Stigma in People With Type 1 or Type 2 Diabetes

Perceptions and knowledge of diabetes in poor urban communities in Accra, Ghana

Diabetes is a major public health concern, leading to costly and life-threating complications while significantly impacting quality of life. However, limited evidence exists on how diabetes is understood in poor urban communities in Africa, including Ghana. Evidence suggests that community beliefs about disease can shape health outcomes and influence intervention strategies. This cross-sectional qualitative study assessed perceptions and knowledge of diabetes in two poor urban communities in Accra, Ghana. Thirteen focus group discussions were conducted, involving ninety-four participants segmented by sex, age, and diabetes status. Participants frequently cited unhealthy diets, alcohol consumption, and smoking as primary causes of diabetes. Knowledge of prevention was primarily focused on maintaining a healthy diet and engaging in physical activity. Managing diabetes was associated with adopting healthy lifestyles and seeking care at a health facility. Additionally, covert diabetes-related stigma was observed in the communities, with implications for illness disclosure and overall quality of life. Community-wide interventions are needed to increase awareness on the causes and consequences of diabetes, address negative social norms, and expand screening programmes to facilitate early detection and guidance for effective disease management.

Psychometric validation and reliability of the Japanese version of the type 1 diabetes stigma assessment scale (DSAS-1 JP)

AIMS

We aimed to develop and validate a Japanese version of the type 1 diabetes (T1D) stigma assessment scale (DSAS-1 JP) to measure the stigma perceived and experienced by adults with T1D.

METHODS

The DSAS-1 JP was created through forward and backward translations, cognitive debriefing with 10 participants, and extensive proofreading. Its reliability and validity were evaluated in 384 adults with T1D using confirmatory factor analysis, Cronbach's α for internal reliability, and Spearman's rank correlation for construct validity.

RESULTS

The DSAS-1 JP was found to be acceptable by the experts and the target population. Confirmatory factor analysis verified the three-factor structure representing 'treated differently', 'blame and judgement', and 'identity concern', with Cronbach's α values of 0.86, 0.85, and 0.89, respectively. Overall, Cronbach's α for the DSAS-1 JP was 0.92. The model fit indices were robust (goodness-of-fit index=0.94, comparative fit index=0.94, root mean square error of approximation=0.068). Correlations of the DSAS-1 JP score with diabetes distress (r = 0.60, p < 0.001), self-esteem (r = -0.28, p < 0.001), and depressive symptoms (r = 0.34, p < 0.001) confirmed its constant validity. The test-retest reliability was strong at 0.77 (p < 0.0001).

CONCLUSION

The DSAS-1 JP is a reliable and valid tool for assessing the extent of perceived and experienced stigma in Japanese adults with T1D.

Association between self-stigma and diabetic complications in Japanese people with type 2 diabetes: a cross-sectional study

OBJECTIVES

To investigate the association between self-stigma evaluated using the Japanese version of the Self-Stigma Scale (SSS-J) and diabetic complications, such as diabetic retinopathy (DR) and diabetic kidney disease (DKD).

DESIGN

Cross-sectional study.

SETTING

One university hospital and one clinic in Fukuoka, Japan.

PARTICIPANTS

People (age ≥20 years) with type 2 diabetes receiving outpatient care, who were treated by diabetologists, and completed the SSS-J questionnaire (n=259).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the level of self-stigma assessed using the SSS-J. The presence of DR and DKD was evaluated as secondary outcomes.

RESULTS

A positive correlation was found between self-stigma and glycated haemoglobin (HbA1c) levels (r=0.132, p=0.034). The mean SSS-J score was significantly higher in people with type 2 diabetes who had DR than in those without DR (p=0.006). There was no significant difference in the mean SSS-J scores of the patients with albuminuria (p=0.318) or a decreased kidney function (p=0.887). Additionally, the relative risk for the presence of DR, as assessed by quartiles of SSS-J scores and a logistic regression analysis, was significantly increased in the Q4 group with the highest SSS-J score after adjustment for sex, age and HbA1c (OR=3.91, 95% CI 1.49 to 10.3, p=0.006). The relative risk for the presence of albuminuria as a DKD significantly increased in the Q4 group immediately after adjustment for sex and age (OR=2.45, 95% CI 1.04 to 5.81, p=0.042). However, this association was attenuated and became non-significant after additional adjustment for HbA1c levels. In contrast, no significant association was observed between the SSS-J score quartiles and decreased kidney function.

CONCLUSIONS

The presence of DR was more strongly associated with self-stigma than DKD. Although the causality between self-stigma and the presence of DR could not be elucidated due to the cross-sectional nature of the study, the present study suggests that addressing self-stigma may aid in glycaemic management and the prevention of DR, emphasising the need for healthcare providers to recognise self-stigma as a barrier to optimal diabetes care.

The relationship between perceived stigma and health-promoting self-care in adult patients with type 2 diabetes

Objectives

The study was conducted to examine the relationship between perceived self-stigma and health promotion self-care in patients with type 2 diabetes.

Methods

The study was conducted with 206 patients with type 2 diabetes who were hospitalized in the endocrinology clinic of a state hospital between July and September 2023 and met the study inclusion criteria. Data were collected using a patient identification form, the Type 2 Diabetes Stigma Assessment Scale (DSAS-2) and the Diabetes Health Promotion Self-Care Scale (DHPSC). Data were analyzed using SPSS Statistical software (Version 22), which combines descriptive and analytical statistics.

Results

The participants' DSAS-2 and DHPSC total mean scores were 47.85 ± 17.81 and 87.83 ± 19.19, respectively. A moderate, negative and statistically significant relationship was found between the participants' DSAS-2 and DHPSC total mean scores (r: 0.467, p:0.000), suggesting that health-promotion self-care is a predictor of perceived stigma.

Conclusion

The study revealed that the patients with type 2 diabetes experienced moderate levels of stigma, and as the level of perceived stigma increased, their self-care behaviors were negatively affected.

Impacts of Diabetes Stigma on Acute Health Care Utilization Among Adults With Type 2 Diabetes

PurposeThe purpose of this study was to examine the relationships between diabetes stigma, patient activation, and acute health care use. It was predicted that greater diabetes stigma would be associated with lower patient activation and greater likelihood of acute health care utilization.MethodsPrimary data were collected cross-sectionally using a web-based panel of US adults with type 2 diabetes (N = 371). Participants were screened for eligibility by providing informed consent, reporting a type 2 diabetes diagnosis from a health care provider, and passing an end-of-survey check to corroborate participants' initial self-reported diagnosis of type 2 diabetes. The Diabetes Stigma Assessment Scale, with its 3 subscales, assessed blame and judgment, perceived discrimination, and self-stigma associated with having diabetes. Patient activation was measured using the Patient Activation Measure. The frequency of diabetes-related emergency department visits and hospitalizations during the prior 12 months measured acute health care use.ResultsSelf-stigma was significantly associated with lower levels of patient activation, and blame and judgment and perceived discrimination were not. Perceived discrimination was also significantly associated with greater risk of emergency department visits and hospitalizations, and self-stigma and blame and judgment were not associated with either indicator of acute health care use.ConclusionsResults suggest self-stigma is associated with lower levels of patient activation and that perceived discrimination is related to increased use of acute health care. Future research may examine avenues to reduce diabetes stigma and its effect on patient activation and acute health care utilization.

The perceived social support, life events, and depressive features among patients with diabetes mellitus

ObjectiveThis study evaluated the relationship between life events, perceived social support, and depressive features among people with diabetes.MethodsThis study was a cross-sectional design using convenience sampling. Questionnaires were distributed to targeted patients in primary health care services in the Nablus district.Questionnaires used wereThe Holmes-Rahe Stress Inventory Scale, The Beck Depression Inventory, and The Multidimensional Scale of Perceived Social Support.ResultsAbout 120 diabetic patients participated in this study. Findings revealed that higher diabetes mellitus prevalence was among older ages (39.2% are 60 years or older). More than half of the participants were smokers. Regarding life events, 53.3% of the patients have a 50% chance of developing major breakdowns in the next two years. Depression was found to be normal among 32.5% of participants, while 22.5% were moderately depressed. More patients had a disagreement that they could find social support from their friends than their family members.DiscussionPeople with diabetes are affected significantly by life events, depressive features, and perceived social support, hence, further attention is needed accompanied by frequent assessment for such factors for effective diabetes management.

