1
|
McKechnie V, Khan S, Saunders R, Amiel SA, Gonder-Frederick LA, Oliver N. Psychometric validation of the hyperglycaemia avoidance scale UK (HAS-UK). Diabet Med 2024:e15342. [PMID: 38687846 DOI: 10.1111/dme.15342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 04/11/2024] [Accepted: 04/18/2024] [Indexed: 05/02/2024]
Abstract
AIMS Hyperglycaemia aversion in type 1 diabetes can be associated with severe hypoglycaemia and impaired awareness of hypoglycaemia but is not routinely assessed clinically. This study aimed to undertake the first psychometric validation of the UK version of the Hyperglycaemia Avoidance Scale (HAS-UK). METHODS The HAS-UK was completed by adults with type 1 diabetes in three separate research studies. Psychometric properties were evaluated, using exploratory factor analysis, internal consistency, and convergent validity. RESULTS Of the 431 participants who completed the HAS-UK in the three studies, mean age was 49.5 years, and 58.0% were women. Mean duration of diabetes was 29 years, with 192 (44.5%) using multiple daily injections and 229 (53.1%) using an insulin pump. Five participants were excluded from analyses due to incomplete HAS-UK responses. Exploratory factor analysis revealed a 3-factor solution, with acceptable internal consistency for 'worry' and 'blood glucose decisions' factors. HAS-UK total score was higher in those using insulin pumps versus multiple daily injections, and 'blood glucose decisions' score was higher in those using a continuous blood glucose sensor versus a meter. CONCLUSIONS The HAS-UK is a reliable measure with acceptable structural validity and is likely to be useful for evaluating hyperglycaemia aversion in people with type 1 diabetes. Future research would benefit from investigating further psychometric properties including test-retest reliability, sensitivity to change, and clinical significance of scores.
Collapse
Affiliation(s)
- Vicky McKechnie
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Clinical Health Psychology and Neuropsychology, Imperial College Healthcare NHS Trust and West London NHS Trust, London, UK
| | - Shaila Khan
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Rob Saunders
- CORE Data Lab, Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational, and Health Psychology, University College London, London, UK
| | - Stephanie A Amiel
- Department of Diabetes, Faculty of Life Sciences, King's College London, London, UK
| | - Linda A Gonder-Frederick
- Center for Diabetes Technology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| |
Collapse
|
2
|
Rodríguez-Muñoz A, Picón-César MJ, Tinahones FJ, Martínez-Montoro JI. Type 1 diabetes-related distress: Current implications in care. Eur J Intern Med 2024:S0953-6205(24)00136-5. [PMID: 38609810 DOI: 10.1016/j.ejim.2024.03.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 03/18/2024] [Accepted: 03/25/2024] [Indexed: 04/14/2024]
Abstract
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.
Collapse
Affiliation(s)
- Alba Rodríguez-Muñoz
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain
| | - María José Picón-César
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain; Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco J Tinahones
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain; Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Faculty of Medicine, University of Málaga, Málaga, Spain
| | - José Ignacio Martínez-Montoro
- Department of Endocrinology and Nutrition, Virgen de la Victoria University Hospital, Málaga, Spain; Instituto de Investigación Biomédica de Málaga (IBIMA)-Plataforma Bionand, Málaga, Spain; Centro de Investigación Biomédica en Red-Fisiopatología de la Obesidad y Nutrición (CIBEROBN), Instituto de Salud Carlos III, Madrid, Spain; Faculty of Medicine, University of Málaga, Málaga, Spain.
