Distress and type 2 diabetes-treatment adherence: A mediating role for perceived control

Relationships of Psychosocial Factors to Diabetes Self-efficacy: A Cross-sectional, Correlational Study

BACKGROUND

Self-care in people with diabetes is poor, which could be influenced by positive and negative psychosocial factors. Self-efficacy is an important factor affecting self-care, and depressive symptoms and diabetes distress may directly and indirectly affect self-efficacy.

OBJECTIVE

The aim of this study was to examine the relationships of depressive symptoms, diabetes distress, age, sex, self-compassion, resilience, self-esteem, and social support to diabetes self-efficacy and the mediating roles of diabetes distress and depressive symptoms in the relationships among people with diabetes.

METHODS

In this cross-sectional, correlational study, data on all the psychosocial and demographic factors were collected (N = 148; 57.6 years old) through Research Electronic Data Capture in 2023. The PROCESS macro for SPSS was used to address the purpose.

RESULTS

The mean score of diabetes self-efficacy was 28.6 (range, 8-40). In 1 model, depressive symptoms were directly and indirectly associated with diabetes self-efficacy through diabetes distress (direct effect, -3.524; t = -3.020, P = .003; indirect effect, -2.089; 95% bootstrap confidence interval, -3.494 to -0.911). In another model, diabetes distress was directly and indirectly associated with diabetes self-efficacy through depressive symptoms (direct effect, -3.778; t = -3.638, P < .001; indirect effect, -0.785; 95% bootstrap confidence interval, -1.868 to -0.089). In addition, self-esteem was associated with both depressive symptoms and diabetes distress. Resilience was associated with diabetes self-efficacy in 1 model.

CONCLUSIONS

Negative psychological factors were directly and indirectly associated with diabetes self-efficacy. Depressive symptoms, diabetes distress, self-esteem, and resilience can be important targets of interventions to improve diabetes self-efficacy.

Exploring the self-efficacy of patients with diabetes: its role as a predictor of diabetes management and well-being

Background

Self-efficacy is a popular psychological concept that refers to an individual's perception or belief in his ability to perform specific actions. This study aimed to assess the predictive value of self-efficacy, measured using the Self-Efficacy for Managing Chronic Disease 6-Item Scale (SEM6S) questionnaire, for diabetes management and overall well-being in patients with diabetes.

Subject and methods

An anonymous online cross-sectional study was conducted to evaluate the self-efficacy of diabetic patients in the Asser region of Saudi Arabia. The participants were requested to upload their most recent glycated hemoglobin A1C (HbA1C) measurements taken in the last three months, which helped in the accurate categorization of their diabetes as either controlled or uncontrolled. We used the valid Arabic version of the SEM6S and WHO-5 well-being questionnaires to assess patient self-efficacy and well-being.

Results

A cohort of 342 patients was enrolled in the study, 67.25% were married, their mean age was 43.17 ± 17.61 years, and 52.69% had university-level or higher education. Among the participants, 46.0% exhibited well-being, while 24.9% reported poor well-being, including 9.4% who were identified as experiencing depression. The mean scores of self-efficacy and well-being were significantly higher among those with controlled diabetes versus uncontrolled diabetes (40.86 ± 13.26 vs. 36.48 ± 13.26) and (67.35 ± 21.22 vs. 60.93 ± 25.05), respectively. The predictors of glycemic control were self-efficacy [Odds ratio (OR)=1.03 (95%CI, 1.01-1.06, P=0.002], having other chronic diseases [OR=3.25 (95%CI), P<0.001], having type 1 diabetes [OR=7.16, 95%CI, P=0.005], being Saudi [OR=7.67, (95%CI, P=0.027], working in a public sector [OR=0.15, (95%CI, 0.05-0.44), P=0.005], being unemployed [OR=0.19, (95%CI, 0.06-0.59), P=0.005], being a smoker [OR=0.44, 95%CI, 0.19-0.98, P=0.048], and duration of diabetes between 6-10 years [OR= 0.33, 95%CI, 0.11-0.95), P=0.043] or more than 10 years OR=0.32, 95%CI, 0.12-0.86), P=0.026]. The main determinants of well-being were having self-efficacy [OR=1.07 (95%CI, 1.04-1.09), P = 0.0001], having public health insurance [OR=4.36 (95%CI, P=0.015], and education level (read and write) [OR=0.13 (95%CI,.02-.70), P=0.021].

Conclusions

The study reveals that non-modifiable and modifiable factors, including self-efficacy, play a crucial role in diabetes control. The study recommends providing targeted educational interventions, using different social media platforms, psychosocial support programs, and inclusive healthcare policies to improve diabetes control and mental well-being among diabetic patients.

Foot self-care behaviour in primary care patients with diabetic foot ulcers: Structural equation modelling of psychological predictors

Diabetic foot ulcers (DFUs) are one of the most prevalent and costly diabetes complications, associated with diminished quality of life and poor prognosis. Management of DFUs relies heavily on patients' foot self-care behaviour. This study aims to explore psychological determinants of this important behaviour among primary care patients. A total of 186 patients with active DFUs self-reported their illness perception, diabetes distress, self-efficacy, and foot self-care behaviour. Structural equation modelling was performed to examine interrelationships among measured variables. The final model demonstrated satisfactory fit, CFI = 0.933, TLI = 0.913, RMSEA = 0.050, SRMR = 0.073, χ2(95) = 132.256 (p = 0.004), and explained 51.1% of the variance of foot self-care. Illness threat perceptions (i.e., consequence, timeline, identity, concern, and emotion) had a direct positive effect on foot self-care behaviours, but also indirectly decreased foot self-care through increasing diabetes distress. Control perceptions (i.e., personal control, treatment control, and coherence) were not directly associated with foot self-care behaviours, but indirectly improved foot self-care by reducing diabetes distress and increasing foot care confidence. These findings suggest illness perceptions, diabetes distress, and self-care confidence as modifiable predictors to be targeted in self-management interventions for patients with DFUs.

Motivation to change predicts college students' utilization of self-help resources

Background: Stress and mental health difficulties are common burdens on college students. College counseling centers have been overrun by demand. Thus, self-help interventions may offer a promising alternative to traditional college counseling services. Methods: The current study examined the influence of perceived stress, motivation to change, and self-efficacy beliefs on college students' use of self-help resources, to determine whether these factors would predict follow-up with self-help recommendations. Results: Results of stepwise linear regression models suggest that perceived stress and self-efficacy did not predict self-help resource utilization. Different types of self-help recommendations did not predict different levels of follow-up. However, motivation to change was a significant predictor college students' self-help resource use, and this variable was particularly important when self-help recommendations were less structured. Conclusions: These findings can help to predict which college students are likely to make use of self-help resources, and inform targeted individual treatment.

Perceptions of diabetes distress during pregnancy in women with type 1 and type 2 diabetes: a qualitative interpretive description study

BACKGROUND

Diabetes distress is commonly seen in adults with pre-existing diabetes and is associated with worsened glycemic management and self-management practices. While a majority of women report increased stress during pregnancy, it is unknown how women with type 1 or type 2 diabetes experience diabetes distress during this unique and transitional time.

PURPOSE

This study aimed to understand the experiences and perceptions of diabetes distress in women with pre-existing diabetes during pregnancy.

METHODS

A qualitative study using an interpretive description approach was conducted. In-depth, one to one interviewing was used to capture rich descriptions of the pregnancy experience. Nested, stratified, and theoretical sampling was used to recruit 18 participants with type 1 and type 2 diabetes from the quantitative strand of this mixed methods study. Constant comparative analysis was used to inductively analyze the data and develop themes.

FINDINGS

Four themes, each with several subthemes, emerged under the main finding of "Diabetes Distress": 1) Worry for Baby's Health - "What's this going to do to the baby?"' 2) Feeling Overwhelmed with Diabetes Management-"It just seemed unattainable"; 3) Living with Diabetes - "There's no way out" and 4) Cycle of Diabetes Distress.

CONCLUSIONS

The findings from this study identify the sources and experiences of diabetes distress during pregnancy in women with pre-existing diabetes. Diabetes distress often presents as cyclical and multifaceted during pregnancy, with elements of fear for the unborn baby, difficulties with diabetes management, and having negative lived experiences of diabetes. Further work is needed to develop appropriate screening tools for pregnancy and interventions to mitigate diabetes distress. Diabetes educators are well-positioned provide emotional support and person-centred self-management education to individuals with diabetes.

Emotional Distress Predicts Reduced Type 2 Diabetes Treatment Adherence in the Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE)

OBJECTIVE

We examined longitudinal associations between emotional distress (specifically, depressive symptoms and diabetes distress) and medication adherence in Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study (GRADE), a large randomized controlled trial comparing four glucose-lowering medications added to metformin in adults with relatively recent-onset type 2 diabetes mellitus (T2DM).

RESEARCH DESIGN AND METHODS

The Emotional Distress Substudy assessed medication adherence, depressive symptoms, and diabetes distress in 1,739 GRADE participants via self-completed questionnaires administered biannually up to 3 years. We examined baseline depressive symptoms and diabetes distress as predictors of medication adherence over 36 months. Bidirectional visit-to-visit relationships were also examined. Treatment satisfaction, beliefs about medication, diabetes care self-efficacy, and perceived control over diabetes were evaluated as mediators of longitudinal associations.

RESULTS

At baseline, mean ± SD age of participants (56% of whom were White, 17% Hispanic/Latino, 18% Black, and 66% male) was 58.0 ± 10.2 years, diabetes duration 4.2 ± 2.8 years, HbA1c 7.5% ± 0.5%, and medication adherence 89.9% ± 11.1%. Higher baseline depressive symptoms and diabetes distress were independently associated with lower adherence over 36 months (P < 0.001). Higher depressive symptoms and diabetes distress at one visit predicted lower adherence at the subsequent 6-month visit (P < 0.0001) but not vice versa. Treatment assignment did not moderate relationships. Patient-reported concerns about diabetes medications mediated the largest percentage (11.9%-15.5%) of the longitudinal link between emotional distress and adherence.

