Hispanic Diabetes Peer Facilitator Training Needs and Connections to Hispanics With Type 2 Diabetes

Introduction: There is a gap in the literature on the role of Hispanic peer facilitators (PFs) in online peer-support communities for Hispanics with diabetes. This paper explores bilingual Hispanic PFs' training experiences and their perspectives on their role in a continuous glucose monitoring and online peer support intervention for people with type 2 diabetes. Methods: We conducted semi-structured interviews with five PFs. A three-stage triangulation of qualitative data using inductive and deductive reasoning was used for the data analysis. Results: We grouped emerging themes into three categories: (a) technical and practical training needs and experiences, (b) building connections through shared diabetes experience, and (c) challenges and benefits of being a PF, such as helplessness, to further support participants and find motivation for their diabetes management. Conclusion: Successful peer facilitation requires more than technical knowledge. PFs need additional communication skills and psychosocial training on diabetes distress, anxiety, and depression. PFs may derive personal benefits in managing their own diabetes and making positive lifestyle changes from participating in an online peer support community.

Continuous glucose monitoring with data sharing in older adults: A qualitative study

AIMS

This study examined the perceptions of the SHARE plus intervention and its effects on communication, collaboration, and involvement in day-to-day diabetes management in older adults with Type 1 diabetes (T1D) and their care partners.

BACKGROUND

The SHARE plus intervention includes continuous glucose monitoring with a data sharing app that allows care partners to view glucose data on a smartphone and receive alerts. People with T1D and their care partners are educated about communication strategies, problem-solving strategies, and action planning when using glucose data sharing.

DESIGN

Qualitative descriptive design.

METHODS

Older adults with T1D wore a continuous glucose monitor for 3 months (n = 10). Care partners (n = 10) used a data-sharing app. The SHARE plus intervention consisted of one 90-min education session. Semi-structured interviews were conducted across 10 dyads (person with diabetes and care partner) following the 12-week study. A qualitative description and a constant comparison approach were used to examine similarities and differences in experiences. Interviews were transcribed, coded, and analysed for common themes. The manuscript adheres to COREQ EQUATOR checklist.

RESULTS

The SHARE plus intervention increased diabetes knowledge across the dyads, improving confidence and helping partners understand how to navigate symptoms and behaviours and when to intervene. Dyads worked together to optimise diabetes management through improved communication, collaboration, and management of disagreements. Although the majority of persons with diabetes and their care partners reported no conflictual communication, disagreements about diabetes management remained in some dyads. The SHARE plus intervention impacted care partners in various ways from a psychological perspective. While live-in-care partners felt peace of mind, care partners living away from persons with diabetes had some increased worry and concern.

CONCLUSION

The SHARE plus intervention results can help guide future development of diabetes dyadic care and education interventions using diabetes technology.

RELEVANCE TO CLINICAL PRACTICE

The SHARE plus intervention is a brief, practical intervention that can help diabetes clinicians improve communication and collaboration among spouses living with older adults with T1D who use continuous glucose monitoring with data sharing.

PATIENT CONTRIBUTION

A person with diabetes was part of the research team and assisted with design of the intervention and subsequent interviews and analysis.

A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings

BACKGROUND

A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data.

METHODS

We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation.

RESULTS

The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals.

CONCLUSION

The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.

Metabolic obesity phenotypes and obesity-related cancer risk in the National Health and Nutrition Examination Survey

INTRODUCTION

Body mass index (BMI) fails to identify up to one-third of normal weight individuals with metabolic dysfunction who may be at increased risk of obesity-related cancer (ORC). Metabolic obesity phenotypes, an alternate metric to assess metabolic dysfunction with or without obesity, were evaluated for association with ORC risk.

METHODS

National Health and Nutrition Examination Survey participants from 1999 to 2018 (N = 19,500) were categorized into phenotypes according to the metabolic syndrome (MetS) criteria and BMI: metabolically healthy normal weight (MHNW), metabolically unhealthy normal weight (MUNW), metabolically healthy overweight/obese (MHO) and metabolically unhealthy overweight/obese (MUO). Adjusted multivariable logistic regression models were used to evaluate associations with ORC.

RESULTS

With metabolic dysfunction defined as ≥1 MetS criteria, ORC cases (n = 528) had higher proportions of MUNW (28.2% vs. 17.4%) and MUO (62.6% vs. 60.9%) phenotypes than cancer-free individuals (n = 18,972). Compared with MHNW participants, MUNW participants had a 2.2-times higher ORC risk [OR (95%CI) = 2.21 (1.27-3.85)]. MHO and MUO participants demonstrated a 43% and 56% increased ORC risk, respectively, compared to MHNW, but these did not reach statistical significance [OR (95% CI) = 1.43 (0.46-4.42), 1.56 (0.91-2.67), respectively]. Hyperglycaemia, hypertension and central obesity were all independently associated with higher ORC risk compared to MHNW.

CONCLUSIONS

MUNW participants have a higher risk of ORC than other abnormal phenotypes, compared with MHNW participants. Incorporating metabolic health measures in addition to assessing BMI may improve ORC risk stratification. Further research on the relationship between metabolic dysfunction and ORC is warranted.

Are people with diabetes getting the support they need? Deficits between support desired and received from family and friends relates to poorer health

OBJECTIVE

To determine the mismatch of desired support versus support received and to evaluate the impact of these mismatches on health outcomes of people with diabetes.

METHODS

This cross-sectional study is a secondary data analysis of medical record and survey data of participants with Type 1 and Type 2 diabetes from a diabetes care and education program. Biophysical metrics included HbA1c, body mass index, systolic blood pressure, diastolic blood pressure, triglycerides, and high- and low-density lipoproteins. Psychosocial and self-care survey outcomes included diabetes distress, diabetes self-care, and diabetes self-efficacy. Support mismatch was a difference score (support desired-support received). Descriptive statistics were computed for demographics, clinical characteristics, and primary outcomes. Multiple linear regressions were computed.

RESULTS

The percentage of participants experiencing support mismatch (surplus/deficits) across six domains was: 15%/27% (foot care), 22%/24% (take medicine), 24%/23% (test blood sugar), 21%/29% (physical activity), and 18%/34% (follow meal plan). Greater support deficits were associated with higher triglyceride levels, increased diabetes distress, and lower diabetes self-efficacy.

CONCLUSIONS

Findings indicate that greater support deficits can be a risk factor for some poorer physical and psychosocial health outcomes.

PRACTICE IMPLICATIONS

Interventions to facilitate functional supportive behaviors are an avenue for future research and clinical practice.

Salud Latina: feasibility of a synchronous online chat for latinos at risk for type 2 diabetes

This study examined the feasibility of Salud Latina, a weekly synchronous online chat intervention, aimed at engaging Latinos in diabetes prevention conversations. Participants were Latino English- and Spanish-speaking individuals. Salud Latina comprised of six synchronous weekly online chats moderated by bilingual Latina moderators trained in diabetes and online engagement. Online chats used open-ended questions. We assessed feasibility, acceptability, and satisfaction of the intervention and qualitatively analyzed the chats to identify barriers and facilitators to healthy behaviors and identify types of support exchanged. Participants (N = 20) were mostly female and English/Spanish bilingual and 80% completed at least four chats. Salud Latina was acceptable, feasible and highly satisfactory. Four themes were identified: (1) barriers to engaging in healthy behaviors, (2) facilitators of healthy behaviors, (3) Salud Latina provides a community of support, and (4) the need to build a Latino culture of health. Participants recognized the importance of engaging in healthy behaviors to prevent or delay T2D. Findings provide insight in how a synchronous online chat intervention could be used to build a social media community within a Latino population to support healthy behaviors. Future research could explore combining synchronous online chats with in-person community or family-level interventions.

Metabolic dysfunction and obesity-related cancer: Results from the cross-sectional National Health and Nutrition Examination Survey

BACKGROUND

Metabolic syndrome (MetS), a group of risk factors that define metabolic dysfunction in adults, is strongly associated with obesity and is an emerging risk factor for cancer. However, the association of MetS and degree of metabolic dysfunction with obesity-related cancer is unknown.

METHODS

Using National Health and Nutrition Examination Survey data from 1999 to 2018, we identified 528 obesity-related cancer cases and 18,972 cancer-free participants. MetS was defined as the presence of or treatment for ≥3 of hyperglycemia, hypertension, hypertriglyceridemia, low HDL-cholesterol, and abdominal obesity. A metabolic syndrome score (MSS) was computed as the total number of abnormal MetS parameters to determine the severity of metabolic dysfunction. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using multivariable logistic regression models, adjusting for sociodemographic and lifestyle factors.

