'Is insulin right for me?': Feasibility of a pilot randomised controlled trial and acceptability of a web-based intervention to reduce psychological barriers to insulin therapy among adults with type 2 diabetes

AIMS

Acceptable and accessible interventions are needed to address 'psychological insulin resistance', which is a common barrier to insulin uptake among adults with type 2 diabetes (T2D). Our aim was to test the feasibility of a randomised controlled trial (RCT) study design and acceptability of a theoretically grounded, psycho-educational, web-based resource to reduce negative insulin appraisals among adults with T2D.

METHODS

A double-blinded, parallel group, two-arm pilot RCT (1:1), comparing intervention with active control (existing online information about insulin). Eligible participants were Australian adults with T2D, taking oral diabetes medications.

EXCLUSION CRITERIA

prior use of injectable medicines; being 'very willing' to commence insulin. Primary outcomes: study feasibility (recruitment ease, protocol fulfilment, attrition, data completeness); secondary outcomes: intervention acceptability (intervention engagement, user feedback) and likely efficacy (negative Insulin Treatment Appraisal Scale [ITAS] scores at follow-up). Online surveys completed at baseline and 2 weeks.

RESULTS

During 4-week recruitment, 76 people expressed interest: 51 eligible and 35 enrolled (intervention = 17, control = 18; median[interquartile range] age = 62[53, 69] years; 17 women). Protocol fulfilment achieved by 26 (74%) participants (n = 13 per arm), with low participant attrition (n = 6, 17%). Intervention acceptability was high (>80% endorsement, except format preference = 60%). ITAS negative scores differed between-groups at follow-up (M diff = -6.5, 95% confidence interval: -10.7 to -2.4), favouring the intervention.

CONCLUSIONS

This novel web-based resource ("Is insulin right for me?") is acceptable and associated with a likely reduction in negative insulin appraisals, relative to existing resources. This pilot shows the study design is feasible and supports conduct of a fully powered RCT.

Web-based intervention to reduce psychological barriers to insulin therapy among adults with non-insulin-treated type 2 diabetes: study protocol for a two-armed randomised controlled trial of 'Is insulin right for me?'

INTRODUCTION

Psychological barriers to insulin therapy are associated with the delay of clinically indicated treatment intensification for people with type 2 diabetes (T2D), yet few evidence-based interventions exist to address these barriers. We describe the protocol for a randomised controlled trial (RCT) examining the efficacy of a novel, theoretically grounded, psychoeducational, web-based resource designed to reduce psychological barriers to insulin among adults with non-insulin treated T2D: 'Is insulin right for me?'.

METHODS AND ANALYSIS

Double-blind, parallel group RCT. A target sample of N=392 participants (n=196/arm) will be randomised (1:1) to 'Is insulin right for me?' (intervention) or widely available online resources (control). Eligible participants include adults (18-75 years), residing in Australia, currently taking oral hypoglycaemic agents to manage T2D. They will be primarily recruited via invitations and reminders from the national diabetes registry (from a purposefully selected sample of N≥12 000).

EXCLUSION CRITERIA

experience of self-administered injectable; previously enrolled in pilot RCT; 'very willing' to start insulin as baseline. Outcomes will be assessed via online survey at 2 weeks and 6 months. Primary outcome between-group: difference in mean negative Insulin Treatment Appraisal Scores (ITAS negative) at 2-week and 6-month follow-up.

SECONDARY OUTCOMES

between-group differences in mean positive insulin appraisals (ITAS positive) and percentage difference in intention to commence insulin at follow-up time points. All data analyses will be conducted according to the intention-to-treat principle.

ETHICS AND DISSEMINATION

Deakin University Human Research Ethics Committee (2020-073). Dissemination via peer-reviewed journals, conferences and a plain-language summary.

TRIAL REGISTRATION NUMBER

ACTRN12621000191897; Australian and New Zealand Clinical Trials Registry.

