aspects of psychosocial wellness affected by the pandemic, and stress and illness management strategies utilized by people with diabetes differed based on socioeconomic status, gender, type of diabetes and race. Resilient coping (β=−0.0517; 95% confidence interval [CI], −0.0918 to −0.0116; p=0.012), diabetes distress (β=0.0260; 95% CI, 0.0149 to 0.0371; p<0.0001) and diabetes self-efficacy (β=−0.0184; 95% CI, −0.0316 to −0.0052; p=0.007) were significantly associated with COVID distress.

Conclusions

Certain subgroups of people with diabetes have experienced a disproportionate amount of COVID distress. Assessing correlates of COVID distress among people with diabetes will help inform interventions such as diabetes self-management education to address the psychosocial distress caused by the pandemic.

Unraveling the concepts of distress, burnout, and depression in type 1 diabetes: A scoping review

BACKGROUND

Psychological complications are frequent in type 1 diabetes (T1D) but they might be difficult to distinguish one from the other in clinical practice. Our objective was to study the distinguishing characteristics, overlaps and their use in the literature between three concepts of T1D: depression, diabetes distress (DD) and diabetes burnout (DB).

METHODS

A scoping review (PRISMA guidelines) performed in three databases (PubMed/MEDLINE, PsycInfo, Web of Science) with the keywords: T1D, depression, diabetes and burnout, from January 1990 to June 2021. We selected original studies with participants with T1D, which reported depression, DD, or DB. We extracted information about the concepts, their sub-concepts and screening tools.

FINDINGS

Of the 4763 studies identified, 201 studies were included in the study. Seventy-three percent, 57% and 45% of sub-concepts do not overlap in depression, DD, and DB, respectively. We observed overlap between depression (27%)/DD (27%) and between DD (20%)/DB (50%).

INTERPRETATION

A number of sub-concepts distinguish depression and DD. Overlaps between concepts suggest that a more precise definition is still lacking. DB is still a relatively new concept and more research is needed to better understand how it can present itself differently, in order to personalize care in comparison to those having DD.

Veterans' Interpretation of Diabetes Distress in Diabetes Self-Management: Findings From Cognitive Interviews

PURPOSE

The purpose of this project was to identify additional facets of diabetes distress (DD) in veterans that may be present due to the veteran's military-related experience.

METHODS

The study team completed cognitive interviews with veterans with type 2 diabetes mellitus (T2DM) to examine how they answered the Diabetes Distress Scale (DD Scale), a tool that assesses DD. The DD Scale was used because of its strong associations with self-management challenges, physician-related distress, and clinical outcomes.

RESULTS

The veterans sample (n= 15) was 73% male, mean age of 61 (SD = 8.6), 53% Black, 53% with glycosylated hemoglobin level <9%, and 67% with prescribed insulin. The DD Scale is readily understood by veterans and interpreted. Thematic analysis indicated additional domains affecting DD and T2DM self-management, including access to care, comorbidities, disruptions in routine, fluctuations in emotions and behaviors, interactions with providers, lifelong nature of diabetes, mental health concerns, military as culture, personal characteristics, physical limitations, physical pain, sources of information and support, spirituality, and stigma.

CONCLUSIONS

This study describes how a veteran's military experience may contribute to DD in the context of T2DM self-management. Findings indicate clinicians and researchers should account for additional domains when developing self-management interventions and discussing self-management behaviors with individuals with T2DM.

Unmet needs for social support and diabetes-related distress among people living with type 2 diabetes in Thai Binh, Vietnam: a cross-sectional study

BACKGROUND

Diabetes-related distress (DRD) refers to negative emotional and affective experiences from daily demands of living with diabetes. People who received social support seem less likely to experience DRD. The prevalence of T2D in Vietnam is rapidly increasing. Yet, DRD and its association with social support have not been investigated. This study investigates DRD and how it is associated with unmet needs for social support in people with T2D in Thai Binh Province, Vietnam.

