Psychometric and screening properties of the WHO-5 well-being index in adult outpatients with Type 1 or Type 2 diabetes mellitus

Depression in people with type 2 diabetes: current perspectives

Type 2 diabetes mellitus (T2DM) is associated with depressive symptoms, and comorbid depression in those with T2DM has been associated with adverse clinical profiles. Recognizing and addressing psychological symptoms remain significant clinical challenges in T2DM. Possible mediators of the reciprocal relationship between T2DM and depression may include physical activity levels, effectiveness of self-management, distress associated with a new T2DM diagnosis, and frailty associated with advanced diabetes duration. The latter considerations contribute to a "J-shaped" trajectory from the time of diagnosis. There remain significant challenges to screening for clinical risks associated with psychological symptoms in T2DM; poorer outcomes may be associated with major depressive episodes, isolated (eg, anhedonic), or subsyndromal depressive symptoms, depressive-like symptoms more specific to T2DM (eg, diabetes-related distress), apathy or fatigue. In this review, we discuss current perspectives on depression in the context of T2DM with implications for screening and management of these highly comorbid conditions.

Transitional Needs of Australian Young Adults With Type 1 Diabetes: Mixed Methods Study

BACKGROUND

Young adulthood is marked by transitions that impact diabetes self-management behaviors, which require ongoing diabetes education and support. Traditional diabetes education programs and services currently do not meet the needs of many young adults with type 1 diabetes mellitus (T1DM) as they continue to fall through the cracks of clinical services. Age-centered diabetes education programs and services present an opportunity for young adults to meet in a supportive environment and gain a better understanding about diabetes management.

OBJECTIVE

The aim of the study was to identify the health and well-being needs of Australian young adults aged between 18 and 35 years with T1DM to develop appropriate solutions to keep them engaged with diabetes self-management.

METHODS

In total, 13 semistructured individual interviews and self-reported surveys were obtained to understand participants' experiences with diabetes education programs and services. Together with survey data, transcribed interviews were analyzed into themes and categories using comparative analysis to identify the health and well-being needs of young adults with T1DM during young adulthood.

RESULTS

Diabetes education and service needs for young adults with T1DM related to improving access to existing diabetes education programs and services, having credible informational resources, as well as having personalized diabetes management advice. Participants especially valued relevant and real-time information and opportunities for peer support, mostly sourced from Web-based platforms.

CONCLUSIONS

There is a need for diabetes education programs and services to be age-appropriate and easily accessible, to provide relevant and credible information, and to provide opportunities for peer support to better support young adults with T1DM. These findings also support the use of diabetes education programs or services delivered online through mHealth systems in this population.

Validation of the WHO-5 as a first-step screening instrument for depression in adults with diabetes: Results from Diabetes MILES - Australia

AIMS

Screening for depression is recommended internationally. The World Health Organization's 5-item Well-being Index (WHO-5) is used clinically to screen for depression but its empirical suitability for this purpose is not well documented. We investigated the psychometric properties of the WHO-5 and its suitability for identifying likely depression in Australian adults with diabetes.

METHODS

The Diabetes MILES - Australia study dataset provided a sample of N=3249 who completed the WHO-5 (positively-worded 5-item measure of emotional well-being) and the PHQ-9 (9-item measure of depressive symptoms). Analyses were conducted for the full sample, and separately by diabetes type and treatment (type 1, non-insulin-treated type 2, and insulin-treated type 2 diabetes). Construct (convergent and factorial) validity and reliability of the WHO-5 were examined. ROC analyses were used to examine the sensitivity and specificity of the WHO-5 as a depression screening instrument, comparing two commonly used WHO-5 cut-off values (≤7 and <13) with the PHQ-9.

RESULTS

For the whole sample, the WHO-5 demonstrated satisfactory internal consistency reliability (α=0.90) and convergent validity with the PHQ-9 (r=-0.73, p<0.001). Confirmatory factor analysis partially supported factorial validity: Χ²(5)=834.94, p<0.001; RMSEA=0.23, 90% CI 0.21-0.24; CFI=0.98, TLI=0.96; factor loadings=0.78-0.92. The AUC was 0.87 (95% CI: 0.86-0.89, p<0.001). The sensitivity/specificity of the WHO-5 for detecting likely depression was 0.44/0.96 for the ≤7 cut-off, and 0.79/0.79 for the <13 cut-off, with similar findings by diabetes type and treatment.

CONCLUSIONS

These findings support use of a WHO-5 cut-point of <13 to identify likely depression in Australian adults with diabetes, regardless of type/treatment.

Continuous Glucose Monitoring in Patients with Type 1 Diabetes and Impaired Awareness of Hypoglycemia: Also Effective in Patients with Psychological Distress?

The aim of this study was to evaluate whether psychological distress modifies the effect of continuous glucose monitoring (CGM) in patients with type 1 diabetes (T1D) and impaired awareness of hypoglycemia. Fifty-two patients with T1D and impaired awareness of hypoglycemia participated in an earlier reported randomized crossover trial with two 16-week intervention periods comparing CGM with self-monitoring of blood glucose (SMBG). During the CGM phase, time spent in euglycemia (4-10 mmol/L), the primary outcome, was 9.6% higher compared with the SMBG phase (P < 0.0001). Psychological distress was operationalized as low emotional well-being (World Health Organization Well-being Index 5 [WHO-5] < 50), high diabetes-related distress (Problem Areas in Diabetes 5 [PAID-5] ≥ 8), and/or high fear of hypoglycemia (Hypoglycemia Fear Survey [HFS] Worry > mean HFS Worry score +1 standard deviation). Modifying effects were assessed by analyzing psychological distress score × intervention-interaction effects. Results showed that both the low emotional well-being group and normal emotional well-being group had equal glycemic outcomes during the CGM phase. High diabetes distress and elevated fear of hypoglycemia did not result in significant interaction effects for glycemic outcomes. This study demonstrated that CGM is equally effective in terms of glycemic improvements in high versus low distressed patients with T1D and impaired awareness of hypoglycemia.

The effect of guided self-determination on self-management in persons with type 1 diabetes mellitus and HbA1c ≥64 mmol/mol: a group-based randomised controlled trial

OBJECTIVES

To determine whether the impact of guided self-determination (GSD) applied in group training (GSD-GT) in people with chronically elevated HbA_1c and type 1 diabetes mellitus (DM) was superior to 'care as usual' in improving HbA_1c and psychological functioning.

SETTING

An outpatient clinic at a university hospital in Western Norway.

PARTICIPANTS

A total of 178 adults (all Caucasian) aged 18-55 (mean age 36.7±10.7, 62% women) with type 1 DM for at least 1 year and HbA_1c ≥64 mmol/mol (8.0%) were randomly assigned to participate in either GSD-GT or a control group (CG). Exclusion criteria were severe comorbidity, major psychiatric disorder, cognitive deficiency/language barriers and pregnancy.

INTERVENTION

Intervention group met seven times for 2 hours over 14 weeks to promote patient autonomy and intrinsic motivation using reflection sheets and advanced professional communication in accordance with the GSD methodology.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was HbA_1c and secondary outcomes (all outcomes 9 months post intervention) were self-monitored blood glucose frequency, self-reported diabetes competence, autonomy support by healthcare providers (Health Care Climate Questionnaire), autonomous versus controlled diabetes motivation (Treatment Self-Regulation Questionnaire), diabetes distress (Problem Areas In Diabetes Scale (PAID) and Diabetes Distress Scale (DDS)), self-esteem (Rosenberg Self-Esteem Scale) and psychological well-being (World Health Organization five-item Well-Being Index scale).

RESULTS

Among participants allocated to the GSD-GT (=90) 48 completed the study, whereas 83 completed in the CG (n=88). With 95% CIs GSD-GT did not have effect on HbA_1c (B -0.18, CI (-0.48, 0.12), p=0.234). GSD-GT improved autonomy-motivated behaviour (B 0.51, CI (0.25, 0.77), p<0.001), diabetes distress (PAID, B -6.96, CI (-11.40, -2.52), p=0.002), total DDS (B -5.15, CI (-9.34, -0.96), p=0.016), DDS emotional burden (B -7.19, CI (-13.20, -1.19), p=0.019) and self-esteem (B 1.43, CI (0.34, 2.52), p=0.011).