RESULTS

About 45.7% of obesity-related cancer cases were classified as having MetS compared with only 33.0% of cancer-free participants. Overall, MetS and MSS were not associated with obesity-related cancer. However, MSS was associated with higher obesity-related cancer risk among participants under 50 years of age (OR [95% CI] = 1.28 [1.08-1.52]). When evaluating MSS categorically, compared with healthy participants with no abnormal MetS parameters (MSS = 0), participants with one or two abnormal parameters had a statistically significant higher risk of obesity-related cancer (OR [95% CI] = 1.73 [1.06-2.83]).

CONCLUSIONS

Metabolic dysfunction is associated with a higher risk of obesity-related cancer, particularly in young adults under 50 years of age, and among participants with one or two abnormal metabolic parameters. A more accurate indicator of metabolic dysfunction, beyond metabolic syndrome, is needed to better assist in stratifying individuals for obesity-related cancer risk.

Navigating Diabetes Online Communities in Clinical Practice

OBJECTIVE

This purpose of this study was to conduct a rapid review and environmental scan of diabetes online communities (DOCs) to highlight the clinical impact of DOC engagement and provide guidance to health care providers for navigating and prescribing DOCs.

METHODS

This two-phase review included a rapid review of clinical outcomes and an assessment of DOC content. We conducted a literature search for studies evaluating DOC use and glucometric (glycated hemoglobin [A1C], time-in-range, hypoglycemia), behavioral, and psychosocial outcomes. The environmental scan of current DOC sites established key features, including available platforms, target population, content areas, and reach.

RESULTS

Twelve papers were included-eight reported DOC use within a context of do-it-yourself (DIY) noncommercial, opensource hybrid closed loop systems community and four were non-DYI related. In latter, all studies were cross-sectional, describing patient-reported outcomes. Two studies reported A1C lowering with DOC use, two DOC use was associated with high self-efficacy, one showed association with higher self-care levels, and one showed higher quality of life scores when compared with population norms. All DIY studies showed improvement in glucometrics after initiation of sensor augmented pump technology with DOC support. Of 54 DOC sites reviewed in the environmental scan, 29 were included. Diabetes online community sites were heterogenous in social media platform and type of diabetes targeted.

CONCLUSION

Diabetes online communities have the potential to improve clinical, behavioral, and psychosocial outcomes. Randomized control trials and/or longitudinal prospective studies evaluating outcomes are needed to further examine the potential benefits of DOC use. Diabetes online communities are diverse and span a variety of social media platforms, providing clinicians opportunities to individualize recommendations for DOC use.

Combining CGM and an Online Peer Support Community for Hispanic Adults with T2D: A Feasibility Study

BACKGROUND

Previous research has identified that people with type 2 diabetes (T2D) within the Hispanic community would benefit from an online peer support community (OPSC) and continuous glucose monitoring (CGM) data to facilitate diabetes self-management.

METHODS

A mixed-methods feasibility study enrolled Hispanic, Spanish-speaking adults with T2D, not on insulin. Participants were provided with CGM and access to an OPSC for 12 weeks. Feasibility was assessed by number of eligible participants who enrolled, attrition, quantity of CGM data, validated clinical measures of self-efficacy, quality of life and adverse events. Engagement in the OPSC was measured using objective metrics on the online platform. Qualitative interviews were conducted upon conclusion of the intervention to assess feasibility, acceptability, participant satisfaction, and key recommendations for improvement.

RESULTS

Of 46 participants screened, 39 were eligible and 26 completed the study. Participants significantly improved self-efficacy scores. Posts in the OPSC related to goal setting had the highest engagement followed by mid-week and end of week check-in posts respectively. Participant interviews described challenges accessing the OPSC platform as a barrier to engagement. Despite this, all participants were satisfied with the intervention. Key recommendations for improvement included providing greater variety of and individualized education and the use of a peer support platform that is easily accessible.

CONCLUSIONS

The CGM + OPSC intervention tailored to the Hispanic community with T2D was feasible, acceptable and satisfactory and improved participant self-efficacy for diabetes management which may lead to improved clinical outcomes.

A New Taxonomy for Technology-Enabled Diabetes Self-Management Interventions: Results of an Umbrella Review

BACKGROUND

A 2017 umbrella review defined the technology-enabled self-management (TES) feedback loop associated with a significant reduction in A1C. The purpose of this 2021 review was to develop a taxonomy of intervention attributes in technology-enabled interventions; review recent, high-quality systematic reviews and meta-analyses to determine if the TES framework was described and if elements contribute to improved diabetes outcomes; and to identify gaps in the literature.

METHODS

We identified key technology attributes needed to describe the active ingredients of TES interventions. We searched multiple databases for English language reviews published between April 2017 and April 2020, focused on PwD (population) receiving diabetes care and education (intervention) using technology-enabled self-management (comparator) in a randomized controlled trial, that impact glycemic, behavioral/psychosocial, and other diabetes self-management outcomes. AMSTAR-2 guidelines were used to assess 50 studies for methodological quality including risk of bias.

RESULTS

The TES Taxonomy was developed to standardize the description of technology-enabled interventions; and ensure research uses the taxonomy for replication and evaluation. Of the 26 included reviews, most evaluated smartphones, mobile applications, texting, internet, and telehealth. Twenty-one meta-analyses with the TES feedback loop significantly lowered A1C.

CONCLUSIONS

Technology-enabled diabetes self-management interventions continue to be associated with improved clinical outcomes. The ongoing rapid adoption and engagement of technology makes it important to focus on uniform measures for behavioral/psychosocial outcomes to highlight healthy coping. Using the TES Taxonomy as a standard approach to describe technology-enabled interventions will support understanding of the impact technology has on diabetes outcomes.

A Telehealth Diabetes Intervention for Rural Populations: Protocol for a Randomized Controlled Trial

Background

Diabetes self-management education and support (DSMES) is a crucial component of diabetes care associated with improved clinical, psychosocial, and behavioral outcomes. The American Association of Diabetes Care and Education Specialists, the American Diabetes Association, and the American Academy of Family Physicians all recommend DSMES yet accessing linguistically and culturally appropriate DSMES is challenging in rural areas. The Diabetes One-Day (D1D) program is an established DSMES group intervention that has not been adapted or evaluated in rural communities.

Objective

The specific aims of this paper are (1) to adapt the existing D1D program for use in rural communities, called rural D1D (R-D1D); and (2) to conduct a patient-level randomized controlled trial to examine the effects of R-D1D and standard patient education, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

Methods

This is a protocol for a pilot type II hybrid implementation-effectiveness trial of a culturally adapted virtual DSMES program for rural populations, R-D1D. We will use Boot Camp Translation, a process grounded in the principles of community-based participatory research, to adapt an existing DSMES program for rural populations, in both English and Spanish. Participants at 2 rural primary care clinics (4 cohorts of N=16 plus care partners, 2 in English and 2 in Spanish) will be randomized to the intervention or standard education control. The evaluation is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Patient-level effectiveness outcomes (hemoglobin A_1c, diabetes distress, and diabetes self-care behaviors) will be assessed using patient-reported outcomes measures and a home A_1c test kit. Practice-level and patient-level acceptability and feasibility will be assessed using surveys and interviews.

Results

This study is supported by the National Institute of Nursing. The study procedures were approved, and the adaptation processes have been completed. Recruitment and enrollment started in July 2021.

Conclusions

To our knowledge, this will be the first study to evaluate both effectiveness and implementation outcomes for virtually delivered DSMES, culturally adapted for rural populations. This research has implications for delivery to other rural locations where access to specialty diabetes care is limited.

Trial Registration

ClinicalTrials.gov NCT04600622; https://clinicaltrials.gov/ct2/show/NCT04600622

International Registered Report Identifier (IRRID)

DERR1-10.2196/34255

Understanding Hypoglycemia in the Real World

PURPOSE

The purpose of this study was to gain a better understanding of real-world hypoglycemia experiences from people living with diabetes.

METHODS

An exploratory cross-sectional study of a convenience sample of 374 English-speaking adults affected by diabetes using an online survey was conducted.

RESULTS

Participant mean age was 37 years with an average diabetes duration of 21 years. On average, participants reported feeling hypoglycemia at 64 mg/dL (3.6 mmol/L), worrying about hypoglycemia at 63 mg/dL (3.5 mmol/L), and treating hypoglycemia at 72 mg/dL (4 mmol/L). Terminology used by study participants did not match the current classifications of hypoglycemia used in clinical research. Participants who have been told they have hypoglycemia unawareness treat at a significantly lower level compared to those without hypoglycemia unawareness. Only 58% always carry hypoglycemia treatment; there was a relationship with increasing age and always carrying hypoglycemia treatment. Thirty-eight percent of participants treat hypoglycemia with the recommended 15 g of carbohydrate (CHO). Survey respondents who wore continuous glucose monitors reported using significantly less CHO to treat hypoglycemia.

