The association between problem areas in diabetes scale scores and glycemic control is modified by types of diabetes therapy: diabetes distress and care registry in Tenri (DDCRT 2)

Implications of Patient-Reported Outcome Measures among patients with recently diagnosed type 2 diabetes

BACKGROUND

For the past two decades, the assessment of the quality of diabetes care has mostly relied on clinical quality indicators. These have not included Patient-Reported Outcome Measures (PROMs) which provide information on outcomes deemed valuable by patients. We aimed to examine the potential utility of PROMs in type 2 diabetes care and to study the association of PROMs with patients' characteristics and clinical quality indicators.

METHODS

A cross-sectional survey of recently (≤ 4 years) diagnosed patients with type 2 diabetes (n = 392) in the setting of a large health plan. PROMs were based on two well-validated questionnaires, the Problem Areas in Diabetes (PAID) one-page questionnaire that measures diabetes-related distress, and the ten item PROMIS-10 global health questionnaire that measures general health. Additional items were added following a previous qualitative study among Israeli patients with diabetes. The survey was carried out using phone interviews, and data collected were linked to the electronic medical records. Multivariable regression models were used to assess the associations of socio-demographic variables and clinical quality indicators with the PROMs.

RESULTS

About a fifth of participants (22%) had high diabetes-related distress (PAID score ≥ 40), a third reported that they did not feel confident in self-management of diabetes and about a third reported having sexual dysfunction. Women, younger patients, and those with a low education level (≤ 12 years) reported worse general health, were more likely to experience high diabetes-related distress, and to have low confidence in diabetes self-management. Interestingly, performance of all seven diabetes quality indicators was associated with worse general health and high diabetes-related distress. Of note, levels of glycated hemoglobin, LDL-cholesterol, or blood pressure were not associated with PROMs.

CONCLUSIONS

PROMs provide important information on patient self-reported health status and are likely to reflect aspects of the quality of care that are not otherwise available to clinicians. Thus, the use of PROMs has the potential to expand the evaluation of diabetes care and promote patient-centered care. We recommend that policy-makers in the Ministry of Health and health maintenance organizations implement PROMs for assessing and improving the care for patients with type 2 diabetes.

Efficacy and safety of a telemedicine system in subjects with gestational diabetes mellitus (TELEGLAM): Study protocol for a randomized controlled trial

Background

Strict glycemic control is important to prevent perinatal complications in patients with gestational diabetes mellitus (GDM). Patients often require insulin injection, and frequent hospital visits are necessary to adjust the dose of insulin, which is considered burdensome for pregnant patients. Telemedicine may reduce the burden of hospital visits, and previous studies have reported its safety in GDM patients. This study aimed to evaluate the efficacy of telemedicine in GDM patients, focusing on patient satisfaction and health economic indicators.

Methods

This is a single-center, two-arm, randomized, open-label parallel-group study. Subjects will be selected from the patient population attending the Department of Endocrinology, Metabolism, and Nephrology, Keio University School of Medicine, Japan. Patients diagnosed with GDM by an oral glucose tolerance test (OGTT) by 29 weeks and 6 days of gestation who have undergone self-monitoring of blood glucose (SMBG) and insulin injection are eligible for inclusion. In the intervention group, telemedicine will be administered using the MeDaCa telemedicine system developed by the Medical Data Card, Inc., Tokyo, Japan. Subjects in the control group will be examined face-to-face every 2-3 weeks, as usual. We set health economic indicators and patient satisfaction as the primary endpoints, and will perform a cost-consequence analysis. Glycemic control indicators and perinatal outcomes will be evaluated as secondary endpoints.

Conclusions

Eligible patients are currently being recruited. Recruitment will be completed when the expected number of patients are enrolled.

Diabetes Distress Is Associated With Future Risk of Progression of Diabetic Nephropathy in Adults With Type 2 Diabetes: A Prospective Cohort Study (Diabetes Distress and Care Registry at Tenri [DDCRT23])

OBJECTIVES

Our aim in this study was to investigate the prospective association between diabetes distress assessed with Problem Areas in Diabetes (PAID) survey scores at baseline and the subsequent risk of development or progression of diabetic nephropathy in people with type 2 diabetes.

METHODS

Longitudinal data were acquired from 2,845 individuals with type 2 diabetes registered in a Japanese diabetes registry. A Cox proportional hazards model was used to adjust for possible confounders to examine the prospective association between baseline diabetes distress (PAID score ≥40) and the development or progression of albuminuria.

RESULTS

Mean patient age, body mass index, and glycated hemoglobin level were 64.8 years, 24.5 kg/m2, and 57.4 mmol/mol (7.5%), respectively. We did not observe a significant association between diabetes distress and the subsequent risk of diabetic nephropathy development from normoalbuminuria to microalbuminuria/macroalbuminuria (multivariable-adjusted hazard ratio [HR]=0.95 over 4.2 years, 95% confidence interval [CI] 0.77 to 1.17, p=0.640); however, we identified a significant association for progression from microalbuminuria to macroalbuminuria (multivariable-adjusted HR=1.34 over 7.0 years, 95% CI 1.01 to 1.80, p=0.045). Stratification by sex revealed a significant association between diabetes distress and the subsequent risk of progressing diabetic nephropathy (HR=1.45, 95% CI 1.06 to 1.98, p=0.019) in males, but not females (HR=1.42, 95% CI 0.95 to 2.14, p=0.087).

CONCLUSIONS

Diabetes distress at baseline, assessed using the PAID survey, was associated with a subsequent risk of progressing diabetic nephropathy independent of possible confounders in males, but not females, with type 2 diabetes.