Assessing the Impact of a Community-Based Narrative Film about Diabetes and Homelessness

Stigma prevents societal acceptance, reinforces social inequities, and greatly complicates the management of diabetes for those dealing with homelessness. Various forms of media, such as film, can educate audiences and play a role in reducing stigma, but the effectiveness of such interventions in changing individuals' knowledge, attitudes, and beliefs (KAB) requires further exploration. This study assessed the impact of a film on diabetes and homelessness through pre- and post-surveys of audience members (n = 202) at 12 screening events. The surveys measured changes in KAB through Likert scale questions, with scores ranging from 1 to 5. Statistical analyses, including Wilcoxon signed-rank and Kruskal-Wallis tests, were used to assess differences in KAB before and after viewing the film, as well as variations based on prior familiarity with diabetes and homelessness. Respondents' knowledge increased significantly across all topics related to both diabetes and homelessness. There were significant differences in all questions that assessed respondents' attitudes. Notably, respondents' beliefs changed significantly to be more positive, except for a single question where the pre-scores already demonstrated reasonably high baseline knowledge. In several domains, respondents familiar with diabetes did not have as significant of a change compared with individuals who were less familiar with diabetes at baseline. These findings suggest that narrative films can positively influence audience members' KAB about stigmatized conditions like diabetes and homelessness. Future research will examine the lasting impact of such interventions on audience members' KAB.

Type 1 diabetes mellitus in children: Patient reported outcomes

The global prevalence of type 1 diabetes mellitus (T1DM) is increasing. Poor glycemic control in children and adolescents leads to both acute and chronic problems, reduced Health Related Quality of Life (HRQoL), and higher healthcare utilization. This study aimed to assess patient-reported outcomes related to self-management adherence, QoL, diabetes-related stigma, glycemic control, and other clinical outcomes along with their determinants, in insulin-treated pediatric T1DM patients in Jordan. A cross-sectional study was conducted from April to October 2023 at two health centers in Northern Jordan. Eligible pediatric T1DM patients attending outpatient clinics were enrolled. Trained pharmacists conducted face-to-face interviews with both children and their guardians, using validated tools that were translated into Arabic. Adherence was evaluated using the Diabetes Management Questionnaire, HRQoL was measured using the Pediatric Quality of Life Inventory 3.0 Diabetes Module, stigma was assessed using the Child Attitude Toward Illness Scale and glycemic control was determined by glycated hemoglobin levels. A total of 150 patients participated in the study. The mean adherence score was 57.4 ± 18.13. Factors such as younger age (P-value = 0.01), higher monthly income (P-value = 0.022) and shorter disease duration (P-value = 0.008) were associated with improved adherence. The mean pediatric QoL score was 63.27 ± 11.86, with male gender (P-value = 0.021) and the absence of disease-related factors (P-value = 0.004) linked to lower QoL scores. Additionally, body mass index (P-value = 0.041) and a family history of DM (P-value = 0.047) were linked to stigma. Most patients (76%) had uncontrolled diabetes, with disease duration (P-value = 0.019) and maternal educational level (P-value = 0.013) influencing glycemic control. These findings highlight that, despite widespread poor glycemic control, insulin adherence and QoL among pediatric T1DM patients in Jordan are above average. Targeted interventions are recommended to improve adherence and, in turn, overall patient outcomes.

A pretrained transformer model for decoding individual glucose dynamics from continuous glucose monitoring data

Continuous glucose monitoring (CGM) technology has grown rapidly to track real-time blood glucose levels and trends with improved sensor accuracy. The ease of use and wide availability of CGM will facilitate safe and effective decision making for diabetes management. Here, we developed an attention-based deep learning model, CGMformer, pretrained on a well-controlled and diverse corpus of CGM data to represent individual's intrinsic metabolic state and enable clinical applications. During pretraining, CGMformer encodes glucose dynamics including glucose level, fluctuation, hyperglycemia, and hypoglycemia into latent space with self-supervised learning. It shows generalizability in imputing glucose value across five external datasets with different populations and metabolic states (MAE = 3.7 mg/dL). We then fine-tuned CGMformer towards a diverse panel of downstream tasks in the screening of diabetes and its complications using task-specific data, which demonstrated a consistently boosted predictive accuracy over direct fine-tuning on a single task (AUROC = 0.914 for type 2 diabetes (T2D) screening and 0.741 for complication screening). By learning an intrinsic representation of an individual's glucose dynamics, CGMformer classifies non-diabetic individuals into six clusters with elevated T2D risks, and identifies a specific cluster with lean body-shape but high risk of glucose metabolism disorders, which is overlooked by traditional glucose measurements. Furthermore, CGMformer achieves high accuracy in predicting an individual's postprandial glucose response with dietary modelling (Pearson correlation coefficient = 0.763) and helps personalized dietary recommendations. Overall, CGMformer pretrains a transformer neural network architecture to learn an intrinsic representation by borrowing information from a large amount of daily glucose profiles, and demonstrates predictive capabilities fine-tuned towards a broad range of downstream applications, holding promise for the early warning of T2D and recommendations for lifestyle modification in diabetes management.

Diabetes and suicide: a nationwide longitudinal cohort study among the Japanese working-age population

BACKGROUND

Although the mental health burden of diabetes has received substantial attention, there is limited evidence on whether the risk of suicide-a severe consequence of mental health problems-increases among individuals with diabetes. Therefore, this study investigated the association between diabetes and suicide in Japan.

METHODS

This nationwide longitudinal cohort study included adults aged 18-74 years, who were enrolled in the Japan Health Insurance Association's health insurance programme between 2015 and 2022. Individuals newly diagnosed with diabetes were matched in a 1:1 ratio with those without diabetes, based on age and sex. We employed multivariable Cox proportional hazard models to estimate the hazard ratios for suicide in relation to the diagnosis of diabetes, adjusting for potential confounders, such as sociodemographic characteristics, history of psychiatric disorders, physical measurements, health behaviours and laboratory data.

RESULTS

Among 4 210 272 individuals in the matched-pair cohort, we observed 337 deaths by suicide among those with diabetes and 250 deaths by suicide among those without diabetes. After conditioning on potential confounders, diabetes diagnosis was linked to an increased risk of suicide (HR (95% CI) = 1.25 (1.06 to 1.47)). The association tended to be larger among those aged younger than 40 years and among women (among those aged 18-39 years, HR=1.69 (95% CI 1.05 to 2.73); among women, HR=1.56 (95% CI 0.92 to 2.64)).

CONCLUSION

Diabetes diagnosis may increase suicide risk among the working-age population, even after conditioning on potential confounders. Our findings underscore the importance of psychosocial support following a diagnosis.

Assessment of Compliance With ASCO Language of Respect Guidelines in Renal Cell Carcinoma Abstracts

PURPOSE

The ASCO Language of Respect (LOR) Guidelines were developed in 2020 to promote patient-respectful language in abstracts and presentations. We assessed adherence to LOR guidelines among renal cell carcinoma (RCC) abstracts presented at the 2023 and 2019 ASCO Annual Meetings.

METHODS

We systematically evaluated each statement in all RCC abstracts for compliance with the three clauses of LOR guidelines: "Do not blame patients," "Respect the role of patients," and "Do not dehumanize patients." Univariable and multivariable analyses were performed to identify factors associated with noncompliance.

RESULTS

Among 101 abstracts from 2023, the majority involved clinical research (66.3%) and had a character count at limit, defined as within 5% of the 2,600-character limit (51.5%). In 60.4% of abstracts, at least one statement violated the LOR guidelines. Proportions of abstracts with one or more statements with dehumanizing, blaming, or disrespectful language were 46.5%, 21.8%, and 1.0%, respectively. Among all variables examined, including research and author characteristics, abstracts at character limit emerged as the only category with significantly higher rates of noncompliance (62.3% v 35.0%, P = .013). Multivariable analyses showed an odds ratio of 3.3 (95% CI, 1.4 to 7.6, P = .006) for abstracts at character limit to have at least one noncompliant statement. Notably, even among abstracts not at character limit, 46.9% contained statements violating the guidelines. Between 2019 and 2023, the rate of statements that violated the LOR guidelines decreased from 71.0% to 60.4%.

CONCLUSION

A significant proportion of RCC abstracts contain language inconsistent with LOR guidelines. Although character limit is a likely contributor, our report highlights the need for our professional societies and abstract reviewers to cultivate greater awareness and adherence to patient-respectful language.

The (un)controlled body: A grounded theory analysis to conceptualise stigma for women with gestational diabetes mellitus

Health-related stigma is associated with adverse outcomes including depression, stress and reduced engagement in health behaviours which are particularly harmful in pregnancy and the postpartum. Women with gestational diabetes mellitus (GDM) report negative psychosocial experiences and may be at risk of stigma related to the condition. We aimed to understand women's experiences of GDM-specific stigma. Individual interviews were conducted with n = 53 women living in the UK with a current or past (within 4 years) GDM. Grounded theory methodology was used to analyse the data. Four themes were identified: (1) Preconceptions and misconceptions; (2) Locating, regaining, and negotiating agency; (3) Tension about and resisting the dominant discourse of stigma; and (4) Reclaiming control over the body. GDM-specific stigma was diverse and far reaching and may have broader implications for perinatal mental health and postnatal wellbeing. It is pertinent to investigate possible prospective associations between GDM-specific stigma, and biomedical and mental health outcomes.

