Development and validation of the Diabetes Medication System Rating Questionnaire-Short Form

AIMS

To develop and validate a short form of the 54-item Diabetes Medication System Rating Questionnaire that maintains the domains and performance characteristics of the long-form questionnaire.

METHODS

Data from the Diabetes Medication System Rating Questionnaire validation study were analysed to select items representing the nine scales (convenience, negative events, interference, self-monitoring of blood glucose burden, efficacy, social burden, psychological well-being, treatment satisfaction and treatment preference). The resulting 20-item Diabetes Medication System Rating Questionnaire Short-Form was administered online, with validated criterion measures of treatment satisfaction and medication adherence, with a retest within 2 weeks. Participants were US adults (N = 413) with Type 2 diabetes using oral agents alone; insulin by syringe and/or pen with or without oral agents; or glucagon-like peptide-1 agents. Most participants (82%) completed the retest.

RESULTS

The median inter-item agreement of scales was 0.76 and the total composite (mean of all items except treatment preference) was 0.88. The median test-retest reliability of scales was 0.86, and of the total composite was 0.95. All statistically significant correlations between Diabetes Medication System Rating Questionnaire Short-Form scales and criterion measures of treatment satisfaction and adherence were in the expected direction. The median correlation of the Diabetes Medication System Rating Questionnaire Short-Form with corresponding criterion measures of treatment satisfaction was 0.59; the mean correlation of the same Diabetes Medication System Rating Questionnaire Short-Form measures with adherence was 0.42. The Diabetes Medication System Rating Questionnaire Short-Form scales were more powerful predictors of adherence than were the criterion measures of treatment satisfaction. The Diabetes Medication System Rating Questionnaire Short-Form scales differentiated between those taking different medications and between those using different insulin delivery devices.

CONCLUSIONS

This study suggests that the Diabetes Medication System Rating Questionnaire Short-Form provides a comprehensive set of measures with acceptable reliability and validity and a reduced burden of administration.

Options for prandial glucose management in type 2 diabetes patients using basal insulin: addition of a short-acting GLP-1 analogue versus progression to basal-bolus therapy

Integrating patient-centered diabetes care and algorithmic medicine poses particular challenges when optimized basal insulin fails to maintain glycaemic control in patients with type 2 diabetes. Multiple entwined physiological, psychosocial and systems barriers to insulin adherence are not easily studied and are not adequately considered in most treatment algorithms. Moreover, the limited number of alternatives to add-on prandial insulin therapy has hindered shared decision-making, a central feature of patient-centered care. This article considers how the addition of a glucagon-like peptide 1 (GLP-1) analogue to basal insulin may provide new opportunities at this stage of treatment, especially for patients concerned about weight gain and risk of hypoglycaemia. A flexible framework for patient-clinician discussions is presented to encourage development of decision-support tools applicable to both specialty and primary care practice.

Patient-reported outcomes in the practice-based opportunities for weight reduction (POWER) trial

PURPOSE

To evaluate effects of two behavioral weight-loss interventions (in-person, remote) on health-related quality of life (HRQOL) compared to a control intervention.

METHODS

Four hundred and fifty-one obese US adults with at least one cardiovascular risk factor completed five measures of HRQOL and depression: MOS SF-12 physical component summary (PCS) and mental component summary; EuroQoL-5 dimensions single index and visual analog scale; PHQ-8 depression symptoms; and PSQI sleep quality scores at baseline and 6 and 24 months after randomization. Change in each outcome was analyzed using outcome-specific mixed-effects models controlling for participant demographic characteristics.

RESULTS

PCS-12 scores over 24 months improved more among participants in the in-person active intervention arm than among control arm participants (P < 0.05, ES = 0.21); there were no other statistically significant treatment arm differences in HRQOL change. Greater weight loss was associated with improvements in most outcomes (P < 0.05 to < 0.0001).

CONCLUSIONS

Participants in the in-person active intervention improved more in physical function HRQOL than participants in the control arm did. Greater weight loss during the study was associated with greater improvement in all PRO except for sleep quality, suggesting that weight loss is a key factor in improving HRQOL.

Impact of diagnosis of diabetes on health-related quality of life among high risk individuals: the Diabetes Prevention Program outcomes study

PURPOSE

The purpose of this study is to assess if diagnosis of type 2 diabetes affected health-related quality of life (HRQoL) among participants in the Diabetes Prevention Program/Diabetes Prevention Program Outcome Study and changes with treatment or diabetes duration.

METHODS

3,210 participants with pre-diabetes were randomized to metformin (MET), intensive lifestyle intervention (ILS), or placebo (PLB). HRQoL was assessed using the SF-36 including: (1) 8 SF-36 subscales; (2) the physical component (PCS) and mental component summary (MCS) scores; and (3) the SF-6D. The sample was categorized by diabetes free versus diagnosed. For diagnosed subgroup, mean scores in the diabetes-free period, at 6 months, 2, 4 and 6 years post-diagnosis, were compared.

