Diabetes distress in Type 1 diabetes--a new measurement fit for purpose

Using Artificial Intelligence-informed Experience-Based Co-Design (AI-EBCD) to create a virtual reality-based mindfulness application to reduce diabetes distress: protocol for a mixed-methods feasibility study

INTRODUCTION

People with type 2 diabetes can experience diabetes distress which can negatively affect health outcomes. Non-pharmacological interventions such as mindfulness can help address diabetes distress. However, face-to-face programmes can be constrained by cost, poor accessibility and lack of availability. Mobile apps for mindfulness may overcome these issues but evidence of their effectiveness is limited, and some have poor interface design with basic visualisations and feedback.

METHODS AND ANALYSIS

Our study will explore using virtual reality (VR) as an immersive and interactive technology that could support mindfulness practice to help reduce diabetes distress. We will use a mixed-methods design to pilot a new co-design process called Artificial Intelligence-informed Experience-Based Co-Design. Phase 1 will identify and evaluate existing VR mindfulness apps, followed by interviews with mindfulness experts to gain their perspectives on practising mindfulness in virtual settings. This will be followed by a participatory design phase with a series of five co-design workshops where adults with type 2 diabetes will (1) discuss diabetes distress and learn about mindfulness, (2) evaluate commercially available VR mindfulness apps, (3) employ artistic methods to produce a personalised mindfulness experience, (4) create digital content for a virtual mindfulness experience via generative artificial intelligence tools and (5) prioritise key design features, functionality and content for a tailored VR mindfulness app. The final phase will focus on developing a bespoke VR mindfulness app and evaluating it with adults with type 2 diabetes using interviews, questionnaires and VR app analytics to determine if the new digital mental health intervention can help reduce diabetes distress and improve quality of life.

ETHICS AND DISSEMINATION

We received ethical approval from The University of Manchester (2024-18262-32710 and 2024-21170-37093). Written informed consent will be obtained from all participants. Dissemination will include scientific publications and presentations, social media, knowledge translation events and educational resources for teaching students.

EMBARK: A Randomized, Controlled Trial Comparing Three Approaches to Reducing Diabetes Distress and Improving HbA1c in Adults With Type 1 Diabetes

OBJECTIVE

To compare the effectiveness of three interventions to reduce diabetes distress (DD) and improve HbA1c among adults with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Individuals with T1D (n = 276) with elevated DD (a score >2 on the total Type 1 Diabetes Distress Scale) and HbA1c (>7.5%) were recruited from multiple settings and randomly assigned to one of three virtual group-based programs: 1) Streamline, an educator-led education and diabetes self-management program; 2) TunedIn, a psychologist-led program focused exclusively on emotional-focused DD reduction; or 3) FixIt, an integration of Streamline and TunedIn. Assessments of the primary outcomes of DD and HbA1c occurred at baseline and at 3, 6, and 12 months.

RESULTS

All three programs demonstrated substantive and sustained reductions in DD (Cohen's d = 0.58-1.14) and HbA1c (range, -0.4 to -0.72) at 12-month follow-up. TunedIn and FixIt participants reported significantly greater DD reductions compared with Streamline participants (P = 0.007). Streamline and TunedIn participants achieved significantly greater HbA1c reductions than did FixIt participants (P = 0.006).

CONCLUSIONS

DD can be successfully reduced among individuals with T1D with elevated HbA1c using both the educational/behavioral and emotion-focused approaches included in the study. Although both approaches are associated with significant and clinically meaningful reductions in DD and HbA1c, TunedIn, the emotion-focused program, had the most consistent benefits across both DD and HbA1c. The study findings suggest the overall value of group-based, fully virtual, and time-limited emotion-focused strategies, like those used in TunedIn, for adults with T1D.

