Continuous glucose monitoring in older adults with diabetes: Data from the diabetes prospective follow-up (DPV) registry

AIMS

To analyse predictors for continuous glucose monitoring (CGM) use in people with diabetes aged ≥60 years using insulin therapy and to assess the rates of CGM use during recent years (2019-2021).

RESEARCH DESIGN AND METHODS

Prospective study including 6849 individuals with diabetes and insulin therapy (type 2 diabetes: n = 5320; type 1 diabetes: n = 1529) aged ≥60 years. Data from 129 treatment centres were retrieved from the Diabetes Prospective Follow-up Registry (DPV) in March 2023.

RESULTS

Sensor use in individuals aged ≥60 years has increased in type 1 (2019: 28%, 2020: 39%, 2021: 45%) and type 2 diabetes (2019: 10%, 2020: 16%, 2021: 18%). Predictors for sensor use in older individuals with type 1 diabetes are younger age and CSII use (p < 0.001). Predictors in older individuals with type 2 diabetes are younger age, longer diabetes duration, higher BMI and CSII use (p < 0.001).

CONCLUSIONS

CGM has become more common in older adults with diabetes and will presumably increase further. Age is a predictor for sensor use in older adults with diabetes. Age-related physical barriers and insufficient usability of devices, lack of interest in technologies, but possibly also effects of prejudice on the grounds of age may contribute to this finding.

Reduktion von diabetesbezogenem Distress bei Typ-1- und Typ-2-Diabetes durch eine kognitiv-verhaltenstherapeutische Gruppenintervention

Das Stresserleben durch die Erkrankung Diabetes mellitus stellt für einen Großteil der betroffenen Personen oft eine deutliche Belastung dar, die sich negativ auf das Diabetes-Selbstmanagement und damit auf die Gesundheit der Betroffenen auswirken kann. Das Ziel der vorliegenden Studie war die Evaluation einer diabetesspezifischen kognitiv-verhaltenstherapeutischen Gruppentherapie zur Reduktion des Stresserlebens, bestehend aus sechs Sitzungen für Personen mit Typ-1- oder Typ-2-Diabetes. Vermittelt wurden Techniken zur Stressbewältigung, wie Achtsamkeit und Entspannungsübungen, sowie kognitive Techniken, die auf den Alltag mit der Diabeteserkrankung und damit verbundene Gedanken und Emotionen der Teilnehmenden bezogen waren. Von 52 Personen (51,9% mit Typ-1-Diabetes, 61,5% weiblich, Alter MW= 50,4 Jahre) lagen nach Studienteilnahme Fragebögen vor. Eine signifikante Verbesserung konnte im Problem Areas In Diabetes Questionnaire (Δ6.24 [95%-KI: 1.85–10.62], p=.006), dem Perceived Stress Survey (Δ2.93 [95%-KI: 1.59–4.26], p=.000) und der Diabetes Acceptance Scale (Δ5.5 [95%-KI: 9.07–1.93], p=.003) erreicht werden. Diese erwies sich auch im Follow-Up nach sechs Monaten als stabil. Der selbstberichtete HbA1c-Wert reduzierte sich im Befragungszeitraum bei der Teilstichprobe von N= 40, von der die Daten verfügbar waren, ebenfalls signifikant (Δ0.73 [95%-KI: 0.015–1.452], p=.046). Das Gruppentherapieprogramm zur Stressreduktion kann als eine niedrigschwellige, psychotherapeutische Interventionen zur Reduktion diabetesbezogener Belastungen angesehen werden. Es könnte ein hilfreiches primär- und sekundärpräventives Angebot für stressbelastete Menschen mit Diabetes in der Standardversorgung darstellen.