CONCLUSIONS

Results from this behavioural intervention must be interpreted cautiously because of recruitment and attrition problems. Medical outcomes did not improve. Psychological outcomes improved, especially reduced diabetes distress.

TRIAL REGISTRATION NUMBER

Clinical Trials.gov NCT 01317459.

The Impact of Continuous Glucose Monitoring on Markers of Quality of Life in Adults With Type 1 Diabetes: Further Findings From the DIAMOND Randomized Clinical Trial

OBJECTIVE

Continuous glucose monitoring (CGM) improves glycemic control, but data are inconclusive about its influence on quality of life (QOL). We investigated the impact of 24 weeks of CGM use on QOL in adults with type 1 diabetes (T1D) who use multiple daily insulin injections.

RESEARCH DESIGN AND METHODS

DIAMOND (Multiple Daily Injections and Continuous Glucose Monitoring in Diabetes) was a prospective randomized trial that assessed CGM versus self-monitoring of blood glucose (SMBG) only in 158 adults with poorly controlled T1D. At baseline and study end, participants completed QOL measures that assessed overall well-being (WHO-5), health status (EQ-5D-5L), diabetes distress (DDS), hypoglycemic fear (worry subscale of the HFS-II), and hypoglycemic confidence (HCS). At study end, CGM participants completed the CGM Satisfaction Survey. Linear regression analyses compared treatment group changes in QOL outcomes over time. Associations between CGM satisfaction and change in QOL outcomes and in glycemic control indices were assessed.

RESULTS

The CGM group demonstrated a greater increase in hypoglycemic confidence (P = 0.01) and a greater decrease in diabetes distress (P = 0.01) than the SMBG group. No significant group differences in well-being, health status, or hypoglycemic fear were observed. CGM satisfaction was not significantly associated with glycemic changes but was associated with reductions in diabetes distress (P < 0.001) and hypoglycemic fear (P = 0.02) and increases in hypoglycemic confidence (P < 0.001) and well-being (P = 0.01).

CONCLUSIONS

CGM contributes to significant improvement in diabetes-specific QOL (i.e., diabetes distress, hypoglycemic confidence) in adults with T1D, but not with QOL measures not specific to diabetes (i.e., well-being, health status). CGM satisfaction was associated with most of the QOL outcomes but not with glycemic outcomes.

Physician-patient communication at diagnosis of type 2 diabetes and its links to patient outcomes: New results from the global IntroDia® study

AIMS

To investigate patient experiences during the diagnosis of type 2 diabetes mellitus (T2DM), focusing on how physician-patient communication at diagnosis influences patients' psychosocial stress and subsequent self-management and outcomes.

METHODS

We surveyed adults with T2DM in 26 countries in a large cross-national study of physician-patient communication during early T2DM treatment (IntroDia®). The self-report questionnaire assessed retrospectively patient experiences during diagnosis conversations (focusing on 43 possible conversational elements, and communication quality) and potential effects on patient-reported outcomes.

RESULTS

Data from 3628 people with T2DM who had been prescribed oral treatment at diagnosis were analysed. Exploratory factor analyses of the conversational elements yielded four coherent, meaningful factors: Encouraging (Cronbach's α=0.86); Collaborative (α=0.88); Recommending Other Resources (α=0.75); and Discouraging (α=0.72). Patient-perceived communication quality (PPCQ) at diagnosis was positively associated with Encouraging (β=+1.764, p<0.001) and Collaborative (β=+0.347, p<0.001), negatively associated with Discouraging (β=-1.181, p<0.001) and not associated with Recommending Other Resources (β=+0.087, p=0.096), using a stable path model. PPCQ was associated with less current diabetes distress, greater current well-being and better current self-care. Conversation elements comprising factors associated with better PPCQ (Encouraging and Collaborative) were recalled more frequently by patients than elements associated with poor PPCQ (Discouraging).

CONCLUSIONS

Better physician-patient communication at T2DM diagnosis may contribute to subsequent greater patient well-being and self-care, and may be enhanced by greater physician use of Collaborative and Encouraging conversation elements.

Mindful with Your Baby: Feasibility, Acceptability, and Effects of a Mindful Parenting Group Training for Mothers and Their Babies in a Mental Health Context

Many mothers experience difficulties after the birth of a baby. Mindful parenting may have benefits for mothers and babies, because it can help mothers regulate stress, and be more attentive towards themselves and their babies, which may have positive effects on their responsivity. This study examined the effectiveness of Mindful with your baby, an 8-week mindful parenting group training for mothers with their babies. The presence of the babies provides on-the-spot practicing opportunities and facilitates generalization of what is learned. Forty-four mothers with their babies (0-18 months), who were referred to a mental health clinic because of elevated stress or mental health problems of the mother, infant (regulation) problems, or mother-infant interaction problems, participated in 10 groups, each comprising of three to six mother-baby dyads. Questionnaires were administered at pretest, posttest, 8-week follow-up, and 1-year follow-up. Dropout rate was 7%. At posttest, 8-week follow-up, and 1-year follow-up, a significant improvement was seen in mindfulness, self-compassion, mindful parenting, (medium to large effects), as well as in well-being, psychopathology, parental confidence, responsivity, and hostility (small to large effects). Parental stress and parental affection only improved at the first and second follow-ups, respectively (small to medium effects), and maternal attention and rejection did not change. The infants improved in their positive affectivity (medium effect) but not in other aspects of their temperament. Mindful with your baby is a promising intervention for mothers with babies who are referred to mental health care because of elevated stress or mental health problems, infant (regulation) problems, or mother-infant interaction problems.

Diabetes Camp as Continuing Education for Diabetes Self-Management in Middle-Aged and Elderly People with Type 2 Diabetes Mellitus

BACKGROUND

Despite the established benefits of diabetes camps for the continuing education of children with type 1 diabetes mellitus, little is known about the long-term metabolic benefits of diabetes camps for middle-aged and elderly people with type 2 diabetes mellitus (T2DM), especially in terms of glycosylated hemoglobin (HbA1c) variability.

METHODS

The 1-year mean and variability of HbA1c before and after the diabetes camp was compared between the participants of the diabetes camp (n=57; median age 65 years [range, 50 to 86 years]; median diabetes duration 14 years [range, 1 to 48 years]). Additional case-control analysis compared the metabolic outcomes of the participants of the diabetes camp and their propensity score-matched controls who underwent conventional diabetes education (n=93).

RESULTS

The levels of HbA1c during the first year after the diabetes camp were comparable to those of the matched controls (P=0.341). In an analysis of all participants of the diabetes camp, the 1-year mean±standard deviation (SD) of HbA1c decreased (P=0.010 and P=0.041) after the diabetes camp, whereas the adjusted SD and coefficient of variance (CV) of HbA1c did not decrease. The adjusted SD and CV significantly decreased after the diabetes camp in participants whose 1-year mean HbA1c was ≥6.5% before the diabetes camp (n=40) and those with a duration of diabetes less than 15 years (n=32).

CONCLUSION

The 1-year mean and SD of HbA1c decreased after the diabetes camp, with significant reduction in the adjusted SD and CV in those with higher baseline HbA1c and a shorter duration of diabetes.

Validation of the Dutch version of the Pregnancy Experience Scale

The Pregnancy Experience Scale - Brief version (PES-Brief) assesses the frequency and intensity of the hassles and uplifts of pregnancy. This study aimed to assess the psychometric properties of the Dutch PES-Brief-Beleving van Zwangerschap Schaal - verkorte versie (BZS-K)-in a sample of healthy Dutch pregnant women. Participants (n=115) completed questionnaires twice during pregnancy, within a three-week interval. Factor analyses resulted in the expected two factors, one positive and one negative. The BZS-K showed sufficient internal consistency (α=.76 for Hassles, .83 for Uplifts) and reproducibility of subscales (Intraclass correlation coefficients (ICC)=.72-.84). Concurrent validity with measures of pregnancy anxiety, general depression, anxiety and stress, and emotional well-being was established. We conclude that the BZS-K is a reliable, valid measure for assessment of women's perceptions of hassles and uplifts of pregnancy.