Quality of Life in University Students with Diabetes Distress: Type 1 and Type 2 of Diabetes Differences

BACKGROUND

This study constitutes a preliminary trial to clarify the relationship between quality of life (QoL) and diabetes distress (DD in patients with diabetes mellitus (DM) by comparing patients with type 1 and type 2 diabetes.

METHODS

A cross-sectional study of university students with diabetes (type 1 and type 2) diabetes. One hundred sixty-six students were assigned to participate in this study. A self-report questionnaire on demographic and clinical parameters was taken. Rating worries and anxieties related to diabetes were evaluated using the diabetes distress scale-17, and quality of life was tested using SF-36 v2.

RESULTS

No significant differences were observed in the level of DD according to sociodemographics in type 1 DM (T1DM) and type 2 DM (T2DM) (p > 0.05). The mean scores for Physical Component Summary (PCS) and Mental Component Summary (MCS) and six subscales of the SF-36 v2 demonstrated no significant differences between T1DM and T2DM (p > 0.05). High scores of diabetes distress were independently associated with lower glycemic control for students with both types of diabetes. Likewise, high scores of distress were associated with lower PCS (p < 0.05). Additionally, the results showed that high scores of diabetes distress were associated with lower MCS (p < 0.05).

CONCLUSIONS

University students with diabetes showed a high level of DD with no significant differences between both types of diabetes; this consequently affects all components of QoL. Psychological support is the better choice for those students for better health and future career.

Use of Real-Time Continuous Glucose Monitoring Improves Glycemic Control and Other Clinical Outcomes in Type 2 Diabetes Patients Treated with Less Intensive Therapy

Objective: Use of real-time continuous glucose monitoring (rtCGM) has been shown to improve glycemic control in patients with type 2 diabetes (T2D) who are treated with intensive insulin therapy. However, most T2D patients are denied coverage for rtCGM due to failure to meet payer eligibility requirements: treatment with ≥3 insulin injections (or pump) and history of 4 × /day blood glucose testing. We investigated the relevance of these criteria to successful rtCGM use. Methods: This 6-month, prospective, interventional, single-arm study assessed the clinical effects of use rtCGM in patients with T2D treated with basal insulin only or noninsulin therapy. Primary outcomes were changes in HbA1c, average glucose, glycemic variability (% coefficient of variation), and percent of time in range (%TIR), below range (%TBR) and above range (%TAR). Results: Thirty-eight patients were included in the analysis (10.1% ± 1.8% HbA1c, 54.7 ± 10.2 years, 35.6 ± 6.4 body mass index). At 6 months, we observed reductions in HbA1c (-3.0% ± 1.3%, P < 0.001) and average glucose (-23.6 ± 38.8, P < 0.001). %TIR increased 15.2 ± 22.3, from 57.0 ± 29.9 to 72.2 ± 23.6, P < 0.001, with all patients maintaining %TBR targets (<4% at 70 mg/dL, <1% at <54 mg/dL). No changes in glycemic variability were observed. The greatest improvements in %TIR and %TAR were seen in patients treated with ≤1 medication. Conclusions: rtCGM use was associated with significant glycemic improvements in T2D patients treated with basal insulin only or noninsulin therapy. Given the growing body of evidence supporting rtCGM use in this population, insurance eligibility criteria should be modified to expand rtCGM use by T2D patients treated with less intensive therapies.

The Impact of Diabetes Distress on the Glycemic Control Among Adolescents and Youth With Type 1 Diabetes in Two Tertiary Centers, Jeddah, Saudi Arabia

Introduction

Adolescents with type 1 diabetes (T1D) experience multiple symptoms of diabetes distress including fear of acute complications such as severe hypoglycemia which may lead to permanent brain damage or death. They also experience fear of acute hyperglycemia that can lead to diabetic ketoacidosis as well as chronic complication including diabetic nephropathy and retinopathy. No previous research was conducted in Saudi Arabia to assess diabetes distress among adolescents and youth with T1D. This study aimed to assess diabetes distress in adolescents and youth with T1D and its relation to clinical characteristics, glycemic control and diabetes co-morbidities.

Methodology

A cross-sectional study was conducted on 158 patients at King Abdulaziz University Hospital and Dr. Erfan and Bagedo General Hospital, Jeddah, Saudi Arabia. Data about participants’ characters, episodes of DKA, last HbA1c level, diabetes co-morbidities were collected. Diabetes distress (DD) was assessed by the Problem Areas in Diabetes (PAID) and Diabetes Distress Scale (DDS) scores.

Results

The prevalence of diabetes distress among our population of adolescents with T1D was 24.1%. The mean scores of PAID and DDS were 43.56 ± 13.84 and 2.22 ± 1.05, respectively. Patients with suboptimal HbA1c had significantly higher mean PAID and DDS scores. There is also a significant positive correlation between HbA1c level and number of ketoacidosis episodes. A highly significant positive correlation was found between PAID and DDS scores.

Conclusion

This study found that participants with uncontrolled HbA1c had significantly higher mean PAID and DDS scores with a significant positive correlation between the last HbA1c measured level and number of ketoacidosis attacks and PAID and DDS scores. Future studies on larger samples are needed to implement interventions to minimize the burden of diabetes distress among adolescents with T1D.