Changing the Narrative: Confronting Diabetes-Related Stigma in Healthcare

Stigma refers to negative attitudes and beliefs that are directed at individuals based on perceived differences, such as living with diabetes. Stigma is commonly experienced by those with diabetes. Stigmatization often originates from healthcare professionals (HCPs) who may be unaware of the consequence of their judgemental attitudes on patients and on how personally challenging living with diabetes can be. A lack of empathy from HCPs can risk individuals choosing not to manage their diabetes as advised or even seek support. Harmful comments may also evoke feelings of guilt or shame in individuals, which can further affect their mental wellbeing and ability to self-care appropriately. Wider HCP understanding and appreciation of the impact of stigma in diabetes care could do much to help individuals with diabetes feel supported and understood and not judged. More constructive, person-centred dialogue offered by HCPs, such as avoiding using the threat of developing diabetes complications to drive individual behaviour change has the potential to contribute to better outcomes in diabetes and improve the confidence of individuals living with diabetes in their healthcare teams.

European Survey on Adults with Type 1 Diabetes and their Caregivers: Insights into Personal Experience and Needs for Improving Diabetes Care

INTRODUCTION

Type 1 diabetes (T1D) requires constant self-management and substantially impacts daily life. We surveyed the experiences/burdens of people with T1D (PWD) and their caregivers.

METHODS

An online survey of PWD/caregivers (aged ≥ 18 years) living in five European countries was conducted from July to August 2021. The survey included questions on the impact of T1D on physical and mental abilities, the frequency of hypoglycemic and hyperglycemic episodes and the impact of T1D on the daily lives of PWD.

RESULTS

Respondents included 458 PWD and 54 caregivers. The main impacts of T1D included fatigue (50% of PWD rated a high/very high impact), a hindrance to daily activities (43%), feeling different than others (42%), and anxiety (40%). The perceived impact of complication risk was significantly lower for PWD paying more attention to controlling their disease (p < 0.001). Most caregivers (80%) reported feeling more anxious than the PWD about their T1D complications. Hypoglycemia/hyperglycemia was a significant predictor of perceived distress owing to T1D. Most PWD (68%) would have liked more psychological support. Over half of respondents (PWD: 53%, caregivers: 56%) felt they had insufficient knowledge about T1D. Acceptance, positivity, and self-organization are the main strategies recommended by PWD/caregivers for living with T1D.

CONCLUSIONS

T1D remains a significant burden for PWD/caregivers, and more educational and psychological support for T1D management is required.

Experiences of stigmatization and its impacts among individuals living with hereditary diseases and family members in Portugal: an exploratory study

Stigma is defined as the perception of an undesirable attribute that leads to discrimination against individuals and groups. Stigmatisation is often triggered due to visible physical or cognitive differences. Although the literature consistently highlights the (fear of) stigmatisation as a significant concern among individuals living with hereditary conditions, no studies in Portugal have specifically provided evidence on this issue. This study aims to address this gap by examining the experiences and impact of stigma on individuals and families affected by hereditary diseases in Portugal. After receiving ethics approval, a total of 216 participants, including affected individuals, asymptomatic carriers and family members from families with a range of hereditary conditions, were recruited through patient support associations. Participants completed an online questionnaire via Limesurvey. Data were analysed through Exploratory Factor Analysis (EFA), median comparison tests, and thematic analysis. Of the participants, 78.7% were women, 55.6% had a university degree, and 20.4% were aged between 42 and 47 years. Findings indicate that stigma impacts individuals across various domains, including social interactions, institutional settings, the workplace, and healthcare. EFA identified a bi-factorial model of stigma, comprising Stigma Experiences and Perceived Support subscales, and the overall scale demonstrated high internal consistency (α = .879). Women and younger participants reported higher levels of stigma. Religiosity and humor emerged as key coping strategies. This study is the first in Portugal to assess stigma among individuals living with hereditary conditions. Our findings contributed to validating a measurement instrument, identified sociodemographic variations, and examined the psychosocial dimensions of stigma among affected patients. These findings highlight the need for comprehensive strategies to address and mitigate stigma, improve support systems, and enhance the well-being and healthcare experiences of individuals and families impacted by hereditary diseases.

Investigating the relationship between social stigma and treatment adherence in type 2 diabetes patients at healthcare centers in Northwest Iran

BACKGROUND

The social stigma associated with type 2 diabetes is a significant global mental and social health issue that can hinder treatment adherence among patients. To address this concern, the present study aimed to examine the relationship between social stigma and treatment adherence levels in type 2 diabetes patients attending healthcare centers in northwest Iran.

METHODS

In this descriptive-correlation study, 432 patients with type 2 diabetes referred to Ardabil city health service centers were selected by simple random and multi-stage cluster method. The data collection tools included the personal-social profile form, type 2 diabetes stigma assessment scale (DSAS-2), and treatment adherence questionnaire. Data were analyzed using SPSS 26 software with descriptive statistics, independent t-tests, analysis of variance, a logistic linear regression model.

RESULTS

The results indicated that the average score for the total social stigma of type 2 diabetes among the studied samples was 59.27 ± 15.52. A high level of perceived social stigma was observed in 55.6% of the patients. The average score for treatment adherence was 97.46 ± 28.79, with an adherence situation at an average level (59.7%). An inverse relationship was identified between the social stigma of diabetes and adherence to treatment (r = -0.29, p < 0.001). Additionally, there was a significant relationship between the average score of social stigma of diabetes and variables such as gender and marital status, as well as between the average score of treatment adherence and the gender of patients. The stepwise multiple linear regression model revealed that 15.1% of the variance in treatment adherence could be explained by age, duration of the disease, and social stigma of diabetes.

CONCLUSION

The study found that, more than half of the patients had social stigma and reported their adherence to treatment as moderate. Also, there was an inverse and significant correlation between social stigma and treatment adherence. Therefore, it is necessary to provide psychological counseling services to reduce social stigma and teach the importance of adherence to treatment in these patients.

Mind Matters: Mental Health and Diabetes Management

CONTEXT

Managing diabetes is an intensive, lifelong responsibility that significantly impacts a person's mental health and diabetes outcomes such as glycemic stability and complications. This mini-review examines the research leading to this conclusion as well as the implications for screening and treatment of mental health issues in people with diabetes within an interdisciplinary care model.

EVIDENCE ACQUISITION

We searched the literature for the past 10 years, including original articles, reviews, and meta-analyses from PubMed and OVID using the search terms diabetes and mental health.

EVIDENCE SYNTHESIS

Diabetes is a lifelong burden, and people with the disease grapple with intensive management, financial burden, fear of hypoglycemia, chronic hyperglycemia complications, and diabetes stigma. These stressors have a debilitating emotional impact, making it difficult to carry out diabetes care tasks, which in turn is associated with poorer short-term glycemic stability and greater mental health symptoms. Psychological syndromes related to a diabetes diagnosis, management, or coping with the disease include major depressive disorder, diabetes distress, anxiety, and eating disorders. Providers managing people with diabetes can leverage 4 validated screening instruments to assess for these syndromes. The main psychological interventions studied to treat these mental health conditions include cognitive behavioral therapy, cognitive conceptualization, dialectical behavioral therapy, relational therapy, and psychoeducation.

CONCLUSION

It is pertinent to address the mental health of people with diabetes as rates of psychological syndromes are significantly higher than among those without diabetes. Interdisciplinary care involving endocrinologists, mental health providers, diabetes educators, and medical nutritionists could improve diabetes self-care and glycemic control.

Is there anything left to eat? A lived experience insight of following a restrictive type 1 diabetes and dialysis diet

OBJECTIVES

Chronic kidney disease has a global morbidity burden of >10%, with diabetes being a major cause.  Nutrition therapy is vital in managing both chronic conditions, yet CKD dietary guidelines contradict healthy eating advice, and can result in major psychological and social burdens. Few studies investigate the patient's experience of being placed on such a restrictive diet. This auto/biographical review provides a unique perspective and aims to assist practitioners as they guide patients on 'what is left to eat.'

METHOD

An auto/biographical approach, supported by a comprehensive literature review using data from MEDLINE, Embase, and PsychoINFO, was used to answer the question: 'What are the diet and lifestyle challenges of following a restrictive Type 1 Diabetes/CKD dialysis diet?'

RESULTS

Restrictive dietary and fluid regimes have a major effect on patients' illness beliefs, anxieties, and independence. This is discussed through five themes: Food is belonging; Normal is a Fallacy; Your numbers define you; A disease disguised as a virtue and Meeting the Elephant: ESKD diagnosis and the burden of dialysis.

CONCLUSION

Dietary intervention is crucial in the management of T1D and ESKD, but equally important is to consider the implications of strict dietary regimes without sufficient evidence, guidance, and support.