CONCLUSIONS

Depressive symptoms and diabetes distress both predict lower adherence to glucose-lowering medications over time among adults with T2DM. Addressing emotional distress and concerns about anticipated negative effects of taking these treatments may be important to support diabetes treatment adherence.

Reliability and validity of the Turkish version of the problem areas in diabetes (PAID) survey: Results from diabetes MILES - Turkey

BACKGROUND AND AIMS

To 1) assess the reliability and validity of the Turkish version of the Problem Areas in Diabetes (PAID), PAID-5 and PAID-1 survey among Turkish adults with type 1 or type 2 diabetes, 2) estimate the level of elevated diabetes-specific distress (DD), and 3) determine the demographic and clinical correlates of DD-symptom severity.

METHODS AND RESULTS

From 2017-2019, 252 adults with type 1(n = 80) (T1DM) or type 2 diabetes (n = 172) (T2DM) self-reported demographic factors, DD(PAID) and related psychological and clinical questionnaires. We examined PAID internal consistency, structural and convergent validity. Associations of measures with DD were explored with hierarchical linear regression analysis. PCA yielded a 3-factor solution for PAID-20 and a 2-factor solution for PAID-5. Cronbach's α for PAID/PAID-5 subscales ranged from 0.63-0.90. All PAID versions correlated most strongly to BIPQ and HFS. The prevalence of elevated distress (PAID-20 ≥33) was 40% in T1DM and 15% in T2DM. DD severity was significantly positively associated (p < 0.01) with more negative diabetes perceptions (BIPQ) and type 1 diabetes.

CONCLUSIONS

The Turkish translation of the PAID and its short forms appeared to have satisfactory psychometric properties. Elevated diabetes distress was more common in T1DM.

COVID-19 pandemic-related healthcare interruptions and diabetes distress: a national study of US adults with diabetes

BACKGROUND

Early COVID-19 pandemic research found changes in health care and diabetes management, as well as increased diabetes distress. This study aims to determine the association between COVID-19 pandemic-related healthcare interruptions and diabetes distress among adults with Type 1 and Type 2 diabetes in the US in 2021.

METHODS

Multinomial logistic regression was used to analyze moderate and high levels of diabetes distress (reference = no diabetes distress) in 228 individuals with Type 1 diabetes and 2534 individuals with Type 2 diabetes interviewed in the National Health Interview Survey in 2021.

RESULTS

Among adults with Type 1 diabetes, 41.2% experienced moderate diabetes distress and 19.1% experienced high diabetes distress, and among adults with Type 2 diabetes, 40.8% experienced moderate diabetes distress and 10.0% experienced high diabetes distress. In adults with Type 1 diabetes, experiencing delayed medical care was associated with an adjusted odds ratio (aOR) of 4.31 (95% CI: 1.91-9.72) for moderate diabetes distress and 3.69 (95% CI: 1.20-11.30) for high diabetes distress. In adults with Type 2 diabetes, experiencing delayed medical care was associated with an aOR of 1.61 (95% CI: 1.25-2.07) for moderate diabetes distress and 2.27 (95% CI: 1.48-3.49) for high diabetes distress. Similar associations were observed between not receiving medical care due to the pandemic and diabetes distress.

CONCLUSION

Among people with diabetes, experiencing delayed medical care and not receiving care due to the pandemic were associated with higher reports of diabetes distress.

Advancing diabetes primary care education and knowledge in Nepal: A scoping review and case study discussion

AIMS

Diabetes mellitus (DM) is a chronic disorder of insulin and glucose metabolism. It affects more than 463 million people worldwide and is expected to reach 700 million by 2045. In the Southeast Asian region, the prevalence of DM has tripled to 115 million due to rapid urbanization, unhealthy diet, sedentary lifestyles, and genetic factors. In Nepal, a developing country, DM affects 8.5% of adults, with an alarming increase in recent years. Lack of diabetes education and limited populational adoption of behavioural changes further hamper care.

METHODS

In the present study, we performed a scoping review to determine the status of awareness, attitudes, and knowledge about diabetes in the Nepalese population with a focus on the educational initiatives that have been implemented. We also conducted a two-week international case study discussion among medical students to brainstorm viable intervention strategies.

RESULTS

Our findings indicate that limited data is available on the level of education or initiatives to improve knowledge and practice among healthcare professionals and community members. Targeted studies of people with diabetes also present heterogeneous results due to differences in the sample population, geographic location, education, age, and gender. Accordingly, we propose five interrelated education-based strategies that leverage existing networks to expand community outreach and engagement, improve system resilience, and improve health outcomes.

CONCLUSIONS

Effective education for healthcare professionals, community, and patients with diabetes is vital in improving diabetes outcomes in Nepal and South Asia. Collaboration, funding, and evaluation are key areas needing reform.

Relationships of multidimensional factors to self-management in patients with diabetes: A Cross-sectional, correlational study

Poor self-management in patients with diabetes is a consistent issue, leading to diabetes complications. The purpose of this study was to examine the relationships of demographic, cognitive, psychological, social, and physiological factors to self-management in patients with diabetes. In this cross-sectional, correlational study, data were collected from 98 patients through REDCap in 2023. Multiple regression analysis was used to address the study purpose. In the sample, adherence to adequate self-management was poor. Knowledge, self-efficacy, and body mass index (BMI) were associated with overall diabetes self-management. Self-efficacy and BMI were associated with diet and exercise. Knowledge and self-efficacy were associated with blood glucose testing. No factors were associated with smoking and foot care. In conclusion, different factors were associated with different types of self-management, but BMI and self-efficacy were associated with most types of self-management. Clinicians and researchers can target BMI, self-efficacy, and knowledge to improve self-management in patients with diabetes.

Health-Related Social Control and Perceived Stress Among High-Risk Latina Mothers with Type 2 Diabetes and Their At-Risk Adult Daughters

BACKGROUND

Diabetes-related multi-morbidity and cultural factors place Latinas with diabetes at increased risk for stress, which can threaten illness management. Families provide an ideal focus for interventions that seek to strengthen interpersonal resources for illness management and, in the process, to reduce stress. The current study sought to examine whether participating in a dyadic intervention was associated with reduced perceived stress and, furthermore, whether this association was mediated by persuasion and pressure, two forms of health-related social control.

METHOD

Latina mothers with diabetes and their at-risk adult daughters participated in either (1) a dyadic intervention that encouraged constructive collaboration to improve health behaviors and reduce stress, or (2) a usual-care minimal control condition. Actor-partner interdependence model analysis was used to estimate the effect of the intervention on dyads' perceived stress, and mother-daughter ratings of health-related social control as potential mediators.

RESULTS

Results revealed that participating in the intervention was associated with significantly reduced perceived stress for daughters, but not for mothers (β =  - 3.00, p = 0.02; β =  - 0.57, p = 0.67, respectively). Analyses also indicated that the association between the intervention and perceived stress was mediated by persuasion, such that mothers' who experienced more health-related persuasion exhibited significantly less post-intervention perceived stress (indirect effect =  - 1.52, 95% CI = [- 3.12, - 0.39]). Pressure exerted by others, however, did not evidence a mediating mechanism for either mothers or daughters.

CONCLUSION

These findings buttress existing research suggesting that persuasion, or others' attempts to increase participants' healthy behaviors in an uncritical way, may be a driving force in reducing perceived stress levels.

Ascertainment of Minimal Clinically Important Differences in the Diabetes Distress Scale-17: A Secondary Analysis of a Randomized Clinical Trial

Importance

The Diabetes Distress Scale-17 (DDS-17) is a common measure of diabetes distress. Despite its popularity, there are no agreed-on minimal clinically important difference (MCID) values for the DDS-17.

Objective

To establish a distribution-based metric for MCID in the DDS-17 and its 4 subscale scores (interpersonal distress, physician distress, regimen distress, and emotional distress).

Design, Setting, and Participants

This secondary analysis of a randomized clinical trial used baseline and postintervention data from a hybrid (implementation-effectiveness) trial evaluating Empowering Patients in Chronic Care (EPICC) vs an enhanced form of usual care (EUC). Participants included adults with uncontrolled type 2 diabetes (glycated hemoglobin A1c [HbA1c] level >8.0%) who received primary care during the prior year in participating Department of Veterans Affairs clinics across Illinois, Indiana, and Texas. Data collection was completed in November 2018, and data analysis was completed in June 2023.

Interventions

Participants in EPICC attended 6 group sessions led by health care professionals based on collaborative goal-setting theory. EUC included diabetes education.

Main Outcomes and Measures

The main outcome was distribution-based MCID values for the total DDS-17 and 4 DDS-17 subscales, calculated using the standard error of measurement. Baseline to postintervention changes in DDS-17 and its 4 subscale scores were grouped into 3 categories: improved, no change, and worsened. Multilevel logistic and linear regression models examined associations between treatment group and MCID change categories and whether improvement in HbA1c varied in association with MCID category.

Results

A total of 248 individuals with complete DDS-17 data were included (mean [SD] age, 67.4 [8.3] years; 235 [94.76%] men), with 123 participants in the EPICC group and 125 participants in the EUC group. The MCID value for DDS-17 was 0.25 and MCID values for the 4 distress subscales were 0.38 for emotional and interpersonal distress and 0.39 for physician and regimen distress. Compared with EUC, more EPICC participants were in the MCID improvement category on DDS-17 (63 participants [51.22%] vs 40 participants [32.00%]; P = .003) and fewer EPICC participants were in the worsened category (20 participants [16.26%] vs 39 participants [31.20%]; P = .008). There was no direct association of DDS-17 MCID improvement (β = -0.25; 95% CI, -0.59 to 0.10; P = .17) or worsening (β = 0.18; 95% CI, -0.22 to 0.59; P = .38) with HbA1c levels among all participants.

Conclusions and Relevance

In this secondary analysis of data from a randomized clinical trial, an MCID improvement or worsening of more than 0.25 on the DDS-17 was quantitatively significant and patients in the EPICC group were more likely to experience improvement than those in the EUC group.

Trial Registration

ClinicalTrials.gov Identifier: NCT01876485.