Evolving Use of Continuous Glucose Monitoring Beyond Intensive Insulin Treatment

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) use in individuals with type 1 diabetes and type 2 diabetes (T2D) who are treated with intensive insulin therapy. A growing body of evidence suggests that CGM use may also confer similar glycemic benefits in T2D individuals who are treated with less-intensive therapies. Investigators are also exploring the potential use of CGM as an aid in weight management. This article reviews the continuing evolution of CGM, focusing on how CGM may be used to improve glycemic control and promote adoption of desired health behaviors within broader T2D and prediabetes populations.

Comparison of Patient-Led and Physician-Led Insulin Titration in Japanese Type 2 Diabetes Mellitus Patients Based on Treatment Distress, Satisfaction, and Self-Efficacy: The COMMIT-Patient Study

INTRODUCTION

In Japan, patient-led insulin titration is rare in type 2 diabetes mellitus (T2DM) patients. Few studies have compared the effects of patient-led versus physician-led insulin titration on patient-reported outcomes in Japanese T2DM patients. This study aimed to compare the effects of patient-led and physician-led insulin titration in Japanese insulin-naïve T2DM patients on safety, glycemic control, and patient-reported outcomes (emotional distress, treatment satisfaction, and self-efficacy).

METHODS

Ultimately, 125 insulin-naïve Japanese T2DM patients were randomly assigned to either a patient-led insulin self-titration group or a physician-led insulin titration group and monitored for 24 weeks. The primary endpoint was a change in emotional distress as measured using the Problem Areas in Diabetes scale (PAID). Secondary endpoints included treatment satisfaction, as measured with the Diabetes Treatment Satisfaction Questionnaire (DTSQ), self-efficacy as measured using the Insulin Therapy Self-Efficacy Scale (ITSS), glycated hemoglobin (HbA1c) levels, fasting plasma glucose levels, body weight, insulin daily dose, and frequency of hypoglycemia.

RESULTS

There was no significant difference between the groups in PAID and DTSQ scores. The results for the primary endpoint should be interpreted taking account that the sample size for the power calculation was not reached. ITSS scores were significantly higher in the patient-led self-titration group. HbA1c and fasting plasma glucose levels were significantly decreased in both groups, but the decrease was significantly larger in the patient-led self-titration group. Although the insulin daily dose was significantly higher in the patient-led self-titration group, severe hypoglycemia did not occur in either group, and the frequency of hypoglycemia was similar in both groups.

CONCLUSION

Self-measurement of blood glucose and self-titration of insulin enhanced the patients' self-efficacy without compromising their emotional distress or treatment satisfaction. Also, insulin self-titration was found to be safe and effective; it resulted in better glycemic control without severe hypoglycemia.

TRIAL REGISTRATION

University Hospital Medical Information Network Clinical Trials Registry (UMIN-CTR) (registration number: UMIN000020316).

The joint association of diabetes distress and depressive symptoms with all-cause mortality in Japanese individuals with type 2 diabetes: a prospective cohort study (Diabetes Distress and Care Registry in Tenri [DDCRT 20])

AIMS/HYPOTHESIS

The independent association of depressive symptoms and diabetes distress with mortality risk in individuals with diabetes has not been evaluated. We examined the temporal joint association of diabetes distress and depressive symptoms at baseline and the subsequent risk of all-cause mortality.

METHODS

The longitudinal data of 3118 individuals with type 2 diabetes were obtained from a large Japanese diabetes registry. To assess the joint association of diabetes distress and depressive symptoms at baseline with the subsequent risk of all-cause mortality, the Cox proportional hazards model was used with adjustment for potential confounders.

RESULTS

The mean age, BMI and HbA_1c levels were 64.7 years, 24.6 kg/m² and 58.6 mmol/mol (7.5%), respectively, and 38.1% of the participants were women. In the multivariable-adjusted models evaluating the diabetes distress and depressive symptoms separately, the HRs for all-cause mortality were 1.67 (95% CI 1.14, 2.43; p = 0.008) and 1.40 (95% CI 1.05, 1.85; p = 0.020), respectively. In such models evaluating the joint association of diabetes distress and depressive symptoms, compared with individuals without diabetes distress or depressive symptoms (DD^-/DS^-), the HRs for all-cause mortality for the group without diabetes distress but with depressive symptoms (DD^-/DS⁺), with diabetes distress but without depressive symptoms (DD⁺/DS^-), and with diabetes distress and depressive symptoms (DD⁺/DS⁺) were 1.34 (95% CI 0.99, 1.86; p = 0.056), 1.96 (95% CI 1.10, 3.50; p = 0.023) and 1.71 (95% CI 1.06, 2.77; p = 0.029), respectively. We did not observe a significant interaction between diabetes distress and depressive symptoms with all-cause mortality risk (p = 0.2636). In the stratified analysis by sex, a significant joint association of diabetes distress and depressive symptoms with the risk of all-cause mortality was observed only in men.

CONCLUSIONS/INTERPRETATION

Diabetes distress and depressive symptoms were independently associated with all-cause mortality risk in male participants with type 2 diabetes, but we did not observe a significant interaction between diabetes distress and depressive symptoms in relation to all-cause mortality. Graphical abstract.

Psychosocial distress, clinical variables and self-management activities associated with type 2 diabetes: a study in Ghana

Aim

Psychosocial distress can act as a barrier to diabetes self-care management and thus compromise diabetes control. Yet in Ghana, healthcare centres mainly focus on the medical aspect of diabetes to the neglect of psychosocial care. This study determined the relationship amongst psychosocial distress, clinical variables, and self-management activities associated with type 2 diabetes management.