Treatment adherence in patients with type 2 diabetes mellitus correlates with different coping styles, low perception of self-influence on disease, and depressive symptoms

BACKGROUND

Insulin analogs are regarded as more convenient to use than human insulin; however, they require a different administration scheme due to their unique pharmacokinetic and pharmacodynamic properties. This study aimed to assess difficulties with adherence to treatment with insulin analogs in patients with type 2 diabetes mellitus (T2DM), who had previously been treated with human insulin. The associations between difficulties with adherence and clinical, demographic, and psychological characteristics were also evaluated.

PATIENTS AND METHODS

The study was conducted on 3,467 consecutively enrolled patients with T2DM (54.4% women), mean age 63.9 years (SD =9.57), who had recently undergone a physician-directed change in treatment from human insulin to insulin analogs. The questionnaires addressed difficulties with switching the therapy, coping styles, well-being, and perception of self-influence on the disease.

RESULTS

No adherence problems in switching therapy were reported in 56.6% of patients. Specific moderate difficulties were reported in 10.4%-22.1% of patients, major difficulties in 0.7%-6.9% of patients, and very significant difficulties in 0.03%-1.3% of patients. Overall, remembering to modify the insulin dose in the case of additional meals was the most frequently reported difficulty, and problems with identifying hypoglycemic symptoms were the least frequently reported. The increased risk of difficulties was moderately related to low perception of self-influence on diabetes and poor well-being. The intensity of problems was higher among those who were less-educated, lived in rural areas, had complications, and/or reported maladaptive coping styles.

CONCLUSION

Switching from human insulin to an insulin analog did not cause adherence problems in more than half of the patients. In the remaining patients, difficulties in adherence correlated with maladaptive coping styles, low perception of self-influence on disease course, and depressive symptoms.

The complex interplay between clinical and person-centered diabetes outcomes in the two genders

Background

New approaches to cope with clinical and psychosocial aspects of type 2 diabetes (T2DM) are needed; gender influences the complex interplay between clinical and non-clinical factors. We used data from the BENCH-D study to assess gender-differences in terms of clinical and person-centered measures in T2DM.

Methods

Clinical quality of care indicators relative to control of HbA1c, lipid profile, blood pressure, and BMI were derived from electronic medical records. Ten self-administered validated questionnaires (SF-12 Health Survey; WHO-5 well-being index; Problem Areas in Diabetes (PAID) 5, Health Care Climate Questionnaire, Patients Assessment of Chronic Illness Care, Diabetes Empowerment Scale, Diabetes Self-care Activities, Global Satisfaction for Diabetes Treatment, Barriers to Taking Medications, Perceived Social Support) were adopted as person-centered outcomes indicators.

Results

Overall, 26 diabetes clinics enrolled 2,335 people (men: 59.7%; women: 40.3%). Lower percentages of women reached HbA1c levels < =7.0% (23.2% vs. 27.8%; p = 0.03), LDL-cholesterol < 100 mg/dl (48.3 vs. 57.8%; p = 0.0005), and BMI <27 Kg/m2 (27.2 vs. 31.6%; p = 0.04) than men. Women had statistically significant poorer scores for physical functioning, psychological well-being, self-care activities dedicated to physical activities, empowerment, diabetes-related distress, satisfaction with treatment, barriers to medication taking, satisfaction with access to chronic care and healthcare communication, and perceived social support than men; 24.8% of women and 8.8% of men had WHO-5 < =28 (likely depression) (p < 0.0001); 67.7% of women and 55.1% of men had PAID-5 > 40 (high levels of diabetes-related distress) (p < 0.0001). At multivariate analysis, factors associated with an increased likelihood of having elevated HbA1c levels (≥8.0%) were different in men and women, e.g. having PAID-5 levels >40 was associated with a higher likelihood of HbA1c ≥8.0% in women (OR = 1.15; 95%CI 1.05–1.25) but not in men (OR = 1.00; 95%CI 0.93–1.08).

Conclusions

In T2DM, women show poorer clinical and person-centered outcomes indicators than men. Diabetes-related distress plays a role as a correlate of metabolic control in women but not in men. The study provides new information about the interplay between clinical and person-centered indicators in men and women which may guide further improvements in diabetes education and support programs.

Investigating Hypoglycemic Confidence in Type 1 and Type 2 Diabetes

BACKGROUND

While research designed to understand the concerns about hypoglycemia among patients with diabetes has been primarily focused on the investigation of fear and anxiety, recent evidence suggests a potentially important and conceptually distinct element-hypoglycemic confidence. To investigate this dimension, we developed the Hypoglycemic Confidence Scale (HCS); herein, we describe the construction and validation of the HCS and examine how key patient factors are associated with hypoglycemic confidence.

METHODS

Items were developed from interviews with six type 1 diabetes (T1D) adults, six insulin-using type 2 diabetes (T2D) adults, and seven diabetes healthcare professionals, resulting in nine self-report items. Separate exploratory factor analyses (EFAs) were conducted with T1D adults (N = 326), with T2D adults using both basal and prandial insulins (T2D-BP, N = 145) and with T2D adults using only basal insulin (T2D-BO, N = 82). Construct validity for the HCS was established with overall well-being (World Health Organization-5), diabetes distress (Diabetes Distress Scale), global anxiety (Generalized Anxiety Disorder), hypoglycemic fear (Hypoglycemic Fear Survey-II), and glycemic control (self-reported A1C). Hierarchical regression analyses examined the unique contribution of HCS scores, independent of hypoglycemic fear, on key psychosocial constructs and A1C.

RESULTS

EFAs of the nine HCS items yielded a single factor solution for each of the three subject samples, accounting for 50.8%, 65.1%, and 73.7% of the variance for the T1D, T2D-BP, and T2D-BO groups, respectively. Construct validity was established by significant correlations with criterion variables. The HCS was associated with well-being and diabetes distress in the T1D (in both cases, P < 0.001) and T2D-BP groups (in both cases, P < .05) and for self-reported A1C in the T2D-BP group (P < .05) independent of hypoglycemic fear.

CONCLUSIONS

Hypoglycemic confidence is a unique dimension of patient experience, different from hypoglycemic fear, and is deserving of further study. The HCS is a reliable valid measure of hypoglycemic confidence for adults with T1D and insulin-using T2D.

Female sex, young age, northern German residence, hypoglycemia and disabling diabetes complications are associated with depressed mood in the WHO-5 questionnaire - A multicenter DPV study among 17,563 adult patients with type 2 diabetes

BACKGROUND

Like other mental illnesses, depression is a culturally sensitive topic. Hence, findings cannot be transferred between countries. We investigated the frequency of depressed mood and its association with diabetes-related factors in a large type 2 diabetes (T2D) cohort from real-life care in Germany.

METHODS

17,563 adults (median [IQR]: 64.5[55.9-71.1] years) from the multicenter diabetes follow-up registry, DPV (diabetes prospective follow-up), were investigated. All had completed the WHO-5 questionnaire, a screening tool for depression. Logistic regression was applied to study the association of demographic and diabetes-related factors with depressed mood (SAS 9.4). P<0.05 was considered significant.

RESULTS

Using a WHO-5 cut-off of <13, 27.4% of patients were at risk for depressed mood. A clinical depression diagnosis was recognized in 8.4%. Female sex (OR: 1.5[95%-CI: 1.4-1.6]), young age (1.2[1.1-1.4]), longer diabetes duration (1.2[1.1-1.3]), and living in Northern Germany (1.3[1.2-1.4]) were each associated with increased odds for depressed mood. After adjusting for these confounders, worse glycemic control (1.4[1.3-1.5]), insulin use (1.3[1.2-1.4]), myocardial infarction (1.3[1.2-1.5]), stroke (1.8[1.5-2.0]), retinopathy (1.4[1.3-1.6]), renal failure (1.4[1.2-1.8]), diabetic foot syndrome (1.3[1.2-1.4]), severe hypoglycemia (1.5[1.2-1.9]), two or more inpatient admissions (2.1[1.8-2.4]), and longer duration of hospital stay (1-<14 days: 1.3[1.2-2.3]; >14 days: 2.1[1.9-2.3]) were related to depressed mood.

