Diabetes MILES--Australia (management and impact for long-term empowerment and success): methods and sample characteristics of a national survey of the psychological aspects of living with type 1 or type 2 diabetes in Australian adults

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

BACKGROUND AND AIMS

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

METHODS AND RESULTS

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

CONCLUSIONS

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

Is there a Relation between Depression and Anxiety to Clinical Characteristics among Patients with T2D in Greece?

BACKGROUND

Diabetes is a chronic disease that may be related to various periods of an individual's life.

AIM

The aim of the present study is the investigation of the existence of depression and anxiety among patients suffering from type 2 diabetes as well as the factors that influence these variables (depression and anxiety).

MATERIALS AND METHODS

The Hospital Anxiety and Depression Scale (HADS) for mental health assessment was used in the context of the collection of the research data. The study involved 100 patients (42 men and 58 women) with an average age of 63.72 ± 9.84 years of life.

RESULT

The results showed that there was a positive correlation between HbA1c value and anxiety as well as HADS questionnaire total score, and a positive correlation between blood glucose value and anxiety as well as HADS questionnaire total score.

CONCLUSION

Both depression and anxiety of these patients are influenced by different clinical factors.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'

INTRODUCTION

Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'.

METHODS AND ANALYSIS

Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000).

EXCLUSION CRITERIA

experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up.

SECONDARY OUTCOMES

between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary.

TRIAL REGISTRATION NUMBER

ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

The psychological profile of youth and young adults with type 1 diabetes in New Zealand

BACKGROUND

The psychological status of New Zealanders living with type 1 diabetes (T1D) is unknown. This study's purpose is to determine the prevalence of general wellbeing, diabetes-specific distress, and disordered eating, and explore their relationships with glycemic control.

METHODS

Participants were patients aged 15-24 years with T1D (N = 200) who attended their routine multidisciplinary clinic at the Waikato Regional Diabetes Service. They completed questionnaires including the World Health Organization Well-Being Index, the Problem Areas in Diabetes scales, and the Diabetes Eating Problem Survey-Revised. Clinical and demographic information were also collected.

RESULTS

Median age of participants was 19.3 years and 14% identified as Māori (indigenous people of Aotearoa New Zealand). Median HbA1c was 73 mmol/mol. One fifth of participants experienced low emotional wellbeing, including 7.5% who experienced likely depression. Diabetes distress was found in 24.1%, and 30.7% experienced disordered eating behaviors. Differences were identified between Māori and non-Māori in measures of diabetes distress and disordered eating, with Māori more likely to score in clinically significant ranges (50% vs. 19.9%; 53.6% vs. 26.7%, p < 0.05). Disordered eating was correlated with Hb_A1c , body mass index, and social deprivation; diabetes distress was associated with Hb_A1c and inversely with age (all p < 0.05).

CONCLUSIONS

This study is the first of its kind to determine that New Zealanders living with T1D experience significant psychological distress. Research with larger Māori representation is needed to more closely review identified inequities. Replication in other local clinics will help contribute to the ongoing development of normative data for Aotearoa New Zealand.

Developing a novel diabetes distress e-learning program for diabetes educators: an intervention mapping approach

Diabetes distress is a common negative emotional response to the ongoing burden of living with diabetes. Elevated diabetes distress is associated with impaired diabetes self-management and quality of life yet rarely identified and addressed in clinical practice. Health professionals report numerous barriers to the provision of care for diabetes distress, including lack of skills and confidence, but few diabetes distress training opportunities exist. The purpose of this paper is to describe how we utilized Intervention Mapping to plan the development, implementation, and evaluation of a novel diabetes distress e-learning program for diabetes educators, to meet a well-documented need and significant gap in diabetes care. A multidisciplinary team (combining expertise in research, health and clinical psychology, diabetes education, nursing, tertiary education, and website architecture) developed a diabetes distress e-learning program. We followed a six-step process (logic model of the problem, program outcomes and objectives, program design, program production, program implementation plan, and evaluation plan) known as Intervention Mapping. The program is underpinned by educational and psychological theory, including Bloom's Taxonomy of Educational Objectives and social cognitive theory. We developed a short (estimated 4 h) e-learning program for diabetes educators, which draws on the content of the Diabetes and Emotional Health handbook and toolkit. It integrates a 7As model, which provides a stepwise approach to identifying and addressing diabetes distress. Our diabetes distress e-learning program has been developed systematically, guided by an Intervention Mapping approach. In the next phase of the project, we will trial the e-learning.

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.

Symptoms of depression and anxiety in adults with type 1 diabetes: Associations with self-care behaviour, glycaemia and incident complications over four years - Results from diabetes MILES-Australia

OBJECTIVE

To examine whether symptoms of depression or anxiety predict glycaemia and incident diabetes complications four years later, and whether diabetes self-care behaviours mediate these associations, in adults with type 1 diabetes (T1DM).

METHODS

Data of 205 adults with T1DM from the 2011 and 2015 Diabetes MILES-Australia surveys were analysed. Variables of interest were: baseline depression and anxiety (PHQ-8 and GAD-7, respectively) symptoms; HbA_1c and incident complications at four-year follow-up; and self-care behaviours at both time points. Longitudinal associations were analysed using structural equation modelling.

RESULTS

Forty-two participants (20.6%) reported incident complications. Baseline depressive symptoms predicted higher HbA_1c at follow-up indirectly via less optimal self-care at follow-up (β = 0.19, P = 0.011). Baseline anxiety was not independently associated with HbA_1c or self-care at follow-up (P ≥ 0.64). Neither depressive nor anxiety symptoms predicted incident complications, although depressive symptoms were associated with less optimal self-care at baseline (β = -0.67, P < 0.001), and this predicted microvascular complications (β = -0.38, P = 0.044); however, the indirect association via self-care was not significant (β = 0.25, P = 0.067).

LIMITATIONS

Participants were self-selected; all study variables were assessed using self-report measures; and adjusting for baseline HbA_1c was not possible.

CONCLUSIONS

Depressive symptoms predicted suboptimal self-care behaviour and glycaemic outcome four years later, while anxiety symptoms did not. The findings suggest that tailored diabetes care should take the potential impact of comorbid depression into consideration to help people improve their diabetes self-care and achieve best possible health outcomes.

Psychosocial Moderators of the Impact of Diabetes Stigma: Results From the Second Diabetes MILES - Australia (MILES-2) Study

OBJECTIVE

To examine the association of diabetes stigma with psychological, behavioral, and HbA_1c outcomes and to investigate moderation effects of self-esteem, self-efficacy, and/or social support.

RESEARCH DESIGN AND METHODS

The national Second Diabetes MILES - Australia (MILES-2) survey included adults with type 1 diabetes (n = 959, 41% of whom were male, with mean ± SD age 44 ± 15 years), insulin-treated type 2 diabetes (n = 487, 60% male, age 61 ± 9 years), and non-insulin-treated type 2 diabetes (n = 642, 55% male, age 61 ± 10 years). (Un)adjusted linear regression analyses tested the association between diabetes stigma (Diabetes Stigma Assessment Scale [DSAS]) and psychological outcomes (depressive symptoms [eight-item version of the Patient Health Questionnaire (PHQ-8)], anxiety symptoms [Generalized Anxiety Disorder 7-item (GAD-7) questionnaire], and diabetes-specific distress [20-item Problem Areas In Diabetes (PAID) scale]), behavioral outcomes (healthy diet and physical activity [Summary of Diabetes Self-Care Activities (SDSCA)]), and self-reported HbA_1c. Interaction effects tested whether associations varied by self-esteem (Rosenberg Self-Esteem Scale [RSES]), self-efficacy (Confidence in Diabetes Self-Care [CIDS] scale), or diabetes-specific social support (Diabetes Support Scale [DSS]).

