An Integrative Review of Social Determinants of Glycemic Targets Achievement in Adults with Type 2 Diabetes in the United States

Several individual social determinants of health have been identified as significant factors contributing to achieving glycemic targets (glycated hemoglobin < 7). However, it remains unclear how these social variables individually or collectively contribute to glycemic targets among adults with type 2 diabetes (T2D) in the United States (U.S.) The purpose of the current integrative review (IR) was to describe and synthesize findings from studies on social determinants of glycemic target achievement in adults with T2D in the U.S. and integrate them into the United States Department of Health and Human Services Conceptual Framework. The databases searched included PubMed, CINAHL Plus with Full Text, Medline with Full Text [EBSCO], Google Scholar, bibliography, and hand searching. A total of 948 records were identified. After excluding duplicates and irrelevant studies based on inclusion and exclusion criteria through title, abstract, and full-text screening, 13 studies were finally included in this IR. The results revealed that race/ethnicity, economic access and stability, educational access and quality, healthcare access and quality, neighborhood and built environment, and social and community context contribute to glycemic target achievement among adult patients with T2D in the U.S. Integrating findings from key studies on social determinants of glycemic health may contribute to developing interventions aimed at reducing and eventually eradicating health disparities for individuals with and at risk for T2D in the U.S.

Sleep Health Among Adults in Outpatient Opioid Use Disorder Treatment: A Systematic Review

The current systematic review synthesized available original research on objective and self-reported sleep health dimensions among adults aged 18 to 50 years in outpatient treatment for opioid use disorder (OUD). A comprehensive search was conducted using multiple electronic databases followed by screening 2,738 records published in English from the inception of each database to September 14, 2021. Quality was assessed with the Mixed Methods Appraisal Tool (version 2001). Fifty nine studies-50 descriptive (21 longitudinal, 18 cross-sectional, and 11 case control), seven interventional (five non-randomized), and two mixed/multi method designs-were included, comprising 18,195 adults with mean ages ranging from 23 to 49 years (mean age = 37.5 [SD = 5.9] years; 54.4% female) with OUD and 604 comparison participants without OUD. Studies were predominantly observational with various designs with self-report and objective measures with participants at various points in treatment. More work is needed to understand the multidimensional depth of sleep health in adults with OUD. Optimizing sleep health in adults with OUD may improve their addiction trajectory and should be a priority in practice and research. [Journal of Psychosocial Nursing and Mental Health Services, 62(1), 19-26.].

Substance Use, Sleep Duration, and Health Among Adults in Ohio

Introduction

Substance use affects approximately 46.3 million people aged 12 years or older (16.5% of the US population) and is associated with poor sleep health overall.

Methods

We conducted a cross-sectional secondary analysis of data from the 2020 Behavioral Risk Factor Surveillance System survey in Ohio. The sample comprised 14,676 adults. We examined associations between the use of 2 types of substances (marijuana and nonprescribed prescription pain medication) and short sleep duration (<6 hours per night) and overall health (mental, physical, and general). We used linear and logistic regression modeling while adjusting for individual-level (age, sex, race and ethnicity, education, income, and body mass index) and area-level (socioeconomic deprivation) covariates.

Results

Of survey respondents who answered questions, 9.2% (1,140 of 12,362) reported using marijuana, and 1.4% (111 of 8,203) used nonprescribed prescription pain medication. Respondents who used marijuana used it an average 17.3 days per month. In adjusted logistic regression models, the odds of reporting short sleep duration were 2.4 times greater among respondents who used nonprescribed prescription pain medication (vs those who did not). The odds of reporting short sleep duration, poor mental health, poor physical health, and poor general health were 1.5, 1.3, 2.1, and 1.9 times greater, respectively, among respondents who reported marijuana use (vs those who did not). In the linear regression models (adjusted), more days of marijuana use were associated with longer sleep duration, worse mental health, and worse general health.

Conclusion

Understanding the connection between substance use and health outcomes is needed to improve trajectories of substance use and recovery. Sleep duration is often underassessed among people who use substances. Expanding diagnostics and treatment options for those who use substances may result in lower levels of substance use and improved overall health.

Environmental exposures and blood pressure in adolescents and adults in the T1D exchange clinic registry

AIMS

To examine the associations between environmental determinants of health and blood pressure and whether age, sex, or race moderated the associations among 18,754 adolescents and adults from the type 1 diabetes (T1D) Exchange Clinic Registry.

METHODS

We used multivariable linear regression. Environmental determinants included exposure to ambient fine particulate matter (PM2.5, obtained from an integrated model), nitrogen dioxide (NO2), noise and light pollution, and the normalized difference vegetation index (NDVI, a marker of green space) at the ZIP code level of residence.

RESULTS

Higher exposure to PM2.5 and NO2, and lower NDVI, was associated with higher systolic and diastolic blood pressure, and higher light pollution exposure were similarly associated with higher diastolic blood pressure. These associations between environmental exposures and blood pressure remained significant after accounting for other covariates (age, sex, race/ethnicity, BMI, and T1D duration). With aging, the negative association between NDVI and blood pressure weakened.

CONCLUSIONS

These findings emphasize the significance of minimizing exposure to environmental pollutants, including PM2.5 and NO2, as well as ensuring access to areas with higher NDVI, to promote cardiovascular health in individuals with T1D.

The Role of Perceived Sleep Quality in Cardiovascular Health Factors and Behaviors Among Young Adults With Type 1 Diabetes

PURPOSE

The purpose of this study was to determine the associations between perceived sleep quality and individual cardiovascular health (CVH) factors (A1C and body mass index [BMI]) and CVH behaviors (physical activity and dietary diabetes self-management) in young adults ages 18 to 25 years with type 1 diabetes (T1D).

METHODS

Associations among perceived sleep quality and CVH factors and behaviors were examined using multivariable linear regression in 69 participants ages 18 to 25 years (mean age 21.4 ± 2.0, mean T1D duration 9.7 ± 5.6 years).

RESULTS

Lower perceived sleep quality was associated with multiple lower CVH factors and behaviors (higher A1C and BMI, lower physical activity, poorer diet) even after adjusting for covariates (age, T1D duration, sex assigned at birth).

CONCLUSION

Experimental studies are needed to better understand the impact of modifying sleep habits on both short- and long-term CVH in adults with T1D.

Internet-Based Recruitment and Retention of Young Adults With Type 1 Diabetes: Cross-Sectional Study

BACKGROUND

Multiple research strategies are required to recruit and engage a representative cohort of young adults in diabetes research. In this report, we describe an approach for internet-based recruitment for a repeated-measures descriptive study.

OBJECTIVE

The objective of this cross-sectional study was to determine whether internet-based recruitment through multiple social media platforms, a clinical research platform, and cooperation with community partnerships-College Diabetes Network and Beyond Type 1-would serve as an effective way to recruit a representative sample of young adults aged 18-25 years with type 1 diabetes (T1D).

METHODS

We conducted a repeated-measures descriptive study. We captured enrollment rates and participant characteristics acquired from each social media platform through survey data and Facebook analytics. This study was advertised via paid postings across a combination of different social media platforms (eg, Facebook, Instagram, Twitter, and Reddit). We used quarterly application postings, quarterly newsletters, and participation in the ResearchMatch registry to identify potentially eligible participants from February 3, 2021, to June 6, 2022.

RESULTS

ResearchMatch proved to be the most cost-effective strategy overall, yielding the highest gender and racial diversity compared to other internet platforms (eg, Facebook, Instagram, Twitter, and Reddit), application postings (eg, Beyond Type 1), and newsletters (eg, College Diabetes Network and a local area college). However, we propose that the combination of these approaches yielded a larger, more diverse sample compared to any individual strategy. Our recruitment cost was US $16.69 per eligible participant, with a 1.27% conversion rate and a 30% eligibility rate.

CONCLUSIONS

Recruiting young adults with T1D across multiple internet-based platforms was an effective strategy to yield a moderately diverse sample. Leveraging various recruitment strategies is necessary to produce a representative sample of young adults with T1D. As the internet becomes a larger forum for study recruitment, participants from underrepresented backgrounds may continue engaging in research through advertisements on the internet and other internet-based recruitment platforms.

Longitudinal Associations Among Symptoms of Family Intensive Care Unit Syndrome

BACKGROUND

Family intensive care unit (ICU) syndrome, a comorbid response to another person's stay in the ICU, is characterized by emotional distress, poor sleep health, and decision fatigue.

OBJECTIVES

This pilot study examined associations among symptoms of emotional distress (anxiety and depression), poor sleep health (sleep disturbance), and decision fatigue in a sample of family members of patients in the ICU.

