Severe hypoglycaemia and its association with psychological well-being in Australian adults with type 1 diabetes attending specialist tertiary clinics

Evaluation of the possible impact of the fear of hypoglycemia on diabetes management in children and adolescents with type 1 diabetes mellitus and their parents: a cross-sectional study

PURPOSE

Hypoglycemia represents a significant source of anxiety for children with type 1 diabetes mellitus (T1DM) and their caretakers. Fear of hypoglycemia (FoH) was measured in children and adolescents with T1DM as well as in their parents using an established research instrument, the Hypoglycemia Fear Survey (HFS).

METHODS

This is a two-center, cross-sectional study involving 100 children and adolescents aged 6-18 years old diagnosed with T1DM. One parent of each child also participated in the study. The participants, who were recruited from two different pediatric endocrine outpatient clinics, were asked to complete the translated Greek version of the HFS, which includes one version for children (C-HFS) and one for parents (P-HFS). The association of the questionnaire responses with subjects' characteristics, such as current age, age at diagnosis, duration of diabetes, HbA1c levels, and mode of diabetes treatment were assessed.

RESULTS

Parents exhibited significantly higher mean HFS scores than their children. No significant correlation was found between the P-HFS or the C-HFS scores and the age of the children, duration of diabetes, HbA1c, or mode of treatment.

CONCLUSION

The finding that parents experience higher levels of FoH compared to their children emphasizes the importance of healthcare providers to screen parental FoH and focus on approaches to support them in order to reduce their psychological burden, thus optimizing children's diabetes management.

A single-site feasibility randomised controlled trial comparing 'my hypo compass' short pyscho-educational intervention with standard care alone in individuals with type 1 diabetes and impaired awareness of hypoglycaemia

AIMS

The HypoCOMPaSS multi-centre trial achieved improvement in hypoglycaemia awareness and 20-fold reduction in severe hypoglycaemia (SH) in a cohort with long-standing type 1 diabetes (T1D). All participants received 'my hypo compass' (MHC) brief structured psycho-educational intervention in addition to optimisation of insulin delivery/glucose monitoring. In this 24-week, prospective, single-centre feasibility RCT, we piloted MHC as a sole intervention in comparison to standard clinical care alone (CON).

METHODS

Participants with T1D and impaired hypoglycaemia awareness (IAH) (Clarke score ≥4) were recruited. MHC comprised a group/individual 1-2 h face-to-face session followed by a telephone call and second face-to-face session at 4 weeks. Outcome measures at 24 weeks were compared with baseline.

RESULTS

Fifty-two individuals provided consent for screening with 39 fulfilling eligibility criteria. Fifteen withdrew before any study intervention. Twenty-four adults with (mean ± SD) T1D duration 41.0 ± 15.1 years commenced/completed the study (100% visit attendance); 12 randomised to MHC and 12 to CON. All had IAH at baseline and at 24 weeks. Annualised SH rate following MHC was 3.8 ± 19.0 (24 weeks) versus 12.6 ± 3.5 (Baseline) and in CON group 2.0 ± 19.0 (24 weeks) versus 4.6 ± 11.5 (Baseline). 'Immediate Action' for and 'Worry' about hyperglycaemia measured by the Hyperglycaemia Avoidance Scale appeared lower following MHC. Participants attended all study visits and reflected positively on the MHC intervention.

CONCLUSIONS

Feasibility of MHC implementation without additional intervention has been demonstrated. MHC education was associated with positive changes in attitudes and behaviours with the potential to reduce SH risk. MHC provides a validated, simple, well-received programme to fulfil the educational component within RCTs targeting problematic hypoglycaemia and as part of holistic clinical care.

Hybrid Closed Loop in Adults With Type 1 Diabetes and Severely Impaired Hypoglycemia Awareness

BACKGROUND

Benefits of hybrid closed-loop (HCL) systems in a high-risk group with type 1 diabetes and impaired awareness of hypoglycemia (IAH) have not been well-explored.

METHODS

Adults with Edmonton HYPO scores ≥1047 were randomized to 26-weeks HCL (MiniMed™ 670G) vs standard therapy (multiple daily injections or insulin pump) without continuous glucose monitoring (CGM) (control). Primary outcome was percentage CGM time-in-range (TIR; 70-180 mg/dL) at 23 to 26 weeks post-randomization. Major secondary endpoints included magnitude of change in counter-regulatory hormones and autonomic symptom responses to hypoglycemia at 26-weeks post-randomization. A post hoc analysis evaluated glycemia risk index (GRI) comparing HCL with control groups at 26 weeks post-randomization.

RESULTS

Nine participants (median [interquartile range (IQR)] age 51 [41, 59] years; 44% male; enrolment HYPO score 1183 [1058, 1308]; Clarke score 6 [6, 6]; n = 5 [HCL]; n = 4 [control]) completed the study. Time-in-range was higher using HCL vs control (70% [68, 74%] vs 48% [44, 50%], P = .014). Time <70 mg/dL did not differ (HCL 3.8% [2.7, 3.9] vs control 6.5% [4.3, 8.6], P = .14) although hypoglycemia episode duration was shorter (30 vs 50 minutes, P < .001) with HCL. Glycemia risk index was lower with HCL vs control (38.1 [30.0, 39.2] vs 70.8 [58.5, 72.4], P = .014). Following 6 months of HCL use, greater dopamine (24.0 [12.3, 27.6] vs -18.5 [-36.5, -4.8], P = .014), and growth hormone (6.3 [4.6, 16.8] vs 0.5 [-0.8, 3.0], P = .050) responses to hypoglycemia were observed.

CONCLUSIONS

Six months of HCL use in high-risk adults with severe IAH increased glucose TIR and improved GRI without increased hypoglycemia, and partially restored counter-regulatory responses.

CLINICAL TRIAL REGISTRATION

ACTRN12617000520336.

Allo Beta Cell transplantation: specific features, unanswered questions, and immunological challenge

Type 1 diabetes (T1D) presents a persistent medical challenge, demanding innovative strategies for sustained glycemic control and enhanced patient well-being. Beta cells are specialized cells in the pancreas that produce insulin, a hormone that regulates blood sugar levels. When beta cells are damaged or destroyed, insulin production decreases, which leads to T1D. Allo Beta Cell Transplantation has emerged as a promising therapeutic avenue, with the goal of reinstating glucose regulation and insulin production in T1D patients. However, the path to success in this approach is fraught with complex immunological hurdles that demand rigorous exploration and resolution for enduring therapeutic efficacy. This exploration focuses on the distinct immunological characteristics inherent to Allo Beta Cell Transplantation. An understanding of these unique challenges is pivotal for the development of effective therapeutic interventions. The critical role of glucose regulation and insulin in immune activation is emphasized, with an emphasis on the intricate interplay between beta cells and immune cells. The transplantation site, particularly the liver, is examined in depth, highlighting its relevance in the context of complex immunological issues. Scrutiny extends to recipient and donor matching, including the utilization of multiple islet donors, while also considering the potential risk of autoimmune recurrence. Moreover, unanswered questions and persistent gaps in knowledge within the field are identified. These include the absence of robust evidence supporting immunosuppression treatments, the need for reliable methods to assess rejection and treatment protocols, the lack of validated biomarkers for monitoring beta cell loss, and the imperative need for improved beta cell imaging techniques. In addition, attention is drawn to emerging directions and transformative strategies in the field. This encompasses alternative immunosuppressive regimens and calcineurin-free immunoprotocols, as well as a reevaluation of induction therapy and recipient preconditioning methods. Innovative approaches targeting autoimmune recurrence, such as CAR Tregs and TCR Tregs, are explored, along with the potential of stem stealth cells, tissue engineering, and encapsulation to overcome the risk of graft rejection. In summary, this review provides a comprehensive overview of the inherent immunological obstacles associated with Allo Beta Cell Transplantation. It offers valuable insights into emerging strategies and directions that hold great promise for advancing the field and ultimately improving outcomes for individuals living with diabetes.

Hypoglycemia and Cardiovascular Disease: Exploring the Connections

It has long been known that administering insulin or insulin secretagogues to treat diabetes has the unfavorable side effect of hypoglycemia. Because hypoglycemia can disrupt normal brain function, it can have a profound impact on people's lives. Studies have shown a connection between hypoglycemia and a higher risk of death and cardiovascular disease. Through experimental studies, numerous potential reasons for the start of cardiovascular events have been discovered. In addition, studies on people have demonstrated that hypoglycemia can result in ventricular arrhythmias. According to recent studies, a number of factors may affect the relationship between hypoglycemia, cardiovascular events, and mortality. Confounding factors may explain the apparent correlation, at least in part. People with comorbidities may experience more hypoglycemia, increasing their risk of mortality. Those who have type 1 or type 2 diabetes, however, seem to be more susceptible to the negative effects of hypoglycemia on the cardiovascular system. When choosing appropriate glucose-lowering treatments and setting glycemic objectives with patients, clinicians should be aware of this risk.