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

INTRODUCTION

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

METHODS AND ANALYSIS

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

ETHICS AND DISSEMINATION

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

TRIAL REGISTRATION NUMBER

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

Diabetes im Alter – Unterstützung Pflegebedürftiger und ihres Umfeldes

Pflegende An- und Zugehörige leisten einen erheblichen Anteil der häuslichen Pflege von älteren Menschen in Deutschland. Die Pflegesituation geht nicht selten mit biopsychosozialen Belastungen sowohl auf Seiten der Pflegenden als auch der Gepflegten einher. Um eine Gefährdung der Pflegesituation zu vermeiden, sollten Belastungen frühzeitig identifiziert werden. Essenziell ist eine rechtzeitige Aufklärung über Unterstützungs- und Hilfsangebote. Im Kontext der Pflege von Menschen mit Diabetes existieren verschiedene diabetesspezifische Unterstützungsmöglichkeiten (z. B. diabetesorientiertes Pflegeassessment), über die Pflegende informiert werden sollten. Die empathische Würdigung der Belastungen und die Wertschätzung für die Pflegetätigkeit sowie das Hervorheben möglicher positiver Aspekte derselben können entlastend wirken. Im Sinne des Empowerment-Ansatzes sollten sowohl die Bedürfnisse der Pflegenden als auch die der pflegebedürftigen Menschen mit Diabetes in Alltags- und Therapieentscheidungen – falls möglich – miteinbezogen werden.

Diabetes technologies in people with type 1 diabetes mellitus and disordered eating: A systematic review on continuous subcutaneous insulin infusion, continuous glucose monitoring and automated insulin delivery

AIMS

In this systematic review, we aimed (1) to identify and describe research investigating the use of advanced diabetes technologies (continuous subcutaneous insulin infusion, CSII; continuous glucose monitoring, CGM; automated insulin delivery, AID) in people with type 1 diabetes (T1DM) and disordered eating and (2) to discuss potential (dis)advantages of diabetes technology use in this population, derived from previous research.

METHODS

We conducted a systematic literature search in two electronic databases for English articles published between 2000 and 2020 addressing eating disorders and/or dysfunctional eating behaviours and diabetes technology use in children, adolescents and adults with T1DM (PROSPERO ID CRD42020160244).

RESULTS

Of 70 publications initially identified, 17 were included. Overall, evidence on the use of diabetes technologies in people with T1DM and disordered eating is scarce. The majority of the studies reports findings on CSII in people with T1DM and dysfunctional eating behaviours or eating disorders. Findings predominantly stem from observational data and are, in most cases, secondary findings of the respective studies. Providing the greatest flexibility in diabetes management, CSII may have benefits in disordered eating. CGM data may complement the diagnostic process of disordered eating with a physiological indicator of insulin restriction (i.e. time spent in hyperglycaemia).

CONCLUSIONS

Results on possible (dis)advantages of diabetes technology use in people with T1DM and disordered eating are based on observational data, small pilot trials and anecdotical evidence from case reports. Prospective data from larger samples are needed to reliably determine potential effects of diabetes technology on disordered eating in T1DM.

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry

AIM

To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuous subcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII.

RESEARCH DESIGN AND METHODS

Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N = 1404 CSII; N = 8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes.

RESULTS

CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA_1c [60.7 mmol/mol (7.7 ± 0.1%) vs. 62.8% (7.9 ± 0.1%)], lower daily insulin dose (0.49 ± 0.02 vs. 0.61 ± 0.01 IU/kg), fewer days in hospital (8.1 ± 0.12 vs. 11.2 ± 0.11 days/person-year), fewer severe hypoglycaemic events (0.16 ± 0.02 vs. 0.21 ± 0.03 events/person-year) and fewer diabetic ketoacidosis (0.06 ± 0.01 vs. 0.08 ± 0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy.

CONCLUSIONS

A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII.

The Effects of Self-Control on Glucose Utilization in a Hyperinsulinemic Euglycemic Glucose Clamp

Abstract. Background. The glucose hypothesis of self-control posits that acts of self-control may draw upon glucose as a source of energy, leading to a decrease in blood glucose levels after exerting self-control, mirroring the temporary depletion of self-control, but supporting evidence is mixed and inconclusive. This might partly be due to using methods that are not suitable to reliably quantify glucose utilization. Aims. We aimed at examining whether self-control exertion leads to an increase in glucose utilization. Method. In a sample of N = 30 healthy participants (50% women, age 26.5 ± 3.5 years) we combined a hyperinsulinemic euglycemic glucose clamp (a well-established and validated procedure in experimental endocrinology to reliably quantify systemic glucose utilization) with a standard self-control dual-task paradigm. In the first task, the experimental group completed a variation of a paper-and-pencil crossing out letter task (COLT) that demanded self-control; the control group completed a variation of the COLT that did not demand self-control. The second task for both groups was a computerized two-color word Stroop which demanded self-control. Results. We did not find a significant main effect for time, nor a time × group interaction with respect to glucose utilization, which indicates that glucose utilization did not differ significantly over time or between groups. Limitations. Due to the time-consuming and complicated clamp method, our sample was rather small. Conclusion. Our results revealed little evidence for the notion that self-control efforts are associated with a relevant increase in peripheral glucose utilization.

