Predictors of diabetes-related distress before and after FreeStyle Libre-1 use: Lessons from the Association of British Clinical Diabetologists nationwide study

Type 1 diabetes-related distress: Current implications in care

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

Effect of intermittently scanned continuous glucose monitoring in people with diabetes with a psychosocial indication for initiation

AIM

To understand the effect of intermittently scanned continuous glucose monitoring (isCGM) in people with diabetes with a 'psychosocial' indication for access.

METHODS

The study utilized baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes in the UK. Diabetes-related distress (DRD) was assessed using the two-item diabetes-related distress scale (DDS). Participants were categorized into two groups: high DRD (DDS score ≥ 3) and lower DRD (DDS score < 3). The t-test was used to assess the difference in the pre- and post-isCGM continuous variables.

RESULTS

The study consisted of 17 036 people with diabetes, with 1314 (7%) using isCGM for 'psychosocial' reasons. Follow-up data were available for 327 participants, 322 (99%) of whom had type 1 diabetes with a median diabetes duration of 15 years; 75% (n = 241) had high levels of DRD. With the initiation of isCGM, after a mean follow-up period of 6.9 months, there was a significant reduction in DDS score; 4 at baseline versus 2.5 at follow-up (P < .001). The prevalence of high DRD reduced from 76% to 38% at follow-up (50% reduction in DRD, P < .001). There was also a significant reduction in HbA1c (78.5 mmol/mol [9.3%] at baseline vs. 66.5 mmol/mol [8.2%] at follow-up; P < .001). This group also experienced an 87% reduction in hospital admissions because of hyperglycaemia/diabetic ketoacidosis (P < .001).

CONCLUSION

People with diabetes who had isCGM initiated for a psychosocial indication had high levels of DRD and HbA1c, which improved with the use of isCGM.

Clinical features of type 1 diabetes in older adults and the impact of intermittently scanned continuous glucose monitoring: An Association of British Clinical Diabetologists (ABCD) study

AIMS

To evaluate the clinical features and impact of flash glucose monitoring in older adults with type 1 diabetes (T1D) across age groups defined as young-old, middle-old, and old-old.

MATERIALS AND METHODS

Clinicians were invited to submit anonymized intermittently scanned continuous glucose monitoring (isCGM) user data to a secure web-based tool within the National Health Service secure network. We collected baseline data before isCGM initiation, such as demographics, glycated haemoglobin (HbA1c) values from the previous 12 months, Gold scores and Diabetes Distress Scale (DDS2) scores. For analysis, people with diabetes were classified as young-old (65-75 years), middle-old (>75-85 years) and old-old (>85 years). We compared baseline clinical characteristics across the age categories using a t test. All the analyses were performed in R 4.1.2.

RESULTS

The study involved 1171 people with diabetes in the young-old group, 374 in the middle-old group, and 47 in the old-old group. There were no significant differences in baseline HbA1c and DDS2 scores among the young-old, middle-old, and old-old age groups. However, Gold score increased with age (3.20 [±1.91] in the young-old vs. 3.46 [±1.94] in the middle-old vs. 4.05 [±2.28] in the old-old group; p < 0.0001). This study showed reduced uptake of insulin pumps (p = 0.005) and structured education (Dose Adjustment For Normal Eating [DAFNE] course; p = 0.007) in the middle-old and old-old populations compared to the young-old population with T1D. With median isCGM use of 7 months, there was a significant improvement in HbA1c in the young-old (p < 0.001) and old-old groups, but not in the middle-old group. Diabetes-related distress score (measured by the DDS2) improved in all three age groups (p < 0.001) and Gold score improved (p < 0.001) in the young-old and old-old populations but not in the middle-old population. There was also a significant improvement in resource utilization across the three age categories following the use of is CGM.

CONCLUSION

This study demonstrated significant differences in hypoglycaemia awareness and insulin pump use across the older age groups of adults with T1D. The implementation of isCGM demonstrated significant improvements in HbA1c, diabetes-related distress, hypoglycaemia unawareness, and resource utilization in older adults with T1D.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Prevalence of impaired awareness of hypoglycaemia in people with diabetes mellitus: A systematic review and meta-analysis from 21 countries and regions

AIMS

Impaired awareness of hypoglycaemia (IAH) is a complication of glucose-lowering therapies for diabetes. The purpose of this review was to estimate the pooled prevalence of IAH and unawareness of hypoglycaemia (UAH).

METHODS

We searched the major databases from inception to 8 August 2022 and included all cross-sectional and cohort studies reporting IAH prevalence in people with diabetes. A random-effects model was used to pool effect values. Subgroup analysis and meta-regression were used to identify study-level characteristics affecting prevalence.