Changes in attitudes to awareness of hypoglycaemia during a hypoglycaemia awareness restoration programme are associated with avoidance of further severe hypoglycaemia episodes within 24 months: the A2A in HypoCOMPaSS study

AIMS/HYPOTHESIS

The aims of this study were to assess cognitions relating to hypoglycaemia in adults with type 1 diabetes and impaired awareness of hypoglycaemia before and after the multimodal HypoCOMPaSS intervention, and to determine cognitive predictors of incomplete response (one or more severe hypoglycaemic episodes over 24 months).

METHODS

This analysis included 91 adults with type 1 diabetes and impaired awareness of hypoglycaemia who completed the Attitudes to Awareness of Hypoglycaemia (A2A) questionnaire before, 24 weeks and 24 months after the intervention, which comprised a short psycho-educational programme with optimisation of insulin therapy and glucose monitoring.

RESULTS

The age and diabetes duration of the participants were 48±12 and 29±12 years, respectively (mean±SD). At baseline, 91% reported one or more severe hypoglycaemic episodes over the preceding 12 months; this decreased to <20% at 24 weeks and after 24 months (p=0.001). The attitudinal barrier 'hyperglycaemia avoidance prioritised' (η²_p=0.250, p=0.001) decreased from baseline to 24 weeks, and this decrease was maintained at 24 months (mean±SD=5.3±0.3 vs 4.3±0.3 vs 4.0±0.3). The decrease in 'asymptomatic hypoglycaemia normalised' from baseline (η²_p=0.113, p=0.045) was significant at 24 weeks (1.5±0.3 vs 0.8±0.2). Predictors of incomplete hypoglycaemia response (one or more further episodes of severe hypoglycaemia) were higher baseline rates of severe hypoglycaemia, higher baseline scores for 'asymptomatic hypoglycaemia normalised', reduced change in 'asymptomatic hypoglycaemia normalised' scores at 24 weeks, and lower baseline 'hypoglycaemia concern minimised' scores (all p<0.05).

CONCLUSIONS/INTERPRETATION

Participation in the HypoCOMPaSS RCT was associated with improvements in hypoglycaemia-associated cognitions, with 'hyperglycaemia avoidance prioritised' most prevalent. Incomplete prevention of subsequent severe hypoglycaemia episodes was associated with persistence of the cognition 'asymptomatic hypoglycaemia normalised'. Understanding and addressing cognitive barriers to hypoglycaemia avoidance is important in individuals prone to severe hypoglycaemia episodes.

CLINICAL TRIALS REGISTRATION

www.isrctn.org : ISRCTN52164803 and https://eudract.ema.europa.eu : EudraCT2009-015396-27.

Hypoglycaemia in type 1 diabetes mellitus: risks and practical prevention strategies

Hypoglycaemia, which occurs when blood levels of glucose fall below what is considered a normal range, is a well-known complication of insulin therapy in individuals with type 1 diabetes mellitus. Despite advances in diabetes mellitus management, hypoglycaemia has continued to affect the majority of these individuals, leading to suboptimal care and decreased quality of life. Multiple epidemiological studies have demonstrated the risks associated with hypoglycaemic events. With this understanding, various advances have been made in therapeutics for diabetes mellitus management. Diabetes mellitus education continues to form the foundation for management and prevention of hypoglycaemia. The advent of newer diabetes mellitus technologies and newer insulins herald improvements in management strategies and hypoglycaemia prevention. Improved understanding of these newer approaches is needed to ensure delivery of safe and effective care to individuals with type 1 diabetes mellitus, leading to reductions in both the short-term and long-term morbidity and mortality associated with hypoglycaemic events.

Evaluation of Clinical Metrics for Identifying Defective Physiologic Responses to Hypoglycemia in Long-Standing Type 1 Diabetes

Repeated hypoglycemia exposure leads to impaired awareness of hypoglycemia (IAH) and the development of defective counterregulatory responses. To date, only pancreas or islet transplantation has demonstrated normalization of hypoglycemia awareness and the endogenous glucose production (EGP) response to defend against insulin-induced hypoglycemia in long-standing type 1 diabetes (T1D). This study aims to validate clinical metrics of IAH (Clarke score), hypoglycemia severity (HYPO score), glycemic lability (lability index), and continuous glucose monitoring (CGM) as predictors of absent autonomic symptom (AS) recognition and defective glucose counterregulation during insulin-induced hypoglycemia, thus enabling early identification of individuals with compromised physiologic defense against clinically significant hypoglycemia. Forty-three subjects with mean ± standard deviation age 43 ± 13 years and T1D duration 28 ± 13 years, including 32 with IAH and 11 with hypoglycemia awareness (Aware), and 12 nondiabetic control subjects, underwent single-blinded randomized-paired hyperinsulinemic-euglycemic and hypoglycemic clamp experiments. Receiver operating characteristic (ROC) curves and sensitivity analyses were performed to assess metric prediction of absent AS recognition and defective EGP responses to hypoglycemia. Clarke score and CGM measures of hypoglycemia exposure demonstrated good ability to predict absent AS recognition (area under the curve ≥0.80). A composite threshold of IAH-Clarke ≥4 with ROC curve-derived thresholds for CGM measures of hypoglycemia exposure showed high specificity and predictive value in identifying an absent AS response during the hypoglycemic clamp. Metrics demonstrated poor ability to predict defective glucose counterregulation by the EGP response, which was impaired even in the Aware group. Screening for IAH alongside assessment of CGM data can increase the specificity for identifying individuals with absent hypoglycemia symptom recognition who may benefit from further intervention.

Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring system in people with type 1 diabetes in Australia

INTRODUCTION

Real-time continuous glucose monitoring (rt-CGM) allows patients with diabetes to adjust insulin dosing, potentially improving glucose control. This study aimed to compare the long-term cost-effectiveness of the Dexcom G6 rt-CGM device versus self-monitoring of blood glucose (SMBG) and flash glucose monitoring (FGM) in Australia in people with type 1 diabetes (T1D).

METHODS

Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model. Clinical input data for the analysis of rt-CGM versus SMBG and FGM were sourced from the DIAMOND study and a network meta-analysis, respectively. Rt-CGM and FGM were associated with quality of life (QoL) benefits due to reduced fear of hypoglycaemia (FoH) and fingerstick testing. Analyses were performed over a lifetime time horizon from an Australian healthcare payer perspective, including direct costs from published data. Future costs and clinical outcomes were discounted at 5% per annum.

RESULTS

Rt-CGM was associated with an increased quality-adjusted life expectancy of 1.199 quality-adjusted life years (QALYs), increased mean total lifetime costs of AUD 21,596 and an incremental cost-effectiveness ratio (ICER) of AUD 18,020 per QALY gained compared with SMBG. Compared with FGM, rt-CGM was associated with an increased quality-adjusted life expectancy of 0.569 QALYs, increased mean total lifetime costs of AUD 11,064 and an ICER of AUD 19,455 per QALY gained. Key drivers of outcomes included HbA_1c benefits and QoL benefits associated with reduced FoH and fingerstick testing.

CONCLUSIONS

Due to improved clinical outcomes and QoL gains rt-CGM is highly cost-effective compared with SMBG and FGM in people with T1D in Australia.

Investigating the day-to-day impact of hypoglycaemia in adults with type 1 or type 2 diabetes: design and validation protocol of the Hypo-METRICS application

INTRODUCTION

Hypoglycaemia is a frequent adverse event and major barrier for achieving optimal blood glucose levels in people with type 1 or type 2 diabetes using insulin. The Hypo-RESOLVE (Hypoglycaemia-Redefining SOLutions for better liVEs) consortium aims to further our understanding of the day-to-day impact of hypoglycaemia. The Hypo-METRICS (Hypoglycaemia-MEasurement, ThResholds and ImpaCtS) application (app) is a novel app for smartphones. This app is developed as part of the Hypo-RESOLVE project, using ecological momentary assessment methods that will minimise recall bias and allow for robust investigation of the day-to-day impact of hypoglycaemia. In this paper, the development and planned psychometric analyses of the app are described.