METHODS

The study used a repeated-measures, correlational design. Participants were 32 surrogate decision makers of cognitively impaired adults who had at least 72 consecutive hours of mechanical ventilation within the neurological, cardiothoracic, and medical ICUs at an academic medical center in northeast Ohio. Surrogate decision makers with a diagnosis of hypersomnia, insomnia, central sleep apnea, obstructive sleep apnea, or narcolepsy were excluded. Severity of symptoms of family ICU syndrome was measured at 3 time points in 1 week. Zero-order Spearman correlations of the study variables were interpreted at baseline and partial Spearman correlations of study variables were interpreted 3 days and 7 days after baseline.

RESULTS

The study variables showed moderate to large associations at baseline. Baseline anxiety and depression were associated with each other and with decision fatigue at day 3. Baseline sleep disturbance was associated with anxiety, depression, and decision fatigue at day 7.

CONCLUSIONS

Understanding the temporal dynamics and mechanisms of the symptoms of family ICU syndrome can inform clinical, research, and policy initiatives that enhance the provision of family-centered critical care.

Resilience as a moderator of role overload and sleep disturbance among caregivers of persons with dementia

The purpose of this study was to examine if resilience moderates the association between role overload and sleep disturbance among caregivers of persons with dementia. This was a secondary analysis of data on 437 informal caregivers (mean age=61.77 years, SD=13.69) of persons with dementia in the United States. Data from the 2017 wave of the National Study of Caregiving were analyzed using multiple regression with interaction terms to evaluate the moderation effect of resilience, while controlling for caregivers' age, race, gender, education, self-rated health, caregiving hours, and primary caregiving status. Higher role overload was associated with greater sleep disturbance and this association was attenuated among caregivers with higher levels of resilience. Our findings highlight the stress-buffering effects of resilience in the context of sleep disturbance in dementia caregivers. Interventions to improve caregivers' ability to recover, resist, and rebound during challenging situations may mitigate role overload and optimize sleep health.

Nursing Students' Use of Harm Reduction in the Clinical Setting

BACKGROUND

The use and awareness of harm reduction education strategies are missing from nursing care of people with substance use disorder (SUD).

PURPOSE

To determine whether targeted training improved nursing students' application of harm reduction education in the clinical setting.

METHODS

This was an experimental 2-group repeated-measures survey study. Nursing students in a baccalaureate program received targeted training for 3 semesters. Training included presentations by people with lived experience, an addiction-trained physician, and a role-play exercise. Students received harm reduction education and reported on the application of this education.

RESULTS

Students in the traditional track cared for more people with SUD than students in the accelerated track. Referral for treatment was the most common education provided, and information related to injection drug use was the least commonly taught education.

CONCLUSIONS

Targeted training increased the number of harm reduction options nursing students presented to people with SUD in the clinical setting.

Cognitive Behavioral Sleep Self-Management Intervention for Young Adults With Type 1 Diabetes (NCT04975230)

The purpose of this study was to explore perceptions of the first dose of a cognitive behavioral sleep self-management intervention (CB-sleep) among young adults aged 18 to 25 years with type 1 diabetes (T1D). We used a qualitative descriptive approach to conduct in-depth semi-structured focused interviews with a purposive sample of 16 young adults with T1D, transitioning from adolescence to early adulthood. Interviews were audio-recorded, transcribed verbatim, and analyzed using qualitative content analysis. Participants described their sleep knowledge (previous, new, and additional), sleep health goals, along with barriers and facilitators of the CB-sleep intervention. Based on these results, we suggest CB-sleep is a useful modality with the potential to support sleep self-management in young adults with T1D during this complex life transition. Furthermore, CB-sleep could be incorporated into an existing diabetes self-management education and support program after pilot testing and determining efficacy to improve sleep and glycemic health.

Risk factors and geographic disparities in premature cardiovascular mortality in US counties: a machine learning approach

Disparities in premature cardiovascular mortality (PCVM) have been associated with socioeconomic, behavioral, and environmental risk factors. Understanding the "phenotypes", or combinations of characteristics associated with the highest risk of PCVM, and the geographic distributions of these phenotypes is critical to targeting PCVM interventions. This study applied the classification and regression tree (CART) to identify county phenotypes of PCVM and geographic information systems to examine the distributions of identified phenotypes. Random forest analysis was applied to evaluate the relative importance of risk factors associated with PCVM. The CART analysis identified seven county phenotypes of PCVM, where high-risk phenotypes were characterized by having greater percentages of people with lower income, higher physical inactivity, and higher food insecurity. These high-risk phenotypes were mostly concentrated in the Black Belt of the American South and the Appalachian region. The random forest analysis identified additional important risk factors associated with PCVM, including broadband access, smoking, receipt of Supplemental Nutrition Assistance Program benefits, and educational attainment. Our study demonstrates the use of machine learning approaches in characterizing community-level phenotypes of PCVM. Interventions to reduce PCVM should be tailored according to these phenotypes in corresponding geographic areas.

Food insecurity and atherosclerotic cardiovascular disease risk in adults with diabetes

OBJECTIVES

Adults with diabetes are at an increased risk of atherosclerotic cardiovascular disease (ASCVD), and food insecurity may be a major and underappreciated risk compounder in this population. We sought to analyze the prevalence of food insecurity and its association with ASCVD in adults with diabetes.

METHODS

A total of 6424 participants with diabetes were included from the 2019 and 2020 National Health Interview Survey. Food insecurity was determined with a 10-question U.S. Adult Food Security Survey Module, and classified as high, marginal, low, and very low. ASCVD was defined as a self-reported history of coronary artery disease, myocardial infarction, or stroke.

RESULTS

Of the 6424 included participants (weighted: n = 21 690 217), 5 405 543 (24.4%) reported a history of ASCVD and 2 946 061 (13.3%) were identified as food insecure (low or very low food security). Adults with food insecurity were more likely to have ASCVD than adults who were food secure (28.9% vs 23.7%; P = 0.008). In the multivariate analyses adjusted for traditional cardiovascular risk factors, all levels of food insecurity were associated with ASCVD compared with food-secure adults (marginal security: odds ratio [OR]: 1.60; 95% confidence interval [CI], 1.18-2.18]; P = 0.003; low security: OR: 2.09; 95% CI, 1.58-2.74]; P < 0.001; very low security: OR: 1.69; 95% CI, 1.22-2.34]; P = 0.001). The association persisted when adjusted for income, location, education, and insurance status. In adults with diabetes and ASCVD, income was a negative factor for food insecurity (OR: 0.71; 95% CI, 0.62-0.80; P < 0.001), but female sex and smoking were positive factors (OR: 1.90; 95% CI, 1.29-2.80; P = 0.001; and OR: 1.97; 95% CI, 1.23-3.18; P = 0.005; respectively). At younger ages, the prevalence of food insecurity increased, especially in adults with ASCVD.

CONCLUSIONS

We showed that 13% of U.S. adults with diabetes are food insecure, which was associated with ASCVD independent of traditional and socioeconomic risk factors. Our findings emphasize the importance of recognizing food insecurity as a driver of ASCVD in adults with diabetes, and encourage future efforts at reducing this disparity.

Socioeconomic deprivation and cardiometabolic risk factors in individuals with type 1 diabetes: T1D exchange clinic registry

AIMS

Social determinants of health (SDOH) influence cardiovascular health in the general population; however, the degree to which this occurs in individuals with type 1 diabetes (T1D) is not well understood. We evaluated associations among socioeconomic deprivation and cardiometabolic risk factors (hemoglobin A1c, low-density lipoprotein, blood pressure, body mass index, physical activity) in individuals with T1D from the T1D Clinic Exchange Registry.

METHODS

We evaluated the association between the social deprivation index (SDI) and cardiometabolic risk factors using multivariable and logistic regression among 18,754 participants ages 13 - 90 years (mean 29.2 ± 17) in the T1D Exchange clinic registry from 6,320 zip code tabulation areas (2007-2017).

RESULTS

SDI was associated with multiple cardiometabolic risk factors even after adjusting for covariates (age, biological sex, T1D duration, and race/ethnicity) in the multivariable linear regression models. Those in the highest socially deprived areas had 1.69 (unadjusted) and 1.78 (adjusted) times odds of a triple concomitant risk burden of poor glycemia, dyslipidemia, and hypertension.

CONCLUSIONS

Persistent SDOH differences could account for a substantial degree of poor achievement of cardiometabolic targets in individuals with T1D. Our results suggest the need for a broader framework to understand the association between T1D and adverse cardiometabolic outcomes.