Gamification and Behavior Change Techniques in Diabetes Self-Management Apps

BACKGROUND

Diabetes management apps may have positive effects on diabetes self-management. It remains unclear, however, which app features are particularly effective and encourage sustained app usage. Behavior change techniques (BCTs) and gamification are promising approaches to improve user engagement. However, little is known about the frequency BCTs and gamification techniques (GTs) are actually used. This app review aims to provide an overview of BCTs and GTs in current diabetes management apps.

METHODS

Google's Play Store was searched for applications using a broad search strategy (keyword: "diabetes"). We limited our research to freely available apps. A total of 56 apps matched the inclusion criteria and were reviewed in terms of the features they offer to support self-management. We used a taxonomy comprising 29 BCTs and 17 GTs to evaluate the applications. Two independent raters tested and evaluated each app.

RESULTS

Interrater agreement was high (ICC = .75 for BCTs; ICC = .90 for GTs). An average of 7.4 BCTs (SD = 3.1) and an average of 1.4 out of 17 GTs (SD = 1.6) were implemented in each app. Five out of 29 BCTs accounted for 55.8% of the BCTs identified in total. The GT most often identified was "feedback" and accounted for 50% of the GTs.

CONCLUSIONS

The potential of BCTs and GTs in diabetes management apps has not been fully exploited yet. Only very restricted sets of BCTs and gamification features were implemented. Systematic research on the efficacy of specific BCTs and GTs is needed to provide further guidance for app design.

Music Listening and Stress in Daily Life-a Matter of Timing

Purpose

Despite increasing evidence suggesting that music listening in daily life has stress-reducing effects, studies mostly rely on subjective, retrospective data on music listening. Thus, the temporal dynamics underlying the stress-reducing effect of music listening remain unclear. Therefore, we aimed to examine the temporal dynamics of the associations between stress and music listening by assessing subjective and objective data on music in daily life.

Design

An exploratory Ambulatory Assessment study examining a total of 60 participants (37 women), aged 18 to 34 years (M = 22.4 years, SD = 3.5) was conducted.

Methods

For 1 week, participants answered questions on music listening and stress six times per day via an electronic diary device, which additionally objectively sampled the exact time point of music listening and its duration.

Results

Self-reports on mere music listening were associated with lower stress reports, whereas objectively assessed data was not. However, concerning duration of music listening, both subjective and objective data on music listening showed associations between a minimum of 20 min of music listening and lower stress reports. Concerning the latency, objective data on music listening revealed that the association between stress reports and music listening occurs in a time-delayed manner.

Conclusions

Although the study design does not allow for causal inferences, substantial associations among subjectively and objectively assessed data on music listening were found to differentially affect the experience of stress after music listening. In particular, when focusing on the temporal dynamics, objectively assessed data allowed for a more fine-grained analysis. In consequence, subjectively and objectively reported data on music listening should be assessed jointly when investigating effects of music listening on health. Experimental research with rigorous methodological control is required in order to corroborate our findings in a laboratory setting.

Wünsche, Sorgen und Bedürfnisse bezüglich der Insulinpumpentherapie im Alter: Ergebnisse einer Befragung bei Menschen mit Typ-1-Diabetes mellitus im höheren Lebensalter und von Diabetesfachkräften

Hintergrund Mehr als die Hälfte aller Menschen mit Diabetes in Deutschland ist älter als 65 Jahre. Für eine erfolgreiche Insulinpumpentherapie (Continuous Subcutaneous Insulin Infusion; CSII) im hohen Erwachsenenalter sind Wünsche, Sorgen und Erfahrungen älterer Menschen mit Typ-1-Diabetes, erlebte Barrieren und förderliche Bedingungen von zentraler Bedeutung.

Methodik Ältere Menschen mit Typ-1-Diabetes, die sich mit einer CSII behandeln (n = 136), sowie Fachkräfte aus dem Diabetesbereich (Diabetes Health Care Professionals; HCP; n = 96) nahmen an einem Fragebogensurvey teil, in dem anhand zweier offener Fragen Wünsche, Sorgen und Erfahrungen älterer Menschen mit Typ-1-Diabetes erfasst wurden. Durch systematische, induktive Datenreduktion wurden aus den Antworten zentrale Kategorien und Subkategorien identifiziert.