Method

Questionnaires were administered to 162 patients from four hospitals in Accra, Ghana, to assess psychosocial distress (e.g. diabetes distress), clinical variables (e.g. glycaemic control), and self- management activities (e.g. medication intake) related to diabetes. In assessing diabetes distress, the use of the PAID allowed evaluation of broader range of emotional concerns (diabetes-related emotional distress), while the DDS allowed evaluation of factors more closely related to diabetes self-management (diabetes distress).

Results

Diabetes-related emotional distress, diabetes distress and depressive symptoms were reciprocally positively correlated, while non-supportive family behaviour correlated negatively with these psychological variables. Diabetes-related emotional distress correlated positively with systolic and diastolic blood pressure, and correlated negatively with exercise regimen. On the other hand, diabetes distress correlated negatively with dietary and exercise regimen and correlated positively with glycaemic levels, while depressive symptoms correlated positively with glycaemic levels, diabetes complication and systolic blood pressure. Contrary to the literature, non-supportive family behaviour correlated positively with diet, exercise and medication regimen.

Conclusion

The positive association of psychological variables with glycaemic levels and blood pressure levels, and the positive association of non-supportive family behaviour with self-management activities suggests the need for psychosocial care to be incorporate in the management of type 2 diabetes in Ghana. Patients can be screened for diabetes-related distress and symptoms of depression and provided psychosocial care where necessary.

Association between diabetes distress and all-cause mortality in Japanese individuals with type 2 diabetes: a prospective cohort study (Diabetes Distress and Care Registry in Tenri [DDCRT 18])

AIMS/HYPOTHESIS

The absence of data on the direct association between diabetes-specific distress and all-cause mortality in individuals with diabetes prompted us to examine the temporal association between Problem Areas in Diabetes (PAID) survey scores and the subsequent risk of all-cause mortality in a cohort of individuals with type 2 diabetes.

METHODS

Longitudinal data from 3305 individuals with diabetes were obtained from a large Japanese diabetes registry. Independent correlations between quintiles of PAID total scores or PAID scores of ≥40 and all-cause mortality (median follow-up of 6.1 years) were examined using Cox proportional hazards models with adjustment for potential confounders.

RESULTS

The study population included 1280 women and 2025 men with a mean age of 64.9 years, BMI of 24.6 kg/m² and HbA_1c level of 58.7 mmol/mol (7.5%). In the multivariable-adjusted model, compared with the first quintile of PAID scores, the multivariable-adjusted HRs (95% CIs) for all-cause mortality for the second to fifth quintiles were 1.11 (0.77, 1.60; p = 0.56), 0.87 (0.56, 1.35; p = 0.524), 0.95 (0.63, 1.46; p = 0.802) and 1.60 (1.09, 2.36; p = 0.016), respectively. Compared with a PAID score of <40, the multivariable-adjusted HR for all-cause mortality of those with a score of ≥10 was 1.56 (95% CI 1.17, 2.08; p = 0.002). In subgroup analyses, the association between PAID score and all-cause mortality was found in men (HR 1.76; 95% CI 1.26, 2.46) but not in women (HR 1.09; 95% CI 0.60, 2.00), with a significant interaction between diabetes distress and sex (p = 0.0336).

CONCLUSIONS/INTERPRETATION

We observed a significant positive association between high diabetes distress and all-cause mortality in men with diabetes.

Real-life glycemic control in patients with type 2 diabetes treated with insulin therapy: A prospective, longitudinal cohort study (Diabetes Distress and Care Registry at Tenri [DDCRT 9])

AIMS/INTRODUCTION

We investigated the association between four insulin regimens, and increase in glycated hemoglobin (HbA1c) and insulin dose in a real-life clinical setting because there are no data about them among insulin regimens.

MATERIALS AND METHODS

Participants included 757 patients with type 2 diabetes having been treated with insulin therapy for more than 1 year. The four insulin regimens were regimen 1 (long-acting insulin, once daily), regimen 2 (biphasic insulin, twice daily), regimen 3 (biphasic insulin, three times daily) and regimen 4 (basal-bolus therapy). Main outcomes were increases in HbA1c levels >0.5% and increases in daily insulin units after 1 year. We carried out multivariable analyses to examine differences in glycemic control and insulin dose with adjustment for possible confounders.

RESULTS

Mean HbA1c level and duration of insulin therapy were 7.8% and 11.3 years, respectively. HbA1c levels increased by >0.5% at follow up in 22.8, 24.9, 20.7, and 29.3% of participants using regimen 1, 2, 3 and 4, respectively, with no significant differences between groups. Daily insulin doses increased in 62.3, 68.8, 65.3 and 38.6% of patients, respectively (P < 0.001). Multivariable regression analysis showed that patients who received regimen 4 had significantly lower odds of requiring future insulin dose increases than those who had received regimen 2 (adjusted odds ratio 0.24, 95% confidence interval 0.14-0.41; P < 0.001).

CONCLUSIONS

Many patients receiving insulin therapy showed increases in HbA1c levels and insulin doses 1 year later. The smallest increase in insulin dose was observed in the basal-bolus therapy group compared with other regimens.

Association of diabetes therapy-related quality of life and physical activity levels in patients with type 2 diabetes receiving medication therapy: the Diabetes Distress and Care Registry at Tenri (DDCRT 17)

AIM

To examine the association between diabetes therapy-related quality of life (DTR-QOL) and physical activity levels, and identify factors associated with high diabetes therapy-related quality of life.

METHODS

Cross-sectional data from 2970 patients with type 2 diabetes in a Japanese diabetes registry were assessed for independent correlations between DTR-QOL (domains 1-4) and high physical activity levels. Data collected by the International Physical Activity Questionnaire were analyzed by logistic regression and adjusted for potential confounders.