Type 1 diabetes-related distress: Current implications in care

Type 1 diabetes (T1D) is a complex chronic disease associated with major health and economic consequences, also involving important issues in the psychosocial sphere. In this regard, T1D-related distress, defined as the emotional burden of living with T1D, has emerged as a specific entity related to the disease. Diabetes distress (DD) is an overlooked but prevalent condition in people living with T1D, and has significant implications in both glycemic control and mental health in this population. Although overlapping symptoms may be found between DD and mental health disorders, specific approaches should be performed for the diagnosis of this problem. In recent years, different DD-targeted interventions have been postulated, including behavioral and psychosocial strategies. Moreover, new technologies in this field may be helpful to address DD in people living with T1D. In this article, we summarize the current knowledge on T1D-related distress, and we also discuss the current approaches and future perspectives in its management.

Living with and managing type 1 diabetes in humanitarian settings: A qualitative synthesis of lived experience and stakeholder tacit knowledge

Humanitarian health actors are beginning to better consider and manage non-communicable diseases, such as diabetes, in emergency and protracted crisis settings. However, a focus on the more globally prevalent type 2 diabetes (T2D) dominates. Blind spots prevail in the unmet needs for type 1 diabetes (T1D), a chronic autoimmune condition where individuals are unable to produce insulin, thereby dependent on lifelong insulin therapy and blood glucose management. Although some T1D management requirements overlap with those of T2D, the immediate risk of fatal complications following insulin therapy disruption, the earlier age of onset during childhood, adolescence or young adulthood, and its lower prevalence compared to T2D within communities and local health systems mean that T1D requires nuanced consideration and targeted interventions. Intending to inform program and policy design for people with T1D (PWT1D), we synthesized themes of lived experience from PLWT1D and their caregivers, and the tacit working knowledge of health providers and policymakers in the context of local humanitarian operations. Through a strategic search of health databases (up to July 2023), we identified 11 articles that include interview excerpts from PWT1D, caregivers, healthcare providers and policymakers about T1D management in humanitarian settings. We used reflexive thematic analysis to guide data extraction, coding, and synthesis, resulting in the identification of four overarching themes: food and insulin security, family relations, knowledge translation, and response to diagnosis. The narratives highlight harsh trade-offs made by PWT1D and their families in the face of insulin and food insecurity, as well as the damaging impact of low T1D education in families, communities and health systems. Targeted family and community-based solutions are urgently required, alongside systemic reforms and international collaboration to enable better T1D coping and management in humanitarian settings.

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.

Associations between use of diabetes technology and diabetes distress: a Danish cross-sectional survey of adults with type 1 diabetes

INTRODUCTION

The study aimed to investigate independent and combined associations between insulin delivery method (insulin pump therapy (IPT) vs multiple daily injections (MDI)), glucose monitoring method (intermittently scanned continuous glucose monitoring (isCGM) and real-time continuous glucose monitoring (rtCGM) vs blood glucose metre (BGM)) and diabetes distress (DD) in adults with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

We combined data from two Danish questionnaire-based surveys, the Steno Tech Survey (n=1591) and the Type 1 Diabetes Distress Scale (T1-DDS) validation survey (n=4205), in which individuals aged ≥18 years with T1D were invited to participate. The 28-item T1-DDS was used to measure DD and DD scores were categorised as little or no distress (score <2.0), moderate distress (2.0-2.9) and high distress (score ≥3.0). Associations between insulin delivery, glucose monitoring methods and DD were assessed using linear regression.

RESULTS

Among 2068 adults with T1D who responded to one of the surveys, the use of IPT was associated with a lower total T1-DDS score (-0.09, 95% CI 0.16 to -0.03) compared with MDI and adjusted for glucose monitoring method. The use of CGM was associated with a higher total T1-DDS score (0.11, 95% CI 0.05 to 0.18) compared with BGM and adjusted for the insulin delivery method. IPT was still associated with a lower T1-DDS score, regardless of being combined with BGM (-0.17, 95% CI -0.28 to -0.06) or CGM (-0.13, 95% CI -0.21 to -0.05), compared with MDI with CGM. No association was found between the type of CGM (isCGM vs rtCGM) and DD among either IPT or MDI users when restricting analysis to individuals using CGM.

CONCLUSIONS

Among Danish adults with T1D, the use of IPT was associated with lower levels of DD, while CGM use was associated with higher levels of DD. DD should be addressed when introducing people with T1D to diabetes technology, CGM in particular.