Ergebnisse Es konnten vier Inhaltskategorien abgeleitet werden: (1) Fremdhilfe, (2) Technische Innovation, (3) Gesundheitspolitik und (4) Umstellung auf ICT. Am häufigsten wurde das Vorhandensein von kompetenter Hilfe von außen durch den HCP aus dem Diabetesbereich sowie durch Angehörige und andere Betroffene gewünscht. Die Befragten formulierten klare Wünsche an ein altersgerechtes Design von Insulinpumpen (z. B. großes Display, Sprachsteuerung). Sorgen der Pumpenträger/-innen bezogen sich u. a. auf Hilflosigkeit, Akutkomplikationen und verschlechterte Stoffwechsellage.

Schlussfolgerung Die Befragten äußerten große Sorgen und Unsicherheiten bezüglich CSII im Alter, auf die seitens der Diabetologie, Industrie und Gesundheitspolitik eingegangen werden sollte, um Insulinpumpentherapie altersgerecht zu gestalten.

Emotion regulation strategies moderate the relationship of fatigue with depersonalization and derealization symptoms

BACKGROUND

The aim of the present study was to investigate the relationships of common emotion regulation strategies (suppression and reappraisal) to self-reported fatigue and depersonalization/derealization symptoms. Specifically, we tested the moderating effect of suppression and reappraisal on the link of fatigue with depersonalization and derealization symptoms. Opposite effects were expected for both emotion regulation strategies assuming that cognitive reappraisal has an adaptive buffering effect, while suppression intensifies the association of fatigue and depersonalization/derealization experiences.

METHODS

In a representative study (N = 2524) we assessed emotion regulation strategies, fatigue, depersonalization/derealization, distress, and demographic variables via questionnaires. 55.5% of the participants were female, mean age was 49.4 (SD = 18.2) years with age groups represented in comparable proportions.

RESULTS

In line with the assumptions, moderated regression analyses revealed an interaction effect of emotion regulation strategies and fatigue. Simple slope analyses indicated a buffering effect of cognitive reappraisal on the positive relation of fatigue with depersonalization and derealization symptoms. In contrast, suppression fosters the positive correlation of fatigue and depersonalization and derealization experiences.

LIMITATIONS

Our study is limited to these two habitual emotion regulation strategies employing a cross sectional design.

CONCLUSION

Our findings provide comprehensive empirical data investigating depersonalization/derealization symptoms from the perspective of emotion regulation research. Cognitive reappraisal might help people suffering from fatigue to prevent depersonalization and derealization tendencies.

Fear of hypoglycemia in patients with type 2 diabetes: The role of interoceptive accuracy and prior episodes of hypoglycemia

OBJECTIVE

Fear of hypoglycemia (FoH) is a limiting factor for diabetes self-management and can have detrimental effects on quality of life. However, relatively little is known about its underlying mechanisms. In line with findings on patients with anxiety disorders, we hypothesized that interoceptive accuracy (IA) might be positively linked to FoH in patients with type 2 diabetes (T2DM).

METHODS

133 patients with T2DM were screened according to the extreme quartiles of the Hypoglycemia Fear Survey worry subscale (HFS-W). Overall, 66 participants (HFS-W<4; HFS-W>17) were included in the present study. Participants completed questionnaires on sociodemographic and diabetes-related measures. Accuracy of heartbeat perception was assessed using the mental tracking task.

RESULTS

Contrary to expectations, IA did not differ significantly between patients with low and high FoH. A linear regression analysis demonstrated that the experience of mild hypoglycemia (β=0.32, p≤0.01) and its interaction with IA (β=-0.26, p=0.040) were significant predictors of FoH, indicating that low IA and a history of experiencing mild hypoglycemia are positively associated with FoH.

CONCLUSION

Our findings suggest a positive association of low IA in combination with prior episodes of hypoglycemia and FoH in patients with T2DM. The results are in line with recent findings on IA in patients with chronic somatic symptom distress more generally and contribute to our understanding of the relations between interoception, body related fears, and physical symptom perception.

Focus group study to identify the central facets of fear of hypoglycaemia in people with Type 2 diabetes mellitus

AIMS

To determine key worries about hypoglycaemia among insulin-using adults with Type 2 diabetes using a focus group approach.