RESULTS

The mean patient age, BMI and HbA1c level were 65.8 years, 24.7 kg/m² and 7.6% (58.7 mmol/mol), respectively. Univariate analysis showed that DTR-QOL domain 1, 2 and 4 scores were significantly associated with physical activity levels (p = 0.0046, p = 0.0004 and p < 0.001, respectively, but domain 3 score was not (p = 0.5073). In a multivariable-adjusted logistic regression model, odds ratios (ORs) of DTR-QOL domains 1, 3 and 4 were independently associated with high physical activity (ORs for 2nd to 4th quartile and p for trend; [domain 1] 1.16, 1.56, 1.22, p = 0.032; [domain 3] 1.45, 1.55, 1.38, p = 0.049; [domain 4] 1.09, 1.30, 1.51, p = 0.001, respectively), but domain 2 was not (ORs for 2nd to 4th quartile and p for trend; 1.19, 1.26, 1.23, p = 0.096).

CONCLUSION

High diabetes therapy-related QOL scores were associated with high levels of physical activity in patients with type 2 diabetes. Because this is a cross-sectional study, further study is needed to evaluate the causal association between therapy-related QOL and physical activity.

Diabetes-related distress and its associated factors among patients with type 2 diabetes mellitus in China

Diabetes-related distress is one of the psychological disorders affecting patients with diabetes, yet there are few studies about diabetes-related distress in Chinese patients. To assess the level of psychological distress and examine its associated factors, we conducted a cross-sectional analysis of patients with type 2 diabetes mellitus from a Chinese tertiary hospital. The Diabetes Distress Scale (DDS) and the General Self-Efficacy Scale (GSES) were administered. There were 210 (57.85%) patients with little or no diabetes-related distress, 84 (23.14%) with moderate diabetes-related distress and 69 (19.01%) with high diabetes-related distress. Stepwise multiple linear regression showed that sleep time was significantly related to the DDS total score and the subscale scores of emotional burden (EB) (β=-0.190, -0.379), respectively. GSES was associated with the DDS total score (β=-0.128) and the EB score (β=-0.153). Oral medication plus insulin was significantly related to regimen-related distress (RD) (β=0.137), physician-related distress (PD) (β=0.152) and interpersonal distress (ID) (β=0.103). Physical activity (β=-0.185) and making meal plan with health care professionals(HCP) (β=-0.169) were associated with RD. The prevalence of diabetes-related distress among patients with type 2 diabetes mellitus was high in China. DDS and EB were associated with poorer sleep time and lower self-efficacy. Interventions to improve sleep are needed. Qualitative and longitudinal studies are required to understand why type 2 diabetic patients are not getting enough sleep.

Higher levels of physical activity are independently associated with a lower incidence of diabetic retinopathy in Japanese patients with type 2 diabetes: A prospective cohort study, Diabetes Distress and Care Registry at Tenri (DDCRT15)

We assessed the prospective association between baseline levels of physical activity (PA) and the incidence of newly developed diabetic retinopathy (DR) in patients with type 2 diabetes. Data from 1,814 patients with type 2 diabetes without DR were obtained from a Japanese diabetes registry at Tenri Hospital, Nara, Japan. To assess the independent correlations between baseline PA levels and newly developed DR, the participants were divided into five categories based on their PA levels. A Cox proportional hazards model with time-varying exposure information was used and adjusted for potential confounders to assess the independent correlations. At baseline, the mean age, BMI, and hemoglobin A1c levels of the patients were 65.5 years, 24.5 kg/m2, and 7.2% (54 mmol/mol), respectively. After 2 years, newly developed DR was confirmed in 184 patients (10.1%). Patients with newly developed DR had longer duration of type 2 diabetes (14.7 versus 11.0 years, p < 0.0001), higher systolic blood pressure (139.2 versus 135.1 mmHg, p = 0.0012), lower estimated glomerular filtration rate (74.0 versus 77.1 mL/min/1.73 m2, p = 0.0382), greater urinary albumin-creatinine ratio (4.00 versus 2.45 mg/mmol, p < 0.0039), and higher HbA1c levels (7.5 versus 7.2%, p = 0.0006) than those without newly developed DR. The multivariable-adjusted hazard ratios for DR development were 0.87 (95% CI, 0.53-1.40; p = 0.557), 0.83 (95% CI, 0.52-1.31; p = 0.421), 0.58 (95% CI, 0.35-0.94; p = 0.027), and 0.63 (95% CI, 0.42-0.94; p = 0.025)for the second, third, fourth, and fifth PA categories, respectively, compared with the reference category of patients with a mean PA of 0 metabolic equivalent of task-hours/week). Higher PA levels are independently associated with a lower incidence of DR in Japanese patients with type 2 diabetes.

Willingness of patients with diabetes to use an ICT-based self-management tool: a cross-sectional study

OBJECTIVES

To examine the prevalence of the willingness of patients with diabetes to use a self-management tool based on information and communication technology (ICT) such as personal computers, smartphones, and mobile phones; and to examine the patient characteristics associated with that willingness.

RESEARCH DESIGN AND METHODS

We conducted a cross-sectional interview survey of 312 adults with diabetes at a university hospital in an urban area in Japan. Participants were classified into 2 groups: those who were willing to use an ICT-based self-management tool and those who were unwilling. Multiple logistic regression analysis was used to identify factors associated with the willingness, including clinical and social factors, current use of ICT, self-management practices, self-efficacy, and diabetes-related emotional distress.