Playful Communication and Care: Exploring Child-Centred Care of Young Children With Type 1 Diabetes Through the Framework of Zone of Proximal Development

Introduction

Little is known about the psychosocial experiences and care needs of young children under the age of 7 years who have been diagnosed with type 1 diabetes. To address this knowledge gap, we examine children’s psychosocial care needs through the lens of child-centred care and the framework of Zone of Proximal Development.

Objectives

To explore current care practices for young children with diabetes and identify aspects of child-centred care already successfully integrated into current practice.

Method

Individual face-to-face, semi-structured interviews were conducted with 20 Healthcare Professionals, representing 11 of 17 paediatric diabetes clinics in Denmark.

Results

Our data provided valuable insights into existing child-centred practices. Our analysis identified practices covering four main themes: 1. Accommodating immediate emotional needs, 2. Putting children before diabetes, 3. Encouraging meaningful participation, 4. Playful communication.

Discussion

Healthcare Professionals provided child-centred care, largely through play-based approaches that make diabetes care meaningful and relevant. Such practices provide the scaffolding necessary to enable young children to gradually engage, comprehend and participate in their own care.

Open-source automated insulin delivery: international consensus statement and practical guidance for health-care professionals

Open-source automated insulin delivery systems, commonly referred to as do-it-yourself automated insulin delivery systems, are examples of user-driven innovations that were co-created and supported by an online community who were directly affected by diabetes. Their uptake continues to increase globally, with current estimates suggesting several thousand active users worldwide. Real-world user-driven evidence is growing and provides insights into safety and effectiveness of these systems. The aim of this consensus statement is two-fold. Firstly, it provides a review of the current evidence, description of the technologies, and discusses the ethics and legal considerations for these systems from an international perspective. Secondly, it provides a much-needed international health-care consensus supporting the implementation of open-source systems in clinical settings, with detailed clinical guidance. This consensus also provides important recommendations for key stakeholders that are involved in diabetes technologies, including developers, regulators, and industry, and provides medico-legal and ethical support for patient-driven, open-source innovations.

The Effect of Structured Exercise Compared with Education on Neuropathic Signs and Symptoms in People at Risk of Neuropathic Diabetic Foot Ulcers: A Randomized Clinical Trial

Background and Objectives: Lifestyle interventions such as exercise prescription and education may play a role in the management of peripheral neuropathy in people with diabetes. The aim of this study was to determine the effect of undertaking an exercise program in comparison with an education program on the signs and symptoms of peripheral neuropathy in people with diabetes at risk of neuropathic foot ulceration. Materials and Methods: Twenty-four adult participants with diabetes and peripheral neuropathy were enrolled in this parallel-group, assessor blinded, randomised clinical trial. Participants were randomly allocated to one of two 8-week lifestyle interventions, exercise or education. The primary outcome measures were the two-part Michigan Neuropathy Screening Instrument (MNSI) and vibratory perception threshold (VPT). Secondary outcome measures included aerobic fitness, balance and lower limb muscular endurance. Results: Participants in both lifestyle interventions significantly improved over time for MNSI clinical signs (MD: -1.04, 95% CI: -1.68 to -0.40), MNSI symptoms (MD: -1.11, 95% CI: -1.89 to -0.33) and VPT (MD: -4.22, 95% CI: -8.04 to -0.40). Although the interaction effects did not reach significance, changes in values from pre to post intervention favoured exercise in comparison to control for MNSI clinical signs (MD -0.42, 95% CI -1.72 to 0.90), MNSI clinical symptoms (MD -0.38, 95% CI -1.96 to 1.2) and VPT (MD -4.22, 95% CI -12.09 to 3.65). Conclusions: Eight weeks of exercise training or lifestyle education can improve neuropathic signs and symptoms in people with diabetes and peripheral neuropathy. These findings support a role for lifestyle interventions in the management of peripheral neuropathy.