CONCLUSIONS

In the real world, experiences related to feeling, worrying about, and treating hypoglycemia trend higher than what is noted in the standardized hypoglycemia classifications. Study findings have implications for teaching and supporting people with diabetes who experience hypoglycemia. Consuming less CHO to treat hypoglycemia could lead to fewer episodes of rebound hyperglycemia and less weight gain. Increased support for continuous glucose monitoring is warranted.

Care Partner Support Following a Diabetes Self-Management Education and Support Intervention

PURPOSE

The purpose of the study was to understand care partner (CP) perceptions of an interdisciplinary diabetes self-management education and support (DSMES) intervention and explore how the interdisciplinary DSMES intervention influences diabetes-specific day-to-day interactions from the CP's perspective.

METHODS

A multiple-methods research design comprised of an online survey including demographics and supportive behaviors and a semistructured interview was conducted. The survey was completed by 16 CPs. Of the 16 CPs, 11 participated in semistructured interviews. Survey data were analyzed using descriptive statistics. Thematic analysis of semistructured interviews was conducted.

RESULTS

CPs provided support in 3 primary areas: (1) meal planning and preparation (87.5%), (2) participating in physical activity (56.3%), and (3) assisting with technology (43.8%). The main themes described by CPs include (1) the importance of diabetes education for caregivers, including the information they retained from the program, the acquisition of tools to support the person with diabetes, and the desire for more and ongoing education; (2) diabetes education enhances the CP's ability to provide social support and the challenges associated with support; and (3) partners described collaborative diabetes management such as finding middle ground and making changes together.

CONCLUSION

CPs play a significant role in patient diabetes self-management by providing social support and partnership. DSMES programs should seek to include CPs to enhance patient support.

Continuous Glucose Monitoring Plus an Online Peer Support Community Reinforces Healthy Behaviors in Hispanic Adults With Type 2 Diabetes

Background

Previous research has suggested beneficial glycemic outcomes for people with type 2 diabetes with the use of continuous glucose monitoring (CGM); yet, there is a dearth of data examining CGM in diverse populations. Additionally, the use of online peer support communities (OPSCs) can further support the application of CGM information to improve health behaviors. The purpose of this qualitative study was to assess participant experiences with a CGM+OPSC intervention.

Methods

Semi-structured interviews were conducted after a 12-week combined CGM+OPSC intervention with Hispanic, Spanish-speaking people with type 2 diabetes not using insulin. The OPSC was managed by five trained bilingual peer facilitators. Interviews were conducted in Spanish. Audio recordings were translated and transcribed and then reviewed by the interviewer for accuracy. Emergent themes were identified through inductive thematic analysis.

Results

Twenty-six participants completed interviews. Three main themes emerged from the data: 1) CGM supports participants' understanding of the relationship between glucose levels and health behaviors such as healthy eating, being active, taking medication, stress reduction, and improving sleep; 2) the OPSC reinforced how to make healthy choices through personal experiments, collective learning, and social support; and 3) CGM+OPSC supports behavior change and increases confidence.

Conclusion

When combined, CGM+OPSC interventions appear to create a positive feedback loop to reinforce and optimize healthy behaviors for diabetes self-management in individuals with type 2 diabetes who are not on insulin. The provision of such an intervention tailored to Hispanic, Spanish-speaking individuals has the potential to address the health care disparity seen in this population.

The Feasibility and Acceptability of a Community-Developed Health Insurance and Financial Toolkit for Emerging Adults With Type 1 Diabetes

Purpose:

The purpose of the study was to assess the feasibility and acceptability of a financial stress and health insurance education toolkit developed by a community advisory board for emerging adults, ages 18 to 25, with type 1 diabetes.

Methods:

This study is a longitudinal, randomized controlled trial that enrolled 39 emerging adults with type 1 diabetes. Participants randomized to the intervention group were given access to the T1D Financial Toolkit, an online financial and health insurance education toolkit, over 30 days. For the present analysis, feasibility was assessed by enrollment and attrition. Optional, qualitative interviews were conducted upon the conclusion of the intervention to evaluate feasibility, acceptability, satisfaction, and key recommendations for improvement.

Results:

Of the 39 participants who enrolled, 36 completed the study. The intervention period had 100% completion in both the control and intervention groups. Eleven participants from the intervention group completed interviews. Participants described few challenges accessing the toolkit and were highly satisfied with the intervention aesthetics, display, and content. Key recommendations included integrating more applied problem-solving into the experience of watching the videos.

Conclusions:

The T1D Financial Toolkit is a financial and health insurance education intervention tailored to emerging adults with type 1 diabetes. This resource is feasible, acceptable, and satisfactory. Diabetes care and education specialists can utilize this tool in practice to provide relevant, developmentally tailored education to emerging adults with type 1 diabetes, prompt applied problem-solving, reduce barriers to self-management, and improve psychosocial outcomes.

Examining a Continuous Glucose Monitoring Plus Online Peer Support Community Intervention to Support Hispanic Adults With Type 2 Diabetes: Protocol for a Mixed Methods Feasibility Study

Background

Type 2 diabetes is twice as likely to affect Hispanic people than their White counterparts. Technology and social support may be an important part of behavior change. In this study, we address gaps in diabetes care for Hispanic Spanish-speaking people with diabetes through an online peer support community (OPSC) pilot intervention using Hispanic Spanish-speaking peer facilitators with diabetes to enhance the use of continuous glucose monitoring (CGM) for diabetes management.

Objective

This study aims to address gaps in diabetes care for Hispanic Spanish-speaking people with diabetes through an OPSC pilot intervention using Hispanic Spanish-speaking peer facilitators with diabetes to enhance the use of CGM for diabetes management.

Methods

A mixed-methods, pre-post test design will be used in this feasibility study. A total of 50 Hispanic participants with type 2 diabetes willing to wear a continuous glucose monitor for 13 weeks will be recruited. Hispanic Spanish-speaking peer facilitators with diabetes and experience wearing a continuous glucose monitor will be employed and undergo training. Peer facilitators will help participants learn how CGM data can inform behavior changes via an OPSC. Participants will interact with the private OPSC at least three times a week. Weekly questions and prompts derived from the Association of Diabetes Care and Education Specialists, previously American Association of Diabetes Educators, and seven self-care behaviors will be delivered by peer facilitators to engage participants. Measures of feasibility and acceptability will be determined by the percentage of participants who enroll, complete the study, and use CGM (number of scans) and objective metrics from the OPSC. Efficacy potential outcomes include change in time in range of 70 to 180 mg/dL from baseline to 12 weeks, A_1c, diabetes online community engagement, self-efficacy, and quality of life. Additionally, semistructured exit interviews will be conducted.

Results

Funding for this project was secured in November 2018 and approved by the institutional review board in April 2019. Peer facilitator recruitment and training were undertaken in the second half of 2019, with participant recruitment and data collection conducted in January and April 2020. The study has now concluded.

Conclusions

This study will generate new evidence about the use of an OPSC for Hispanic Spanish-speaking patients with diabetes to make behavior changes incorporating feedback from CGM.

Trial Registration

ClinicalTrials.gov NCT03799796; https://clinicaltrials.gov/ct2/show/NCT03799796

International Registered Report Identifier (IRRID)

RR1-10.2196/31595

SHARE plus: Delivering a Telehealth CGM Data-Sharing Intervention to Older Adults and Their Care Partners

Care partners of older adults with type 1 diabetes often become part of the diabetes care team but lack knowledge of how to become involved with glucose management. This article describes a study confirming the feasibility of SHARE plus, a telehealth intervention involving continuous glucose monitoring and data-sharing to assist these individuals in working together on diabetes management. The intervention provides a strategy for increasing remote patient monitoring and facilitating care partner involvement in diabetes management.

Observed dyadic collaboration among couples coping with type 1 diabetes

Previous research linking collaboration to relationship and health outcomes has relied almost exclusively on individual self-report and failed to take into consideration the dyadic nature of collaboration. We enrolled couples (n = 193) in which one person had Type 1 diabetes (52% female; 91% non-Hispanic white) into the study and asked them to discuss a diabetes-related issue of high concern for 8 min. These videotaped interactions were coded for dyadic collaboration. Mood was measured before and after the discussion. After the discussion, patients and partners reported support provided and received during the discussion. Results showed that observed dyadic collaboration was related to improvements in mood and greater support exchanges for both patients and partners when self-reported collaboration was statistically controlled. Gender moderated the effects on partners, such that benefits of dyadic collaboration were stronger for women than men. Future research may benefit from including collaborative elements into couple-focused interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Financial Barriers in Emerging Adults With Type 1 Diabetes: A Qualitative Analysis

Background

Emerging adulthood is a period fraught with challenging life transitions for many and is especially difficult for individuals with type 1 diabetes, as they encounter more obstacles to independently managing their diabetes. We examined the barriers faced by emerging adults and parents of emerging adults with type 1 diabetes and the impact these barriers had on their lives.