ROLE OVERLOAD AND SLEEP DISTURBANCE AMONG CAREGIVERS OF PERSONS WITH DEMENTIA: THE MODERATING EFFECT OF RESILIENCE

Sleep disturbance is a significant sleep health problem among caregivers of persons with dementia and could exacerbate numerous adverse health outcomes. Resilience is one’s ability to recover from challenges and is a protective factor that is posited to blunt the effect of caregiving stress on sleep disturbance. Therefore, the purpose of this study was to examine if resilience moderates the association between perceived role overload and sleep disturbance using data from the 2017 wave of the National Study of Caregiving. The sample consisted of 480 informal caregivers (mean age = 61.77 years, SD = 13.69 years) of persons with dementia in the U.S. Participants completed self-report questionnaires about their sociodemographic and health characteristics, perceived role overload, resilience (i.e., adjusting to change and recovering from hardship), and sleep disturbance (i.e., frequency of trouble maintaining sleep). Data were analyzed using multiple regression with interaction terms to evaluate the moderation effect of resilience. Higher perceived role overload was associated with higher sleep disturbance, while controlling for caregivers’ age, race, gender, education, and self-rated health. The association of perceived role overload with sleep disturbance was attenuated among caregivers with higher levels of resilience (b = -.029, 95% CI: -.058, -.001). This study highlights the stress-buffering and sleep health benefits of resilience in the context of dementia caregiving. Among caregivers of persons with dementia, approaches to improve their ability to recover, resist, and rebound during caregiving challenges may mitigate stress and optimize their sleep health.

Racial and Ethnic Cardiometabolic Risk Disparities in the Type 1 Diabetes Exchange Clinic Registry Cohort

OBJECTIVE

To determine whether individuals from a historically underrepresented racial group have a higher cardiometabolic risk than historically represented individuals with type 1 diabetes (T1D) considering socioeconomic deprivation.

METHODS

We used the multivariable logistic and linear regression models to examine socioeconomic deprivation (upper 10th percentile) by race/ethnicity interaction for each cardiometabolic risk factor and cardiometabolic risk burden score, respectively, across 6320 zip code tabulation areas. We also determined the age-adjusted prevalence of low, moderate, and high cardiometabolic risks defined as 0, 1 to 2, and 3 or more risk factors for hypertension, obesity, dyslipidemia, and off-target glycemia for non-Hispanic White (n = 15 746), non-Hispanic Black (n = 1019), Hispanic (n = 1115), and other (n = 887), respectively.

RESULTS

The sample comprised 18 767 adolescents and adults with T1D. Those identifying as non-Hispanic Black were more likely to have a high cardiometabolic risk profile, including a 4.5-fold increase in the odds of off-target glycemia, a twofold increase in the odds of systolic hypertension, and 0.29 (unadjusted) and 0.46 (adjusted) increases in a higher cardiometabolic risk burden compared with non-Hispanic White individuals (P < .01). Those identifying as Hispanic had a 3.4-fold increase in the odds of off-target glycemia but were less likely to be overweight/obese or have systolic hypertension compared with non-Hispanic White. However, the lower likelihood of overweight/obesity and hypertension did not persist after considering covariates.

CONCLUSION

There is a need to investigate additional determinants of racially/ethnically underrepresented cardiometabolic health, including structural racism and implicit bias in cardiometabolic care for individuals with T1D.

Sociocultural Moderators of Emotion Regulation in Family Members of the Critically Ill

Coping with a loved one's critical illness as a surrogate decision-maker (SDM) elicits intense psychological distress. Emotion regulation (ER) may mitigate psychological distress. However, ER tendencies and their effects on psychological distress vary by racial and gender identity, which can inform the tailoring of ER-focused interventions. For this study, we examined between-group differences and the moderating effects of race and gender on ER (reappraisal and suppression) and psychological distress. We recruited 274 SDMs from a Midwestern academic medical center. Men reported a greater tendency to use suppression than women, and SDMs identifying as non-White reported a greater tendency to use reappraisal and suppression. Reappraisal resulted in greater psychological distress for non-White men and less psychological distress for White women. Incorporating tailored ER skill building into supportive interventions may improve the short- and long-term psychological well-being of SDMs, which may improve their ability to make value-concordant decisions and fulfill other informal caregiving responsibilities.

A composite measure of sleep health is associated with glycaemic target achievement in young adults with type 1 diabetes

We investigated whether sleep health (each individual dimension and a composite measure) was associated with better glycaemia among a cohort of young adults with type 1 diabetes (mean age 21.5 years, mean body mass index 24.55 kg m^-2 ). Multiple validated self-report questionnaires were completed, and raw continuous glucose monitor data were shared. One self-reported sleep characteristic for each of the five sleep health dimensions was selected. A composite score was calculated by summing the number of "good" sleep health dimensions. We evaluated the associations between sleep health and glycaemia, and whether covariates, including age, type 1 diabetes duration and sleep apnea risk, influenced the relationships among the study variables using multivariable linear regression. Individual dimensions of sleep satisfaction (β = 0.380, p = 0.019; β = -0.414, p = 0.010), timing (β = 0.392, p = 0.015; β = -0.393, p = 0.015) and sleep efficiency (β = 0.428, p = 0.007) were associated with higher achievement of glycaemic targets (J-index and time in range); however, these associations did not persist after considering covariates. A better Sleep Health Composite score was associated with higher achievement of glycaemic targets even after considering covariates. Using a multidimensional framework can guide future research on causal pathways between sleep and diabetes health, interventions to target sleep health profiles, and may improve sleep screening in routine diabetes care.

Socioeconomic Deprivation, Sleep Duration, and Mental Health during the First Year of the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) has had a rapid and sustained negative impact on sleep and mental health in the United States with disproportionate morbidity and mortality among socioeconomically deprived populations. We used multivariable and logistic regression to evaluate the associations among sleep duration, mental health, and socioeconomic deprivation (social deprivation index) in 14,676 Ohio residents from 1101 zip code tabulation areas from the 2020 Behavioral Risk Factor Surveillance System (BRFSS) survey. Higher socioeconomic deprivation was associated with shorter sleep and poorer mental health after adjusting for covariates (age, sex, race, education, income, and body mass index) in the multivariable linear regression models. Those in the highest socioeconomically deprived areas had 1.6 and 1.5 times higher odds of short sleep (duration < 6 h) and poor mental health (>14 poor mental health days), respectively, in the logistic regression models. Previous researchers have focused on limited socio-environmental factors such as crowding and income. We examined the role of a composite area based measure of socioeconomic deprivation in sleep duration and mental health during the first year of COVID-19. Our results suggest the need for a broader framework to understand the associations among socioeconomic deprivation, sleep duration, and mental health during a catastrophic event.

0235 A Systematic Review of Sleep Health and Outpatient Opioid Use Disorder Treatment in Adults

Introduction

Opioid Use Disorder (OUD) affects 2 million people in the United States and poor sleep health (satisfaction, alertness, timing, efficiency, and duration) is a primary driver of medication-assisted treatment (MAT) failure and relapse. It is known that people in therapy for OUD have a high prevalence of sleep problems (&gt;75%) and poorer sleep health compared to people without OUD (e.g., lower sleep efficiency, shorter duration, and more awakenings). However, sleep health is not routinely assessed. Thus, in this systematic review, we examined original studies on sleep health within the context of adults receiving outpatient MAT for OUD.

Methods

We conducted a systematic review of original research on sleep health in adults receiving outpatient treatment for OUD. Multiple electronic databases (PubMed, PsycINFO, and CINAHL) were searched for relevant studies published in English from the establishment of each database to September 14, 2021. Quality was assessed with the Mixed Methods Appraisal Tool (v. 2001).

Results

Sixty two studies were selected including 17,913 adults with OUD and 604 comparison participants without OUD (mean age = 37.4 ± 6.6 years; 54.1% male). Sixty-one studies were quantitative (50 cross sectional, 6 longitunal, 5 interventional) and 1 was mixed methods. Participants with OUD had poorer satisfaction (Pittsburgh Sleep Quality Index mean 7.4 ± 2.2 v. 4.7 ± 2.3), shorter polysomnography (PSG) measured total sleep time (336.6 ± 41.4 mins (5.6 h) v. 411.8 ± 33.3 mins (6.8 h), spent less time in PSG measured slow wave N3 sleep (7.2 ± 5.8% v. 13.4 ± 6.4%), and had a lower percentage of PSG measured rapid eye movement sleep (14.6 ± 4.6% v. 21.7 ± 4.0%) than comparison participants without OUD.

Conclusion

Studies were predominantly observational ranging from a period of 1-2 nights to 2 years with participants at various points in treatment. More work is needed to understand the multidimensional depth of sleep health in adults with OUD. Optimizing sleep health in adults with OUD may improve their addiction trajectory and should be a priority in practice and research.

Support (If Any)

American Academy of Sleep Medicine (220-BS-19).

"Feeling Anxious about Catching COVID": Facilitators and Barriers of Sleep Health among Young Adults with Type 1 Diabetes

BACKGROUND

The COVID-19 pandemic has imposed pervasive stress and significant disruptions in sleep health in young adults. The purpose of this study was to describe the perceived facilitators and barriers of sleep health among young adults with type 1 diabetes during the COVID-19 pandemic.