RESULTS

The mean age of the 312 participants was 66.3 years (SD=11.5) and 198 (63%) were male. Most of the participants (93%) had type 2 diabetes. Although only 51 (16%) currently used ICT-based self-management tools, a total of 157 (50%) expressed the willingness to use such a tool. Factors associated with the willingness included: not having nephropathy (OR=2.02, 95% CI 1.14 to 3.58); outpatient visits once a month or more (vs less than once a month, OR=2.13, 95% CI 1.13 to 3.99); current use of personal computers and/or smartphones (OR=4.91, 95% CI 2.69 to 8.98); and having greater diabetes-related emotional distress (OR=1.10, 95% CI 1.01 to 1.20).

CONCLUSIONS

Approximately half of the patients showed interest in using an ICT-based self-management tool. Willing patients may expect ICT-based self-management tools to complement outpatient visits and to make self-management easier. Starting with patients who display the willingness factors might optimize programs based on such tools.

Association of serum uric acid levels with the risk of development or progression of albuminuria among Japanese patients with type 2 diabetes: a prospective cohort study [Diabetes Distress and Care Registry at Tenri (DDCRT 10)]

AIMS

To assess the prospective association between baseline serum uric acid level and subsequent risk of development or progression in albuminuria.

METHODS

Longitudinal data were obtained from 2518 patients with type 2 diabetes in the development cohort and registered in a Japanese diabetes registry. To assess the independent correlations between baseline serum uric acid quartiles and either the development or progression of diabetic nephropathy for 2 years, the Cox proportional hazards model was used and adjusted for potential confounders.

RESULTS

The mean patient age, body mass index, and glycated hemoglobin (HbA1c) level were 66.1 years, 24.6 kg/m(2), and 7.5 % (57.6 mmol/mol), respectively. The baseline serum uric acid levels, with mean values of 3.6, 4.9, 5.8, and 7.3 mg/dL from the first to fourth quartiles, were significantly associated with the urinary albumin/creatinine ratio at baseline (p < 0.001). Baseline uric acid levels were not significantly associated with the development of nephropathy, but they were with the progression of nephropathy. The multivariable-adjusted hazards ratios for the progression from microalbuminuria to macroalbuminuria were 2.17 [95 % confidence interval (CI) 1.15-4.08; p = 0.016], 3.04 (95 % CI 1.67-5.53; p < 0.001), and 3.56 (95 % CI 1.83-6.93; p < 0.0011) for the first, third, and fourth quartiles of serum uric acid levels, respectively, as compared to that for the second quartile. We did not observe significant association between uric acid levels and change in estimated glomerular filtration rate.

CONCLUSIONS

Low and high serum uric levels, independent of possible confounders, were associated with a subsequent risk of progression, not development, in albuminuria in type 2 diabetes patients. Therefore, serum uric acid levels may be useful for predicting the future risk of progression of microalbuminuria.

What is the best measure for assessing diabetes distress? A comparison of the Problem Areas in Diabetes and Diabetes Distress Scale: results from Diabetes MILES–Australia

This study used Rasch analysis to examine the psychometric validity of the Diabetes Distress Scale and the Problem Areas in Diabetes scale to assess diabetes distress in 3338 adults with diabetes (1609 completed the Problem Areas in Diabetes scale ( n = 675 type 1 diabetes; n = 934 type 2 diabetes) and 1705 completed the Diabetes Distress Scale ( n = 693 type 1 diabetes; n = 1012 type 2 diabetes)). While criterion and convergent validity were good, Rasch analysis revealed suboptimal precision and targeting, and item misfit. Unresolvable multidimensionality within the Diabetes Distress Scale suggests a total score should be avoided, while suboptimal precision suggests that the Physician-related and Interpersonal distress subscales should be used cautiously.

Serum uric acid levels are associated with a high risk of rapid chronic kidney disease progression among patients with type 2 diabetes: a prospective cohort study [Diabetes Distress and Care Registry at Tenri (DDCRT 12)]

Background

We assessed the prospective association between baseline serum uric acid (SUA) concentrations and consequent risk of chronic kidney disease (CKD) progression in type 2 diabetes patients.

Methods

Longitudinal data from a Japanese diabetes registry including 3454 type 2 diabetes patients were obtained. To assess the independent correlations between SUA and rapid CKD progression [i.e., 30 % reduction in estimated glomerular filtration rate (eGFR) over 2 years], participants were divided into five groups based on SUA levels: <5.0, ≥5.0-6.0, ≥6.0-7.0, ≥7.0-8.0, and ≥8.0 mg/dl. Cox proportional hazards model adjusted for potential confounders was used for analysis.

Results

After 2 years, rapid CKD progression was recognized in 169 patients (4.89 %) who showed longer duration of type 2 diabetes (15.5 vs. 13.5 years, p = 0.005); higher systolic blood pressure (142.0 vs. 138.3 mmHg, p = 0.016), SUA (6.15 vs. 5.32 mg/dl, p < 0.001), and urinary albumin-creatinine ratio (1127.4 vs. 184.7 mg/gCr, p < 0.001); and lower diastolic blood pressure (69.7 vs. 72.8 mmHg, p = 0.003). Multivariate ratios for rapid CKD progression were 1.19 (p = 0.371), 1.02 (p = 0.937), 1.18 (p = 0.625), and 3.04 (p = 0.004), respectively, for the first, third, fourth, and fifth serum UA range groups; a second group was used as a reference.

Conclusions

Higher SUA levels, independent of possible confounders, were associated with rapid eGFR decline and CKD progression in type 2 diabetes patients. SUA may be a useful biomarker for predicting future risk of rapid diabetic CKD progression.