Bump2Baby and Me: protocol for a randomised trial of mHealth coaching for healthy gestational weight gain and improved postnatal outcomes in high-risk women and their children

Background

Gestational diabetes (GDM) impacts 8–18% of pregnancies and greatly increases both maternal and child risk of developing non-communicable diseases such as type 2 diabetes and obesity. Whilst lifestyle interventions in pregnancy and postpartum reduce this risk, a research translation gap remains around delivering implementable interventions with adequate population penetration and participation. Impact Diabetes Bump2Baby is an implementation project of an evidence-based system of care for the prevention of overweight and obesity. Bump2Baby and Me is the multicentre randomised controlled trial investigating the effectiveness of a mHealth coaching programme in pregnancy and postpartum for women at high risk of developing GDM.

Methods

Eight hundred women will be recruited in early pregnancy from 4 clinical sites within Ireland, the UK, Spain, and Australia. Women will be screened for eligibility using the validated Monash GDM screening tool. Participants will be enrolled from 12 to 24 weeks’ gestation and randomised on a 1:1 basis into the intervention or control arm. Alongside usual care, the intervention involves mHealth coaching via a smartphone application, which uses a combination of synchronous and asynchronous video and text messaging, and allows for personalised support and goal setting with a trained health coach. The control arm receives usual care. All women and their children will be followed from early pregnancy until 12 months postpartum. The primary outcome will be a difference in maternal body mass index (BMI) of 0.8 kg/m² at 12 months postpartum. Secondary maternal and infant outcomes include the development of GDM, gestational weight gain, pregnancy outcomes, improvements in diet, physical activity, sleep, and neonatal weight and infant growth patterns. The 5-year project is funded by the EU Commission Horizon 2020 and the Australian National Health and Medical Research Council. Ethical approval has been received.

Discussion

Previous interventions have not moved beyond tightly controlled efficacy trials into routine service delivery. This project aims to provide evidence-based, sustainable support that could be incorporated into usual care for women during pregnancy and postpartum. This study will contribute evidence to inform the early prevention of non-communicable diseases like obesity and diabetes in mothers and the next generation.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12620001240932. Registered on 19 November 2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05892-4.

Diabetes Distress During COVID-19: Three Brief ‘Snapshot’ Surveys of Adults With Diabetes Calling the Australian National Diabetes Services Scheme Helpline

The aim of this study was to take ‘snapshots’ of how people with diabetes are feeling emotionally during the coronavirus disease 2019 (COVID-19) pandemic. Three ‘snapshot’ surveys were conducted during May 2020, August 2020 and April 2021, each over a two-week period. Adults (≥18 years) with diabetes calling the Australian Government’s National Diabetes Services Scheme Helpline (NDSS) were invited to participate. Those who accepted were asked three questions sourced/adapted from the Problem Areas in Diabetes scale. Responses were recorded on a 5-point scale (0=’not a problem’, 4=’serious problem’). Of interest were scores ≥2, indicating this was at least a ‘moderate problem’. The survey was administered by NDSS Helpline staff via telephone. Basic demographic and clinical data were collected. In total, 1,278 surveys were completed over the three ‘snapshots’ (1st N=449; 2nd N=414; 3rd N=415). Participants were aged (median[IQR]) 62[47,72] years, 56% were women, and 57% had type 2 diabetes. At the 3rd ‘snapshot’, 21% had received a COVID-19 vaccine. Our findings show that feeling at least moderately ‘burned out’ by the constant effort needed to manage diabetes is salient, and consistently experienced by adults with diabetes calling the NDSS Helpline at three timepoints during the coronavirus pandemic. Those who participated in the 3rd ‘snapshot’ survey were less likely to report that feeling ‘alone with their diabetes’ or ‘worrying about their diabetes because of the COVID-19 pandemic’ were moderate or serious problems for them. Except for younger adults, findings indicate that the easing of restrictions may mitigate some of the effects of the pandemic on diabetes-specific emotional problems, including feeling ‘burned out’, ‘alone’ with diabetes, and/or worried about diabetes due to COVID-19. Prospective data are needed to improve our understanding of the emotional impact of COVID-19 on people with diabetes and to inform when and how to target support for those who need it most.