METHODS AND ANALYSIS

The three phases of development of the Hypo-METRICS app are: (1) establish a working group-comprising diabetologists, psychologists and people with diabetes-to define the problem and identify relevant areas of daily functioning; (2) develop app items, with user-testing, and implement into the app platform; and (3) plan a large-scale, multicountry study including interviews with users and psychometric validation. The app includes 7 modules (29 unique items) assessing: self-report of hypoglycaemic episodes (during the day and night, respectively), sleep quality, well-being/cognitive function, social interactions, fear of hypoglycaemia/hyperglycaemia and work/productivity. The app is designed for use within three fixed time intervals per day (morning, afternoon and evening). The first version was released mid-2020 for use (in conjunction with continuous glucose monitoring and activity tracking) in the Hypo-METRICS study; an international observational longitudinal study. As part of this study, semistructured user-experience interviews and psychometric analyses will be conducted.

ETHICS AND DISSEMINATION

Use of the novel Hypo-METRICS app in a multicountry clinical study has received ethical approval in each of the five countries involved (Oxford B Research Ethics Committee, CMO Region Arnhem-Nijmegen, Ethikkommission der Medizinischen Universität Graz, Videnskabsetisk Komite for Region Hovedstaden and the Comite Die Protection Des Personnes SUD Mediterranne IV). The results from the study will be published in peer review journals and presented at national and international conferences.

TRIAL REGISTRATION NUMBER

NCT04304963.

Unmet support needs relating to hypoglycaemia among adults with type 1 diabetes: Results of a multi-country web-based qualitative study

OBJECTIVE

Hypoglycaemic episodes and fear of hypoglycaemia can be burdensome for adults with type 1 diabetes. This study explored support needs relating to hypoglycaemia among adults with type 1 diabetes living in Denmark, Germany, the Netherlands and the United Kingdom.

RESEARCH DESIGN AND METHODS

Respondents participated in a web-based qualitative study involving four open-ended questions that asked what they wished other people understood about hypoglycaemia and what other people could do differently to support them with hypoglycaemia. Responses were analyzed using reflexive thematic analysis.

RESULTS

Participants were 219 adults with type 1 diabetes (mean ± SD age 39 ± 13 years; mean ± SD diabetes duration 20 ± 14 years). They described unmet needs relating to: (1) Clinical support, involving access to new diabetes technologies, training on hypoglycaemia prevention, personalised care and psychological support; (2) Practical support, involving family and friends better supporting them with hypoglycaemia management and prevention; (3) Education for other people, involving others becoming more informed about hypoglycaemia; and (4) An appreciation of the burden, involving others recognizing the experience and impact of episodes, and the burden of living with the risk of hypoglycaemia.

CONCLUSIONS

Adults with type 1 diabetes report several unmet support needs relating to hypoglycaemia. Service delivery should be person-centred and prioritise the individual's support needs. Clinical conversations are needed to identify the individual's support needs and develop tailored support plans. People with diabetes and their family members should be offered hypoglycaemia-specific education and training.

Felix dies natalis, insulin… ceterum autem censeo "beta is better"

One hundred years after its discovery, insulin remains the life-saving therapy for many patients with diabetes. It has been a 100-years-old success story thanks to the fact that insulin therapy has continuously integrated the knowledge developed over a century. In 1982, insulin becomes the first therapeutic protein to be produced using recombinant DNA technology. The first "mini" insulin pump and the first insulin pen become available in 1983 and 1985, respectively. In 1996, the first generation of insulin analogues were produced. In 1999, the first continuous glucose-monitoring device for reading interstitial glucose was approved by the FDA. In 2010s, the ultra-long action insulins were introduced. An equally exciting story developed in parallel. In 1966. Kelly et al. performed the first clinical pancreas transplant at the University of Minnesota, and now it is a well-established clinical option. First successful islet transplantations in humans were obtained in the late 1980s and 1990s. Their ability to consistently re-establish the endogenous insulin secretion was obtained in 2000s. More recently, the possibility to generate large numbers of functional human β cells from pluripotent stem cells was demonstrated, and the first clinical trial using stem cell-derived insulin producing cell was started in 2014. This year, the discovery of this life-saving hormone turns 100 years. This provides a unique opportunity not only to celebrate this extraordinary success story, but also to reflect on the limits of insulin therapy and renew the commitment of the scientific community to an insulin free world for our patients.

Assessment of diabetes-related distress among type 2 diabetic patients, Riyadh, Saudi Arabia

OBJECTIVES

To assess the prevalence of diabetes-related distress (DRD) among Type 2 diabetics in the diabetic center of King Salman Hospital, Riyadh, Saudi Arabia.

METHODS

This was an observational descriptive study conducted between December 2019 and January 2020 among T2DM patients followed up at the diabetic clinics of the Diabetic Center of King Salman Hospital in Riyadh, Saudi Arabia. We used the 17-items Diabetes Distress Scale (DDS17) to measure DRD.

RESULTS

A total of 399 T2DM patients were included in the study, 58.4% were males. High distress was seen in 40 patients. Multivariate analysis showed that longer duration of diabetes (>15 years), female gender, longer intervals in-between visits (>6 months), and experience of episodes of severe hypoglycemia as the most significant factors related to higher levels of distress. The patients who were diabetics longer than 15 years had an increased risk for high distress by 3.6 times, infrequent clinic visits (longer than 6 months) increased the risk for high distress by 5.3 times×, and patients who experienced severe hypoglycemia had an increased risk for high distress by 5.8 times.

CONCLUSION

This study showed a high (35.6%) prevalence of moderate to severe DRD. Long-standing diabetes, a longer interval of a clinic visit, and severe hypoglycemia increase the risk for DRD by 3.6, 5.3, and 5.8 folds. Health care providers should focus on reducing DRD and devise ways to increase self-care practices and coping skills.

Developing a novel diabetes distress e-learning program for diabetes educators: an intervention mapping approach

Diabetes distress is a common negative emotional response to the ongoing burden of living with diabetes. Elevated diabetes distress is associated with impaired diabetes self-management and quality of life yet rarely identified and addressed in clinical practice. Health professionals report numerous barriers to the provision of care for diabetes distress, including lack of skills and confidence, but few diabetes distress training opportunities exist. The purpose of this paper is to describe how we utilized Intervention Mapping to plan the development, implementation, and evaluation of a novel diabetes distress e-learning program for diabetes educators, to meet a well-documented need and significant gap in diabetes care. A multidisciplinary team (combining expertise in research, health and clinical psychology, diabetes education, nursing, tertiary education, and website architecture) developed a diabetes distress e-learning program. We followed a six-step process (logic model of the problem, program outcomes and objectives, program design, program production, program implementation plan, and evaluation plan) known as Intervention Mapping. The program is underpinned by educational and psychological theory, including Bloom's Taxonomy of Educational Objectives and social cognitive theory. We developed a short (estimated 4 h) e-learning program for diabetes educators, which draws on the content of the Diabetes and Emotional Health handbook and toolkit. It integrates a 7As model, which provides a stepwise approach to identifying and addressing diabetes distress. Our diabetes distress e-learning program has been developed systematically, guided by an Intervention Mapping approach. In the next phase of the project, we will trial the e-learning.

The suitability of patient-reported outcome measures used to assess the impact of hypoglycaemia on quality of life in people with diabetes: a systematic review using COSMIN methods

AIMS/HYPOTHESIS

It is generally accepted that hypoglycaemia can negatively impact the quality of life (QoL) of people living with diabetes. However, the suitability of patient-reported outcome measures (PROMs) used to assess this impact is unclear. The aim of this systematic review was to identify PROMs used to assess the impact of hypoglycaemia on QoL and examine their quality and psychometric properties.

METHODS

Systematic searches (MEDLINE, EMBASE, PsycINFO, CINAHL and The Cochrane Library databases) were undertaken to identify published articles reporting on the development or validation of hypoglycaemia-specific PROMs used to assess the impact of hypoglycaemia on QoL (or domains of QoL) in adults with diabetes. A protocol was developed and registered with PROSPERO (registration no. CRD42019125153). Studies were assessed for inclusion at title/abstract stage by one reviewer. Full-text articles were scrutinised where considered relevant or potentially relevant or where doubt existed. Twenty per cent of articles were assessed by a second reviewer. PROMS were evaluated, according to COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines, and data were extracted independently by two reviewers against COSMIN criteria. Assessment of each PROM's content validity included reviewer ratings (N = 16) of relevance, comprehensiveness and comprehensibility: by researchers (n = 6); clinicians (n = 6); and adults with diabetes (n = 4).

RESULTS

Of the 214 PROMs used to assess the impact of hypoglycaemia on QoL (or domains of QoL), seven hypoglycaemia-specific PROMS were identified and subjected to full evaluation: the Fear of Hypoglycemia 15-item scale; the Hypoglycemia Fear Survey; the Hypoglycemia Fear Survey version II; the Hypoglycemia Fear Survey-II short-form; the Hypoglycemic Attitudes and Behavior Scale; the Hypoglycemic Confidence Scale; and the QoLHYPO questionnaire. Content validity was rated as 'inconsistent', with most as '(very) low' quality, while structural validity was deemed 'unsatisfactory'. Other measurement properties (e.g. reliability) varied, and evidence gaps were apparent across all PROMs. None of the identified studies addressed cross-cultural validity or measurement error. Criterion validity and responsiveness were not assessed due to the lack of a 'gold standard' measure of the impact of hypoglycaemia on QoL against which to compare the PROMS.