PARTICIPANTS

Thirty-two young adults with T1D (87.5% female; mean age = 21.5, SD = 2.0) participated in an online survey between January and July 2021. Young adults between the ages of 18-25 years with T1D for at least 6 months were eligible to participate, while those who had a previous OSA diagnosis, were currently pregnant, or worked the night shift were not eligible to participate.

METHODS

A qualitative descriptive approach was used to explore the perceived facilitators and barriers to sleep among a convenience sample. Qualitative content was analyzed and coded for themes using qualitative content analysis. Responses were coded using an in vivo approach.

RESULTS

Young adults with T1D identified changes in facilitators and barriers of sufficient sleep from before the COVID-19 pandemic to during the pandemic. Three overarching barriers and facilitators were identified: (1) general, (2) diabetes-specific, and (3) COVID-19 specific.

CONCLUSIONS

Our findings can inform future educational and cognitive-behavioral interventions to promote sleep health in young adults with T1D and other complex chronic conditions. When designing sleep-promoting interventions for young adults with T1D in the COVID-19 pandemic and post-pandemic, researchers should consider T1D as well as COVID-specific barriers and facilitators.

Objective Sleep-Wake Characteristics Are Associated With Diabetes Symptoms in Young Adults With Type 1 Diabetes

PURPOSE

The primary purpose of this descriptive cross-sectional study was to examine the associations between sleep-wake characteristics (total sleep time, sleep variability, sleep onset latency, and sleep efficiency), distress symptoms (general and diabetes), and diabetes physical symptoms in young adults ages 18 to 30 years with type 1 diabetes (T1D). The secondary purpose was to determine whether biological sex, body mass index (BMI), and T1D duration (covariates) influence the relationships among the study variables.

METHODS

Forty-six young adults with T1D, recruited from diabetes clinics from December 2018 to February 2020, wore a wrist actigraph and continuous glucose monitor concurrently for 6 to 14 days and completed the PROMIS Emotional Distress Scale, Diabetes Distress Scale, and Diabetes Symptom Checklist-Revised.

RESULTS

Shorter total sleep time and poorer sleep efficiency were associated with higher diabetes emotional distress symptoms. Higher sleep variability was associated with higher neurological pain symptoms. A longer sleep onset latency was associated with higher symptoms of diabetes distress, including psychological, cognitive, hyperglycemia, and a higher total symptom burden. Associations remained statistically significant after adjusting for biological sex and BMI, with the exception of sleep onset latency and total symptom burden.

CONCLUSIONS

Poorer objective sleep-wake characteristics were associated with higher diabetes symptoms even after considering biological sex and BMI among young adults with T1D.

Neighborhood-level Social Vulnerability and Prevalence of Cardiovascular Risk Factors and Coronary Heart Disease

Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). The social vulnerability index (SVI) is an estimate of a neighborhood's potential for deleterious outcomes when faced with natural disasters or disease outbreaks. We sought to investigate the association of the SVI with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We linked census tract SVI with prevalence of census tract CVD risk factors (smoking, high cholesterol, diabetes, high blood pressure, low physical activity and obesity), and prevalence of CHD obtained from the behavioral risk factor surveillance system. We evaluated the association between SVI, its sub-scales, CVD risk factors and CHD prevalence using linear regression. Among 72,173 census tracts, prevalence of all cardiovascular risk factors increased linearly with SVI. A higher SVI was associated with a higher CHD prevalence (R² = 0.17, P < 0.0001). The relationship between SVI and CHD was stronger when accounting for census-tract median age (R² = 0.57, P < 0.0001). A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence. In the United States, social vulnerability can explain significant portion of geographic variation in CHD, and its risk factors. Neighborhoods with high social vulnerability are at disproportionately increased risk of CHD and its risk factors. Social determinants of health are implicated in the geographic variation in cardiovascular diseases (CVDs). We investigated the association of social vulnerability index (SVI) with cardiovascular risk factors and the prevalence of coronary heart disease (CHD) in the United States at the census tract level. We show that cardiovascular risk factors and CHD were more common with higher SVI. A multivariable linear regression model including 4 SVI themes separately explained considerably more variation in CHD prevalence than the composite SVI alone (50.0% vs 17.3%). Socioeconomic status and household composition and/or disability were the SVI themes most closely associated with cardiovascular risk factors and CHD prevalence.

Building Therapeutic Commitment in University Nursing Students

BACKGROUND

Nurses report feeling unprepared to care for people with a substance use disorder (SUD).

PURPOSE

The purpose was to determine whether targeted antistigma interventions improved nursing students' attitudes and perceived stigma toward people with SUD.

METHODS

This was a quasi-experimental, repeated-measures survey study. Participants completed the 20-item Drug and Drug Problems Questionnaire (DDPPQ) and the 8-item Perceived Stigma of Substance Abuse Scale (PSAS) at baseline and postintervention in their first clinical semester. Booster sessions were held for 2 additional clinical semesters after the initial intervention in the first clinical semester. The DDPPQ and PSAS were completed at the end of each semester for 3 semesters of the nursing program.

RESULTS

After the educational interventions, there was a significant improvement in overall therapeutic attitudes except for 1 sub-scale, role-related self-esteem.

CONCLUSIONS

Antistigma interventions led to a decrease in stigma and improved overall therapeutic attitudes toward people with SUD.

Variations in Sleep Characteristics and Glucose Regulation in Young Adults With Type 1 Diabetes

CONTEXT

Short sleep duration and sleep disruptions are associated with impaired glucoregulation in type 1 diabetes (T1D). However, the mechanistic pathways between sleep and glucose variability remain unclear.

OBJECTIVE

To determine within- and between-person associations between objective sleep-wake characteristics and glucose variability indices.

METHODS

Multilevel models were used to analyze concurrent sleep and glucose patterns over 7 days in 42 young adults with T1D in their natural home environment. Young adults with T1D (mean age 22.2 ± 3.0 years, HbA1c 7.2%, 32.6% male) for at least 6 months with no other medical or major psychiatric comorbidity were included. Sleep-wake characteristics were measured via wrist actigraphy and glucose variability indices via a continuous glucose monitor (CGM).

RESULTS

Lower sleep efficiency predicted higher glucose variability (less time in range β = 0.011 and more time in hyperglycemia β = -0.011) within-person. A longer wake after sleep onset and more sleep disruptions were associated with higher glucose variability between persons (β = 0.28 and 0.31). Higher glucose variability predicted poorer sleep within-person (delayed bedtime, waketime, mid-sleep time, and lower sleep efficiency), while higher glucose variability was associated with poorer sleep and more sleep disruptions between persons (lower sleep efficiency, longer wake after sleep onset, and a higher sleep fragmentation index).

CONCLUSION

Clinicians can address the reciprocal nature of the sleep-glucose relationship by optimizing sleep and targeting efforts toward a euglycemic range overnight. Sleep habits are a modifiable personal target in diabetes care.

A systematic review of sleep deprivation and neurobehavioral function in young adults

AIM

To examine the effect of sleep deprivation (total and partial) on neurobehavioral function compared to a healthy sleep opportunity (7-9 h) in young adults 18-30 years.

BACKGROUND

More than one-third of young adults are sleep deprived, which negatively affects a range of neurobehavioral functions, including psychomotor vigilance performance (cognitive), affect, and daytime sleepiness.

METHODS

A systematic review of randomized controlled trials (RCTs) on sleep deprivation and neurobehavioral function. Multiple electronic databases (Cochrane Central Registry of Controlled Trials [CENTRAL], PubMed, PsycINFO, CINAHL, and Web of Science) were searched for relevant RCTs published in English from the establishment of each database to December 31, 2020.

RESULTS

Nineteen RCTs were selected (N = 766, mean age = 23.7 ± 3.1 years; 44.8% female). Seven were between-person (5 were parallel-group designs and 2 had multiple arms), and 12 were within-person designs (9 were cross over and 3 used a Latin square approach). Total sleep deprivation had the strongest detrimental effect on psychomotor vigilance performance, with the largest effects on vigilance tasks in young adults in the included studies.

CONCLUSION

Acute sleep deprivation degrades multiple dimensions of neurobehavioral function including psychomotor vigilance performance, affect, and daytime sleepiness in young adults. The effect of chronic sleep deprivation on the developing brain and associated neurobehavioral functions in young adults remains unclear.