TRIAL REGISTRATION NUMBER

NCT04311164 (Results).

Evaluation of hybrid closed-loop insulin delivery system in type 1 diabetes in real-world clinical practice: One-year observational study

BACKGROUND

In 2016, the Food and Drug Administration approved the first hybrid closed-loop (HCL) insulin delivery system for adults with type 1 diabetes (T1D). There is limited information on the impact of using HCL systems on patient-reported outcomes (PROs) in patients with T1D in real-world clinical practice. In this independent study, we evaluated glycemic parameters and PROs over one year of continuous use of Medtronic's 670G HCL in real-world clinical practice.

AIM

To assess the effects of hybrid closed loop system on glycemic control and quality of life in adults with T1D.

METHODS

We evaluated 71 patients with T1D (mean age: 45.5 ± 12.1 years; 59% females; body weight: 83.8 ± 18.7 kg, body mass index: 28.7 ± 5.6 kg/m2, A1C: 7.6% ± 0.8%) who were treated with HCL at Joslin Clinic from 2017 to 2019. We measured A1C and percent of glucose time-in-range (%TIR) at baseline and 12 months. We measured percent time in auto mode (%TiAM) for the last two weeks preceding the final visit and assessed PROs through several validated quality-of-life surveys related to general health and diabetes management.

RESULTS

At 12 mo, A1C decreased by 0.3% ± 0.1% (P = 0.001) and %TIR increased by 8.1% ± 2.5% (P = 0.002). The average %TiAM was only 64.3% ± 32.8% and was not associated with A1C, %TIR or PROs. PROs, provided at baseline and at the end of the study, showed that the physical functioning submodule of 36Item Short-Form Health Survey increased significantly by 22.9% (P < 0.001). Hypoglycemia fear survey/worry scale decreased significantly by 24.9% (P < 0.000); Problem Areas In Diabetes reduced significantly by -17.2% (P = 0.002). The emotional burden submodules of dietary diversity score reduced significantly by -44.7% (P = 0.001). Furthermore, analysis of Clarke questionnaire showed no increase in awareness of hypoglycemic episodes. WHO-5 showed no improvements in subject's wellbeing among participants after starting the 670G HCL system. Finally, analysis of Pittsburgh Sleep Quality Index showed no difference in sleep quality, sleep latency, or duration of sleep from baseline to 12 mo.

CONCLUSION

The use of HCL in real-world clinical practice for one year was associated with significant improvements in A1C, %TIR, physical functioning, hypoglycemia fear, emotional distress, and emotional burden related to diabetes management. However, these changes were not associated with time in auto mode.

Explaining improvement in diabetes distress: a longitudinal analysis of the predictive relevance of resilience and acceptance in people with type 1 diabetes

AIMS

To analyze if midterm improvement in diabetes distress can be explained by resilience, diabetes acceptance, and patient characteristics.

METHODS

N = 179 adults with type 1 diabetes were enrolled during their stay at a tertiary diabetes center (monocentric enrolment) and followed up over three months in a prospective, observational study ('DIA-LINK1'). Improvement in diabetes distress was assessed as reduction in the Problem Areas in Diabetes Scale score from baseline to follow-up. Resilience (Resilience Scale-13), acceptance (Diabetes Acceptance Scale), and patient characteristics were analyzed as predictors of improvement in diabetes distress using hierarchical multiple regression.

RESULTS

Greater reductions in diabetes distress were significantly explained by lower diabetes acceptance at baseline (β = -0.34, p < 0.01), while resilience, diabetes complications, and other person-related variables were not significantly related to changes in diabetes distress (all p > 0.05). When change in diabetes acceptance from baseline to follow-up was added to the model, improved diabetes distress was explained by increasing diabetes acceptance (β = 0.41, p < 0.01) and a shorter duration of diabetes (β = -0.18, p = 0.03), while baseline diabetes acceptance was no longer significantly associated (β = -0.14, p > 0.05).