RESULTS

Sixty-two studies from 21 countries published between 2000 and 2022 were included, with 39,180 participants (type 1 diabetes: 19,304 vs. Type 2 diabetes: 14,650). The pooled prevalence was 23.2% (95% CI: 18.4%-29.3%) via the Clarke questionnaire, 26.2% (95% CI: 22.9%-29.9%) via the Gold score, and 58.5% (95% CI: 53.0%-64.6%) via the Pedersen-Bjergaard method, all from studies classified as presenting a moderate and low risk of bias. The prevalence of IAH was generally higher in people with type 1 diabetes than in those with type 2 diabetes and lowest in Europe. Meta-regression results show that the duration of diabetes was a factor influencing the prevalence of IAH. The prevalence of UAH by the Pedersen-Bjergaard method was 17.6 (95% CI: 14.9%-20.3%).

CONCLUSIONS

IAH is a prevalent risk event among people with type 1 and type 2 diabetes, showing clinical heterogeneity and regional variability. UAH, an adverse progression of IAH, is also a serious burden. More primary research on the prevalence of IAH is needed in areas with a high diabetes burden.

Time in range following flash glucose monitoring: Relationship with glycaemic control, diabetes-related distress and resource utilisation in the Association of British Clinical Diabetologists national audit

AIMS

The aim of this study was to understand the relationship between time in range (TIR) achieved using the isCGM with changes in glycaemic control, diabetes-related distress (DRD) and resource utilisation in people living with diabetes.

METHODS

Clinicians from 106 National Health System (NHS) UK hospitals submitted isCGM user baseline and follow-up data in a web-based tool held within the UK NHS network. Linear regression analysis was used to identify the relationship between follow-up glucose TIR (3.9-10 mmol/L) categories (TIR% 50-70 and TIR% >70) with change in haemoglobin A1c (HbA1c), DRD and Gold score (measure of hypoglycaemia unawareness, where a score ≥4 suggests impaired awareness of hypoglycaemia).

RESULTS

Of 16,427 participants, 1241 had TIR follow-up data available. In this cohort, the mean TIR was 44.8% (±22.5). With the use of isCGM, at 7.9 months mean follow-up, improvements were observed in HbA1c (-6.9 [13.5] mmol/mol, p < 0.001), Gold score (-0.35 [1.5], p < 0.001) and Diabetes Distress Screening (-0.73 [1.23], p < 0.001). In the regression analysis restricted to people living with type 1 diabetes, TIR% 50-70 was associated with a -8.9 mmol/mol (±0.6, p < 0.001) reduction in HbA1c; TIR% >70 with a -14 mmol/mol (±0.8, p < 0.001) reduction in HbA1c. Incremental improvement in TIR% was also associated with significant improvements in Gold score and DRD. TIR% >70 was associated with no hospital admissions due to hypoglycaemia, hyperglycaemia/diabetic ketoacidosis, and a 60% reduction in the paramedic callouts and 77% reduction in the incidence of severe hypoglycaemia.

CONCLUSION

In a large cohort of UK isCGM users, we demonstrate a significant association of higher TIR% with improvement in HbA1c, hypoglycaemia awareness, DRD and resource utilisation.

Commencement of flash glucose monitoring is associated with a decreased rate of depressive disorders among persons with diabetes (FLARE-NL7)

INTRODUCTION

Depressive disorders are more common among persons with diabetes, as compared with persons without diabetes. The burden of glucose management is known to associate with depressive symptoms. This study aims to assess the effects of commencement of FreeStyle Libre flash glucose monitoring (FSL-FGM) on the mental health status of persons with diabetes.

RESEARCH DESIGN AND METHODS

Post-hoc analysis of data from a 1-year prospective nationwide FSL-FGM registry. Participants who used FSL-FGM for 12 months and completed the 12-Item Short Form Health Survey version 2 (SF-12^v2) questionnaires at baseline, 6 and 12 months were included. An SF-12^v2 Mental Component Score (MCS) of ≤45 was used as a cut-off to discriminate between persons with and without a depressive disorder.

RESULTS

A total of 674 patients were included with a mean age of 48.2 (±15.8) years, 51.2% men, 78.2% type 1 diabetes and baseline HbA1c 62.8 (±13.4) mmol/mol (7.9±1.2%). At baseline, 235 (34.9%) persons had an SF-12 MCS ≤45 while after 6 and 12 months these numbers decreased: 202 (30.0%, p<0.01) and 173 (25.7%, p<0.01). Overall, MCS improved from 48.5 at baseline to 50.7 after 6 months and 51.3 after 12 months. In multivariable regression analysis, age and MCS at baseline were associated with improvement of MCS after 12 months of FSL-FGM use.

CONCLUSIONS

This analysis suggests that use of FSL-FGM is associated with a decreased rate of depressive disorders among persons with diabetes. Future studies are needed to corroborate these findings.