Establishing a Global Standard for Wearable Devices in Sport and Exercise Medicine: Perspectives from Academic and Industry Stakeholders

Millions of consumer sport and fitness wearables (CSFWs) are used worldwide, and millions of datapoints are generated by each device. Moreover, these numbers are rapidly growing, and they contain a heterogeneity of devices, data types, and contexts for data collection. Companies and consumers would benefit from guiding standards on device quality and data formats. To address this growing need, we convened a virtual panel of industry and academic stakeholders, and this manuscript summarizes the outcomes of the discussion. Our objectives were to identify (1) key facilitators of and barriers to participation by CSFW manufacturers in guiding standards and (2) stakeholder priorities. The venues were the Yale Center for Biomedical Data Science Digital Health Monthly Seminar Series (62 participants) and the New England Chapter of the American College of Sports Medicine Annual Meeting (59 participants). In the discussion, stakeholders outlined both facilitators of (e.g., commercial return on investment in device quality, lucrative research partnerships, and transparent and multilevel evaluation of device quality) and barriers (e.g., competitive advantage conflict, lack of flexibility in previously developed devices) to participation in guiding standards. There was general agreement to adopt Keadle et al.'s standard pathway for testing devices (i.e., benchtop, laboratory, field-based, implementation) without consensus on the prioritization of these steps. Overall, there was enthusiasm not to add prescriptive or regulatory steps, but instead create a networking hub that connects companies to consumers and researchers for flexible guidance navigating the heterogeneity, multi-tiered development, dynamicity, and nebulousness of the CSFW field.

Exploring Sleep Health in Young Adults with Type 1 Diabetes

The purpose of this qualitative descriptive study was to describe the sleep health goals in 35 young adults age 18-30 years with type 1 diabetes (T1D). We reviewed clinician sleep reports generated from wrist-worn actigraphs with participants during an in-depth semistructured telephone interview. Interviews were audio-recorded then transcribed verbatim. We performed a constant comparison method for content analysis using NVivo^TM. The following two overarching health goals are identified: (a) promoting sleep (quantity, quality, hygiene, bedtime/waketime) and (b) improving diabetes self-management (time in range, sleep and glucose monitoring, and diet). Young adults in the study readily generated goals after visualizing their sleep reports. Sleep data visualization and debriefing is an effective strategy to elicit health goals for young adults with T1D. Supporting young adults with T1D to achieve their health goals for sleep promotion and diabetes self-management is a promising direction for improved sleep and consequently the attainment of glycemic targets.

Evaluation of Web-Based and In-Person Methods to Recruit Adults With Type 1 Diabetes for a Mobile Exercise Intervention: Prospective Observational Study

BACKGROUND

Our clinical trial of a mobile exercise intervention for adults 18 to 65 years old with type 1 diabetes (T1D) occurred during COVID-19 social distancing restrictions, prompting us to test web-based recruitment methods previously underexplored for this demographic.

OBJECTIVE

Our objectives for this study were to (1) evaluate the effectiveness and cost of using social media news feed advertisements, a clinic-based approach method, and web-based snowball sampling to reach inadequately active adults with T1D and (2) compare characteristics of enrollees against normative data.

METHODS

Participants were recruited between November 2019 and August 2020. In method #1, Facebook and Instagram news feed advertisements ran for five 1-to-8-day windows targeting adults (18 to 64 years old) in the greater New Haven and Hartford, Connecticut, areas with one or more diabetes-related profile interest. If interested, participants completed a webform so that the research team could contact them for eligibility screening. In method #2, patients 18 to 24 years old with T1D were approached in person at clinical visits in November and December 2019. Those who were interested immediately completed eligibility screening. Older patients could not be approached due to clinic restrictions. In method #3, snowball sampling was conducted by physically active individuals with T1D contacting their peers on Facebook and via email for 48 days, with details to contact the research staff to express interest and complete eligibility screening. Other methods referred participants to the study similarly to snowball sampling.

RESULTS

In method #1, advertisements were displayed to 11,738 unique viewers and attracted 274 clickers (2.33%); 20 participants from this group (7.3%) volunteered, of whom 8 (40%) were eligible. Costs averaged US $1.20 per click and US $95.88 per eligible volunteer. Men had lower click rates than women (1.71% vs 3.17%; P<.001), but their responsiveness and eligibility rates did not differ. In method #2, we approached 40 patients; 32 of these patients (80%) inquired about the study, of whom 20 (63%) volunteered, and 2 of these volunteers (10%) were eligible. Costs including personnel for in-person approaches averaged US $21.01 per inquirer and US $479.79 per eligible volunteer. In method #3, snowball sampling generated 13 inquirers; 12 of these inquirers (92%) volunteered, of whom 8 (67%) were eligible. Incremental costs to attract inquirers were negligible, and total costs averaged US $20.59 per eligible volunteer. Other methods yielded 7 inquirers; 5 of these inquirers (71%) volunteered, of whom 2 (40%) were eligible. Incremental costs to attract inquirers were negligible, and total costs averaged US $34.94 per eligible volunteer. Demographic overrepresentations emerged in the overall cohort (ie, optimal glycemic control, obesity, and low exercise), among those recruited by news feed advertisements (ie, obesity and older age), and among those recruited by snowball sampling (ie, optimal glycemic control and low exercise).

CONCLUSIONS

Web-based advertising and recruitment strategies are a promising means to attract adults with T1D to clinical trials and exercise interventions, with costs comparing favorably to prior trials despite targeting an uncommon condition (ie, T1D) and commitment to an intervention. These strategies should be tailored in future studies to increase access to higher-risk participants.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04204733; https://clinicaltrials.gov/ct2/show/NCT04204733.

Circadian characteristics of the rest-activity rhythm, executive function, and glucose fluctuations in young adults with type 1 diabetes

Circadian alignment is an important element in individual health, and one behavioral marker, rest-activity rhythm, could influence self-management in young adults with type 1 diabetes (T1D). Little is known about the rest-activity rhythms, executive function, and glycemia among young adults with type 1 diabetes (T1D). The purpose of this study was to evaluate parametric and nonparametric circadian characteristics of the rest-activity rhythm and the associations between these variables, sleep-wake behavior, executive function, and glycemia among young adults with T1D. Young adults with T1D, recruited from diabetes clinics, wore wrist actigraphs and a continuous glucose monitor (CGM) concurrently for 6-14 days. Participants completed a 3-minute Trail Making Test on paper and electronic questionnaires - 8-item PROMIS v1.0 Emotional Distress Scale, 17-item Diabetes Distress Scale, including twice-daily Pittsburgh sleep diaries. Cosinor and nonparametric analyses were used to compute the rest-activity rhythm parameters, and linear regression modeling procedures were performed to determine the associations among the study variables. The sample included 46 young adults (mean age 22.3 ± 3.2; 32.6% male; 84.8% non-Hispanic White, HbA1c mean 7.2 ± 1.1%, BMI mean 27.0 ± 4.4 kg/m²). A number of parametric associations were observed between a stronger rhythm, better objective sleep-wake characteristics, and less daytime sleepiness. Nonparametric circadian parameters were significantly associated with several outcomes: a stronger rhythm adherence (higher inter-daily stability) with better objective sleep-wake characteristics, better executive function, lower diabetes distress, less hyperglycemia risk, and more time spent in hypoglycemia/hypoglycemia risk; and a more robust rhythm (higher relative amplitude) with better objective sleep-wake characteristics and more time spent in hypoglycemia/higher hypoglycemia risk. Future work should be directed at designs that test causality, such as interventions directed at the strength and stability of rest-activity rhythms, for the potential to improve glucoregulation and other diabetes outcomes.

Sleep-wake characteristics, daytime sleepiness, and glycemia in young adults with type 1 diabetes

STUDY OBJECTIVES

The purpose of this study was to describe objective sleep-wake characteristics and glycemia over 7 - 14 days in young adults with type 1 diabetes (T1D). Additionally, person level associations among objective sleep-wake characteristics (total sleep time, sleep variability, and sleep fragmentation index), daytime sleepiness, and glycemia (glycemic control and glucose variability) were examined.

METHODS

In this cross-sectional study, objective sleep-wake characteristics were measured via actigraphy and glucose variability via continuous glucose monitoring (CGM) over 6-14 days. At baseline, participants completed a psychomotor vigilance test (PVT), Trail Making Test, and questionnaires on daytime sleepiness, sleep quality, and sleep disturbance including sleep diaries.

RESULTS

Forty-six participants (mean age 22.3 ± 3.2 years) wore a wrist actigraph and CGM concurrently for 6-14 days. Greater sleep variability was directly associated with greater glucose variability (mean of daily differences) (r = 0.33, p = .036). Higher daytime sleepiness was directly associated with greater glucose variability (mean of daily differences) (r = 0.50, p = .001). The association between sleep variability and glucose variability (mean of daily differences) was no longer significant when accounting for daytime sleepiness and controlling for T1D duration (p > .05). A higher sleep fragmentation index was associated with greater glucose variability (B = 1.27, p = .010, pr² = .40) after controlling for T1D duration and accounting for higher daytime sleepiness.