RESULTS

Significant positive associations were observed between DSAS and PHQ-8, GAD-7, and PAID across diabetes type/treatment groups (all P < 0.001), whereby each SD increase in DSAS scores was associated with approximately one-half SD deterioration in emotional well-being. Associations between DSAS and SDSCA and HbA_1c were nonmeaningful. Self-esteem moderated psychological outcomes among participants with type 1 and non-insulin-treated type 2 diabetes and diabetes distress among those with insulin-treated type 2 diabetes. Interaction effects were partially observed for social support but not for self-efficacy.

CONCLUSIONS

This study provides evidence of the association between diabetes stigma and depressive/anxiety symptoms and diabetes distress and for the moderating effects of self-esteem and social support among adults with type 1 and type 2 diabetes. Further research is needed to examine associations with objectively measured behavioral and clinical outcomes.

The Diabetes and Emotional Health Handbook and Toolkit for Health Professionals Supporting Adults With Type 1 and Type 2 Diabetes: Formative Evaluation

BACKGROUND

Health professionals have expressed unmet needs, including lacking the skills, confidence, training, and resources needed to properly attend to the psychological needs of people with diabetes.

OBJECTIVE

Informed by needs assessments, this study aimed to develop practical, evidence-based resources to support health professionals to address the emotional needs of adults with type 1 or type 2 diabetes.

METHODS

We developed a new handbook and toolkit informed by formative evaluation, including literature reviews, stakeholder consultation and review, and a qualitative study. In the qualitative study, health professionals participated in interviews after reading sections of the handbook and toolkit.

RESULTS

The literature review uncovered that psychological problems are common among adults with diabetes, but health professionals lack resources to provide related support. We planned and drafted resources to fill this unmet need, guided by stakeholder consultation and an Expert Reference Group (ERG). Before finalizing the resources, we implemented feedback received from stakeholders (ERG, health professionals, academics, and people with diabetes). The resulting resources were the practical, evidence-based Diabetes and Emotional Health handbook and toolkit. A total of 19 health professionals took part in the qualitative study about the handbook and toolkit. They viewed the resources favorably, felt empowered to support people with diabetes experiencing psychological problems, and felt motivated to share the resources with others. Some gave examples of how they had used the handbook in clinical practice. A perceived highlight was the inclusion of a process model outlining 7 steps for identifying and supporting people with emotional problems: the 7 A's model. With funding from the National Diabetes Services Scheme (NDSS), more than 2400 copies of Diabetes and Emotional Health have been distributed. It is freely available on the Web. The NDSS is an initiative of the Australian Government administered with the assistance of Diabetes Australia.

CONCLUSIONS

The new evidence-based resources are perceived by stakeholders as effective aids to assist health professionals in providing emotional support to adults with diabetes. The 7 A's model may have clinical utility for routine monitoring of other psychological and health-related problems, as part of person-centered clinical care.

Outer Retinal Structure and Function Deficits Contribute to Circadian Disruption in Patients With Type 2 Diabetes

Purpose

Light transmitted by retinal photoreceptors provides the input for circadian photoentrainment. In diabetes, there is a high prevalence of circadian and sleep disruption but the underlying causes are not well understood. Patients with diabetes can exhibit dysfunctional photoreceptors but their role in circadian health is not known. Here we quantify photoreceptor function and contributions to circadian health and sleep in patients with diabetes without diabetic retinopathy and healthy controls.

Methods

Rod, cone, and melanopsin function was derived using chromatic pupillometry in 47 participants including 23 patients with type 2 diabetes and 24 age-matched healthy controls after an ophthalmic examination including retinal thickness assessment using optical coherence tomography. Circadian health was determined using dim light melatonin onset (DLMO) and sleep questionnaires; light exposure was measured using actigraphy.

Results

Compared with the control group, the patients with diabetes had a significantly earlier DLMO (1 hour) (P = 0.008), higher subjective sleep scores (P < 0.05), a reduction in pupil constriction amplitude for red stimuli (P = 0.039) and for the early postillumination pupil response (PIPR) for blue (P = 0.024) stimuli. There were no between-group differences in the light exposure pattern, activity levels, and intrinsic melanopsin-mediated PIPR amplitude (P > 0.05). A significant correlation was evident between outer retinal thickness and DLMO (r = -0.65, P = 0.03) and the pupil constriction amplitude (r = 0.63, P = 0.03); patients with thinner retina had earlier DLMO and lower pupil amplitudes.

Conclusions

We infer that the observed changes in circadian function in patients with no diabetic retinopathy are due to structural and functional outer retinal rod photoreceptor deficits at early stage of diabetic eye disease.

Comorbid elevated symptoms of anxiety and depression in adults with type 1 or type 2 diabetes: Results from the International Diabetes MILES Study

AIMS

We examined: (a) the prevalence of comorbid elevated symptoms of anxiety/depression; (b) its demographic/clinical correlates; (c) associations with self-care behaviors, by diabetes type.

METHODS

Cross-sectional self-report data of 6590 adults with diabetes (42% type 1; 58% type 2) from the Australian and Dutch Diabetes MILES studies were used. Elevated symptoms of anxiety/depression were defined as GAD-7 ≥ 10/PHQ-9 ≥ 10.

RESULTS

In both diabetes types, comorbid elevated symptoms of anxiety/depression were present in 9% and symptoms of anxiety alone in 2%; symptoms of depression alone were present in 8% of adults with type 1 diabetes and 11% with type 2 diabetes. Shorter diabetes duration (type 1 only) was the only characteristic that distinguished those with comorbid elevated symptoms of anxiety/depression but not those with symptoms of anxiety/depression alone from the reference group (no/minimal symptoms of anxiety/depression). Those with comorbid elevated symptoms of anxiety/depression had increased odds of sub-optimal diabetes self-care behaviors compared with the reference group, with higher odds than those with symptoms of anxiety or depression alone.

CONCLUSIONS

Comorbid elevated symptoms of anxiety/depression affected one in ten respondents, who also had increased odds of suboptimal diabetes self-care. Those with shorter type 1 diabetes duration may be at increased risk.

What Do Adults with Type 2 Diabetes Want from the "Perfect" App? Results from the Second Diabetes MILES: Australia (MILES-2) Study

Background: We investigated what Australian adults with type 2 diabetes (T2D) want from the "perfect" diabetes self-management application. Methods: Adults with T2D completed a national online survey including an open-ended question: "If you were describing the perfect app to help you manage your diabetes, what would it do?" Qualitative responses were subjected to thematic analysis. Results: Of the 339 participants who provided usable responses, 153 (45%) were women, the mean age was 58 ± 10 years, and 139 participants (41%) managed their diabetes with insulin. Two primary themes emerged. First, participants expressed a desire for assistance with practical aspects of diabetes self-management to improve, and reduce the cognitive burden of, self-management; this included tracking and visualizing multiple sources of data, using data to inform automated, personalized coaching, reminders, and alarms, and automating upload and linking of data through connected devices. Second, they desired assistance with psychological and emotional aspects of diabetes self-management; this included ongoing encouragement and motivation, help with stress management or negative emotions, and complementing existing health care by facilitating interconnectivity with health professionals. Conclusions: Our findings suggest that the clear desire of people with type 2 diabetes is for the "perfect app" to reduce not only the practical, but also the cognitive and emotional burden of diabetes self-management. They provide further evidence that understanding the desires of people living with diabetes needs to be the first step in app development to ensure that apps provide features, support, and benefits that people with diabetes value.

Psychosocial health care needs of people with type 2 diabetes in primary care: Views of patients and health care providers

Aims

This study examined (a) psychosocial health care needs of people with type 2 diabetes from the perspective of patients and diabetes healthcare providers in primary care, in terms of topics, attention in diabetes care and preferences and (b) factors associated with a positive attitude towards specialized psychosocial health care.

Design

Qualitative focus group study.

