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Martine-Edith G, Divilly P, Zaremba N, Søholm U, Broadley M, Baumann PM, Mahmoudi Z, Gomes M, Ali N, Abbink EJ, de Galan B, Brøsen J, Pedersen-Bjergaard U, Vaag AA, McCrimmon RJ, Renard E, Heller S, Evans M, Cigler M, Mader JK, Speight J, Pouwer F, Amiel SA, Choudhary P, Hypo-Resolve FT. A Comparison of the Rates of Clock-Based Nocturnal Hypoglycemia and Hypoglycemia While Asleep Among People Living with Diabetes: Findings from the Hypo-METRICS Study. Diabetes Technol Ther 2024. [PMID: 38386436 DOI: 10.1089/dia.2023.0522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
Introduction: Nocturnal hypoglycemia is generally calculated between 00:00 and 06:00. However, those hours may not accurately reflect sleeping patterns and it is unknown whether this leads to bias. We therefore compared hypoglycemia rates while asleep with those of clock-based nocturnal hypoglycemia in adults with type 1 diabetes (T1D) or insulin-treated type 2 diabetes (T2D). Methods: Participants from the Hypo-METRICS study wore a blinded continuous glucose monitor and a Fitbit Charge 4 activity monitor for 10 weeks. They recorded details of episodes of hypoglycemia using a smartphone app. Sensor-detected hypoglycemia (SDH) and person-reported hypoglycemia (PRH) were categorized as nocturnal (00:00-06:00 h) versus diurnal and while asleep versus awake defined by Fitbit sleeping intervals. Paired-sample Wilcoxon tests were used to examine the differences in hypoglycemia rates. Results: A total of 574 participants [47% T1D, 45% women, 89% white, median (interquartile range) age 56 (45-66) years, and hemoglobin A1c 7.3% (6.8-8.0)] were included. Median sleep duration was 6.1 h (5.2-6.8), bedtime and waking time ∼23:30 and 07:30, respectively. There were higher median weekly rates of SDH and PRH while asleep than clock-based nocturnal SDH and PRH among people with T1D, especially for SDH <70 mg/dL (1.7 vs. 1.4, P < 0.001). Higher weekly rates of SDH while asleep than nocturnal SDH were found among people with T2D, especially for SDH <70 mg/dL (0.8 vs. 0.7, P < 0.001). Conclusion: Using 00:00 to 06:00 as a proxy for sleeping hours may underestimate hypoglycemia while asleep. Future hypoglycemia research should consider the use of sleep trackers to record sleep and reflect hypoglycemia while asleep more accurately. The trial registration number is NCT04304963.
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Affiliation(s)
- Gilberte Martine-Edith
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Patrick Divilly
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Department, St Vincent's University Hospital, Elm Park, Dublin, Ireland
| | - Natalie Zaremba
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Uffe Søholm
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Zeinab Mahmoudi
- Data Science, Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Mikel Gomes
- Data Science, Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Namam Ali
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Evertine J Abbink
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Allan A Vaag
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Simon Heller
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Mark Evans
- Welcome-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Monika Cigler
- Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Julia K Mader
- Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Pratik Choudhary
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
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Martine-Edith G, Zaremba N, Divilly P, Søholm U, Broadley M, Baumann PM, Mahmoudi Z, Gomes M, Ali N, Abbink EJ, de Galan B, Brøsen J, Pedersen-Bjergaard U, Vaag AA, McCrimmon RJ, Renard E, Heller S, Evans M, Cigler M, Mader JK, Amiel SA, Speight J, Pouwer F, Choudhary P. Associations Between Hypoglycemia Awareness Status and Symptoms of Hypoglycemia Among Adults with Type 1 or Insulin-Treated Type 2 Diabetes Using the Hypo-METRICS Smartphone Application. Diabetes Technol Ther 2024. [PMID: 38512385 DOI: 10.1089/dia.2023.0596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Introduction: This study examined associations between hypoglycemia awareness status and hypoglycemia symptoms reported in real-time using the novel Hypoglycaemia-MEasurement, ThResholds and ImpaCtS (Hypo-METRICS) smartphone application (app) among adults with insulin-treated type 1 (T1D) or type 2 diabetes (T2D). Methods: Adults who experienced at least one hypoglycemic episode in the previous 3 months were recruited to the Hypo-METRICS study. They prospectively reported hypoglycemia episodes using