CONCLUSIONS

Sleep-wake variability, sleep fragmentation, daytime sleepiness, and the associations with glycemia are new dimensions to consider in young adults with T1D. Sleep habits in this population may explain higher glucose variability and optimizing sleep may improve overall diabetes management.

643 Rest Activity Rhythms, Symptom Burden, and Glucose Variability in Young Adults with Type 1 Diabetes

Introduction

Circadian alignment is an important element in individual health, and one behavioral marker, rest-activity rhythm (RAR), may influence disease management in young adults with type 1 diabetes (T1D). Thus, in this descriptive study, we examined whether circadian rhythm is correlated with symptoms (emotional and diabetes distress, and diabetes physical symptom burden) and glucose variability in young adults with T1D.

Methods

Using convenience sampling, young adults with T1D underwent concurrent actigraphy and continuous glucose monitoring for 6–14 days to generate the following RAR parameters: (MESOR, amplitude, acrophase, and circadian quotient) and glucose variability indices (coefficient of variation and time in range). Participants completed the 8-item Epworth Sleepiness Scale, 8-item PROMIS v1.0 Emotional Distress Scale, 17-item Diabetes Distress Scale, and 34-item Diabetes Symptom Checklist-Revised. Cosinor analysis was used to compute the RAR parameters and linear regression modeling procedures were performed to determine the associations among the study variables.

Results

The sample included 46 young adults (mean age 22.3±3.2; 32.6% male; 84.8% non-Hispanic White, A1C mean 7.2±1.1%, BMI 27.0±4.4 kg/m2). A more robust rhythm (higher amplitude) was associated with a lower diabetes symptom burden (ß=-0.31, p=.035). A higher circadian quotient was associated with less daytime sleepiness (ß=-0.41, p=.004). All associations between the RAR parameters and symptom measures remained statistically significant (p&lt;.05) after adjustment for sex and BMI. The associations between the RAR parameters and glucose variability indices were not significant.

Conclusion

RAR was associated with daytime sleepiness, as well as symptom burden in young adults with T1D even after consideration of sex and BMI. Future investigators should clarify the causality of these associations and the potential for improving the strength and stability of RAR in the mitigation of daytime sleepiness and symptoms.

Support (if any)

This research is or was partially supported by grants from the American Academy of Sleep Medicine (220-BS-19), National Institute of Nursing Research (K99NR018886 & T32NR0008346), Sigma Theta Tau International, and Dexcom provided continuous glucose monitors (G4) free of charge for participants who did not have a device.

Ecological momentary assessment for health behaviors and contextual factors in persons with diabetes: A systematic review

AIM

The objective of this systematic review was to summarize the ecological momentary assessment (EMA) methodology and associations between EMA-measured psychosocial, contextual factors and diabetes self-management.

METHODS

The inclusion criteria were: research of EMA and diabetes self-management behaviors such as glucose checks, administration of insulin and eating-and dietary intake behaviors among persons with diabetes. A comprehensive search of several databases was conducted across all dates until July 2020.

RESULTS

A modified Checklist for Reporting EMA Studies was used to assess the quality of studies. Among the ten included studies, participants were predominantly White adolescents with type 1 diabetes (T1D) and type 2 diabetes was studied in two studies. Time-varying, psychosocial contexts such as negative affect or negative social interaction were associated with missed insulin injection and poor adherence to glucose check. More preceding psychological stress was associated with more calorie intake from snacks or binge eating behaviors. Mornings were the most challenging time of day for adherence to diabetes self-management among adolescents with T1D. Intentional insulin withholding was more common in the afternoon in adults with T1D.

CONCLUSIONS

EMA has potential clinical utility in the assessment of diabetes self-management and in the development of timely and individualized diabetes interventions.

Daily variations in sleep and glucose in adolescents with type 1 diabetes

OBJECTIVE

We used multilevel models (MLMs) to determine person (between-persons) and day level (within-person) associations between glucose variability indices and sleep characteristics in adolescents with type 1 diabetes (T1D).

METHODS

Adolescents with T1D (Mean age 13.4 ± 1.8 years; 37.8% male; mean HbA1c 8.2 ± 1.2%, 66 mmol/mol) monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and a continuous glucose monitor (CGM) (their own or a provided, blinded CGM). Glucose variability indices included J index, coefficient of variation, low and high blood glucose risk indices (LBGI and HBGI), time in range, and sleep characteristics, including bedtime, wake time, total sleep time, sleep efficiency, wake after sleep onset, awakenings, and sleep fragmentation index.

RESULTS

More overall glucose variability was associated within person, more sleep disruptions (more awakenings and more fragmentation) or poorer sleep in our study (earlier wake time or longer wake after sleep onset). Also, more time spent in hypoglycemia <70 mg/dL and a higher LBGI was associated within person with earlier wake time indicating poorer sleep. However, a lower LBGI was associated with a later between-persons wake time.

CONCLUSIONS

Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person association between habitual short sleep duration and glucose variability. Providers should regularly assess sleep habits in adolescents as a way to improve glycemic control. Targeting a euglycemic range overnight is also important to promote better sleep and to decrease sleep disruptions.

A systematic review and meta-analysis of behavioral sleep interventions for adolescents and emerging adults

In the United States, more than two-thirds of adolescents and one-third of emerging adults report habitual short sleep duration, which is a known risk factor for psychological distress. The primary aim of this systematic review and meta-analysis was to evaluate the effect of behavioral sleep-promoting interventions on the sleep characteristics (e.g., total sleep time and sleep efficiency) of adolescents and emerging adults (aged 12-25 y) who do not have a sleep disorder. The secondary aim was to determine the effect of behavioral sleep-promoting interventions on psychological distress. Multiple electronic databases were searched for relevant randomized controlled trials (RCTs) published in English. Fourteen RCTs were included in the qualitative synthesis (N = 932), seven were included in the meta-analysis (n = 711) to address the primary aim, and three (n = 253) were included to address the secondary aim. The pooled standardized mean difference for sleep-promoting interventions after treatment for total sleep time was 34.92 min (95% CI: 8.70, 61.14). Sleep-promoting interventions had no significant effect on sleep efficiency. More RCTs that involve adolescents and emerging adults are needed to determine the effect of sleep-promoting interventions on reducing psychological distress in this high-risk age group.

Sleep, self-management, neurocognitive function, and glycemia in emerging adults with Type 1 diabetes mellitus: A research protocol

Type 1 Diabetes (T1D) affects 1.6 million Americans, and only 14% of emerging adults ages 18-25 years achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, including habitual short sleep duration (<6.5 hr total sleep time and high within-person variability in total sleep time), is associated with poorer glycemic control. Emerging adults with T1D have a more pronounced sleep extension on weekends compared with matched controls, consistent with sleep deficiency; however, associations among sleep variability and glycemic control have not been explored in this population. Sleep deficiency may affect the complex higher-order neurocognitive functioning needed for successful diabetes self-management (DSM). We report the protocol for an ongoing study designed to characterize sleep and the associations among sleep deficiency, neurocognitive function, DSM, diabetes quality of life, and glycemia among a sample of 40 emerging adults with T1D. We monitor sleep via wrist-worn actigraphy and glucose via continuous glucose monitoring concurrently over 14 days. We are collecting data on self-report and objective sleep, a 10-min psychomotor vigilance test on a PVT-192 device, a 3-min Trail Making Test on paper, and questionnaires, including twice-daily Pittsburgh sleep diaries using Research Electronic Data Capture (REDCap)^TM . Results from this study will be used to support the development and testing of the efficacy of a tailored sleep self-management intervention that may improve total sleep time, sleep variability, neurocognitive function, DSM, glycemic control, and glucose variability among emerging adults with T1D.

Sleep and Glycemia in Youth With Type 1 Diabetes

INTRODUCTION

Short sleep duration and quality are problems for many youth, and are associated with difficulties in executive function. Our purpose was to describe subjective and objective sleep characteristics and their associations with executive function, stress and coping, adjustment, and self-management in youth with type 1 diabetes (T1D).

METHOD

Youth with T1D (N = 40; mean age, 13.4 ± 1.9 years; 60% female; 77.1% non-Hispanic white; diabetes duration, 7.1 ± 4.6 years; and hemoglobin A1c, 8.2 ± 1.2%) wore an actigraph and a continuous glucose monitor for 3-7 days and completed questionnaires. Descriptive and bivariate analyses were conducted.

RESULTS

Sleep variability was associated with stress and depressive symptoms, as well as more glucose variability. Consistent rest-activity rhythm timing was associated with fewer trait anxiety symptoms. Robust rhythms were associated with better diabetes self-management.

DISCUSSION

Providers should routinely assess sleep habits in youth, especially those with T1D. Improving consistency in sleep timing and sleep duration may be a potential therapeutic target to improve diabetes clinical outcomes.