RESULTS

PCS and SF-6D scores declined in all participants in all treatment arms (P < .001). MCS scores did not change significantly in any treatment arm regardless of diagnosis. ILS participants reported a greater decrease in PCS scores at 6 months post-diagnosis (P < .001) and a more rapid decline immediately post-diagnosis in SF-6D scores (P = .003) than the MET or PLB arms. ILS participants reported a significant decrease in the social functioning subscale at 6 months (P < .001) and two years (P < .001) post-diagnosis.

CONCLUSIONS

Participants reported a decline in measures of overall health state (SF-6D) and overall physical HRQoL, whether or not they were diagnosed with diabetes during the study. There was no change in overall mental HRQoL. Participants in the ILS arm with diabetes reported a more significant decline in some HRQoL measures than those in the MET and PLB arms that developed diabetes.

Treatment satisfaction in the sensor-augmented pump therapy for A1C reduction 3 (STAR 3) trial

AIM

To identify insulin delivery system perceptions that contributed to improvements in overall satisfaction with insulin therapy (treatment satisfaction) that were larger in those using sensor-augmented pump therapy than those using multiple daily injections with self monitoring of blood glucose.

METHODS

The Sensor-Augmented Pump Therapy for A1C Reduction 3 (STAR 3), a randomized 12-month clinical trial, compared sensor-augmented pump therapy to multiple daily injections + self monitoring of blood glucose in adult and paediatric patients. The Insulin Delivery System Rating Questionnaire measured perceptions of convenience, problems, interference with daily activities, blood glucose monitoring burden, social burden, clinical efficacy, diabetes worries and psychological well-being, as well as treatment satisfaction. We conducted separate multiple regression analyses for the 334 adult patients and 147 paediatric patients and their caregivers to assess the independent associations (P < 0.05) between change from baseline to follow-up in user perceptions and treatment satisfaction.

RESULTS

Increased convenience was associated with improved treatment satisfaction in all user groups. Reduced interference with daily activities (caregivers), reduced social burden (adults) and increased efficacy (both) also were associated with improved treatment satisfaction.

CONCLUSIONS

Treatment satisfaction among children was primarily a function of convenience, while perceived clinical efficacy was also a primary determinant among adults, reflecting different emphases on the treatment process itself vs. treatment consequences. Among adult patients and caregivers, improved treatment satisfaction was also a function of reductions in social burden and interference with daily activities (respectively), reflecting concern with the broader psychosocial impact of sensor-augmented pump therapy on their lives.

Validation of a tool to assess medication treatment satisfaction in patients with Type 2 diabetes: the Diabetes Medication System Rating Questionnaire (DMSRQ)

AIM

To assess the reliability and validity of the Diabetes Medication System Rating Questionnaire among 537 US adults with Type 2 diabetes using five different diabetes medication regimens (oral agents with and without insulin; insulin only by syringe and by pen; glucagon-like peptide 1 agents).

METHODS

The Diabetes Medication System Rating Questionnaire assesses the treatment experience of patients using any diabetes medication system that uses nine measures (Convenience, Negative Events, Interference, Self-Monitoring of Blood Glucose Burden, Efficacy, Social Burden, Psychological Well-Being, Treatment Satisfaction, Treatment Preference). It was administered via an initial online survey, along with other validated measures of treatment satisfaction and medication adherence, with a retest administered within 2 weeks. Participants were 52.5% male, 57.4% aged 40-64 years, 83.6% white and 95.2% non-Hispanic. Most (75.6%) had attended college and 58.3% had been diagnosed with diabetes for more than 10 years.

RESULTS

Median inter-item agreement was 0.86. Median test-retest reliability was also 0.86. All correlations between Diabetes Medication System Rating Questionnaire measures and criterion measures of treatment satisfaction and adherence were statistically significant (P<0.01) in the expected direction. Correlations between Diabetes Medication System Rating Questionnaire and the corresponding criterion measures of treatment satisfaction ranged from 0.349 to 0.629 (absolute values; interpolated median 0.568); correlations of the same measures with adherence ranged from 0.384 to 0.450 (absolute values; mean 0.411). Diabetes Medication System Rating Questionnaire measures differentiated among groups taking different medications and those using different delivery systems for the same medication.

CONCLUSIONS

  This study suggests that the Diabetes Medication System Rating Questionnaire has good reliability and validity and provides a more comprehensive set of measures than existing medication satisfaction questionnaires.

Use of antidepressant medication and risk of type 2 diabetes: results from three cohorts of US adults

AIMS/HYPOTHESIS

The results of several studies have suggested a potential positive association between use of antidepressant medication (ADM) and incident type 2 diabetes mellitus. We examined this association in three cohorts of US adults.