The Role of Community Organisation, Religion, Spirituality and Cultural Beliefs on Diabetes Social Support and Self-Management in Sub-Saharan Africa: Integrative Literature Review

To examine the evidence for the role of community organisations, religion, spirituality, cultural beliefs, and social support in diabetes self-management, we undertook an integrative literature review utilising MEDLINE, APA PsycINFO, CINAHL, and grey literature databases. The selected articles were appraised for quality, and the extracted data were analysed thematically. The search yielded 1586 articles, and after eliminating duplicates, 1434 titles and abstracts were screened, followed by a full-text review of 103 articles. Ultimately, 47 articles met the inclusion criteria for the review, utilising various study designs, including qualitative, quantitative, mixed-methods, and nonrandomised clinical trials. These findings indicate that spirituality and religiosity can positively affect diabetes self-management by providing motivation, coping skills, social support, and guidance for healthy behaviours. A strong social support system enhances diabetes self-management and glycaemic control for individuals with diabetes. However, some aspects of religion and culture, such as beliefs about medications, may also pose challenges or barriers to diabetes self-management. Adherence to medication, food choices, physical activity, and the use of complementary or alternative medicine can be influenced by sociocultural factors. Additionally, cultural beliefs and social norms influence understanding diabetes aetiology, management, and symptom reactions. The findings highlight that it is crucial to understand the cultural, religious, or spiritual influences that can either assist or impede self-management habits in individuals with diabetes and could inform interventions that support personalised and effective care.

Changes in 90-Day Time in Range Among Youth with Type 1 Diabetes Initiating Different Automated Insulin Delivery Systems

OBJECTIVE

Glycemic outcomes in youth with type 1 diabetes (T1D) in the United States using the two most common automated insulin delivery (AID) systems, Insulet Omnipod 5 (OP5) and Tandem Control IQ (CIQ), have not been compared. We performed the first head-to-head analysis of changes in glycemic metrics among youth initiating AID.

METHODS

This single center, retrospective study included youth <21 years with T1D, who started OP5 or CIQ between 1/2020 and 12/2023, and had ≥70% CGM active time. 14-day baseline and 90-day CGM and AID data were obtained. A multiple linear regression model assessed for changes in 90-day time in range (TIR) according to AID system, adjusting for covariates. Sub-analyses were conducted according to baseline TIR categories.

RESULTS

Among the 428 youth included, there were 214 (50%) in each AID group. OP5 users had a shorter T1D duration (1.6 vs 5.5 years, p<0.001) and were more likely to have transitioned from multiple daily injections (76.1% vs 20.1%, p<0.001). Baseline TIR was similar between groups (OP5 51.6% vs CIQ 53.1%, p=0.70). 90-day TIR increased in both groups (p<0.001), rising by 11.8%-points (95% CI[10.4,13.3]) in OP5 users and 9.8%-points (95% CI[8.3,11.2]) in CIQ users, without any significant between group differences (p=0.08). There were no between group differences in 90-day TIR according to categorical baseline TIR.

CONCLUSIONS

There are no clinically significant differences in 90-day TIR among youth with T1D initiating the two most commonly used AID systems. Patient preference and shared decision making should continue to guide the selection of AID systems.

A cultural adaptation and validation study of the Intentional Nonadherence Scale (INAS) among people with type 2 diabetes in Singapore

AIMS

To examine the psychometric properties of the Intentional Non-adherence Scale (INAS) among people with type 2 diabetes mellitus (PwT2D) in Singapore.

METHODS

This study consisted of Phase 1: translation and adaptation of the questionnaire into local Mandarin and English and Phase 2: a longitudinal validation study at the outpatient clinics of a hospital in Singapore. In Phase 1, cognitive interviews were conducted with 20 PwT2D and healthcare providers to examine the content validity of the INAS. In Phase 2, 290 PwT2D were recruited. Fifty-three of them were involved in test-retest reliability analysis, while 185 were followed-up in 3-6 months to assess the predictive validity of the INAS. The INAS was also evaluated for its structural validity, construct validity and internal reliability.

RESULTS

Exploratory factor analysis revealed four factors, namely "Resisting illness and medication", "Sensitivity to medication", "Testing treatment" and "Inconvenience". All INAS factors showed good internal consistency (Cronbach's alpha = 0.84-0.94) and moderate test-retest reliability (intraclass correlation coefficient = 0.50-0.62). Construct validity of the INAS was demonstrated in its relationship with medication adherence, glycated haemoglobin (HbA1c), beliefs about medications, illness perception and mood. Quantile and linear regression for medication adherence and HbA1c in 3-6 months did not show statistical associations with the INAS after adjusting for potential confounders.

CONCLUSIONS

Our study supports the reliability and most aspects of validity of the INAS, which revealed new factors that may affect medication adherence and HbA1c. In clinical settings, healthcare providers may consider using this questionnaire to evaluate potential intentional nonadherence.

Salivary glycated albumin could be as reliable a marker of glycemic control as blood glycated albumin in people with diabetes

AIMS

Measurements of diabetes-related biomarkers are necessary to assess glycemic control. The commonly used finger-prick blood glucose and HbA1c measurements are invasive, as is blood glycated albumin (GA) measurement. Therefore, we developed a non-invasive method, namely, measurement of the salivary GA with high accuracy using a high-performance liquid chromatography (HPLC) method.

METHODS

We recruited participants with diabetes mellitus admitted to The University of Tokyo Hospital. Blood and saliva samples were collected at three time points (fasting and 2-hour postprandial at admission and fasting at discharge). After partial purification using an antibody-based column, the samples were subjected to GA measurement by HPLC method.

RESULTS

Among the 56 participants with diabetes mellitus enrolled in the study, there was a correlation between the GA levels measured in blood and saliva at the three time points described above (n = 45, R2 = 0.985, P < 0.001; n = 48, R2 = 0.973, P < 0.001; n = 51, R2 = 0.979, P < 0.001). Multiple regression analysis revealed the associations were maintained even after adjustments for age, BMI, and nephropathy stage.

CONCLUSIONS

This exploratory research revealed that the salivary GA levels by this method were accurate and might be able to replace blood GA measurement. The home salivary GA measurement is expected to be developed that may reduce the burden and complications in people with diabetes mellitus and improve the quality of life.

Challenging diabetes mellitus-related stigma with targeted education

Diabetes mellitus is a highly prevalent chronic metabolic disorder that requires rigorous self-management to prevent complications and maintain health. Managing diabetes can also be psychologically challenging for those living with the condition, significantly affecting their mental health, particularly when diabetes-related stigma manifests as discrimination, social rejection and internalised shame. This article examines how diabetes-related stigma often stems from misconceptions about the condition, but nonetheless can adversely affect the self-care, physical health and quality of life of people living with the condition. The author explains how mitigating this stigma through targeted education, empathic communication and advocacy is essential and explores the pivotal role of nurses in reducing diabetes-related stigma.

Perspectives of patients with type 1 and type 2 diabetes on barriers to diabetes care: a qualitative study

BACKGROUND

Diabetes care incorporates multiple integrated elements like self-care practices, patient education and awareness, societal support, equitable access to healthcare facilities and trained healthcare professionals, commitment from the diabetes associations and government policies. There is a dearth of research exploring the barriers experienced by both People with Type 1 diabetes (PwT1D) and People with Type 2 diabetes (PwT2D) in accessing the holistic elements of diabetes care. This study thus aimed at exploring the perceived barriers among PwT1D and PwT2D in accessing diabetes care services in urban and rural areas of Nepal.

METHOD

This study was a qualitative research using phenomenological approach where an in-depth interview with 23 participants on insulin was conducted. This included 15 PwT1D and 8 PwT2D, residing in the capital and rural areas and attending the hospitals and clinic in the urban and semi-urban regions in Nepal. A semi-structured questionnaire was used for the interview. The interviews were transcribed verbatim and deductive thematic analysis was done.

RESULTS

Majority were female participants and most had received a formal education and were visiting the hospitals located in capital city. Mean age for PwT1D was (27.86 ± 1.85) years whereas the median age for PwT2D was [47.5 (IQR, 16.5)] years. Seven themes were generated from the study representing key barriers from patient's perspective. These were: Theme (1) Double stigma: Diabetes diagnosis and insulin use, Theme (2) Non-adherence to insulin and Self-Monitoring of Blood Glucose (SMBG), Theme (3) Logistic challenges in rural areas: Scarcity of healthcare professionals and other healthcare facilities, Theme (4) Dissatisfaction with healthcare services, Theme (5) Patients seeking alternative treatment strategies over allopathic treatment, Theme (6) Limitations of health insurance scheme and Theme (7) Limited role of national diabetes organizations.

CONCLUSION

There is a need in raising awareness among general public especially on T1DM to address the issue of diabetes stigma. An effort in implementation of policies supporting diabetes care and refinement of National Health Insurance Scheme is equally essential. Similarly, strengthening of Health Care System by ensuring availability of insulin, laboratory facilities and trained healthcare professionals in rural areas should be focused to address the inequity in access to healthcare in rural and urban sectors.