Facilitators and Barriers of Sleep in Young Adults With Type 1 Diabetes

PURPOSE

The purpose of this study was to explore the perceived facilitators and barriers for obtaining sufficient sleep in young adults with type 1 diabetes (T1D).

METHODS

A qualitative descriptive approach was used to generate data. In-depth semi-structured interviews with 30 young adults with T1D (66.7% female, mean age = 22.1 years) were conducted. Interviews were transcribed verbatim and coded using NVivo.

RESULTS

Young adults with T1D reported feeling challenged at bedtime and overnight by the demands of a complex disease management regimen. General and diabetes-specific barriers and facilitators to obtaining sufficient sleep were the overarching themes in the present study. Young adults perceived that electronic device use was a facilitator for relaxation before bed and a barrier to sleep by some participants. Delays in bedtime or disruptions in sleep were common diabetes-specific barriers.

CONCLUSIONS

When designing sleep-promoting interventions for young adults with T1D, researchers should consider diabetes-specific challenges and solutions in addition to those present in the general young adult population.

1005 Characterizing Sleep and Glycemia in Emerging Adults with Type 1 Diabetes

Introduction

Type 1 Diabetes (T1D) affects 1.25 million Americans, and only 14% of emerging adults (ages 18-30 years) achieve targets for glycemic control (A1C &lt; 7.0%). Sleep deficiency, less than 6.5 hours total sleep time (TST), is associated with poorer glycemic control.

Methods

Emerging adults with T1D wore a wrist actigraph and their own or provided continuous glucose monitor (CGM) concurrently 24 hours/day for 6-8 days. Participants completed a 10-minute psychomotor vigilance test (PVT) on a device, 3-minute Trail Making Test on paper, and questionnaires including twice daily Pittsburgh sleep diaries in Research Electronic Data Capture (REDCap). TST, sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), and sleep fragmentation index (SFI) were determined via actigraphy, glycemic control via A1C, and glucose variability via CGM. The purpose of this descriptive study was to explore associations between TST, sleep variability (SD of TST), neurocognitive function (psychomotor vigilance and executive function) and diabetes outcomes (glycemia and distress).

Results

The sample included 36 emerging adults (mean age 22.8±3.1; 30.6% male; 91.7% White, 86.1% non-Hispanic; A1C mean 7.1±1.0%, BMI 27.3±4.8 kg/m2). Mean TST was 7.1±1.2 hours, SOL was 19.7±13.5 minutes, SE was 85.5±4.6%, WASO was 34.7±18.2 minutes, and SFI was 17.7±6.2. Shorter TST was associated with more severe sleepiness (r=-0.48,p=0.004) and more diabetes distress (r=-0.37, p=0.03). More sleep variability was associated with more severe sleepiness (r=0.36, p=0.03), longer response times (RT) ≥ 500ms (rho=0.39, p=0.02) measured via PVT, more nocturnal glucose variability (r=0.38, p=0.04), greater mean daily differences in glucose levels (r=0.42, p=0.02). Shorter mean RT was associated with more time in glucose range (rho=-0.37, p=0.04).

Conclusion

Improving TST and sleep variability are potential therapeutic targets to improve glucoregulation in this high-risk population. Researchers should consider within-person multi-level modeling to inform our understanding of the true nature of the sleep-glucose association in emerging adults with T1D.

Support

T32 NR0008346, Sigma Theta Tau International, Dexcom provided continuous glucose monitors (G4) free of charge for participants who did not have their own device.

0927 Variations in Sleep and Glucose in Adolescents with Type 1 Diabetes

Introduction

The association between short sleep duration and poorer glycemic control in adolescents ages 10-16 with type 1 diabetes (T1D) is well established. Researchers have used cross-sectional, between-subjects’ methods, with limited focus on the potential intraindividual variation among these variables. The purpose of this analysis was to examine the within person associations between glucose variability indices (J index, low/high blood glucose index, time in range) and sleep characteristics (bedtime, waketime, total sleep time, sleep efficiency, wake after sleep onset [WASO], awakenings, and sleep fragmentation index) in adolescents with T1D.

Methods

Adolescents monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and either their own continuous glucose monitor (CGM) or a provided blinded CGM. General linear mixed models (GLMM) were used to determine within-person and day level associations.

Results

The sample included 38 adolescents (M age 13.4±1.8; 37.8% male; M A1C 8.2±1.2%). Average glucose levels were controlled in all GLMMs. Adolescents had earlier waketimes on days when more time was spent in hypoglycemia &lt;70mg/dL (β=-0.15, p&lt;0.001). At the person level, adolescents had greater WASO with more % time spent in severe hypoglycemia &lt;54mg/dL with more severe low blood glucose indices (β=0.35, p&lt;0.01 and β=0.34, p&lt;0.01 respectively). At the daily level, adolescents had greater WASO (β=0.20, p=0.01) and more awakenings (β=0.16, p=0.04) on the days they had more overall glucose variability (J index) and more severe high blood glucose indices (β=0.17, p=0.04), but were less likely to have more % time in hypoglycemia (β=-0.15, p=0.02).

Conclusion

Glucose variability was positively associated with poor sleep (e.g., WASO and awakenings) in adolescents with T1D both at the daily and intraindividual level. Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person associations between habitual short sleep duration and glucose variability.

Support

NINR T32NR0008346 & P20NR014126, Medtronic MiniMed provided CGMs at a discounted rate for the study.

End-of-Life Nursing Knowledge Among Nursing Students

BACKGROUND

The U.S. health care system is poorly designed to meet the needs of patients at the end of life (EOL) and their families. Nursing students often have reported feeling inadequate to provide EOL care.

METHOD

Following an EOL simulation, reflective journals were collected from junior and senior nursing students and analyzed for themes using qualitative content analysis. The condensed meaning units were abstracted into codes based on Carper's fundamental patterns of knowing.

RESULTS

Thirty-one junior and senior nursing students (mean age, 21.04 ± 0.52 years, 96.2% female) in a baccalaureate program participated in the study. The broad themes of student reflections included empirics (theoretical or natural historical) aesthetics (transformative nursing action), personal (interpersonal process of nurse-patient interaction), and ethics (emotion influences actions).

CONCLUSION

Student perception and participation in all roles contributes to the gestalt of the experience of a highly emotional EOL simulation for both students and faculty. [J Nurs Educ. 2020;59(3):154-157.].

Differences in hope, core self-evaluations, emotional well-being, and health risk behaviors in freshman university students

The purpose of this cross-sectional anonymous survey study was to explore differences in hope, core self-evaluations (CSE), emotional well-being, health risk behaviors, and academic performance by gender, race, and social desirability in a sample of freshman university students. Four hundred and ninety-five freshmen ages 18 to 21 (M age 18.4), 67% female attending a large public university in the Northeast participated in the study. A Health Risk Behavior Score, with scores ranging from 3 to 9, was calculated by creating risk categories for drug use, alcohol use, and sexual risk-taking. Hope and health risk behaviors did not differ by gender, however, men reported higher CSE and emotional well-being. There were racial differences in hope, CSE, emotional well-being, and health risk behaviors. Nurses and researchers should consider gender and racial differences when designing or implementing hope interventions. Future researchers should compare their findings with ours for patterns or convergence and divergence and aim for larger representative samples of nonwhite groups. These are necessary next steps to advance the understanding of the role hope may play in promoting mental health among diverse college students.

Violence exposure, conflict, and health outcomes in inner-city African American adolescents

PURPOSE

To examine relationships among community and school violence exposure, parent-adolescent conflict, coping style, and self-reported health in a sample of 432 high-risk, inner-city African American adolescents at age 14 years.

DESIGN AND METHODS

Multiple regression and principal component analysis were used to analyze the secondary data. After controlling for multiple covariates (eg, sex, age, blood lead levels, and socioeconomic status), both violence exposure and posttraumatic stress symptoms (PTSS) were related to health outcomes. The survey of exposure to community violence, the safe-school survey, and the conflict tactics scale were used to measure community violence, school violence, and parent-adolescent conflict. Coping was evaluated using the general coping scale. The child health illness profile-adolescent edition was used to obtain self-reported health measures, and the clinician-assisted PTSD scale was used to measure PTSS.

RESULTS

Higher exposure to community violence was associated with less emotional comfort, less family involvement, higher individual risk, and poorer academic and work performance. Parent-adolescent conflict predicted less physical and emotional comfort and poorer home safety and health.

CONCLUSIONS

Our findings suggest that it is important to evaluate both violence exposure and the responses to the exposure, which can include both PTSS and diverse coping strategies.