METHODS

We followed 29,776 men in the Health Professionals Follow-up Study (HPFS, 1990-2006), 61,791 women in the Nurses' Health Study I (NHS I, 1996-2008) and 76,868 women in NHS II (1993-2005), who were free of diabetes mellitus, cardiovascular disease or cancer at baseline. The mean baseline ages for participants from the HPFS and NHS I and II were 56.4, 61.3 and 38.1 years, respectively. ADM use and other covariates were assessed at baseline and updated every 2 years. A time-dependent Cox proportional hazards model was used, and HRs were pooled together across the three cohorts.

RESULTS

During 1,644,679 person-years of follow-up, we documented 6,641 new cases of type 2 diabetes. ADM use was associated with an increased risk of diabetes in all three cohorts in age-adjusted models (pooled HR 1.68 [95% CI 1.27, 2.23]). The association was attenuated after adjustment for diabetes risk factors and histories of high cholesterol and hypertension (1.30 [1.14, 1.49]), and further attenuated by controlling for updated BMI (1.17 [1.09, 1.25]). Use of selective serotonin reuptake inhibitors and other antidepressants (mainly tricyclic antidepressants) were both associated with an elevated risk of diabetes, with pooled multivariate-adjusted HRs of 1.10 (1.00, 1.22) and 1.26 (1.11, 1.42), respectively.

CONCLUSIONS/INTERPRETATION

The results suggest that ADM users had a moderately elevated risk of type 2 diabetes mellitus compared with non-users, even after adjustment for BMI.

Factors associated with physician perceptions of and willingness to recommend inhaled insulin

OBJECTIVE

To examine predictors of physician perceptions of an inhaled insulin, willingness to prescribe that insulin, and estimates of patient initiation of therapy with that insulin.

RESEARCH DESIGN AND METHODS

The study was an Internet survey of a US national sample (n = 602) of physicians who treat adults with diabetes. Respondents were given a brief description of potential clinical benefits and administration procedures for the study inhaled insulin (SII).

MAIN OUTCOME MEASURES

Measures included clinical beliefs, benefit ratings and overall evaluation of SII relative to other mealtime insulins, willingness to recommend SII, and estimates of patient initiation of therapy with that insulin. Multivariate regression assessed significant independent associations controlling for respondent and patient case-mix characteristics.

RESULTS

Physicians who self-identified as medical innovators or who reported high levels of involvement with patients tended to rate the SII higher, while respondents who self-identified as diabetes experts or who avoided using insulin tended to rate the SII lower. Medical innovators and those who rated the SII high on efficacy in avoiding discomfort and inconvenience were more likely to say they would recommend the SII to their patients and that their patients would use it. Family physicians were most likely and endocrinologists least likely to say they would recommend the SII for a variety of patient profiles.

CONCLUSIONS

Physicians see a variety of important benefits for the SII, and would recommend inhaled insulin to patients with different treatment regimens and treatment needs, especially those patients who are hesitant to initiate insulin therapy or concerned about taking more insulin injections. These findings should be considered in light of study limitations, including the fact that responses were based on expected benefits, and not on benefits actually experienced by physicians in the study, the fact that no information was provided about the cost of the SII, though this could have an important influence on prescription decisions, and the fact that the study sample was a self-selected group, rather than a representative sample of all physicians treating patients with diabetes.

Depression predicts first but not recurrent diabetic foot ulcers

AIMS/HYPOTHESIS

This study examined the relationship between symptoms of depression and the development of diabetic foot ulcers.

METHODS

Participants were 333 patients (71% male; mean age 62 years; 73% with type 2 diabetes) with diabetic peripheral neuropathy (DPN), but without peripheral vascular disease (PVD). Severity of DPN and the presence of PVD were assessed by clinical examination. Depression, other diabetes complications and foot self-care were assessed by self-report. Cox regression tested whether depression was an independent predictor of foot ulceration over 18 months, whether this relationship was moderated by foot ulcer history, and whether foot self-care mediated this relationship.

RESULTS

During follow-up, 63 patients developed a foot ulcer. Those with prior foot ulcers had more than four-fold greater risk of subsequent foot ulceration compared with those without a history of foot ulcer. A significant interaction effect showed that depression was significantly related to the development of first but not recurrent foot ulcers. This relationship was independent of biological risk factors. In the final model, each standard deviation increase in depression symptoms was significantly associated with increased risk of developing first foot ulcers (HR 1.68, 95% CI 1.20-2.35), while foot self-care was associated with lower risk (HR 0.61, 95% CI 0.40-0.94). Foot self-care did not mediate the relationship between depression and foot ulceration.

CONCLUSIONS/INTERPRETATION

These data suggest that depression is associated with increased risk of first foot ulcers in DPN patients and that this relationship is independent of biological risk factors and foot self-care. Interventions that target depression and foot self-care before the development of foot ulcers may maximise the likelihood of successful prevention of foot ulceration.

