Psychosocial Factors and Glycemic Control in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with poor glycemic control and early onset of complications. Identification of psychosocial factors associated with poor glycemic control is needed to inform efficacious interventions.

Objective

To identify psychosocial factors associated with glycated hemoglobin (HbA1c) levels in young adults with youth-onset type 2 diabetes.

Design, Setting, and Participants

For the iCount cohort study, HbA1c levels were measured twice (at baseline [T1] and at 1 year [T2]) during the last years (2017-2019) of the observational phase of the multicenter Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study. Participants were young adults who had been diagnosed with type 2 diabetes during childhood or adolescence. Data were analyzed from December 2021 to September 2023.

Main Outcomes and Measures

Glycemic control was examined categorically (high [≥8.0%] vs low [<8.0%] HbA1c), continuously (HbA1c level), and over time (change in HbA1c: decreased ≥0.5%, remained stable, or increased ≥0.5%). Psychosocial measures included beliefs about medicines, depression and anxiety symptoms, diabetes distress, diabetes self-efficacy, self-management support, and unmet material needs. Multivariable logistic and linear regression models evaluated the association of each psychosocial factor with the probability of T2 HbA1c of 8.0% or greater, T2 HbA1c level, and change in HbA1c.

Results

Of the 411 TODAY2 participants approached, 381 enrolled in the iCount study, and 348 with T1 and T2 HbA1c data comprised the analysis group. The 348 participants had a mean (SD) age of 26.1 (2.5) years and a mean (SD) HbA1c of 9.4% (2.8%). Most participants (229 [65.8%]) were women. In adjusted multivariable regressions, greater beliefs that diabetes medicines are necessary (odds ratio [OR], 1.19 [95% CI, 1.03-1.37]; P = .02), concerns about medicines (OR, 1.20 [95% CI, 1.00-1.45]; P = .049), diabetes distress (OR, 1.08 [95% CI, 1.02-1.15]; P = .006), and high distress (OR, 2.18 [95% CI, 1.15-4.13]; P = .02) increased the odds of high HbA1c at T2. Greater support (OR, 0.67 [95% CI, 0.46-0.97]; P = .04) and diabetes self-efficacy (OR, 0.91 [95% CI, 0.84-0.99]; P = .02) decreased the odds of high HbA1c at T2. Diabetes distress was associated with higher HbA1c level at T2 (coefficient, 0.08 [95% CI, 0.02-0.13]; P = .01). Beliefs that diabetes medicines are necessary (OR, 1.20 [95% CI, 1.03-1.39]; P = .02) and concerns about medicines (OR, 1.22 [95% CI, 1.00-1.47]; P = .048) increased the odds of an HbA1c decrease of at least 0.5% over 1 year.

Conclusions and Relevance

In this cohort study of young adults with youth-onset type 2 diabetes, beliefs about medicines, high diabetes distress, low diabetes self-efficacy, and self-management support were associated with high HbA1c over time. Future research should assess whether interventions that address these factors result in improved glycemic control in this at-risk group.

Psychosocial Factors Predicting Healthcare Usage in Young Adults with Youth-Onset Type 2 Diabetes: The TODAY2 iCount Observational Study

BACKGROUND

Established diabetes care ("diabetes home") and regular healthcare visits are important to achieve optimal health. Nothing is known about psychosocial factors that predict healthcare usage (HCU) in young adults with youth-onset type 2 diabetes, at risk for early complications.

OBJECTIVE

To identify psychosocial predictors of HCU in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

DESIGN

Longitudinal, measured at T1 (baseline) and T2 (1 year later). Logistic and linear regressions, adjusted for potential confounders, identified predictors of sub-optimal HCU (defined as no diabetes home, 0 visits for routine care, or  ≥ 1 urgent care visit in prior 6 months).

PARTICIPANTS

N = 366 TODAY2 participants with T1 and T2 data (381 consented). Mean age = 26.0 years, 67.8% female, 37.7% non-Hispanic Black, 35.8% Hispanic, 20.2% non-Hispanic white, 6.3% "other," mean HbA1c = 9.4%.

MAIN MEASURES

HCU survey; reliable and valid measures of diabetes self-efficacy, depressive symptoms, anxiety symptoms, diabetes distress, beliefs about medicines, diabetes attitudes, material need insecurities, self-management support.

KEY RESULTS

25.4% had no diabetes home, 23.7% had 0 routine care visits, 46% had  ≥ 1 urgent care visit (prior 6 months). Beliefs in the necessity of (adjusted odds ratio [OR] = 1.28; 95% confidence interval [CI] = 1.12, 1.46, p < 0.001), and concerns about (OR = 1.29;CI = 1.08,1.54, p = 0.004), diabetes medicines, and its negative psychosocial impacts (OR = 1.57;CI = 1.04, 2.38, p = 0.03), predicted higher odds of having a diabetes home at T2. Beliefs that medicines are harmful predicted lower odds of a diabetes home (OR = 0.56;CI = 0.37,0.85, p = 0.006). Necessity beliefs (OR = 1.2;CI = 1.06,1.36, p = 0.004), and self-management support (OR = 1.5;CI = 1.08,2.07, p = 0.01) predicted higher odds of having  ≥ 1 diabetes care visit, harm beliefs predicted lower odds (OR = 0.6;CI = 0.41,0.88, p = 0.01).

CONCLUSIONS

Sub-optimal healthcare usage, common in young adults with youth-onset type 2 diabetes, is predicted by beliefs about medicines, diabetes impact, and self-management support. We must address these factors to help this vulnerable group establish stable diabetes care.

Antihypertensive and Lipid-Lowering Medication Adherence in Young Adults With Youth-Onset Type 2 Diabetes

Importance

Youth-onset type 2 diabetes is associated with early development of chronic complications. Treatment of elevated blood pressure (BP), nephropathy, and dyslipidemia are critical to reduce morbidity. Data are needed on adherence to BP- and lipid-lowering medications in young adults with youth-onset diabetes.

Objective

To assess adherence and factors associated with adherence to BP- and lipid-lowering medications in young adults with youth-onset type 2 diabetes and diagnoses of hypertension, nephropathy, or dyslipidemia.

Design, Setting, and Participants

This cohort study measured medication adherence with 3 monthly unannounced pill counts at 2 time points 1 year apart during iCount, conducted during the last years (2017-2019) of the observational phase of the Treatment Options for Type 2 Diabetes in Adolescents and Youth study. Psychosocial factors associated with medication adherence were examined. Participants included individuals with youth-onset type 2 diabetes with hypertension, nephropathy, or dyslipidemia receiving diabetes care in their communities. Data were analyzed from September 2022 to September 2023.

Main Outcomes and Measures

The main outcome was BP- and lipid-lowering medication adherence, with low adherence defined as using less than 80% of pills and high adherence, at least 80% of pills. Psychosocial factors were measured using the Beliefs about Medicines Questionnaire and Material Needs Insecurities Survey.

Results

Of 381 participants in iCount, 243 participants (mean [SD] age, 26.12 [2.51] years; 159 [65.43%] women) with hypertension, nephropathy, or dyslipidemia were included in analysis. Among 196 participants with hypertension or nephropathy, 157 (80.1%) had low adherence. Participants with low adherence, compared with those with high adherence, were younger (mean [SD] age, 25.99 [2.41] vs 27.26 [2.41] years; P = .005), had higher glycated hemoglobin A1c (mean [SD], 10.33% [2.66 percentage points] vs 8.85% [2.39 percentage points]; P = .001), shorter diabetes duration (mean [SD], 12.32 [1.49] vs 12.90 [1.46] years; P = .03), and less education (eg, 17 participants [10.83%] vs 0 participants with no high school diploma; P = .004). Of 146 participants with dyslipidemia, 137 (93.8%) had low adherence and only 9 participants (6.2%) had high adherence. Of 103 participants with low adherence to BP-lowering medications and using oral hypoglycemic agents, 83 (80.58%) had low adherence to oral hypoglycemic agents. Beliefs that medications are necessary were higher for participants with high adherence to BP-lowering medications than those with low adherence in unadjusted analyses (mean [SD] necessity score, 16.87 [6.78] vs 13.89 [9.15]; P = .03). In adjusted multivariable analyses of participants with hypertension or nephropathy, having at least 1 unmet social need (odds ratio [OR], 0.20; 95% CI, 0.05-0.65; P = .04) and medication concerns (OR, 0.63; 95% CI, 0.40-0.96; P = .01) were associated with worse medication adherence 1 year follow-up. Diabetes distress, self-efficacy, depressive and anxiety symptoms, and self-management support were not associated with 1-year medication adherence.