Nursing student perceptions of hope in children: A qualitative descriptive study

Hope has been linked to positive health outcomes in the literature. Hope is abstract, multidimensional, future oriented, and occurs cognitively making it difficult to assess in children. Most of the research on hope has been conducted with adults and adolescents. Therefore, it is essential to analyze the concept of hope in children to provide nurses with tools to identify hope behaviors in children. The aim of this qualitative descriptive study was to describe hope behaviors in children from a nursing student perspective. Data were gathered from three focus groups (N = 19) of nursing students enrolled in a pediatric clinical rotation using a semistructured interview technique. Three themes of hope behaviors emerged from the three focus groups and were (a) future oriented, (b) goal oriented-getting up and doing things, and (c) pathways thinking processes-getting from point A to point B. Health care providers should consider hope behavioral cues, which can warrant interventions to increase hope in their young patients. Current findings demonstrate the need for the development of hope interventions that involve younger patients, thereby making their effects more sustainable across the lifespan.

Sleep characteristics in young adults with type 1 diabetes

Only 14% of young adults with Type 1 Diabetes (T1D) achieve targets for glycemic control (HbA1C < 7.0%), with deterioration over time. Complex cognitive processes required to manage glycemia are vulnerable to sleep deficiency. Using Whittemore and Knafl's approach, we conducted an integrative review of research literature on sleep characteristics and glycemia in these young adults. Quality was assessed using the Mixed Methods Appraisal Tool (v. 2011). Multiple databases were searched for articles published in English in peer-reviewed journals from 2003 to 2018, using search terms 'sleep' and 'T1D' with age limiters 18-40. Of 218 studies initially retrieved, 17 original studies met the inclusion criteria. The following themes were identified in young adults with T1D: (1) They had poorer objective and subjective sleep quality, more variability, and impaired awakening response to hypoglycemia compared with controls; (2) They had poorer glycemic control that was associated with shorter sleep duration, poorer sleep quality, and less time in deep sleep; and (3) Hypoglycemia negatively impacted diabetes management, sleep quality, and next day functioning. Sleep deficiency, as indicated by short sleep duration is associated with a range of negative health outcomes for people with T1D; therefore, optimizing sleep should be a priority in practice and research.

Fatigue Among Adults With Type 1 Diabetes Mellitus and Implications for Self-Management: An Integrative Review

Purpose The aim of this review was to integrate empirical and theoretical literature on fatigue among adults with type 1 diabetes mellitus (T1DM). A methodological review using an integrative approach was used. Databases MEDLINE via Pubmed, CINAHL, PsycINFO, and Science Direct were searched for peer-reviewed articles published in English from 2007-2017, using the following search terms and Boolean operators: "Type 1 Diabetes" and "Fatigue." Of 199 articles initially retrieved, 14 were chosen for inclusion. These articles included 13 quantitative (7 cross-sectional, 2 cohort, 2 secondary data analyses, 2 experimental) and 1 qualitative phenomenology. Fatigue was identified as one of the most troublesome symptoms reported in persons with T1DM. Four main themes emerged: fatigue in T1DM is multidimensional and related to psychological, physiological, situational, and sociodemographic factors. Conclusions Fatigue is considered a classic symptom of hyperglycemia; however, there were minimal data to support the theory that fatigue is related to hyperglycemia or hypoglycemia. Studies on fatigue among persons with T1DM are limited to small samples and cross-sectional designs with few randomized controlled trials addressing fatigue and diabetes-related symptoms. Evidence is conflicting regarding the onset of fatigue among persons with T1DM and the relationship between fatigue and diabetes duration. The prevalence of fatigue is likely influenced by disease physiology, psychological stress, and lifestyle factors, but more research is needed to confirm these relationships as causal inference is unclear.

Hope and Mental Health in Young Adult College Students: An Integrative Review

One in five young adults are diagnosed with a mental illness and many experience psychological distress during their first year of college due to new pressures in academia. The purpose of the current integrative review was to describe and synthesize hope and mental health in young adults in college. PubMed, CINAHL, and PsycINFO were searched for articles published in peer-reviewed journals from 2011-2016. Twenty empirical works were selected for inclusion and five themes emerged: (a) Hope is Associated With Improved Coping, (b) Hope is Associated With Improved Well-Being, (c) Hope is a Moderator Between Depression and Negative Life Events, (d) Hope is a Protective Factor in Suicide, and (e) Hope is a Factor in Healthy Behavior Engagement. Hope may be a protective factor in suicide and negative, self-deprecatory thinking. Further research is needed to determine if increasing hope in young adult college students will decrease the risk of suicide and non-suicidal self-injury, increase healthy behavior engagement, and improve coping and well-being. [Journal of Psychosocial Nursing and Mental Health Services, 55(2), 28-35.].

The Role of Hope for Adolescents with a Chronic Illness: An Integrative Review

Hope is a human strength essential for adolescents' enduring and coping with chronic illness however, the role of hope is not well understood in this population.

OBJECTIVES

This integrative review describes what is currently known about the role of hope in adolescents with a chronic illness.

METHOD

A methodological review using an integrative approach by R. Whittemore and K. Knafl (2005) was performed.

DATABASES

MEDLINE via Pubmed; CINAHL; PyscINFO and Google scholar were searched for articles published in peer-reviewed journals from 1995 to 2015, using search terms 'hope and chronic illness' with age limiters for all except Google scholar (title search of "hope and adolescents").

RESULTS

Of the 197 studies initially retrieved: a total of 27 quantitative studies, 8 qualitative studies and 19 theoretical works were selected for review. Seven themes emerged including that hope: (i) promotes health (ii) facilitates coping and adjustment, (iii) enhances quality of life, (iv) is essential in purpose in life and illness (v) improves self-esteem, (vi) is an important factor in resilience and (vii) affects maturation. Persons reporting higher levels of hope find multiple routes to goals, view setbacks as challenges, and better manage psychological symptoms.

DISCUSSION

Although theory and a limited body of empirical research to date suggest a link between hopeful thinking and physical health, the specific mechanisms remain unclear. As hope is linked to resilience, further research should explore whether adolescents with higher hope return to baseline faster than their lower hope counterparts.

Nighttime bracing with the Providence brace in adolescent girls with idiopathic scoliosis

STUDY DESIGN

A prospective study was conducted of 102 consecutive female patients with adolescent idiopathic scoliosis. Those patients with Risser 0, 1, and 2 met the criteria for inclusion and were treated only with the Providence brace.

OBJECTIVES

To report the authors' experience with a hypercorrective nighttime brace and to evaluate the results with respect to risk factors for progression. Second, the study compares results with expectations from the natural history as reported by others.

SUMMARY OF BACKGROUND DATA

Compliance with full-time brace treatment for adolescent idiopathic scoliosis has been a problem. Since the introduction of the Milwaukee brace, alternatives such as low-profile braces, reduced wearing schedules, and nighttime only bracing have been tried. However, many factors influence the success or failure besides compliance. These include in-brace correction, brace design, and the orthotist's skills. This is the first report of the results of treatment with a new nighttime brace that is made with CAD/CAM technology that can achieve higher initial in-brace corrections than other reported methods.

METHODS

Results were analyzed with respect to curve size, curve pattern, maturity, and level of the primary curve apex. Both compliant and noncompliant patients were included in the analysis. A univariate analysis was done on those factors thought to influence success with bracing using the Pearson chi2 test.

RESULTS

The average initial in-brace correction with a supine radiograph was 96% for major curves and 98% for minor curves. Seventy-five patients (74%) did not progress >5 degrees and 27 patients (26%) progressed > or =6 degrees or went on to surgery. Twenty-nine percent of Risser 0 or 1 patients progressed and 17% of patients Risser 2 progressed. The risk of progression anticipated by natural history data, which included all curve patterns, was 68% for Risser 0 and 1 and 23% for Risser 2. Risser 3 and 4 patients were excluded from the study. Seventy-six percent of patients with curve apexes between T8 and L1 had successful outcomes using the Providence brace. This is compared with a 74% success rate in the prospective Scoliosis Research Society study of patients wearing a thoraco lumbar sacral orthosis for 16 hours per day with curve apexes between T8 and L1. With the Providence brace, 63% of thoracic curves and 65% of double curves were successful. Ninety-four percent of lumbar curves and 93% of thoracolumbar curves were successful.

CONCLUSION

Excellent initial in-brace correction of adolescent idiopathic scoliosis was observed with this computer-designed and manufactured recumbent brace. Patients with high apex curves cephalad to T8 (n = 31) had a success rate of 61% compared with a success rate of 79% (n = 71) if the apex was at or below T9. Compared with previous natural history and the prospective study data, the Providence brace is effective in preventing progression of adolescent idiopathic scoliosis for curves <35 degrees. It was effective for larger curves with a low apex. The authors' experience with patients with curves >35 degrees (n = 8) is too small to validate its effectiveness for larger curves with a higher apex.