the app for 10 weeks. Any of eight hypoglycemia symptoms were considered present if intensity was rated between "A little bit" to "Very much" and absent if rated "Not at all." Associations between hypoglycemia awareness (as defined by Gold score) and hypoglycemia symptoms were modeled using mixed-effects binary logistic regression, adjusting for glucose monitoring method and diabetes duration. Results: Of 531 participants (48% T1D, 52% T2D), 45% were women, 91% white, and 59% used Flash or continuous glucose monitoring. Impaired awareness of hypoglycemia (IAH) was associated with lower odds of reporting autonomic symptoms than normal awareness of hypoglycemia (NAH) (T1D odds ratio [OR] 0.43 [95% confidence interval {CI} 0.25-0.73], P = 0.002); T2D OR 0.51 [95% CI 0.26-0.99], P = 0.048), with no differences in neuroglycopenic symptoms. In T1D, relative to NAH, IAH was associated with higher odds of reporting autonomic symptoms at a glucose concentration <54 than >70 mg/dL (OR 2.18 [95% CI 1.21-3.94], P = 0.010). Conclusion: The Hypo-METRICS app is sensitive to differences in hypoglycemia symptoms according to hypoglycemia awareness in both diabetes types. Given its high ecological validity and low recall bias, the app may be a useful tool in research and clinical settings. The clinical trial registration number is NCT04304963.
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Affiliation(s)
- Gilberte Martine-Edith
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Natalie Zaremba
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Patrick Divilly
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Department, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Uffe Søholm
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Petra Martina Baumann
- Medical University of Graz, Division of Endocrinology and Diabetology, Graz, Austria
| | - Zeinab Mahmoudi
- Data Science, Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Mikel Gomes
- Data Science, Department of Pharmacometrics, Novo Nordisk A/S, Søborg, Denmark
| | - Namam Ali
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Evertine J Abbink
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julie Brøsen
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Copenhagen University Hospital-North Zealand, Hillerød, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Allan A Vaag
- Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Simon Heller
- School of Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Mark Evans
- Welcome-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Monika Cigler
- Medical University of Graz, Division of Endocrinology and Diabetology, Graz, Austria
| | - Julia K Mader
- Medical University of Graz, Division of Endocrinology and Diabetology, Graz, Austria
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Jane Speight
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
| | - Pratik Choudhary
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
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Søholm U, Holmes-Truscott E, Broadley M, Amiel SA, Hendrieckx C, Choudhary P, Pouwer F, Shaw JAM, Speight J. Hypoglycaemia symptom frequency, severity, burden, and utility among adults with type 1 diabetes and impaired awareness of hypoglycaemia: Baseline and 24-week findings from the HypoCOMPaSS study. Diabet Med 2024; 41:e15231. [PMID: 37746767 DOI: 10.1111/dme.15231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/19/2023] [Accepted: 09/20/2023] [Indexed: 09/26/2023]
Abstract
AIMS To determine the frequency, severity, burden, and utility of hypoglycaemia symptoms among adults with type 1 diabetes (T1D) and impaired awareness of hypoglycaemia (IAH) at baseline and week 24 following the HypoCOMPaSS awareness restoration intervention. METHODS Adults (N = 96) with T1D (duration: 29 ± 12 years; 64% women) and IAH completed the Hypoglycaemia Burden Questionnaire (HypoB-Q), assessing experience of 20 pre-specified hypoglycaemia symptoms, at baseline and week 24. RESULTS At baseline, 93 (97%) participants experienced at least one symptom (mean ± SD 10.6 ± 4.6 symptoms). The proportion recognising each specific symptom ranged from 15% to 83%. At 24 weeks, symptom severity and burden appear reduced, and utility increased. CONCLUSIONS Adults with T1D and IAH experience a range of hypoglycaemia symptoms. Perceptions of symptom burden or utility are malleable. Although larger scale studies are needed to confirm, these findings suggest that changing the salience of the symptomatic response may be more important in recovering protection from hypoglycaemia through regained awareness than intensifying symptom frequency or severity.