CONCLUSIONS/INTERPRETATION

None of the hypoglycaemia-specific PROMs identified had sufficient evidence to demonstrate satisfactory validity, reliability and responsiveness. All were limited in terms of content and structural validity, which restricts their utility for assessing the impact of hypoglycaemia on QoL in the clinic or research setting. Further research is needed to address the content validity of existing PROMs, or the development of new PROM(s), for the purpose of assessing the impact of hypoglycaemia on QoL.

PROSPERO REGISTRATION

CRD42019125153.

Diabetes distress instruments in adults with Type 1 diabetes: A systematic review using the COSMIN (COnsensus-based Standards for the selection of health status Measurement INstruments) checklist

AIMS

To identify all extant instruments used to measure diabetes distress in adults with Type 1 diabetes and to evaluate the evidence for the measurement properties of these instruments.

METHODS

Medline, Embase, CINAHL plus and PsycINFO were systematically searched from inception up until 12 March 2020 for all publications which evaluated the psychometric properties of diabetes distress measurement instruments. The quality of the methodology and the measurement properties in the identified studies were evaluated using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guidelines.

RESULTS

Seven out of the 7656 articles retrieved in the search were included in the final review. Four diabetes distress measurement instruments were identified, none of which displayed evidence for all measurement properties specified in the COSMIN guidelines. The Problem Areas in Diabetes-11 (PAID-11) demonstrated the best psychometric properties, displaying strong evidence for structural validity, internal consistency, hypothesis testing, responsiveness and criterion validity. The Problem Areas in Diabetes scale (PAID) was the most frequently investigated instrument, demonstrating good relevance and hypothesis testing across four studies; however, concerns remain over its factor structure.

CONCLUSION

The PAID-11 appears to be the most psychometrically sound instrument for measuring diabetes distress in adults with Type 1 diabetes, displaying strong evidence for a range of measurement properties. However, as only one study evaluated this instrument and its content validity has yet to be assessed, further validation is warranted. Additional qualitative work is needed to assess the content validity of these instruments among individuals with Type 1 diabetes.

The impact of hypoglycaemia on quality of life outcomes among adults with type 1 diabetes: A systematic review

Hypoglycaemia is a common barrier to optimal glycaemic management and often feared among adults with type 1 diabetes. The aim of this systematic review was to summarize current evidence regarding the impact of hypoglycaemia on quality of life (QoL) and related outcomes. Electronic searches of MEDLINE, PsycINFO, CINAHL, Cochrane Database of Systematic Reviews, and Cochrane Central Register of Controlled Trials were conducted. Peer-reviewed empirical studies investigating the relationship between hypoglycaemia and QoL were eligible for inclusion. Thirty studies met the inclusion criteria. Extracted data was summarized in a narrative synthesis according to Synthesis Without Meta-Analysis guidelines. None of the studies examined the impact of hypoglycaemia on general QoL. There was no association between hypoglycaemia and diabetes-specific QoL in four of the 30 studies. Severe hypoglycaemia was associated with greater fear of hypoglycaemia and diabetes distress, and lower general emotional well-being, but not with depression, anxiety, or health status. Self-treated hypoglycaemia was associated with greater fear of hypoglycaemia. With the exception of fear of hypoglycaemia, this review shows mixed associations between hypoglycaemia and psychological outcomes. Further research is needed to investigate the impact of hypoglycaemia on other domains of QoL.

Pancreatic islet reserve in type 1 diabetes

Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by pancreatic islet β cell loss and dysfunction resulting in insulin deficiency and hyperglycemia. During a presymptomatic phase of established β cell autoimmunity, β cell loss may first be evident through assessment of β cell secretory capacity, a measure of functional β cell mass. Reduction in pancreatic islet β cell reserve eventually manifests as impaired first-phase insulin response to glucose and abnormal glucose tolerance, which progresses until the functional capacity for β cell secretion can no longer meet the demand for insulin to control glycemia. A functional β cell mass of ∼25% of normal may be required to avoid symptomatic T1D but is already associated with dysregulated glucagon secretion. With symptomatic T1D, stimulated C-peptide levels >0.60 ng/mL (0.200 pmol/mL) indicate the presence of clinically meaningful residual β cell function for contributing to glycemic control, although even higher residual C-peptide appears necessary for evidencing glucose-dependent islet β and α cell function that may contribute to maintaining (near)normal glycemia. β cell replacement by islet transplantation can restore a physiologic reserve capacity for insulin secretion, confirming thresholds for functional β cell mass required for independence from insulin therapy.

The diagnosis and management of diabetes in Australia: Does the "Rule of Halves" apply?

The Rule of Halves (ROH) is a theoretical framework which states that roughly half of all people with a condition are diagnosed; half of those diagnosed receive care; half of those who receive care achieve their treatment targets; and half of those who reach their targets achieve the desired treatment outcomes. This review examined the applicability of the ROH to diabetes in Australia. Five databases were searched for articles and government reports published between January 2000 and August 2019. Data was extracted for each level of the framework, and pooled sample proportions calculated for the total population and sub-group analysis by ethnicity and type of diabetes. The results showed that 72% of people with diabetes are diagnosed. Approximately 50% are receiving standard care, and 40-60% are meeting treatment targets for HbA1c, blood pressure and lipid levels. Overall, Australia is doing better than the ROH when it comes to achieving treatment outcomes; prevalence of microvascular complications was 20-30% and cardiovascular disease 62%. Indigenous people were less likely to meet treatment targets and more likely to experience adverse complications of diabetes. This review indicates the ROH does generally apply for diabetes care and management in Australia, highlighting the need for further improvement.

Fear of hypoglycemia in patients with type 1 and 2 diabetes: a systematic review

AIMS AND OBJECTIVES

To summarize and thematize fear of hypoglycemia (FOH) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) to provide a theoretical basis for the development of effective interventions.

BACKGROUND

FOH is common in this population and can reduce quality of life(QOL) and adversely impact upon diabetes self-care management.

DESIGN

a systematic review METHODS: Articles published between 2000 and 2019 were searched in PubMed, MEDLINE, EMBASE, Web of Science and three Chinese databases (CNKI, Wan-fang data and VIP). Eligible articles were selected using the Preferred Reporting Item for Systematic Review and Meta-analysis (PRISMA) guidelines. The quality of all articles finally included was evaluated by the Joanna Briggs Institute (JBI) Critical Appraisal tools.

RESULTS

Eighteen studies from 8654 papers were included. The sample size of each study ranged from 48 to 3812 subjects. FOH negatively impacted QOL, particularly psychosocial functioning, daily life and sleep quality.

CONCLUSIONS

FOH is a common and serious problem for patients, leading to poor QOL. It has been suggested that psychological concerns, QOL and effective countermeasures in individuals with T1D and T2D should be taken seriously. Advanced technology should be evaluated for its benefits before being used by patients.

RELEVANCE TO CLINICAL PRACTICE

The review highlights that FOH negatively impacts QOL, including psychosocial factors, daily life and sleep quality. Healthcare providers should develop targeted and professional assessment tools for FOH and QOL for patients with T2D, especially for patients who are about 60 years old. Advanced technology should be evaluated for its benefits before being used by patients.

Factors associated with fear of hypoglycaemia among the T1D Exchange Glu population in a cross-sectional online survey

OBJECTIVES

Fear of hypoglycaemia (FoH) has been associated with suboptimal diabetes management and health outcomes. This study investigated factors associated with behavioural and emotional aspects of FoH among adults living with type 1 diabetes (T1D) mellitus.

DESIGN

Cross-sectional study.

SETTING

Online survey hosted on T1D Exchange Glu, an online community for patients living with T1D mellitus.

MEASURES

The Hypoglycaemia Fear Survey II-short form and the Hypoglycaemic Attitudes and Behaviour Scale were used to assess FoH. Multivariable regressions were performed on assessment scores.

RESULTS

The study included 494 participants (mean±SD age 43.9±12.2 years, duration of T1D mellitus 16.6±16.8 years, self-reported glycosylated hemoglobin (HbA1c) 6.9%±0.8% (52±9 mmol/mol)), 63% men, 89% on insulin pump, 25% experienced a severe hypoglycaemic event in the last 6 months. Multivariable regression analyses showed higher anxiety, depression severity and diabetes distress were independently associated with FoH (all p<0.01). Longer diabetes duration was associated with lower FoH (p<0.01). Past experience with severe hypoglycaemia was associated with higher worry of hypoglycaemia (p<0.01) but not avoidance behaviour (ns).