| |
Collapse
|
3
|
Hermanns N, Kulzer B, Ehrmann D. Person-reported outcomes in diabetes care: What are they and why are they so important? Diabetes Obes Metab 2024; 26 Suppl 1:30-45. [PMID: 38311448 DOI: 10.1111/dom.15471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 01/10/2024] [Accepted: 01/12/2024] [Indexed: 02/06/2024]
Abstract
In this review, we aim to show how person-reported outcomes (PROs) and person-reported experiences (PREs) can significantly contribute to the way diabetes care is delivered, the involvement of people with diabetes in diabetes care, and the collaboration between health care professionals and people with diabetes. This review focuses on the definition and measurement of PROs and PREs, the importance of PROs and PREs for person-centred diabetes care, and integrating the perspectives of people with diabetes in the evaluation of medical, psychological and technological interventions. PROs have been increasingly accepted by Health Technology Assessment bodies and are therefore valued in the context of reimbursement decisions and consequently by regulators and other health care stakeholders for the allocation of health care resources. Furthermore, the review identified current challenges to the assessment and use of PROs and PREs in clinical care and research. These challenges relate to the combination of questionnaires and ecological momentary assessment for measuring PROs and PREs, lack of consensus on a core outcome set, limited sensitivity to change within many measures and insufficient standardization of what can be considered a minimal clinically important difference. Another issue that has not been sufficiently addressed is the involvement of people with diabetes in the design and development of measures to assess PROs and PREs.
Collapse
Affiliation(s)
- Norbert Hermanns
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, Otto-Friedrich-University of Bamberg, Bamberg, Germany
| | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, Otto-Friedrich-University of Bamberg, Bamberg, Germany
| | - Dominic Ehrmann
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, Otto-Friedrich-University of Bamberg, Bamberg, Germany
| |
Collapse
|
4
|
Zuniga-Kennedy M, Wang OH, Fonseca LM, Cleveland MJ, Bulger JD, Grinspoon E, Hansen D, Hawks ZW, Jung L, Singh S, Sliwinski M, Verdejo A, Miller KM, Weinstock RS, Germine L, Chaytor N. Nocturnal hypoglycemia is associated with next day cognitive performance in adults with type 1 diabetes: Pilot data from the GluCog study. Clin Neuropsychol 2024:1-20. [PMID: 38380810 DOI: 10.1080/13854046.2024.2315749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/11/2024] [Indexed: 02/22/2024]
Abstract
OBJECTIVE Individuals with type 1 diabetes (T1D) have increased risk for cognitive dysfunction and high rates of sleep disturbance. Despite associations between glycemia and cognitive performance using cross-sectional and experimental methods few studies have evaluated this relationship in a naturalistic setting, or the impact of nocturnal versus daytime hypoglycemia. Ecological Momentary Assessment (EMA) may provide insight into the dynamic associations between cognition, affective, and physiological states. The current study couples EMA data with continuous glucose monitoring (CGM) to examine the within-person impact of nocturnal glycemia on next day cognitive performance in adults with T1D. Due to high rates of sleep disturbance and emotional distress in people with T1D, the potential impacts of sleep characteristics and negative affect were also evaluated. METHODS This pilot study utilized EMA in 18 adults with T1D to examine the impact of glycemic excursions, measured using CGM, on cognitive performance, measured via mobile cognitive assessment using the TestMyBrain platform. Multilevel modeling was used to test the within-person effects of nocturnal hypoglycemia and hyperglycemia on next day cognition. RESULTS Results indicated that increases in nocturnal hypoglycemia were associated with slower next day processing speed. This association was not significantly attenuated by negative affect, sleepiness, or sleep quality. CONCLUSIONS These results, while preliminary due to small sample size, showcase the power of intensive longitudinal designs using ambulatory cognitive assessment to uncover novel determinants of cognitive fluctuation in real world settings, an approach that may be utilized in other populations. Findings suggest reducing nocturnal hypoglycemia may improve cognition in adults with T1D.