Patient-Centered Outcomes After a Medication Adherence Intervention: a Pilot Study

PRCIS

Self-determination theory (SDT) guided behavioral interventions are effective in improving several patient-centered metrics, including glaucoma-related distress. However, whether improvement in patient-centered metrics can drive an improvement in medication-taking behavior remains to be seen.

OBJECTIVE

The 7-month Support, Educate, Empower (SEE) personalized glaucoma coaching program was previously shown to improve glaucoma medication adherence by 21 percent points. This study's goal was to assess the impact of the SEE program on self-determination theory (SDT) metrics and other patient-centered outcome measures.

PARTICIPANTS AND METHODS

Glaucoma patients (≥40 y old, taking ≥1 medication) self-reporting poor medication adherence were recruited at the University of Michigan. Eight surveys (with 10 subscales) were completed before and after the 7-month SEE program. Three surveys assessed changes in SDT (Treatment Self-regulation Questionnaire, Healthcare-Climate Questionnaire, Perceived Competence) while the others assessed participants' Glaucoma Knowledge, Glaucoma Medication Self-efficacy, Glaucoma-related distress, Perceived benefits, confidence asking and getting questions answered.

RESULTS

Thirty-nine participants completed the SEE program. Significant improvements were in 7 subscales, including all three SDT tenets of competence (mean change =0.9, SD =±1.2, adjusted P =0.0002), autonomy (0.5, ±0.9, 0.044), and relatedness ( P =0.002). Glaucoma-related distress (-2.0, ±3.2, 0.004), confidence in asking questions (1.1, ±2.0, 0.008), and confidence in getting questions answered (1.0, ±2.0, 0.009) also improved. Glaucoma-related distress was correlated with perceived competence ( r =-0.56, adjusted P =0.005), and an increase in perceived competence was associated with a decrease in glaucoma-related distress (β=-0.43, 95% CI -0.67 - -0.20, adjusted P =0.007).

CONCLUSIONS

The SEE program improved participants' autonomous motivation, perceived support, perceived competence, glaucoma-related distress, and competence. These results point to the promising potential of SDT-guided behavioral interventions in improving patient-centered metrics.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

AIMS

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friend Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

METHODS

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9 months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

RESULTS

PWDs (N = 329) were 52% male and 39% reported minoritized race or ethnicity ; 50% enrolled with elevated diabetes distress. Support persons (N = 294) were 26% male and 33% reported minoritized race or ethnicity. FAMS improved PWDs' diabetes distress (d = -0.19) and global well-being (d = 0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention (9-month) and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

CONCLUSIONS

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Effect of a religious coping intervention of rational emotive behavior therapy on mental health of adult learners with type II diabetes

BACKGROUND

Some previous studies have highlighted the high rate of mental health problems associated with type II diabetes (T2DM). The primary purpose of this study was to investigate the effect of a religious coping intervention of rational emotive behavior therapy (REBT) on the mental health of adult learners with T2DM.

METHODS

This study utilized a randomized controlled trial to select 146 adult learners with T2DM and mental health-related problems. The treatment group was made up of 73 adult learners, while the control group was also made up of 73 adult learners. The experimental group received 8 sessions of a religious coping intervention of REBT, while the control group received usual care. Data were collected using the patient health questionnaire, Warwick-Edinburgh mental well-being scale, and Kessler psychological distress scale. Repeated ANOVA and univariate analysis of covariance were used for data analyses.

RESULTS

The religious coping intervention of REBT substantially enhanced the mental health of adult learners with T2DM as measured by Warwick-Edinburgh mental well-being scale (P < .000) and patient health questionnaire (P < .000). The religious coping intervention of REBT significantly alleviated the psychological distress of adult learners with T2DM as measured by Kessler psychological distress scale (P < .000).

CONCLUSION

In this study, it has been demonstrated that a religious coping intervention of REBT effectively improves the mental health of adult learners with T2DM. The study concludes that the religious coping intervention of REBT is a practical alternative medicine approach to enhancing the mental health of adult learners with T2DM.

Well-being outcomes of a family-focused intervention for persons with type 2 diabetes and support persons: Main, mediated, and subgroup effects from the FAMS 2.0 RCT

Aims

Type 2 diabetes self-management occurs within social contexts. We sought to test the effects of Family/friends Activation to Motivate Self-care (FAMS), a self-care support intervention delivered via mobile phones, on psychosocial outcomes for persons with diabetes (PWDs) and their support persons.

Methods

PWDs had the option to enroll with a friend/family member as a support person in a 15-month RCT to evaluate FAMS versus enhanced usual care. FAMS included 9-months of monthly phone coaching and text message support for PWDs, and text message support for enrolled support persons.

Results

PWDs (N=329) were 52% male and 39% from minoritized racial or ethnic groups; 50% enrolled with elevated diabetes distress. Support persons (N=294) were 26% male and 33% minoritized racial or ethnic groups. FAMS improved PWDs' diabetes distress ( d =-0.19) and global well-being ( d =0.21) during the intervention, with patterns of larger effects among minoritized groups. Post-intervention and sustained (15-month) improvements were driven by changes in PWDs' self-efficacy, self-care behaviors, and autonomy support. Among support persons, FAMS improved helpful involvement without increasing burden or harmful involvement.

Conclusions

FAMS improved PWDs' psychosocial well-being, with post-intervention and sustained improvements driven by improved self-efficacy, self-care, and autonomy support. Support persons increased helpful involvement without adverse effects.

Low-Intensity mental health Support via a Telehealth Enabled Network for adults with diabetes (LISTEN): protocol for a hybrid type 1 effectiveness implementation trial

BACKGROUND

Mental health problems are common among people with diabetes. However, evidence-based strategies for the prevention and early intervention of emotional problems in people with diabetes are lacking. Our aim is to assess the real-world effectiveness, cost-effectiveness, and implementation of a Low-Intensity mental health Support via a Telehealth Enabled Network (LISTEN), facilitated by diabetes health professionals (HPs).

METHODS

A hybrid type I effectiveness-implementation trial, including a two-arm parallel randomised controlled trial, alongside mixed methods process evaluation. Recruited primarily via the National Diabetes Services Scheme, Australian adults with diabetes (N = 454) will be eligible if they are experiencing elevated diabetes distress. Participants are randomised (1:1 ratio) to LISTEN-a brief, low-intensity mental health support program based on a problem-solving therapy framework and delivered via telehealth (intervention) or usual care (web-based resources about diabetes and emotional health). Data are collected via online assessments at baseline (T0), 8 weeks (T1) and 6 months (T2, primary endpoint) follow-up. The primary outcome is between-group differences in diabetes distress at T2. Secondary outcomes include the immediate (T1) and longer-term (T2) effect of the intervention on psychological distress, general emotional well-being, and coping self-efficacy. A within-trial economic evaluation will be conducted. Implementation outcomes will be assessed using mixed methods, according to the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Data collection will include qualitative interviews and field notes.

DISCUSSION

It is anticipated that LISTEN will reduce diabetes distress among adults with diabetes. The pragmatic trial results will determine whether LISTEN is effective, cost-effective, and should be implemented at scale. Qualitative findings will be used to refine the intervention and implementation strategies as required.

TRIAL REGISTRATION

This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN: ACTRN12622000168752) on 1 February, 2022.

Overcoming the struggle of living with type 2 diabetes - diabetes specialist nurses' and patients' perspectives on digital interventions

BACKGROUND

Diabetes self-management education and support (DSMES) is a cornerstone in the treatment of type 2 diabetes mellitus (T2DM). It is unclear whether delivering DSMES as a digital health intervention (DHI) might meet the needs experienced by patients with T2DM and diabetes specialist nurses (DSN) of the primary health care system in Sweden.

METHODS

Fourteen patients with T2DM and four DSN participated in three separate focus groups: two groups comprised patients and one group comprised DSN. The patients discussed the questions: "What needs did you experience after your T2DM diagnosis?" and "How might these needs be met with a DHI?" The DSN discussed the questions: "What needs do you experience when treating a patient with newly diagnosed T2DM?" and "How might these needs be met with a DHI?". Furthermore, data were collected in the form of field notes from group discussions at a meeting including 18 DSNs working with T2DM in PHCCs. The discussions from focus groups were transcribed verbatim and analyzed together with the field notes from the meeting using inductive content analysis.

RESULTS

The analysis yielded the overall theme: "Overcoming the struggle of living with T2DM", which was summarized in two categories: "learning and being prepared" and "giving and receiving support". Important findings were that, for success, a DHI for DSMES must be integrated into routine care, provide structured, high-quality information, suggest tasks to stimulate behavioral changes, and provide feedback from the DSN to the patient.

CONCLUSION

This study highlighted several important aspects, from the perspectives of both the patient with T2DM and the DSN, which should be taken into consideration for the successful development and use of a DHI for DSMES.

Cardiovascular disease burden is associated with worsened depression symptoms in the U.S. general population

BACKGROUND

Cardiovascular disease (CVD) and depression are the leading causes of disability in the U.S. Using five cycles (2009-2018) of the U.S. National Health and Nutrition Examination Survey, we examined the cross-sectional association between CVD risk factor burden and depression severity in nonpregnant adults with no history of CVD events.

METHODS

With at least 3000 participants per cycle, the overall N was 18,175. CVD risk factors were ascertained through self-report, lab tests, or medications. The sum of hypertension, diabetes, dyslipidemia, and current smoking represented a CVD risk score variable (range: 0-4). Depression severity was assessed using scores on the 9-item patient health questionnaire: 0-9 (none-mild) and 10-27 (moderate-to-severe). Logistic regression models were performed to investigate the association between CVD risk score categories and moderate-to-severe depression. Cycle-specific odds ratios (OR) were meta-analyzed to obtain a pooled OR (95 % CI) (Q-statistic p > 0.05).

RESULTS

Compared to participants with no CVD risk factors, participants with risk scores of 1, 2, 3, and 4, had 1.28 (0.92-1.77), 2.18 (1.62-2.94), 2.53 (1.86-3.49), 2.97 (1.67-5.31) times higher odds of moderate-to-severe depression, respectively, after adjusting for socio-demographics and antidepressant use (linear trend p < 0.0001). This relationship persisted after additionally adjusting for lifestyle variables.