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Affiliation(s)
- Uffe Søholm
- Medical & Science, Patient Focused Drug Development, Novo Nordisk A/S, Søborg, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Diabetes, School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Elizabeth Holmes-Truscott
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- School of Psychology, Institute for Health Transformations, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- School of Psychology, Institute for Health Transformations, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
| | - Pratik Choudhary
- Department of Diabetes, School of Cardiovascular Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
- Department of Medical Psychology, Amsterdam UMC, Amsterdam, The Netherlands
| | - James A M Shaw
- Translational and Clinical Research Institute, The Medical School, Newcastle University, Newcastle upon Tyne, UK
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- School of Psychology, Institute for Health Transformations, Deakin University, Geelong, Victoria, Australia
- Institute for Health Transformation, Deakin University, Geelong, Victoria, Australia
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Søholm U, Zaremba N, Broadley M, Axelsen JL, Divilly P, Martine-Edith G, Amiel SA, Mader JK, Pedersen-Bjergaard U, McCrimmon RJ, Renard E, Evans M, de Galan B, Heller S, Hendrieckx C, Choudhary P, Speight J, Pouwer F. Assessing the Content Validity, Acceptability, and Feasibility of the Hypo-METRICS App: Survey and Interview Study. JMIR Diabetes 2023; 8:e42100. [PMID: 37773626 PMCID: PMC10576226 DOI: 10.2196/42100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 06/02/2023] [Accepted: 08/16/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND The Hypoglycaemia - MEasurement, ThResholds and ImpaCtS (Hypo-METRICS) smartphone app was developed to investigate the impact of hypoglycemia on daily functioning in adults with type 1 diabetes mellitus or insulin-treated type 2 diabetes mellitus. The app uses ecological momentary assessments, thereby minimizing recall bias and maximizing ecological validity. It was used in the Hypo-METRICS study, a European multicenter observational study wherein participants wore a blinded continuous glucose monitoring device and completed the app assessments 3 times daily for 70 days. OBJECTIVE The 3 aims of the study were to explore the content validity of the app, the acceptability and feasibility of using the app for the duration of the Hypo-METRICS study, and suggestions for future versions of the app. METHODS Participants who had completed the 70-day Hypo-METRICS study in the United Kingdom were invited to participate in a brief web-based survey and an interview (approximately 1h) to explore their experiences with the app during the Hypo-METRICS study. Thematic analysis of the qualitative data was conducted using both deductive and inductive methods. RESULTS A total of 18 adults with diabetes (type 1 diabetes: n=10, 56%; 5/10, 50% female; mean age 47, SD 16 years; type 2 diabetes: n=8, 44%; 2/8, 25% female; mean age 61, SD 9 years) filled out the survey and were interviewed. In exploring content validity, participants overall described the Hypo-METRICS app as relevant, understandable, and comprehensive. In total, 3 themes were derived: hypoglycemia symptoms and experiences are idiosyncratic; it was easy to select ratings on the app, but day-to-day changes were perceived as minimal; and instructions could be improved. Participants offered suggestions for changes or additional questions and functions that could increase engagement and improve content (such as providing more examples with the questions). In exploring acceptability and feasibility, 5 themes were derived: helping science and people with diabetes; easy to fit in, but more flexibility wanted; hypoglycemia delaying responses and increasing completion time; design, functionality, and customizability of the app; and limited change in awareness of symptoms and impact. Participants described using the app as a positive experience overall and as having a possible, although limited, intervention effect in terms of both hypoglycemia awareness and personal impact. CONCLUSIONS The Hypo-METRICS app shows promise as a new research tool to assess the impact of hypoglycemia on an individual's daily functioning. Despite suggested improvements, participants' responses indicated that the app has satisfactory content validity, overall fits in with everyday life, and is suitable for a 10-week research study. Although developed for research purposes, real-time assessments may have clinical value for monitoring and reviewing hypoglycemia symptom awareness and personal impact.