Conclusions and Relevance

These findings suggest that adherence to BP- and lipid-lowering medications was very poor in this cohort. To improve medication adherence and prevent early vascular events, approaches that identify and address medication concerns and unmet social needs are needed.

Psychosocial factors predict medication adherence in young adults with youth-onset type 2 diabetes: Longitudinal results from the TODAY2 iCount study

AIM

To identify psychosocial predictors of medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

METHODS

Participants (mean age: 26 years) completed validated psychosocial measures. Unannounced telephone pill counts were completed at T1 (baseline) and T2 (follow-up, approximately 1 year later) to assess adherence to oral hypoglycaemia agents (OHAs). Adherence to insulin was assessed by self-report. Logistic and linear regressions identified factors that predicted 'low adherence' (<80% of pills/insulin) and per cent adherence, adjusted for potential confounders.

RESULTS

Of 171 participants with OHA adherence scores at T1 and T2 (65% women, 43% Hispanic and 35% non-Hispanic Black), 65.4% were low adherent. After adjustment (including T1 adherence), concerns about diabetes medicines (adverse effects, dependence) at T1 predicted higher odds of being low adherent (categorical) at T2 (p = 0.019). Housing insecurity (p = 0.045) and reporting ≥2 need insecurities (p = 0.027) at T1 predicted lower per cent adherence (continuous) at T2. Of 157 participants with insulin adherence scores at T1 and T2 (69% women, 38% Hispanic and 38% non-Hispanic Black), 36.3% were low adherent. After adjustment (including T1 adherence), beliefs that medicines are overused predicted higher odds of insulin low adherence at T2 (p = 0.013), and beliefs that medicines are harmful (p = 0.004) and overused (p = 0.010) predicted lower per cent insulin adherence at T2.

CONCLUSIONS

Suboptimal medication adherence, common in young adults with youth-onset type 2 diabetes, is predicted by interfering beliefs about medicines and social factors. We must address these beliefs and unmet needs to develop tailored interventions for this vulnerable group.

Association of psychosocial factors with medication adherence in emerging adults with youth-onset type 2 diabetes: The iCount study

AIMS

To assess associations of psychosocial factors with medication adherence in young adults with youth-onset type 2 diabetes in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY2) cohort.

METHODS

Participants (mean age 26 years) completed validated psychosocial measures. Adherence to oral hypoglycemia agents (OHAs) was assessed with 3-monthly unannounced phone pill counts; insulin adherence by self-report. Logistic and linear regressions identified factors associated with "low-adherence" (<80% of pills/insulin) controlling for confounders.

RESULTS

Of 212 participants taking OHAs (67% female, 39% Hispanic, 36% non-Hispanic Black), 69.8% were low-adherent. After adjustment, beliefs that medicines are necessary was associated with lower odds of low-adherence (p = 0.040, dichotomous). Less self-management support (p = 0.008), no healthcare coverage (p = 0.001), ≥1 (p = 0.008)/≥2 (p = 0.045) need insecurities were associated with higher odds of low-adherence. Factors associated with lower % adherence (continuous) were beliefs that medicines are harmful (p < 0.001)/overused (p = 0.007)/less necessary (p = 0.022), low self-management support (p = 0.003), food insecurity (p = 0.036), no healthcare coverage (p < 0.001), ≥1 (p = 0.003)/≥2 (p = 0.018) need insecurities. Of 192 taking insulin (69% female, 36% Hispanic, 41% non-Hispanic Black, 16% non-Hispanic white), 37.0% were low-adherent. Beliefs that medicines are overused (p = 0.009), that diabetes is not serious (p = 0.010), low diabetes self-efficacy (p = 0.035), high distress (p = 0.027), low self-management support (p = 0.001), food insecurity (p = 0.020), ≥1 (p = 0.011)/≥2 (p = 0.015) insecurities increased odds of insulin low-adherence.

CONCLUSIONS

Poor medication adherence, common in young adults with youth-onset type 2 diabetes, is associated with interfering beliefs, diabetes distress and social factors. We must address these factors to develop tailored interventions for this vulnerable group.

Diabetes Distress in Young Adults With Youth-Onset Type 2 Diabetes: TODAY2 Study Results

OBJECTIVE

To assess the prevalence of high diabetes distress and associated factors in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study cohort of young adults with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants completed the Diabetes Distress Scale (DDS) at end-of-study visits. Factors examined for association with high distress were demographic (sex, race/ethnicity, age, education, income), medical (HbA1c, BMI, complications), psychological (depressive and anxiety symptoms), and social (number in household, offspring, health care coverage, established with diabetes care provider). Univariate logistic regression identified factors associated with high distress that were controlled for in multivariate logistic regressions.

RESULTS

Of 438 participants, 66% were female (mean age 26.8 years, 18% non-Hispanic White, 37% non-Hispanic Black, 38% Hispanic). High distress (DDS ≥2) was reported by 105 (24%) participants. Subscales identified 40% with high regimen distress and 29.7% with high emotional burden. A greater percentage of those with high distress were female (P = 0.002), diagnosed with hypertension (P = 0.037) and retinopathy (P = 0.005), treated with insulin, had higher HbA1c, and had moderate to severe depressive and anxiety symptoms (all P < 0.001). In multivariate analyses, female sex (P < 0.001), HbA1c (P < 0.001), anxiety symptoms (P = 0.036), and lack of health care coverage (P = 0.019) were associated with high distress, after controlling for potential confounders. Moderate to severe depressive symptoms were associated with high regimen distress (P = 0.018) and emotional burden (P < 0.001); insulin treatment was associated with high emotional burden (P = 0.027).

CONCLUSIONS

Future research should identify modifiable factors associated with high diabetes distress in young adults with youth-onset type 2 diabetes that may inform distress interventions with this medically vulnerable group.

Medication adherence in young adults with youth-onset type 2 diabetes: iCount, an observational study

AIMS

To assess prevalence of, and factors associated with, medication adherence of young adults with youth-onset type 2 diabetes.

METHODS

Oral hypoglycaemia agent (OHA) adherence was measured with unannounced telephone pill counts, insulin adherence was self-reported. Those taking ≥ 80% of pills/insulin were classified "high-adherent," <80% of pills/insulin "low-adherent." Analyses included unadjusted, and adjusted linear and logistic regressions assessing associations of participant factors with adherence.

RESULTS

For people taking OHAs (N = 212, mean age 26 yrs, 67% women, 18% non-Hispanic White, 35% non-Hispanic Black, 41% Hispanic), 69.8% were low-adherent. HbA1c was lower in the high-adherent group (9.2%/77 mmol/mol vs. 10.0%/86 mmol/mol, p < 0.04). More non-Hispanic Blacks were low-adherent (85.7%) than Hispanics (60.2%) and non-Hispanic whites (55.3%, p < 0.002); 91.4% of participants without healthcare coverage were low-adherent vs. 65.5% of those with coverage (p < 0.004). After adjustment, gender (p = 0.024), race/ethnicity (p < 0.001) and healthcare coverage (p = 0.001) remained related to OHA adherence. For insulin (N = 192), 37% were low-adherent. HbA1c was associated with insulin adherence (low = 11.2%/99 mmol/mol vs. high = 10.0%/86 mmol/mol, p < 0.001) with and without adjustment.

CONCLUSIONS

Young adults with youth-onset type 2 diabetes, especially females, non-Hispanic Blacks and those without healthcare coverage, commonly had low-OHA adherence. Glycaemic control was also poor. Interventions to improve medication adherence are needed for this vulnerable group.