National analysis of the Modified Monash Model, population distribution and a socio-economic index to inform rural health workforce planning

AIMS

To describe the population distribution and socio-economic position of residents across all states and territories of Australia, stratified using the 7 Modified Monash Model classifications. The numerical summary, and the methods described, can be applied by a variety of end users including workforce planners, researchers, policy-makers and funding bodies for guiding future investment under different scenarios, and aid in evaluating geographically focused programs.

CONTEXT

The Commonwealth Department of Health is transitioning to the Modified Monash Model to objectively describe geographical access. This change applies to the Rural Health Multidisciplinary Training Program, one of the Australian Government's key policies to address the maldistribution of the rural health workforce. Unlike the previously applied Australian Statistical Geography Standard-Remoteness Areas, a summary of the population in each Modified Monash Model classification is not available, nor is a socio-economic overview of the communities within these areas.

APPROACH

Spatial analysis of Australian Bureau of Statistics data (Modified Monash Model, population data and the Index of Relative Socio-economic Advantage and Disadvantage collected or derived from the 2016 census) at the Statistical Area 1-the smallest unit for the release of census data.

CONCLUSION

Linking the Modified Monash Model, a socio-economic index and granular population data at the national level highlights the disadvantage of many residents in small rural towns (Modified Monash 5). The Modified Monash Model does not exhibit a continuum of the largest population residing in the most accessible classification and the smallest population residing in the least accessible classification that is seen in the Australian Statistical Geography Standard-Remoteness Areas. Coupled with policy relevance, the advantage of using the Modified Monash Model as the basis for analysis is that it highlights areas that have both a critical mass of residents and differing levels of socio-economic advantage and disadvantage. This will help end users to target funding to those regions where there is potential to improve access to services for the greatest number of rural residents.

Shift work is associated with increased risk of COVID-19: Findings from the UK Biobank cohort

Despite the strong evidence on circadian rhythm disruption in shift workers and consequent increased vulnerability for infection, longitudinal association between shift work and COVID-19 infection is unexplored. In this study, data from UK Biobank participants who were tested for COVID-19 infection (16 March to 7 September 2020) were used to explore the link between shift work and COVID-19 infection. Using the baseline occupational information, participants were categorised as non-shift workers, day shift workers, mixed shift workers and night shift workers. Multivariable regression models were used to assess the association between shift work and COVID-19 infection. Among the 18,221 participants (9.4% positive cases), 11.2% were health workers, and 16.4% were involved in shift-work-based jobs. Ethnic minorities (18%) and people in night-shift-based jobs (18.1%) had a significantly higher prevalence of COVID-19 infection than others. Adjusted logistics regression model suggest that, compared with their counterparts, people employed in a night-shift-based job were 1.85-fold (95% CI: 1.42-2.41) more likely to have COVID-19 infection. Sensitivity analysis focusing on people working in a non-healthcare setting suggests that people in shift-work-based jobs had 1.81-fold (95% CI: 1.04%-3.18%) higher odds of COVID-19 infection than their counterparts. Shift workers, particularly night shift workers, irrespective of their occupational group, seem to be at high risk of COVID-19 infection. If similar results are obtained from other studies, then it would mandate to revisit the criteria for defining high-risk groups for COVID-19 and implementing appropriate interventions to protect people in shift-based jobs.

'Is Insulin Right for Me?' Development of a theory-informed, web-based resource for reducing psychological barriers to insulin therapy in type 2 diabetes

OBJECTIVE

To develop a theory and evidence-based web intervention to reduce psychological barriers towards insulin therapy among adults with non-insulin-treated type 2 diabetes (T2D).