LIMITATIONS

NHANES data is cross-sectional and self-reported, thus preventing causal assessments and leading to potential recall bias.

CONCLUSIONS

Among U.S. adults, CVD risk factor burden was associated with worsened depression symptoms. Integrated mental and physical healthcare services could improve risk stratification among persons with CVD and depression, possibly reducing long-term disability and healthcare costs.

Emotional distress, self-management, and glycemic control among participants enrolled in the glycemia reduction approaches in diabetes: A comparative effectiveness (GRADE) study

OBJECTIVE

We examined emotional distress in relation to metformin adherence, overall diabetes self-management, and glycemic control among adults with early type 2 diabetes (T2DM) enrolled in the GRADE study.

METHODS

Linear regression models examined cross-sectional associations of baseline depression symptoms and diabetes distress with adherence to metformin, self-management, and HbA1c, adjusting for covariates. Cognitive-affective (e.g., sadness) and somatic (e.g., sleep/appetite disturbance) depression symptoms and diabetes distress subscales were also examined.

RESULTS

This substudy of 1,739 GRADE participants (56 % Non-Hispanic White, 18 % Non-Hispanic Black, 17 % Hispanic, 68 % male, mean[SD] age = 57.96[10.22] years, diabetes duration = 4.21[2.81] years, and HbA1c = 7.51[0.48]) found that the prevalence of clinically significant depression and diabetes distress was 8.7 % and 25 %, respectively. Fully adjusted models showed that depression symptoms were associated with lower self-management (p < 0.0001); this effect was only significant for somatic symptoms. Diabetes distress was associated with lower adherence (p = 0.0001) and self-management (p < 0.0001); effects were significant for all subscales, except physician-related distress. No significant relationships of total depression symptom severity or diabetes distress with HbA1c were found.

CONCLUSIONS

Depression symptoms and diabetes distress were robustly associated with problematic diabetes self-management among participants in GRADE. These findings highlight the need for routine assessment of depression symptoms and diabetes distress early in T2DM care.

Association between diabetes-related distress and glycemic control in primary care patients with Type 2 diabetes during the coronavirus disease 2019 (COVID-19) pandemic in Egypt

BACKGROUND

Diabetes-related distress and glycemic control are of a particular concern to primary care physicians because of the impact of the coronavirus disease 2019 pandemic on diabetic patients' lifestyle, psychological well-being and healthcare access. Our aim was to evaluate the relationship between diabetes-related distress and glycemic control in diabetic patients with Type 2 diabetes mellitus (T2DM) in primary care settings during the pandemic.

MATERIALS AND METHODS

This cross-sectional study was conducted at primary healthcare clinics in a rural area in Egypt among 430 patients with T2DM during the period from September 2020 to June 2021. All patients were interviewed for their sociodemographic, lifestyle, and clinical characteristics. Diabetes-related distress was measured by the problem areas in the diabetes scale (PAID), where a total score of ≥40 indicated a severe diabetes-related distress. The most recent glycosylated hemoglobin (HbA1c) measurements were used to indicate the glycemic control. Quantile regression model (0.50 quantile) was used to perform the multivariate analysis to identify significant factors associated with HbA1c level.

RESULTS

Most of the participants had a suboptimal glycemic control (92.3%), while 13.3% had severe diabetes-related distress. HbA1c level was significantly and positively correlated with the total PAID score and all its sub-domains. Multivariate quantile regression revealed that obesity, multi-morbidity, and severe diabetes-related distress were the only significant determinants of the HbA1c median level. Obese patients had significantly higher median HbA1c compared to patients who were not obese (coefficient = 0.25, P < 0.001). Patients with two or more comorbidities (i.e., multimorbidity) had a significantly higher median HbA1c than patients with single or no chronic comorbidities (coefficient = 0.41, P < 0.001). Severe diabetes-related distress was significantly associated with higher median HbA1c compared to nonsevere diabetes-related distress (coefficient = 0.20, P = 0.018).

CONCLUSION

Diabetes-related distress had a significant association with HbA1c level. Family physicians should implement multifaceted programs to optimize diabetes control and reduce any associated distress.

The relationship between patient empowerment and related constructs, affective symptoms and quality of life in patients with type 2 diabetes: a systematic review and meta-analysis

Introduction

The aim of this systematic review is to assess the relationship between patient empowerment and other empowerment-related constructs, and affective symptoms and quality of life in patients with type 2 diabetes.

Methods

A systematic review of the literature was conducted, according to the PRISMA guidelines. Studies addressing adult patients with type 2 diabetes and reporting the association between empowerment-related constructs and subjective measures of anxiety, depression and distress, as well as self-reported quality of life were included. The following electronic databases were consulted from inception to July 2022: Medline, Embase, PsycINFO, and Cochrane Library. The methodological quality of the included studies was analyzed using validated tools adapted to each study design. Meta-analyses of correlations were performed using an inverse variance restricted maximum likelihood random-effects.

Results

The initial search yielded 2463 references and seventy-one studies were finally included. We found a weak-to-moderate inverse association between patient empowerment-related constructs and both anxiety (r = -0.22) and depression (r = -0.29). Moreover, empowerment-related constructs were moderately negatively correlated with distress (r = -0.31) and moderately positively correlated with general quality of life (r = 0.32). Small associations between empowerment-related constructs and both mental (r = 0.23) and physical quality of life (r = 0.13) were also reported.

Discussion

This evidence is mostly from cross-sectional studies. High-quality prospective studies are needed not only to better understand the role of patient empowerment but to assess causal associations. The results of the study highlight the importance of patient empowerment and other empowerment-related constructs such as self-efficacy or perceived control in diabetes care. Thus, they should be considered in the design, development and implementation of effective interventions and policies aimed at improving psychosocial outcomes in patients with type 2 diabetes.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020192429, identifier CRD42020192429.

ACTonDiabetes: study protocol of a pragmatic randomised controlled trial for the evaluation of an acceptance and commitment-based internet-based and mobile-based intervention for adults living with type 1 or type 2 diabetes

INTRODUCTION

Living with diabetes can be burdensome and lead to serious emotional distress and impaired mental health. Acceptance and commitment therapy (ACT) can support people facing the challenges of living with diabetes. This trial aims to evaluate the effectiveness and cost-effectiveness of the internet-based and mobile-based intervention (IMI) 'ACTonDiabetes' in reducing diabetes distress against enhanced treatment as usual (TAU+) following specialised diabetes care.

METHODS AND ANALYSIS

A two-armed pragmatic randomised controlled trial will be conducted to evaluate the guided IMI ACTonDiabetes against TAU+. A total of 210 adults with type 1 or type 2 diabetes and elevated diabetes distress (Problem Areas in Diabetes ≥40) will be recruited at a specialised diabetes centre. The intervention begins 2-4 weeks after hospital discharge and takes about 7-10 weeks to complete. Assessments are performed at baseline and 5 and 10 weeks as well as 6 and 12 months after randomisation. The primary outcome is diabetes distress at a 10-week follow-up (T2). Secondary outcomes are depression (Patient Health Questionnaire-8), psychological well-being (WHO-5), quality of life (Assessment of Quality of Life-8 Dimension), Diabetes-related Self-Management Questionnaire, diabetes acceptance (Acceptance and Action Diabetes Questionnaire) and negative treatment effects (Inventory for the Assessment of Negative Effects of Psychotherapy). All statistical analyses will be performed based on the intention-to-treat principle with additional per-protocol analyses. Changes in outcomes will be evaluated using the general linear model. A health-economic evaluation will be conducted from a societal perspective. Reasons for drop-out will be systematically investigated.

ETHICS AND DISSEMINATION

This clinical trial has been approved by the State Medical Chamber of Baden-Württemberg (file no. B-F-2019-010). Trial results will be submitted for publication in a peer-reviewed journal and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00016738.

An Exploratory Mixed Methods Study of Diabetes self-management in Blind Americans

This study used mixed methods to investigate the experiences of 33 participants who are blind (PWB) and have diabetes in managing their diabetes, support (or lack thereof) from their health care providers, and diabetes distress as PWB. Participants most frequently reported barriers to check blood glucose (55%), maintaining a healthy diet (45%), and distress due to their intersectional status of having blindness and diabetes. Those who mentioned intersectional distress of managing diabetes as a PWB tended to be Braille illiterate and less likely to use mobility tools that are symbolic of blindness (e.g., white cane, guide dog). These results illuminate heterogenous characteristics of PWB with diabetes, an understudied population of public health significance, to be considered when setting priorities for diabetes self-management support and health care coverage policy.

Self-efficacy mediates the associations of diabetes distress and depressive symptoms with type 2 diabetes management and glycemic control

BACKGROUND

Adults with type 2 diabetes (T2D) often experience two common diabetes-related psychological distress: diabetes distress and depressive symptoms. Both are associated with adverse diabetes outcomes including poor self-management and glycemic control. However, diabetes distress and depressive symptoms differ in their associations with diabetes outcomes in T2D patients.

OBJECTIVE

This study proposes a hypothetical model to examine whether self-efficacy mediates the adverse effects of depressive symptoms and/or diabetes distress on self-care behaviors and glycemic control. Additionally, we examined the bi-directional relationships between diabetes distress and depressive symptoms to identify potential underlying mechanisms.

METHODS

This study conducted in 15 rural health clinics in Jiangsu province China. 900 adults with T2D participated in the prospective cohort study. The data Diabetes distress (the 17-item Diabetes Distress Scale, DDS17), depressive symptoms(the 10-item Center for Epidemiologic Studies Depression Scale, CESD-10), self-efficacy, self-care behaviors (diet and physical activity), metabolic variables (fasting plasma glucose, FPG) and demographic characteristics were assessed at baseline. Subsequent 12-month Hemoglobin A1C (HbA1c) were measured after baseline. Hierarchical multiple regression and bootstrap mediation analysis were used to test the effects and pathways among these associations.