Understanding Experiences of Diabetes Distress: A Systematic Review and Thematic Synthesis

Background: Diabetes distress is a common emotional issue for those living with diabetes, which has the potential to negatively impact well-being, management behaviors, and HbA1c levels. These implications have led to diabetes distress becoming an important consideration in diabetes healthcare and management. Nonetheless, discussions remain ongoing on how to best conceptualize this experience. Recent research has attempted to enhance conceptualization by considering the underlying emotional mechanisms that may underpin the highly contextualized experience of diabetes distress. Qualitative insights can further add to these understandings; however, the research in this remit is yet to be systematically reviewed. This review therefore sought to add to the growing body of literature attempting to better conceptualize diabetes distress and the underlying mechanisms that may contribute to this experience. A secondary aim was to leverage this understanding to consider ways to improve patient-healthcare interactions. Methods: A qualitative systematic review and thematic synthesis was undertaken. Eligible studies were identified through PsycINFO, MEDLINE, CINAHL, and EMBASE databases from November 2020 to May 2021. Study quality was assessed using the McMaster Critical Review Form. Results: Nineteen papers were included in the review. The analysis resulted in seven descriptive themes which contributed to three analytical themes: (1) threatened autonomy, (2) sense of helplessness, and (3) negative sense of self. These results highlight that a major area underpinning experiences of diabetes distress is not feeling in control. Conclusions: Consideration should be given to how psychological factors, such as locus of control and learned helplessness, may constitute underlying mechanisms impacting emotional regulation in those experiencing diabetes distress. Clinicians should consider including and leading discussions around distress during appointments, as well as using approaches that promote patient autonomy and empowerment.

Remote Digital Technologies for the Early Detection and Monitoring of Cognitive Decline in Patients With Type 2 Diabetes: Insights From Studies of Neurodegenerative Diseases

Type 2 diabetes (T2D) is a risk factor for cognitive decline. In neurodegenerative disease research, remote digital cognitive assessments and unobtrusive sensors are gaining traction for their potential to improve early detection and monitoring of cognitive impairment. Given the high prevalence of cognitive impairments in T2D, these digital tools are highly relevant. Further research incorporating remote digital biomarkers of cognition, behavior, and motor functioning may enable comprehensive characterizations of patients with T2D and may ultimately improve clinical care and equitable access to research participation. The aim of this commentary article is to review the feasibility, validity, and limitations of using remote digital cognitive tests and unobtrusive detection methods to identify and monitor cognitive decline in neurodegenerative conditions and apply these insights to patients with T2D.

Metabolic and lifestyle factors accelerate disease onset and alter gut microbiome in inflammatory non-communicable diseases

BACKGROUND

Biomedical and lifestyle factors in Western populations have significantly shifted in recent decades, influencing public health and contributing to the increasing prevalence of non-communicable diseases (NCDs) that share inflammation as common pathology.

METHODS

We investigated the relationship between these factors and 11 NCDs in the cross-sectional FoCus cohort (n = 1220), using logistic regression models. Associations with age-at-disease-onset were specifically analyzed for type 2 diabetes (T2D, low-grade chronic inflammation) and inflammatory bowel disease (IBD, high-grade chronic inflammation) in disease-specific cohorts (FoCus-T2D, n = 514; IBD-KC, n = 1110). Important factors for disease risk were identified using Cox-PH-regression models and time-to-event analysis. We further explored the interaction between identified risk factors and gut microbiome composition using linear models.

RESULTS

Lifestyle factors were clearly linked to disease phenotypes, particularly in T2D and IBD. Still, some factors affected only the age-at-onset, but not disease prevalence. High-quality nutrition significantly delayed onset for both IBD and T2D (IBD: HR = 0.81 [0.66; 0.98]; T2D: HR = 0.45 [0.28; 0.72]). Smoking accelerated T2D onset (HR = 1.82 [1.25; 2.65]) but delayed onset in ulcerative colitis (UC: HR = 0.47 [0.28; 0.79]). Higher microbiota diversity delayed IBD onset (Shannon: HR = 0.58 [0.49; 0.71]) but had no effect on T2D. The abundance of specific microbial genera was strongly associated with various biomedical and lifestyle factors in T2D and IBD. In unaffected controls, these effects were smaller or reversed, potentially indicating a greater susceptibility of the gut microbiome to negative influences in T2D and IBD.

CONCLUSIONS

The dual insights into age-at-disease-onset and gut microbiota composition in disease emphasize the role of certain biomedical and lifestyle factors, e.g., nutrition quality, in disease prevention and management. Understanding these relationships provides a foundation for developing targeted strategies to mitigate the impact of metabolic and inflammatory diseases through lifestyle modifications and gut health management.

Measuring internalized health-related stigma across health conditions: development and validation of the I-HEARTS Scale

BACKGROUND

Health-related stigma and its internalization among individuals with chronic health conditions contribute to impaired mental and physical health and quality of life. Research on health-related stigma has been siloed, with disease-specific measures that may not capture the experiences of individuals with multiple health conditions and that prevent comparisons across health conditions. The current study aimed to develop and test a transdiagnostic measure of internalized health-related stigma for use among adults with different physical health conditions.

METHODS

An existing measure of internalized mental health stigma was adapted to assess stigma due to chronic physical health conditions following COSMIN procedures, with input from advisory boards of community members living with a range of stigmatized health conditions (obesity, type 1 and type 2 diabetes, skin diseases, HIV, chronic pain, and cancers) and of health professionals who specialized in these conditions. The new Internalized Health-Related Stigma (I-HEARTS) Scale was tested in an online sample of 300 adults with these health conditions, recruited from ResearchMatch. Additional psychosocial measures of mental health and quality of life were administered, and participants provided information about their health conditions and demographic characteristics. Exploratory factor analysis and tests of reliability and validity were conducted to determine the psychometric properties of the I-HEARTS Scale, and k-means clustering and receiver of characteristic curve analysis were used to determine a clinically meaningful cutoff score indicating high levels of internalized stigma.

RESULTS

Factor analysis results yielded a 25-item scale with a 3-factor solution, with subscales of Perceived and Anticipated Stigma, Stereotype Application and Self-Devaluation, and Stigma Resistance. Psychometric properties for internal consistency, inter-item and item-total correlations, and test-retest reliability were strong. Certain demographics (e.g., younger age) and characteristics related to health conditions (e.g., greater symptom severity) were associated with higher levels of internalized stigma. I-HEARTS Scale scores correlated moderately to strongly with related but distinct psychosocial measures, and a cutoff score of 3.40 or higher on the 1-7 rating scale was determined to indicate clinically meaningful levels of internalized stigma.

CONCLUSIONS

The I-HEARTS Scale is a reliable and valid measure for the assessment of internalized health-related stigma among adults with varied stigmatized chronic health conditions. STUDY PRE-REGISTRATION: https://osf.io/84c5d/?view_only=87238512f6d6475c87f8f64280a8a15f .

Health-related quality of life assessment in health economic analyses involving type 2 diabetes

AIM

Incorporating health-related quality of life (HRQoL) measures into health economic analyses can help to provide evidence to inform decisions about how to improve patient outcomes in the most cost-effective manner. The aim of this narrative review was to assess which HRQoL instruments have been used in economic evaluations of type 2 diabetes management including in Indigenous communities.

METHOD

MEDLINE (Ovid), Embase (Ovid) and Cochrane were searched from inception to June 2022. Studies included patients with type 2 diabetes; economic evaluations, derived scores from direct questioning of individuals; and were in English. Records were assessed for bias using the JBI critical appraisal tools.

RESULTS

A total of 3737 records were identified, with 22 publications meeting the criteria for inclusion. Across those 22 articles, nine HRQoL instruments had been utilised. Generic tools were most frequently used to measure HRQoL, including EQ-5D (-3 L and -5 L) (n = 10, 38%); SF-12 (n = 5, 19%); and SF-36 (n = 4, 15%). Two tools addressing the specific stressors faced by people with type 2 diabetes were utilised: Problem Areas In Diabetes tool (n = 1, 4%) and Diabetes Distress Scale (n = 1, 4%). Two publications reported whether the study population included Indigenous peoples.

CONCLUSION

A wide range of HRQoL instruments are used in economic evaluations of type 2 diabetes management, with the most frequent being varying forms of the EQ-5D. Few economic evaluations noted whether Indigenous peoples were featured in the study population. More research into HRQoL in people living with type 2 diabetes is urgently needed to improve evidence on effectiveness and cost-effectiveness of interventions.

Physicians' stigmatizing attitudes about individuals with type 2 diabetes: Associations with communication practices and perceived barriers to care

AIMS

The stigma of type 2 diabetes (T2D) has received growing attention in the healthcare setting. However, there has been almost no research examining how healthcare professional biases about diabetes relate to patient care. This cross-sectional study examined how physicians' self-reported biases, stereotypes, and attributions about diabetes and obesity were related to their patient care practices.

METHODS

Physicians treating T2D, specializing in internal medicine or endocrinology (n=205), completed a battery of online questionnaires.