METHODS

Thirteen focus groups were conducted in three diabetes outpatient care units and one peer support group was set up, in Germany. A total of 64 insulin-dependent adults with Type 2 diabetes (36.5% women, mean age 65.2 ± 11.0 years) discussed their worries about hypoglycaemia. The qualitative results were assigned into thematic categories using a bottom-up coding procedure. Participants completed the Hypoglycaemia Fear Survey and demographic measures were recorded. The results of the Hypoglycaemia Fear Survey were contrasted with the focus group findings to evaluate how accurately the Hypoglycaemia Fear Survey comprehensively captures features of fear of hypoglycaemia in Type 2 diabetes.

RESULTS

Eight themes were identified: 'unconsciousness/death'; 'aloneness/ helplessness', 'fear of hurting somebody'; 'shame'; 'loss of physical control'; 'long-term complications'; 'diabetes self-management issues'; and 'impaired awareness'. A total of 30 participants (46.9%) scored ≥3 on at least one item of the Hypoglycaemia Fear Survey worry subscale, indicating elevated worries. The Hypoglycaemia Fear Survey comprehensively captured all identified themes. Self-efficacy with regard to diabetes self-management seemed to play an important role in fear of hypoglycaemia in Type 2 diabetes.

CONCLUSIONS

Given that even subclinical worries can have negative effects on quality of life and diabetes self-management, emphasis should be placed on diabetes education; in particular, to help patients to develop self-efficacy concerning diabetes self-management. The Hypoglycaemia Fear Survey comprehensively captures hypoglycaemia worries in Type 2 diabetes. Additional assessment of self-efficacy might be beneficial to identify people at risk of developing hypoglycaemia worries.

Bioimpedance analysis: potential for measuring lower limb skeletal muscle mass

BACKGROUND

Ambulation, balance, and lower extremity bone mass and strength are all partially dependent on lower limb skeletal muscle mass. At present, both research and clinical methods of evaluating lower limb skeletal muscle mass as a component of nutrition assessment are limited. One potential simple and inexpensive method is lower extremity bioimpedance analysis (BIA). The present study had two objectives: to examine the determinants of lower limb resistance, with the underlying hypothesis that fluid-containing muscle is the main electrical conductor of the lower limbs; and to establish if a correlation of equivalent magnitude and similar covariates is observed when height squared (H2) is used instead of lower limb length squared (L2) in multiple regression models relating resistance to independent variables.

METHODS

Lower limb resistance was measured using a contact-electrode BIA system, and lower limb fat and skeletal muscle were estimated by dual-energy x-ray absorptiometry in healthy adults. A physical BIA model was developed in the form of a regression equation with path-length (as L2 and H2)-adjusted resistance as dependent variables and lower limb skeletal muscle, fat, age, and gender as potential independent variables.

RESULTS

There were 94 subjects, 34 men and 60 women, with a mean (-/+SD) age of 41.5+/-17.8 years. Strong associations were observed between L2/resistance and lower limb skeletal muscle, although for both men and women, age entered into the model as a significant covariate (total R2, men = .79 and women = .72; both p < .001). Similar models were observed with H2/resistance as dependent variable. Additional analyses showed a significantly lower resistance in lower limb skeletal muscle and height-matched old vs young subjects.

CONCLUSIONS

Strong associations exist between measured lower limb resistance and lower limb muscle mass, adjusting for electrical path length either by L2 or H2. These observations suggest the potential of predicting skeletal muscle using BIA-measured lower limb resistance adjusted for stature. Age is also an independent variable in lower limb resistance-skeletal muscle associations, suggesting the need to establish underlying mechanisms of age-related resistance effects and to consider subject age when developing BIA prediction models.

Upper extremity skeletal muscle mass: potential of measurement with single frequency bioimpedance analysis

This study examined the potential of single frequency (50 kHz) BIA for estimation of upper extremity skeletal muscle (SM) mass. Subjects (n = 50) were weight stable adults varying in age (X +/- SD, 51.6 +/- 17 yr) and body mass index (27.2 +/- 5.9 kg/m2). Determinants of arm to arm impedance index (length L; L2/Z) were examined using multiple regression analysis. A good correlation was observed between L2/Z and arm SM estimated by dual-energy X-ray absorptiometry (r = 0.88, p < 0.001). Additional significant model covariates were arm fat mass (p < 0.05), bone mass (p < 0.01), and age (p < 0.001). These findings suggest that upper extremity SM may be rapidly and easily quantified using a simple and inexpensive BIA system combined with appropriate age-adjusted impedance prediction equations.