Cardiovascular disease risk factors, depression symptoms and antidepressant medicine use in the Look AHEAD (Action for Health in Diabetes) clinical trial of weight loss in diabetes

AIMS/HYPOTHESIS

To determine the associations of baseline depression symptoms and use of antidepressant medicines (ADMs) with baseline cardiovascular disease (CVD) risk factors in Look AHEAD (Action for Health in Diabetes) trial participants.

METHODS

Look AHEAD participants (n = 5,145; age 58.7 +/- 6.8 years; BMI 35.8 +/- 5.8 kg/m(2)) were assessed for CVD risk factors (elevated HbA(1c) or insulin use, elevated BP or antihypertensive use, elevated lipid levels or lipid-lowering medication, current smoking, BMI > or = 30 kg/m(2), lower peak exercise capacity assessed as metabolic equivalents [METs], and ankle-brachial index <0.9 or >1.3). Participants also completed the Beck Depression Inventory (BDI) and reported their use of ADMs.

RESULTS

Of the participants, 14.7% had BDI scores > or = 11, consistent with mild-moderate depression, and 16.5% took ADMs; 4.4% had both depression markers (i.e. elevated symptom scores and took ADMs). In logistic regression analyses of CVD risk (elevated risk factor or use of medication to control the risk factor), controlled for demographic factors, continuous BDI scores and ADM use were each independently associated with elevated BP (or medication), current smoking, BMI > or = 30 kg/m(2) and lower MET values. ADM use was also associated with elevated serum lipids or use of lipid-lowering medication.

CONCLUSIONS/INTERPRETATION

Among Look AHEAD participants, depression symptoms or ADM use on entry to the study were each independently associated with a wide range of CVD risk factors. Future research should assess the temporal dynamics of the relationships of depression symptoms and ADM use with CVD risk factors.

TRIAL REGISTRATION

Clinicaltrials.gov NCT00017953

FUNDING

This study is funded by the National Institutes of Health with additional support from the Centers for Disease Control and Prevention.

Predictors of depressive symptoms in persons with diabetic peripheral neuropathy: a longitudinal study

AIMS/HYPOTHESIS

The aim of the study was to determine whether diabetic peripheral neuropathy (DPN) is a risk factor for depressive symptoms and examine the potential mechanisms for this relationship.

METHODS

This longitudinal study (9 and 18 month follow-up) of 338 DPN patients (mean age 61 years; 71% male; 73% type 2 diabetes) examined the temporal relationships between DPN severity (mean +/- SD; neuropathy disability score [NDS], 7.4 +/- 2.2; mean vibration perception threshold, 41.5 +/- 9.5 V), DPN somatic experiences (symptoms and foot ulceration), DPN psychosocial consequences (restrictions in activities of daily living [ADL] and social self-perception) and the Hospital Anxiety and Depression subscale measuring depressive symptoms (HADS-D; mean 4.9 +/- 3.7).

RESULTS

Controlling for baseline HADS-D and demographic/disease variables, NDS at baseline significantly predicted increased HADS-D over 18 months. This association was mediated by baseline unsteadiness, which was significantly associated with increased HADS-D. Baseline ADL restrictions significantly predicted increased HADS-D and partly mediated the association between baseline unsteadiness and change in HADS-D. Increased pain, unsteadiness and ADL restrictions from baseline to 9 months each significantly predicted increased HADS-D over 18 months. Change in social self-perception from baseline to 9 months significantly predicted increased HADS-D and partly mediated the relationships of change in unsteadiness and ADL restrictions with change in HADS-D.

CONCLUSIONS/INTERPRETATION

These results confirm that neuropathy is a risk factor for depressive symptoms because it generates pain and unsteadiness. Unsteadiness is the symptom with the strongest association with depression, and is linked to depressive symptoms by perceptions of diminished self-worth as a result of inability to perform social roles.

Improved treatment satisfaction and weight-related quality of life with exenatide once weekly or twice daily

AIMS

To assess treatment satisfaction and weight-related quality of life (QOL) in subjects with Type 2 diabetes treated with exenatide once weekly (QW) or twice daily (BID).

METHODS

In this 52-week randomized, multi-centre, open-label study, 295 subjects managed with diet and exercise and/or oral glucose-lowering medications received either exenatide QW or BID during weeks 1-30; thereafter, subjects receiving exenatide BID were switched to exenatide QW, with 258 total subjects receiving exenatide QW during weeks 30-52. Diabetes Treatment Satisfaction Questionnaire-status (DTSQ-s) and Impact of Weight on Quality of Life-Lite (IWQOL-Lite) were assessed at baseline and weeks 30 and 52. Mean group changes from baseline to week 30 were estimated by ancova; changes from week 30 to week 52 were assessed by Student's t-test.