LIMITATION

Due to the cross-sectional design, no causality can be drawn.

CONCLUSIONS

In T2D, depressed mood is not uncommon. However, in routine care a clinical depression might be missed and regular screening is advisable. Besides the well-known associations with depressed mood, northern German residence and mainly life-compromising diabetes comorbidities were identified as related factors.

The effect of peer support in adults with insulin pump-treated type 1 diabetes: a pilot study of a flexible and participatory intervention

AIM

The aim of this study was to explore the effects of a flexible and participatory peer support intervention in a clinical setting for adults with type 1 diabetes treated with an insulin pump, focusing on enhancing diabetes-specific social capital. The key questions were as follows: 1) what effects are appropriate to expect, according to participants? and 2) to what extent did these effects occur?

METHODS

Two peer support intervention programs were conducted in a diabetes specialist clinic (N=30). A participatory and adaptable approach allowed flexibility in the content of peer support meetings, which were facilitated by a diabetes nurse. Individual interviews explored participants' perception of effects of the intervention. Interview data were analyzed qualitatively. Participants (n=27) completed a baseline and postintervention questionnaire that included items assessing diabetes empowerment, diabetes distress, diabetes-specific social support, and diabetes loneliness. HbA1c levels were compared before and after the intervention.

RESULTS

Participants experienced enhanced diabetes-specific social capital, diabetes motivation, awareness of personal diabetes practices, and serenity and openness in life with diabetes. They also became more aware of treatment and support possibilities. Negative effects included feeling sad or upset after the meetings or feeling different than and not as well-controlled as other participants. Quantitative analyses showed enhanced social support, decreased eating distress and trends toward enhanced diabetes empowerment, decreased diabetes loneliness, and decreased diabetes distress (powerlessness). We found fewer positive and/or negative outcomes among participants who felt no need for peer support or felt that the group was not a unit or that important issues were not addressed.

CONCLUSION

The study indicated that flexible and participatory peer support can strengthen diabetes-specific social capital and improve participants' well-being and diabetes empowerment. Awareness of participants' incentives for attending peer support, as well as the risk of people feeling isolated within peer support groups, is essential to creating effective diabetes-specific social support.

Impact of the Omnipod® Insulin Management System on Quality of Life: A Survey of Current Users

BACKGROUND

Few recent studies have examined the impact of continuous subcutaneous insulin infusion systems on patient-reported quality of life (QOL). We explored QOL changes resulting from treatment with the Omnipod^® Insulin Management System (Insulet Corp., Billerica, MA).

METHODS

One thousand two hundred forty-five adults (>18 years) with type 1 diabetes and current Omnipod users completed an online questionnaire examining perceived changes in QOL and glycemic control since Omnipod initiation. The QOL dimensions included overall well-being (World Health Organization-5, modified to examine changes retrospectively), diabetes distress (Type 1 Diabetes Distress Scale, current distress and a modified retrospective version), and psychosocial impact (two subscales from the Diabetes Technology Impact Measure, perceived control over diabetes, and hypoglycemic safety). Regression analyses examined associations between demographics, key psychological factors, and perceived change in glycemic control with the QOL dimensions.

RESULTS

Broad QOL and clinical benefits associated with Omnipod use were common. The majority reported positive changes in the following: overall well-being (53.5%), perceived control over diabetes (72.5%), hypoglycemic safety (50.6%), and diabetes distress (69.6%). Worsening in any of these areas was uncommon. In addition, 64.2% of patients reported glycemic improvement post-Omnipod initiation, while 35.2% reported a decrease in severe hypoglycemic episodes. Trust in one's Omnipod, perceived improvement in glycemic control, and reductions in severe hypoglycemia independently predicted benefits in all QOL measures (all P < 0.001).

CONCLUSIONS

These findings suggest that Omnipod users perceived substantial QOL benefits from the device; benefits are more apparent in those who trust the device and have noted positive changes in glycemic control.

Randomized Trial of Long-Acting Insulin Glargine Titration Web Tool (LTHome) Versus Enhanced Usual Therapy of Glargine Titration (INNOVATE Trial)

BACKGROUND

Basal insulin titration in the real world is often unsuccessful. LTHome, a web tool, applies a rules engine-based algorithm providing insulin titration advice directly to the patient.

METHODS

This pilot, randomized trial evaluates basal insulin glargine titration by LTHome compared to enhanced usual therapy ([EUT]-diabetes education program) over 12 weeks. Important inclusion criteria: 18-75 years, type 2 diabetes, computer literacy, and HbA1c >7.0%. Trial protocol was approved by ethics board.

RESULTS

We randomized 139 subjects. The achievement of primary composite outcome (four out of seven fasting plasma glucose [FPG] within 5-7.2 mmol/L + mean for three consecutive FPG within 5-7.2 mmol/L + no severe hypoglycemia) was 15% in LTHome versus 41% in EUT (noninferiority not met, P-value = 0.92). Other outcomes were similar between the LTHome and EUT arms: alternate composite outcome achievement (last five FPG mean within the range of 5-7.2 mmol/L + no hypoglycemia, 47% and 51%, P = 0.73); A1c reduction (-1.0% and -1.1%, P = 0.66); proportion achieving A1c ≤7% (14% and 20%, P = 0.36); and hypoglycemia incidence (31% and 37%, P = 0.4), respectively. Patient satisfaction score improvements were greater in LTHome versus EUT (change in fear of hypoglycemia score P = 0.04 and change in diabetes distress score P = 0.04). The mean number of additional healthcare provider visits was 0.13 for LTHome and 1.22 for EUT (P < 0.01).

CONCLUSION

INNOVATE trial suggests clinical utility of LTHome compared to EUT in real-life settings. Further research is needed to evaluate the efficacy and safety of automated insulin titration algorithms.

Telemedicine Versus Standard Follow-Up Care for Diabetes-Related Foot Ulcers: Protocol for a Cluster Randomized Controlled Noninferiority Trial (DiaFOTo)

Background

This paper presents the protocol for an ongoing study to evaluate a telemedicine follow-up intervention for patients with diabetes-related foot ulcers. Diabetes-related foot ulcers represent challenges for patients and the health services. The large increase in the prevalence of diabetes, combined with the aging population, means that the absolute number of patients with diabetes-related foot ulcers is likely to continue to increase. Health care services therefore need to provide close clinical follow-up care for people with diabetes both in primary and specialist care. Information and communication technologies may enable more integrated treatment and care pathways across organizational boundaries. However, we lack knowledge about the effect of telemedicine follow-up and how such services can be optimally organized.

Objective

To present the design and methods of a study evaluating a telemedicine follow-up intervention for patients with diabetes-related foot ulcers.

Methods

The study is designed as a cluster randomized controlled trial (noninferiority trial) involving municipalities or municipality districts (clusters) belonging to one clinical site in Western Norway. The study includes patients with type 1 and type 2 diabetes presenting with a new foot ulcer at the initial visit to the clinic. Patients in the intervention group receive telemedicine follow-up care in the community. The key ingredient in the intervention is the close integration between health care levels. The intervention is facilitated by the use of an interactive wound platform consisting of a Web-based ulcer record combined with a mobile phone, enabling counseling and communication between nurses in the community and specialist health care. Patients in the control group receive standard hospital outpatient care. The primary endpoint in the trial is healing time; secondary outcomes include amputation and death, patient-reported outcome measures, and follow-up data on the recurrence of foot ulcers. In addition, qualitative substudies are being performed to provide a more comprehensive evaluation of the ongoing processes during the trial with the patients in the intervention and control groups and those health care professionals either working in primary care or in specialist care delivering the intervention.