Healthcare Personnel (HCP) Attitudes About Coronavirus Disease 2019 (COVID-19) Vaccination After Emergency Use Authorization

BACKGROUND

We previously reported on coronavirus disease 2019 (COVID-19) vaccination intent among healthcare personnel (HCP) before emergency use authorization. We found widespread hesitancy and a substantial proportion of HCP did not intend to vaccinate.

METHODS

We conducted a cross-sectional survey of HCP, including clinical and nonclinical staff, researchers, and trainees between 21 February and 19 March 2021. The survey evaluated vaccine attitudes, beliefs, intent, and acceptance.

RESULTS

Overall, 3981 (87.7%) of respondents had already received a COVID-19 vaccine or planned to get vaccinated. There were significant differences in vaccine acceptance by gender, age, race, and hospital role. Males (93.7%) were more likely than females (89.8%) to report vaccine acceptance (P < .001). Mean age was higher among those reporting vaccine acceptance (P < .001). Physicians and scientists showed the highest acceptance rate (97.3%), whereas staff in ancillary services showed the lowest acceptance rate (79.9%). Unvaccinated respondents were more likely to be females, to have refused vaccines in the past due to reasons other than illness or allergy, to care for COVID-19 patients, or to rely on themselves when making vaccination decision. Vaccine acceptance was more than twice previous intent among Black respondents, an increase from 30.8% to 73.8%, and across all hospital roles with all > 80% vaccine acceptance.

CONCLUSIONS

The majority of HCP were vaccinated, much higher than reporting intent before vaccine was available. However, many HCP-particularly ancillary services-are still hesitant. Feasible and effective interventions to address the hesitant, including individually-tailored education strategies are needed, or vaccine can be mandated.

Glycemic outcomes related to depression in adults with type 1 diabetes

Glycemic outcomes of adults with type 1 diabetes may be affected by depression. Our aim was to compare outcomes of "depressed" (Patient Health Questionnaire-9 ⩾ 10, N = 83) to "not-depressed" matched control (Patient Health Questionnaire-2 < 3, N = 166) adults with type 1 diabetes with objective measures. The depressed group had poorer blood glucose control and, for those with glucose meter downloads, fewer glucose tests/day. The groups did not differ on glucose variability or episodes of hypoglycemia. Depression in adults with type 1 diabetes is associated with poorer glycemic control and less blood glucose monitoring. Future research should examine whether treatment of depression results in better self-care and glycemic outcomes.

Barriers to Weight Loss and Physical Activity, and Coach Approaches to Addressing Barriers, in a Real-World Adaptation of the DPP Lifestyle Intervention: A Process Analysis

PURPOSE

The purpose of this study is to identify barriers to weight loss and physical activity, as well as approaches used by coaches, in a real-world, community sample of adults with metabolic syndrome (at risk for type 2 diabetes) who participated in a Diabetes Prevention Program (DPP)-adapted weight loss intervention and compare findings to data from the screened and highly selected DPP sample.

METHODS

SHINE (Support, Health Information, Nutrition, and Exercise) was a telephonic DPP adaptation. Primary care staff delivered the DPP curriculum, and lifestyle coaches provided monthly direction to achieve weight loss. For this substudy, barriers to weight loss and physical activity described by participants, as well as approaches coaches used to address them, were gathered. Groupings of barriers (DPP defined) were analyzed in relation to demographic characteristics and compared to data from the DPP sample.

RESULTS

Top weight loss barriers were problems with self-monitoring, too little physical activity, internal thought/mood cues, vacation/holidays, and social cues. Percentages reporting a barrier were much higher in SHINE. Top physical activity barriers were problems with self-monitoring, access/weather, time management, aches/pains, and vacation/holidays. These did not correspond closely to DPP data. Coaches used problem solving, self-monitoring skills review, increased physical activity, and motivational strategies. SHINE coaches were more likely than DPP coaches to use alternative approaches.

CONCLUSIONS

Barriers to weight loss and physical activity in a community sample of persons at risk for diabetes occurred at much higher rates than in the highly screened DPP sample. Training coaches in a variety of patient-centered approaches may maximize their positive impact.

The importance of relationship processes for lowering BMI over time in women with type 2 diabetes in a randomized controlled trial

OBJECTIVE

Weight change may be affected by dyadic processes within couple relationships. The aim of this secondary data analysis was to explore trends in BMI across time, and assess whether relationship processes (i.e., relationship satisfaction, positive problem-solving), predict BMI trajectories in men and women.

METHODS

Data are from 268 participants in the Diabetes Support Project, a randomized trial of behavioral intervention for individuals with type 2 diabetes (T2D) in poor glycemic control. For secondary analyses, BMI was measured at pre-treatment (baseline), 4 months (post-treatment), 8 months, and 12 months. Multiple relationship variables were measured at all time points and were modeled as predictors and correlates of change in BMI across time.

RESULTS

In general, BMI trajectories had higher starting values (intercepts) for females than for males in the sample (b = -2.51, p < .05), and slopes trended downward from pre-treatment to 12 months (b = -.09, p <  .05). Downward trajectories of BMI were more pronounced for women with higher relationship satisfaction (b = .05, p <  .05) and higher positive problem solving skills (b = .06, p < .05) at baseline. Change in relationship processes were not correlated with change in BMI across time.

CONCLUSION

For women with T2D in this behavioral intervention study, relationship process scores at the beginning of treatment predicted changes in BMI over time, with better problem solving and higher relationship satisfaction at baseline related to steeper decreases in BMI across treatment. Additional research is needed to understand how improving relationship interaction prior to diabetes treatment may positively influence weight loss during treatment.

Glycemic outcomes related to depression in adults with type 1 diabetes

Glycemic outcomes of adults with type 1 diabetes may be affected by depression. Our aim was to compare outcomes of “depressed” (Patient Health Questionnaire-9 ⩾ 10, N = 83) to “not-depressed” matched control (Patient Health Questionnaire-2 < 3, N = 166) adults with type 1 diabetes with objective measures. The depressed group had poorer blood glucose control and, for those with glucose meter downloads, fewer glucose tests/day. The groups did not differ on glucose variability or episodes of hypoglycemia. Depression in adults with type 1 diabetes is associated with poorer glycemic control and less blood glucose monitoring. Future research should examine whether treatment of depression results in better self-care and glycemic outcomes.

Longitudinal Changes in Depression Symptoms and Glycemia in Adults With Type 1 Diabetes

OBJECTIVE

This study assessed longitudinal change in depression symptoms over ≥4 years in adults with type 1 diabetes and examined the association between change in depression symptom status and glycemia.

RESEARCH DESIGN AND METHODS

Adults in the T1D Exchange registry with HbA_1c and Patient Health Questionnaire (PHQ-8) at 1 year (baseline) and 5 years post-enrollment (follow-up; n = 2,744, mean age, 42 years; 57% female, 92% white; mean HbA_1c, 7.6% [58 mmol/mol]) were included. Depression status was defined as Persistent Elevated Depression Symptoms (EDS) (EDS at baseline and follow-up), Resolved EDS (EDS at baseline, no EDS at follow-up), New Onset EDS (no EDS at baseline, EDS at follow-up), and Not Depressed (no EDS at baseline or follow-up).

RESULTS

Overall, 131 (5%) had Persistent EDS, 122 (4%) had Resolved EDS, 168 (6%) had New Onset EDS, and 2,323 (85%) were Not Depressed. Of those with EDS (PHQ ≥ 10) at baseline, 53% had EDS at follow-up; of those not depressed at baseline, 7% had EDS at follow-up. An increase in PHQ-8 was associated with an increase in HbA_1c (P < 0.001). Although HbA_1c increased in all groups, the increase was less in the Resolved EDS and Not Depressed groups (P = 0.001). Persistent EDS and New Onset EDS groups were more likely to experience diabetic ketoacidosis (DKA) (P < 0.001).