RESULTS

Physicians who attributed poor patient compliance as the primary barrier to provision of diabetes care had worse perceptions of individuals with T2D and were less likely to use person-centered approaches with their patients. Physicians' stigmatizing attitudes about T2D were associated with less use of person-first language, while more positive perceptions of individuals with T2D were associated with greater use of motivational interviewing. Weight-related stigma was associated with less use of person-centered approaches to care and less confidence in their ability to provide care.

CONCLUSIONS

Findings reiterate the associations between weight stigma and poorer physician communication and suggest that similar patterns occur in the provision of care for individuals with T2D. Physicians who treat T2D may benefit from stigma reduction interventions for both diabetes and weight-related stigmas.

A World Café Approach to Exploring Perspectives on Diabetes Stigma in the United Kingdom

INTRODUCTION

Research has found that a high percentage of people with diabetes experience stigma, with perceptions of stigma being significantly higher among people with Type 1 diabetes compared to those with Type 2 diabetes. These experiences of diabetes stigma can lead to psychological, behavioural and medical consequences. The aim of the current study was to explore the perceptions of diabetes stigma and propose strategies for addressing this from the perspective of key stakeholders.

METHODS

A mixed methods design was used, commencing with an online qualitative survey (n = 128) and followed by a World Café (n = 11), where attendees reflected on their own experiences with stigma and discussed the survey findings.

RESULTS

The survey indicated that 75% of those with Type 1 diabetes and 51% with Type 2 had experienced diabetes stigma. The World Café identified three main areas that participants felt impacted their experiences with stigma or had the potential to help improve stigma: healthcare interactions, public awareness and media representations.

CONCLUSIONS

The findings supported previous research showing that diabetes stigma is prevalent among people with diabetes. The World Café was an excellent means of sharing knowledge and experiences among stakeholders, the findings of which will inform strategies to bring about change.

PATIENT OR PUBLIC CONTRIBUTION

World Café is a collaborative method where stakeholders contribute to the production and analysis of data through rounds of discussion and feedback.

A mediation analysis evaluating change in self-stigma on diabetes outcomes among people with depression in urban India: A secondary analysis from the INDEPENDENT trial of the collaborative care model

Self-stigma-the internalization of negative community attitudes and beliefs about a disease or condition-represents an important barrier to improving patient care outcomes for people living with common mental disorders and diabetes. Integrated behavioral healthcare interventions are recognized as evidence-based approaches to improve access to behavioral healthcare and for improving patient outcomes, including for those with comorbid diabetes, yet their impact on addressing self-stigma remains unclear. Using secondary data from the Integrating Depression and Diabetes Treatment (INDEPENDENT) study-a trial that aimed to improve diabetes outcomes for people with undertreated and comorbid depression in four urban Indian cities via the Collaborative Care Model-we longitudinally analyzed self-stigma scores and evaluated whether change in total self-stigma scores on diabetes outcomes is mediated by depressive symptom severity. Self-stigma scores did not differ longitudinally comparing Collaborative Care Model participants to enhanced standard-of-care participants (mean monthly rate of change in Self-Stigma Scale for Chronic Illness-4 Item scores; B = 0.0087; 95% CI: -0.0018, 0.019, P = .10). Decreases in total self-stigma scores over 12 months predicted diabetes outcomes at 12 months (HbA1c, total effect; B = 0.070 95%CI: 0.0032, 0.14; P < .05), however depressive symptoms did not mediate this relationship (average direct effect; B = 0.064; 95% CI: -0.0043, 0.13, P = .069). Considering the local and plural notions of stigma in India, further research is needed on culturally grounded approaches to measure and address stigma in India, and on the role of integrated care delivery models alongside multi-level stigma reduction interventions. Trial registration : ClinicalTrials.gov, NCT02022111. https://clinicaltrials.gov/study/NCT02022111.

Barriers and Facilitators to Incorporating an Integrative Mind-Body Intervention in Youth With Type 2 Diabetes

Objective

There has been little to no qualitative research done with adolescents and young adults (AYA) with type 2 diabetes (T2D) that can guide creation of interventions for this demographic. Using qualitative research methods, a novel mind-body intervention called Intervention for Early Onset Type 2 Diabetes (INTEND) has been developed for AYA aged 15 to 20 years, with the goal of improving self-management and coping skills, by enhancing routine care with augmented education coupled with mind-body skills.

Method

Qualitative interviews with AYA 15 to 20 years of age with T2D, their parents, and professionals caring specifically for this population were done through a focus group model. Transcripts were created, depersonalized, and coded using a Consensual Qualitative Research (CQR) method. Identified themes then guided the creation of course materials that included education about self-management of T2D and how to use the 4 mind-body technique toward self-care and regulation.

Results

The qualitative approach used in the development of this intervention revealed important findings in understanding key barriers faced by this group, key facilitators that improve their quality of life, and core components of an intervention that would be acceptable to them.

Conclusion

Results of this qualitative study helped craft an intervention tool that can subsequently be deployed and evaluated for effectiveness. Findings of the qualitative research model allow us to better understand the lived experience of AYA living with T2D.

Clinical guidance

•Stigma of type 2 diabetes in adolescents may interfere with patients' ability to adequately adhere to treatment recommendations•Clinicians need to identify social supports for adolescents with type 2 diabetes•Identifying family members and including them in treatment plans may help adolescents with type 2 diabetes.

Clinical Usage and Potential Benefits of a Continuous Glucose Monitoring Predict App

Continuous glucose monitoring (CGM) has become an increasingly important tool for self-management in people with diabetes mellitus (DM). In this paper, we discuss recommendations on how to implement predictive features provided by the Accu-Chek SmartGuide Predict app in clinical practice. The Predict app's features are aimed at ultimately reducing diabetes stress and fear of hypoglycemia in people with DM. Furthermore, we explore the use cases and potential benefits of continuous glucose prediction, predictions of low glucose, and nocturnal hypoglycemia.

Concept and Implementation of a Novel Continuous Glucose Monitoring Solution With Glucose Predictions on Board

The recently CE-marked continuous real-time glucose monitoring (rtCGM) solution Accu-Chek® (AC) SmartGuide Solution was developed to enable people with diabetes mellitus (DM) to proactively control their glucose levels using predictive technologies. The comprehensive solution consists of three components that harmonize well with each other. The CGM device is composed of a sensor applicator and a glucose sensor patch whose data are transferred to the connected smartphone by Bluetooth® Low Energy. The user interface of the CGM solution is powered by the AC SmartGuide app delivering current and past glucose metrics, and the AC SmartGuide Predict app providing a glucose prediction suite enabled by artificial intelligence (AI). This article describes the innovative CGM solution.

Cultural Beliefs About Diabetes-Related Social Exclusion and Diabetes Distress Impact Self-Care Behaviors and HbA1c Among Patients with Type 2 Diabetes

BACKGROUND

Type 2 diabetes mellitus (T2DM) disproportionally impacts Latin Americans (Latinos) in the U.S. compared to non-Latino Whites, as reflected by an increased risk for disease complications and higher mortality rates. Guided by an Integrative Model of Culture, Psychological Processes, and Health Behavior, the purpose of the present study was to examine the role of cultural beliefs and diabetes distress as determinants of self-care behaviors and HbA1c among Latino patients with T2DM.

METHODS

Participants included 109 Latino patients with T2DM recruited from a diabetes treatment center located in a region of Southern California with high diabetes mortality rates. Structural equation modeling was employed to examine the extent to which cultural beliefs about diabetes-related social exclusion and diabetes distress impact self-care behaviors and self-reported HbA1c.

RESULTS

Consistent with the study hypotheses, cultural beliefs about diabetes-related social exclusion predicted diabetes distress, which in turn predicted poor diabetes self-care.

CONCLUSIONS

Findings suggest an important need for intervention efforts that address both cultural and psychological factors in order to improve diabetes self-care behaviors and associated disease outcomes among Latino patients with T2DM. Future research could benefit from investigating protective aspects of culture that could help counter the negative implications of cultural beliefs about social exclusion and diabetes distress associated with poor self-care.

Predictors of stigma perception by people with type 1 diabetes: A cross-sectional analysis of the BETTER registry

AIMS

This study investigates stigma predictors across ages and genders, addressing a critical gap in understanding diverse populations to reduce related suboptimal clinical and psychosocial outcomes.

METHODS

Cross-sectional analysis of self-reported data from BETTER, a Canadian registry of people with type 1 diabetes. Participants (n = 709) completed the 19-item-Diabetes-Stigma Assessment-Scale (DSAS-1) categorized into treated differently, blame and judgment, and identity concerns sub-scales. Associations with diabetes distress (DDS-17-score/102), depression (PHQ-9-score/27), social-support (ESSI-score/34), fear of hypoglycemia (HFS-II-score/132), and hyperglycemia-avoidance-behaviours (HAS-score/88) were computed.