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Affiliation(s)
- Uffe Søholm
- Medical & Science, Patient Focused Drug Development, Novo Nordisk A/S, Søborg, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Natalie Zaremba
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Patrick Divilly
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Gilberte Martine-Edith
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Stephanie A Amiel
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
| | - Julia K Mader
- Division of Endocrinology and Diabetology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, Centre National de la Recherche Scientifique, Institut National de la Santé et de la Recherche Médicale, Montpellier, France
| | - Mark Evans
- Welcome-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, Netherlands
- Department of Internal Medicine, Division of Endocrinology and Metabolic Disease, Maastricht University Medical Centre, Maastricht, Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Christel Hendrieckx
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Australia
| | - Pratik Choudhary
- Department of Diabetes, School of Cardiovascular and Metabolic Medicine and Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Carlton, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Institute for Health Transformation, Deakin University, Geelong, Australia
- Steno Diabetes Center Odense, Odense, Denmark
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5
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Søholm U, Broadley M, Zaremba N, Divilly P, Nefs G, Carlton J, Mader JK, Baumann PM, Gomes M, Martine-Edith G, Pollard DJ, Rath D, Heller S, Pedersen-Bjergaard U, McCrimmon RJ, Renard E, Evans M, de Galan B, Forkmann T, Amiel SA, Hendrieckx C, Speight J, Choudhary P, Pouwer F. Psychometric properties of an innovative smartphone application to investigate the daily impact of hypoglycemia in people with type 1 or type 2 diabetes: The Hypo-METRICS app. PLoS One 2023; 18:e0283148. [PMID: 36930585 PMCID: PMC10022775 DOI: 10.1371/journal.pone.0283148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 03/02/2023] [Indexed: 03/18/2023] Open
Abstract
INTRODUCTION The aim of this study was to determine the acceptability and psychometric properties of the Hypo-METRICS (Hypoglycemia MEasurement, ThResholds and ImpaCtS) application (app): a novel tool designed to assess the direct impact of symptomatic and asymptomatic hypoglycemia on daily functioning in people with insulin-treated diabetes. MATERIALS AND METHODS 100 adults with type 1 diabetes mellitus (T1DM, n = 64) or insulin-treated type 2 diabetes mellitus (T2DM, n = 36) completed three daily 'check-ins' (morning, afternoon and evening) via the Hypo-METRICs app across 10 weeks, to respond to 29 unique questions about their subjective daily functioning. Questions addressed sleep quality, energy level, mood, affect, cognitive functioning, fear of hypoglycemia and hyperglycemia, social functioning, and work/productivity. Completion rates, structural validity, internal consistency, and test-retest reliability were explored. App responses were correlated with validated person-reported outcome measures to investigate convergent (rs>±0.3) and divergent (rs<±0.3) validity. RESULTS Participants' mean±SD age was 54±16 years, diabetes duration was 23±13 years, and most recent HbA1c was 56.6±9.8 mmol/mol. Participants submitted mean±SD 191±16 out of 210 possible 'check-ins' (91%). Structural validity was confirmed with multi-level confirmatory factor analysis showing good model fit on the adjusted model (Comparative Fit Index >0.95, Root-Mean-Square Error of Approximation <0.06, Standardized Root-Mean-square Residual<0.08). Scales had satisfactory internal consistency (all ω≥0.5), and high test-retest reliability (rs≥0.7). Convergent and divergent validity were demonstrated for most scales. CONCLUSION High completion rates and satisfactory psychometric properties demonstrated that the Hypo-METRICS app is acceptable to adults with T1DM and T2DM, and a reliable and valid tool to explore the daily impact of hypoglycemia.
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Affiliation(s)
- Uffe Søholm
- Medical & Science, Patient Focused Drug Development, Novo Nordisk A/S, Søborg, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
- * E-mail:
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Natalie Zaremba
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
| | - Patrick Divilly
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
| | - Giesje Nefs
- Department of Medical Psychology, Radboud Institute for Health Sciences, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, the Netherlands
- National Treatment and Research Center for Children, Adolescents and Adults with Type 1 Diabetes, Rotterdam, The Netherlands
| | - Jill Carlton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Julia K. Mader
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | | | - Mikel Gomes
- Digital Therapeutics, Scientific Modelling, Novo Nordisk A/S, Søborg, Denmark
| | - Gilberte Martine-Edith
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
| | - Daniel J. Pollard
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom
| | - Dajana Rath
- Department of Clinical Psychology, University of Duisburg-Essen, Essen, Germany
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital Hillerød, Hillerød, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Rory J. McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Eric Renard
- Department of Endocrinology, Diabetes, Nutrition, Montpellier University Hospital, Montpellier, France
- Institute of Functional Genomics, University of Montpellier, CNRS, INSERM, Montpellier, France
| | - Mark Evans
- Welcome Trust-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, the Netherlands
- Department of Internal Medicine, Division of Endocrinology and Metabolic Disease, Maastricht University Medical Centre, Maastricht, the Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, the Netherlands
| | - Thomas Forkmann
- Department of Clinical Psychology, University of Duisburg-Essen, Essen, Germany
| | - Stephanie A. Amiel
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
| | - Christel Hendrieckx
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Australia
| | - Pratik Choudhary
- Faculty of Life Sciences and Medicine, Department of Diabetes, School of Cardiovascular Medicine and Sciences, King’s College London, London, United Kingdom
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
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Divilly P, Zaremba N, Mahmoudi Z, Søholm U, Pollard DJ, Broadley M, Abbink EJ, de Galan B, Pedersen‐Bjergaard U, Renard E, Evans M, Speight J, Brennan A, McCrimmon RJ, Müllenborn M, Heller S, Seibold A, Mader JK, Amiel SA, Pouwer F, Choudhary P. Hypo-METRICS: Hypoglycaemia-MEasurement, ThResholds and ImpaCtS-A multi-country clinical study to define the optimal threshold and duration of sensor-detected hypoglycaemia that impact the experience of hypoglycaemia, quality of life and health economic outcomes: The study protocol. Diabet Med 2022; 39:e14892. [PMID: 35633291 PMCID: PMC9542005 DOI: 10.1111/dme.14892] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 05/26/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Hypoglycaemia is a significant burden to people living with diabetes and an impediment to achieving optimal glycaemic outcomes. The use of continuous glucose monitoring (CGM) has improved the capacity to assess duration and level of hypoglycaemia. The personal impact of sensor-detected hypoglycaemia (SDH) is unclear. Hypo-METRICS is an observational study designed to define the threshold and duration of sensor glucose that provides the optimal sensitivity and specificity for events that people living with diabetes experience as hypoglycaemia. METHODS We will recruit 600 participants: 350 with insulin-treated type 2 diabetes, 200 with type 1 diabetes and awareness of hypoglycaemia and 50 with type 1 diabetes and impaired awareness of hypoglycaemia who have recent experience of hypoglycaemia. Participants will wear a blinded CGM device and an actigraphy monitor to differentiate awake and sleep times for 10 weeks. Participants will be asked to complete three short surveys each day using a bespoke mobile phone app, a technique known as ecological momentary assessment. Participants will also record all episodes of self-detected hypoglycaemia on the mobile app. We will use particle Markov chain Monte Carlo optimization to identify the optimal threshold and duration of SDH that have optimum sensitivity and specificity for detecting patient-reported hypoglycaemia. Key secondary objectives include measuring the impact of symptomatic and asymptomatic SDH on daily functioning and health economic outcomes. ETHICS AND DISSEMINATION The protocol was approved by local ethical boards in all participating centres. Study results will be shared with participants, in peer-reviewed journal publications and conference presentations.
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Affiliation(s)
- Patrick Divilly
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Natalie Zaremba
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Zeinab Mahmoudi
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
- Digital Therapeutics, Scientific Modelling, Novo Nordisk A/SSøborgDenmark
| | - Uffe Søholm
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
- Department of PsychologyUniversity of Southern DenmarkOdenseDenmark
| | - Daniel J. Pollard
- School of Health and Related Research (ScHARR)University of SheffieldSheffieldUK
| | - Melanie Broadley
- Department of PsychologyUniversity of Southern DenmarkOdenseDenmark
| | - Evertine J. Abbink
- Department of internal medicineRadboud university medical centreNijmegenThe Netherlands
| | - Bastiaan de Galan
- Department of internal medicineRadboud university medical centreNijmegenThe Netherlands
- Department of Internal MedicineDivision of EndocrinologyMaastricht University Medical CentreMaastrichtThe Netherlands
- CARIM School for Cardiovascular DiseasesMaastricht UniversityMaastrichtThe Netherlands
| | - Ulrik Pedersen‐Bjergaard
- Department of Endocrinology and NephrologyNordsjællands Hospital HillerødHillerødDenmark
- Institute of Clinical MedicineUniversity of CopenhagenCopenhagenDenmark
| | - Eric Renard
- Department of Endocrinology, Diabetes, NutritionMontpellier University HospitalMontpellierFrance