RESULTS

Of 843 participants (93.67%) of total cohort with available subsequent 12-month HbA1c levels, mean age was 66.08 years and 66.55% were women, 25.15% of them had depressive symptoms (CES-D ≥ 10), 12.20% had moderate diabetes distress (mean DDS ≥2) and 4.98% had the both two psychological distress. Hierarchical multiple regression showed higher DDS score significantly predicted unhealthy diet(β = -1.10, P < 0.001) but not physical activities, while CESD score was negatively associated with physical activity (β = -0.06, P < 0.001) but not diet. No independent effects of the two psychological distress variables on subsequent 12-month HbA₁c were observed. Mediation analysis supported that elevated self-efficacy solely mediated the negative effect of both diabetes distress and depressive symptoms on diet (DDS score: β = -0.238, 95 BCE% CI [-0.350, -0.141]; CESD score: β = -0.010, 95 BCE% CI [-0.016, -0.005]), physical activities (DDS score: β = -0.446, 95 BCE% CI [-0.630, -0.283]; CESD score: β = -0.019, 95 BCE% CI [-0.030, -0.010]) and subsequent 12-month HbA1c (DDS score: β = 0.105, 95 BCE% CI [0.030,0.189]; CESD score: β = 0.004, 95 BCE% CI [0.001,0.009])_. Additionally, the interplay of diabetes distress and depressive symptoms exerts their effects on diabetes outcomes directly and indirectly via self-efficacy.

CONCLUSIONS

Self-efficacy may contribute to better diabetes outcomes and ameliorate negative effects of diabetes distress and depressive symptoms.

Diabetes Distress, Depressive Symptoms, and Anxiety Symptoms in People With Type 2 Diabetes: A Network Analysis Approach to Understanding Comorbidity

OBJECTIVE

In this study, we aimed to explore interactions between individual items that assess diabetes distress, depressive symptoms, and anxiety symptoms in a cohort of adults with type 2 diabetes using network analysis.

RESEARCH DESIGN AND METHODS

Participants (N = 1,796) were from the Montreal Evaluation of Diabetes Treatment (EDIT) study from Quebec, Canada. A network of diabetes distress was estimated using the 17 items of the Diabetes Distress Scale (DDS-17). A second network was estimated using the DDS-17 items, the nine items of the Patient Health Questionnaire (PHQ-9), and the seven items of the Generalized Anxiety Disorder Assessment (GAD-7). Network analysis was used to identify central items, clusters of items, and items that may act as bridges between diabetes distress, depressive symptoms, and anxiety symptoms.

RESULTS

Regimen-related and physician-related problems were among the most central (highly connected) and influential (most positive connections) in the diabetes distress network. The depressive symptom of failure was found to be a potential bridge between depression and diabetes distress, being highly connected to diabetes distress items. The anxiety symptoms of worrying too much, uncontrollable worry, and trouble relaxing were identified as bridges linking both anxiety and depressive items and anxiety and diabetes distress items, respectively.

CONCLUSIONS

Regimen-related and physician-related diabetes-specific problems may be important in contributing to the development and maintenance of diabetes distress. Feelings of failure and worry are potentially strong candidates for explaining comorbidity. These individual diabetes-specific problems and mental health symptoms could hold promise for targeted interventions for people with type 2 diabetes.

Depression, anxiety, and diabetes-related distress in type 2 diabetes in primary care in Greece: Different roles for glycemic control and self-care

Objectives:

The psychological distress of people living with diabetes is increased and associated with poorer glycemic outcomes and self-care. We aimed to examine the frequency of depression, anxiety, and diabetes-related distress (DRD) of individuals with type 2 diabetes (T2D) in primary care (PC) and their comparative associations with clinical, self-care, and socio-demographic characteristics, testing for possible different roles on glycemic control and self-care.

Methods:

This is a cross-sectional study of 182 adults with a T2D diagnosis of at least six months, recruited between August 2019-March 2020 and May-October 2020, from an urban PC unit. Participants were screened for symptoms of depression (Patient Health Questionnaire-9 (PHQ-9)), anxiety (Generalized Anxiety Disorder-7 (GAD-7)), and DRD (Diabetes Distress Scale (DDS)). Clinical, self-care, and socio-demographic parameters were recorded.

Results:

The frequency of clinically significant symptoms of depression was 16.6%, (PHQ-9 score ⩾10), anxiety 17.7% (GAD-7 score ⩾10), and DRD 22.6% (DDS score ⩾2). All PHQ-9, GAD-7, and DDS scores intercorrelated, and higher scores were found to be associated with female gender, lower income, and prior diagnosis of depression. Higher PHQ-9 and GAD-7 scores were found to be associated with lower education, more hypoglycemia episodes, more blood glucose self-tests and antidepressant or benzodiazepine use. The retired/housewives scored significantly lower in GAD-7 and DDS compared to the unemployed participants. Higher DDS scores were associated with higher glycated hemoglobin, higher fasting plasma glucose, and insulin use. It was also noted that higher PHQ-9 scores were associated with lower uric acid levels and were significantly higher in the sedentary lifestyle group.

Conclusion:

DRD was associated with poorer glycemic outcomes while depressive symptoms were associated with lower physical activity perhaps sharing different roles for glycemic control and self-care. The psychological burden of individuals with T2D may be considered in PC.

Interprofessional Collaboration and Diabetes Management in Primary Care: A Systematic Review and Meta-Analysis of Patient-Reported Outcomes

The global spread of diabetes poses serious threats to public health requiring a patient-centered approach based both on interprofessional collaboration (IPC) given by the cooperation of several different health professionals, and patients’ perspective through the assessment of Patient-Reported Outcomes (PROs). The aim of the present study is to evaluate the impact of interprofessional collaboration interventions, for the management of type 2 diabetes in primary care settings, through PROs. A systematic review and meta-analysis was conducted querying the PubMed, Scopus and Embase databases. Out of the 1961 papers initially retrieved, 19 met the inclusion criteria. Interprofessional collaboration is significantly associated with an increase in both patient’s satisfaction (SMD 0.32 95% CI 0.05–0.59) and in the mental well-being component of the HRQoL (SMD 0.18; 95% CI 0.06–0.30), and there was also promising evidence supporting the association between an interprofessional approach and an increase in self-care and in generic and specific quality-of-life. No statistical differences were found, supporting the positive impact on IPC interventions on the physical component of the HRQoL, depression, emotional distress, and self-efficacy. In conclusion, the effect of IPC impacts positively on the few areas assessed by PROMs. Policymakers should promote the widespread adoption of a collaborative approach as well as to endorse an active engagement of patients across the whole process of care.

Increased Patient Empowerment Is Associated with Improvement in Anxiety and Depression Symptoms in Type 2 Diabetes Mellitus: Findings from the INDICA Study

Introduction. In cross-sectional analyses, higher levels of patient empowerment have been related to lower symptoms of anxiety and depression. The aims of this study are: (1) to assess if patient empowerment predicts anxiety and depression symptoms after 12 and 24 months among patients with type 2 diabetes mellitus, and (2) to analyze whether a change in patient empowerment is associated with a change in anxiety and depression level. Methods. This is a secondary analysis of the INDICA study, a 24 month-long, multi-arm randomized controlled trial. Patient empowerment (DES-SF), depression (BDI-II), and state-anxiety (STAI-S) were assessed at the baseline (pre-intervention) and after 12 and 24 months. Multilevel mixed linear models with a random intercept were performed to correct for our clustered data. Results. The multilevel regression models showed that the baseline empowerment did not significantly predict anxiety and depression after 12 and 24 months. However, a higher increase in patient empowerment was significantly associated with reductions of anxiety (p < 0.001) and depression levels (p < 0.001). This association was not significantly different between the two follow-ups. Conclusion. This study contributes to the knowledge on how to reduce affective symptoms in patients with uncomplicated T2DM through comprehensive patient-centered interventions, and it highlights patient empowerment as a significant contributor.

Illness perceptions as a mediator between emotional distress and management self-efficacy among Chinese Americans with type 2 diabetes

Objectives: Emotional distress and illness perceptions have been linked to patients' self-efficacy for diabetes management. This study, guided by Leventhal's Self-Regulatory Model, explores the direct effects of emotional distress (diabetes distress and depressive symptoms) on diabetes management self-efficacy, and the indirect effects through illness perceptions among Chinese Americans with type 2 diabetes (T2DM).Design: Data were obtained from a cross-sectional study of Chinese Americans with T2DM recruited from health fairs and other community settings (N = 155, 47.1% male, mean age 69.07 years). Data analyses including descriptive statistics, correlation, and PROCESS mediation models were used to examine the mediation effects of illness perceptions.Results: Diabetes distress and depressive symptoms had direct negative effects on self-efficacy. Perceived treatment control mediated the association between diabetes distress and self-efficacy, while none of the illness perceptions dimensions impacted the relationship between depressive symptoms and self-efficacy.Conclusion: Improved perceptions of treatment control can ameliorate diabetes distress and improve diabetes management self-efficacy among Chinese Americans. Health providers should elicit patients' illness perceptions as a first step in evaluating their diabetes management self-efficacy and provide appropriate culturally-tailored interventions.

Psychosocial profiles and longitudinal achievement of optimal cardiovascular risk factor levels: the Coronary Artery Risk Development in Young Adults (CARDIA) study

Psychosocial factors are associated with the achievement of optimal cardiovascular disease risk factor (CVDRF) levels. To date, little research has examined multiple psychosocial factors simultaneously to identify distinguishing psychosocial profiles among individuals with CVDRF. Further, it is unknown whether profiles are associated with achievement of CVDRF levels longitudinally. Therefore, we characterized psychosocial profiles of individuals with CVDRF and assessed whether they are associated with achievement of optimal CVDRF levels over 15 years. We included 1148 CARDIA participants with prevalent hypertension, hypercholesterolemia and/or diabetes mellitus in 2000-2001. Eleven psychosocial variables reflecting psychological health, personality traits, and social factors were included. Optimal levels were deemed achieved if: Hemoglobin A1c (HbA1c) < 7.0%, low-density lipoprotein (LDL) cholesterol < 100 mg/dl, and systolic blood pressure (SBP) < 140 mm Hg. Latent profile analysis revealed three psychosocial profile groups "Healthy", "Distressed and Disadvantaged" and "Discriminated Against". There were no significant differences in achievement of CVDRF levels of the 3 targets combined across profiles. Participants in the "Distressed and Disadvantaged" profile were less likely to meet optimal HbA1c levels compared to individuals in the "Healthy" profile after demographic adjustment. Associations were attenuated after full covariate adjustment. Distinct psychosocial profiles exist among individuals with CVDRF, representing meaningful differences. Implications for CVDRF management are discussed.