CONCLUSIONS

These results highlighted the multifaceted nature of FoH, which warrants further discussion between providers and patients to uncover drivers of and actions required to reduce FoH and improve patient care and outcomes.

Differentiating Hypoglycemia Awareness Status from Hypoglycemia Experience in Tools for Measuring Impaired Awareness of Hypoglycemia

Background: Developing technologies in real-time continuous glucose monitoring (CGM) are successfully reducing severe hypoglycemia (SH) in trials and clinical practice. Their impact on impaired awareness of hypoglycemia, a major risk factor for SH, is uncertain. Methods: The present study examined two scales for assessing hypoglycemia awareness status, the Gold score and the eight-item Minimally Modified Clarke Hypoglycemia Survey (MMCHS), commonly used in trials of CGM, in Portuguese-speaking adults with type 1 diabetes and conducted an exploratory factor analysis on MMCHS. Results: A bifactorial structure in MMCHS was revealed, with a clear distinction between items that measure SH experience and those that measure hypoglycemia awareness status. The latter is associated with the same risk for SH as the Gold score. Conclusions: We conclude that improvement in awareness scores by the MMCHS may reflect only a reduction in SH with no restoration of endogenous awareness, making the current literature consistent in evidence that CGM does not improve endogenous awareness and nonsensor supported protection from SH. This has implications for risk of SH when CGM is not being worn.

Reducing the burden of hypoglycaemia in people with diabetes through increased understanding: design of the Hypoglycaemia REdefining SOLutions for better liVEs (Hypo-RESOLVE) project

BACKGROUND

Hypoglycaemia is the most frequent complication of treatment with insulin or insulin secretagogues in people with diabetes. Severe hypoglycaemia, i.e. an event requiring external help because of cognitive dysfunction, is associated with a higher risk of adverse cardiovascular outcomes and all-cause mortality, but underlying mechanism(s) are poorly understood. There is also a gap in the understanding of the clinical, psychological and health economic impact of 'non-severe' hypoglycaemia and the glucose level below which hypoglycaemia causes harm.

AIM

To increase understanding of hypoglycaemia by addressing the above issues over a 4-year period.

METHODS

Hypo-RESOLVE is structured across eight work packages, each with a distinct focus. We will construct a large, sustainable database including hypoglycaemia data from >100 clinical trials to examine predictors of hypoglycaemia and establish glucose threshold(s) below which hypoglycaemia constitutes a risk for adverse biomedical and psychological outcomes, and increases healthcare costs. We will also investigate the mechanism(s) underlying the antecedents and consequences of hypoglycaemia, the significance of glucose sensor-detected hypoglycaemia, the impact of hypoglycaemia in families, and the costs of hypoglycaemia for healthcare systems.

RESULTS

The outcomes of Hypo-RESOLVE will inform evidence-based definitions regarding the classification of hypoglycaemia in diabetes for use in daily clinical practice, future clinical trials and as a benchmark for comparing glucose-lowering interventions and strategies across trials. Stakeholders will be engaged to achieve broadly adopted agreement.

CONCLUSION

Hypo-RESOLVE will advance our understanding and refine the classification of hypoglycaemia, with the ultimate aim being to alleviate the burden and consequences of hypoglycaemia in people with diabetes.

β-Cell and renal transplantation options for diabetes

Despite major advances in structured education, insulin delivery and glucose monitoring, diabetes self-management remains an unremitting challenge. Insulin therapy is inextricably linked to risk of dangerous hypoglycaemia and sustained hyperglycaemia remains a leading cause of renal failure. This review sets out to demystify transplantation for diabetes multidisciplinary teams, facilitating consideration and incorporation within holistic overall person-centred management. Deceased and living donor kidney, whole pancreas and isolated islet transplant procedures, indications and potential benefits are described, in addition to outcomes within the integrated UK transplant programme.

Characterization of pre-transplant psychosocial burden in an integrated national islet transplant program

The psychological burden experienced by people with diabetes prior to islet transplantation is recognized but has not been studied comprehensively, especially in relation to glycemia. Therefore, we conducted a rigorous pre-operative psychosocial profile of UK islet transplant recipients, and compared groups with higher/lower HbA1 c to test the null hypothesis that pre-transplant hypoglycemia awareness and psychosocial burden would not be related to baseline HbA1 c in this high-risk cohort. Pre-transplant, recipients (n = 44) completed validated hypoglycemia awareness questionnaires and generic/diabetes-specific measures of psychological traits and states. Scores were compared in groups, dichotomized by HbA1 c (≤8% versus >8%). Participants were aged (mean±SD) 53 ± 10 years; 64% were women; with HbA1 c 8.3 ± 1.7%. Median rate of severe hypoglycemia over the preceding 12 months was 13 events/person-year and 90% had impaired awareness of hypoglycemia (Gold/Clarke score ≥4). Participants had elevated fear of hypoglycemia (HFS-II Worry), impaired diabetes-specific quality of life (DQoL) and low generic health status (SF-36; EQ-5D). One quarter reported scores indicating likely anxiety/depression (HAD). Dispositional optimism (LOT-R) and generalized self-efficacy (GSE) were within published 'norms.' Despite negative perceptions of diabetes (including low personal control), participants were confident that islet transplantation would help (BIPQ). Hypoglycemia awareness and psychosocial profile were comparable in lower (n = 24) and higher (n = 20) HbA1 c groups. Islet transplant candidates report sub-optimal generic psychological states (anxiety/depressive symptoms), health status and diabetes-specific psychological states (fear of hypoglycemia, diabetes-specific quality of life). While their generic psychological traits (optimism, self-efficacy) are comparable with the general population, they are highly optimistic about forthcoming transplant. HbA1 c is not a proxy measure of psychosocial burden, which requires the use of validated questionnaires to systematically identify those who may benefit most from psychological assessment and support.

How has psycho-behavioural research advanced our understanding of hypoglycaemia in type 1 diabetes?

Almost 100 years since the discovery of insulin, hypoglycaemia remains a barrier for people with type 1 diabetes to achieve and maintain blood glucose at levels which prevent long-term diabetes-related complications. Although hypoglycaemia is primarily attributable to the limitations of current treatment and defective hormonal counter-regulation in type 1 diabetes, the central role of psycho-behavioural factors in preventing, recognizing and treating hypoglycaemia has been acknowledged since the early 1980s. Over the past 25 years, as documented in the present review, there has been a substantial increase in psycho-behavioural research focused on understanding the experience and impact of hypoglycaemia. The significant contributions have been in understanding the impact of hypoglycaemia on a person's emotional well-being and aspects of life (e.g. sleep, driving, work/social life), identifying modifiable psychological and behavioural risk factors, as well as in developing psycho-behavioural interventions to prevent and better manage (severe) hypoglycaemia. The impact of hypoglycaemia on family members has also been confirmed. Structured diabetes education programmes and psycho-behavioural interventions with a focus on hypoglycaemia have both been shown to be effective in addressing problematic hypoglycaemia. However, the findings have also revealed the complexity of the problem and the need for a personalized approach, taking into account the individual's knowledge of, and emotional/behavioural reactions to hypoglycaemia. Evidence is emerging that people with persistent and recurrent severe hypoglycaemia, characterized by deeply entrenched cognitions and lack of concern around hypoglycaemia, can benefit from tailored cognitive behavioural therapy.

The Diabetes and Emotional Health Handbook and Toolkit for Health Professionals Supporting Adults With Type 1 and Type 2 Diabetes: Formative Evaluation

BACKGROUND

Health professionals have expressed unmet needs, including lacking the skills, confidence, training, and resources needed to properly attend to the psychological needs of people with diabetes.

OBJECTIVE

Informed by needs assessments, this study aimed to develop practical, evidence-based resources to support health professionals to address the emotional needs of adults with type 1 or type 2 diabetes.

METHODS

We developed a new handbook and toolkit informed by formative evaluation, including literature reviews, stakeholder consultation and review, and a qualitative study. In the qualitative study, health professionals participated in interviews after reading sections of the handbook and toolkit.