METHODS

A total of 806 people, age ≥ 40 years, treated for T2D at primary hospitals in Thai Binh Province, Vietnam, completed a questionnaire-based cross-sectional survey. DRD was self-reported, based on the Problem Areas In Diabetes scale 5 (PAID5). We assessed 6 types of unmet needs for social support from family/friends/community including: (i) Transport and company when visiting health facilities; (ii) Reminders to take medication; (iii) Purchase and preparation of food; (iv) Reminders to engage in physical exercise; (v) Emotional support; and (vi) Financial support. Multivariable logistic regression was used to model DRD as an outcome of each type of unmet need for social support, and as an outcome of the number of unmet needs for social support, adjusted for three sets of covariates.

RESULTS

In this study, 50.0% of people with T2D experienced DRD. Odds for DRD were higher among those who had any unmet need for social support. After adjustment for household economic status, only unmet needs for emotional and financial support were associated with higher odds ratios of DRD (OR = 2.59, CI95%: 1.19-5.63 and OR = 1.63, CI95%: 1.10-2.40, respectively). People who had ≥2 type of unmet need were not a higher risk of experiencing DRD as compared to those with no unmet need.

CONCLUSIONS

Half of the people with T2D experienced DRD. The results suggest that having enough finances may decrease most needs for social support with the exception of emotional support. Thus, social support to financial and emotional of diabetes aspects may contribute to prevent or reverse DRD.

Cultural adaptation and psychometric evaluation of the Kinyarwanda version of the problem areas in diabetes (PAID) questionnaire

Background

High prevalence rates in diabetes-related distress have been observed in several studies; however, in the region of Sub-Saharan Africa evidence is lacking as is, for example, the case for Rwanda, where diabetes prevalence is expected to increase over the next decade. The aim of this study is to report on the translation and cultural adaption of the problem areas in diabetes (PAID) questionnaire into Kinyarwanda and its psychometric properties.

Methods

The questionnaire was translated following a standard procedure. Interviews were conducted with 29 participants before producing a final version. For the psychometric evaluation, a sample of 266 patients with diabetes mellitus, aged 21–64 years old were examined. Participants either came from a separate cluster-randomised controlled trial or were recruited ad-hoc for this study. The evaluation included testing internal consistency, known groups validity, and construct validity. A series of confirmatory factor analysis were conducted investigating seven previously established factorial structures. An exploratory factor analysis (EFA) was also carried out to examine the structure further.

Results

The full scale showed good internal reliability (Cronbach’s α = 0.88). A four-factor solution previously tested in Spain with subdimensions of emotional, treatment, food-related and social-support problems demonstrated adequate approximate fit (RMSEA = 0.056; CFI = 0.951; TLI = 0.943). The EFA revealed a four-factor structure; however, two of these factors were not as homogeneous and easily interpretable as those of the Spanish model.

Conclusions

The psychometric properties of the Kinyarwanda version of PAID are acceptable. The questionnaire can be helpful in research and clinical practice in Rwanda, however certain cross-cultural differences should be taken into account.

Distress and depression among patients with diabetes mellitus: prevalence and associated factors: a cross-sectional study

PURPOSE

This study aimed to validate the internal consistency of the Persian version of the diabetes distress scale-17 (DDS-17) and to investigate the prevalence of diabetes distress (DD), depression, and possible relevant factors.

METHODS

This was a cross-sectional study on 820 diabetes patients (62.4 % females) in Tehran, Iran between January and June 2017. The Ethics Committee of Shahid Beheshti University of Medical Sciences approved the protocol. Patients filled out a demographic and health survey, DDS-17, the Beck Depression Inventory Second Edition (BDI-II) and the Summary of Diabetes Self-Care Activities Measure (SDSCA). DDS-17 consist of emotional burden, and physician, regimen, and interpersonal related distress. The correlation between DDS subscales and association between DDS and BDI-II or SDSCA scores were assessed using SPSS.