Can the management of depression in type 2 diabetes be democratized?

Both type 2 diabetes and depression are common and are projected to increase. There is increasing evidence for a bidirectional relationship between the two. Diabetes is a risk factor for depression; contrariwise, individuals with depression are at greater risk of developing diabetes. They are a burden for both the individual and the society. Co-existent depression worsens diabetic control because of obesity, insulin resistance and the adverse metabolic effects of anti-diabetes medicines. In addition, compliance to lifestyle measures required for diabetes is also compromised such as following a specific diet, taking proper medications on time, getting metabolic parameters assessed and maintaining a sleep cycle. Depression occurs in many grades; mild depression is more common in diabetes than frank or full-blown depression leading to suicide. Unfortunately, there are not enough trained and accessible mental health professionals such as psychologists or psychiatrists to deal with the increasing burden of depression in diabetes. Therefore, alternate models for management of mild to moderate depression are required. There is evidence that a team-approach by employing health care assistants can lower the risk of cardiac risk factors. INtegrating DEPrEssioN and Diabetes treatmENT study was carried out to determine whether the team-approach using non-health care professionals could be effective in managing mild to moderate depression and to study its effects on metabolic parameters among subjects with type 2 diabetes mellitus. The international study, carried out in four independent centers in India assessed the impact of a trained but not qualified non-psychiatrist in coordinating and forming a fulcrum between the patient, the family and the consultant endocrinologist/diabetologist. The interventions were fine-tuned to be culturally appropriate by qualitative interviews before they began. It was shown that the outcomes of both depression and diabetes could be improved by the employment of a clinical care coordinator. It is possible to scale up the studies to wider geographical areas and health-care organizations.

Caregiver status and illness self-efficacy during the COVID-19 pandemic among older adults with chronic conditions

OBJECTIVES

Older adults providing unpaid care to a relative or friend during the COVID-19 pandemic may have diminished self-efficacy in managing their own chronic illness, especially in the context of more complex self-management. We evaluated whether adults aged 50 and older with caregiving roles are more likely to report reduced illness self-efficacy since the pandemic, and whether this link is exacerbated by a higher number of conditions.

METHODS

Participants (105 caregivers and 590 noncaregivers) residing in Michigan (82.6%) and 33 other U.S. states completed one online survey between May 14 and July 9, 2020.

RESULTS

Controlling for sociodemographic and health characteristics, stressors related to COVID-19, and behavioral and psychosocial changes since the pandemic, caregivers were more likely than noncaregivers to report reduced illness self-efficacy when they had a higher number of chronic conditions.

CONCLUSION

These findings highlight the importance of maintaining caregivers' self-care during the COVID-19 pandemic and in future public health crises.

Prevalence and predictors of diabetes distress among adults with type 2 diabetes mellitus: a facility-based cross-sectional study of Bangladesh

INTRODUCTION

Diabetes distress (DD) is common and has considerable impacts on diabetes management. Unfortunately, DD is less discussed and frequently underestimated. This study evaluated the prevalence and predictors of DD in adults with type 2 diabetes mellitus (T2DM).

METHODS

A cross-sectional study was conducted at several specialized endocrinology outpatient clinics in Bangladesh from July 2019 to June 2020; 259 adults with T2DM participated. Participants' DD and depression were measured using the 17-item Diabetes Distress Scale (DDS-17) and 9-item Patient Health Questionnaire (PHQ-9), respectively. DDS-17 scores ≥2 and PHQ-9 scores ≥10 were the cutoffs for DD and significant depression, respectively.

RESULTS

The mean (±SD) age of the participants was 50.36 (±12.7) years, with the majority (54.8%) being male; their median (IQR) duration of diabetes was 6 (3-11) years. Among the study participants, 52.5% had DD (29.7% moderate and 22.8% high DD). The prevalence of emotional burden, physician-related distress, regimen-related distress, and interpersonal distress was 68.7, 28.6, 66, and 37.7%, respectively. Depression was present in 40.5%; 28.6% of the participants had DD and depression. The total DDS-17 score was positively correlated with the PHQ-9 score (r = 0.325, p < 0.001). Rural residence (OR 1.94), presence of any diabetic complication (OR 3.125), insulin use (OR 2.687), and presence of major depression (OR 4.753) were positive predictors of DD. In contrast, age ≥ 40 years at diabetes diagnosis (OR 0.047) and diabetes duration of > 10 years (OR 0.240) were negative predictors of DD (p < 0.05 in all instances).

CONCLUSIONS

The prevalence of DD in our setting is notably high; DD and depression frequently overlap. Screening for diabetes distress may be considered, especially in high-risk patients.

A Self-Report Measure of Diabetes Self-Management for Type 1 and Type 2 Diabetes: The Diabetes Self-Management Questionnaire-Revised (DSMQ-R) – Clinimetric Evidence From Five Studies

Aims

Measurement tools to evaluate self-management behavior are useful for diabetes research and clinical practice. The Diabetes Self-Management Questionnaire (DSMQ) was introduced in 2013 and has become a widely used tool. This article presents a revised and updated version, DSMQ-R, and evaluates its properties in assessing self-management practices in type 1 diabetes (T1D) and type 2 diabetes (T2D).

Methods

The DSMQ-R is a multidimensional questionnaire with 27 items regarding essential self-management practices for T1D and T2D (including diabetes-adjusted eating, glucose testing/monitoring, medication taking, physical activity and cooperation with the diabetes team). For the revised form, the original items were partially amended and the wording was updated; eleven items were newly added. The tool was applied as part of health-related surveys in five clinical studies (two cross-sectional, three prospective) including a total of 1,447 people with T1D and T2D. Using this data base, clinimetric properties were rigorously tested.

Results

The analyses showed high internal and retest reliability coefficients for the total scale and moderate to high coefficients for the subscales. Reliability coefficients for scales including the new items were consistently higher. Correlations with convergent criteria and related variables supported validity. Responsiveness was supported by significant short to medium term changes in prospective studies. Significant associations with glycemic outcomes were observed for DSMQ-R-assessed medication taking, glucose monitoring and eating behaviors.

Conclusions

The results support good clinimetric properties of the DSMQ-R. The tool can be useful for research and clinical practice and may facilitate the identification of improvable self-management practices in individuals.

Impact of worries associated with COVID-19 on diabetes-related psychological symptoms in older adults with Type 2 diabetes

This study examined the associations between worries associated with COVID-19, diabetes-specific distress, and depressive symptoms in older adults with type 2 diabetes (T2D), who are particularly vulnerable to COVID-19 and its psychological impacts. A cross-sectional online survey was conducted with 84 older adults with T2D from June to December 2020. Participants had little to moderate worries associated with COVID-19, with the greatest worries about the economy recession, followed by a family member catching COVID-19, lifestyle disruptions, and overwhelmed local hospitals. Bivariate correlation and tobit regression revealed that increases in worries associated with COVID-19 were associated with increased diabetes distress and depressive symptoms. Specifically, worries associated with COVID-19 increased diabetes-specific emotional burden and physician-related and regimen-related distress. Increased diabetes distress and depressive symptoms worsened by COVID-19 may ultimately lead to poor glucose control. Additional assessment by mental health experts should be considered for older adults with T2D during and after infectious disease pandemic.

Medication Adherence and Associated Factors in Patients With Type 2 Diabetes: A Structural Equation Model

Background: The number of patients with type 2 diabetes (T2D) is increasing. Medication treatment is of great importance to stabilize blood glucose. Previous studies have reported that neuroticism, self-efficacy, and social support are factors associated with medication adherence, but few studies have fully investigated the mechanisms between these factors and medication adherence in patients with T2D. Purpose: To explore the prevalence of medication adherence and the factors associated with medication adherence in patients with T2D. Methods: A cross-sectional study consisting of 483 patients with T2D was conducted from July to December 2020. Questionnaires containing sociodemographic and clinical characteristics, the Morisky Medication Adherence Scale-8 (MMAS-8), the neuroticism subscale of the Eysenck Personality Questionnaire-Revised Short Scale (EPQ-RS), the Multidimensional Scale of Perceived Social Support (MSPSS), and the Diabetes Management Self-efficacy Scale (DMSES) were used to collect data. The structural equation model (SEM) was used to test the hypotheses. Results: This study included 305 (63.1%) medication adherence and 178 (36.9%) medication non-adherence patients with T2D. Social support directly influenced medication adherence (β = 0.115, P = 0.029) and indirectly influenced medication adherence through self-efficacy (β = 0.044, P = 0.016). Self-efficacy directly influenced medication adherence (β = 0.139, P = 0.023). Neuroticism indirectly affected medication adherence through social support (β = -0.027, P = 0.023) and self-efficacy (β = -0.019, P = 0.014). Moreover, there was a sequential mediating effect of social support and self-efficacy on the relationship between neuroticism and medication adherence (β = -0.010, P = 0.012). After controlling for age and gender, similar results were obtained. The model fit indices showed a good fit. Conclusions: The medication adherence of patients with T2D needs to be improved. Neuroticism, social support, and self-efficacy had direct or indirect effects on medication adherence in patients with T2D. Healthcare providers should comprehensively develop intervention programs based on neuroticism, social support, and self-efficacy to improve medication adherence in patients with T2D.