Collapse
Affiliation(s)
| | - Olivia H Wang
- Elson S, Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | - Luciana M Fonseca
- Elson S, Floyd College of Medicine, Washington State University, Spokane, WA, USA
- Old Age Research Group (PROTER), Department and Institute of Psychiatry, University of Sao Paulo, Sao Paulo, Brazil
| | | | - Jane D Bulger
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Devon Hansen
- Elson S, Floyd College of Medicine, Washington State University, Spokane, WA, USA
| | | | | | - Shifali Singh
- Harvard Medical School, McLean Hospital, Belmont, MA, USA
| | - Martin Sliwinski
- Department of Human Development and Family Studies, Pennsylvania State University, University Park, PA, USA
| | | | | | - Ruth S Weinstock
- Department of Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | | | - Naomi Chaytor
- Elson S, Floyd College of Medicine, Washington State University, Spokane, WA, USA
| |
Collapse
|
5
|
Lehmann G, Ziebell P, Schmitt A, Kulzer B, Hermanns N, Ehrmann D. Explaining improvement in diabetes distress: a longitudinal analysis of the predictive relevance of resilience and acceptance in people with type 1 diabetes. Acta Diabetol 2024; 61:151-159. [PMID: 37747554 PMCID: PMC10866794 DOI: 10.1007/s00592-023-02180-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 09/03/2023] [Indexed: 09/26/2023]
Abstract
AIMS To analyze if midterm improvement in diabetes distress can be explained by resilience, diabetes acceptance, and patient characteristics. METHODS N = 179 adults with type 1 diabetes were enrolled during their stay at a tertiary diabetes center (monocentric enrolment) and followed up over three months in a prospective, observational study ('DIA-LINK1'). Improvement in diabetes distress was assessed as reduction in the Problem Areas in Diabetes Scale score from baseline to follow-up. Resilience (Resilience Scale-13), acceptance (Diabetes Acceptance Scale), and patient characteristics were analyzed as predictors of improvement in diabetes distress using hierarchical multiple regression. RESULTS Greater reductions in diabetes distress were significantly explained by lower diabetes acceptance at baseline (β = -0.34, p < 0.01), while resilience, diabetes complications, and other person-related variables were not significantly related to changes in diabetes distress (all p > 0.05). When change in diabetes acceptance from baseline to follow-up was added to the model, improved diabetes distress was explained by increasing diabetes acceptance (β = 0.41, p < 0.01) and a shorter duration of diabetes (β = -0.18, p = 0.03), while baseline diabetes acceptance was no longer significantly associated (β = -0.14, p > 0.05). CONCLUSIONS Diabetes acceptance is inversely related to diabetes distress, and increasing acceptance explained greater improvement in diabetes distress. These findings suggest that increasing diabetes acceptance may facilitate the reduction of diabetes distress. Treatment approaches targeting acceptance might be useful for the mental healthcare of people with type 1 diabetes and clinically elevated diabetes distress.
Collapse
Affiliation(s)
- Gina Lehmann
- Institute of Psychology, Julius-Maximilians-University of Würzburg, Würzburg, Germany
| | - Philipp Ziebell
- Institute of Psychology, Julius-Maximilians-University of Würzburg, Würzburg, Germany
| | - Andreas Schmitt
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Bernhard Kulzer
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Department for Psychology, Otto-Friedrich-University of Bamberg, Bamberg, Germany
| | - Norbert Hermanns
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, 97980, Bad Mergentheim, Germany
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
- Department for Psychology, Otto-Friedrich-University of Bamberg, Bamberg, Germany
| | - Dominic Ehrmann
- Research Institute of the Diabetes Academy Mergentheim (FIDAM), Johann-Hammer-Str. 24, 97980, Bad Mergentheim, Germany.
- German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany.