RESULTS

Perceived stigma was highest in youth aged 14-24 years (46·0 ± 15·6, p < 0·001) and women (41·2 ± 15·7, p = 0·009), compared to other age groups and men. Blame and Judgment contributed to most of stigma perception. Youth perceived significantly more blame and judgment (p < 0·001) and identity concerns (p = 0·001) compared to middle-aged adults and seniors. Women perceive significantly more blame and judgment compared to men (p < 0·001). The perception of being treated differently was not reported to be an issue across ages and genders. Participants with higher scores of depression, diabetes-distress, fear of hypoglycemia, hyperglycemia-avoidance behaviours, and lesser social-support, reported increased stigma.

CONCLUSIONS

Stigma varies by age and gender, underscoring the need for targeted interventions to reduce it. Challenging stereotypes and reducing stigma-related stressors are essential for better outcomes.

Understanding the Negative Effect of Stigma: A Pediatrician's Guide to Employing Anti-stigma Language/Care to Improve Engagement and Outcomes

A primer for pediatric providers on understanding stigma in health care, the terminology and types of stigma, the conditions commonly faced with stigma in pediatrics, the components of evidence-based anti-stigma initiatives, and guidance to effect change within a pediatric practice. The authors outline the negative effects of stigma in pediatrics and how to combat the problem at the source, and explore self-stigma, public stigma, and structural stigma and how it applies to weight, diabetes, disability, HIV, mental health, and substance use in pediatrics.

Identifying the deficiencies of currently available CGM to improve uptake and benefit

BACKGROUND AND AIMS

The use of diabetes technologies is increasing worldwide, with health systems facilitating improved access to devices. Continuous glucose monitoring is a complex intervention that provides information on glucose concentration, rate and direction of change, historical data and alerts and alarms for extremes of glucose. These data do not themselves change glycaemia and require translation to a meaningful action for impact. It is, therefore, crucial that such systems advance to better meet the needs of individuals using them.

METHODS

Narrative review of the use of, engagement with, limitations and unmet needs of continuous glucose monitoring systems.

RESULTS

CGM devices have made a significant contribution to the self-management of diabetes; however, challenges with access and user experience persist, with multiple limitations to uptake and benefit. These limitations include physical size and implementation, with associated stigma, alarm fatigue, sleep disturbance and the challenge of addressing large volumes of real-time data. Greater personalisation throughout the continuous glucose monitoring journey, with a focus on usability, may improve the benefits derived from the device and reduce the burden of self-management. Healthcare professionals may have unconscious biases that affect the provision of continuous glucose monitors due to deprivation, education, age, ethnicity and other characteristics.

CONCLUSIONS

Continuous glucose monitoring exerts a dose-dependent response; the more it is used, the more effective it is. For optimal use, continuous glucose monitors must not just reduce the burden of management in one dimension but facilitate net improvement in all domains of self-management for all users.

Diabetes Stigma and Clinical Outcomes: An International Review

Diabetes stigma is the social burden of living with diabetes. People with diabetes may experience or perceive an adverse social judgment, prejudice, or stereotype about living with diabetes at work, school, in healthcare settings, popular culture, or relationships. This review describes the methods that have been used to assess diabetes stigma, and explores the prevalence of diabetes stigma, associated sociodemographic and socioeconomic factors, cultural factors, and how diabetes stigma is associated with clinical outcomes, including HbA1c levels, diabetic ketoacidosis, severe hypoglycemia, and chronic complications, in addition to psychosocial complications in youth, adolescents, and adults with type 1 diabetes (T1D) and type 2 diabetes (T2D). The prevalence of diabetes stigma has been reported as high as 78% in adults with T1D, 70% in adults with T2D, 98% in youth and adolescents with T1D, and is unknown in youth and adolescents with T2D. Diabetes stigma has been associated with lower psychosocial functioning, decreased self-care behaviors, higher HbA1c levels, and higher frequency of diabetes complications in adults with T1D and T2D. In adolescents and young adults with T1D, diabetes stigma is associated with lower psychosocial functioning, higher HbA1c levels, and higher frequency of diabetic ketoacidosis and severe hypoglycemia episodes in addition to chronic complications. In youth and adolescents with T2D, one study demonstrated an association of diabetes stigma with lower psychosocial functioning, higher HbA1c levels, and presence of retinopathy. Gaps exist in our understanding of the mechanisms of diabetes stigma, particularly in youth and adolescents with T2D.

Perceived stigma among diabetic patients and their caregivers: a review

AIMS

Considerable number of studies in the existing literature indicate the existence of stigma related to many diseases, disabilities, and disorders, but less attention has been given to diabetes-related stigma. This narrative review of literature aims to explore the existence of stigma surrounding type 1 diabetes mellitus (T1DM).

METHODS

Literature were searched using search engines, Google Scholar, PubMed, and Scopus electronic databases published from year 2000 to 2020. Both qualitative and quantitative studies focusing on the stigma associated with T1DM were included. A total of 21 articles met the inclusion criteria. Thematic analysis of collected research material was done.

RESULTS

Results provided substantial evidence that stigma associated with T1DM was experienced by T1DM patients and their caregivers at some point in their lives and it had affected their lives in different domains such as difficulty finding a spouse, discrimination at employment opportunities, educational institutions, management of disease, being misjudged as a druggie, poor quality of life of the patient and caregiver, depressive symptoms among parents of patients, constant worrying of their child's disease management, and so on.

CONCLUSION

Stigma related to T1DM is experienced by individuals suffering from it, and it is widespread. It not only affects the sufferers but their loved ones also. To reduce and cope-up with stigma, there is a need to increase public education and awareness at a mass level. Further research and awareness will serve to build our understanding of the experience of diabetes-related stigma.

"I Haven't Told Anyone but You": Experiences and Biopsychosocial Support Needs of People With Type 2 Diabetes and Binge Eating

Up to 25% of people with type 2 diabetes (T2D) may binge eat which is almost 10 times as many as in the general population. Binge eating is associated with depression, anxiety, and social isolation. Moreover, binge eating may increase the risk of obesity and high blood glucose levels, both of which can accelerate the onset of complications to diabetes and death in people with T2D. Still, little is known about the experiences, needs, and preferences of people with T2D and binge eating that can inform and develop current and future treatment efforts. The aim of the study was therefore to gain in-depth insights into the experiences and biopsychosocial support needs of women and men with T2D and binge eating. Twenty semi-structured individual interviews (65% with females) were conducted and analyzed according to the methodology of Interpretive Description. Four themes were identified: (a) T2D and binge eating: Feeling trapped in a vicious circle; (b) Unwanted outcasts: Responding to continuous criticism; (c) Biomedical relief: Blaming and adjusting the body; and, (d) Silent struggles: Wanting to cease the secrecy. Pertinent to all themes were the guilt, shame, and worries about developing complications that the participants experienced when binge eating despite having T2D. Although binge eating triggered emotional distress, binge eating was at the same time a way of coping with such distress. Implications for treatment and future research are discussed, including the need to systematically assess and address binge eating in routine T2D care.

Perception of Type 2 Diabetes Mellitus (T2DM) patients on diabetes self-care management in Fiji

INTRODUCTION

The prevalence of diabetes has increased globally where Type 2 Diabetes Mellitus (T2DM) is more common than any other type of diabetes. Self- care management education of diabetes provides skills and information for diabetic patients to effectively perform their own self diabetic self-care for optimum glycemic index control. As T2DM is a growing health issue in Fiji, promoting diabetes self manages among patients is a need, however there is lack of evidence in this regard. Therefore, the aim of this study is to explore the perception of T2DM patients on diabetic self-care management.

METHOD

This study used a qualitative method among T2DM patients regarding diabetic self-care management in Central Division, Fiji in 2022. This study was conducted in SOPD (Special Out Patient Department) clinics in the three chosen governmental health centers in the central division of Fiji. The study sample inclusion criteria were only T2DM patients, and no other types of diabetes, patients who are 18years and above, patients who are attending clinic at least for more than 6 months, self-identified as Fijian participants of any ethnicity or gender. The study settings were also purposively selected but the study sample was selected using purposive sampling. In depth interview using semi-structured open-ended questionnaires was used to collect data. Thematic analysis was done, followed by reviewing themes, defining and naming them.

RESULTS

Thirty patients participated in this study. Five major themes emerged from the in-depth interview including; patient factors that affect diabetes self-care management, behavior and attitude towards T2DM self-care management, health services delivery, challenges and barriers faced by patients to perform diabetes self-care management, and recommendations to improve patient self-care management. Patients in this study have good knowledge about T2DM and the self-care management they have to perform. It is the patients' attitude and behavior towards T2DM self-care management that affects patients to perform self-care management. The study also showed patients have gained good knowledge from Health Care Workers (HCW). Socio-economic and psychological status also played a vital part in patients' self-care management. Apart from challenges, there were opportunities to learn the difficulties patients face in order to perform self-care management.