Methods

Using purposive sampling, participants were selected from general practices. In 2012–2013, three focus groups were conducted in people with type 2 diabetes (N = 20) and three with healthcare providers (N = 18).

Results

Opinions differed considerably on whether there was a need for psychosocial health care. Topics focused mainly on diabetes‐specific issues ranging from a need for additional diabetes education to attention and support in regular diabetes care. However, not all healthcare providers felt competent enough to address psychosocial problems. Some participants reported a need for specialized psychosocial help. A positive attitude towards specialized psychosocial health care appeared to be influenced by care setting (e.g., in the primary care practice or ‘outside’ mental health care), care accessibility, proactive discussion of psychosocial issues with and referral by healthcare providers and previous experiences with psychosocial health care.

Conclusion

Although only few participants expressed a need for specialized psychosocial care, attention for psychosocial well‐being in regular diabetes care was generally appreciated.

Impact

People with type 2 diabetes generally felt psychosocial care could be provided as part of regular diabetes care. Suggestions for healthcare providers to meet psychosocial health care needs include training and discussion tools.

What information is important for accredited exercise physiologists to facilitate change in clients living with type 2 diabetes mellitus?

Accredited Exercise Physiologists (AEPs) prescribe exercise and physical activity interventions for people living with type 2 diabetes mellitus (T2DM). During initial consultations, AEPs face the challenge of collecting enough information to facilitate behaviour change and adherence to treatment recommendations. The objective of this research is to explore the initial consultation practices of AEPs with clients living with T2DM and resultant recommendations provided to clients to promote long-term adherence. This study was an exploratory descriptive qualitative study. Twenty-one AEPs who currently practice in the Townsville Region participated in focus groups or semi-structured interviews. Data were analysed using a thematic and triangulation approach. Results revealed that an interview style consultation is standard practice, which varied based on experience of the AEP. Interviewing techniques facilitating behaviour change were under-utilised, especially among less-experienced AEPs who focused on the medical information. Assessment of the psychosocial wellbeing of the client living with T2DM by AEPs was limited. AEPs recommended that group exercise sessions yielded greater success for clients adopting physical activity. It is recommended that new graduate AEPs develop greater confidence in strategies of gathering information to facilitate behaviour change in clients with T2DM. A mentorship program could ensure the continued development of new graduate AEPs through the transfer of knowledge and skills.

The Importance of Sex Stratification in Autoimmune Disease Biomarker Research: A Systematic Review

The immune system is highly dynamic and regulated by many baseline characteristic factors. As such, significant variability may exist among different patient groups suffering from the same autoimmune disease (AD). However, contemporary research practices tend to take the reductionist aggregate approach: they do not segment AD patients before embarking on biomarker discovery. This approach has been productive: many novel AD biomarkers have recently been discovered. Yet, subsequent validation studies of these biomarkers tend to suffer from a lack of specificity, sensitivity, and reproducibility which hamper their translation for clinical use. To enhance reproducibility in validation studies, an optimal discovery-phase study design is paramount: one which takes into account different parameters affecting the immune system biology. In this systematic review, we highlight need for stratification in one such parameter, i.e., sex stratification. We will first explore sex differences in immune system biology and AD prevalence, followed by reported sex-bias in the clinical phenotypes of two ADs—one which more commonly affects females: systemic lupus erythematosus, and one which more commonly affects males: ankylosing spondylitis. The practice of sex stratification in biomarker research may not only advance the discovery of sex-specific AD biomarkers but more importantly, promote reproducibility in subsequent validation studies, thus easing the translation of these novel biomarkers from bench to bedside to improve AD diagnosis. In addition, such practice will also promote deeper understanding for differential AD pathophysiology in males and females, which will be useful for the development of more effective interventions for each sex type.

A tailored intervention to promote uptake of retinal screening among young adults with type 2 diabetes - an intervention mapping approach

BACKGROUND

Young adults (18-39 years) with type 2 diabetes are at risk of early development and rapid progression of diabetic retinopathy, a leading cause of vision loss and blindness in working-age adults. Retinal screening is key to the early detection of diabetic retinopathy, with risk of vision loss significantly reduced by timely treatment thereafter. Despite this, retinal screening rates are low among this at-risk group. The objective of this study was to develop a theoretically-grounded, evidence-based retinal screening promotion leaflet, tailored to young adults with type 2 diabetes.

METHODS

Utilising the six steps of Intervention Mapping, our multidisciplinary planning team conducted a mixed-methods needs assessment (Step 1); identified modifiable behavioural determinants of screening behaviour and constructed a matrix of change objectives (Step 2); designed, reviewed and debriefed leaflet content with stakeholders (Steps 3 and 4); and developed program implementation and evaluation plans (Steps 5 and 6).

RESULTS

Step 1 included in-depth qualitative interviews (N = 10) and an online survey that recruited a nationally-representative sample (N = 227), both informed by literature review. The needs assessment highlighted the crucial roles of knowledge (about diabetic retinopathy and screening), perception of personal risk, awareness of the approval of significant others and engagement with healthcare team, on retinal screening intentions and uptake. In Step 2, we selected five modifiable behavioural determinants to be targeted: knowledge, attitudes, normative beliefs, intention, and behavioural skills. In Steps 3 and 4, the "Who is looking after your eyes?" leaflet was developed, containing persuasive messages targeting each determinant and utilising engaging, cohort-appropriate imagery. In Steps 5 and 6, we planned Statewide implementation and designed a randomised controlled trial to evaluate the leaflet.

CONCLUSIONS

This research provides an example of a systematic, evidence-based approach to the development of a simple health intervention designed to promote uptake of screening in accordance with national guidelines. The methods and findings illustrate how Intervention Mapping can be employed to develop tailored retinal screening promotion materials for specific priority populations. This paper has implications for future program planners and is intended to assist those wishing to use Intervention Mapping to create similar theoretically-driven, tailored resources.

The Use of Mobile Applications Among Adults with Type 1 and Type 2 Diabetes: Results from the Second MILES-Australia (MILES-2) Study

BACKGROUND

While the number of diabetes-specific mobile applications (apps) continues to grow, there is a lack of knowledge about their actual use.

METHODS

The second MILES (Management and Impact for Long-term Empowerment and Success)-Australia study was a national cross-sectional survey of the psychological, behavioral, and social aspects of diabetes for adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). Associations between diabetes-specific app usage and demographic, clinical, and psychosocial variables were examined.

RESULTS

Of the 1589 respondents responding to the diabetes-specific app questions, 795 had T1D (mean ± standard deviation age 43 ± 14 years; 61% women; diabetes duration 19 ± 14 years) and 794 had T2D (age 60 ± 9 years; 40% women; diabetes duration 11 ± 7 years). Among adults with T1D, 24% (n = 188) reported using apps, with carbohydrate counting (74%; n = 139) as the most common cited purpose. App usage was significantly associated with shorter diabetes duration, more frequent glucose monitoring, and lower self-reported HbA1c. Among adults with T2D, 8% (n = 64) reported using apps, with glucose monitoring (62%; n = 39) as the most common purpose. For all respondents, the most commonly reported reason for not using apps was a belief that they could not help with diabetes self-management.

CONCLUSIONS

A minority of adults with T1D and T2D use apps to support their self-management. App use among adults with T1D is associated with a more recent T1D diagnosis, more frequent glucose monitoring, and lower self-reported HbA1c. Future efforts should focus on this association and determine the mechanisms by which app use is related to better clinical outcomes.

Validation of the WHO-5 as a first-step screening instrument for depression in adults with diabetes: Results from Diabetes MILES - Australia

AIMS

Screening for depression is recommended internationally. The World Health Organization's 5-item Well-being Index (WHO-5) is used clinically to screen for depression but its empirical suitability for this purpose is not well documented. We investigated the psychometric properties of the WHO-5 and its suitability for identifying likely depression in Australian adults with diabetes.