- Department for Psychology, Otto-Friedrich-University of Bamberg, Bamberg, Germany.
| |
Collapse
|
6
|
Berg CA, Tracy EL, Boggess SB, Butner JE, Loyola MDR, Wiebe DJ. Global stress and daily general and type 1 diabetes stressors and links to daily affect and diabetes outcomes during emerging adulthood. J Behav Med 2024; 47:82-93. [PMID: 37389781 DOI: 10.1007/s10865-023-00425-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/25/2023] [Indexed: 07/01/2023]
Abstract
We examined how global stress and general stressors of daily life relate to emotional well-being and type 1 diabetes (T1D) outcomes and amplify the effects of diabetes stressors in emerging adults. Two-hundred and seven 18-19-year-olds with T1D (duration 8.47 years) completed the Perceived Stress Scale (global stress) and a daily diary assessing daily diabetes and general stressors, positive and negative affect, self-care behaviors, and blood glucose (BG). Multi-level analyses indicated that global stress and within-person daily general and diabetes stressors were associated with more negative and less positive affect. In addition, general stress (between-person) was associated with more negative affect. Global stress amplified the association between daily diabetes stressors and negative affect, with greater affect reactivity to stress for those experiencing higher global stress. Global stress and both within- and between-person diabetes stressors were associated with lower self-care and higher BG. Emerging adults' general stressors in their daily lives relate to poorer well-being beyond the experience of diabetes stressors.
Collapse
|
7
|
de Wit M, van Raalte DH, van den Berg K, Racca C, Muijs LT, Lutgers HL, Siegelaar SE, Serné E, Snoek FJ. Glucose variability and mood in people with type 1 diabetes using ecological momentary assessment. J Psychosom Res 2023; 173:111477. [PMID: 37643560 DOI: 10.1016/j.jpsychores.2023.111477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 08/21/2023] [Accepted: 08/22/2023] [Indexed: 08/31/2023]
Abstract
OBJECTIVE Mood fluctuations related to blood glucose excursions are a commonly reported source of diabetes-distress, but research is scarce. We aimed to assess the relationship between real-time glucose variability and mood in adults with type 1 diabetes (T1D) using ecological momentary assessments. METHODS In this prospective observational study, participants wore a masked continuous glucose monitor and received prompts on their smartphone 6 times a day to answer questions about their current mood (Profile Of Mood States (POMS)-SF (dimensions: Anxiety, Depressive symptoms, Anger, Fatigue, Vigor)) for 14 days. Mixed model analyses examined associations over time between daily Coefficient of Variation (CV) of blood glucose and mean and variability (CV) of POMS scores. Further, within-person differences in sleep and nocturnal hypoglycemia were explored. RESULTS 18 people with T1D (10 female, mean age 44.3 years) participated. A total of 264 out of 367 days (70.2%) could be included in the analyses. No overall significant associations were found between CV of blood glucose and mean and CV of POMS scores, however, nocturnal hypoglycemia moderated the associations between CV of blood glucose and POMS scales (mean Fatigue Estimate 1.998, p < .006, mean Vigor Estimate -3.308, p < .001; CV Anger Estimate 0.731p = 0.02, CV Vigor Estimate -0.525, p = .006). CONCLUSION We found no overall relationship between real-time glycemic variability and mood per day. Further research into within-person differences such as sleep and nocturnal hypoglycemia is warranted.
Collapse
Affiliation(s)
- Maartje de Wit
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Medical Psychology, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands.