CONCLUSIONS

T1D Exchange registry data provide evidence for relationships over time between persistently, and newly developing EDSs and worsening glycemic control, and suggest relationships between depression symptoms and the occurrence of severe hypoglycemia and DKA. Successful treatment of depression symptoms may lead to better long-term diabetes outcomes.

Two for one? Effects of a couples intervention on partners of persons with Type 2 diabetes: a randomized controlled trial

AIMS

To compare the outcomes of partners who participated in a telephone couples behavioural intervention to improve glycaemic control in persons with Type 2 diabetes with those of untreated partners of participants in an individual intervention or education; to explore 'ripple effects', i.e. positive behaviour changes seen in untreated partners.

METHODS

The Diabetes Support Project was a three-arm randomized telephone intervention trial comparing outcomes of couples calls (CC), individual calls (IC) and diabetes education calls (DE). Couples included one partner with Type 2 diabetes and HbA_1c ≥ 58 mmol/mol (7.5%). All arms received self-management education (two calls). CC and IC arms participated in 10 additional behaviour change calls. CC included partners, emphasizing partner communication, collaboration and support. Blinded assessments were performed at 4, 8 and 12 months. Partner outcomes were psychosocial (diabetes distress, relationship satisfaction, depressive symptoms), medical (BMI, blood pressure) and behavioural (fat intake, activity).

RESULTS

Partners' (N = 268) mean age was 55.8 years, 64.6% were female and 29.9% were from minority ethnic groups. CC (vs. IC and DE) partners had greater reductions in diabetes distress, greater increases in marital satisfaction (4 and 8 months), and some improvements in diastolic BP. There were no consistent differences among arms in other outcomes. There was no evidence of a dietary or activity behaviour ripple effect on untreated partners, i.e. comparing partners in the IC and DE arms.

CONCLUSIONS

A collaborative couples intervention resulted in significant improvements in partner diabetes distress and relationship satisfaction. There were no consistent effects on behavioural or medical partner outcomes, and no evidence of diet or activity behaviour ripple effects, suggesting that partners should be targeted directly to achieve these changes. (Clinical Trial Registry No: NCT01017523).

Impact of lifestyle behavior change on glycemic control in youth with type 2 diabetes

BACKGROUND

Little is known about the feasibility and impact of lifestyle intervention, determined by change in diet and cardiovascular fitness (CRF), on glycemic control in youth who are overweight with type 2 diabetes. This was examined in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial cohort from across 15 US centers.

SUBJECTS

TODAY enrolled 699 youth aged 10 to 17 years with type 2 diabetes <2 years and body mass index ≥85th percentile at baseline.

METHODS

Dietary data were collected by an interviewer-administered food frequency questionnaire; CRF was assessed using a submaximal cycle ergometer test. Change from baseline in these variables was analyzed using generalized linear mixed models for both continuous and categorical measures. Models were adjusted for age, baseline HbA1c, treatment group, and medication adherence. Data were collected at baseline, 6, and 24 months. Trial registration ClinicalTrials.gov NCT00081328.

RESULTS

At 6 months, ~25% of females and ~33% of males improved CRF. In males, this was related to a decreased HbA1c (P = .001) and a lower percent experiencing glycemic failure (HbA1c ≥8%; P = .007). Females who decreased their saturated fat intake and/or increased their fiber intake had lower HbA1c at month 24 (P = .01 and P = .007, respectively). Males who increased their sweetened beverage intake at 6-month follow-up were at a 1.6-fold higher risk of experiencing glycemic failure (P = .04).

CONCLUSIONS

Few youth improved fitness and/or diet over time, although those who did showed a beneficial impact on glycemic outcomes. Although lifestyle behaviors are difficult to change in youth with type 2 diabetes, interventions are needed that are feasible (in scope, complexity, and demands), sustainable, and clinically meaningful.

"Miscarried helping" in adults with Type 2 diabetes: Helping for Health Inventory-Couples

OBJECTIVE

Family-partner support has been associated with better blood glucose control, self-care adherence, and quality of life in adult patients with Type 2 diabetes (T2D). "Miscarried helping" has described interactions between youth with chronic diseases and their family members, in which a family member is helpful, but efforts are perceived as negative by the patient. Miscarried helping has not, however, been measured in adults with diabetes, which was the purpose of our study.

METHOD

Data from a randomized clinical trial (n = 268) were analyzed to establish the psychometric properties and correlates of an adaptation of a measure of miscarried helping developed in pediatric populations, for use with adults with T2D.

RESULTS

The Helping for Health Inventory-Couples Version (HHI-C) was found to have three underlying factors and demonstrated adequate internal consistency across time (α at baseline = .86, 4 months = .87, 8 months = .86, and 12 months = .83) and showed high test-retest reliability (p < .01) over a 12-month period. Convergent validity was partially supported, because baseline HHI-C was positively associated with maladaptive conflict resolution strategies (p = .03) and negatively associated with adaptive conflict resolution strategies (p = .04) and diabetes knowledge (p < .01). The HHI-C did not correlate with body mass index or hemoglobin A1c, a measure of glycemic control. The HHI-C was positively associated with diabetes distress (p < .01) and depressive symptoms (p = .01).

DISCUSSION

This study is the 1st known reporting of the psychometric properties of a measure of miscarried helping for adults with T2D. This valid measure of miscarried helping could be useful in future studies evaluating novel, relationship-based approaches to assist adults with T2D in disease management. (PsycINFO Database Record

Does Length of Relationship or Gender Predict Response to Behavioral Diabetes Intervention?

Purpose The purpose of the study was to determine, through secondary analysis, whether the length of a couple's relationship and the participants' gender are associated with glycemic response to a type 2 diabetes (T2D) behavioral couples-based intervention. Methods A randomized trial was conducted to test the impact of a couples-level, telephone-based behavioral intervention on hemoglobin A1C in patients with T2D. One hundred and four patients and partners participated in the couples intervention arm, and 94 individuals participated in the individual arm. A1C levels were measured at baseline and 1-year follow-up. Results Results of the regression analysis showed that for men with T2D (n = 35) in the couples intervention group, longer length of relationship was associated with lower A1C at 1-year follow-up, after controlling for baseline A1C, diabetes duration, and income. Length of relationship was not significantly related to follow-up glycemic measures for women or men with T2D in the individual intervention. Conclusions Study findings suggests that for men with T2D in a couples-based intervention, those in longer relationships may be more likely to benefit from the intervention. More research is needed to better understand factors that contribute to successful couples-based behavioral approaches to help adults with T2D improve their glycemic control.

Mentoring Interventions for Underrepresented Scholars in Biomedical and Behavioral Sciences: Effects on Quality of Mentoring Interactions and Discussions

Mentors rarely receive education about the unique needs of underrepresented scholars in the biomedical and behavioral sciences. We hypothesized that mentor-training and peer-mentoring interventions for these scholars would enrich the perceived quality and breadth of discussions between mentor-protégé dyads (i.e., mentor-protégé pairs). Our multicenter, randomized study of 150 underrepresented scholar-mentor dyads compared: 1) mentor training, 2) protégé peer mentoring, 3) combined mentor training and peer mentoring, and 4) a control condition (i.e., usual practice of mentoring). In this secondary analysis, the outcome variables were quality of dyad time and breadth of their discussions. Protégé participants were graduate students, fellows, and junior faculty in behavioral and biomedical research and healthcare. Dyads with mentor training were more likely than those without mentor training to have discussed teaching and work-life balance. Dyads with peer mentoring were more likely than those without peer mentoring to have discussed clinical care and career plans. The combined intervention dyads were more likely than controls to perceive that the quality of their time together was good/excellent. Our study supports the value of these mentoring interventions to enhance the breadth of dyad discussions and quality of time together, both important components of a good mentoring relationship.