RESULTS

Statistically significant improvements from baseline to week 30 were observed in both treatment groups for DTSQ-s and IWQOL-Lite measures, with significantly greater reduction in perceived frequency of hyperglycaemia and greater satisfaction with continuing treatment in the QW group compared with the BID group. Effect sizes for change in DTSQ-s total scores were 0.84 QW, 0.64 BID; for IWQOL-Lite: 0.96 QW, 0.82 BID. Treatment satisfaction and QOL improved significantly between weeks 30 and 52 for those switching from BID to QW. Occurrence of adverse events did not affect patients' improvements in treatment satisfaction and QOL.

CONCLUSIONS

Patients treated with exenatide QW or BID experienced significant and clinically meaningful improvements in treatment satisfaction and QOL. Patients who switched from exenatide BID to exenatide QW administration reported further significant improvements.

Patient and provider perceptions of care for diabetes: results of the cross-national DAWN Study

AIMS/HYPOTHESIS

We assessed country-level and individual-level patterns in patient and provider perceptions of diabetes care.

METHODS

The study used a cross-sectional design with face-to-face or telephone interviews of diabetic patients and healthcare providers in 13 countries from Asia, Australia, Europe and North America. Participants were randomly selected adults with type 1 or type 2 diabetes (n=5,104), and randomly selected diabetes-care providers, including primary-care physicians (n=2,070), diabetes specialist physicians (n=635) and nurses (n=1,122). Multivariate analysis was used to examine the relationships between outcomes and both country and respondent characteristics, and the interaction between these two factors.

RESULTS

Providers rated chronic-care systems and remuneration for chronic care as mediocre. Patients reported that ease of access to care was high, but not without financial barriers. Patients reported moderate levels of collaboration among providers, and providers indicated that several specialist disciplines were not readily available to them. Patients reported high levels of collaboration with providers in their own care. Provider endorsement of primary prevention strategies for type 2 diabetes was high. Patients with fewer socio-economic resources and more diabetes complications had lower access (and/or higher barriers) to care and lower quality of patient-provider collaboration. Countries differed significantly for all outcomes, and the relationships between respondent characteristics and outcomes varied by country.

CONCLUSIONS/INTERPRETATION

There is much need for improvement in applying the chronic-care model to the treatment and prevention of diabetes in all of the countries studied. Each country must develop its own priorities for improving diabetes care and comparison with other countries can help identify strengths as well as weaknesses.

Psychosocial problems and barriers to improved diabetes management: results of the Cross-National Diabetes Attitudes, Wishes and Needs (DAWN) Study

AIMS

To examine patient- and provider-reported psychosocial problems and barriers to effective self-care and resources for dealing with those barriers.

METHODS

Cross-sectional study using face-to-face or telephone interviews with diabetic patients and health-care providers in 13 countries in Asia, Australia, Europe and North America. Participants were randomly selected adults (n = 5104) with Type 1 or Type 2 diabetes, and providers (n = 3827), including primary care physicians, diabetes specialist physicians and nurses.

RESULTS

Regimen adherence was poor, especially for diet and exercise; provider estimates of patient self-care were lower than patient reports for all behaviours. Diabetes-related worries were common among patients, and providers generally recognized these worries. Many patients (41%) had poor psychological well-being. Providers reported that most patients had psychological problems that affected diabetes self-care, yet providers often reported they did not have the resources to manage these problems, and few patients (10%) reported receiving psychological treatment.

CONCLUSIONS

Psychosocial problems appear to be common among diabetic patients worldwide. Addressing these problems may improve diabetes outcomes, but providers often lack critical resources for doing so, particularly skill, time and adequate referral sources.

The impact of barriers and self-efficacy on self-care behaviors in type 2 diabetes

PURPOSE

This cross-sectional, correlational study examined the relationships of diabetes-specific treatment barriers and self-efficacy with self-care behaviors.

METHODS

A total of 309 people with type 2 diabetes participated in this study. All of the factors were assessed by self-report questionnaires. Self-care behaviors included exercise, diet, skipping medication, testing blood for glucose, adjusting insulin to avoid or correct hyperglycemia, and adjusting diet to avoid or correct hypoglycemia.

RESULTS

Perceived barriers to carrying out self-care behaviors were associated with worse diet and exercise behavior. Greater self-efficacy predicted more frequent blood glucose testing, less frequent skipping of medication and binge eating, and closer adherence to an ideal diet. Nontraditional dimensions of self-efficacy were associated with worse self-care. Self-efficacy explained 4% to 10% of the variance in diabetes self-care behaviors beyond that accounted for by patient characteristics and health beliefs about barriers.

CONCLUSIONS

The findings of this study provided support for Rosenstock's proposal that a person's self-perceived capability to carry out a behavior should be incorporated into an expanded health belief model.