Methods

Emerging adults and parents of emerging adults with type 1 diabetes were recruited from primary care and specialty clinics and via social media posts. In the parent study, semi-structured interviews were conducted to understand what supported and did not support diabetes self-management. Interviews were transcribed, coded, and analyzed for common themes. This sub-analysis analyzed data related to financial challenges in accessing diabetes management equipment and supplies.

Results

This study included emerging adults with type 1 diabetes (n = 33; mean age 20 ± 2.9 years) and parents of emerging adults with type 1 diabetes (n = 17; mean age 47.5 ± 6.9 years). The majority of emerging adults used an insulin pump and continuous glucose monitoring system (n = 24 [73%]). Four main themes emerged related to access to care: 1) affordability of diabetes management tools, 2) managing insurance, 3) communication with pharmacies and health care providers, and 4) emotional consequences of financial stress.

Conclusion

The current health system is challenging for emerging adults with type 1 diabetes and parents and is causing substantial emotional and financial stress. Future research is needed to address interventions for helping emerging adults and their parents navigate the cost of living with diabetes.

The Effects of Diabetes Self-Management Education on Quality of Life for Persons With Type 1 Diabetes: A Systematic Review of Randomized Controlled Trials

PURPOSE

It is well documented that chronic conditions, such as diabetes, impact quality of life (QoL). QoL assessment is essential when developing and evaluating diabetes self-management education support interventions. The aim of this systematic review was to evaluate the evidence and gaps in the research and the impact of diabetes self-management education (DSME) on QoL outcomes in persons with type 1 diabetes mellitus (T1DM).

METHODS

A systematic review of English language studies published between January 1, 2007, and March 31, 2020, was conducted using a modified Cochrane review method. Studies were included if they were randomized controlled trials (RCTs), participants had T1DM with or without caregivers, a DSME intervention alone or a component(s) of the ADCES7™ Self-Care Behaviors was described, and QoL was a primary or secondary outcome. A 3-tiered review process was utilized for selecting articles. Retained articles were assessed for risk of bias.

RESULTS

Nineteen articles, reporting on 17 RCTs, met inclusion criteria, of which 7 studies reported QoL as the primary outcome and 10 as a secondary outcome. Seven studies detected significant impact of DMSE on QoL outcomes in either the participants or family caregivers, which varied in participant populations, selection of QoL tools (generic vs diabetes-specific), intervention type, intervention length, and type of interventionist.

CONCLUSION

DSME has the potential to influence QoL outcomes in people with T1DM. Research using more standardized methods are needed to delineate impact on a broader range of factors that influence QoL for those living with T1DM across the life span and their caregivers.

Equity in the Provision of Diabetes Self-Management Education and Support

Diabetes self-management education and support (DSMES) interventions must be accessible to all people with diabetes. To address equity in the delivery of DSMES, interventions should consider the unique needs of various populations. This article outlines the needs of a wide range of populations, including people with diabetes who are racially or ethnically diverse; have limited English proficiency or literacy; are deaf or hard of hearing; are blind or have low vision; are neurodiverse; live with learning disabilities or intellectual or developmental disabilities; have dementia or cognitive impairment; or are of sexual and/or gender minority. The authors discuss how best to tailor DSMES to meet the needs of these diverse groups.

Who Needs Diabetes Education? A Qualitative Analysis of Emerging Adults With Type 1 Diabetes

BACKGROUND

The purpose of this study is to explore the diabetes self-management education (DSME) needs of emerging adults with type 1 diabetes mellitus (T1DM) because addressing these needs may facilitate optimal glycemic management during this challenging transitional period.

METHODS

A hybrid qualitative design was utilized. Emerging adults and parents of emerging adults were recruited from endocrinology and primary care clinics and through a Utah-specific T1DM online community. Interviews were conducted to asses needs to achieve target A1C. Data were interpreted thematically.

RESULTS

Emerging adults with T1DM (N = 33) and parents of emerging adults with T1DM (N = 17) were interviewed. Three main themes emerged: (1) mixed desire for personal DSME; (2) I don't need the education, others do; and (3) health care provider (HCP) attributes that make a difference. Associated subthemes were reported.

CONCLUSIONS

Emerging adults reported that further education for themselves was not needed, although newly diagnosed individuals would benefit from increased training in diabetes management. Although many emerging adults had a supportive social network, they endorsed the need for greater public education to avoid diabetes misinformation. Emerging adults felt more connected with HCPs that had diabetes-specific training (ie, endocrinologist) or those who personally live with T1DM.

Continuous Glucose Monitoring Data Sharing in Older Adults with Type 1 Diabetes: A feasibility study (Preprint)

Background

Family members or friends (care partners [CPs]) of older adults with type 1 diabetes (T1DM) regularly become part of the diabetes care team, but they often lack knowledge about how to become involved to prevent hypo- and hyperglycemia. Continuous glucose monitoring (CGM) allows a person with diabetes to see their glucose levels continuously and to receive predictive alerts. A smartphone data-sharing app called the Follow app allows the person with diabetes to share continuous glucose numbers with others and to receive predictive alerts of impending hypo- and hyperglycemia. However, there are barriers to sharing this continuous glucose level data with CPs.

Objective

This study aimed to address the barriers to sharing CGM data. Our objective was to examine the feasibility of using CGM with the Follow app and a data-sharing intervention called SHARE plus in older adults with T1DM and their CPs. SHARE plus includes dyadic communication strategies, problem-solving strategies, and action planning to facilitate CGM data sharing.

Methods

Older adults with T1DM (n=20) and their CPs (n=20) received the SHARE plus intervention at baseline. People with diabetes wore the CGM for 12 weeks while sharing their glucose data using the Follow app with CPs. Feasibility data were analyzed using descriptive statistics.

Results

The SHARE plus intervention was feasible and was associated with high self-reported satisfaction for people with diabetes and their CPs as well as high adherence to CGM (mean 96%, SD 6.8%). Broad improvements were shown in the diabetes-related quality of life through the use of CGM in people with diabetes and their CPs. Although the majority of people with diabetes (11/20, 55%) were willing to share hyperglycemia data, several chose not to. The majority of people with diabetes (14/20, 70%) were willing to talk about glucose numbers with a CP.

Conclusions

Older adults with T1DM and their CPs identified having someone else aware of glucose levels and working together with a partner on diabetes self-management as positive aspects of the use of the SHARE plus intervention. Clinicians can use these results to provide data sharing coaching in older adults and their CPs.

Personal Continuous Glucose Monitoring Use Among Adults with Type 2 Diabetes: Clinical Efficacy and Economic Impacts

PURPOSE OF REVIEW

This article reviews recent clinical efficacy research and economic analysis of the use of personal continuous glucose monitoring (CGM) in type 2 diabetes (T2D).

RECENT FINDINGS

Studies from the past 5 years include a variety of randomized controlled trials, meta-analyses, and other studies which generally favor CGM over self-monitoring of blood glucose (SMBG) in T2D, especially among people with T2D treated with insulin. Concurrently, some studies show no significant difference, but there is no evidence of worse outcomes with CGM. CGM is frequently associated with greater reduction in HbA1c than is SMBG. HbA1c reductions tend to be greater when baseline HbA1c is higher. Reductions in hypoglycemia and hyperglycemia have also been demonstrated with CGM in people with T2D, as have comfort with, preference for, and psychosocial benefits of CGM compared to SMBG. There is a small but growing evidence base on the economics and cost-effectiveness of CGM in T2D. CGM has been clearly demonstrated to have clinical benefits in people with T2D, especially among those treated with insulin. Economic and cost-effectiveness data are more scant but are generally favorable. CGM should be an important consideration in the management of T2D, and its use is likely to increase as efficacy data accumulate further and as costs associated with CGM gradually decrease.

Using projective exercises to identify patient perspectives of living with comorbid type 2 diabetes and asthma

OBJECTIVE

Patient self-management of a single chronic condition can be challenging, but few studies have examined the emotional impact of living with comorbid conditions and how that differs from a single chronic condition. This study examined patient perspectives of the emotional impact of living with asthma or asthma with comorbid type 2 diabetes (asthma+diabetes).

METHODS

Data were collected from 41 adults (asthma only n = 22, asthma+diabetes n = 19) using semi-structured interviews on two separate online bulletin boards. Respondents engaged in discussions that leveraged two projective exercises: describing their health condition(s) as an animal, and selecting one of eight images that best illustrated how they were living with and managing their health condition(s).

RESULTS

Respondents described physical and emotional challenges related to managing asthma or asthma+diabetes. Animal- and image- projective exercises were categorized by response and health condition. Thematic analysis across both projective exercises identified four themes: (1) frustrations with dual diagnosis, (2) juggling the dual diagnosis, (3) anticipating the future, and (4) unpredictability.