METHODS

Salient psychological barriers towards insulin were identified from the literature and classified using the Theoretical Domains Framework (TDF). Relevant TDF domains were mapped to evidence-based behaviour change techniques (BCTs), which informed the content for each barrier. Acceptability was explored using cognitive debriefing interviews (n=6 adults with T2D).

RESULTS

'Is Insulin Right for Me' addresses eight barriers, phrased as common questions: Does insulin mean my diabetes is more serious? Do insulin injections cause complications? Is it my fault I need to inject insulin? Will I gain weight? Will injecting hurt? What about hypos? Will injecting insulin be a burden? What will others think of me? BCTs, including persuasive communication and modelling/demonstration, were delivered using appropriate methods (eg, demonstration of the injection process). Participant suggestions for improvement included clear and direct messages, normalising insulin and avoiding confronting images.

CONCLUSIONS

'Is Insulin Right for Me' is the first theory and evidence-based, web intervention designed to reduce psychological barriers towards insulin therapy for adults with T2D. Evaluation is needed to determine its impact on negative appraisals and receptiveness towards insulin.

Loddon Mallee healthcare worker COVID-19 study-protocol for a prospective cohort study examining the health and well-being of rural Australian healthcare workers during the COVID-19 pandemic

INTRODUCTION

The COVID-19 pandemic is creating immense psychosocial disturbance. While global, broad-based research is being conducted, little is known about the effects of the COVID-19 pandemic on health and well-being or how protective and resilience factors influence the human response in Australian rural and regional communities. Rural and regional communities often have less resources to deal with such public health emergencies and face additional environmental adversity. Healthcare workers, including those in rural and regional areas, have felt the immediate impacts of COVID-19 in a multitude of ways and these impacts will continue for years to come. Therefore, this study aims to describe and understand the impacts of the COVID-19 pandemic on the rural and regional healthcare workforce within the Loddon Mallee region, Victoria, Australia.

METHODS AND ANALYSIS

This prospective cohort of rural and regional healthcare workers will be recruited and followed over 3 years to examine the effects of the COVID-19 pandemic on their health and well-being. Self-administered online questionnaires will be administered every 6 months for a 36-month period. Multiple outcomes will be assessed; however, the primary outcomes are emotional health and well-being and psychological resilience. Emotional health and well-being will be measured using validated instruments that will assess multiple domains of the emotional health and well-being continuum.Linear and logistic regression and latent growth curve modelling will be used to examine the association between baseline and follow-up participant emotional health, well-being and resilience while adjusting for potentially time-varying confounding variables. Participant characteristics measured at baseline will also be tested for association with incident health, morbidity, mortality and health service utilisation outcomes at follow-up.

ETHICS AND DISSEMINATION

Ethical approval has been obtained through the Bendigo Health Human Research Ethics Committee. The study findings will be disseminated through international conferences, international peer-reviewed journals and social media.

TRIAL REGISTRATION NUMBER

ACTRN12620001269921.

Sleep trajectories and mediators of poor sleep: findings from the longitudinal analysis of 41,094 participants of the UK Biobank cohort

STUDY OBJECTIVES

To explore sleep trajectories and identify the risk factors and mediators of poor sleep in middle-aged adults.

METHODS

Group-based multi-trajectory modelling was applied to the three waves of sleep data the from UK Biobank cohort to identify latent trajectories of sleep and group characteristics. Self-reported sleep duration, sleep problems (based on insomnia symptoms, snoring and trouble waking up) and daytime sleepiness (based on daytime tiredness and sleepiness) were included in the trajectory analyses. Multinomial logistic regression and mediation analysis were used to identify the main factors associated with poor sleep.

RESULTS

Analysis of sleep data from 41,094 participants (51.9% females) with a median age of 57 years (interquartile range 50-62 years) identified three distinct trajectories of sleep: healthy sleepers (40.8%); borderline poor sleepers (31.6%); and poor sleepers (27.6%). Socio-economic disadvantage, ethnic minority background, shift work, unhealthy lifestyle, poor health, depressive symptoms and obesity were the main risk factors associated with poor sleep. Around a third of the total effect of socio-economic deprivation on poor sleep was mediated through depressive symptoms.