Psychological issues and treatments for people with diabetes

This article examines psychological issues and their treatment among people with diabetes. The paper contains two main sections, one dealing with diagnosable clinical disorders, and the other with more mundane but nevertheless important subclinical problems in living with diabetes. We review the published literature on prevalence, manifestation, consequences, and treatment of psychological disorders in persons with diabetes, primarily depression, anxiety, and eating disorders. In describing everyday problems in living with diabetes we expand our sources beyond the published literature to include our own clinical and consulting experiences as well as our unpublished qualitative research. These problems include dietary restrictions, self-monitoring of blood glucose, taking insulin injections, and lack of support from family and health care professionals. We describe methods for dealing with such problems and discuss the tension between focusing on emotional distress versus practical issues of disease management. Finally, we briefly present some potentially positive consequences of living with diabetes so that readers can be aware of the inspirational aspects of personal experience with this disease.

How diabetes specialists treat their own diabetes: findings from a study of the AADE and ADA membership

PURPOSE

The purpose of this study was to determine how diabetes specialists, who themselves have diabetes, manage their own care.

METHODS

An independent research organization faxed anonymous, 1-page surveys to all professional members of the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA) who had valid fax numbers. Only those individuals with diabetes were asked to fill out and return the survey.

RESULTS

Of the 12,525 surveys that were distributed, 802 (6.4%) were returned. The prevalence of type 1 diabetes in this sample was estimated to be 13 times higher than in the general US population, whereas the prevalence of type 2 diabetes was 42% to 54% lower. Of the respondents with type 1 diabetes, most (96%) practiced intensive treatment regimens, and more than half used an insulin infusion pump.

CONCLUSIONS

Diabetes specialists treat their own diabetes according to current standards of medical care, with insulin pumps being the preferred method of insulin therapy for type 1 diabetes in this sample. Knowing that experts almost universally practice intensive treatment regimens may be a powerful motivator for patients and sends a strong message to primary care providers and payers regarding the need for treating diabetes according to current standards of care.

Quality of life and diabetes

Quality of life is an important health outcome in its own right, representing the ultimate goal of all health interventions. This paper reviews the published, English-language literature on self-perceived quality of life among adults with diabetes. Quality of life is measured as physical and social functioning, and perceived physical and mental well-being. People with diabetes have a worse quality of life than people with no chronic illness, but a better quality of life than people with most other serious chronic diseases. Duration and type of diabetes are not consistently associated with quality of life. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease-specific determinant of quality of life. Numerous demographic and psychosocial factors influence quality of life and should be controlled when comparing subgroups. Studies of clinical and educational interventions suggest that improving patients' health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease-specific measures. Quality of life measures should be used to guide and evaluate treatment interventions.

Quality of life and diabetes

Quality of life is an important health outcome in its own right, representing the ultimate goal of all health interventions. This paper reviews the published, English-language literature on self-perceived quality of life among adults with diabetes. Quality of life is measured as physical and social functioning, and perceived physical and mental well-being. People with diabetes have a worse quality of life than people with no chronic illness, but a better quality of life than people with most other serious chronic diseases. Duration and type of diabetes are not consistently associated with quality of life. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease-specific determinant of quality of life. Numerous demographic and psychosocial factors influence quality of life and should be controlled when comparing subgroups. Studies of clinical and educational interventions suggest that improving patients' health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease-specific measures. Quality of life measures should be used to guide and evaluate treatment interventions.

Behavioral science in diabetes. Contributions and opportunities

OBJECTIVE

To summarize the current status of behavioral research and practice in diabetes and to identify promising future directions.

RESEARCH DESIGN AND METHODS

We review behavioral science contributions to diabetes in self-management and patient empowerment, interventions with children and adolescents, and special problems including blood glucose awareness training and complications such as depression. We also identify emerging areas in which behavioral science stands to make significant contributions, including quality of life, worksite and community programs, interventions using new information technologies, and translation research evaluating practical programs in representative settings. We then discuss the gap between the generally encouraging research on behavioral contributions to diabetes and the infrequent incorporation of such contributions in practice. Suggestions are made for how to close this gap, including ways to increase understanding of behavioral issues, opportunities for funding of key research and implementation questions, and how behavioral science principles can become more integrated into diabetes organizations and care.

CONCLUSIONS

Changes are required on the part of behavioral scientists in how they organize and present their research and on the part of potential users of this knowledge, including other health professions, organizations, and funding agencies. Integrating behavioral science advances with other promising genetic, medical, nutritional, technology, health care, and policy opportunities promises not only to broaden our understanding of diabetes but also to improve patient care, quality of life, and public health for persons with diabetes.

Quality of life and diabetes

Quality of life is an important health outcome in its own right, representing the ultimate goal of all health interventions. This paper reviews the published, English-language literature on self-perceived quality of life among adults with diabetes. Quality of life is measured as physical and social functioning, and perceived physical and mental well-being. People with diabetes have a worse quality of life than people with no chronic illness, but a better quality of life than people with most other serious chronic diseases. Duration and type of diabetes are not consistently associated with quality of life. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease-specific determinant of quality of life. Numerous demographic and psychosocial factors influence quality of life and should be controlled when comparing subgroups. Studies of clinical and educational interventions suggest that improving patients' health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease-specific measures. Quality of life measures should be used to guide and evaluate treatment interventions.