Diabetes distress: understanding the hidden struggles of living with diabetes and exploring intervention strategies

Diabetes distress is a rational emotional response to the threat of a life-changing illness. Distinct from depression, it is conceptually rooted in the demands of diabetes management and is a product of emotional adjustment. Diabetes distress has been found to be significantly associated with glycated haemoglobin (HbA1c) level and the likelihood of an individual adopting self-care behaviours. The lack of perceived support from family, friends and healthcare professionals significantly contributes to elevated diabetes distress, and this issue tends to be overlooked when designing interventions. Pioneering large-scale research, DAWN2, gives voices to the families of those with diabetes and reaffirms the need to consider psychosocial factors in routine diabetes care. Structured diabetes education programmes are the most widely used in helping individuals cope with diabetes, but they tend not to include the psychological or interpersonal aspects of diabetes management in their curricula. The need for health practitioners, irrespective of background, to demonstrate an understanding of diabetes distress and to actively engage in discussion with individuals struggling to cope with diabetes is emphasised.

Serum high-sensitivity C-reactive protein levels are associated with high risk of development, not progression, of diabetic nephropathy among Japanese type 2 diabetic patients: a prospective cohort study (Diabetes Distress and Care Registry at Tenri [DDCRT7])

OBJECTIVE

To assess the prospective association between baseline serum hs-CRP concentration and the subsequent risk of development or progression of diabetic nephropathy.

RESEARCH DESIGN AND METHODS

Longitudinal data were obtained from 2,518 patients with type 2 diabetes registered in a Japanese diabetes registry. To assess the independent correlations between serum baseline hs-CRP and either the development or progression of diabetic nephropathy 1 year later, the Cox proportional hazards model was used and adjusted for potential confounders.

RESULTS

The mean patient age, BMI, and HbA1c level were 66.1 years, 24.6 kg/m2, and 7.5% (57.6 mmol/mol), respectively. Baseline serum hs-CRP levels were significantly associated with the urinary albumin-to-creatinine ratio at baseline (P < 0.001). Multivariable adjusted hazard ratio for the development from normoalbuminuria to microalbuminuria was 1.31 (95% CI 0.80-2.17; P = 0.286), 1.55 (1.16-2.08; P = 0.003), and 1.57 (1.22-2.03; P = 0.001), respectively, for the second, third, and fourth quartiles of serum hs-CRP levels, showing a statistically significant linear trend across categories (P < 0.001). We did not observe a significant association between hs-CRP levels and the subsequent risk of diabetic nephropathy progression (P for trend = 0.575).

CONCLUSIONS

Serum hs-CRP levels, independent of possible confounders, were associated with a subsequent risk of developing, not progressing, diabetic nephropathy in type 2 diabetic patients. Serum hs-CRP may be useful for predicting the future risk of developing diabetic nephropathy.

Liraglutide Versus Sitagliptin in a 24-week, Multicenter, Open-label, Randomized, Parallel-group Study in Japanese Type 2 Diabetes Mellitus Patients Responding Inadequately to a Sulfonylurea and/or One or Two Other Oral Antidiabetic Drugs (JDDM 33)

OBJECTIVE

Liraglutide (glucagon-like peptide-1 [GLP-1] receptor agonist) and sitagliptin (dipeptidyl peptidase-4 inhibitor) are approved in Japan for treating type 2 diabetes mellitus (T2DM). We compared the efficacy and safety of adding liraglutide or sitagliptin to a sulfonylurea in Japanese T2DM patients.

METHODS

Patients aged 18 to <80 years with hemoglobin A1c (HbA1c; National Glycohemoglobin Standardization Program [NGSP]) of 6.9–9.4%, body mass index ≤35 kg/m², and treatment with a sulfonylurea and/or one or two non-sulfonylurea oral antidiabetic drugs for greater than or equal to eight weeks before enrollment were eligible. Patients were randomized in an open-label manner to either 0.9 mg/day liraglutide (n = 50) or 50–100 mg/day sitagliptin (n = 49) and were treated for 24 weeks. Non-sulfonylureas were discontinued before randomization. Patients using other oral antidiabetic drugs started sulfonylurea treatment. The primary endpoint was the change in HbA1c from baseline to Week 24.

RESULTS

HbA1c decreased in both groups, and the reduction was significantly greater throughout in the liraglutide group except for Week 24 (0.59 ± 0.80 vs. 0.24 ± 0.94%; P = 0.0525). Fasting plasma glucose (FPG) decreased significantly in the liraglutide group compared with the sitagliptin group (−21.15 ± 31.22 vs. +0.46 ± 39.39 mg/dL; P = 0.0014). Homeostasis model assessment of β cell function and C-peptide increased significantly in the liraglutide group but not in the sitagliptin group. Hypoglycemic symptoms and adverse events occurred in four and nine patients, respectively, in the liraglutide group, and in two and five patients, respectively, in the sitagliptin group.

CONCLUSION

Treatment with liraglutide or sitagliptin together with a sulfonylurea improved HbA1c in Japanese T2DM patients in primary care. Both drugs were associated with low rates of adverse events and hypoglycemia. The improvement in β cell function probably contributed to the improvement in glycemic control in the liraglutide group.

Elevated levels of hs-CRP are associated with high prevalence of depression in japanese patients with type 2 diabetes: the Diabetes Distress and Care Registry at Tenri (DDCRT 6)

OBJECTIVE

Because of the absence of data on the direct association between inflammation and depression in patients with diabetes, we examined the association between hs-CRP levels and the high prevalence of depression in adult patients with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Cross-sectional data were obtained from 3,573 patients with type 2 diabetes recruited from a Japanese diabetes registry. A multiple logistic regression analysis adjusted for potential confounders was used to assess independent associations between hs-CRP levels and major depression, as defined by the Patient Health Questionnaire-9.