CONCLUSIONS

The distinct groups with differential risk for developing sleep issues and stable sleep trajectories highlight the non-transient nature of sleep issues. Early management of depressive symptoms can help in reducing the future burden of poor sleep. Due to the increased risk of poor sleep, people from socio-economically deprived groups, particularly females from ethnic minorities, should be the highest priority for interventions aiming to improve population sleep health.

The psychosocial experience and needs of children newly diagnosed with type 1 diabetes from their own perspective: a systematic and narrative review

AIM

To understand the psychosocial experience of children and identify their primary support needs following a type 1 diabetes diagnosis.

METHODS

A systematic review and narrative synthesis of the literature in this area was conducted.

RESULTS

A total of 32 studies were included in the review. At diagnosis, the majority of children experienced high distress, including grief, anxiety, anger, irritation and injection anxiety. The intensity of this reaction decreased rapidly over the following weeks. At diagnosis, rates of depressive symptoms, anxiety, stress disorders and suicidal ideation were elevated. The initial reaction tended to peak shortly after diagnosis and declined over the following year. Thereafter, symptoms of depression and anxiety appeared to increase once again, corresponding with the children's experience of diabetes management and implications as being more difficult and upsetting. Injection anxiety, distress and depressive symptoms persisted for a smaller group of children.

CONCLUSION

The initial high prevalence of depressive symptoms following diagnosis is transitional and should be regarded as a normal adaptive response. To facilitate this adaptive process, specific child-centred support should be prioritized as an integrated part of early diabetes care. Our findings point to five inter-related support needs following a type 1 diabetes diagnosis: (1) children need time to adjust to the diagnosis; (2) children need supportive relationships; (3) children need an opportunity for meaningful participation and appropriate protection; (4) children need to engage and explore; and (5) children need to feel supported, but not different.

Risk factors and outcomes of anxiety symptom trajectories in type 2 diabetes: the Fremantle Diabetes Study Phase II

AIM

To identify determinants and outcomes of 4-year trajectories of anxiety symptoms in a community-based cohort with type 2 diabetes.

METHODS

Some 1091 participants in the Fremantle Diabetes Study-Phase II with type 2 diabetes completed the Generalized Anxiety Disorder Scale at baseline and biennially for 4 years, in addition to psychological, biomedical and self-management measures. Latent growth mixture modelling identified trajectories of anxiety symptom severity, and regression models determined predictors of trajectory membership and associated outcomes.

RESULTS

Two distinct groups of participants were identified: those with continuously low-no anxiety symptoms (87%) and those with improving but consistently high anxiety symptoms (elevated anxiety; 13%). Higher HbA_1c and BMI, macrovascular complications and a history of generalized anxiety and/or major depressive disorder increased the risk of elevated anxiety. Elevated anxiety did not predict change in health-related outcomes over time. Elevated anxiety and depression symptoms were highly comorbid and those with both displayed the most persistent anxiety symptoms.

CONCLUSIONS

A subgroup of individuals with type 2 diabetes are at risk of persistently elevated anxiety symptoms. Routine monitoring of the severity of psychological symptoms over time in this population should facilitate earlier and more intensive mood management.

Psychosocial factors associated with HbA1c in adults with insulin pump-treated type 1 diabetes: a systematic review

AIMS

To identify currently available studies on the association between psychosocial factors and HbA_1c in adults with insulin pump-treated type 1 diabetes, by performing a systematic review of the literature.

METHODS

MEDLINE, Embase, CINAHL and PsycINFO were searched for original studies on the association between psychosocial factors and HbA_1c in ≥ 50 adult, non-pregnant, insulin pump users with type 1 diabetes.