Persistence of depressive symptoms in diabetic adults

OBJECTIVE

To determine the level and pattern of persistent depressive symptoms among adults with diabetes and identify factors associated with increased risk of being persistently depressed.

RESEARCH DESIGN AND METHODS

A self-report depression symptom inventory was administered to 245 patients at two initial time points--the beginning and end of a comprehensive outpatient diabetes education program--and at 6-month follow-up.

RESULTS

Only 13% of subjects were persistently depressed (i.e., exceeded the criterion for depression symptoms at all three time points). The rate of being depressed at follow-up was 10% for those negative for depression symptoms at either of the initial time points, 36% for those positive at one initial time point, and 73% for those positive at both initial time points (P < 0.0001). Those at increased risk for being persistently depressed were those who did not graduate from high school, had more than two complications of diabetes, and were not treated with insulin.

CONCLUSIONS

Persistent depressive symptomatology is present in a substantial number of diabetic adults and can be effectively predicted using simple screening instruments during initial contacts. Risk factors for being persistently depressed only partly overlap those for transient depressive symptoms and represent a possible biological dimension.

Levels and risks of depression and anxiety symptomatology among diabetic adults

OBJECTIVE

To determine levels of depression and anxiety symptoms among adults with diabetes and identify factors associated with increased risk.

RESEARCH DESIGN AND METHODS

This study administered self-report symptom inventories to patients at the beginning (n = 634) and end (n = 578) of an outpatient diabetes education program. Subjects (n = 246) contacted by mail 6 months later completed the same instruments.

RESULTS

Rates of disturbance for depression (41.3%; 95% CI: 37.4-45.2%) and anxiety (49.2%; 95% CI: 45.3-53.1%) were higher than those typical in the general population (10-20%). Probability of disturbance ranged from 5-7% for those with the lowest risk profile to 82-92% for those with the highest risk profile. Diabetes-related complications were the only disease factor associated with significantly increased risk of disturbance. Women and those with less education were at much higher risk. Only 13% of those followed for 6 months were disturbed at all three time-points.

CONCLUSIONS

Diabetes is associated with increased risk of psychological disturbance, especially for those with more diabetes-related complications. Sociodemographic factors account for much of the risk differential among people with diabetes.

Structure and correlates of diabetes-specific locus of control

OBJECTIVE

To examine the structure and correlates of diabetes-specific locus of control.

RESEARCH DESIGN AND METHODS

Study participants were 165 adult patients from a comprehensive outpatient diabetes education program who completed a research protocol at the outset of the program. The protocol included measures of diabetes locus of control (DLC), glycemic control, self-care behavior, and emotional well-being.

RESULTS

Scales measuring internal and powerful other DLC each had two components. One component of internal DLC, autonomy, was significantly associated with positive outcomes, and the other component, self-blame, was related to negative outcomes. The two components of powerful other DLC were differently correlated with various aspects of strict regimen adherence, and chance DLC was associated with a variety of measures reflecting a pattern of dysfunction.

CONCLUSIONS

The concept of DLC appears to have explanatory power in accounting for health outcomes, especially when internal DLC measures of autonomy and self-blame are differentiated. It is important to find educational interventions that work effectively with patients who believe that health outcomes are controlled by chance, because they seem to be at special risk for health-related problems.

Implications of the DCCT. Looking beyond tight control

The main conclusion of the recently completed, landmark Diabetes Control and Complications Trial (DCCT), i. e., the fact that tight control significantly reduces the risk of diabetes-related complications, has been widely acclaimed. This enthusiasm has been fueled in part by the magnitude of the advantage tight control seems to offer: the 2% difference in average HbA1c between the DCCT standard and intensive treatment groups was associated with a 60% reduction in risk for diabetic reti-nopathy, nephropathy, and neuropathy.

Modeling the effect of diabetes education on glycemic control

The objective of this study was to identify the mechanisms by which diabetes education improves glycemic control. Study participants were 82 adult patients from a comprehensive outpatient diabetes education program who completed a research protocol at the outset of the program and again 6 to 12 months later. The research protocol included a glycosylated hemoglobin assay and self-reported frequency of two insulin administration events (shot skipping and dosage adjustment), self-monitoring of blood glucose (SMBG), and exercise. Those who did not improve any aspect of self-care reduced their mean glycohemoglobin from 9.7 to 9.0. Those who improved exercise or SMBG (but not both) reduced their glycohemoglobin from 10.9 to 9.6. Those who improved both exercise and SMBG and those who improved insulin administration had the largest improvement in glycemic control, from 12.5 to 9.6. These findings suggest that if diabetes education can help patients improve self-care behavior, it can bring about dramatic improvements in glycemic control. Improved insulin administration is the single most powerful way to improve glycemia, but improving other aspects of self-care also can produce substantial gains.