CONCLUSION

The results of this study revealed a combination of individual, cultural, and health systematic related factors as the mots influencer of diabetes self-management among patients in Fiji. Patients have to take ownership of their own health in order to improve their blood sugar reading and reduce complication of diabetes. Tailored interventions that consider patients' belief and address potential challenges would be useful. A lot is needed in terms of upgrading facilities for the comfort of patients and need to collaborate more with other multidisciplinary team and stakeholders.

Experiences and Views of Young People and Health Care Professionals of Using Social Media to Self-Manage Type 1 Diabetes Mellitus: Thematic Synthesis of Qualitative Studies

BACKGROUND

Social media have shown the potential to support type 1 diabetes self-management by providing informational, emotional, and peer-to-peer support. However, the perceptions of young people and health care professionals' (HCPs) toward the use of social media for type 1 diabetes self-management have not been systematically reviewed.

OBJECTIVE

The aim of this study is to explore and summarize the experiences and views of young people with type 1 diabetes and their HCPs on using social media for self-management across qualitative findings.

METHODS

We searched MEDLINE, Embase, PsycINFO, and CINAHL from 2012 to 2023 using Medical Subject Heading terms and text words related to type 1 diabetes and social media. We screened and selected the studies according to the inclusion and exclusion criteria. We quality appraised and characterized the included studies and conducted a thematic synthesis.

RESULTS

We included 11 studies in our synthesis. A total of 9 of them were qualitative and 2 were mixed methods studies. Ten focused on young people with type 1 diabetes and 1 on HCPs. All used content analysis and were of moderate to high quality. Thirteen descriptive themes were yielded by our thematic synthesis, contributing to five analytic themes: (1) differences in how young people interact with social media, (2) characteristics of social media platforms that influence their use and uptake for type 1 diabetes self-management, (3) social media as a source of information, (4) impact on young people's coping and emotional well-being, and (5) impact on support from and relationships with HCPs and services.

CONCLUSIONS

The synthesis suggests that we should consider leveraging social media's peer support capabilities to augment the traditional services for young people with type 1 diabetes. However, the patients may have privacy concerns about HCPs' involvement in their online activities. This warrants an update of existing guidelines to help young people use social media safely for self-managing their diabetes.

Experience of stigma among persons with type 2 diabetes in Africa: a systematic review

Diabetes stigma is a pervasive social phenomenon with significant impacts on individuals living with type 2 diabetes mellitus (T2DM). Despite the negative health impact of diabetes stigma, little is known about the experience of this phenomenon in Africa. This review aimed to synthesize existing quantitative and qualitative studies that examine the experiences and outcomes of T2DM stigma in Africa. A mixed studies review methodology was utilized to conduct this research. Relevant articles were identified by searching the Cumulative Index to Nursing and Allied Health Literature, PubMed, MEDLINE and PsycINFO databases. The mixed method appraisal tool was used to assess the quality of included studies. Of 2626 records identified, 10 articles met the inclusion criteria. The prevalence of diabetes stigma was as high as 70%. The results of the review indicate that individuals with T2DM in Africa are labelled as 'having HIV', 'nearing their death' and 'wasting resources'. These experiences were associated with low quality of life, disease concealment and avoidance of self-management behaviours. The findings highlight the urgent need for further stigma-centric studies to fully understand how T2DM stigma is experienced in Africa. The evidence from such studies would inform the development and evaluation of effective interventions to address this social consequence of T2DM.

Protocol of a Prospective Observational Study on Lifestyle and Quality of Life in Adults with Type 1 Diabetes in Japan

INTRODUCTION

Recent studies have shown that the quality of life (QOL) of people living with type 1 diabetes (T1D) is poor and must be improved. However, the living situation and QOL of adults living with T1D in Japan have not been fully clarified. This study will examine their lifestyle, QOL, and clinical situation, as well as the relationships between them.

METHODS

This is a prospective, 5-year follow-up observational study. Between December 2019 and September 2021, we enrolled adults in Japan who were living with T1D and receiving insulin therapy, and are acquiring longitudinal clinical data and the responses to seven questionnaires regarding lifestyle and QOL. The primary study outcomes are (1) the relationship between Problem Areas in Diabetes (PAID) scores and various factors including demographic data, clinical characteristics, medical history, lifestyle habits, treatment history, biochemical data, and the scores of questionnaires; and (2) the relationship between Beck Depression Inventory (BDI)-II scores and various factors aforementioned. The secondary outcomes are the relationships between various factors aforementioned and each of the following: (1) blood glucose control, (2) blood lipid control, (3) dietary patterns, (4) fear of hypoglycemia, (5) sleep patterns, and (6) physical activity.

PLANNED OUTCOME

We registered 352 participants. The median age was 49 (41-63) years, and the median duration of T1D was 13 (8-20) years. All the results will be available in 2026. We expect to clarify the factors associated with decreased QOL, and that this knowledge will contribute to improving QOL in adults in Japan who are living with T1D and receiving insulin therapy.

TRIAL REGISTRATION

Clinical Trials.gov identifier, UMIN000044088.

Impact of Negative or Stigmatizing Messages on Diabetes Outcomes: An Integrative Review

PURPOSE

The purpose was to determine if negative or stigmatizing language and messaging have an impact on diabetes distress, outcomes, or care behaviors in people with diabetes. Since 2012, when the first language position statement was published, the way health care professionals talk to people with diabetes has been an ongoing topic of discussion. However, there have been no recent literature reviews evaluating the impact of problem language on outcomes among people with type 1 and type 2 diabetes.

METHODS

An integrative review was conducted using 4 electronic databases: CINAHL, Embase, Web of Science, and Medline (Ovid). Studies reporting on diabetes, language, stigma, diabetes distress, glycemic outcomes, and self-care behaviors were included.

RESULTS

The review included 9 studies, all of which were of high quality. The impact of negative or stigmatizing language on self-care behaviors was the most commonly addressed outcome. Whereas some studies revealed no change, others reported a decrease in self-care behaviors by people with diabetes who had negative perceptions of provider messages. Actual or perceived use of negative or stigmatizing language is linked to higher A1C. Four studies reported an association between messages and diabetes distress.

CONCLUSIONS

Negative/stigmatizing language has both an immediate and long-term effect on people with diabetes. The inconsistent approaches to studying language in diabetes makes it challenging to compare outcomes and identify themes. Future research is needed to identify effective interventions to change the messages in diabetes.

"Shame on Me": Exploring the Role of Self-Stigma in Psychological Outcomes Among Type 2 Diabetes Patients in Hong Kong

BACKGROUND

Studies have suggested that type 2 diabetes mellitus (T2DM) are at risk of self-stigmatization (i.e., internalized sense of shame about having diabetes). Self-stigma has been found to be associated with poorer psychological outcomes among chronic disease patients; relevant studies examining such an association and its psychosocial mechanisms are scarce among Chinese T2DM patients. This study aimed to examine the association between self-stigma and psychological outcomes among T2DM patients in Hong Kong. Self-stigma was hypothesized to be associated with higher psychological distress and lower quality of life (QoL). Such associations were also hypothesized to be mediated by lower perceived social support, lower self-care self-efficacy, plus higher self-perceived burden to significant others.

METHODS

T2DM patients (N = 206) recruited from hospitals and clinics in Hong Kong were invited to complete a cross-sectional survey measuring the aforementioned variables.

RESULTS

After controlling for covariates, multiple mediation analysis results indicated the indirect effects from self-stigma to psychological distress via increased self-perceived burden (β = 0.07; 95% CI = 0.02, 0.15) and decreased self-care self-efficacy (β = 0.05; 95% CI = 0.01, 0.11) were significant. Moreover, the indirect effect from self-stigma to QoL via decreased self-care self-efficacy was also significant (β = -0.07; 95% CI = -0.14, -0.02). After considering the mediators, the direct effects from self-stigma to higher psychological distress and lower QoL remained significant (βs = 0.15 and -0.15 respectively, ps < .05).

CONCLUSIONS

Self-stigma could be linked to poorer psychological outcomes through increased self-perceived burden and decreased self-care self-efficacy among T2DM patients. Targeting those variables when designing interventions might facilitate those patients' psychological adjustments.

The Experiences of People Who Smoke With Type 2 Diabetes: A Qualitative Interview Study Using the Capability, Opportunity, Motivation, and Behavior Model

ABSTRACT

Few interventions to support smoking cessation include content specifically about diabetes. This is problematic, as people with diabetes face unique challenges when they stop smoking. The purpose of this study was to understand patients' needs and challenges in relation to smoking with Type 2 diabetes and assess the acceptability of a text message intervention to support smoking cessation. People who smoke and have Type 2 diabetes in the United States and the United Kingdom were recruited to participate in semistructured interviews (n = 20), guided by the Capability, Opportunity, Motivation, and Behavior model. A combination of inductive and deductive approaches with framework analysis was used to analyze the data. Results indicated that the participants' experiences related to the constructs of the Capability, Opportunity, Motivation, and Behavior model and the categories of mental health and diabetes distress were also notable parts of their experiences. Results can be used to guide intervention development in this unique group.