RESULTS

The search resulted in 1777 unique records, of which eight were eligible for inclusion. All identified studies were observational, with sample sizes ranging from 51 to 214. Seven different psychosocial factors were investigated in the eight studies. Study analysis suggested that HbA_1c may be associated with diabetes numeracy and quality of life. There were no indications of associations between HbA_1c and fear of hypoglycaemia or self-efficacy. Results regarding associations between HbA_1c and coping style, diabetes distress and locus of control were inconsistent.

CONCLUSIONS

This systematic review summarizes the currently limited information on the association between psychosocial factors and HbA_1c during insulin pump therapy. The evidence base of the included studies was weak, and this review highlights the need for more research in these areas, with improved methodological and theoretical frameworks, including exploration of a broader spectrum of psychosocial variables and their potential association with HbA_1c and other metabolic outcomes. (PROSPERO International prospective register of systematic reviews registration no: CRD42020145705).

Twenty-five years of diabetes distress research

The term 'diabetes distress' first entered the psychosocial research vernacular in 1995, and refers to 'the negative emotional or affective experience resulting from the challenge of living with the demands of diabetes'. At first the proponents of the concept were hesitant in advocating that diabetes distress was a major barrier to individuals' self-care and management of diabetes. Since then, a burgeoning body of evidence, now including several systematic reviews of intervention studies, suggests that diabetes distress, in both type 1 and type 2 diabetes, across ages and in all countries and cultures where it has been studied, is common and can be a barrier to optimal emotional well-being, self-care and management of diabetes. As a consequence, monitoring diabetes distress as part of routine clinical care is part of many national guidelines. The present narrative review summarizes this research and related literature, to postulate the aetiology of diabetes distress, and thus how it may be prevented. The current evidence base for the management of diabetes distress is summarized, and the next steps in the prevention and management of diabetes distress identified.

The inclination to shun healthy behaviours that generate only transient benefits: the role of future clarity

Research has not definitively ascertained the circumstances that motivate people to live a healthier lifestyle. To redress this shortfall, we report two overlapping studies that examined whether people are more inclined to value health benefits that seem enduring and fundamental rather than transient or superficial-even after controlling effort and cost. In these studies, 242 participants indicated the degree to which they implement 17 health behaviours-as well as the extent to which they perceive the benefits of these behaviours as enduring and fundamental. Furthermore, participants completed a measure that gauges future clarity. Finally, they chose which of two drugs-drugs that differ only on the longevity of effects-they prefer. Participants were more inclined to implement health behaviours that seemed to generate enduring and fundamental benefits. This effect was more pronounced in people who perceive their future as vivid and certain. Furthermore, participants tended to choose the drug that was touted as generating more enduring benefits, even after controlling cost and effort. As these results imply, to encourage healthy behaviour, health practitioners should help people clarify their future goals and then advocate behaviours that generate lasting benefits.

The foot-health of people with diabetes in regional and rural Australia: baseline results from an observational cohort study

BACKGROUND

There is limited Australian epidemiological research that reports on the foot-health characteristics of people with diabetes, especially within rural and regional settings. The objective of this study was to explore the associations between demographic, socio-economic and diabetes-related variables with diabetes-related foot morbidity in people residing in regional and rural Australia.

METHODS

Adults with diabetes were recruited from non-metropolitan Australian publicly-funded podiatry services. The primary variable of interest was the University of Texas diabetic foot risk classification designated to each participant at baseline. Independent risk factors for diabetes-related foot morbidity were identified using multivariable analysis.

RESULTS

Eight-hundred and ninety-nine participants enrolled, 443 (49.3%) in Tasmania and 456 (50.7%) in Victoria. Mean age was 67 years (SD 12.7), 9.2% had type 1 diabetes, 506 (56.3%) were male, 498 (55.4%) had diabetes for longer than 10 years and 550 (61.2%) either did not know the ideal HbA1c target or reported that it was ≥7.0. A majority had peripheral neuropathy or worse foot morbidity (61.0%). Foot morbidity was associated with male sex (OR 2.42, 95% CI 1.82-3.22), duration of diabetes > 20 years (OR 3.25, 95% CI 2.22-4.75), and Tasmanian residence (OR 3.38, 95% CI 2.35-4.86).