METHODS

The Diabetes MILES - Australia study dataset provided a sample of N=3249 who completed the WHO-5 (positively-worded 5-item measure of emotional well-being) and the PHQ-9 (9-item measure of depressive symptoms). Analyses were conducted for the full sample, and separately by diabetes type and treatment (type 1, non-insulin-treated type 2, and insulin-treated type 2 diabetes). Construct (convergent and factorial) validity and reliability of the WHO-5 were examined. ROC analyses were used to examine the sensitivity and specificity of the WHO-5 as a depression screening instrument, comparing two commonly used WHO-5 cut-off values (≤7 and <13) with the PHQ-9.

RESULTS

For the whole sample, the WHO-5 demonstrated satisfactory internal consistency reliability (α=0.90) and convergent validity with the PHQ-9 (r=-0.73, p<0.001). Confirmatory factor analysis partially supported factorial validity: Χ²(5)=834.94, p<0.001; RMSEA=0.23, 90% CI 0.21-0.24; CFI=0.98, TLI=0.96; factor loadings=0.78-0.92. The AUC was 0.87 (95% CI: 0.86-0.89, p<0.001). The sensitivity/specificity of the WHO-5 for detecting likely depression was 0.44/0.96 for the ≤7 cut-off, and 0.79/0.79 for the <13 cut-off, with similar findings by diabetes type and treatment.

CONCLUSIONS

These findings support use of a WHO-5 cut-point of <13 to identify likely depression in Australian adults with diabetes, regardless of type/treatment.

The Prevalence and Awareness of Cardiovascular Diseases Risk Factors among the Lebanese Population: A Prospective Study Comparing Urban to Rural Populations

Introduction. CVDs are largely driven by modifiable risk factors. This study sought to determine the awareness and prevalence of the modifiable CVDs risk factors among the Lebanese population. Methods. In a cross-sectional survey, 1000 participants aged ≥ 45 years were randomly selected from pharmacies and interviewed. The data was analyzed with SPSS version 21.0 software. Results. Differences between urban and rural areas include alcohol consumption (2.8% versus 1.7%; p = 0.0001), cardioprotective vegetable servings (6.1% versus 2.3%; p = 0.016), sedentary hours per day (18.6% versus 15.1%; p = 0.002), and hypertension (38.5% versus 25.4%; p = 0.001). The prevalence of overweight and obesity (77.3% versus 75.2%; p = 0.468), smoking (39.3% versus 43.3%; p = 0.232), diabetes (25.4% versus 21.4%; p = 0.173), and dyslipidemia (25 versus 21.2%) was reported. Measurements revealed 19.3% of undiagnosed hypertension (12.4% versus 22.4%, p = 0.001), 61.7% of hypertension (59.8% versus 62.6%; p = 0.203), and 7.9% of undiagnosed diabetes (6.6% versus 8.6%; p = 0.323). The declared awareness of CVDs risk factors was highest for smoking (91.5% versus 89.7%; p = 0.339) and lowest for diabetes (54.4 versus 55.7%; p = 0.692). Conclusion. This study has shown a high prevalence of modifiable CVDs risk factors in the Lebanese population ≥ 45 years, among which hypertension is the most prominent.

Severe hypoglycemia, impaired awareness of hypoglycemia, and self-monitoring in adults with type 1 diabetes: Results from Diabetes MILES-Australia

AIMS

To assess prevalence of severe hypoglycemia, awareness and symptoms of hypoglycemia, and their associations with self-monitoring of blood glucose.

METHODS

Diabetes MILES-Australia Study participants completed validated questionnaires and study-specific items.

RESULTS

Of 642 adults with type 1 diabetes, 21% reported ≥1 severe hypoglycemic event in the past six months, and 21% reported impaired awareness of hypoglycemia (IAH). Severe hypoglycemia was increased four-fold for those with IAH compared with intact awareness (1.4±3.9 versus 0.3±1.0). Of those with IAH, 92% perceived autonomic and 88% neuroglycopenic symptoms, albeit at lower glucose thresholds compared to people with intact awareness. Those with IAH were more likely to perceive both symptom types at the same glucose level or to perceive neuroglycopenic symptoms first (all p<0.001). Eighteen percent with IAH treated hypoglycemia only when they perceived symptoms and another 18% only when their capillary glucose was <3.0mmol/L.

CONCLUSIONS

One in five adults with type 1 diabetes had IAH or experienced severe hypoglycemia in the past sixmonths. Total loss of hypoglycemia symptoms was rare; most people with IAH retained autonomic symptoms, perceived at relatively low glucose levels. Frequent self-monitoring of blood glucose prompted early recognition and treatment of hypoglycemia, suggesting severe hypoglycemia risk can be minimized.

Cohort profiles of the cross-sectional and prospective participant groups in the second Diabetes MILES-Australia (MILES-2) study

PURPOSE

More research into the psychosocial aspects of diabetes is needed so that the health and quality of life of people with the condition can be improved. To fill this gap, we conducted the second Diabetes MILES-Australia study (MILES-2), a survey focused on psychological, behavioural and social aspects of diabetes. The aim of the MILES-2 study was to provide a (1) longitudinal follow-up of the original MILES 2011 study cohort; (2) cross-sectional assessment of a new cohort.

PARTICIPANTS

Eligible participants were English-speaking Australians with type 1 or type 2 diabetes, aged 18-75 years. Longitudinal cohort participants were mailed/emailed study invitations directly by researchers. Random sampling (stratified by diabetes type, insulin use, state) of the National Diabetes Services Scheme (NDSS) database and nationwide advertisements were used to recruit new cohort participants. The final sample included N=2342 eligible respondents (longitudinal cohort: n=504; 2015 new cohort: n=1838); 54% had type 2 diabetes.

FINDINGS TO DATE

Survey respondents were from an advantaged socioeconomic background compared to the general population. Respondents with type 1 diabetes were over-represented in the new cohort (45%) relative to the planned stratification (40% type 1 diabetes, 60% type 2 diabetes). Respondents with insulin-treated type 2 diabetes were under-represented in the new cohort relative to the stratified sampling (42% invited vs 50% response). Participants who completed both the 2011 and 2015 surveys were more likely than those completing the 2011 survey only to have type 1 diabetes, report a higher education and annual income, and live in metropolitan areas. Participant feedback indicated that the survey was perceived as relevant and valuable.

FUTURE PLANS

The depth and breadth of the data available in this large sample will highlight unmet needs and priority areas for future investigation and, crucially, will inform policy, programme and intervention development and evaluation in Australia.

Suicidal ideation reported by adults with Type 1 or Type 2 diabetes: results from Diabetes MILES-Australia

AIMS

To examine the prevalence and correlates of suicidal ideation (SI) in a community-based sample of adults with Type 1 or Type 2 diabetes.

METHODS

Participants were 3338 adults aged 18-70 years with Type 1 diabetes (n = 1376) or Type 2 diabetes (non-insulin: n = 1238; insulin: n = 724) from a national survey administered to a random sample registered with the National Diabetes Services Scheme. Depression and SI were assessed using the Patient Health Questionnaire, and diabetes-specific distress with the Problem Areas In Diabetes scale. Separate logistic regression analyses by diabetes type/treatment were used to determine relative contribution to SI.

RESULTS

Overall, we observed a SI rate of 14% in our sample. Participants with Type 2 diabetes using insulin reported more frequent depressive symptoms, and were more likely to report recent SI (19%) compared with those with either Type 1 diabetes or Type 2 diabetes not using insulin (14 and 12%, respectively). After controlling for depression, there was little difference in the prevalence of SI between diabetes types/treatments, but higher diabetes-specific distress significantly increased the odds of SI.

CONCLUSIONS

As SI is a significant risk factor for a suicide attempt, the findings have implications for healthcare professionals, pointing to the importance of adequate screening and action plans for appropriate follow-up of those reporting depression. Our findings are also indicative of the psychological toll of diabetes more generally, and the need to integrate physical and mental healthcare for people with diabetes.