| | - Daniël H van Raalte
- Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Vasculair Medicine, de Boelelaan 1117, Amsterdam, the Netherlands; Diabetes Center Amsterdam UMC, location Vrije Universiteit Amsterdam, Vasculair Medicine, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovasculair Science, Amsterdam, the Netherlands
| | - Kirsten van den Berg
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Medical Psychology, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands
| | - Catherina Racca
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands
| | - Linda T Muijs
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Medical Psychology, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands
| | - Helen L Lutgers
- Medical Center Leeuwarden, Department of Internal Medicine, Leeuwarden, the Netherlands
| | - Sarah E Siegelaar
- Amsterdam UMC, location University of Amsterdam, Department of Endocrinology and Metabolism, Meibergdreef 9, Amsterdam, the Netherlands; Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands
| | - Erik Serné
- Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Endocrinology and Metabolism, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam UMC, location Vrije Universiteit Amsterdam, Vasculair Medicine, de Boelelaan 1117, Amsterdam, the Netherlands; Diabetes Center Amsterdam UMC, location Vrije Universiteit Amsterdam, Vasculair Medicine, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Cardiovasculair Science, Amsterdam, the Netherlands
| | - Frank J Snoek
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Medical Psychology, de Boelelaan 1117, Amsterdam, the Netherlands; Amsterdam Public Health, Mental Health, Amsterdam, the Netherlands
| |
Collapse
|
8
|
Søholm U, Zaremba N, Broadley M, Axelsen JL, Divilly P, Martine-Edith G, Amiel SA, Mader JK, Pedersen-Bjergaard U, McCrimmon RJ, Renard E, Evans M, de Galan B, Heller S, Hendrieckx C, Choudhary P, Speight J, Pouwer F. Assessing the Content Validity, Acceptability, and Feasibility of the Hypo-METRICS App: Survey and Interview Study. JMIR Diabetes 2023; 8:e42100. [PMID: 37773626 PMCID: PMC10576226 DOI: 10.2196/42100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 06/02/2023] [Accepted: 08/16/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The Hypoglycaemia - MEasurement, ThResholds and ImpaCtS (Hypo-METRICS) smartphone app was developed to investigate the impact of hypoglycemia on daily functioning in adults with type 1 diabetes mellitus or insulin-treated type 2 diabetes mellitus. The app uses ecological momentary assessments, thereby minimizing recall bias and maximizing ecological validity. It was used in the Hypo-METRICS study, a European multicenter observational study wherein participants wore a blinded continuous glucose monitoring device and completed the app assessments 3 times daily for 70 days. OBJECTIVE The 3 aims of the study were to explore the content validity of the app, the acceptability and feasibility of using the app for the duration of the Hypo-METRICS study, and suggestions for future versions of the app. METHODS Participants who had completed the 70-day Hypo-METRICS study in the United Kingdom were invited to participate in a brief web-based survey and an interview (approximately 1h) to explore their experiences with the app during the Hypo-METRICS study. Thematic analysis of the qualitative data was conducted using both deductive and inductive methods. RESULTS A total of 18 adults with diabetes (type 1 diabetes: n=10, 56%; 5/10, 50% female; mean age 47, SD 16 years; type 2 diabetes: n=8, 44%; 2/8, 25% female; mean age 61, SD 9 years) filled out the survey and were interviewed. In exploring content validity, participants overall described the Hypo-METRICS app as relevant, understandable, and comprehensive. In total, 3 themes were derived: hypoglycemia symptoms and experiences are idiosyncratic; it was easy to select ratings on the app, but day-to-day changes were perceived as minimal; and instructions could be improved. Participants offered suggestions for changes or additional questions and functions that could increase engagement and improve content (such as providing more examples with the questions). In exploring acceptability and feasibility, 5 themes were derived: helping science and people with diabetes; easy to fit in, but more flexibility wanted; hypoglycemia delaying responses and increasing completion time; design, functionality, and customizability of the app; and limited change in awareness of symptoms and impact. Participants described using the app as a positive experience overall and as having a possible, although limited, intervention effect in terms of both hypoglycemia awareness and personal impact. CONCLUSIONS The Hypo-METRICS app shows promise as a new research tool to assess the impact of hypoglycemia on an individual's daily functioning. Despite suggested improvements, participants' responses indicated that the app has satisfactory content validity, overall fits in with everyday life, and is suitable for a 10-week research study. Although developed for research purposes, real-time assessments may have clinical value for monitoring and reviewing hypoglycemia symptom awareness and personal impact.