CONCLUSIONS

A high proportion of the regional Australian clinical population with diabetes seen by the publicly-funded podiatric services in this study were at high risk of future limb threatening foot morbidity, and participants residing in Northern Tasmania are more likely to have worse diabetes-related foot morbidity than those from regional Victoria. Service models should be reviewed to ensure that diabetes-related foot services are appropriately developed and resourced to deliver interdisciplinary evidence-based care.

Depression prevalence in Type 2 diabetes is not related to diabetes-depression symptom overlap but is related to symptom dimensions within patient self-report measures: a meta-analysis

AIM

Depression is common in Type 2 diabetes, yet rates vary. Overlap between symptoms of depression and diabetes may account for this variability in depression prevalence rates. We examined to what extent depression prevalence was a function of the proportion of depression-diabetes symptom overlap (items within symptom dimensions) and sample characteristics.

METHODS

Electronic and hand searching of published and unpublished works identified 147 eligible papers. Of 3656 screened, 147 studies (149 samples, N = 17-229 047, mean sample age 25.4-82.8 years, with 152 prevalence estimates), using 24 validated depression questionnaires were selected. Sample size, publication type, sample type, gender, age, BMI, HbA_1c , depression questionnaire and prevalence rates were extracted.

RESULTS

Prevalence rates ranged from 1.8% to 88% (mean = 28.30%) and were higher in younger samples, samples with higher mean HbA_1c and clinic samples. Diabetes-depression symptom overlap did not affect prevalence. A higher proportion of anhedonia, cognition, cognitive, negative affect and sleep disturbance symptoms, and a lower proportion of somatic symptoms were consistently associated with higher depression prevalence.

CONCLUSIONS

The lack of an overall effect of diabetes-depression symptom overlap might suggest that assessment of depression in Type 2 diabetes is generally not confounded by co-occuring symptoms. However, questionnaires with proportionally more or fewer items measuring other symptom categories were associated with higher estimates of depression prevalence. Depression measures that focus on the cardinal symptoms of depression (e.g. negative affect and cognition), limiting symptoms associated with increasing diabetes symptomatology (e.g. sleep disturbance, cognitive) may most accurately diagnose depression.

Discerning depressive symptoms in patients with obstructive sleep apnea: the effect of continuous positive airway pressure therapy on Hamilton Depression Rating Scale symptoms

The assessment of depression in obstructive sleep apnea (OSA) is confounded by the overlap in symptoms between the disorders. However, previous analysis by our group has suggested that while some depressive symptoms tend to overlap with OSA (such as insomnia, lethargy, impaired concentration, psychomotor retardation) other, nonoverlapping symptoms appear more specific to depression (such as negative affect, anhedonia, and depressive cognitions). We sought to determine the value of such categorization of depressive symptoms in identifying clinical depression within OSA patient populations by examining the response of these two categories of depression symptoms to treatment of OSA by continuous positive airway pressure (CPAP). Three hundred fifty-seven unselected, CPAP-naïve OSA patients were treated with CPAP and followed over 12 weeks. Depressive symptoms were elicited before, during and at the end of this period using the Hamilton Rating Scale for Depression (HAM-D). Data were analyzed using latent growth curve modeling. At baseline, individuals reported proportionally more severe overlapping than nonoverlapping depressive symptoms. Both overlapping and nonoverlapping symptoms significantly decreased over time, but with a greater reduction in the severity of overlapping than nonoverlapping depressive symptoms. Moreover, greater CPAP use was associated with a faster rate of improvement in overlapping symptoms, but not in nonoverlapping symptoms. These findings suggest that nonoverlapping depressive symptoms may be useful discriminators of clinical depression amongst patients with untreated, symptomatic OSA.