- Institute of Functional GenomicsUniversity of MontpellierCNRS, INSERMMontpellierFrance
| | - Mark Evans
- Wellcome Trust‐MRC Institute of Metabolic Science and Department of MedicineUniversity of CambridgeUK
| | - Jane Speight
- School of PsychologyDeakin UniversityGeelongAustralia
- The Australian Centre for Behavioural Research in DiabetesDiabetes VictoriaMelbourneAustralia
| | - Alan Brennan
- School of Health and Related Research (ScHARR)University of SheffieldSheffieldUK
| | | | | | | | | | - Julia K. Mader
- Division of Endocrinology and DiabetologyDepartment of Internal MedicineMedical University of GrazGrazAustria
- Division of Endocrinology and DiabetologyMedical University of GrazGrazAustria
| | - Stephanie A. Amiel
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
| | - Frans Pouwer
- Department of PsychologyUniversity of Southern DenmarkOdenseDenmark
- Steno Diabetes Center OdenseOdenseDenmark
| | - Pratik Choudhary
- Department of DiabetesSchool of Life Course SciencesFaculty of Life Sciences and MedicineKing's College LondonLondonUK
- Diabetes Research CentreUniversity of LeicesterLeicesterUK
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Broadley M, Chatwin H, Søholm U, Amiel SA, Carlton J, De Galan BE, Hendrieckx C, McCrimmon RJ, Skovlund SE, Pouwer F, Speight J. The 12-Item Hypoglycemia Impact Profile (HIP12): psychometric validation of a brief measure of the impact of hypoglycemia on quality of life among adults with type 1 or type 2 diabetes. BMJ Open Diabetes Res Care 2022; 10:10/4/e002890. [PMID: 35977753 PMCID: PMC9389129 DOI: 10.1136/bmjdrc-2022-002890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/15/2022] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION The aim of this study was to determine the psychometric properties of the 12-Item Hypoglycemia Impact Profile (HIP12), a brief measure of the impact of hypoglycemia on quality of life (QoL) among adults with type 1 (T1D) or type 2 diabetes (T2D). RESEARCH DESIGN AND METHODS Adults with T1D (n=1071) or T2D (n=194) participating in the multicountry, online study, 'Your SAY: Hypoglycemia', completed the HIP12. Psychometric analyses were undertaken to determine acceptability, structural validity, internal consistency, convergent/divergent validity, and known-groups validity. RESULTS Most (98%) participants completed all items on the HIP12. The expected one-factor solution was supported for T1D, T2D, native English speaker, and non-native English speaker groups. Internal consistency was high across all groups (ω=0.91-0.93). Convergent and divergent validity were satisfactory. Known-groups validity was demonstrated for both diabetes types, by frequency of severe hypoglycemia (0 vs ≥1 episode in the past 12 months) and self-treated episodes (<2 vs 2-4 vs ≥5 per week). The measure also discriminated by awareness of hypoglycemia in those with T1D. CONCLUSIONS The HIP12 is an acceptable, internally consistent, and valid tool for assessing the impact of hypoglycemia on QoL among adults with T1D. The findings in the relatively small sample with T2D are encouraging and warrant replication in a larger sample.
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Affiliation(s)
- Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Hannah Chatwin
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Uffe Søholm
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | - Jill Carlton
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Bastiaan E De Galan
- Department of Internal Medicine, Diabetes Section, Radboudumc, Nijmegen, The Netherlands
- Department of Internal Medicine/Endocrinology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Rory J McCrimmon
- Division of Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Søren E Skovlund
- Patient-Centered Research Science, Evidera, London, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- Steno Diabetes Center Odense, Odense, Denmark
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
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Søholm U, Broadley M, Zaremba N, Divilly P, Nefs G, Mahmoudi Z, de Galan B, Pedersen-Bjergaard U, Brennan A, Pollard DJ, McCrimmon RJ, A Amiel S, Hendrieckx C, Speight J, Choudhary P, Pouwer F. Investigating the day-to-day impact of hypoglycaemia in adults with type 1 or type 2 diabetes: design and validation protocol of the Hypo-METRICS application. BMJ Open 2022; 12:e051651. [PMID: 35105572 PMCID: PMC8808414 DOI: 10.1136/bmjopen-2021-051651] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hypoglycaemia is a frequent adverse event and major barrier for achieving optimal blood glucose levels in people with type 1 or type 2 diabetes using insulin. The Hypo-RESOLVE (Hypoglycaemia-Redefining SOLutions for better liVEs) consortium aims to further our understanding of the day-to-day impact of hypoglycaemia. The Hypo-METRICS (Hypoglycaemia-MEasurement, ThResholds and ImpaCtS) application (app) is a novel app for smartphones. This app is developed as part of the Hypo-RESOLVE project, using ecological momentary assessment methods that will minimise recall bias and allow for robust investigation of the day-to-day impact of hypoglycaemia. In this paper, the development