RESULTS

The mean age was 58.91 ± 12.35 years. Majority of patients had high DD (37.2 %) and severe depression (38.7 %). The general and specific diets got the highest score in six SDSCA subscales. The Persian version of DDS-17 had excellent internal consistency with Cronbach's alpha coefficient of 0.924. The DDS score had significant relationship with socioeconomic level (p < .001), type of DM (p < .001), type of treatment (p < .001), glycemic control status (p < .001), complication (p < .001) and depression level (p < .001). The level of hemoglobin A1c was the most useful predictor of DDS score (p < .001).

CONCLUSIONS

High prevalence of depression and distress in patient with diabetes calls for greater emphasizes on the importance of enhanced physicians and patients' knowledge in these areas.

Diabetes distress instruments in adults with Type 1 diabetes: A systematic review using the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist

AIMS

To identify all extant instruments used to measure diabetes distress in adults with Type 1 diabetes and to evaluate the evidence for the measurement properties of these instruments.

METHODS

Medline, Embase, CINAHL plus and PsycINFO were systematically searched from inception up until 12 March 2020 for all publications which evaluated the psychometric properties of diabetes distress measurement instruments. The quality of the methodology and the measurement properties in the identified studies were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

Seven out of the 7656 articles retrieved in the search were included in the final review. Four diabetes distress measurement instruments were identified, none of which displayed evidence for all measurement properties specified in the COSMIN guidelines. The Problem Areas in Diabetes-11 (PAID-11) demonstrated the best psychometric properties, displaying strong evidence for structural validity, internal consistency, hypothesis testing, responsiveness and criterion validity. The Problem Areas in Diabetes scale (PAID) was the most frequently investigated instrument, demonstrating good relevance and hypothesis testing across four studies; however, concerns remain over its factor structure.

CONCLUSION

The PAID-11 appears to be the most psychometrically sound instrument for measuring diabetes distress in adults with Type 1 diabetes, displaying strong evidence for a range of measurement properties. However, as only one study evaluated this instrument and its content validity has yet to be assessed, further validation is warranted. Additional qualitative work is needed to assess the content validity of these instruments among individuals with Type 1 diabetes.

Spousal Influence on Diabetes Self-care: Moderating Effects of Distress and Relationship Quality on Glycemic Control

BACKGROUND

Spouses often attempt to influence patients' diabetes self-care. Spousal influence has been linked to beneficial health outcomes in some studies, but to negative outcomes in others.

PURPOSE

We aimed to clarify the conditions under which spousal influence impedes glycemic control in patients with type 2 diabetes. Spousal influence was hypothesized to associate with poorer glycemic control among patients with high diabetes distress and low relationship quality.

METHODS

Patients with type 2 diabetes and their spouses (N = 63 couples) completed self-report measures before patients initiated a 7-day period of continuous glucose monitoring. Mean glucose level and coefficient of variation (CV) were regressed on spousal influence, diabetes distress, relationship quality, and their two- and three-way interactions.

RESULTS

The three-way interaction significantly predicted glucose variability, but not mean level. Results revealed a cross-over interaction between spousal influence and diabetes distress at high (but not low) levels of relationship quality, such that spousal influence was associated with less variability among patients with low distress, but more among those with high distress. Among patients with high distress and low relationship quality, a 1 SD increase in spousal influence predicted a difference roughly equivalent to the difference between the sample mean CV and a CV in the unstable glycemia range.

CONCLUSIONS

This was the first study to examine moderators of the link between spousal influence and glycemic control in diabetes. A large effect was found for glucose variability, but not mean levels. These novel results highlight the importance of intimate relationships in diabetes management.

Quality of life in patients with type 2 diabetes after switching to insulin degludec: results from a cross-sectional survey

PURPOSE

Five quality of life (QoL) domains are particularly important to patients with type 2 diabetes (T2D) using basal insulin-sense of physical well-being, sense of safety regarding hypoglycemia, sense of diabetes as burdensome, feelings of freedom and flexibility, and sleep quality.