RESULTS

The literature review uncovered that psychological problems are common among adults with diabetes, but health professionals lack resources to provide related support. We planned and drafted resources to fill this unmet need, guided by stakeholder consultation and an Expert Reference Group (ERG). Before finalizing the resources, we implemented feedback received from stakeholders (ERG, health professionals, academics, and people with diabetes). The resulting resources were the practical, evidence-based Diabetes and Emotional Health handbook and toolkit. A total of 19 health professionals took part in the qualitative study about the handbook and toolkit. They viewed the resources favorably, felt empowered to support people with diabetes experiencing psychological problems, and felt motivated to share the resources with others. Some gave examples of how they had used the handbook in clinical practice. A perceived highlight was the inclusion of a process model outlining 7 steps for identifying and supporting people with emotional problems: the 7 A's model. With funding from the National Diabetes Services Scheme (NDSS), more than 2400 copies of Diabetes and Emotional Health have been distributed. It is freely available on the Web. The NDSS is an initiative of the Australian Government administered with the assistance of Diabetes Australia.

CONCLUSIONS

The new evidence-based resources are perceived by stakeholders as effective aids to assist health professionals in providing emotional support to adults with diabetes. The 7 A's model may have clinical utility for routine monitoring of other psychological and health-related problems, as part of person-centered clinical care.

Cognitions Associated With Hypoglycemia Awareness Status and Severe Hypoglycemia Experience in Adults With Type 1 Diabetes

OBJECTIVE

Impaired awareness of hypoglycemia (IAH) and recurrent severe hypoglycemia (RSH) remain problematic for people with type 1 diabetes (T1D), despite major therapeutic advances. We explored beliefs around hypo- and hyperglycemia in adults with T1D with, and without, IAH and RSH.

RESEARCH DESIGN AND METHODS

A cross-sectional U.S. multicenter survey included Attitudes to Awareness of Hypoglycemia (A2A; a 19-item questionnaire concerning beliefs about hypoglycemia), the Gold score (single item: awareness of hypoglycemia), and a question about severe hypoglycemia over the preceding year. The survey was emailed to 6,200 adult participants of the annual T1D Exchange clinic registry data collection. A2A data were subjected to principal component analysis with varimax rotation.

RESULTS

Among 1,978 respondents (response rate 32%), 61.7% were women, mean ± SD age was 39.6 ± 16.3 years, and T1D duration was 23.1 ± 13.8 years. Thirty-seven percent reported IAH, 16% RSH, and 9% both. A2A items segregated into three factors, differently distributed by hypoglycemia experience. Respondents with IAH or RSH expressed appropriate concern about hypoglycemia, but those with IAH were more likely to prioritize hyperglycemia concerns than those with intact awareness (P = 0.002). Those with RSH showed greater normalization of asymptomatic hypoglycemia than those without (P = 0.019) and trended toward prioritizing hyperglycemia concerns (P = 0.097), driven by those with both IAH and RSH.

CONCLUSIONS

Adults with T1D with IAH and RSH report specific cognitions about hypoglycemia and hyperglycemia, which may act as barriers to hypoglycemia avoidance and recovery of awareness. These may be modifiable and present a target for enhancing engagement of vulnerable people with strategies to avoid future hypoglycemia.

Hypoglycaemia, cardiovascular disease, and mortality in diabetes: epidemiology, pathogenesis, and management

Hypoglycaemia has long been recognised as a dangerous side-effect of treatment of diabetes with insulin or insulin secretagogues. With its potential to disrupt cerebral function, hypoglycaemia can have a major effect on peoples' lives. Study findings have suggested that hypoglycaemia is associated with an increased risk of cardiovascular events and mortality. Different mechanisms by which hypoglycaemia might provoke cardiovascular events have been identified in experimental studies, and in clinical studies cardiac arrhythmias have been reported to be induced by hypoglycaemia, with one report describing sudden death during a severe episode. Emerging evidence suggests that the association between hypoglycaemia and cardiovascular events and mortality is likely to be multifactorial. The association is probably partly caused by confounding, with hypoglycaemia occurring more frequently in people with comorbidities who are also more likely to die than those without. However, people with type 1 or type 2 diabetes also seem at risk of hypoglycaemia-induced cardiovascular effects. This risk should be recognised by clinicians when agreeing glycaemic goals with patients and choosing appropriate glucose-lowering therapies.

PAID-11: A brief measure of diabetes distress validated in adults with type 1 diabetes

OBJECTIVE

The Problem Areas In Diabetes (PAID) questionnaire is widely used to assess emotional distress related to living with diabetes, although it is lengthy for routine clinical use. Our aim was to determine whether the original 20-item PAID questionnaire can be abbreviated, whilst maintaining its reliability, validity and utility.

METHODS

We analysed data from the UK DAFNE (Dose Adjustment For Normal Eating) education programme for adults with Type 1 diabetes. Data were analysed at baseline (n = 1547) and 1-year post intervention (n = 846). Exploratory factor analysis (EFA) with principal axis factoring method was used to examine PAID responses within a random half of the baseline data (n = 746). Then, two confirmatory factor analyses (CFA) were conducted using the remaining baseline (n = 801) and 1-year data. Reliability, predictive validity, convergent validity and responsiveness were also examined.

RESULTS

Based on the EFA results, which were corroborated by CFA, an 11-item PAID questionnaire was identified with a cut-off score of 18 indicating severe diabetes distress. In the current sample, this brief version had high internal consistency (Cronbach's α = 0.93). Predictive validity was demonstrated with the PAID-11 identifying severe diabetes distress from the original 20-item measure, with 95% sensitivity and 96% specificity. Convergent validity was demonstrated by strong positive correlations with HADS anxiety and depressive symptoms (average r = 0.65 and r = 0.55, respectively), while divergent validity was shown with weaker correlations with EQ5D health status (average r = 0.37).

CONCLUSIONS

Based on present results, PAID-11 appears to be a valid and reliable measure, which seems suitable for use as a brief tool for the detection of diabetes distress in adults with type 1 diabetes. Importantly, this tool may reduce participant burden in multi-measure studies. However, further studies are urgently needed to determine the validity and utility of PAID-11 beyond the UK DAFNE population.

Suboptimal behaviour and knowledge regarding overnight glycaemia in adults with type 1 diabetes is common

BACKGROUND

In people with type 1 diabetes (T1D), nocturnal hypoglycaemia (NH) can be slept through and can cause seizures, arrhythmias and death. Hypoglycaemia avoidance can induce hyperglycaemia and ketosis. Patient behaviour impacts clinical outcomes and may be changed by education.

AIM

To develop and utilise a survey to evaluate patient self-management of overnight glycaemia in adults with T1D.

METHODS

Adults with T1D attending two Australian tertiary referral diabetes clinics completed a survey about their diabetes self-management and glycaemic control, including responses to hypothetical pre-bed blood glucose (BG) levels (4-20 mmol/L). Statistical analyses included t-tests, Chi square tests and ANOVA with significance considered at P < 0.05.

RESULTS

There were 205 participants (103 females), with a mean (SD) age of 41 (17) years, T1D duration of 20 (16) years, HbA1c of 7.8(1.4)%, (61.3(8.2) mmol/mol), 38% on insulin pump therapy (CSII) and 36% with impaired hypoglycaemia awareness (IHA). Mean (SD) number of BG tests/day was 5.4 (2.7). Patients set higher BG target levels at bedtime and overnight: 7.5(1.4) and 7.1(1.3) mmol/L, respectively, compared to daytime (6.9(1.0); P < 0.0001 and P = 0.002 respectively). Only 36% of participants reported treating nocturnal hypoglycaemia (NH) with the recommended refined, then complex, carbohydrate. Only 28% of patients made safe choices in all bedtime BG scenarios, with higher rates for CSII users, P = 0.0005. Further education was desired by 32% of respondents, with higher rates in those with (44%) versus without IHA (25%), P = 0.006.

CONCLUSIONS

Many adults with T1D have suboptimal knowledge and behaviour regarding overnight BG self-management. A survey, piloted herein, may facilitate the identification of patients who could benefit from further education.

Sustained Reduction in Severe Hypoglycemia in Adults With Type 1 Diabetes Complicated by Impaired Awareness of Hypoglycemia: Two-Year Follow-up in the HypoCOMPaSS Randomized Clinical Trial

OBJECTIVE

Severe hypoglycemia is a feared complication of type 1 diabetes; yet, few trials have targeted prevention using optimized self-management (educational, therapeutic, and technological support). We aimed to investigate whether improved awareness and reduced severe hypoglycemia, achieved during an intensive randomized clinical trial (RCT), were sustained after return to routine care.

RESEARCH DESIGN AND METHODS

Ninety-six adults with type 1 diabetes (29 ± 12 years' duration) and impaired awareness of hypoglycemia at five U.K. tertiary referral diabetes centers were recruited into a 24-week 2 × 2 factorial RCT (HypoCOMPaSS). Participants were randomized to pump (continuous subcutaneous insulin infusion [CSII]) or multiple daily injections (MDIs) and real-time continuous glucose monitoring (RT-CGM) or self-monitoring of blood glucose (SMBG), with equal education/attention to all groups. At 24 weeks, participants returned to routine care with follow-up until 24 months, including free choice of MDI/CSII; RT-CGM vs. SMBG comparison continued to 24 months. Primary outcome was mean difference (baseline to 24 months [between groups]) in hypoglycemia awareness.