Diabetes MILES Youth-Australia: methods and sample characteristics of a national survey of the psychological aspects of living with type 1 diabetes in Australian youth and their parents

Background

Type 1 diabetes is a complex and demanding condition, which places a substantial behavioural and psychological burden on young people and their families. Around one-third of adolescents with type 1 diabetes need mental health support. Parents of a child with type 1 diabetes are also at increased risk of psychological distress. A better understanding of the motivators, behaviours and psychological well-being of young people with diabetes and their parents will inform improvement of resources for supporting self-management and reducing the burden of diabetes. The Diabetes MILES (Management and Impact for Long-term Empowerment and Success) Youth–Australia Study is the first large-scale, national survey of the impact of diabetes on the psychosocial outcomes of Australian adolescents with type 1 diabetes and their parents.

Methods/design

The survey was web-based to enable a large-scale, national survey to be undertaken. Recruitment involved multiple strategies: postal invitations; articles in consumer magazines; advertising in diabetes clinics; social media (e.g. Facebook, Twitter). Recruitment began in August 2014 and the survey was available online for approximately 8 weeks. A total of 781 young people (aged 10–19 years) with type 1 diabetes and 826 parents completed the survey. Both genders, all ages within the relevant range, and all Australian states and territories were represented, although compared to the general Australian population of youth with type 1 diabetes, respondents were from a relatively advantaged socioeconomic background.

Discussion

The online survey format was a successful and economical approach for engaging young people with type 1 diabetes and their parents. This rich quantitative and qualitative dataset focuses not only on diabetes management and healthcare access but also on important psychosocial factors (e.g. social support, general emotional well-being, and diabetes distress). Analysis of the Diabetes MILES Youth–Australia Study data is ongoing, and will provide further insights into the psychosocial problems facing young people with type 1 diabetes and their parents. These will inform future research and support services to meet the needs of young Australians with type 1 diabetes and their families.

Electronic supplementary material

The online version of this article (doi:10.1186/s40359-016-0149-9) contains supplementary material, which is available to authorized users.

What is the best measure for assessing diabetes distress? A comparison of the Problem Areas in Diabetes and Diabetes Distress Scale: results from Diabetes MILES–Australia

This study used Rasch analysis to examine the psychometric validity of the Diabetes Distress Scale and the Problem Areas in Diabetes scale to assess diabetes distress in 3338 adults with diabetes (1609 completed the Problem Areas in Diabetes scale ( n = 675 type 1 diabetes; n = 934 type 2 diabetes) and 1705 completed the Diabetes Distress Scale ( n = 693 type 1 diabetes; n = 1012 type 2 diabetes)). While criterion and convergent validity were good, Rasch analysis revealed suboptimal precision and targeting, and item misfit. Unresolvable multidimensionality within the Diabetes Distress Scale suggests a total score should be avoided, while suboptimal precision suggests that the Physician-related and Interpersonal distress subscales should be used cautiously.

Explaining psychological insulin resistance in adults with non-insulin-treated type 2 diabetes: The roles of diabetes distress and current medication concerns. Results from Diabetes MILES--Australia

AIMS

To investigate the contribution of general and diabetes-specific emotional wellbeing and beliefs about medicines in the prediction of insulin therapy appraisals in adults with non-insulin-treated type 2 diabetes.

METHODS

The sample included Diabetes MILES-Australia cross-sectional survey participants whose primary diabetes treatment was oral hypoglycaemic agents (N=313; 49% women; mean±SD age: 57±9 years; diabetes duration: 7±6 years). They completed validated measures of beliefs about the 'harm' and 'overuse' of medications in general (BMQ General); 'concerns' about and 'necessity' of current diabetes medications (BMQ Specific); negative insulin therapy appraisals (ITAS); depression (PHQ-9); anxiety (GAD-7), and diabetes distress (DDS-17). Factors associated with ITAS Negative scores were examined using hierarchical multiple regressions.

RESULTS

Twenty-two percent of the variance in ITAS Negative scores (52±10), was explained by: number of complications (β=-.15, p=.005), DDS-17 subscale 'emotional burden' (β=.23, p<.001), and 'concerns' about current diabetes treatment (β=.29, p<.001). General beliefs about medications and general emotional wellbeing did not contribute significantly to the model.

CONCLUSIONS

Psychological insulin resistance may reflect broader distress about diabetes and concerns about its treatment but not general beliefs about medicines, depression or anxiety. Reducing diabetes distress and current treatment concerns may improve attitudes towards insulin as a potential therapeutic option.

Utilisation of general practitioner services and achievement of guideline targets by people with diabetes who joined a peer-support program in Victoria, Australia

This paper describes the use of general practitioner (GP) services and achievement of guideline targets by 285 adults with type 2 diabetes in urban and regional areas of Victoria, Australia. Anthropometric and biomedical measures and responses to a self-administered questionnaire were collected. Findings indicate that almost all participants had visited a GP and had had their hypoglycated haemoglobin (HbA1c) measured in the past 6 months; less than one-third had visited a practice nurse. Fifty per cent achieved a HbA1c target of 7.0%; 40%, a total cholesterol ≤ 4.00 mmol/L; 39%, BP Systolic ≤ 130 mmHg; 51%, BP Diastolic ≤ 80 mmHg; 15%, body mass index ≤ 25 kg/m2; and 34% reported a moderately intense level of physical activity, that is, ≥ 30 min, 5 days a week. However, 39% of individuals achieved at least two targets and 18% achieved at least three of these guideline targets. Regional participants were more likely to report having a management plan and having visited a practice nurse, but they were less likely to have visited other health professionals. Therefore, a more sustained effort that also includes collaborative care approaches is required to improve the management of diabetes in Australia.

Negative appraisals of insulin therapy are common among adults with Type 2 diabetes using insulin: Results from Diabetes MILES - Australia cross-sectional survey

AIM

To identify insulin therapy appraisals among adults with Type 2 diabetes using insulin and how negative appraisals relate to clinical, self-care and psychosocial outcomes.

METHODS

Diabetes MILES - Australia 2011 was a national survey of adults with diabetes, focused on behavioural and psychosocial issues. Subgroup analyses were conducted on the responses of 273 adults with Type 2 diabetes using insulin (46% women; mean ± sd age: 59 ± 9 years; diabetes duration: 12 ± 7 years; years using insulin: 4 ± 4). They completed validated measures of insulin therapy appraisals (ITAS), depression (PHQ-9), anxiety (GAD-7), diabetes distress (PAID) and diabetes-specific self-efficacy (DES-SF).

RESULTS

Insulin was perceived to be very important, and its benefits (e.g. improves health) were endorsed by most (82%). Fifty-one per cent believed that taking insulin means their diabetes has become worse; 51% that insulin causes weight gain; 39% that they have 'failed to manage' their diabetes. Those with the greatest and least 'ITAS negative' scores did not differ by diabetes duration or years using insulin, or by average number of insulin injections or blood glucose checks per day. Those with more negative insulin appraisals were significantly younger (Mean Diff. = 5 years, P < 0.001), less satisfied with recent blood glucose levels (P < 0.001, d = 0.63), had reduced diabetes-specific self-efficacy (P < 0.001, d = 0.7), and were more likely to report depressive symptoms, anxiety or diabetes distress (all P < 0.001, d = 0.65-1.1).

CONCLUSIONS

Negative insulin therapy appraisals are common among adults with Type 2 diabetes using insulin, and are associated with lower general and diabetes-specific emotional well-being, reduced diabetes-specific self-efficacy and satisfaction with blood glucose.