METHODS

An online survey assessed these QoL domains in adult patients with T2D in the USA who had switched from a previous basal insulin to insulin degludec (IDeg): modified versions of the World Health Organization (Five) Well-Being Index (WHO-5), Hypoglycemia Attitudes and Behavior Scale (HABS; confidence and anxiety subscales only), and Diabetes Distress Scale (DDS; emotional burden and regimen-related distress subscales only); three items assessing feelings of freedom and flexibility; and one item assessing sleep quality (hours of restful sleep). Patients rated each item for their previous basal insulin and currently while using IDeg. Correlations between sleep quality and the other QoL scales were also assessed.

RESULTS

In total, 152 patients completed the survey and were included in the study sample. Patients reported significantly improved scores while using IDeg on all WHO-5, DDS, HABS, feelings of freedom and flexibility item scores, and total raw/mean subscale scores (P < 0.0001). Patients also reported a significantly greater number of hours of restful sleep [mean (SD) 6.6 (2.0) vs. 5.5 (1.8); P < 0.0001]. Better sleep quality statistically significantly correlated with improved QoL in all other domains assessed.

CONCLUSIONS

Treatment with IDeg after switching from a previous basal insulin was associated with statistically significant improvements in all QoL domains assessed.

Real-time continuous glucose monitoring versus self-monitoring of blood glucose in adults with insulin-treated type 2 diabetes: a protocol for a randomised controlled single-centre trial

INTRODUCTION

Medical treatment options for type 2 diabetes (T2D) have increased over the last decade and enhance the possibility of individualised treatment strategies where insulin is still one of them. In spite of the advancements in treatment options, less than one-third of the population with T2D obtain their optimal glycaemic goal. In persons with type 1 diabetes, continuous glucose monitoring (CGM) has shown to be the most important driver for improvement in glycaemic control, even more than insulin-pump therapy. The use of technology in T2D has only been investigated in few studies.The overall objective of the research study is to examine the effectiveness of the use of CGM versus self-monitoring of blood glucose (SMBG) in persons with insulin-treated T2D on glycaemic variables and patient-reported outcomes on treatment satisfaction, health behaviour and well-being. The independent effect of peer support will also be studied.

METHODS AND ANALYSIS

The study is a single centre, prospective, randomised, open-labelled, three-armed study with the randomisation 2:1:2 in group A with CGM, group B with CGM and peer support, and group C as a control group with SMBG. The participants receive a training course unique for the allocation group. The study runs for 12 months and includes 100 adult participants with insulin-treated T2D, treated at the outpatient clinic at Steno Diabetes Center Copenhagen. Primary outcome is difference in change in time in range. Recruitment begins in August 2020 and ends in July 2021. Final 12-month follow-up is anticipated to be in August 2022.

ETHICS AND DISSEMINATION

The study will be carried out in accordance with the Helsinki Declaration and is approved by the Scientific Ethics Committee of the Capital Region (H-20000843). Data collection and handling will be performed in accordance with the General Data Protection Regulation and is approved by the Danish Data Protection Agency (J-2020-100). Dissemination will be in international peer-reviewed journals, conferences and a plain-language summary for participants.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04331444).

PROTOCOL VERSION

V.3, 11 December 2020.

Emotional Regulation and Diabetes Distress in Adults With Type 1 and Type 2 Diabetes

OBJECTIVE

To explore the correlates of diabetes-related distress (DD) with psychometrically valid assessments of emotional regulation in individuals with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

Adults with diabetes (n = 298) were assessed for psychological issues possibly associated with diabetes and were further evaluated with measures of negative emotional experience (ER-Exp) and skill at regulating such experiences (ER-Skill) and measures of DD, perceived psychosocial stress, diabetes literacy, and diabetes self-care.

RESULTS

ER-Exp was directly related to DD, while ER-Skill was inversely related to DD. Together, these ER variables displayed a medium-size relationship (β = 0.45) with DD. Inclusion of variables related to diabetes self-care and perceived psychosocial stress was associated with only an 18% reduction (i.e., β = 0.45 to β = 0.38) in the strength of this relationship, while the magnitude of relationships between DD and perceived psychosocial stress (β = 0.15) and diabetes self-care (β = -0.09) was relatively small.