DISCUSSION

Projective exercises are one way to elicit feelings about living with chronic conditions. Healthcare providers can improve support for patients with more than one health condition by providing education on how to manage comorbid conditions.

Economic impact and health care utilization outcomes of Diabetes Self-Management Education and Support interventions for persons with diabetes: a systematic review protocol

OBJECTIVE

The aim of this systematic review is to summarize and synthesize existing research on the economic impact of Diabetes Self-Management Education and Support.

INTRODUCTION

Diabetes Self-Management Education and Support is an essential component of diabetes care, yet it continues to be underutilized. A gap exists regarding the true measured economic impact of this intervention.

INCLUSION CRITERIA

This review will consider studies that report the measured economic impact and health care utilization of Diabetes Self-Management Education and Support for persons with diabetes or their caregivers. The inclusion criteria are as follows: quantitative studies providing measured data on the economic outcomes and health care utilization of Diabetes Self-Management Education and Support interventions that include at least one of the Association for Diabetes Care and Education Specialists Seven Self-Care Behaviors (ADCES7).

METHODS

The review will search the following databases: MEDLINE; Epub Ahead of Print, In-Process and Other Non-Indexed Citations, Daily and Versions; Embase; Scopus; CINAHL; ERIC, Cochrane Database of Systematic Reviews; and the Cochrane Register of Controlled Trials. Additionally, a search of the grey literature will be performed using Google Scholar. Date limitations will be from January 2006 to May 2020. Two members of the research team will independently screen abstracts and full texts, and extract data. The screening process will be described using the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Articles will be assessed for risk of bias using the JBI critical appraisal tools. Data will be narratively summarized.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42020166743).

Economic Impact and Health Care Utilization Outcomes of Diabetes Self-Management Education and Support Interventions for Persons With Diabetes: A Systematic Review and Recommendations for Future Research

PURPOSE

Value-driven outcomes are important because health systems determine sustainability of diabetes self-management education and support (DSMES) programming. Health care utilization and clinical outcomes are critical factors when considering the impact of DSMES programs.

OBJECTIVE

The aim of this systematic review was to describe studies that report on the economic and health care utilization outcomes of diabetes self-management programs.

METHODS

A systematic literature review was performed in multiple databases. Studies reporting economic and health care utilization outcomes related to DSMES and including 1 or more of the ADCES7 Self-Care BehaviorsTM from January 2006 to May 2020 were included. Eligible articles needed to compare the intervention and comparison group and report on economic impact. The methodological quality was assessed with the Joanna Briggs Institute Critical Appraisal Checklist specific to each individual study design.

RESULTS

A total of 22 of 14 556 articles published between 2007 and 2020 were included. Cost benefits varied, and there were considerable methodological heterogeneity among design, economic measures, population, perspective, intervention, and biophysical outcomes.

CONCLUSION

DSMES interventions may positively impact economic outcomes and/or health care utilization, although not all studies showed consistent benefit. This review highlights an evidence gap, and future health economic evaluations are warranted.

Couples Managing Type 1 Diabetes Using Diabetes Technology

OBJECTIVE

Diabetes technology has improved the lives of people with diabetes (PWD), but there is little research on how insulin pumps and continuous glucose monitoring (CGM) affect couples' relationships. The purpose of this study was to examine how the use of diabetes technology affects couple interactions.

METHODS

In a secondary data analysis, we used a multiple-method qualitative analysis, including a constant-comparison approach, to examine similarities and differences in couple interactions related to diabetes technology. PWD and their spouses were interviewed separately, using a semi-structured interview guide; the interviews primarily focused on how couples coped with type 1 diabetes.

RESULTS

Participants (n = 134 couples) were using an insulin pump or CGM system. Average age was 44 ± 12.05 years for PWD and 44 ± 12.62 years for spouses. Couples' average length of relationship was 18 ± 12.50 years. Among the PWD, 54 used a pump only, 12 used CGM only, and 68 used both. Four main themes emerged: 1) diabetes technology facilitates shared diabetes management for couples, 2) diabetes technology facilitates spousal involvement in diabetes care, 3) diabetes technology is a source of relationship tension, and 4) diabetes technology causes positive/negative responses to sleep and alarms.

CONCLUSION

Overall, couples perceived diabetes technology as having a positive effect on their relationship by increasing collaboration, promoting communication, and reducing diabetes burden and vigilance. Technology also was perceived to increase relationship tension, lifestyle inconveniences, and positive/negative responses regarding sleep and alarms. Involvement of spouses in diabetes technology education should be considered.

Strategies for overcoming therapeutic inertia in type 2 diabetes: A systematic review and meta-analysis

AIMS

To systematically investigate the effect of interventions to overcome therapeutic inertia on glycaemic control in individuals with type 2 diabetes.

MATERIALS AND METHODS

We electronically searched for randomized controlled trials or quasi-experimental studies published between January 1, 2004 and December 31, 2019 evaluating the effect of interventions on glycated haemoglobin (HbA1c) control. Characteristics of included studies and HbA1c difference between intervention and control arms (main outcome) were extracted. Interventions were grouped as: care management and patient education; nurse or certified diabetes educator (CDE); pharmacist; or physician-based.

RESULTS

Thirty-six studies including 22 243 individuals were combined in nonlinear random-effects meta-regressions; the median (range) duration of intervention was 1 year (0.9 to 36 months). Compared to the control arm, HbA1c reduction ranged from: -17.7 mmol/mol (-1.62%) to -4.4 mmol/mol (-0.40%) for nurse- or CDE-based interventions; -13.1 mmol/mol (-1.20%) to 3.3 mmol/mol (0.30%) for care management and patient education interventions; -9.8 mmol/mol (-0.90%) to -6.6 mmol/mol (-0.60%) for pharmacist-based interventions; and -4.4 mmol/mol (-0.40%) to 2.8 mmol/mol (0.26%) for physician-based interventions. Across the included studies, a reduction in HbA1c was observed only during the first year (6 months: -4.2 mmol/mol, 95% confidence interval [CI] -6.2, -2.2 [-0.38%, 95% CI -0.56, -0.20]; 1 year: -1.6 mmol/mol, 95% CI -3.3, 0.1 [-0.15%, 95% CI -0.30, 0.01]) and in individuals with preintervention HbA1c >75 mmol/mol (9%).

CONCLUSIONS

The most effective approaches to mitigating therapeutic inertia and improving HbA1c were those that empower nonphysician providers such as pharmacists, nurses and diabetes educators to initiate and intensify treatment independently, supported by appropriate guidelines.

GoFundMe isn't a Medical Plan: An Ecological Study of Crowdfunding Insulin Success (Preprint)

Background

Individuals in need of medical care turn to crowdfunding websites to engage a “crowd” or group for financial support. In the last decade, access to insulin has decreased considerably for several reasons, including the rising cost of insulin, increasing popularity of high-deductible insurance plans, and increasing insurance premiums. Many people with diabetes are forced to ration or go without insulin, and they turn to crowdfunding websites to seek financial donations to purchase insulin needed to reduce health risks and mortality, and sustain quality of life. 

Objective

This study aimed to explore crowdfunding campaign requests to purchase insulin in the United States.

Methods

In this retrospective, quantitative, and qualitative study, we coded the text of GoFundMe online crowdfunding campaigns and viral measures (shares, hearts, and comments) from February 25 to April 15, 2019. We described campaigns (N=205) and explored the factors associated with campaign success using correlations and qualitative thematic analysis.

Results

The majority of campaigns were initiated by middle-aged adults (age 26-64 years; 77/205, 37.6%), those with type 1 diabetes (94/205, 45.9%), and those needing funds owing to insurance coverage issues (125/205, 61.0%). The factors associated with campaign success included requests for ≤US $500 (P=.007) and higher viral measures (shares, P=.007; hearts, P<.001; comments, P=.002). The following 4 themes emerged from the campaign text: (1) desire for self-management and survival, (2) diabetes management untenable given insulin access, (3) aftermath of insulin unaffordability, and (4) privacy issues with crowdfunding. Campaign comments were both supportive (tangible, informational, and emotional) and unsupportive (questioned the need for the campaign and deemed crowdfunding inappropriate).

Conclusions

Despite crowdfunding websites being used to support the purchase of insulin, campaigns raised only a fraction of the money requested. Therefore, GoFundMe campaigns are not a reliable solution to obtain funds for insulin in the United States. Applying quantitative and qualitative methods is adequate to analyze online crowdfunding for costs of medications such as insulin. However, it is critical for people with diabetes to use resources other than online crowdfunding to access and obtain insulin owing to low success rates. Clinicians should routinely assess difficulty accessing or affording insulin, and federal health care policies should support lowering the cost of insulin.