Psychosocial problems and interventions in diabetes. A review of the literature

This article reviews and organizes the recent literature on psychosocial problems and interventions in diabetes to see if it is possible to identify effective modes of treatment for numerous different psychosocial problems. An attempt was made to review extensively the references on psychosocial problems and to review exhaustively the references on psychosocial interventions. The review was organized under four major headings: psychological sequelae of medical crises, psychopathology in diabetes, stress and hassles in living with diabetes, and family dysfunctions. Results of the literature review were similar for all areas: although some studies suggested that these problems are especially severe for people with diabetes, the best-designed studies suggested that this was not so. Regardless of the prevalence of these problems in the diabetic population at large, individuals who suffer from these problems are at special risk for reduced physical and emotional well-being, so they need psychosocial interventions that effectively resolve their difficulties. Unfortunately, the literature on psychosocial interventions in diabetes is meager, and it lacks the systematic, quantitative evaluations necessary to identify effective modes of treatment for different psychosocial problems. It is possible to state tentatively that certain interventions have been used for specific problems with some indication that they can be effective. Issues for future research are identified. Addressing these issues might provide a foundation for making decisions about areas ripe for clinical trials, and ultimately determining which intervention is best suited for treating any given psychosocial problem.

Differential effect of diabetes education on self-regulation and life-style behaviors

OBJECTIVE

To examine the effect of diabetes education on self-regulation and life-style behaviors.

RESEARCH DESIGN AND METHODS

Participants in an outpatient diabetes education program completed a protocol measuring several self-care behaviors and glycemic control at entry (n = 165) and 6 (n = 124) and 12 (n = 89) mo after the program.

RESULTS

Improvement was noted at 6 mo for most self-care behaviors and glycemic control. At 12 mo, lower glycosylated hemoglobin levels were maintained (P less than 0.001) without increases in perceived hypoglycemia. Improvement was not maintained for those self-care behaviors that require change in life-style, i.e., diet and exercise. However, self-care behaviors that allow patients to self-regulate their glycemic control--self-monitoring of blood glucose and insulin dose self-adjustment--were improved at 12 mo over preprogram levels (P less than 0.001). Frequency of insulin self-adjustment continued to increase during the period between follow-ups.

CONCLUSIONS

The findings suggest that diabetes education is effective in promoting self-regulation behaviors, although it has less effect on traditional regimen behaviors such as diet and exercise.

Effect of diabetes education on self-care, metabolic control, and emotional well-being

Participants (n=165) entering a week-long outpatient education program completed a protocol measuring self-care patterns, glycosylated hemoglobin levels, and emotional well-being. Emotional well-being was reassessed at the end of the program, and the entire protocol was completed again at 6 mo (n=124). At the program's end, participants improved on all measures of emotional well-being (P less than .01). Self-esteem and diabetes self-efficacy rose, whereas anxiety and depression fell. At 6 mo, improvement in emotional well-being continued, and important self-care behaviors improved from preprogram levels. Self-monitoring of blood glucose and exercise rose (both P less than .001), and bringing (P less than .01) and glycosylated hemoglobin levels (P less than .001) fell. Program effects were unrelated to demographic or disease characteristics but strongly related to initial status. Participants who entered the program with high levels of emotional well-being or good self-care patterns or glycemic control tended to change little, if at all, at later measurements. On the other hand, people who entered the program with low levels of emotional well-being or with poor self-care patterns or glycemic control improved substantially. Our findings suggest that diabetes education can promote long-term benefits in self-care, metabolic control, and emotional status if the program is specifically designed to provide these benefits. Aspects of the program that contribute to its efficacy are discussed.

Polyvalent pneumococcal immunization of patients with plasma cell dyscrasias

Thirteen patients with plasma cell dyscrasias and 27 healthy adults were immunized with polyvalent pneumococcal vaccine. Antibody responses were determined by radioimmunoassay. Patients with plasma cell disorders had significantly lower preimmunization and postimmunization antibody titers compared with those of the controls (P-0.01 abd 0.008, respectively). Even though the overall response in myeloma patients was poor, occasional rises in antibody titers occurred. Immunizing myeloma patients with the pneumococcal vaccine is recommended.

Medicine and the behavioral sciences: the Johns Hopkins M. D. - Ph. D. program

The behavioral sciences have much to offer medical research and practice, and they are likely to play an increasingly important role in medical education. The need for researchers and teachers trained in both medicine and behavioral sciences has been addressed at Johns Hopkins by the establishment of a joint degree program. Concurrent, as opposed to consecutive, training in both fields shortens the duration of study and fosters interdisciplinary research early in the trainee's career.