and planned psychometric analyses of the app are described. METHODS AND ANALYSIS The three phases of development of the Hypo-METRICS app are: (1) establish a working group-comprising diabetologists, psychologists and people with diabetes-to define the problem and identify relevant areas of daily functioning; (2) develop app items, with user-testing, and implement into the app platform; and (3) plan a large-scale, multicountry study including interviews with users and psychometric validation. The app includes 7 modules (29 unique items) assessing: self-report of hypoglycaemic episodes (during the day and night, respectively), sleep quality, well-being/cognitive function, social interactions, fear of hypoglycaemia/hyperglycaemia and work/productivity. The app is designed for use within three fixed time intervals per day (morning, afternoon and evening). The first version was released mid-2020 for use (in conjunction with continuous glucose monitoring and activity tracking) in the Hypo-METRICS study; an international observational longitudinal study. As part of this study, semistructured user-experience interviews and psychometric analyses will be conducted. ETHICS AND DISSEMINATION Use of the novel Hypo-METRICS app in a multicountry clinical study has received ethical approval in each of the five countries involved (Oxford B Research Ethics Committee, CMO Region Arnhem-Nijmegen, Ethikkommission der Medizinischen Universität Graz, Videnskabsetisk Komite for Region Hovedstaden and the Comite Die Protection Des Personnes SUD Mediterranne IV). The results from the study will be published in peer review journals and presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT04304963.
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Affiliation(s)
- Uffe Søholm
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Melanie Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Natalie Zaremba
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Patrick Divilly
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Giesje Nefs
- Department of Medical Psychology, Radboud University Medical Centre, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Department of Medical and Clinical Psychology, Tilburg University, Tilburg, Noord-Brabant, The Netherlands
- Diabeter, National treatment and research center for children, adolescents and adults with type 1 diabetes, Rotterdam, Netherlands
| | - Zeinab Mahmoudi
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Digital Therapeutics, Novo Nordisk A/S, Søborg, Denmark
| | - Bastiaan de Galan
- Department of Internal Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
- Department of Internal Medicine, Maastricht University Medical Centre, Division of Endocrinology and Metabolic Disease, Maastricht, Limburg, The Netherlands
- CARIM School for Cardiovascular Diseases, Maastricht University, Maastricht, The Netherlands
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology & Nephrology, Endocrine Section, Nordsjællands Hospital, Hillerød, Hillerød, Denmark
- Faculty of Health Sciences, Copenhagen University, Copenhagen, Denmark
| | - Alan Brennan
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Daniel John Pollard
- School of Health & Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Rory J McCrimmon
- Systems Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Stephanie A Amiel
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
| | - Christel Hendrieckx
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- The Australian Centre for Behavioural Research in Diabetes, Diabetes Australia Victoria, Melbourne, Victoria, Australia
- School of Psychology, Deakin University, Geelong, Victoria, Australia
| | - Pratik Choudhary
- Department of Diabetes, King's College London, School of Life Course Sciences, London, UK
- Diabetes Research Centre, University of Leicester, UK LE5 4PW, Leicester, UK
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, Victoria, Australia
- Steno Diabetes Center Odense (SDCO), Odense, Denmark
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Søholm U, Broadley MM, Choudhary P, Zaremba N, Amiel SA, Speight J, Pouwer F. Does nocturnal hypoglycaemia really improve quality of life? Diabetologia 2021; 64:1893-1894. [PMID: 34014372 DOI: 10.1007/s00125-021-05475-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 04/09/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Uffe Søholm
- Department of Psychology, University of Southern Denmark, Odense, Denmark.
| | - Melanie M Broadley
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | - Pratik Choudhary
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Natalie Zaremba
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Stephanie A Amiel
- Department of Diabetes, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Jane Speight
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, VIC, Australia
- The Australian Centre for Behavioural Research in Diabetes (ACBRD), Melbourne, VIC, Australia
| | - Frans Pouwer
- Department of Psychology, University of Southern Denmark, Odense, Denmark
- School of Psychology, Deakin University, Geelong, VIC, Australia
- Steno Diabetes Center Odense, Odense, Denmark
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