Daily stress spillover and crossover in couples coping with type 1 diabetes

In the context of a chronic illness such as Type 1 diabetes (T1D), managing general stressors may be linked to diabetes-specific stressors for persons with T1D, an intraindividual contagion phenomenon (i.e., spillover). Among those with romantic partners, stress may also be associated with the partner's stress (i.e., crossover). These intraindividual and interpersonal processes may be further strengthened or weakened in the presence of individual (e.g., sleep satisfaction) and interpersonal (e.g., relationship satisfaction) factors. This study examined spillover and crossover effects between daily general and diabetes-specific stressors and whether sleep satisfaction and relationship satisfaction moderated spillover and crossover effects among couples in which one person had T1D. Persons with T1D (n = 199; Mage = 46.82, 52.3% female) and their romantic partners (n = 199; Mage = 46.41, 47.2% female) reported general stressors and sleep satisfaction, and persons with T1D reported diabetes-specific stressors on 14 consecutive days. Both couple members completed a survey that assessed relationship satisfaction. Multilevel models revealed significant within-person and between-person stress spillover and crossover effects. When examining the moderating role of sleep satisfaction, however, persons with T1D with better sleep satisfaction did not experience spillover between one domain and the other. Furthermore, partners with higher relationship satisfaction did not experience crossover between the persons with T1D-specific stressors and their general stressors. These findings support the conceptualization of the link between general and diabetes-specific stressors as both an intraindividual and a dyadic process among couples coping with T1D. In addition, better sleep satisfaction can prevent spillover effects, and relationship satisfaction can prevent stress crossover effects. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Diabetes Identity: A Mechanism of Social Change

Historically, diabetes identity has been examined at the individual level as it relates to clinical outcomes and self-management practices. Yet, identity is not experienced as an individually isolated phenomenon. The purpose of this study is twofold: (a) examine the social meaning of diabetes identity and (b) formulate a theoretical model of diabetes identity through a sociopolitical lens. Adults living with diabetes engaged in a diabetes online community (N = 20) participated in a 60-minute semi-structured interview focused on social diabetes experiences and diabetes identity. Seven themes emerged related to illness, individuation, and culture, resulting in a novel theoretical model of diabetes identity: willingness to identify, tales of the un-sick, legends of the responsible, a tradition of change-making, sense of sameness, mystification of difference, and diabetes as a unifying social category. Our study extends previous literature focused on self-management practices and compliance, resulting in a theoretical model of diabetes identity centered around social change.

Health Care Provider Knowledge and Perceptions of FDA-Approved and Do-It-Yourself Automated Insulin Delivery

BACKGROUND

Automated insulin delivery (AID) technology may reduce variability in blood glucose, resulting in lower risk for hypoglycemia and associated complications, and by extension improve quality of life. While clinical trials, research, and patient experience have consistently demonstrated the value of AID, this technology is still inaccessible to many patients. Patient-driven innovation has resulted in alternative do-it-yourself (DIY) solutions to available off-the-shelf AID devices.

METHOD

This two-phase cross-sectional observational study addressed health care provider (HCP) perceptions of AID as well as the perceived need for, development of, and evaluation of an AID fact sheet comparing the most commonly used Federal Drug Administration approved AID and DIY AID devices.

RESULTS

Negative attitudes toward the use of DIY AID were low. The majority of HCPs saw their lack of knowledge about how DIY AID work to be the greatest barrier to answering patient questions about what is available (74.4%). Additionally, the majority of HCPs (64.5%) indicated they were either "likely" or "very likely" to use the fact sheet when answering patient questions about AID options.

CONCLUSION

Increased awareness and utilization of AID technology offer hope to further reduce the burden of diabetes, but there is a need to bridge the knowledge gap about DIY AID. A fact sheet provides a way to facilitate discussions of this emerging technology between HCPs and patients. Next steps could investigate additional ways to put needed information in the hands of HCPs.

The transition experiences of adolescents with type 1 diabetes from paediatric to adult care providers

PURPOSE

Emerging adults with type 1 diabetes (T1D) are at increased risk for poor health outcomes as they transition from paediatric to adult healthcare providers. This is in part due to the complexities of young adult life as individuals with T1D enter the workforce, leave home or start college while learning to manage the disease on their own. We sought to identify the barriers and facilitators adolescents face during their emerging adult years with T1D.

METHODS

Young adults, aged 24-35, who lived with T1D during their adolescent years were recruited online to complete a survey regarding their experience with care transition. Categorical data were analysed using descriptive statistics. A thematic analysis, guided by the Framework for Emerging Adults with T1D, was used to explore the free-text data.

RESULTS

In total, 25 adults (84% female) with mean age of 28 ± 3.2 years participated. Themes that arose from the analysis of the paediatric to adult care transition experiences included (1) importance of support from key players, (2) challenges navigating the healthcare system, (3) mental health needs of emerging adults with T1D, (4) managing day-to-day life with T1D and (5) early independence to ease transition.

CONCLUSION

Individuals with T1D face a variety of challenges as they transition from paediatric to adult care providers. A proactive approach in educating adolescents is needed.

Patient-Driven Diabetes Technologies: Sentiment and Personas of the #WeAreNotWaiting and #OpenAPS Movements

BACKGROUND

Patients with diabetes have developed innovative do-it-yourself (DIY) methods for adapting existing medical devices to better fit individual needs.

METHOD

A multiple method study used Symplur Analytics to analyze aggregated Twitter data of #WeAreNotWaiting and #OpenAPS tweets between 2014 and 2017 to examine DIY patient-led innovation. Conversation sentiment was examined between diabetes stakeholders to determine changes over time. Two hundred of the most shared photos were analyzed to understand visual representations of DIY patient-led innovations. Finally, discourse analysis was used to identify the personas who engage in DIY patient-led diabetes technologies activities and conversations on Twitter.

RESULTS

A total of 7886 participants who generated 46 578 tweets were included. Sentiment analysis showed that 82%-85% of interactions around DIY patient-led innovation was positive among patient/caregiver and physician groups. Through photo analysis, five content themes emerged: (1) disseminating media and conference coverage, (2) showcasing devices, (3) celebrating connections, (4) providing instructions, and (5) celebrating accomplishments. Six personas emerged across the overlapping userbase: (1) fearless leaders, (2) loopers living it up, (3) parents on a mission, (4) the tech titans, (5) movement supporters, and (6) healthcare provider advocates. Personas had varying goals and behaviors within the community.

CONCLUSIONS

#WeAreNotWaiting and #OpenAPS on Twitter reveal a fast-moving patient-led movement focused on DIY patient innovation that is further mobilized by an expanding and diverse userbase. Further research is indicated to bring technology savvy persons with diabetes into conversation with healthcare providers and researchers alike.

The Underground Exchange of Diabetes Medications and Supplies: Donating, Trading, and Borrowing, Oh My!

BACKGROUND

The cost of diabetes medications and supplies is rising, resulting in access challenges. This study assessed the prevalence of and factors predicting underground exchange activities-donating, trading, borrowing, and purchasing diabetes medications and supplies.

RESEARCH DESIGN AND METHODS

A convenience sample of people affected by diabetes was recruited online to complete a survey. Mixed method analysis was undertaken, including logistic regression to examine the relationship between self-reported difficulty purchasing diabetes medications and supplies and engagement in underground exchange activity. Thematic qualitative analysis was used to examine open-text responses.

RESULTS

Participants (N = 159) self-reported engagement in underground exchange activities, including donating (56.6%), donation receiving (34.6%), trading (23.9%), purchasing (15.1%), and borrowing (22%). Such activity took place among a variety of individuals, including friends, family, coworkers, online acquaintances and strangers. Diabetes-specific financial stress predicted engagement in trading diabetes mediations or supplies (OR 6.3, 95% CI 2.2-18.5) and receiving donated medications or supplies (OR 2.8, 95% CI 1.1-7.2). One overarching theme, unmet needs, and three subthemes emerged: (1) factors influencing underground exchange activity, (2) perceived benefits of underground exchange activity, and (3) perceived consequences of underground exchange activity.

CONCLUSION

Over half of the participants in this study engaged in underground exchange activities out of necessity. Providers must be aware about this underground exchange and inquire about safety and possible alternative resources. There is an urgent need to improve access to medications that are essential for life. Our study points to a failure in the US healthcare system since such underground exchanges may not be necessary if medications and supplies were accessible.