Results

The project has been funded. The inclusion of patients started in September 2012. Because recruitment goals were not met in the initial period, two more clinical sites have been included to meet sample size requirements. Patient recruitment will continue until June 2016. Data collection in the qualitative substudies has been completed.

Conclusions

This telemedicine trial operates in a novel setting and targets patients with diabetes-related foot ulcers during a 12-month follow-up period. The trial addresses whether integrated care using telemedicine between primary and specialist health care can be an equivalent alternative to standard outpatient care.

Trial Registration

ClinicalTrials.gov NCT01710774; https://clinicaltrials.gov/ct2/show/NCT01710774 (Archived by WebCite at http://www.webcitation.org/6im6KfFov).

The Impact of Real-Time Continuous Glucose Monitoring in Patients 65 Years and Older

BACKGROUND

Older adults with type 1 diabetes (T1D) or insulin-using type 2 diabetes (iT2D) are at high risk for severe hypoglycemic episodes. Real-time continuous glucose monitoring (RT-CGM) in this population may reduce this risk, but when patients switch to Medicare at age 65, RT-CGM is no longer a covered benefit. We developed a survey to examine health and quality of life (QOL) benefits of RT-CGM in seniors (age ≥ 65).

METHODS

Two groups of seniors with T1D or iT2D-current RT-CGM users (n = 210) and RT-CGM "hopefuls" (patients who wanted but could not obtain RT-CGM due to lack of insurance coverage; n = 75)-completed an online survey. The survey examined history of hypoglycemic experiences as well as current quality of life (QOL), including generic and diabetes-specific measures.

RESULTS

Current users reported fewer moderate (P < .01) and fewer severe hypoglycemic episodes (P < .01) over the past 6 months than "hopefuls" and greater reductions over time in hypoglycemic events requiring the assistance of another, ER visits, and paramedic visits to the home (in all cases, P < .01). Regarding QOL, current users reported significantly better well-being (P < .001), less hypoglycemic fear (P < .05), and less diabetes distress (P < .05) than "hopefuls."

CONCLUSIONS

These data suggest that RT-CGM use in seniors is associated with reductions in episodes of severe hypoglycemia and improved QOL, suggesting that restrictive access to RT-CGM in the Medicare age population may have deleterious health, economic, and QOL consequences.

Design and Methods of a Randomized Trial of Continuous Glucose Monitoring in Persons With Type 1 Diabetes With Impaired Glycemic Control Treated With Multiple Daily Insulin Injections (GOLD Study)

BACKGROUND

The majority of individuals with type 1 diabetes today have glucose levels exceeding guidelines. The primary aim of this study was to evaluate whether continuous glucose monitoring (CGM), using the Dexcom G4 stand-alone system, improves glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections (MDI).

METHODS

Individuals with type 1 diabetes and inadequate glycemic control (HbA1c ≥ 7.5% = 58 mmol/mol) treated with MDI were randomized in a cross-over design to the Dexcom G4 versus conventional care for 6 months followed by a 4-month wash-out period. Masked CGM was performed before randomization, during conventional treatment, and during the wash-out period to evaluate effects on hypoglycemia, hyperglycemia, and glycemic variability. Questionnaires were used to evaluate diabetes treatment satisfaction, fear of hypoglycemia, hypoglycemia confidence, diabetes-related distress, overall well-being, and physical activity during the different phases of the trial. The primary endpoint was the difference in HbA1c at the end of each treatment phase.

RESULTS

A total of 205 patients were screened, of whom 161 were randomized between February and December 2014. Study completion is anticipated in April 2016.

CONCLUSIONS

It is expected that the results of this study will establish whether using the Dexcom G4 stand-alone system in individuals with type 1 diabetes treated with MDI improves glycemic control, reduces hypoglycemia, and influences quality-of-life indicators and glycemic variability.

Does low well-being modify the effects of PRISMA (Dutch DESMOND), a structured self-management-education program for people with type 2 diabetes?

AIMS

Diabetes self-management education improves behavioural and clinical outcomes in type 2 diabetes patients, however little is known about the modifying effects of well-being. This is relevant given high prevalence of depression and distress among diabetes patients. We aimed to test whether low well-being modifies the effects of the PRISMA self-management education program (Dutch DESMOND).

METHODS

297 primary care type 2 diabetes patients participated in the PRISMA observational study with a pre-post measurement design. Patients were grouped in low (n=63) and normal well-being (n=234). Low well-being was defined as either low mood (WHO-5<50) and/or high diabetes-distress (PAID-5>8). Outcome measures were: diabetes self-efficacy (CIDS), illness perception (IPQ) and diabetes self-care activities (SDSCA).

RESULTS

Improvements were found in illness perception (b=1.586, p<0.001), general diet (b=1.508, p=0.001), foot care (b=0.678, p=0.037), weekly average diet (b=1.140, p=0.001), creating action plan (b=0.405, p=0.007). Well-being interaction effects were found for general diet (p=0.009), weekly average diet (p=0.022), and creating an action plan (p=0.002).

CONCLUSIONS

PRISMA self-management education seems as effective for people with normal well-being as for people with low well-being. Further research should examine whether addressing mood and diabetes-distress as part of self-management education could reduce attrition and maintain or improve well-being among participants.

Do Climate Change Policies Promote or Conflict with Subjective Wellbeing: A Case Study of Suzhou, China

As public expectations for health rise, health measurements broaden from a focus on death, disease, and disability to wellbeing. However, wellbeing hasn’t been incorporated into the framework of climate change policy decision-making in Chinese cities. Based on survey data (n = 763) from Suzhou, this study used Generalized Estimation Equation approach to model external conditions associated with wellbeing. Then, semi-quantitative analyses were conducted to provide a first indication to whether local climate change policies promote or conflict with wellbeing through altering these conditions. Our findings suggested: (i) Socio-demographic (age, job satisfaction, health), psychosocial (satisfaction with social life, ontological security/resilience) and environmental conditions (distance to busy road, noise annoyance and range hoods in the kitchen) were significantly associated with wellbeing; (ii) None of existing climate change strategies in Suzhou conflict with wellbeing. Three mitigation policies (promotion of tertiary and high–tech industry, increased renewable energy in buildings, and restrictions on car use) and one adaption policy (increasing resilience) brought positive co–benefits for wellbeing, through the availability of high-satisfied jobs, reduced dependence on range hoods, noise reduction, and valuing citizens, respectively. This study also provided implications for other similar Chinese cities that potential consequences of climate change interventions for wellbeing should be considered.

Understanding the Areas and Correlates of Diabetes-Related Distress in Parents of Teens With Type 1 Diabetes

OBJECTIVE

To identify the unique areas of diabetes-related distress (DD) for parents of teens with type 1 diabetes and parent and teen characteristics associated with DD.

METHODS

Areas of DD were developed from structured interviews and translated into 46 survey items. Items were analyzed with exploratory factor analysis (EFA).

RESULTS

An EFA with 332 parents (88% mothers) reduced items to four Parent Diabetes Distress Scale (PDDS) factors (20 items, α = .94): Personal, Teen Management, Parent/Teen Relationship, and Healthcare Team Distress. Parent DD was higher among fathers, younger or single parents, parents of teens with higher hemoglobin A1c or severe low blood glucose levels, authoritarian parenting, depressive symptoms, and low emotional support.

CONCLUSIONS

4 areas of parent DD were identified using a newly developed measure, the PDDS. DD was associated with family demographic, teen diabetes status, and parent contextual factors, and can help identify parents who may be more vulnerable to DD.