Patient-Centered Goal-Setting in the National Diabetes Prevention Program: A Pilot Study

OBJECTIVE

Difficulty achieving preset goals (e.g., ≥5% weight loss, ≥150 min of weekly physical activity) in the yearlong National Diabetes Prevention Program (NDPP) can prompt dropout and diminish benefits. We piloted a more patient-centered NDPP adaptation (NDPP-Flex) that promotes a variety of attainable and individually tailored goals to reduce diabetes risks, along with flexibility to adjust goals each week as needed.

RESEARCH DESIGN AND METHODS

Retention, physical activity, weight, and glycated hemoglobin (HbA_1c) were evaluated among diverse participants with diabetes risks who received our pilot of NDPP-Flex beginning in January and July 2018 (n = 95), with a planned comparison with standard NDPP delivery in preceding cohorts that launched between September 2016 and October 2017 (n = 245). Both the standard NDPP and NDPP-Flex interventions were 1 year in duration and implemented in phases (i.e., nonrandomized).

RESULTS

Average adjusted retention (e.g., 158.90 ± 15.20 vs. 166.71 ± 9.38 days; P = 0.674), physical activity (157.97 ± 11.91 vs. 175.64 ± 7.54 weekly min; P = 0.231), and weight loss (1.46 ± 0.38% vs. 1.90 ± 0.24%; P = 0.396) were similar between NDPP-Flex versus standard NDPP. However, NDPP-Flex participants had greater HbA_1c reduction on average (0.22 ± 0.05% vs. 0.06 ± 0.03%; P = 0.018) and were more likely to have normoglycemia at follow-up (odds ratio 4.62; P = 0.013 [95% CI 1.38-15.50]) than participants in the standard NDPP.

CONCLUSIONS

An adapted, more patient-centered NDPP that focuses on flexible, self-selected goals may be a promising strategy to improve glycemia even in the absence of substantial weight loss.

The effectiveness of self-management programmes for people with type 2 diabetes receiving insulin injection: A systematic review and meta-analysis

BACKGROUND

People with type 2 diabetes (T2D) receiving insulin injection are reported to encounter challenges to achieve optimal glycaemic control. The evidence on effectiveness of self-management programmes for T2D people receiving insulin injection is far from conclusive.

AIM

To examine the effectiveness of self-management programmes for people with T2D receiving insulin injection.

METHODS

Twelve databases were searched from dates of inception to June 2021. All randomised controlled trials (RCTs) and controlled clinical trials examining the effectiveness of self-management programmes were included. The methodological quality was appraised using the Joanna Briggs Institute critical appraisal tools by two independent researchers. Data were summarised narratively or pooled statistically where appropriate.

RESULTS

Nine RCTs involving 2613 participants were included. At post-intervention, meta-analysis results showed that self-management programmes significantly improved glycated haemoglobin A1c (HbA1c) (mean difference [MD]: -0.21, 95% confidence interval [CI] -0.29 to -0.12, P < .001), self-management behaviours (standardised MD [SMD]: 0.23, 95% CI: 0.12 to 0.33, P < .001) and self-efficacy (SMD: 0.20, 95% CI: 0.09 to 0.31, P = .0002). Only one intensive lifestyle intervention reported significant improvements in body weight and waist circumference. Three RCTs demonstrated significant improvements in body mass index compared with the control group. Only one study demonstrated significant improvements in total cholesterol and triglycerides in favour of the intervention group. At six months post-intervention, pooled results of two studies revealed decreased diabetes-related distress (MD: -2.98, 95% CI: -5.15 to -0.82, P = .007). No significant changes in blood pressure, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, depression and anxiety were found.

CONCLUSIONS

Self-management programmes have the potential to improve glycaemic control, weight management, blood lipids, self-management behaviours, self-efficacy and diabetes-related distress of people with T2D receiving insulin injection. More rigorous experimental trials are warranted to examine the effectiveness of self-management programme and its maintenance.

Contributing factors of fatigue in patients with type 2 diabetes: A systematic review

Remarkable evidence supports the link between type 2 diabetes (T2DM) and fatigue. However, a unifying recommendation to identify and prevent fatigue or to prevent its clinical consequences in T2DM is not available at present. Therefore, this study aimed to conduct a systematic review to summarize the definition, measurement tools, and contributing factors of fatigue in T2DM. Nine articles were included for analysis, and results showed that T2DM fatigue was associated with five major factors, including sociodemographic factors, clinical disease factors, inflammatory factors, psychological factors, and behavior and lifestyle. The contributing factors of T2DM fatigue are reviewed, and clinical benefits provide a theoretical basis for further clinical intervention to prevent the occurrence of fatigue and improve the patient's treatment compliance and self-management ability and may be beneficial to their quality of life.

Coping skills and glycaemic control: the mediating role of diabetes distress

AIMS

The present study examined the mediating role of diabetes distress on the relationship between coping and glycaemic control, and evaluated if the afore-mentioned mediation was moderated by insulin treatment in people with type 2 diabetes.

METHODS

A total of 473 adults with type 2 diabetes were recruited from an outpatient clinic in Hong Kong and invited to take part in a survey that measured adaptive coping, maladaptive coping, and diabetes stress. Glycaemic control was measured by glycated haemoglobin values extracted from medical records. PROCESS v3.4 macro was used to test the moderated mediation model.

RESULTS

Adaptive coping was negatively associated with diabetes distress (-0.29, 95% CI: -0.53, -0.06), whereas maladaptive coping was positively associated with diabetes distress (1.82, 95% CI: 1.12, 2.51). Diabetes distress had a positive relationship with glycated haemoglobin (0.04, 95% CI: 0.02, 0.05), but no correlations were found between glycated haemoglobin and adaptive coping or maladaptive coping. Insulin treatment not only weakened the diabetes distress-glycaemic control relationship (-0.04, 95% CI: -0.06, -0.01), but also weakened the mediation effect of maladaptive coping-glycaemic control relationship via diabetes distress (-0.07, 95% CI: -0.12, -0.02).

CONCLUSIONS

The study findings revealed the role of diabetes distress and insulin treatment in the link between coping skills and glycaemic control. Interventions to help boost confidence and autonomy in people with diabetes could help them lessen diabetes distress.

Prevalence of depressive and anxiety symptoms in women with gestational diabetes: a longitudinal cohort study

AIMS

Prevalence of mental disorders in women with gestational diabetes mellitus (GDM) is not well defined; however, their presence could interfere with effective glucose self-management. Therefore, we aimed to assess the incidence of depression and anxiety symptoms in women with GDM in the 2nd and 3rd trimester of pregnancy and their impact on glycemic control.

METHODS

We included consecutive women undergoing the GDM screening test at the University Medical Centre Ljubljana. Women with GDM (n = 77) and women without GDM (n = 103) completed questionnaires on depression and anxiety symptomatology, health locus of control and social support.

RESULTS

The incidence of depression symptoms in the 2nd trimester is higher in women with GDM (23.4%) than in women without GDM (10.7%; p = 0.022; OR = 2.6). The incidence of depression and anxiety symptomatology did not change significantly from 2nd to 3rd trimester within both groups; however, an increase in the average severity of depression symptomatology was observed. Glycemic control was negatively associated with the external health locus of control.

CONCLUSIONS

Our results highlight the need for depression screening early on during pregnancy, especially in women with GDM. Timely psychological support may contribute to better GDM management and possibly prevent negative pregnancy outcomes.

The association between diabetes-related distress and fear of hypoglycaemia in patients with type 2 diabetes mellitus: A cross-sectional descriptive study

AIM

The study aimed to explore the association between diabetes-related distress as a dependent variable and fear of hypoglycaemia as a independent variable in Chinese individuals with type 2 diabetes, which can provide a basis for the development of effective nursing interventions.

DESIGN

A cross-sectional descriptive study.

METHODS

Pre-piloted scales were used to determine whether they experienced fear of hypoglycaemia and whether this impacted upon their management of the disease. From June-October 2019, participants were asked to complete the "hypoglycaemia fear survey" and "diabetes distress scales" to assess levels of fear and distress. Stepwise multivariate regression analysis was applied to reveal relationship between distress as a dependent variable and fear as a independent variable. Covariates included demographic, clinical or lifestyle factors.

RESULTS

A total of 258 participants were recruited for the survey, and they were characterized by little or no distress (39.53%), moderate distress (45.35%) and high distress (15.12%). The prevalence of moderate to severe distress in patients was 60.47%. Increased diabetes-related distress was strongly correlated with increased fear of hypoglycaemia and closely associated with the scores of the worry and behaviour subscales. These results indicated that 62.3% of diabetes-related distress may be explained by fear of hypoglycaemia.

CONCLUSION

Increased diabetes-related distress is associated with increased fear of hypoglycaemia in individuals with type 2 diabetes.

The Relationships Between Diabetes Self-Care, Diabetes Time Management, and Diabetes Distress in Women With Type 2 Diabetes Mellitus

PURPOSE

The purpose of this study was to examine the relationships between and among diabetes self-care, diabetes time management, and diabetes distress in women with type 2 diabetes mellitus (T2DM).

METHODS

A descriptive correlational design with a total of 188 participants completed 3 valid and reliable instruments to measure the main study variables, the Diabetes Self-Management Questionnaire, the Diabetes Time Management Questionnaire, and the Diabetes Distress Scale, in an uncontrolled, natural setting using mix-mode surveys (electronic and paper). Survey responses were analyzed using several descriptive, bivariate, and multivariate analyses.

RESULTS

Diabetes time management was the strongest, statistically significant, unique contributor to explaining self-care. The regression model showed that diabetes time management demonstrated a large effect size and that diabetes distress demonstrated a small effect size.

CONCLUSIONS

The 2 predictor variables among diabetes self-care in women showed diabetes time management had a stronger effect size compared to diabetes distress. This is the first known study to measure the influence of diabetes time management on diabetes self-care and to examine the relationship between and among diabetes time management and diabetes distress. Diabetes time management, an understudied variable in individuals with T2DM, has the potential to be a contributor to improve patient outcomes.

Medication Intake, Perceived Barriers, and Their Correlates Among Adults With Type 1 and Type 2 Diabetes: Results From Diabetes MILES – The Netherlands

Purpose

The purpose of this study is to investigate medication intake, perceived barriers and their correlates in adults with type 1 or type 2 diabetes.