Competencies for Diabetes Care and Education Specialists

Purpose

Diabetes care and education specialists provide collaborative, comprehensive, and person-centered care and education to people with diabetes and cardiometabolic conditions. The implementation of the vision for the specialty has prompted the need to reexamine the knowledge, skills, and abilities necessary for diabetes care and education specialists in today’s dynamic health care environment. The purpose of this article is to introduce an updated set of competencies reflective of the profession in this dynamic health care environment. Diabetes care and education specialists are health care professionals who have achieved a core body of knowledge and skills in the biological and social sciences, communication, counseling, and education and who have experience in the care of people with diabetes and related conditions. Members of this specialty encompass a diverse set of health disciplines, including nurses, dietitians, pharmacists, physicians, mental health professionals, podiatrists, optometrists, exercise physiologists, physicians, and others. The competencies are intended to guide practice regardless of discipline and encourage mastery through continuing education, individual study, and mentorship.

Conclusion

This document articulates the competencies required for diabetes care and education specialists in today’s dynamic health care environment as they pursue excellence in the specialty.

Developing the 2020 Diabetes Care & Education Specialist Competencies: A Modified Delphi Study

Purpose

The purpose of the study was to develop diabetes care and education specialty competencies that align with the Association of Diabetes Care & Education Specialists (ADCES).

Method

A Delphi method of consensus development was used, comprising 5 survey rounds. Interprofessional diabetes specialty experts were asked to identify and rate trends and issues important to diabetes specialists on a global scale. Use of a 5-round Delphi process allowed diabetes care and education specialty experts to refine their views considering the progress of the group’s work from round to round.

Results

A total of 457 diabetes care and education specialists across the United States in various professions participated in the Delphi rounds to identify a final set of 130 competencies across 6 domains.

Conclusion

Use of the Delphi method as a consensus guideline helped to identify core competencies for diabetes care and education specialists, reflecting the knowledge and skills necessary to provide evidence-based, high-quality care.

Daily illness appraisal and collaboration in couples with type 1 diabetes

OBJECTIVE

Dyadic coping theories posit that spousal involvement may benefit illness management through collaborative and supportive (C&S) strategies and shared illness appraisals. Illness appraisals have only been examined as individual differences rather than fluctuating daily as individuals manage the difficult Type 1 diabetes regimen. The study examined how daily illness appraisals of individuals with Type 1 diabetes and their spouses were linked to spouses' daily C&S strategies and whether C&S strategies were most beneficial for daily diabetes outcomes when they occurred in the context of shared illness appraisals.

METHOD

Couples (N = 199) in which one person had Type 1 diabetes (M age patients = 46.81; 52.3% female; spouses = 46.40, 47.5% female) completed a 14-day diary assessing illness appraisals (ranging from nonshared through shared) and spouses' C&S strategies. Patients reported daily self-regulation failures, self-care behaviors, and perceived coping effectiveness. Daily blood glucose was gathered from glucometers.

RESULTS

Multilevel models indicated both within-person and between-person effects of patients' and spouses' illness appraisals on C&S strategies with higher shared illness appraisals associated with greater C&S strategies. Greater shared illness appraisals were associated with fewer self-regulation failures and better self-care. C&S strategies were associated with lower self-care and higher blood glucose levels. Appraisal interacted with C&S strategies such that C&S strategies were associated with more self-regulation failures, lower self-care, and lower perceived coping effectiveness when patients reported lower shared appraisals.

CONCLUSIONS

Results suggest that C&S strategies may be more detrimental for diabetes management when individuals view diabetes as less shared. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In-Person and Technology-Mediated Peer Support in Diabetes Care: A Systematic Review of Reviews and Gap Analysis

PURPOSE

The purpose of this study is to report a systematic review of reviews of evidence and gaps focused on in-person and technology-mediated diabetes peer support and its impact on clinical, behavioral, and psychosocial outcomes.

METHODS

We conducted a systematic review of reviews in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Reviews published in English from December 1978 through December 2018 examining clinical, behavioral, and psychosocial outcomes were included. The search yielded 167 reviews that were examined for inclusion/exclusion criteria.

RESULTS

Nine systematic reviews and meta-analyses meeting criteria were included. Findings suggest peer support interventions can have a positive impact on clinical (A1C, blood pressure, cholesterol, weight), behavioral (diabetes knowledge, being active, healthy eating, medication management, self-management, self-efficacy, empowerment), and psychosocial (social support, health and diabetes distress, depression, quality of life) outcomes. Research gaps exist related to understanding the effects of emerging technology-mediated peer support modalities and the effects of peer support on gestational diabetes.

CONCLUSION

Many clinical, behavioral, and psychosocial benefits related to in-person and technology-mediated peer support exist. Diabetes care and education specialists should incorporate and recommend peer support resources for people with diabetes.

The Role of Self-regulation Failures and Self-care in the Link Between Daily Sleep Quality and Blood Glucose Among Adults with Type 1 Diabetes

BACKGROUND

Sleep, a process that restores the body's ability to self-regulate, may be one important factor affecting self-care behaviors and blood glucose (BG) levels. The link between sleep quality, self-care behaviors, and BG levels may occur by sleep-altering daily self-regulatory failures.

PURPOSE

This study examined whether the relation between sleep quality and self-care behaviors occurred through self-regulation failures and whether the relation between sleep quality and BG levels occurred through self-regulation failures and self-care behaviors sequentially.

METHODS

One hundred and ninety-nine adults with type 1 diabetes (T1D) completed an online questionnaire for 14 days in which they reported sleep quality, self-regulation failures, and self-care behaviors. BG levels were gathered from glucometers. Analyses involved multilevel mediation models and focused on daily within-person and between-person variability of sleep quality.

RESULTS

Better daily sleep quality was associated with higher self-care behaviors at both within-person and between-person levels, and self-regulation failures mediated the association between daily sleep quality and daily self-care behaviors at both within-person and between-person levels. Better daily sleep quality was associated with better BG levels at the within-person level and self-regulation behaviors and self-care behaviors sequentially mediated the association between daily sleep quality and daily BG levels at the within-person level.

CONCLUSION

This study provides a process account of the importance of daily sleep quality of adults with T1D, as well as one potential mechanism-self-regulation-that may explain the effect of sleep quality on diabetes outcomes.

Social Media in the Diabetes Community: a Novel Way to Assess Psychosocial Needs in People with Diabetes and Their Caregivers

PURPOSE OF REVIEW

Diabetes is a chronic disease that, regardless of type, requires intensive, ongoing self-management. As a result, people with diabetes (PWD) often have complex environmental, social, behavioral, and informational needs, many of which are unmet in healthcare settings and systems. To help meet these needs, many PWD interact with diabetes online communities (DOCs), including platforms such as Facebook, Twitter, and blogs, to share real-life support, problems, and concerns with other PWD, offering a rich source of data on patient-reported outcomes. This article reviews recent psychosocial needs and outcomes identified by studies of DOCs and/or their users.

RECENT FINDINGS

Participation in DOCs appears driven by a need for psychosocial support, unmet by providers and the healthcare system, as well as a sense of duty to provide it to others. The most common activities observed in DOCs are giving and receiving various types of support: psychosocial, technical, informational, and self-management. General and specific challenges (e.g., continuous glucose monitoring) as well as frustrations and worries associated with those challenges are commonly expressed, leading to reciprocal sharing, support, and encouragement, in a judgment-free manner, from other PWD. This leads users to feel more understood, empowered, validated, less alone, and more supported. Negative findings were reported very rarely and focused more on how other participants used social media rather than on the exchange of misplaced or dangerous information or advice. Diabetes online communities have grown from unmet needs for problem-solving and psychosocial support for living with a complex condition and from the availability of a new communications medium (i.e., social media). This has enabled communities of peers to both seek and receive support for living with diabetes, providing an important supplement to what is provided in healthcare settings and offering valuable information about what is most important to PWD and their families, with the potential to improve psychosocial care.

The Role and Value of Ongoing and Peer Support in Diabetes Care and Education

PURPOSE

Increasing attention is being given to the challenges and emotional toll of managing diabetes. This Perspectives in Practice details the specialty's guiding documents for initial and ongoing support. It also defines various types of social support, including peer support, for optimal diabetes care. Focusing on peer support, this paper provides a review of the body of evidence demonstrating the value of peer support to improve clinical and behavioral outcomes. To achieve positive outcomes, it is optimal for people with diabetes to have access to ongoing support from their health care provider, including diabetes care and education specialists. They should also be made aware of, and given referral to options and opportunities for peer support. This Perspectives in Practice concludes with a call to action for diabetes care and education specialists to deliver to integrate and promote the value of peer support in the care they provide.

CONCLUSION

Managing diabetes during the stages and ages of life is chronically challenging and complex. Various types of support offered by health care providers, including diabetes care and education specialists and others in the person's social support milieu, can positively affect emotional well-being. Health care providers should routinely assess their client's social supports and refer the person with diabetes and/or their caregivers to evidence-based types of peer support mutually determined to be of most value. Diabetes care and education specialists should increase their awareness of opportunities to integrate the value of and referral to peer support in their counseling and to gain greater insight into the diabetes-lived experience.