Health and Psychosocial Outcomes of a Telephonic Couples Behavior Change Intervention in Patients With Poorly Controlled Type 2 Diabetes: A Randomized Clinical Trial

OBJECTIVE

To compare glycemic control and secondary outcomes of a 4-month telephonic couples behavioral intervention to individual intervention, and to education, for adults with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A randomized trial with the following three arms: couples calls (CC) (n = 104); individual calls (IC) (n = 94); and diabetes education (DE) (n = 82). All arms had self-management education (two calls). CC and IC had 10 additional behavior change calls. CC addressed collaboration and relationships/communication. Participants consisted of 280 couples, among whom one partner had type 2 diabetes and an A1C level ≥7.5%. Blinded assessments occurred at 4, 8, and 12 months. The primary outcome was change in A1C; and secondary outcomes were BMI, waist circumference, blood pressure, depressive symptoms, diabetes self-efficacy, and diabetes distress.

RESULTS

Patients had a mean age of 56.8 years; 61.6% were male, and 30.4% were minorities. The baseline mean A1C level was 9.1%. Intention-to-treat analyses found significant A1C reductions for all (12 months: CC -0.47%, IC -0.52%, DE -0.57%), with no differences between arms. Preplanned within-arm analyses were stratified by baseline A1C tertiles: lowest tertile (7.5-8.2%), no change from baseline; middle tertile (8.3-9.2%), only CC led to significantly lower A1C level; and highest tertile (≥9.3%), significant improvement for all interventions. For BMI, CC showed significant improvement, and CC and DE led to decreased waist circumference. The IC group showed greater blood pressure improvement. Results for secondary psychosocial outcomes favored the CC group.

CONCLUSIONS

In adults with poorly controlled type 2 diabetes, a collaborative couples intervention resulted in significant, lasting improvement in A1C levels, obesity measures, and some psychosocial outcomes. For those with exceedingly high A1C levels, education alone was beneficial, but additional intervention is needed to achieve glycemic targets.

Adults with type 1 diabetes: Partner relationships and outcomes

Health outcomes of adults with type 1 diabetes may be affected by relationship status and quality. Our objective was to examine associations between relationship status, relationship factors, and outcomes in adults with type 1 diabetes. N = 1660 participants completed surveys measuring relationship satisfaction and perceived partner support style (active engagement, protective buffering, over-protection). Differences in glycemic control and adherence for those married/partnered versus not were insignificant. Higher relationship satisfaction, and having an engaged, not over-protective, partner was associated with better glycemic control and self-care. Helping partners support patients, avoiding over-protection, may enhance relationship and diabetes-related patient outcomes for adults with type 1 diabetes.

Cost-effectiveness of SHINE: A Telephone Translation of the Diabetes Prevention Program

BACKGROUND

The Support, Health Information, Nutrition, and Exercise (SHINE) trial recently showed that a telephone adaptation of the Diabetes Prevention Program (DPP) lifestyle intervention was effective in reducing weight among patients with metabolic syndrome. The aim of this study is to determine whether a conference call (CC) adaptation was cost effective relative to an individual call (IC) adaptation of the DPP lifestyle intervention in the primary care setting.

METHODS

We performed a stochastic cost-effectiveness analysis alongside a clinical trial comparing two telephone adaptations of the DPP lifestyle intervention. The primary outcomes were incremental cost-effectiveness ratios estimated for weight loss, body mass index (BMI), waist circumference, and quality-adjusted life years (QALYs). Costs were estimated from the perspective of society and included direct medical costs, indirect costs, and intervention costs.

RESULTS

After one year, participants receiving the CC intervention accumulated fewer costs ($2,831 vs. $2,933) than the IC group, lost more weight (6.2 kg vs. 5.1 kg), had greater reduction in BMI (2.1 vs. 1.9), and had greater reduction in waist circumference (6.5 cm vs. 5.9 cm). However, participants in the CC group had fewer QALYs than those in the IC group (0.635 vs. 0.646). The incremental cost-effectiveness ratio for CC vs. IC was $9,250/QALY, with a 48% probability of being cost-effective at a willingness-to-pay of $100,000/QALY.

CONCLUSIONS

CC delivery of the DPP was cost effective relative to IC delivery in the first year in terms of cost per clinical measure (weight lost, BMI, and waist circumference) but not in terms of cost per QALY, most likely because of the short time horizon.

A Randomized Controlled Trial of Mentoring Interventions for Underrepresented Minorities

PURPOSE

To conduct a randomized controlled trial to evaluate the effects of different mentoring interventions on the basic psychological need satisfaction of underrepresented minorities and women in academia.

METHOD

Participants were 150 mentor/protégé dyads from three academic medical centers and eight other colleges and universities in western and central New York, randomized from 2010 to 2013 into mentor training (using principles of self-determination theory); peer mentoring for protégés; mentor training and peer mentoring for protégés combined; or control/usual practice. Protégé participants were graduate students, fellows, and junior faculty who were from underrepresented groups based on race, ethnicity, gender, or disability.The primary analysis was a comparison of intervention effects on changes in protégés' satisfaction of their basic psychological needs (competence, autonomy, and relatedness) with their mentor. They completed a well-validated, online questionnaire every two months for one year.

RESULTS

There was no significant effect at the end of one year of either mentor training or peer mentoring on protégés' psychological basic need satisfaction with mentor specifically or at work in general. Exploratory analyses showed a significant effect of the mentor-based intervention on the protégés' overall psychological need satisfaction with their mentor at two months, the time point closest to completing mentor training.

CONCLUSIONS

This randomized controlled trial showed a potential short-term effect of mentor training on changing basic psychological need satisfaction of underrepresented scholars with their mentors. Despite the lack of sustained effect of either mentor training or peer mentoring, these short-term changes suggest feasibility and potential for future study.

Incorrect Insulin Administration: A Problem That Warrants Attention

In Brief Incorrect administration of insulin (e.g., too little, too much, or at wrong times) can result in transient and serious hypo- and hyperglycemia, wide glycemic excursions, and diabetic ketoacidosis. The authors systematically assessed the insulin-related knowledge and injection skills of a sample of adults with diabetes and found that errors in self-administering insulin, including choosing an incorrect insulin dose, were common. Injection site selection and diabetes numeracy were also concerns. Correct timing of injections and confidence in choosing correct doses, but not skills scores, related to better A1C and blood glucose levels.

Parental Characteristics Associated With Outcomes in Youth With Type 2 Diabetes: Results From the TODAY Clinical Trial

OBJECTIVE

This study examined parental factors associated with outcomes of youth in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial.

RESEARCH DESIGN AND METHODS

Of 699 youth with type 2 diabetes in the TODAY cohort, 623 (89.1%) had a parent participate and provide data at baseline, including weight, HbA1c, blood pressure, symptoms of depression, binge eating (BE), and medical history. Youth were followed 2-6.5 years. Data were analyzed using regression models and survival curve methods.

RESULTS

Parental diabetes (43.6% of parents) was associated with higher baseline HbA1c (P < 0.0001) and failure of youths to maintain glycemic control on study treatment (53.6% vs. 38.2% failure rate among those without a diabetic parent, P = 0.0002). Parental hypertension (40.6% of parents) was associated with hypertension in youth during TODAY (40.4% vs. 27.4% of youth with and without parental hypertension had hypertension, P = 0.0008) and with higher youth baseline BMI z scores (P = 0.0038). Parents had a mean baseline BMI of 33.6 kg/m(2). Parental obesity (BMI >30 kg/m(2)) was associated with higher baseline BMI z scores in the youth (P < 0.0001). Depressive symptoms in parents (20.6% of parents) were related to youth depressive symptoms at baseline only (P = 0.0430); subclinical BE in parents was related to the presence of subclinical BE (P = 0.0354) and depressive symptoms (P = 0.0326) in youth throughout the study period.

CONCLUSIONS

Parental diabetes and hypertension were associated with lack of glycemic control, hypertension, and higher BMI z scores in youth. Further research is needed to better understand and address parental biological and behavioral factors to improve youth health outcomes.

Sustained weight loss one year after group telephone intervention: 3-year results from the SHINE study

A telephone delivered translation of the DPP weight loss program, delivered by trained primary care staff over 2 years, resulted in significant weight loss for patients with metabolic syndrome. Participants in groups (conference calls) continued to lose weight a full year after the program ended, while those called individually regained.