Uptake and Effects of the e-Vita Personal Health Record with Self-Management Support and Coaching, for Type 2 Diabetes Patients Treated in Primary Care

We studied the use, uptake, and effects of e-Vita, a personal health record, with self-management support and personalized asynchronized coaching, for type 2 diabetes patients treated in primary care. Patients were invited by their practice nurse to join the study aimed at testing use and effects of a personal health record. Patients were followed up for 6 months. Uptake and usage were monitored using log data. Outcomes were self-reported diabetes self-care, diabetes-related distress, and emotional wellbeing. Patients' health status was collected from their medical chart. 132 patients agreed to participate in the study of which less than half (46.1%) did not return to the personal health record after 1st login. Only 5 patients used the self-management support program within the personal health record, 3 of whom asked a coach for feedback. Low use of the personal health record was registered. No statistical significant differences on any of the outcome measures were found between baseline and 6 month follow-up. This study showed minimal impact of implementing a personal health record including self-management support in primary diabetes care. Successful adoption of web-based platforms, as ongoing patient centered care, is hard to achieve without additional strategies aimed at enhancing patient motivation and engaging professionals.

The Italian Diabetes and Exercise Study 2 (IDES-2): a long-term behavioral intervention for adoption and maintenance of a physically active lifestyle

BACKGROUND

Physical activity (PA)/exercise have become an integral part of the management of type 2 diabetes mellitus (T2DM). However, current guidelines are difficult to put into action in this population due to a number of barriers, especially the lack of acceptable, feasible, and validated behavioral intervention strategies. The present manuscript reports the rationale, study design and methods, and design considerations of the Italian Diabetes and Exercise Study (IDES)-2, a randomized controlled trial testing the efficacy of a behavior change strategy in increasing total daily PA and reducing sedentary time (SED-time) in patients with T2DM.

METHODS/DESIGN

Starting 7 January 2014, the IDES_2 began enrolling 300 patients with known T2DM of at least 1-year duration in three tertiary referral outpatient Diabetes Clinics in Rome. Additional requirements are age 40 to 80 years, body mass index 27 to 40 kg/m(2), sedentary lifestyle, and physically inactive for at least 6 months, ability to walk 1.6 km without assistance, and eligibility after cardiovascular evaluation. Patients are randomized by center and within each center, by age and type of diabetes treatment to either the intervention or the control group. Patients in the intervention (INT) group (n = 150) receive theoretical and practical exercise counseling consisting of aggregated behavior change techniques (one individual theoretical counseling session plus eight twice-a-week individual theoretical and practical exercise counseling sessions) once a year for 3 years. Patients in the control (CON) group (n = 150), receive standard care, including general physician recommendations for daily PA. The primary outcomes are total daily PA and SED-time, as measured objectively by the use of an accelerometer. Secondary outcomes include physical fitness, modifiable cardiovascular risk factors, musculoskeletal disturbances, well-being/depression, and health-related quality of life.

DISCUSSION

The behavioral intervention strategy tested in the IDES_2 is based on solid theoretical grounds and uses several behavioral change techniques, two factors which were found to improve effectiveness of behavioral intervention. In addition, physicians and exercise specialists have been specifically trained for counselling/prescribing and supervising PA/exercise, respectively, in subjects suffering from metabolic disorders. Finally, the large sample size, the long study duration, and the objective measurement of PA allow statistically significant and scientifically robust conclusions to be drawn on the feasibility and efficacy of this intervention in T2DM patients.

TRIAL REGISTRATION

ClinicalTrials.gov; NCT01600937 ; 10 October 2012.

Impact of Resistance Training on Factors Involved in the Development of New-Onset Diabetes After Transplantation in Renal Transplant Recipients: An Open Randomized Pilot Study

OBJECTIVES

New-onsetdiabetes after transplant (NODAT) is a major contributor to cardiovascular disease after transplantation. Kidney transplantation (KT) recipients have low levels of exercise capacity. Resistance training (RT) might be of special benefit in this population because underlying disease and immunosuppressive drugs favour muscle loss and insulin resistance. The aim of this study was to assess the feasibility of implementing an RT program within a population of KT recipients and its impact on the incidence of NODAT and cardiometabolic risk factors.

METHODS

This pilot study was an open-randomized study. We randomized 24 patients with a 1:1 allocation to 2 parallel groups, the exercise group (E) or the control group (C). The E group was submitted to RT 3 times a week for 16 weeks. Anthropometric, body composition, cardiometabolic risk factors, muscle strength, cardiorespiratory fitness and well-being were measured before and after 16 weeks.

RESULTS

Of the 24 recruited participants, 20 completed the study (10 in the E group and 10 in the C group). No injuries were reported. The intervention was associated with a significant increase in muscle strength (p=0.003). A significant group effect, in favour of the E group, was detected for the well-being score (p=0.03). However, no changes in body composition, cardiometabolic risk factors or cardiorespiratory fitness were noted for either group after the intervention.

CONCLUSIONS

This pilot study suggests that RT appears to be secure and feasible and improves strength and well-being in patients after KT. However, it does not improve cardiometabolic risk factors.

Identifying the worries and concerns about hypoglycemia in adults with type 2 diabetes

AIMS

To identify the hypoglycemic concerns of adults with type 2 diabetes (T2D) and examine how these concerns are associated with key patient characteristics.

METHODS

Qualitative interviews with 16 T2D adults and 11 diabetes care providers were conducted. Survey items were then developed and submitted to exploratory factor analyses (EFAs). Construct validity was assessed by correlations with diabetes distress, anxiety and depressive symptoms, well-being, hypoglycemic fear, hypoglycemia history and glycemic control (A1C).

RESULTS

An EFA with 226 insulin users and 198 non-insulin users yielded 3 factors (14 items): Hypoglycemia Anxiety, Avoidance and Confidence. For both T2D groups, higher Anxiety and Avoidance were significantly associated with more hypoglycemia, lower well-being, and greater diabetes distress, depressive symptoms and hypoglycemic fear. Similar associations, in the converse direction, were found for Confidence. Among insulin users only, Anxiety was independently associated with greater emotional distress and more hypoglycemia, while Confidence was independently linked to less emotional distress and lower A1C. Avoidance was independently associated with greater emotional distress in both groups.

CONCLUSIONS

Using the new 14-item Hypoglycemic Attitudes and Behavior Scale (HABS), we found that hypoglycemic concerns are significant in T2D adults, are linked to emotional distress and A1C, and merit attention in clinical practice.

Development of a New Measure for Assessing Insulin Delivery Device Satisfaction in Patients with Type 1 and Type 2 Diabetes

BACKGROUND

Although many different types of insulin delivery devices are currently available, there is no well-accepted, validated method to assess patient satisfaction with these devices and their impact on quality of life and other patient-reported outcomes. To address this problem, we developed the Insulin Device Satisfaction Survey (IDSS) and herein describe its construction and validation. We then examine how key patient factors are associated with device satisfaction.

MATERIALS AND METHODS

Items were developed from interviews with adults with type 1 diabetes (T1D) (n=10) and type 2 diabetes (T2D) using insulin (n=10), as well as eight healthcare professionals, leading to an initial pool of 32 items. Separate exploratory factor analyses (EFAs) were conducted with T1D subjects (n=279) and insulin-using T2D subjects (n=209). Construct validity was established with overall well-being (World Health Organization-5), diabetes distress (Diabetes Distress Scale), diabetes self-efficacy (Self-Efficacy for Diabetes Management Scale), and subscales from the Insulin Delivery System Rating Questionnaire. Regression analyses examined associations between total scale satisfaction and demographics, insulin adherence, clinical indicators, and device type (pump vs. nonpump users).

RESULTS

The two EFAs resulted in a 14-item scale for T1D subjects and a 12-item scale for T2D subjects, with eight items common across both samples. The EFAs yielded three coherent, meaningful factors in each sample, accounting for 55.6% (T1D sample) and 64.1% (T2D sample) of the variance. Validity was established by significant correlations with all criterion variables. For both samples, higher IDSS scores were significantly associated with better glycemic control and greater insulin adherence and pump use. For T2D subjects only, IDDS scores were significantly linked to fewer long-term complications, fewer low blood glucose readings, and older age.

CONCLUSIONS

The IDSS is a reliable, valid measure of insulin device satisfaction in both its T1D form and T2 form. It provides a comprehensive profile of sources of device satisfaction for use in clinical care and research.

The detection and management of diabetes distress in people with type 1 diabetes

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30 %. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.