Subjective sleep impairment in adults with type 1 or type 2 diabetes: Results from Diabetes MILES--The Netherlands

AIMS

Despite growing recognition of the impact of sleep on diabetes, a clear profile of people with diabetes regarding subjective sleep impairment has yet to be established. This study examines: (1) subjective sleep characteristics in adults with type 1 and type 2 diabetes; (2) the relationship of poor subjective sleep quality with glycaemic control, self-care and daytime functioning; (3) possible risk markers for poor sleep quality.

METHODS

In a cross-sectional study, Dutch adults with type 1 (n=267) or type 2 diabetes (n=361) completed an online survey, including the Pittsburgh Sleep Quality Index (PSQI), socio-demographic, clinical, self-care and psychological measures.

RESULTS

Poor sleep quality (PSQI-score >5) was reported by 31% of adults with type 1 and 42% of adults with type 2 diabetes. Participants with good and poor sleep quality did not differ in self-reported HbA1c or the frequency of meeting lifestyle recommendations. Poor sleep quality was related to a higher self-care burden and higher levels of daytime sleepiness, fatigue, depressive and anxiety symptoms, and diabetes-specific distress. In multivariable logistic regression analyses examining risk markers, poor sleep quality was associated with depressive symptoms in adults with type 1 (OR=1.39, 95% CI 1.25-1.54) and type 2 diabetes (OR=1.31, 1.16-1.47), and with being female in those with type 2 diabetes (OR=2.72, 1.42-5.20).

CONCLUSIONS

Poor subjective sleep quality is prevalent both in adults with type 1 and type 2 diabetes, and is related to poor daytime functioning and higher self-care burden. The temporal relation with depression and merits of therapy should be explored.

Type D personality, suboptimal health behaviors and emotional distress in adults with diabetes: results from Diabetes MILES-The Netherlands

AIMS

Type D personality - defined as high negative affectivity (NA) and high social inhibition (SI) - has been associated with adverse cardiovascular prognosis. We explored the differential associations of Type D personality and its constituent components with health behaviors, emotional distress and standard biomedical risk factors as potential risk mechanisms in adults with diabetes.

METHODS

3314 Dutch adults with self-reported type 1 or 2 diabetes completed an online survey, including the DS14 Type D Scale. AN(C)OVAs and X(2) tests were used to compare participants scoring (i) low on NA and SI; (ii) high on SI only; (iii) high on NA only; (iv) high on NA and SI (Type D).

RESULTS

Participants with Type D personality (29%) were less likely to follow a healthy diet or to consult healthcare professionals in case of problems with diabetes management than those scoring high on neither or only one component. They also reported more barriers surrounding medication use, diabetes-specific social anxiety, loneliness and symptoms of depression and anxiety. There were no differences in standard biomedical risk factors (body mass index, blood pressure, cholesterol, HbA1c). After adjustment for demographics, clinical characteristics, NA, and SI in multivariable logistic regression analyses, Type D personality was independently associated with 2 to 3-fold increased odds of suboptimal health behaviors and over 15-fold increased odds of general emotional distress.

CONCLUSIONS

Type D personality was not related to standard biomedical risk factors, but was associated with unhealthy behaviors and negative emotions that are likely to have adverse impact on adults with diabetes.

Diabetes distress: understanding the hidden struggles of living with diabetes and exploring intervention strategies

Diabetes distress is a rational emotional response to the threat of a life-changing illness. Distinct from depression, it is conceptually rooted in the demands of diabetes management and is a product of emotional adjustment. Diabetes distress has been found to be significantly associated with glycated haemoglobin (HbA1c) level and the likelihood of an individual adopting self-care behaviours. The lack of perceived support from family, friends and healthcare professionals significantly contributes to elevated diabetes distress, and this issue tends to be overlooked when designing interventions. Pioneering large-scale research, DAWN2, gives voices to the families of those with diabetes and reaffirms the need to consider psychosocial factors in routine diabetes care. Structured diabetes education programmes are the most widely used in helping individuals cope with diabetes, but they tend not to include the psychological or interpersonal aspects of diabetes management in their curricula. The need for health practitioners, irrespective of background, to demonstrate an understanding of diabetes distress and to actively engage in discussion with individuals struggling to cope with diabetes is emphasised.

If it does not significantly change HbA1c levels why should we waste time on it? A plea for the prioritization of psychological well-being in people with diabetes

Despite improvements in pharmacological treatments and methods of care and care delivery, the burden of living with diabetes remains an ongoing challenge, as many people with diabetes are at increased risk of mental health disorders, psychological disturbances and functional problems associated with living with diabetes. Person-centred collaborative care that also meets the psychological needs of the individual is not available to many people with diabetes. The present article examines the role of psychological factors in the onset of diabetes and in relation to living with diabetes. It is argued that the pursuit of psychological well-being is worthy of individual attention in the care of people with diabetes and should not be contingent upon attainment of somatic indices of health. The barriers to attaining this goal are examined, including the costs of treating (or not treating) psychological problems in people with diabetes. Recommendations on how to improve diabetes care are offered, including psychological interventions that are both evidence-based and cost-effective.

Depression, anxiety and self-care behaviours of young adults with Type 2 diabetes: results from the International Diabetes Management and Impact for Long-term Empowerment and Success (MILES) Study

AIM

Young adults with Type 2 diabetes have higher physical morbidity and mortality than other diabetes sub-groups, but differences in psychosocial outcomes have not yet been investigated. We sought to compare depression and anxiety symptoms and self-care behaviours of young adults with Type 2 diabetes with two matched control groups.

METHODS

Using cross-sectional survey data from the Australian and Dutch Diabetes Management and Impact for Long-term Empowerment and Success (MILES) studies, we matched 93 young adults (aged 18-39 years) with Type 2 diabetes (case group) with: (i) 93 older adults ( ≥ 40 years) with Type 2 diabetes (Type 2 diabetes control group; matched on country, gender, education, diabetes duration and insulin use) and (ii) 93 young adults with Type 1 diabetes (Type 1 diabetes control group; matched on country, gender, age and education). Groups were compared with regard to depression symptoms (nine-item Patient Health Questionnaire), anxiety symptoms (seven-item Generalised Anxiety Disorder questionnaire) and frequency of selected self-care behaviours (single item per behaviour).

RESULTS

Participants in the case group had higher depression scores (Cohen's d = 0.40) and were more likely to have clinically meaningful depressive symptoms (Cramer's V = 0.23) than those in the Type 2 diabetes control group. Participants in the case group had statistically equivalent depression scores to the Type 1 diabetes control group. The groups did not differ in anxiety scores. Those in the case group were less likely than both control groups to take insulin as recommended (Cramer's V = 0.24-0.34), but there were no significant differences between the groups in oral medication-taking. The case group were less likely than the Type 2 diabetes control group to eat healthily (Cramer's V = 0.16), and less likely than the Type 1 diabetes control group to be physically active (Cramer's V = 0.15).

CONCLUSIONS

Our results suggest that Type 2 diabetes is as challenging as Type 1 diabetes for young adults and more so than for older adults. Young adults with Type 2 diabetes may require more intensive psychological and self-care support than their older counterparts.

Gender differences in autoimmune disease

Autoimmune diseases are a range of diseases in which the immune response to self-antigens results in damage or dysfunction of tissues. Autoimmune diseases can be systemic or can affect specific organs or body systems. For most autoimmune diseases there is a clear sex difference in prevalence, whereby females are generally more frequently affected than males. In this review, we consider gender differences in systemic and organ-specific autoimmune diseases, and we summarize human data that outlines the prevalence of common autoimmune diseases specific to adult males and females in countries commonly surveyed. We discuss possible mechanisms for sex specific differences including gender differences in immune response and organ vulnerability, reproductive capacity including pregnancy, sex hormones, genetic predisposition, parental inheritance, and epigenetics. Evidence demonstrates that gender has a significant influence on the development of autoimmune disease. Thus, considerations of gender should be at the forefront of all studies that attempt to define mechanisms that underpin autoimmune disease.