Depression, stress, and weight loss in individuals with metabolic syndrome in SHINE, a DPP translation study

OBJECTIVE

To examine the relationships between elevated depression symptoms (EDS) or stress and weight loss in SHINE, a telephonic, primary-care based, translation of the Diabetes Prevention Program.

METHODS

N = 257 adults with metabolic syndrome were randomized to individual (IC) or group (CC) phone participation. Weight, depression, anti-depressant use (ADMs), and stress (baseline, 6 months, 1 and 2 years) were assessed. Univariate analyses used linear and logistic regression, t tests for continuous variables and exact tests for categorical variables. Stratified analyses assessed modifiers of effects of depression/stress on weight loss.

RESULTS

Approximately 35% reported EDS, with no change over time. Approximately 28% of all participants used ADMs. Participants with EDS had lower mean % weight loss and a smaller % who achieved ≥5% weight loss. Participants with EDS were less likely to be "completers" (40.1% vs. 61.5%, P = 0.002), coached (48.0% vs. 60.7%, P = 0.049), or log diet/activity (19.4% vs. 42.7%, P < 0.001), behaviors related to weight loss. Results were similar for high stress. ADM use had no independent effect on weight loss.

CONCLUSIONS

Individuals with metabolic syndrome and EDS and/or high stress were less likely to lose significant weight. Pre-intervention depression and stress screening to intervene may improve weight loss.

Parenting style, parent-youth conflict, and medication adherence in youth with type 2 diabetes participating in an intensive lifestyle change intervention

Parenting behaviors and family conflict relate to type 1 diabetes outcomes in youth. Our purpose was to understand these relationships in parents and youth with type 2 diabetes (T2DM). The TODAY (Treatment Options for Type 2 Diabetes in Adolescents and Youth) trial enrolled youth (10-17 years) with T2DM and parent/guardian. For this ancillary study, we enrolled a sample of youth-parent pairs (N = 137) in 1 study arm (metformin plus lifestyle intervention). They completed questionnaires measuring parenting style related to normative (e.g., completing homework) and diabetes self-care (e.g., testing blood glucose) tasks, and parent-youth verbal conflict (baseline, 6, and 12 months). Parenting style was consistent across normative and diabetes tasks, with gradual increases in autonomy perceived by youth. Conversations were generally calm, with greater conflict regarding normative than diabetes tasks at baseline (youth: p < .001, parent: p = .01), 6 months (youth: p = .02, parent: p > .05), and 12 months (youth: p > .05., parent: p = .05). A permissive parenting style toward normative tasks and a less authoritarian style toward diabetes tasks, at baseline, predicted better medication adherence (8-12 months) (normative: adjusted R2 = 0.48, p < .001; diabetes: adjusted R2 = 0.47, p < .001). Parent-youth conflict did not predict medication adherence. Youth with T2DM who perceive more autonomy (less parental control) in day-to-day and diabetes tasks are more likely to adhere to medication regimens. It may be valuable to assess youth perceptions of parenting style and help parents understand youths' needs for autonomy.

Depression in adults in the T1D Exchange Clinic Registry

OBJECTIVE

Little is known about the frequency of depression in adults with type 1 diabetes (T1D) or its relationship to diabetes outcomes. The T1D Exchange clinic registry allowed us to explore depression in a large, heterogeneous sample.

RESEARCH DESIGN AND METHODS

Participants ≥18 years old (N = 6,172; median age 34 years; median diabetes duration 16 years; 55% female; and 89% non-Hispanic white) completed the eight-item Patient Health Questionnaire (PHQ-8), a validated, reliable measure of current depression. Probable major depression was defined in four ways: PHQ-8 ≥10, PHQ-8 ≥12, per diagnostic algorithm, and as a continuous variable. Characteristics and clinical outcomes of those with and without depression were compared using logistic and linear regression models.

RESULTS

A total of 4.6-10.3% of participants were classified as probable major depression depending on how defined. Participants classified as depressed were more likely female, nonwhite race/ethnicity, to have a lower household income and lower education level, to exercise less often, to miss insulin doses, and to have one or more complications (neuropathy, nephropathy, treatment for retinopathy, or cardiovascular/cerebrovascular disease) (all P < 0.01). HbA1c was higher in the depressed versus not depressed groups (8.4 ± 1.7% [68 ± 8.6 mmol/mol] vs. 7.8 ± 1.4% [62 ± 15.3 mmol/mol]; P < 0.001). Occurrence of one or more diabetic ketoacidosis events (11 vs. 4%; P < 0.001) and one or more severe hypoglycemic events (18 vs. 9%; P < 0.001) in the past 3 months was higher among depressed participants.

CONCLUSIONS

In the T1D Exchange clinic registry, adults with probable major depression have worse clinical outcomes than those not depressed. Whether identification and treatment of depression improves diabetes outcomes requires study. Depression is common in T1D, and better identification and treatment of this comorbid condition is needed.

Weight loss success in metabolic syndrome by telephone interventions: results from the SHINE Study

BACKGROUND

The Diabetes Prevention Program (DPP) intensive lifestyle intervention resulted in significant weight loss, reducing the development of diabetes, but needs to be adapted to primary care provider (PCP) practices.

OBJECTIVES

To compare a DPP-translation using individual (IC) vs. conference (CC) calls delivered by PCP staff for the outcome of percent weight loss over 2 years.

DESIGN

Randomized clinical trial.

SETTING

Five PCP sites.

PARTICIPANTS

Obese patients with metabolic syndrome, without diabetes (IC, n = 129; CC, n = 128).

INTERVENTION

Telephone delivery of the DPP Lifestyle Balance intervention [16-session core curriculum in year 1, 12-session continued telephone contact in year 2 plus telephone coaching sessions (dietitians).

MAIN MEASURES

Weight (kg), body mass index (BMI), and waist circumference.

KEY RESULTS

BASELINE DATA

age = 52 years, BMI = 39 kg/m(2), 75 % female, 85 % non-Hispanic White, 13 % non-Hispanic Black, and 48 % annual incomes <$40,000/year. In the intention-to-treat analyses at year 2, mean percent weight loss was -5.6 % (CC, p < 0.001) and -1.8 % (IC, p = 0.046) and was greater for CC than for IC (p = 0.016). At year 2, mean weight loss was 6.2 kg (CC) and 2.2 kg (IC) (p < 0.001). There was similar weight loss at year 1, but between year 1 and year 2 CC participants continued to lose while IC participants regained. At year 2, 52 % and 43 % (CC) and 29 % and 22 % (IC) of participants lost at least 5 % and 7 % of initial weight. BMI also decreased more for CC than IC (-2.1 kg/m(2) vs. -0.8 kg/m(2) p < 0.001). Waist circumference decreased by 3.1 cm (CC) and 2.4 cm (IC) at year 2. Completers (≥9 of 16 sessions; mean 13.3 sessions) lost significantly more weight than non-completers (mean 4.3 sessions).

CONCLUSIONS

PCP staff delivery of the DPP lifestyle intervention by telephone can be effective in achieving weight loss in obese people with metabolic syndrome. Greater weight loss may be attained with a group telephone intervention.

Personal and relationship challenges of adults with type 1 diabetes: a qualitative focus group study

OBJECTIVE

Little is known about the psychosocial challenges of adults living with type 1 diabetes or its impact on partner relationships. This qualitative study was undertaken to gain better understanding of these issues.

RESEARCH DESIGN AND METHODS

Four focus groups were held, two with adult type 1 diabetic patients (n = 16) and two with partners (n = 14). Two broad questions were posed: "What are the emotional and interpersonal challenges you have experienced because you have (your partner has) type 1 diabetes?" and "How does the fact that you have (your partner has) type 1 diabetes affect your relationship with your partner, positively and/or negatively?" Sessions were recorded and transcribed, and analyzed by a team of four researchers, using constant comparative methods to identify core domains and concepts.