Development of a New Measure for Assessing Glucose Monitoring Device-Related Treatment Satisfaction and Quality of Life

BACKGROUND

Many different devices are available to patients to measure glucose levels, but there is no validated method to assess treatment satisfaction with glucose monitoring devices and its impact on quality of life and other patient-reported outcomes. To address this problem, we developed the Glucose Monitoring System Satisfaction Survey (GMSS). We describe the construction and validation of the GMSS and examine how key patient factors are associated with glucose device satisfaction.

MATERIALS AND METHODS

Items were developed from interviews with 15 adults with either type 1 diabetes (T1D) or type 2 diabetes (T2D) and 10 diabetes healthcare professionals, resulting in an initial pool of 42 items. Separate exploratory factor analyses (EFAs) were conducted with adults with T1D (n=254) and with insulin-using T2D (n=206). Construct validity was established with overall well-being (World Health Organization-5), diabetes distress (Diabetes Distress Scale), attitudes toward glucose monitoring (Self-Monitoring of Blood Glucose Obstacles scale), and the previously validated Blood Glucose Monitoring System Rating Questionnaire. Regression analyses examined associations between total scale satisfaction and demographics, diabetes status, and glucose monitor use.

RESULTS

The two EFAs resulted in two 15-item scales, one for T1D and one for T2D, and yielded four coherent and meaningful factors in each sample: three factors with the same items in common for both samples (Emotional Burden, Behavioral Burden, and Openness) and a fourth factor unique to each sample (Trust for T1D, Worthwhileness for T2D). The final EFA accounted for 66.5% of the variance in the T1D sample and 67.0% in the T2D sample. Validity was established by significant correlations with criterion variables.

CONCLUSIONS

The GMSS is a reliable, valid measure of glucose device satisfaction in its T1D form and in its insulin-using T2D form. It provides a comprehensive profile of sources of device satisfaction for use in clinical care and research.

The WHO-5 Well-Being Index: a systematic review of the literature

BACKGROUND

The 5-item World Health Organization Well-Being Index (WHO-5) is among the most widely used questionnaires assessing subjective psychological well-being. Since its first publication in 1998, the WHO-5 has been translated into more than 30 languages and has been used in research studies all over the world. We now provide a systematic review of the literature on the WHO-5.

METHODS

We conducted a systematic search for literature on the WHO-5 in PubMed and PsycINFO in accordance with the PRISMA guidelines. In our review of the identified articles, we focused particularly on the following aspects: (1) the clinimetric validity of the WHO-5; (2) the responsiveness/sensitivity of the WHO-5 in controlled clinical trials; (3) the potential of the WHO-5 as a screening tool for depression, and (4) the applicability of the WHO-5 across study fields.

RESULTS

A total of 213 articles met the predefined criteria for inclusion in the review. The review demonstrated that the WHO-5 has high clinimetric validity, can be used as an outcome measure balancing the wanted and unwanted effects of treatments, is a sensitive and specific screening tool for depression and its applicability across study fields is very high.

CONCLUSIONS

The WHO-5 is a short questionnaire consisting of 5 simple and non-invasive questions, which tap into the subjective well-being of the respondents. The scale has adequate validity both as a screening tool for depression and as an outcome measure in clinical trials and has been applied successfully across a wide range of study fields.

The social burden of hypoglycemia in the elderly

AIMS

The study aimed to evaluate the frequency of episodes of symptomatic hypoglycemia (SH) in elderly patients with type 2 diabetes and their impact on quality of life.

METHODS

The study was conducted in 12 Italian regions. Participants filled in a questionnaire collecting data on socio-demographic and clinical characteristics and episodes of SH occurred in the last 4 weeks. The questionnaire included validated scales measuring fear of hypoglycemia (FHQ), psychological well-being (WHO-5), and diabetes-related distress (PAID-5).

RESULTS

Overall, 1,323 participants were involved (mean age 70.0 ± 8.7, 47.6 % male, disease duration 15.6 ± 11.7, 63.2 % treated with oral agents, 16.9 % with insulin alone, 14.4 % with insulin plus oral agents), of whom 44.6 % reported 1-3 episodes of SH and 23.8 % reported more than 3 episodes. Patients who reported SH had significantly higher levels of fear of hypoglycemia, lower psychological well-being, and higher diabetes-related distress (p < 0.0001 for all the scales). At multivariate analysis, the experience of more than 3 episodes of hypoglycemia was associated with a 13-fold higher risk of high fear of hypoglycemia (aOR = 13.3; CI 95 % 8.4-21.0), an almost 60-fold higher risk of high diabetes-related distress (PAID-5 score ≥40) (aOR = 59.1; CI 95 % 29.2-119.8), and a higher risk of low psychological well-being (WHO-5 <50) (aOR = 1.5; CI 95 % 0.9-2.4).

CONCLUSIONS

The occurrence of symptoms of hypoglycemia is very common among older adults with diabetes and their presence is associated with an extremely negative impact on quality of life. Minimizing the risk of hypoglycemia represents a high priority in the diabetes treatment of elderly people.

Physical activity, depressed mood and pregnancy worries in European obese pregnant women: results from the DALI study

BACKGROUND

The purpose of this study was to examine the association between mental health status (i.e. depressed mood and pregnancy-related worries) and objectively measured physical activity levels in obese pregnant women from seven European countries.

METHODS

Baseline data from the vitamin D and lifestyle intervention for the prevention of gestational diabetes mellitus (DALI) study were used. Time spent in moderate-to-vigorous physical activity (MVPA) and sedentary behaviour was measured with accelerometers. Depressed mood was measured with the WHO well-being index (WHO-5) and pregnancy-related worries with the Cambridge Worry Scale (CWS). In addition, socio-demographic characteristics, lifestyle factors, and perceptions and attitude regarding weight management and physical activity were measured. Linear regression analyses were performed to assess the association of mental health status with MVPA and sedentary behaviour.

RESULTS

A total of 98 obese pregnant women from Austria, Belgium, Ireland, Italy, Poland, Spain and the Netherlands were included. Women had a mean age of 31.6 ± 5.8 years, a pre-pregnancy BMI of 34.1 ± 4.3 kg/m(2), and were on average 15.4 ± 2.8 weeks pregnant. WHO-5 scores indicative of depressed mood (<50) were reported by 27.1 % of the women and most frequently endorsed pregnancy-related worries pertained to own and the baby's health. Women with good well-being spent 85% more time in MVPA compared to women with a depressed mood (P = 0.03). No differences in MVPA levels were found for women with no, some, or many pregnancy worries. Depressed mood and pregnancy-related worries were not associated with sedentary behaviour.

CONCLUSIONS

These findings suggest that in pregnant women who are obese, a depressed mood, but not pregnancy-related worries, may be associated with less physical activity. The combined risk of poor mental health and low physical activity levels makes women vulnerable for pregnancy complications. Whether a depressed mood may be a barrier for improving physical activity warrants further study.

Effectiveness of a PLISSIT model intervention in patients with type 2 diabetes mellitus in primary care: design of a cluster-randomised controlled trial

Background

Sexual dysfunction is prevalent in patients with type 2 diabetes mellitus, but remains one of the most frequently neglected complications in diabetes care. Both patients and care providers appear to have difficulty with discussing sexual problems in diabetes care. A sexual counselling model for care providers, such as the PLISSIT model, might be a useful tool to improve the discussion of sexual issues in patients with type 2 diabetes mellitus. PLISSIT stands for Permission, Limited Information, Specific Suggestions, and Intensive Therapy. Even though the use of the PLISSIT model has often been recommended in diabetes care, no evidence with regards to its effectiveness in patients with type 2 diabetes mellitus exists. This study describes the design of a cluster-randomised controlled trial evaluating the effectiveness of a PLISSIT-model intervention in men and women with type 2 diabetes mellitus in primary care.