RESULTS

Mean age, BMI, and HbA1c levels were 66.0 years, 24.6 kg/m(2), and 7.4% (57.8 mmol/mol), respectively, and 122 patients (3.4%) suffered from major depression. In the age- and sex-adjusted model, the odds ratio (OR) for major depression was 1.86 (95% CI 1.01-3.42; P = 0.045) in the highest CRP quintile compared with that in the 3rd CRP quintile; however, this association disappeared after adjustment for other possible confounders (OR 1.58 [95% CI 0.85-2.94]; P = 0.148). Among patients with a BMI of ≥25 kg/m(2), a significant association was observed between the highest hs-CRP quintile and major depression (multivariable-adjusted OR 2.69 [95% CI 1.09-7.08]; P = 0.032).

CONCLUSIONS

We observed a significant positive association between high hs-CRP levels and depression in patients with diabetes who had a high BMI.

Diabetes Attitude Scale: validation in type-2 diabetes patients in multiple centers in China

Objective

The aim of the paper is to report the development and psychometric testing of Diabetes Attitude Scale.

Method

A prospective study was performed. The cultural equivalency and content validity of the Diabetes Attitude Scale were determined by panels of endocrinologists, physiologists, nurses and dieticians. An accurate and usable translation was obtained for each of five subscales examining attitudes on need for special training, the seriousness of type-2 diabetes, the need for controlling the condition, its psychosocial impact and the degree of autonomy given to patients in decision making. The validation was derived from 5961 patients with type-2 diabetes, recruited from 50 centers in 29 provinces throughout China between March 1st and September 30th, 2010.

Results

The modified Diabetes Attitude Scale showed an acceptable level of internal consistency. The strength of the inter-correlations among the domains of five subscales suggests that the instrument measures related but separate domains of patients' attitudes toward diabetes. Moreover, the test-retest intraclass correlation coefficients were high enough to support the stability of the Chinese version of the third version of the scale.

Conclusions

The psychometric properties of the Chinese version of Diabetes Attitude Scale demonstrated satisfactory validity and reliability and appeared to effectively evaluate attitudes toward diabetes in patients with type-2 diabetes.

Correlations between serum bilirubin levels and diabetic nephropathy progression among Japanese type 2 diabetic patients: a prospective cohort study (Diabetes Distress and Care Registry at Tenri [DDCRT 5])

OBJECTIVE To assess the correlations between serum bilirubin levels and diabetic nephropathy development and progression in type 2 diabetic patients. RESEARCH DESIGN AND METHODS Longitudinal data were obtained from 2,511 type 2 diabetic patients registered in a Japanese diabetes registry. To assess the independent correlations between serum bilirubin levels and either the development or progression of diabetic nephropathy, we used logistic regression analysis adjusted for potential confounders. RESULTS The median follow-up period was 503.4 days (range 238-777). The mean patient age, BMI, and HbA1c level was 65.2 years, 24.7 kg/m(2), and 7.5% (58.5 mmol/mol), respectively. Baseline serum bilirubin levels were significantly associated with the urinary albumin-creatinine ratio at baseline (P < 0.001) and 1 year after registration (P < 0.001). Multivariable adjusted odds ratios for progression from microalbuminuria to macroalbuminuria for the second, third, and fourth quartile of serum bilirubin levels were 0.89 (95% CI 0.49-1.58), 0.93 (0.47-1.83), and 0.33 (0.13-0.84), respectively, showing a statistically significant linear trend across categories (P = 0.032). However, this trend disappeared after adjustment for hemoglobin levels. CONCLUSIONS Serum bilirubin levels were associated with diabetic nephropathy progression in type 2 diabetic patients independent of possible confounders. Serum bilirubin levels might be the link in the correlation between hemoglobin levels and nephropathy progression.

Patient-reported adherence to insulin regimen is associated with glycemic control among Japanese patients with type 2 diabetes: Diabetes Distress and Care Registry at Tenri (DDCRT 3)

AIMS

We investigated the association between self-reported adherence to an insulin regimen and glycemic control in Japanese patients with type 2 diabetes.

METHODS

Data from 1441 patients with type 2 diabetes who were treated with insulin were obtained from a diabetes registry in Japan. We obtained information on self-reported adherence to an insulin regimen. Relative risk regression analysis was employed to assess the independent association of various demographic factors with good glycemic control (HbA1c<7.0% [53 mmol/mol]) while adjusting for possible confounders.

RESULTS

The mean age, body mass index, and number of daily insulin injections of participants were 65.4 years, 24.7 kg/m(2), and 2.3, respectively. Of all patients, 70.6% reported high adherence to their insulin regimen. Compared with participants with higher adherence, the crude relative risk of good glycemic control was 0.82 (95% CI, 0.67-1.00) for those with middle adherence and 0.64 (95% CI, 0.31-1.31) for those with lower adherence (P=0.029 for trend). Subgroup analysis confirmed this association in patients below 65 years old, but not in those 65 years old and over.

CONCLUSIONS

A higher adherence to a daily insulin regimen was associated with a greater likelihood of good glycemic control in Japanese type 2 diabetes patients. This association was not seen in patients of 65 years old or over. Self-reported adherence to an insulin regimen may prove useful in titrating insulin dose in patients in the younger age group, but requires further investigation.