CONCLUSIONS

These data suggest that DD is meaningfully linked with negative emotionality, and skill at regulating such emotions, in adults with diabetes. This relationship appears to be stronger than that between DD and perceived psychological stress or diabetes self-care. If so, DD (and possibly A1C) may be improved in those with diabetes and difficulties with negative emotionality.

Ethically incentivising healthy behaviours: views of parents and adolescents with type 1 diabetes

BACKGROUND

To assess ethical concerns associated with participation in a financial incentive (FI) programme to help adolescents with type 1 diabetes improve diabetes self-management.

METHODS

Focus groups with 46 adolescents with type 1 diabetes ages 12-17 and 38 of their parents were conducted in the Seattle, Washington metropolitan area. Semistructured focus group guides addressed ethical concerns related to the use of FI to promote change in diabetes self-management. Qualitative data were analysed and emergent themes identified.

RESULTS

We identified three themes related to the ethical issues adolescents and parents anticipated with FI programme participation. First, FI programmes may variably change pressure and conflict in different families in ways that are not necessarily problematic. Second, the pressure to share FIs in some families and how FI payments are structured may lead to unfairness in some cases. Third, some adolescents may be likely to fabricate information in any circumstances, not simply because of FIs, but this could compromise the integrity of FI programmes relying on measures that cannot be externally verified.

CONCLUSIONS

Many adolescents with type 1 diabetes and their parents see positive potential of FIs to help adolescents improve their self-management. However, ethical concerns about unfairness, potentially harmful increases in conflict/pressure and dishonesty should be addressed in the design and evaluation of FI programmes.

A standard set of person-centred outcomes for diabetes mellitus: results of an international and unified approach

AIMS

To select a core list of standard outcomes for diabetes to be routinely applied internationally, including patient-reported outcomes.

METHODS

We conducted a structured systematic review of outcome measures, focusing on adults with either type 1 or type 2 diabetes. This process was followed by a consensus-driven modified Delphi panel, including a multidisciplinary group of academics, health professionals and people with diabetes. External feedback to validate the set of outcome measures was sought from people with diabetes and health professionals.

RESULTS

The panel identified an essential set of clinical outcomes related to diabetes control, acute events, chronic complications, health service utilisation, and survival that can be measured using routine administrative data and/or clinical records. Three instruments were recommended for annual measurement of patient-reported outcome measures: the WHO Well-Being Index for psychological well-being; the depression module of the Patient Health Questionnaire for depression; and the Problem Areas in Diabetes scale for diabetes distress. A range of factors related to demographic, diagnostic profile, lifestyle, social support and treatment of diabetes were also identified for case-mix adjustment.

CONCLUSIONS

We recommend the standard set identified in this study for use in routine practice to monitor, benchmark and improve diabetes care. The inclusion of patient-reported outcomes enables people living with diabetes to report directly on their condition in a structured way.

Improving Self-Care Management in Low-Income Latinos With Type 2 Diabetes Using Peer-Led U.S. Conversation Maps: A Quality Improvement Project in a Free Clinic

A culturally sensitive Healthy Interactions Conversations Maps program was implemented for teaching diabetes self-management education (DSME) to Latinos with type 2 diabetes using peer-led educators in a community health center. Patients were invited to participate in a group care setting to improve access to providers and DSME. Goals were to improve diabetes distress, self-efficacy, and glycemic control as measured by A1C. Significant improvements were found for mean diabetes self-efficacy scores from before (2.53 ± 0.59) to after (2.91 ± 0.50) DSME (P <0.001). Mean A1C decreased significantly from before (9.51 ± 1.72%) to after (8.79 ± 1.68%) DSME (P = 0.043) at the end of the 6-month intervention. Thus, this program was found to be a useful tool for providing DSME in community health clinics serving low-income Latinos.