RESULTS

Four main domains were identified: 1) impact of diabetes on the relationship, including level of partner involvement, emotional impact of diabetes on the relationship, and concerns about child-rearing; 2) understanding the impact of hypoglycemia; 3) stress of potential complications; and 4) benefits of technology. Themes suggest that, although partner involvement varies (very little to significant), there exists significant anxiety about hypoglycemia and future complications and sources of conflict that may increase relationship stress. Partner support is highly valued, and technology has a positive influence.

CONCLUSIONS

Adults with type 1 diabetes face unique emotional and interpersonal challenges. Future research should focus on gaining a better understanding of how they cope and the effect of psychosocial stressors and coping on adherence, quality of life, and glycemic control.

Adherence to diabetes self care for white, African-American and Hispanic American telemedicine participants: 5 year results from the IDEATel project

OBJECTIVES

Adherence to diabetes self care is poor for Hispanic American and African-American patients. This study examined the change in adherence over time and in response to a telemedicine intervention for elderly diabetes patients in these groups compared to white diabetes patients. We also examined whether adherence mediated the effect of the intervention on glycemic control (A1c).

DESIGN

The Informatics for Diabetes Education and Telemedicine project randomized medically underserved Medicare patients (n=1665) to telemedicine case management (televideo educator visits, individualized goal-setting/problem solving) or usual care. Hispanic and African-American educators delivered the intervention in Spanish if needed.

MAIN OUTCOME MEASURES

Annual assessment included A1c and self-reported adherence (Summary of Diabetes Self-Care Activities scale). A simple model (only time and group terms) and a model with covariates (e.g., age) were examined for baseline and 5 years of follow-up. SAS PROC Mixed was used with non-linear terms to examine mediating effects of adherence on A1c, by performing tests of the mediating path coefficients.

RESULTS

Over time, self-reported adherence improved for the treatment group compared to usual care (p<0.001). There was no significant interaction with racial/ethnic group membership, i.e., all groups improved. However, minority subjects were consistently less adherent than whites. Also, greater comorbidity and diabetes symptoms predicted poorer adherence, greater duration of diabetes and more years of education predicted better adherence. Adherence was a significant mediator of A1c (p<0.001).

CONCLUSIONS

A unique, tailored telemedicine intervention was effective in achieving improved adherence to diabetes self care. However, African-American and Hispanic American participants were less adherent than white participants at all time points despite an individualized and accessible intervention. The finding that adherence did mediate glycemic control suggests that unique interventions for minority groups may be needed to overcome this disparity.

Depressive symptoms and quality of life in adolescents with type 2 diabetes: baseline data from the TODAY study

OBJECTIVE

The study objective was to examine the prevalence of depressive symptoms and relationships to quality of life and demographics in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study's large, ethnically diverse youth with type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 704 youth with type 2 diabetes <2 years' duration, aged 10-17 years, and BMI ≥85th percentile completed depressive symptoms and quality of life measures.

RESULTS

Some 14.8% reported clinically significant depressive symptoms, and older girls had significantly higher rates than older boys.

CONCLUSIONS

Rates of significant depressive symptoms were similar to those of healthy adolescents and lower than those of teens with type 1 diabetes. Elevated depressive symptoms, particularly in older girls, suggest clinicians assess vulnerability.

Challenges and Lessons Learned in the Development and Implementation of a Couples-Focused Telephone Intervention for Adults with Type 2 Diabetes: The Diabetes Support Project

BACKGROUND: Type 2 diabetes (T2DM) studies report that marital/family support relates to glycemic control, adherence and quality-of-life. Yet, there are few reports of couples-focused interventions. PURPOSE: To describe the challenges faced and lessons learned in the implementation of a theoretically-based, couples intervention. METHODS: 350 couples (one partner has T2DM in poor glycemic control) are randomized to a couples intervention, individual intervention, or enhanced usual care. All contacts are by telephone, to increase reach. OUTCOMES: medical (e.g. glycemic control), psychosocial (e.g. diabetes distress), and behavioral (e.g. regimen adherence). Challenges in recruitment, assessment and intervention with couples are described, with suggestions about how to address them. RESULTS: Findings concerning the efficacy and cost-effectiveness of the couples intervention, its effect on partners, and possible mechanisms of demonstrated changes, are anticipated in 2013. CONCLUSIONS: Interventionists need specific skills to work with couples to promote communal coping and increase the likelihood of an efficacious couples intervention.

Goal setting using telemedicine in rural underserved older adults with diabetes: experiences from the informatics for diabetes education and telemedicine project

OBJECTIVE

To describe the use of telemedicine for setting goals for behavior change and examine the success in achieving these goals in rural underserved older adults with diabetes.

MATERIALS AND METHODS

Medicare beneficiaries with diabetes living in rural upstate New York who were enrolled in the telemedicine intervention of the Informatics for Diabetes Education and Telemedicine (IDEATel) project (n = 610) participated in home televisits with nurse and dietitian educators every 4-6 weeks for 2-6 years. Behavior change goals related to nutrition, physical activity, monitoring, diabetes health maintenance, and/or use of the home telemedicine unit were established at the conclusion of each televisit and assessed at the next visit.

RESULTS

Collaborative goal setting was employed during 18,355 televisits (mean of 33 goal-setting televisits/participant). The most common goals were related to monitoring, followed by diabetes health maintenance, nutrition, exercise, and use of the telemedicine equipment. Overall, 68% of behavioral goals were rated as "improved" or "met." The greatest success was achieved for goals related to proper insulin injection technique and daily foot care. These elderly participants had the most difficulty achieving goals related to use of the computer. No gender differences in goal achievement were observed.

CONCLUSION

Televisits can be successfully used to collaboratively establish behavior change goals to help improve diabetes self-management in underserved elderly rural adults.

Improvement in diabetes self-efficacy and glycaemic control using telemedicine in a sample of older, ethnically diverse individuals who have diabetes: the IDEATel project

BACKGROUND

with increasing prevalence of diabetes in older people, it is important to understand factors that affect their outcomes. The Informatics for Diabetes Education and Telemedicine (IDEATel) project is a demonstration project to evaluate the feasibility and effectiveness of telemedicine with diverse, medically underserved, older diabetes patients. Subjects were randomised to telemedicine case management or usual care. This intervention has been shown to result in improved medical outcomes and self-efficacy. Self-efficacy refers to one's belief that (s)he can successfully engage in a behaviour. Self-efficacy has been shown to relate to behaviour change and glycaemic control in middle-aged individuals, but not studied in older individuals.

OBJECTIVES

to assess whether (a) diabetes self-efficacy relates to the primary medical outcome of glycaemic control, and to secondary outcomes (blood pressure and cholesterol), and (b) whether, after an intervention, change in diabetes self-efficacy relates to change in these medical outcomes in a group of older, ethnically diverse individuals.

METHODS

three waves of longitudinal data from participants in IDEATel were analysed.

RESULTS

diabetes self-efficacy at baseline correlated with glycaemic control, blood pressure and cholesterol. An increase in diabetes self-efficacy over time was related to an improvement in glycaemic control (P < 0.0001), but not in blood pressure and lipid levels. The intervention was significantly related to improved self-efficacy over time (P < 0.0001), and both directly (P = 0.022) and indirectly through self-efficacy (P < 0.001) to improved glycaemic control. The mediation effect of self-efficacy was also significant (P< 0.004).

CONCLUSIONS

diabetes self-efficacy is a relevant construct for older diabetes patients. Thus, interventions that target enhanced self-efficacy may also result in improved glycaemic control.