Collapse
Affiliation(s)
- Uffe Søholm
- Medical & Science, Patient Focused Drug Development, Novo Nordisk A/S, Søborg, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Natalie Zaremba
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Patrick Divilly
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Gilberte Martine-Edith
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Julia K Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Montpellier, France
| | - Mark Evans
- Welcome-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Internal Medicine, Division of Endocrinology and Metabolic Disease, Maastricht University Medical Centre, Maastricht, Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Christel Hendrieckx
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Australia
| | - Pratik Choudhary
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- Steno Diabetes Center Odense, Odense, Denmark
| |
Collapse
|
9
|
Hernandez R, Hoogendoorn C, Gonzalez JS, Jin H, Pyatak EA, Spruijt-Metz D, Junghaenel DU, Lee PJ, Schneider S. Reliability and Validity of Noncognitive Ecological Momentary Assessment Survey Response Times as an Indicator of Cognitive Processing Speed in People's Natural Environment: Intensive Longitudinal Study. JMIR Mhealth Uhealth 2023; 11:e45203. [PMID: 37252787 PMCID: PMC10265432 DOI: 10.2196/45203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 03/14/2023] [Accepted: 04/27/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Various populations with chronic conditions are at risk for decreased cognitive performance, making assessment of their cognition important. Formal mobile cognitive assessments measure cognitive performance with greater ecological validity than traditional laboratory-based testing but add to participant task demands. Given that responding to a survey is considered a cognitively demanding task itself, information that is passively collected as a by-product of ecological momentary assessment (EMA) may be a means through which people's cognitive performance in their natural environment can be estimated when formal ambulatory cognitive assessment is not feasible. We specifically examined whether the item response times (RTs) to EMA questions (eg, mood) can serve as approximations of cognitive processing speed. OBJECTIVE This study aims to investigate whether the RTs from noncognitive EMA surveys can serve as approximate indicators of between-person (BP) differences and momentary within-person (WP) variability in cognitive processing speed. METHODS Data from a 2-week EMA study investigating the relationships among glucose, emotion, and functioning in adults with type 1 diabetes were analyzed. Validated mobile cognitive tests assessing processing speed (Symbol Search task) and sustained attention (Go-No Go task) were administered together with noncognitive EMA surveys 5 to 6 times per day via smartphones. Multilevel modeling was used to examine the reliability of EMA RTs, their convergent validity with the Symbol Search task, and their divergent validity with the Go-No Go task. Other tests of the validity of EMA RTs included the examination of their associations with age, depression, fatigue, and the time of day. RESULTS Overall, in BP analyses, evidence was found supporting the reliability and convergent validity of EMA question RTs from even a single repeatedly administered EMA item as a measure of average processing speed. BP correlations between the Symbol Search task and EMA RTs ranged from 0.43 to 0.58 (P<.001). EMA RTs had significant BP associations with age (P<.001), as expected, but not with depression (P=.20) or average fatigue (P=.18). In WP analyses, the RTs to 16 slider items and all 22 EMA items (including the 16 slider items) had acceptable (>0.70) WP reliability. After correcting for unreliability in multilevel models, EMA RTs from most combinations of items showed moderate WP correlations with the Symbol Search task (ranged from 0.29 to 0.58; P<.001) and demonstrated theoretically expected relationships with momentary fatigue and the time of day. The associations between EMA RTs and the Symbol Search task were greater than those between EMA RTs and the Go-No Go task at both the BP and WP levels, providing evidence of divergent validity. CONCLUSIONS Assessing the RTs to EMA items (eg, mood) may be a method of approximating people's average levels of and momentary fluctuations in processing speed without adding tasks beyond the survey questions.