RESULTS

Improvement in hypoglycemia awareness was sustained (Gold score at baseline 5.1 ± 1.1 vs. 24 months 3.7 ± 1.9; P < 0.0001). Severe hypoglycemia rate was reduced from 8.9 ± 12.8 episodes/person-year over the 12 months prestudy to 0.4 ± 0.8 over 24 months (P < 0.0001). HbA_1c improved (baseline 8.2 ± 3.2% [66 ± 12 mmol/mol] vs. 24 months 7.7 ± 3.1% [61 ± 10 mmol/mol]; P = 0.003). Improvement in treatment satisfaction and reduced fear of hypoglycemia were sustained. There were no significant differences between interventions at 24 months.

CONCLUSIONS

Optimized insulin replacement and glucose monitoring underpinned by hypoglycemia-focused structured education should be provided to all with type 1 diabetes complicated by impaired awareness of hypoglycemia.

Effect of 6 months of hybrid closed-loop insulin delivery in adults with type 1 diabetes: a randomised controlled trial protocol

INTRODUCTION

Manual determination of insulin dosing largely fails to optimise glucose control in type 1 diabetes. Automated insulin delivery via closed-loop systems has improved glucose control in short-term studies. The objective of the present study is to determine the effectiveness of 6 months' closed-loop compared with manually determined insulin dosing on time-in-target glucose range in adults with type 1 diabetes.

METHODS AND ANALYSIS

This open-label, seven-centre, randomised controlled parallel group clinical trial will compare home-based hybrid closed-loop versus standard diabetes therapy in Australia. Adults aged ≥25 years with type 1 diabetes using intensive insulin therapy (via multiple daily injections or insulin pump, total enrolment target n=120) will undertake a run-in period including diabetes and carbohydrate-counting education, clinical optimisation and baseline data collection. Participants will then be randomised 1:1 either to 26 weeks of MiniMed 670G hybrid closed-loop system therapy (Medtronic, Northridge, CA, USA) or continuation of their current diabetes therapy. The hybrid closed-loop system delivers insulin automatically to address basal requirements and correct to target glucose level, while bolus doses for meals require user initiation and carbohydrate estimation. Analysis will be intention to treat, with the primary outcome time in continuous glucose monitoring (CGM) target range (3.9-10.0 mmol/L) during the final 3 weeks of intervention. Secondary outcomes include: other CGM parameters, HbA_1c, severe hypoglycaemia, psychosocial well-being, sleep, cognition, electrocardiography, costs, quality of life, biomarkers of vascular health and hybrid closed-loop system performance. Semistructured interviews will assess the expectations and experiences of a subgroup of hybrid closed-loop users.

ETHICS AND DISSEMINATION

The study has Human Research Ethics Committee approval. The study will be conducted in accordance with the principles of the Declaration of Helsinki and Good Clinical Practice. Results will be disseminated at scientific conferences and via peer-reviewed publications.

TRIAL REGISTRATION NUMBER

ACTRN12617000520336; Pre-results.

Hypoglycaemia in type 1 diabetes: technological treatments, their limitations and the place of psychology

Advances in technology allowing improved insulin delivery and glucose monitoring can significantly reduce the burden of hypoglycaemia when used appropriately. However, limitations of the current technology, and the skills, commitment and motivation required to use them, mean that it does not work for all people. Education and informed professional support are key to success. In the context of problematic hypoglycaemia, data suggest that newer technology has lower efficacy and uptake in those with most need. Identifying the causes of hypoglycaemia and understanding some of the underlying behavioural drivers may prove useful and psycho-educational strategies may be effective in selected individuals. Ultimately, as in many spheres of medicine, successful management of problematic hypoglycaemia depends upon matching the right treatment to the right individual.

Spanish translation, adaptation and validation of the Hypoglycemia Fear Survey in adults with type 1 diabetes in the Community of Madrid

BACKGROUND AND OBJECTIVE

The negative impact of hypoglycemia on patients with type 1 diabetes mellitus (T1DM) may lead to development of fear of hypoglycemia. In this study, the original Hypoglycemia Fear Survey (HFS) questionnaire was translated into Spanish, adapted and validated, and variables associated to fear of hypoglycemia in T1DM were analyzed.

MATERIAL AND METHODS

The HFS was translated and adapted to Spanish using the forward-backward translation method. The resulting questionnaire, EsHFS, was administrated to a population with T1DM. The following parameters of the questionnaire were analyzed: feasibility, reliability (Cronbach's alpha), content validity (correlating EsHFS and EsDQOL [Diabetes Quality of Life] questionnaire), and stability (by means of test-retest correlation).

RESULTS

The EsHFS questionnaire consists of 24 items and three subscales including: subscale 1 on worry; subscale 2 on hypoglycemia-avoidant behavior, and subscale 3 on hyperglycemia-influenced behavior.

STUDY POPULATION

163 subjects, with a mean aged (SD) of 36 (10.5) years, 24% on continuous subcutaneous insulin infusion. Of these, 99.8% completed the EsHFS questionnaire in less than 10minutes. Cronbach's alpha for global EsHFS was 0.92. EsHFS and its subscales correlated with EsDQOL. Test-retest correlation (Pearson) was r=0.92. Age, female sex, lower educational level, living alone, frequency of daily self-monitoring and non-severe hypoglycemia, and history of severe and/or asymptomatic hypoglycemia were independently associated to the result of EsHFS.

CONCLUSIONS

The Spanish version of the HFS, EsHFS, has good psychometric properties and may be a useful tool to assess fear of hypoglycemia in Spanish-speaking patients with T1DM.

Fear of hypoglycaemia and its relation to hypoglycaemia awareness and symptom intensity in Type 1 diabetes

AIMS

To investigate fear of hypoglycaemia (FoH) in relation to hypoglycaemia awareness, history of severe hypoglycaemia (SH) and hypoglycaemia symptoms in adults with Type 1 diabetes.

METHODS

Questionnaire-based cross-sectional survey. We assessed FoH with the Hypoglycaemia Fear Survey-II Worry subscale, hypoglycaemia awareness status with the Gold score, and used the Edinburgh Hypoglycaemia Scale to grade the presence and intensity of hypoglycaemia symptoms. All these measures have previously been validated for research application. We used multivariable linear regression to examine associations between FoH and hypoglycaemia awareness status, history of SH and hypoglycaemia symptom score.

RESULTS

Of 636 invitees, 445 (70%) responded, with 435 responses eligible for analyses. Seventy-four persons had IAH (17%). Among those, 47 (64%) reported ≥ 1 SH during the preceding year, in contrast to this being reported by 113 (31%) of persons with normal awareness. The mean (SD) FoH worry score was 1.33 (0.78). This score was 0.64 (95% CI, 0.45-0.83) higher among people with impaired vs. normal hypoglycaemia awareness and 0.53 (95% CI, 0.33-0.73) higher among people with ≥ 3 episodes of SH the preceding year vs. people with no such episode. A higher number and intensity of hypoglycaemia symptoms was associated with higher FoH, as demonstrated by an increase in mean FoH worry score of 0.30 (95% CI, 0.23-0.36) per point increase in mean Edinburgh hypoglycaemia score.

CONCLUSIONS

Impaired awareness of hypoglycaemia, history of SH and higher Edinburgh hypoglycaemia scores were all associated with increased FoH in adults with Type 1 diabetes.

Emerging adulthood and Type 1 diabetes: insights from the DAWN2 Study

AIMS

To compare clinical, psychological, education and social variables in emerging adults (aged 18-30 years) with Type 1 diabetes with their adult counterparts aged >30 years.

METHODS

A single assessment multinational sample was surveyed as part of the larger second Diabetes Attitudes, Wishes and Needs (DAWN2) study. Participants completed a series of surveys incorporating demographic as well as clinical questions (comorbidities, hypoglycaemia) and validated self-report scales concerning psychosocial (health impact, quality of life, beliefs and attitudes, self-management behaviours, healthcare experience and family support) and diabetes education factors.

RESULTS

Emerging adults differed from adults aged >30 years with regard to a number of psychosocial variables. Emerging adults reported better overall quality of life, social support and support from their healthcare team compared with adults aged >30 years of age; however, emerging adults experienced greater diabetes-specific distress and were less engaged in self-management. Diabetes education was related to a number of indicators, while experience of discrimination was harmful, but these impacts did not differ between emerging adults and adults aged >30 years. An analysis of geographical regions suggested that emerging adults in North America and Europe had better well-being than older adults, while the opposite was observed in Asia.