'I'm not a druggie, I'm just a diabetic': a qualitative study of stigma from the perspective of adults with type 1 diabetes

OBJECTIVES

While health-related stigma has been the subject of considerable research in other conditions (eg, HIV/AIDS, obesity), it has not received substantial attention in diabetes. Our aim was to explore perceptions and experiences of diabetes-related stigma from the perspective of adults with type 1 diabetes mellitus (T1DM).

DESIGN

A qualitative study using semistructured interviews, which were audio recorded, transcribed and subject to thematic analysis.

SETTING

All interviews were conducted in non-clinical settings in metropolitan areas of Victoria, Australia.

PARTICIPANTS

Adults aged ≥18 years with T1DM living in Victoria were eligible to take part. Participants were recruited primarily through the state consumer organisation representing people with diabetes. A total of 27 adults with T1DM took part: 15 (56%) were women; median IQR age was 42 (23) years and diabetes duration was 15 (20) years).

RESULTS

Australian adults with T1DM perceive and experience T1DM-specific stigma as well as stigma-by-association with type 2 diabetes. Such stigma is characterised by blame, negative social judgement, stereotyping, exclusion, rejection and discrimination. Participants identified the media, family and friends, healthcare professionals and school teachers as sources of stigma. The negative consequences of this stigma span numerous life domains, including impact on relationships and social identity, emotional well-being and behavioural management of T1DM. This stigma also led to reluctance to disclose the condition in various environments. Adults with T1DM can be both the target and the source of diabetes-related stigma.

CONCLUSIONS

Stigmatisation is part of the social experience of living with T1DM for Australian adults. Strategies and interventions to address and mitigate this diabetes-related stigma need to be developed and evaluated.

Further investigation of the psychometric properties of the Insulin Treatment Appraisal Scale among insulin-using and non-insulin-using adults with type 2 diabetes: results from Diabetes MILES-Australia

Background

Negative attitudes towards insulin are commonly reported by people with type 2 diabetes mellitus (T2DM) and can act as a barrier to timely insulin initiation. The Insulin Treatment Appraisal Scale (ITAS) is a widely used 20-item measure of attitudes towards insulin. While designed for completion by both insulin using and non-insulin using adults with T2DM, its psychometric properties have not been investigated separately for these groups. Furthermore, the total score is routinely reported in preference to the published two-factor structure (negative/positive appraisals). Further psychometric validation of the ITAS is required to examine its properties.

Methods

The ITAS was completed by a subgroup of 748 Diabetes MILES – Australia study participants with T2DM, who were either insulin using (n = 249; 45% women; mean age = 58 ± 9 years; mean diabetes duration = 13, SD = 8 years) or non-insulin using (n = 499; 47% women; mean age 57 ± 9 years; mean diabetes duration 7 ± 6 years). We replicated the psychometric analyses reported in the ITAS development paper. In addition, we explored factor structure and investigated internal consistency separately for the insulin using and non-insulin using samples.

Results

Factor analyses supported a two-factor structure with good internal consistency (negative subscale α = .90; positive subscale α = .69). Scale performance differed slightly in the insulin using and non-insulin using samples, with some items loading inconsistently between groups. A one-factor solution was not supported in either sample, with the positive items and some negative items failing to load adequately. Consistent with prior research, negative appraisals were significantly more common among non-insulin using participants compared to those using insulin (d = 1.04), while the positive subscale score did not discriminate between groups.

Conclusions

The data supported a two factor structure and the positive subscale did not discriminate between insulin using and non-insulin using participants. As such, we recommend use of the negative subscale score in preference to the ITAS total score, and suggest close attention is paid to the relevance of the positive items in the given population.

Severe obesity and diabetes self-care attitudes, behaviours and burden: implications for weight management from a matched case-controlled study. Results from Diabetes MILES--Australia

AIMS

To investigate whether diabetes self-care attitudes, behaviours and perceived burden, particularly related to weight management, diet and physical activity, differ between adults with Type 2 diabetes who are severely obese and matched non-severely obese control subjects.

METHODS

The 1795 respondents to the Diabetes MILES--Australia national survey had Type 2 diabetes and reported height and weight data, enabling BMI calculation: 530 (30%) were severely obese (BMI ≥ 35 kg/m(2); median BMI = 41.6 kg/m(2)) and these were matched with 530 control subjects (BMI < 35 kg/m(2); median BMI = 28.2 kg/m(2)). Diabetes self-care behaviours, attitudes and burden were measured with the Diabetes Self-Care Inventory-Revised. Within-group and between-group trends were examined.

RESULTS

The group with BMI ≥ 35 kg/m(2) was less likely to achieve healthy diet and exercise targets, placed less importance on diet and exercise recommendations, and found the burden of diet and exercise recommendations to be greater than the group with BMI < 35 kg/m(2). The group with BMI ≥ 35 kg/m(2) was more likely to be actively trying to lose weight, but found weight control a greater burden. These issues accentuated with increasing obesity and were greatest in those with BMI > 45 kg/m(2). There were no between-group differences in other aspects of diabetes self-care: self-monitoring of blood glucose, use of medications and smoking. Moderate-to-severe symptoms of depression were independently associated with reduced likelihood of healthy diet and physical activity, and with greater burden associated with diet, physical activity and weight management.

CONCLUSIONS

Severely obese people with diabetes demonstrated self-care attitudes, behaviours and burdens that infer barriers to weight loss. However, other important diabetes self-care behaviours are supported equally by severely obese and non-severely obese individuals.

'I call it the blame and shame disease': a qualitative study about perceptions of social stigma surrounding type 2 diabetes

OBJECTIVES

While health-related stigma has been the subject of considerable research in other conditions (obesity and HIV/AIDS), it has not received substantial attention in diabetes. The aim of the current study was to explore the social experiences of Australian adults living with type 2 diabetes mellitus (T2DM), with a particular focus on the perception and experience of diabetes-related stigma.

DESIGN

A qualitative study using semistructured interviews, which were audio recorded, transcribed and subject to thematic analysis.

SETTING

This study was conducted in non-clinical settings in metropolitan and regional areas in the Australian state of Victoria. Participants were recruited primarily through the state consumer organisation representing people with diabetes.

PARTICIPANTS

All adults aged ≥18 years with T2DM living in Victoria were eligible to take part. Twenty-five adults with T2DM participated (12 women; median age 61 years; median diabetes duration 5 years).

RESULTS

A total of 21 (84%) participants indicated that they believed T2DM was stigmatised, or reported evidence of stigmatisation. Specific themes about the experience of stigma were feeling blamed by others for causing their own condition, being subject to negative stereotyping, being discriminated against or having restricted opportunities in life. Other themes focused on sources of stigma, which included the media, healthcare professionals, friends, family and colleagues. Themes relating to the consequences of this stigma were also evident, including participants' unwillingness to disclose their condition to others and psychological distress. Participants believed that people with type 1 diabetes do not experience similar stigmatisation.

CONCLUSIONS

Our study found evidence of people with T2DM experiencing and perceiving diabetes-related social stigma. Further research is needed to explore ways to measure and minimise diabetes-related stigma at the individual and societal levels, and also to explore perceptions and experiences of stigma in people with type 1 diabetes.

Severely obese people with diabetes experience impaired emotional well-being associated with socioeconomic disadvantage: results from diabetes MILES - Australia

AIM

To examine the emotional well-being of severely obese Australians with type 2 diabetes, along with markers of social and economic disadvantage, using the Diabetes MILES - Australia dataset.

METHODS

Diabetes MILES - Australia was a national survey of 3338 adults with diabetes that focused on psychosocial issues; 1795 had type 2 diabetes and reported BMI. We extracted data regarding depression (PHQ-9), anxiety (GAD-7), obesity- and diabetes-related comorbidities, and demographics. The severely obese group (SOG) (BMI ≥ 35; median BMI=41.6) constituted 530 (30%) of the type 2 diabetes respondents and was matched with 530 controls (CG) (BMI<35; median BMI=28.2). Within- and between-group trends were examined.