Collapse
Affiliation(s)
- Raymond Hernandez
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
| | - Claire Hoogendoorn
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States
- Fleischer Institute for Diabetes and Metabolism, Division of Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Jeffrey S Gonzalez
- Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, NY, United States
- Fleischer Institute for Diabetes and Metabolism, Division of Endocrinology, Department of Medicine, Albert Einstein College of Medicine, Bronx, NY, United States
| | - Haomiao Jin
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
- School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, United Kingdom
| | - Elizabeth A Pyatak
- Chan Division of Occupational Science and Occupational Therapy, University of Southern California, Los Angeles, CA, United States
| | - Donna Spruijt-Metz
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
- Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
- Department of Psychology, University of Southern California, Los Angeles, CA, United States
| | - Doerte U Junghaenel
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
- Department of Psychology, University of Southern California, Los Angeles, CA, United States
| | - Pey-Jiuan Lee
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
| | - Stefan Schneider
- Center of Economic and Social Research, University of Southern California, Los Angeles, CA, United States
- Department of Psychology, University of Southern California, Los Angeles, CA, United States
| |
Collapse
|
10
|
Ehrmann D, Chatwin H, Schmitt A, Soeholm U, Kulzer B, Axelsen JL, Broadley M, Haak T, Pouwer F, Hermanns N. Reduced heart rate variability in people with type 1 diabetes and elevated diabetes distress: Results from the longitudinal observational DIA-LINK1 study. Diabet Med 2023; 40:e15040. [PMID: 36625417 DOI: 10.1111/dme.15040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/16/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023]
Abstract
AIMS People with type 1 diabetes have a higher risk for cardiovascular disease (CVD). Reduced heart rate variability (HRV) is a clinical marker for CVD. In this observational study using continuous HRV measurement across 26 days, we investigated whether psychological stressors (diabetes distress, depressive symptoms) and glycaemic parameters (hypo- and hyperglycaemic exposure, glycaemic variability and HbA1c ) are associated with lower HRV in people with type 1 diabetes. METHODS Data from the non-interventional prospective DIA-LINK1 study were analysed. At baseline, depressive symptoms and diabetes distress were assessed. Glucose values and HRV were recorded daily for 26 days using continuous glucose monitoring (CGM) and a wrist-worn health tracker respectively. Multilevel modelling with participant as nesting factor was used to analyse associations between day-to-day HRV and diabetes distress, depressive symptoms and CGM-derived parameters. RESULTS Data from 149 participants were analysed (age: 38.3 ± 13.1 years, HbA1c : 8.6 ± 1.9%). Participants with elevated diabetes distress had a significantly lower HRV across the 26 days compared to participants without elevated distress (β = -0.28; p = 0.004). Elevated depressive symptoms were not significantly associated with HRV (β = -0.18; p = 0.074). Higher daily exposure to hyperglycaemia (β = -0.44; p = 0.044), higher average exposure to hypoglycaemia (β = -0.18; p = 0.042) and higher HbA1c (β = -0.20; p = 0.018) were associated with reduced HRV across the 26 days. Sensitivity analysis with HRV averaged across all days corroborated these results. CONCLUSIONS Diabetes distress is a clinically meaningful psychosocial stressor that could play a role in the cardiovascular health of people with type 1 diabetes. These findings highlight the need for integrated psychosocial care in diabetes management.
Collapse
Affiliation(s)
- Dominic Ehrmann
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
| | - Hannah Chatwin
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- National Centre for Register-Based Research (NCRR), Aarhus BSS, Aarhus University, Aarhus, Denmark
| | - Andreas Schmitt
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Bad Mergentheim, Germany
| | - Uffe Soeholm
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Medical & Science, Patient Focused Drug Development, Novo Nordisk A/S, Søborg, Denmark
| | - Bernhard Kulzer
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Bad Mergentheim, Germany
| | | | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Thomas Haak
- Diabetes Centre Mergentheim, Diabetes Clinic, Bad Mergentheim, Germany
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Centre Odense (SDCO), Odense, Denmark
- Department of Medical Psychology, 1117 Amsterdam UMC, Amsterdam, The Netherlands
| | - Norbert Hermanns
- Research Institute Diabetes Academy Mergentheim (FIDAM), Bad Mergentheim, Germany
- Department of Clinical Psychology and Psychotherapy, University of Bamberg, Bamberg, Germany