CONCLUSIONS

Emerging adults, particularly those in the later phase (ages 25-30 years) are especially at risk in terms of diabetes-specific distress. There is a need for novel interventions to meet the needs of these vulnerable emerging adults more effectively.

The role of hypoglycemia in the burden of living with diabetes among adults with diabetes and family members: results from the DAWN2 study in The Netherlands

Background

To examine the relation between self-reported hypoglycemic events, worries about these episodes, and the burden of diabetes in adults with diabetes and family members from The Netherlands.

Methods

As part of the second multinational Diabetes Attitudes, Wishes and Needs (DAWN2) study, 412 Dutch adults with type 1 or type 2 diabetes and 86 family members completed questions about the burden of living with diabetes, the frequency of hypoglycemia, worries about these events, and several demographic and clinical factors. Analyses included hierarchical logistic regression.

Results

In total, 41% of people with diabetes and 56% of family members considered diabetes at least somewhat of a burden. In people with diabetes, diabetes burden was independently associated with self-reported current insulin use (fully adjusted OR = 2.75, 95% CI 1.49–5.10), self-reported frequent non-severe hypoglycemia in the past year (OR = 2.45, 1.25–4.83), self-reported severe hypoglycemia in the past year (OR = 1.91, 1.02–3.58), and being very worried about hypoglycemia at least occasionally (OR = 3.64, 2.18–6.10). For family members, the odds of experiencing living with diabetes as a burden was increased only for participants who were at least occasionally very worried about hypoglycemia (adjusted OR = 5.07, 1.12–23.00).

Conclusions

Approximately half of adults with diabetes and adult family members experienced at least some diabetes burden. In both groups, diabetes burden appeared to be associated with being very worried about hypoglycemia at least occasionally. If these results are replicated, new intervention studies could test new ways of decreasing the traumatic consequences of previous or anticipated hypoglycemic events for people with diabetes and family members.

A Canadian Cross-Sectional Survey on Psychosocial Supports for Adults Living With Type 1 or 2 Diabetes: Health-Care Providers' Awareness, Capacity and Motivation

OBJECTIVES

Addressing psychosocial issues is critical for diabetes self-management. This work explores health-care professionals' (HCPs') 1) perceived relevance of various psychosocial issues in diabetes management and 2) confidence in working on these issues within their services.

METHODS

An online cross-sectional survey was developed based on the Capacity-Opportunity-Motivation Behaviour Model. It assessed self-rated confidence in supporting patients with psychosocial issues (capability), perceived relevance of these issues (motivation) and facilitators of skill development (opportunity). An e-mail invitation was sent to all Diabetes Canada's professional members, conference delegates and committee members. Qualitative responses were analyzed using thematic analysis.

RESULTS

Of the 260 responses received (25% response rate), many were Diabetes Canada professional members (83%) and/or certified diabetes educators (66%). The largest professional groups in the sample were registered nurses (44%) and registered dietitians (33%). All psychosocial issues were perceived as somewhat or extremely important by at least 80% of respondents (range, 80% to 97%). However, HCPs were less confident in supporting their patients with these psychosocial issues; significantly fewer respondents reported that they felt somewhat or extremely confident (range, 26% to 62%). Depression (80%) and anxiety (80%) were the issues in which guidance was most desired. Most respondents wanted some form of formal self-management support training (83%). Preferred training methods included in-person workshops (56%), webinars (56%) and conference sessions (51%).

CONCLUSIONS

Motivation to address psychosocial issues in diabetes was high, but capacity to do so and opportunity to learn how were both low. These findings can be used to develop a targeted strategy to help address this gap.

Reporting Severe Hypoglycemia in Type 1 Diabetes: Facts and Pitfalls

PURPOSE OF REVIEW

To describe potential factors influencing reporting of severe hypoglycemia in adult patients with type 1 diabetes and to analyze their effect on reported rates of severe hypoglycemia.

RECENT FINDINGS

Reported rates of severe hypoglycemia defined as need for third party assistance vary between 0.3-3.0 events per patient-year in unselected cohorts, corresponding to a yearly prevalence range of 10-53%. When defined as need for parenteral therapy with glucose or glucagon or need for admission to an emergency unit or hospitalization, incidence and prevalence rates of severe hypoglycemia are 0.02-0.5 events per patient-year and 1-29%, respectively. When subjects with recurrent severe hypoglycemia in the past or suffering from impaired hypoglycemia awareness are excluded from participation in studies, lower rates are reported. Studies applying anonymous reporting or reporting by partners report higher rates of severe hypoglycemia. There is a large variation between studies reporting incidence and prevalence of severe hypoglycemia in patients with type 1 diabetes, mainly explained by definition of severity, methods of reporting, and patient selection. These findings call for consensus about hypoglycemia definition and reporting in future research.

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.

Hypoglycemia evaluation and reporting in diabetes: Importance for the development of new therapies

Hypoglycemia complicating diabetes therapy is well recognized to be an ever-present threat to patients, their families, providers, payers, and regulators. Despite this being widely acknowledged, the regulatory stance on hypoglycemia as an endpoint in clinical trials to support new product registration has not evolved in any meaningful way since the publication of a position paper by an American Diabetes Association (ADA) Workgroup in 2005. As the impact of hypoglycemia on persons affected by diabetes is of major importance when assessing new treatments, the historical position of regulatory agencies on hypoglycemia is reviewed with respect to product approvals. The purpose of this article is to present proposals for facilitating development of therapies that reduce hypoglycemia risk through (1) development of composite measures of benefit for regulatory endpoints and (2) facilitation of the fulfillment of an unmet clinical need for reducing hypoglycemia. In view of greater comprehension of the effects of hypoglycemia, coupled with improved methodology to assess its frequency, the authors recommend: (1) a numerical cut point of <54 mg/dl (<3.0 mmol/L) as a clinically relevant level with which to define meaningful hypoglycemia for trials of diabetes therapies; (2) utilization in clinical trials of mature glucose monitoring technologies for purposes of regulatory evaluation and clinical decision-making; and (3) development of primary efficacy endpoint composites that include hypoglycemia rates and glycemic control.

Fear of hypoglycemia: Influence on glycemic variability and self-management behavior in young adults with type 1 diabetes

PURPOSE

The purpose of this study was to examine how fear of hypoglycemia (FOH) is associated with glycemic variability (GV) and self-management behavior in young adults (aged 18-35) with type 1 diabetes (T1DM).

PROCEDURES

Using a prospective repeated-measures design, in 35 young adults, within- and between-person and temporal associations of FOH, specific self-management behaviors, and GV were measured. The data were collected using questionnaires and real-time measures using daily diaries, insulin pump downloads, actigraphy, and continuous glucose monitoring.

FINDINGS

FOH was associated with greater glycemic variability. Significant temporal associations emerged. Concurrent day (glucose SD, p=.011) and previous-evening fear levels were associated with GV (glucose SD, p=.007). FOH was also associated with greater calorie intake (r=.492, p=.003) and less physical activity (light activity, r=-.341, p=.045).

CONCLUSIONS

The significant associations of FOH with GV, dietary patterns, and physical activity provide evidence for FOH as an important psychological factor associated with diabetes care.

Severe hypoglycemia, impaired awareness of hypoglycemia, and self-monitoring in adults with type 1 diabetes: Results from Diabetes MILES-Australia

AIMS

To assess prevalence of severe hypoglycemia, awareness and symptoms of hypoglycemia, and their associations with self-monitoring of blood glucose.

METHODS

Diabetes MILES-Australia Study participants completed validated questionnaires and study-specific items.

RESULTS

Of 642 adults with type 1 diabetes, 21% reported ≥1 severe hypoglycemic event in the past six months, and 21% reported impaired awareness of hypoglycemia (IAH). Severe hypoglycemia was increased four-fold for those with IAH compared with intact awareness (1.4±3.9 versus 0.3±1.0). Of those with IAH, 92% perceived autonomic and 88% neuroglycopenic symptoms, albeit at lower glucose thresholds compared to people with intact awareness. Those with IAH were more likely to perceive both symptom types at the same glucose level or to perceive neuroglycopenic symptoms first (all p<0.001). Eighteen percent with IAH treated hypoglycemia only when they perceived symptoms and another 18% only when their capillary glucose was <3.0mmol/L.

CONCLUSIONS

One in five adults with type 1 diabetes had IAH or experienced severe hypoglycemia in the past sixmonths. Total loss of hypoglycemia symptoms was rare; most people with IAH retained autonomic symptoms, perceived at relatively low glucose levels. Frequent self-monitoring of blood glucose prompted early recognition and treatment of hypoglycemia, suggesting severe hypoglycemia risk can be minimized.