Post-traumatic stress disorder and diabetes: co-morbidity and outcomes in a male veterans sample

The purpose of this study was to assess the prevalence and correlates of comorbid diabetes and Post-Traumatic Stress disorder(PTSD)and potential relationships between PTSD and diabetes outcomes. Male patients enrolled in a VA primary care database (N = 73,270) were classified as having diabetes from pharmacy records (N = 14,438) and grouped into those with diagnoses of PTSD with depression (N = 649), PTSD-only (N = 480), Depression-only (N = 1696), Other psychiatric diagnosis (N = 736), or No psychiatric diagnosis (N = 10,877) based on the Purpose of Visit diagnoses in the medical record. Outcomes included glycemic control (HbA1c), cholesterol and triglycerides. Correlates were age, substance use disorder, other psychiatric diagnosis, number of primary care encounters, and medications. The prevalence of comorbid diabetes and PTSD was 8% (n = 1129). Of these, 57% (n = 649) had comorbid depression. Patients with PTSD and depression had higher rates of substance use disorder and higher cholesterol and LDL. Patients with depression had poorer glycemic control. Patients with PTSD and depression weighed more and had higher BMI than patients with neither diagnosis. Thus, male diabetes patients with PTSD and depression may be vulnerable to substance use disorders and to weight/lipid problems that can affect health. Depression is a likely contributor to poor glycemic control. Careful screening for mental health comorbidities is needed for diabetes patients.

Depression and glycemic control in elderly ethnically diverse patients with diabetes: the IDEATel project

OBJECTIVE

The purpose of the study was to investigate the effect of comorbid depression on glycemic control and on response to a telemedicine case management intervention for elderly, ethnically diverse diabetic patients.

RESEARCH DESIGN AND METHODS

Medicare beneficiaries in underserved areas were participants (n = 1,665) in the Informatics for Diabetes Education and Telemedicine (IDEATel) project and randomized to a telemedicine case management intervention or usual care. The data analyzed include baseline demographics (age, sex, race/ethnicity, marital status, insulin use, years of education, years of diabetes, and pack-years smoked) and measures of glycemic control (HbA(1c) [A1C]), comorbidity, diabetes symptom severity, functional disability and depression, and 1-year (n = 1,578) A1C. The association between depression and glycemic control was analyzed cross-sectionally and prospectively.

RESULTS

At baseline, there was a significant correlation between depression and A1C and a trend for depression to predict A1C when other factors were controlled. However, in prospective analyses, depression did not predict change in A1C, either in the control or intervention group.

CONCLUSIONS

In this large sample of elderly diabetic patients, a weak relationship between depression and A1C was found, but depression did not prospectively predict change in glycemic control. Thus, there is no evidence that depression should be used to exclude patients from interventions. Also, we should evaluate the impact of depression on outcomes other than glycemic control.

Emotional health predicts pain and function after fusion: a prospective multicenter study

STUDY DESIGN

Prospective.

OBJECTIVES

To assess whether patients with poorer emotional health before fusion surgery will have worse pain and function after surgery, and to identify patient variables that predict fusion outcomes.

SUMMARY OF BACKGROUND DATA

A systematic review of fusion outcomes studies reported an average of 68% "satisfactory" outcomes. The persistence of pain and functional limitations leads to emotional and financial costs. Therefore, it is important to identify the factors that affect fusion outcome. Research has explored psychosocial factors (e.g., depression, anxiety) as being important outcome predictors.

METHODS

Data from subjects enrolled in a multisite trial of 2 fusion systems were analyzed. Subjects completed measures of health-related quality of life (SF-36), pain (visual analog scale), and function (Oswestry Disability Index). A total of 160 subjects completed measures before fusion, 155 completed measures 12 months after fusion, and 115 completed measures 24 months after fusion. Subject variables (i.e., age, gender, smoking, workers' compensation, and second surgery status) and presurgical pain/function were regressed on pain/function outcomes after surgery. This model was compared to one that included presurgical Mental Component Scores (MCSs), which is a SF-36 derived measure of emotional health, to determine whether MCS data significantly improved the prediction of pain/function.

RESULTS

Higher presurgical MCS (i.e., better emotional health) predicted less back and leg pain after surgery. Similarly, higher presurgical MCS predicted better physical function after surgery. Other important predictors of pain and function were presurgical pain and function, workers' compensation, and smoking status. The associations were modest (2% to 9% of independent variance accounted for), but significant.

CONCLUSIONS

Presurgical emotional status is one significant predictor of pain and function outcomes up to 2 years after fusion. Other significant predictors included workers' compensation status, smoking status, and presurgical pain/function. Studies to identify and intervenewith patients with poorer emotional status will clarify whether presurgical mental health intervention can improve pain and function outcomes after surgery or whether these patients are not candidates for surgery.

Psychological attributes of preoperative total joint replacement patients: implications for optimal physical outcome

In this study, 107 primary total joint replacement (TJR) patients were assessed preoperatively using the SF-36 (Mental Component Score [MCS] and Physical Component Score [PCS]), Beck Depression Inventory (BDI), Spielberger Trait Anxiety Inventory, Interpersonal Support Evaluation List, and the Coping Strategies Questionnaire. Patients with preoperative MCS < 50 had significantly higher trait anxiety (P <.001), higher BDI scores (P <.001), and lower appraisal (P <.018) and belonging (P <.006) support when compared with patients with preoperative MCS > or = 50. Low MCS patients used more catastrophizing coping techniques (P <.001) and reported poorer pain control (P <.04). A multivariate prediction model found that adding preoperative MCS to baseline demographic and physical function (PCS) measures significantly improved the prediction of 6-month change in PCS. Further research should evaluate the role of multimodality emotional support in assuring optimal physical return after TJR.

The relationship between marital quality and adherence to the diabetes care regimen

BACKGROUND

Diabetes is a chronic illness that requires significant behavior change through adherence to, and maintenance of, a complex health care regimen. Social support has been found to be a factor that influences adherence.

PURPOSE

This article reports a cross-sectional and prospective assessment of the relationship between marital quality (i.e., intimacy and adjustment) and self-reported adherence to the diabetes care regimen.

METHODS

Seventy-eight insulin-treated adults with diabetes were assessed at Time 1 (T1) when they completed two marital quality measures and a measure of adherence to the diabetes care regimen. Sixty participants were contacted 2 years later (Time 2; T2), and the self-care measure was readministered. Blood glucose (sugar) control was assessed by hemoglobin A1c. Demographic data (age, gender, type and duration of diabetes, years married, other medical problems, family history of diabetes, years of education) were gathered from charts and questionnaires. Linear regression analyses were used to assess the ability of the two marital measures at T1 to predict adherence to self-care at T2, controlling for confounding baseline variables.

RESULTS

Results showed that both of the marital quality measures predicted many aspects of self-care at T1. Dietary self-care related to marital intimacy and adjustment, as did adherence to exercise and to doctor's recommendations. Neither adherence to blood glucose testing nor blood glucose control was related to marital quality. Prospective analyses showed that neither marital quality measure at T1 was a prospective predictor of aspects of adherence to self-care at T2.

CONCLUSIONS

Future efforts to improve self-care should explore the value of interventions that target the spouse and/or the couple's relationship.

A comparison of health-related quality of life of elderly and younger insulin-treated adults with diabetes

BACKGROUND

diabetes is a significant disease of elderly people, an age group whose numbers will double over the next 20-30 years. Yet studies which assess diabetes-related quality of life have rarely included elderly participants.

OBJECTIVES

to compare and contrast the health-related quality of life of elderly (> or = 65 years) and younger individuals with diabetes using reliable and valid assessment tools.

METHODS

191 adults (> or = 30 years) with diabetes currently on an insulin regimen were recruited. Medical and demographic data were gathered from the medical chart. Participants completed a generic quality of life measure (SF-36) and 3 diabetes-specific measures. Statistical analyses compared adults (30-64 years) to elderly adults (> or = 65 years).

RESULTS

on the generic SF-36, physical and mental summary scores did not differ. However, elderly participants reported greater role limitations due to physical problems, and better social function. On diabetes-specific measures, elderly participants reported higher satisfaction with diabetes-related aspects of their lives, less diabetes-related emotional distress, and better ability to cope with their diabetes.

CONCLUSIONS

the differences that did emerge between the two groups suggest that, though experiencing more limitations in their ability to function in their roles, elderly individuals with diabetes may still feel that they can cope with these limitations and thus manage the distress and lifestyle demands of the diabetes. The value of subscale analysis of the SF-36 and use of diabetes-specific health-related quality of life measures is also affirmed.