Methods/Design

Patients with type 2 diabetes mellitus, aged 40–75 years, who indicate to be dissatisfied about their sexual functioning and that they would like to talk about their sexual problem(s) with their general practitioner are recruited. All participants receive an information leaflet from the practice nurse. In the intervention group, each participant will also receive sexual counselling based on the PLISSIT model from their general practitioner. In the control group, usual care will be provided to those participants requesting an appointment with their general practitioner when the information leaflet was not deemed sufficient. Primary outcomes include sexual functioning, satisfaction about sexual function, and quality of life. Secondary outcomes are depressive symptoms, sexual distress, emotional well-being, and treatment satisfaction. Outcomes will be measured by means of self-report questionnaires at baseline, and after 3 and 12 months post-baseline. Treatment satisfaction will be assessed in telephone interviews.

Discussion

This paper describes the design of a cluster-randomised controlled trial that will investigate the effectiveness of a PLISSIT-model intervention in patients with type 2 diabetes mellitus in primary care. Our study will add important and currently missing insight into the effectiveness of PLISSIT on important patient-reported outcomes of men and women with type 2 diabetes mellitus.

Trial registration

Dutch Trial Registry NTR4807.

Understanding the sources of diabetes distress in adults with type 1 diabetes

AIMS

To identify the unique sources of diabetes distress (DD) for adults with type 1 diabetes (T1D).

METHODS

Sources of DD were developed from qualitative interviews with 25 T1D adults and 10 diabetes health care providers. Survey items were then developed and analyzed using both exploratory (EFA) and confirmatory CFA) analyses on two patient samples. Construct validity was assessed by correlations with depressive symptoms (PHQ8), complications, HbA1C, BMI, and hypoglycemia worry scale (HWS). Scale cut-points were created using multiple regression.

RESULTS

An EFA with 305 U.S. participants yielded 7 coherent, reliable sources of distress that were replicated by a CFA with 109 Canadian participants: Powerlessness, Negative Social Perceptions, Physician Distress, Friend/Family Distress, Hypoglycemia Distress, Management Distress, Eating Distress. Prevalence of DD was high with 41.6% reporting at least moderate DD. Higher DD was reported for women, those with complications, poor glycemic control, younger age, without a partner, and non-White patients.

CONCLUSIONS

We identified a profile of seven major sources of DD among T1D using a newly developed assessment instrument. The prevalence of DD is high and is related to glycemic control and several patient demographic and disease-related patient characteristics, arguing for a need to address DD in clinical care.

Neighborhood epidemiological monitoring and adult mental health: European Quality of Life Survey, 2007-2012

Little is monitored on perceived neighborhood noise, quality of drinking water, air quality, rubbish, traffic, etc. at a continental scale. This study was aimed to examine the relationships of such neighborhood risks and mental health in adults and the very old in an international and population-based setting across Europe. Data were retrieved from the European Quality of Life Survey, 2007-2012 including demographics, living conditions, income and financial situation, housing and local environment, family, work, health, social participation and quality of social services. Adults aged 18 and above were included for statistical analysis (n = 79,270). Analysis included chi-square test, t test and logistic regression modeling. People who lived in town or city tended to indicate certain major problems for them such as noise (odds ratio (OR) 2.34, 95% confidence interval (CI) 2.17-2.53, P < 0.001), air quality (OR 2.76, 95% CI 2.54-3.00, P < 0.001), low quality of drinking water (OR 1.33, 95% CI 1.23-1.43, P < 0.001), crime and/or violence (OR 2.92, 95% CI 2.68-3.19, P < 0.001), rubbish (OR 3.68, 95% CI 3.41-3.97, P < 0.001) and traffic congestion (OR 2.64, 95% CI 2.45-2.85, P < 0.001). People who reported major problems on noise (OR 2.19, 95% CI 1.96-2.45, P < 0.001), air quality (OR 2.11, 95% CI 1.87-2.37, P < 0.001), low quality of drinking water (OR 2.40, 95% CI 2.14-2.68, P < 0.001), crime and/or violence (OR 2.13, 95% CI 1.88-2.41, P < 0.001), rubbish (OR 1.98, 95% CI 1.77-2.11, P < 0.001) and traffic congestion (OR 1.50, 95% CI 1.34-1.68, P < 0.001) were also classified as having depression. Perceived neighborhood conditions were associated with adult mental health across Europe. Future neighborhood monitoring research moving from the etiological to neighborhood management would be suggested.

Wellbeing impacts of city policies for reducing greenhouse gas emissions

To mitigate climate change, city authorities are developing policies in areas such as transportation, housing and energy use, to reduce greenhouse gas emissions. In addition to their effects on greenhouse gas emissions, these policies are likely to have consequences for the wellbeing of their populations for example through changes in opportunities to take physical exercise. In order to explore the potential consequences for wellbeing, we first explore what ‘wellbeing’ is and how it can be operationalized for urban planners. In this paper, we illustrate how wellbeing can be divided into objective and subjective aspects which can be measured quantitatively; our review of measures informs the development of a theoretical model linking wellbeing to policies which cities use to reduce greenhouse gas emissions. Finally, we discuss the extent to which the links proposed in the conceptual model are supported by the literature and how cities can assess wellbeing implications of policies.

Benchmarking network for clinical and humanistic outcomes in diabetes (BENCH-D) study: protocol, tools, and population

Background

In the context of the DAWN-2 initiatives, the BENCH-D Study aims to test a model of regional benchmarking to improve not only the quality of diabetes care, but also patient-centred outcomes.

Methods/Design

As part of the AMD-Annals quality improvement program, 32 diabetes clinics in 4 Italian regions extracted clinical data from electronic databases for measuring process and outcome quality indicators. A random sample of patients with type 2 diabetes filled in a questionnaire including validated instruments to assess patient-centred indicators: SF-12 Health Survey, WHO-5 Well-Being Index, Diabetes Empowerment Scale, Problem Areas in Diabetes, Health Care Climate Questionnaire, Patients Assessment of Chronic Illness Care, Barriers to Medications, Patient Support, Diabetes Self-care Activities, and Global Satisfaction for Diabetes Treatment. Data were discussed with participants in regional meetings. Main problems, obstacles and solutions were identified through a standardized process, and a regional mandate was produced to drive the priority actions. Overall, clinical indicators on 78,854 patients have been measured; additionally, 2,390 patients filled-in the questionnaire. The regional mandates were officially launched in March 2012. Clinical and patient-centred indicators will be evaluated again after 18 months. A final assessment of clinical indicators will take place after 30 months.

Discussion

In the context of the BENCH-D study, a set of instruments has been validated to measure patient well-being and satisfaction with the care. In the four regional meetings, different priorities were identified, reflecting different organizational resources of the different areas. In all the regions, a major challenge was represented by the need of skills and instruments to address psychosocial issues of people with diabetes. The BENCH-D study allows a field testing of benchmarking activities focused on clinical and patient-centred indicators.

Web-based self-management with and without coaching for type 2 diabetes patients in primary care: design of a randomized controlled trial

BACKGROUND

Self-management is recognized as the cornerstone of overall diabetes management. Web-based self-management programs have the potential of supporting type 2 diabetes patients with managing their diabetes and reducing the workload for the care provider, where the addition of online coaching could improve patient motivation and reduce program attrition. This study aims to test the hypothesis that a web-based self-management program with coaching will prove more effective on improving patient self-management behavior and clinical outcome measures than a web-based self-management program without coaching.

METHODS

The effects of a web-based self-management program with and without coaching will be tested with a nested randomized controlled trial within a healthcare group in the Netherlands. In one year 220 type 2 diabetes patients will be randomized into an intervention group (n = 110) or a control group (n = 110). The control group will receive only the online self-management program. The intervention group will receive the online self-management program and additional online coaching. Participants will be followed for one year, with follow-up measurements at 6 and 12 months.

DISCUSSION

The intervention being tested is set to support type 2 diabetes patients with their diabetes self-management and is expected to have beneficial effects on self-care activities, well being and clinical outcomes. When proven effective this self-management support program could be offered to other health care groups and their type 2 diabetes patients in the Netherlands.

TRIAL REGISTRATION

Nederlands Trial Register NTR4064.