Methods

In this cross-sectional study, 3,383 Dutch adults with diabetes (42% type 1; 58% type 2) completed the 12-item ‘Adherence Starts with Knowledge’ questionnaire (ASK-12; total score range: 12-60) and reported socio-demographics, clinical and psychological characteristics and health behaviors. Univariable and multivariable logistic regression analyses were used.

Results

Adults with type 1 diabetes had a slightly lower mean ASK-12 score (i.e. more optimal medication intake and fewer perceived barriers) than adults with non-insulin-treated type 2 diabetes. After adjustment for covariates, correlates with suboptimal intake and barriers were fewer severe hypoglycemic events and more depressive symptoms and diabetes-specific distress. In type 2 diabetes, correlates were longer diabetes duration, more depressive symptoms and diabetes-specific distress.

Conclusions

Adults with type 1 diabetes showed slightly more optimal medication intake and fewer perceived barriers than adults with non-insulin treated type 2 diabetes. Correlates differed only slightly between diabetes types. The strong association with depressive symptoms and diabetes-specific distress in both diabetes types warrants attention, as improving these outcomes in some people with diabetes might indirectly improve medication intake.

Diabetes related distress is high in inpatients with diabetes

OBJECTIVE

The aim of the present study was to assess diabetes-related distress in inpatients and its association with metabolic control in people with diabetes type 1 (DM1) and type 2 (DM2).

RESEARCH DESIGN AND METHODS

In a cross-sectional study, 107 inpatients with DM1 (age 45.9 years, diabetes duration 18.7 years, HbA1c 8.4%/67.8 mmol/mol) and 109 with DM2 (age 62.0 years, diabetes duration 16.2 years, HbA1c 8.9%/74.3 mmol/mol) from a University department for endocrinology and metabolic diseases (Germany) were included over 2 years. Diabetes-related distress was assessed with the PAID questionnaire (range 0-100, higher scores imply higher diabetes-related distress, cut-off ≥ 40). The PAID questionnaire was completed by 214 of 216 participants.

RESULTS

Fifty-one of 214 individuals (23.8%) showed high distress (PAID score ≥ 40). The mean PAID score was 28.1 ± 17.5 in all participants with no difference between DM1 and DM2 (28.1 ± 17.4 vs. 26.2 ± 16.9, p = 0.532). Individuals with DM2 on insulin scored higher than patients without insulin (27.8 ± 17.6 vs. 18.7 ± 8.5, p = 0.004). Additionally, people with DM1 treated with a system for continuous glucose monitoring (n = 50, 33.1 ± 18.8) scored higher than participants without such system (n = 32, 20.6 ± 13.3, p = 0.001). HbA1c was not correlated with the PAID score in both, DM1 (r = 0.040, p = 0.684) and DM2 (r = - 0.024, p = 0.804). Participants with DM2 and severe hypoglycaemia/last 12 months scored higher than people without (PAID score 43.0 ± 20.4 vs. 25.1 ± 16.5, p = 0.026). Frequency of non-severe hypoglycaemia was not associated with the PAID score in DM1 and DM2.

CONCLUSIONS

Patients with diabetes treated in hospital for problems with diabetes suffer frequently from diabetes-related distress (~ 24%) regardless of diabetes type.

Study of emotional distress in a comparative effectiveness trial of diabetes treatments: Rationale and design

Emotional distress, including depression and diabetes-specific distress (e.g., feeling overwhelmed by living with diabetes, feelings of failure related to diabetes self-care), is a significant and prevalent problem for patients with type 2 diabetes. Both depression and diabetes distress have been associated with metabolic/glycemic control, diabetes complications, mortality, and quality of life. Recent findings further suggest that risk for emotional distress is influenced by diabetes treatment. The GRADE Study (Glycemia Reduction Approaches in Diabetes: A Comparative Effectiveness Study) is generating prospective data that will provide a unique opportunity to examine the relationships between emotional distress, diabetes treatment, and outcomes in an experimental design. The GRADE study is a randomized clinical trial that will compare the metabolic effects of four common anti-hyperglycemic drugs when combined with metformin. This sub-study recruited a subset (n = 1739) of GRADE participants and will examine patient-level variation in baseline emotional distress as a predictor of glycemic control and other health outcomes, independent of treatment effects. The study will also provide an experimental examination of treatment regimen effects on emotional distress over time as part of the overall evaluation of comparative effectiveness. Evaluation of emotional distress using validated measures will allow us to disentangle the roles of depressive symptoms and diabetes distress, factors that share significant overlap but require distinct approaches to screening and treatment. Study findings may directly influence practice decisions regarding screening and treatment for emotional distress as part of diabetes care. ClinicalTrials.gov Identifier: NCT01794143.

Perceived Control, Voice Handicap, and Barriers to Voice Therapy

OBJECTIVE

To characterize the associations of perceived control with voice outcomes and self-reported likelihood of attending voice therapy using a national practice-based research network.

STUDY DESIGN

Cross-sectional study of prospectively enrolled adult patients seen for dysphonia.

SETTING

Creating Healthcare Excellence through Education and Research (CHEER) network of community and academic practice sites.

SUBJECTS AND METHODS

Data collected included patient-reported demographics, outcome measures of voice (Voice Handicap Index-10), perceived control (present control subscale of voice-specific Perceived Control over Stressful Events Scale), personality (Ten Item Personality Inventory), likelihood of attending voice therapy if recommended, and barriers to attending voice therapy.

RESULTS

Patients (N = 247) were enrolled over 12 months from 10 sites, of whom 170 received a recommendation for voice therapy. The majority (85%) of this group planned to attend voice therapy. Voice-specific perceived control and VHI-10 were inversely related (r = -0.31, P < 0.001), even when controlling for personality. No study variables were associated with self-reported likelihood of attending voice therapy, but perceived control was the most consistent correlate of specific barriers to attending voice therapy (eg, "hard to translate into everyday use") and was inversely related to these barriers.

CONCLUSIONS

Patients scoring higher on a voice-specific measure of perceived control reported less voice handicap, independent of personality, and higher perceived control was associated with having fewer concerns about voice therapy goals and process. Perceived control is a potential target for intervention in patients with voice disorders.

Facilitating participation in cardiovascular preventive initiatives among people with diabetes: a qualitative study

Background

Type 2 diabetes (T2D) is associated with a significantly increased risk of cardiovascular disease (CVD). The DIAbetic CArdioVAscular Screening and intervention trial (DIACAVAS) was designed to clarify whether advanced imaging for subclinical atherosclerosis combined with medical treatment is an effective strategy to develop individualised treatment algorithms for Danish men and women with T2D aged 40–60. But in the DIACAVAS pilot study, the uptake was only 41%. Consequently, we explored how people experienced living with T2D to understand how to improve the uptake in initiatives targeting the prevention of CVD.

Methods

We used semi-structured interviews to obtain information on how the respondents experienced having T2D. For supplementary information, we used structured interviews on e.g. socioeconomic factors. From April to October 2019, 17 participants aged 40–60 years were recruited from general practices and diabetes outpatient clinics in Denmark. Several levels of analysis were involved consistent with inductive content analysis.

Results

The participants’ experiences of living with T2D fell along two continuums, from an emotional to a cognitive expression and from reactive to proactive disease management. This led to identification of four archetypal characteristics: (I) powerlessness, (II) empowerment, (III) health literacy, and (IV) self-efficacy. These characteristics indicated the importance of using different approaches to facilitate participation in cardiovascular preventive initiatives. Additionally, findings inspired us to develop a model for facilitating participation in future preventive initiatives.

Conclusion

Encouraging people with T2D to participate in cardiovascular preventive initiatives may necessitate a tailored invitation strategy. We propose a model for an invitational process that takes into consideration invitees’ characteristics, including powerlessness, empowerment, health literacy and self-efficacy. This model may enhance participation in such initiatives. However, participation is a general concern, not only in relation to cardiovascular prevention. Our proposed model may be applicable in preventive services for people with T2D in general.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-10172-6.

One-year intensive lifestyle intervention and improvements in health-related quality of life and mental health in persons with type 2 diabetes: a secondary analysis of the U-TURN randomized controlled trial

INTRODUCTION

The effects of lifestyle interventions in persons with type 2 diabetes (T2D) on health-related quality of life (HRQoL) and subjective well-being are ambiguous, and no studies have explored the effect of exercise interventions that meet or exceed current recommended exercise levels. We investigated whether a 1-year intensive lifestyle intervention is superior in improving HRQoL compared with standard care in T2D persons.

RESEARCH DESIGN AND METHODS

We performed secondary analyses of a previously conducted randomized controlled trial (April 2015 to August 2016). Persons with non-insulin-dependent T2D (duration ≤10 years) were randomized to 1-year supervised exercise and individualized dietary counseling (ie, 'U-TURN'), or standard care. The primary HRQoL outcome was change in the 36-item Short Form Health Survey (SF-36) physical component score (PCS) from baseline to 12 months of follow-up, and a key secondary outcome was changes in the SF-36 mental component score (MCS).

RESULTS

We included 98 participants (U-TURN group=64, standard care group=34) with a mean age of 54.6 years (SD 8.9). Between-group analyses at 12-month follow-up showed SF-36 PCS change of 0.8 (95% CI -0.7 to 2.3) in the U-TURN group and deterioration of 2.4 (95% CI -4.6 to -0.1) in the standard care group (difference of 3.2, 95% CI 0.5 to 5.9, p=0.02) while no changes were detected in SF-36 MCS. At 12 months, 19 participants (30%) in the U-TURN group and 6 participants (18%) in the standard care group achieved clinically significant improvement in SF-36 PCS score (adjusted risk ratio 2.6, 95% CI 1.0 to 4.5 corresponding to number needed to treat of 4, 95% CI 1.6 to infinite).

CONCLUSION

In persons with T2D diagnosed for less than 10 years, intensive lifestyle intervention improved the physical component of HRQoL, but not the mental component of HRQoL after 1 year, compared with standard care.

TRIAL REGISTRATION NUMBER

NCT02417012.