Perceptions of the Diabetes Online Community's Credibility, Social Capital, and Help and Harm: Cross-Sectional Comparison Between Baby Boomers and Younger Adults

Background

The use of online health communities such as the diabetes online community (DOC) is growing. Individuals who engage in the DOC are able to interact with peers who have the same medical condition. It is not known if older adults are perceiving the DOC differently compared with younger adults.

Objective

The purpose of this study was to explore and understand how the DOC is perceived in terms of social capital, source credibility, and help and harm. The findings from this study will shed light on how users of different age groups (baby boomers and younger adult counterparts) perceive DOC use.

Methods

This study represents a subset of participants from a larger study of DOC users. Baby boomers and younger adults with diabetes were recruited from the DOC to participate in a cross-sectional survey. Demographics, electronic health use (reasons to join the DOC, DOC intensity, DOC engagement, internet social capital, and help or harm from the DOC), source credibility, health-related quality of life, and diabetes self-care data were collected. We examined the differences between baby boomer and younger adult responses.

Results

The participants included baby boomers (N=76) and younger adult counterparts (N=102). Participants scored their diabetes health care team (mean 33.5 [SD 8]) significantly higher than the DOC (mean 32 [SD 6.4]) with regard to competence (P<.05) and trustworthiness (diabetes health care team mean 36.3 [SD 7.1]; DOC mean 33.6 [SD 6.2]; P<.001). High bonding and bridging social capital correlated with high DOC intensity (r=.629; P<.001 and r=.676; P<.001, respectively) and high DOC engagement (r=.474; P<.01 and r=.507; P≤.01, respectively). The greater majority (69.8%) reported the DOC as being helpful, and 1.8% reported that the DOC had caused minor harm. Baby boomers perceived DOC credibility, social capital, help, and harm similarly to their younger adult counterparts.

Conclusions

Baby boomers are using and perceiving the DOC similarly to younger adults. DOC users find the DOC to be credible; however, they scored their health care team higher with regard to competence and trustworthiness. The DOC is beneficial with low risk and may augment current diabetes care.

Yours, Mine, and Ours: A Qualitative Analysis of the Impact of Type 1 Diabetes Management in Older Adult Married Couples

OBJECTIVE

The purpose of this study was to understand perceptions of diabetes management responsibilities and the impact of diabetes on day-to-day activities in older adulthood for individuals with type 1 diabetes and their spouses.

DESIGN AND METHODS

This qualitative content analysis used a constant-compare approach to analyze individual interviews conducted with older adults and their spouses. People with type 1 diabetes (PWD) and their spouses were interviewed regarding how they coped or dealt with diabetes, what activities they carried out or avoided because of diabetes, and how they appraised diabetes as an individual or shared problem.

RESULTS

Participants (n = 52) included 26 older adults with diabetes (mean age 69 years, SD 2.56 years; 38.5% female) and their spouses (mean age 68 years, SD 5.11 years; 61.5% female). Half of the PWD (50%) and the majority of spouses (76.9%) appraised diabetes as a shared issue. Five themes emerged from the interview data: 1) Perceptions pf PWD of spouse involvement in diabetes care, 2) PWD underestimated the impact of diabetes on their spouse's daily lives, 3) gendered nature of spouses supporting diabetes management, 4) evolution of diabetes and the relationship across developmental time, and 5) differences in diabetes management among couples.

CONCLUSION

Older adults with type 1 diabetes and their spouses have different perspectives regarding diabetes support and responsibility and may not always realize what support is being provided or needed to optimize effective diabetes management. Advancing age with or without diabetes complications may necessitate that spouses provide diabetes support. Diabetes management training for spouses would likely be helpful.

An Evaluation of Digital Health Tools for Diabetes Self-Management in Hispanic Adults: Exploratory Study

Background

Although multiple self-monitoring technologies for type 2 diabetes mellitus (T2DM) show promise for improving T2DM self-care behaviors and clinical outcomes, they have been understudied in Hispanic adult populations who suffer disproportionately from T2DM.

Objective

The objective of this study was to evaluate the acceptability, feasibility, and potential integration of wearable sensors for diabetes self-monitoring among Hispanic adults with self-reported T2DM.

Methods

We conducted a pilot study of T2DM self-monitoring technologies among Hispanic adults with self-reported T2DM. Participants (n=21) received a real-time continuous glucose monitor (RT-CGM), a wrist-worn physical activity (PA) tracker, and a tablet-based digital food diary to self-monitor blood glucose, PA, and food intake, respectively, for 1 week. The RT-CGM captured viewable blood glucose concentration (mg/dL) and PA trackers collected accelerometer-based data, viewable on the device or an associated tablet app. After 1 week of use, we conducted a semistructured interview with each participant to understand experiences and thoughts on integration of the data from the devices into a technology-facilitated T2DM self-management intervention. We also conducted a brief written questionnaire to understand participants’ self-reported T2DM history and past experience using digital health tools for T2DM self-management. Feasibility was measured by device utilization and objective RT-CGM, PA tracker, and diet logging data. Acceptability and potential integration were evaluated through thematic analysis of verbatim interview transcripts.

Results

Participants (n=21, 76% female, 50.4 [SD 11] years) had a mean self-reported hemoglobin A_1c of 7.4 [SD 1.8] mg/dL and had been diagnosed with T2DM for 7.4 [SD 5.2] years (range: 1-16 years). Most (89%) were treated with oral medications, whereas the others self-managed through diet and exercise. Nearly all participants (n=20) used both the RT-CGM and PA tracker, and 52% (11/21) logged at least one meal, with 33% (7/21) logging meals for 4 or more days. Of the 8 possible days, PA data were recorded for 7.1 [SD 1.8] days (range: 2-8), and participants averaged 7822 [SD 3984] steps per day. Interview transcripts revealed that participants felt most positive about the RT-CGM as it unveiled previously unknown relationships between lifestyle and health and contributed to changes in T2DM-related thoughts and behaviors. Participants felt generally positive about incorporating the wearable sensors and mobile apps into a future intervention if support were provided by a health coach or health care provider, device training were provided, apps were tailored to their language and culture, and content were both actionable and delivered on a single platform.

Conclusions

Sensor-based tools for facilitating T2DM self-monitoring appear to be a feasible and acceptable technology among low-income Hispanic adults. We identified barriers to acceptability and highlighted preferences for wearable sensor integration in a community-based intervention. These findings have implications for the design of T2DM interventions targeting Hispanic adults.

Diabetes Education Impact on Hypoglycemia Outcomes: A Systematic Review of Evidence and Gaps in the Literature

PURPOSE

The primary purpose of this study is to report a systematic review of evidence and gaps in the literature among well-conducted studies assessing the impact of diabetes education on hypoglycemia outcomes and secondarily reporting the impact on other included target outcomes.

METHODS

The authors used a modified Cochrane method to systematically search and review English-language titles, abstracts, and full-text articles published in the United States between January 2001 and December 2017, with diabetes education specified as an intervention and a directly measurable outcome for hypoglycemia risk or events included.

RESULTS

Fourteen quasi-experimental, experimental, and case-control studies met the inclusion criteria, with 8 articles reporting a positive impact of diabetes self-management education and support (DSMES) on hypoglycemia outcomes; 2 of the 8 reported decreased hypoglycemia events, and 1 reported decreased events in both the intervention and control groups. In addition, 5 studies targeted change in reported hypoglycemia symptoms, with all 5 reporting a significant decrease. DSMES also demonstrated an impact on intermediate (knowledge gain, behavior change) and long-term (humanistic and economic/utilization) outcomes. An absence of common hypoglycemia measures and terminology and suboptimal descriptions of DSMES programs for content, delivery, duration, practitioner types, and participants were identified as gaps in the literature.

CONCLUSIONS

Most retained studies reported that diabetes education positively affected varied measures of hypoglycemia outcomes (number of events, reported symptoms) as well as other targeted outcomes. Diabetes education is an important intervention for reducing hypoglycemia events and/or symptoms and should be included as a component of future hypoglycemia risk mitigation studies.

Patient and partner illness appraisals and health among adults with type 1 diabetes

In a study of 199 couples in which one person had type 1 diabetes, we examined how patient appraisal of the diabetes as shared versus individual was associated with collaborative, supportive and unsupportive behavior and whether patient shared illness appraisal was most beneficial for health when it occurred in the context of supportive behavior. We assessed illness appraisal among patients with type 1 diabetes and their partners and had patients complete relationship and health measures. Results showed partners were more likely than patients to hold shared illness appraisals. Patients' shared appraisals were associated with more collaborative and instrumental support, more emotional support, less protective buffering, and more overprotective behavior. When patients and partners were consistent in their shared appraisals, support was highest. Regression analysis showed collaborative and instrumental support, as well as emotional support, was related to better psychological and physical health when patients held shared compared to individual illness appraisals.