RESULTS

The SOG had higher depression scores (median (IQR) 6.0 (3-12)) than CG (5.0 (2-10)); p<0.001, and were more likely to report moderate-severe depressive symptoms (37% versus 27%; p<0.001). The groups did not differ on anxiety. The SOG, compared with the CG, were more likely to live alone (21% versus 17%), receive a disability pension (21% versus 15%), earn ≤$40.000/year (51% versus 41%; all p<0.05), and were less likely to be employed (46% versus 53%), university or higher educated (17% versus 26%), or have health insurance (50% versus 60%; all p ≤ 0.01). Moderate-severe depression was positively associated with cumulative stressors of severe obesity, socioeconomic disadvantage, and obesity- and diabetes-related comorbidity.

CONCLUSIONS

Severely obese people living with type 2 diabetes have cumulative stressors related to health, disability, demographic and socioeconomic factors, and impaired emotional well-being.

Differentiating disordered affect in children and adolescents with type 1 diabetes

BACKGROUND

There is evidence for increased risk of affective disorders (AD) in adults with type 1 diabetes however, the prevalence and characteristics of AD in young people with the condition is unclear. Comorbid AD in type 1 diabetes is associated with deleterious self-management, sub-optimal clinical indicators, reduced quality of life, poorer physical health, increased complications, increased high risk behaviours in adolescence and young adulthood, and earlier mortality. The present study investigated the prevalence and character of AD in young people with type 1 diabetes.

METHODS

The self-report PH-PANAS-C was employed in a cross-sectional, case-control design to identify and differentiate full-syndrome (FS) and subthreshold (St) levels of AD in 53 participants with type 1 diabetes (case) and 54 age-balanced controls (N=107; 7-18 yrs).

RESULTS

Case participants reported greater AD than controls. When differentiated, only anxiety was significantly more prevalent. Case participants reported less positive affect, and greater negative affect and autonomic arousal. Further, 1:3 case participants presented with St symptoms of AD.

LIMITATIONS

Self-report measures are known to produce moderated responses therefore symptoms may be more severe than reported. There has been some suggestion that responses to somatic items in the PH-PANAS-C may relate to diabetes-specific states rather than affect-related symptoms however, recent evidence has refuted this argument.

CONCLUSIONS

AD, particularly anxiety, represents a significant clinical concern in young people with type 1 diabetes both as a disorder in its own right and as a major impediment to primary care and management of the diabetes. The significant dominance of anxiety-related symptoms and prevalence of subthreshold presentation warrant further investigation.

Does the shortage of diabetes specialists in regional and rural Australia matter? Results from Diabetes MILES--Australia

AIM

To investigate differences in access to services and health outcomes between people living with Type 1 (T1DM) and Type 2 (T2DM) diabetes in rural/regional and metropolitan areas.

METHODS

Diabetes MILES--Australia was a national postal/online survey of persons registered with the National Diabetes Services Scheme. Selected variables, including utilisation of health care services and self-care indicators, were analysed for 3338 respondents with T1DM (41%) or T2DM (59%).

RESULTS

Respondents from rural/regional (n=1574, 48%) and metropolitan areas were represented equally (n=1700, 52%). After adjusting for diabetes duration, demographic and socioeconomic variables, rural/regional respondents with T1DM (RR 0.90, 95% CI 0.83-0.97) and T2DM (RR 0.69, 95% CI 0.59-0.81) were less likely to report consulting an endocrinologist during the past 12 months. Rural/regional respondents with T1DM were more than twice as likely to have accessed a community/practice nurse for diabetes care (RR 2.22, 95% CI 1.25-3.93) while those with T2DM were more likely to have accessed a diabetes educator (RR 1.21, 95% CI 1.07-1.36) or dietician (RR 1.17, 95% CI 1.07-1.36). For the T1DM and T2DM groups were no differences between rural/regional and metropolitan respondents in self-reported hypoglycaemic events during past week and the majority of self-care indicators.

CONCLUSIONS

Despite a lack of access to medical specialists, respondents with T1DM and T2DM living in rural/regional areas did not report worse health or self-care indicators. The results suggest that multidisciplinary primary services in rural areas may be providing additional care for people with diabetes, compensating for poor access to specialists.

The needs, concerns, and characteristics of younger Australian adults with Type 2 diabetes

AIMS

The mean age of onset of Type 2 diabetes mellitus is decreasing in Australia and internationally. We conducted an internet-based survey to improve our understanding of the emotional well-being and unmet needs of younger adults with Type 2 diabetes, and to inform service provision for this group.

METHODS

A random sample of National Diabetes Services Scheme registrants (n = 1,417) with Type 2 diabetes, aged 18-39 years, living in the Australian state of Victoria received an invitation to complete the online survey. The study was also advertised state-wide. The survey included validated scales (PAID-5: diabetes-related distress; WHO-5: general emotional well-being) and study-specific items. A total of 149 eligible respondents participated.

RESULTS

Almost two-thirds (63%) of respondents reported severe-diabetes related distress; more than a quarter (27%) had impaired general emotional well-being. Most (82%) were overweight or obese (BMI ≥ 25); most (77%) had at least one other co-morbidity. Lack of motivation, feeling burned out, and being time-poor were identified as top barriers to self-management. More than half (59%) of respondents had not participated in structured diabetes education. Respondents perceived that younger adults with Type 2 diabetes had different health-care needs than their older counterparts (68%), and that most Type 2 diabetes information/services were aimed at older adults (62%). Of a range of potential new services, respondents indicated greatest interest in an online forum specifically for younger adults with Type 2 diabetes.

CONCLUSIONS

Younger adults with Type 2 diabetes have impaired emotional well-being and physical health. Population-based research is needed to confirm the current findings, to further inform service delivery and optimise outcomes for this group.

Diabetes MILES--The Netherlands: rationale, design and sample characteristics of a national survey examining the psychosocial aspects of living with diabetes in Dutch adults

BACKGROUND

As the number of people with diabetes is increasing rapidly worldwide, a more thorough understanding of the psychosocial aspects of living with this condition has become an important health care priority. While our knowledge has grown substantially over the past two decades with respect to the physical, emotional and social difficulties that people with diabetes may encounter, many important issues remain to be elucidated. Under the umbrella of the Diabetes MILES (Management and Impact for Long-term Empowerment and Success) Study International Collaborative, Diabetes MILES--The Netherlands aims to examine how Dutch adults with diabetes manage their condition and how it affects their lives. Topics of special interest in Diabetes MILES--The Netherlands include subtypes of depression, Type D personality, mindfulness, sleep and sexual functioning.

METHODS/DESIGN

Diabetes MILES--The Netherlands was designed as a national online observational study among adults with diabetes. In addition to a main set of self-report measures, the survey consisted of five complementary modules to which participants were allocated randomly. From September to October 2011, a total of 3,960 individuals with diabetes (40% type 1, 53% type 2) completed the battery of questionnaires covering a broad range of topics, including general health, self-management, emotional well-being and contact with health care providers. People with self-reported type 1 diabetes (specifically those on insulin pump therapy) were over-represented, as were those using insulin among respondents with self-reported type 2 diabetes. People from ethnic minorities were under-represented. The sex distribution was fairly equal in the total sample, participants spanned a broad age range (19-90 years), and diabetes duration ranged from recent diagnosis to living with the condition for over fifty years.

DISCUSSION

The Diabetes MILES Study enables detailed investigation of the psychosocial aspects of living with diabetes and an opportunity to put these findings in an international context. With several papers planned resulting from a pooled Australian-Dutch dataset and data collections planned in other countries, the Diabetes MILES Study International Collaborative will contribute substantially to identifying potentially unmet needs of those living with diabetes and to inform clinical research and care across the globe.