- German Centre for Diabetes Research (DZD), München-Neuherberg, Germany
- Diabetes Centre Mergentheim, Diabetes Clinic, Bad Mergentheim, Germany
| |
Collapse
|
11
|
Mizokami-Stout K, Strong RW, Singh S, Bulger JD, Cleveland M, Grinspoon E, Janess K, Jung L, Miller K, Passell E, Ressler K, Sliwinski MJ, Verdejo A, Weinstock RS, Germine L, Chaytor NS. Glycemic Variability and Fluctuations in Cognitive Status in Adults With Type 1 Diabetes (GluCog): Observational Study Using Ecological Momentary Assessment of Cognition. JMIR Diabetes 2023; 8:e39750. [PMID: 36602848 PMCID: PMC9853340 DOI: 10.2196/39750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 09/06/2022] [Accepted: 09/20/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Individuals with type 1 diabetes represent a population with important vulnerabilities to dynamic physiological, behavioral, and psychological interactions, as well as cognitive processes. Ecological momentary assessment (EMA), a methodological approach used to study intraindividual variation over time, has only recently been used to deliver cognitive assessments in daily life, and many methodological questions remain. The Glycemic Variability and Fluctuations in Cognitive Status in Adults with Type 1 Diabetes (GluCog) study uses EMA to deliver cognitive and self-report measures while simultaneously collecting passive interstitial glucose in adults with type 1 diabetes. OBJECTIVE We aimed to report the results of an EMA optimization pilot and how these data were used to refine the study design of the GluCog study. An optimization pilot was designed to determine whether low-frequency EMA (3 EMAs per day) over more days or high-frequency EMA (6 EMAs per day) for fewer days would result in a better EMA completion rate and capture more hypoglycemia episodes. The secondary aim was to reduce the number of cognitive EMA tasks from 6 to 3. METHODS Baseline cognitive tasks and psychological questionnaires were completed by all the participants (N=20), followed by EMA delivery of brief cognitive and self-report measures for 15 days while wearing a blinded continuous glucose monitor. These data were coded for the presence of hypoglycemia (<70 mg/dL) within 60 minutes of each EMA. The participants were randomized into group A (n=10 for group A and B; starting with 3 EMAs per day for 10 days and then switching to 6 EMAs per day for an additional 5 days) or group B (N=10; starting with 6 EMAs per day for 5 days and then switching to 3 EMAs per day for an additional 10 days). RESULTS A paired samples 2-tailed t test found no significant difference in the completion rate between the 2 schedules (t17=1.16; P=.26; Cohen dz=0.27), with both schedules producing >80% EMA completion. However, more hypoglycemia episodes were captured during the schedule with the 3 EMAs per day than during the schedule with 6 EMAs per day. CONCLUSIONS The results from this EMA optimization pilot guided key design decisions regarding the EMA frequency and study duration for the main GluCog study. The present report responds to the urgent need for systematic and detailed information on EMA study designs, particularly those using cognitive assessments coupled with physiological measures. Given the complexity of EMA studies, choosing the right instruments and assessment schedules is an important aspect of study design and subsequent data interpretation.
Collapse
Affiliation(s)
| | - Roger W Strong
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Shifali Singh
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Jane D Bulger
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Michael Cleveland
- Department of Human Development, Washington State University, Pullman, WA, United States
| | - Elizabeth Grinspoon
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kamille Janess
- Jaeb Center for Health Research, Tampa, FL, United States
| | - Lanee Jung
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kellee Miller
- Jaeb Center for Health Research, Tampa, FL, United States
| | - Eliza Passell
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Kerry Ressler
- The Silvio O Conte Center for Stress Peptide Advanced Research, Education, & Dissemination Center (SPARED), Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA, United States
| | - Martin John Sliwinski
- Department of Human Development and Family Studies, The Pennsylvania State University, State College, PA, United States.,Center for Healthy Aging, Pennsylvania State University, State College, PA, United States
| | | | - Ruth S Weinstock
- Department of Medicine, State University of New York Upstate Medical University, Syracuse, NY, United States
| | - Laura Germine
- Institute for Technology in Psychiatry, McLean Hospital, Belmont, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Naomi S Chaytor
- Department of Community and Behavioral Health, Elson S Floyd College of Medicine, Washington State University, Spokane, WA, United States
| |
Collapse
|