CONCLUSIONS

Diabetes acceptance is inversely related to diabetes distress, and increasing acceptance explained greater improvement in diabetes distress. These findings suggest that increasing diabetes acceptance may facilitate the reduction of diabetes distress. Treatment approaches targeting acceptance might be useful for the mental healthcare of people with type 1 diabetes and clinically elevated diabetes distress.

Adaptation and psychometric assessment of the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" in a Brazilian population

Objectives

To adapt the instrument "Partners of Adults with Type 1 Diabetes Distress Scale" (Partner-DDS) into Brazilian culture, and to evaluate the psychometric characteristics of the adapted version.

Methods

All the cultural adaptation steps of the measure's instruments were followed. The psychometric properties such as reliability (stability by test-retest; internal consistency), and convergent construct validity were performed.

Results

Of all 72 partners, 69.4% were male, mean age: 42.69 ± 14.09 years, mean of marriage duration: 14.74 ± 12.41 years, and mean schooling: 11.81 ± 3.91 years.The internal consistency of the instrument (Cronbach Alpha) was 0.90. The intra-class coefficient (stability) was 0.80 (0.72-0.84). The Spearman coefficient (convergent construct validity) between the Partner-DDS scale and the Anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) was 0.4273 (p < 0.0002).

Conclusions

The steps of the instruments' cultural adaptation were appropriately performed. The Brazilian version of the Partner- DDS scale demonstrates reliable psychometric properties for being used in POPWT1D distress evaluation in Brazil.

Innovation

The cultural adaptation of Partner-DDS scale into Brazilian Portuguese is a helpful innovation to assess the emotional burden in POPWT1D. This tool could be used to provide education and psychological support for this population.

A Short-Form Measure of Diabetes Distress Among Adults With Type 1 Diabetes for Use in Clinical Practice: Development and Validation of the T1-DDS-7

OBJECTIVE

Valid and reliable diabetes distress assessment is essential for identifying adults with elevated levels of concern and to guide targeted support. However, assessing diabetes distress must also be feasible in time-limited settings. We aimed to identify a short-form measure of the 28-item Type 1 Diabetes Distress Scale (T1-DDS-28) representing seven sources of type 1 diabetes distress that would be convenient for use in clinical practice.

RESEARCH DESIGN AND METHODS

Based on the evaluation of influence and importance by 14 experts in diabetes care and research, we identified the best-performing item within each of seven sources of diabetes distress included in the T1-DDS-28. To further validate the proposed short-form measure, we used survey data from 2,016 adults living with type 1 diabetes. Validity was examined by exploratory factor analysis, Cronbach's α, test-retest reliability analysis, and correlations with other psychosocial measures.

RESULTS

We identified a short-form measure of the T1-DDS-28 consisting of seven items, each representing a source of diabetes distress. These items showed satisfactory reliability (factor loadings > 0.45; α = 0.82; test-retest correlation, r = 0.90) and validity (correlation with T1-DDS-28, r = 0.95; area under the curve = 0.91; sensitivity 93%; specificity 89%) when combined in the short-form scale (T1-DDS-7).

CONCLUSIONS

We propose the T1-DDS-7 as a valid and reliable measure for routine screening of diabetes distress among adults with type 1 diabetes. In case of elevated levels of diabetes distress, we recommend that a full-scale assessment and open dialogue follow the short-form measure before determining further treatment.

Patient-reported outcomes for people with diabetes: what and how to measure? A narrative review

Patient-reported outcomes (PROs) are valuable for shared decision making and research. Patient-reported outcome measures (PROMs) are questionnaires used to measure PROs, such as health-related quality of life (HRQL). Although core outcome sets for trials and clinical practice have been developed separately, they, as well as other initiatives, recommend different PROs and PROMs. In research and clinical practice, different PROMs are used (some generic, some disease-specific), which measure many different things. This is a threat to the validity of research and clinical findings in the field of diabetes. In this narrative review, we aim to provide recommendations for the selection of relevant PROs and psychometrically sound PROMs for people with diabetes for use in clinical practice and research. Based on a general conceptual framework of PROs, we suggest that relevant PROs to measure in people with diabetes are: disease-specific symptoms (e.g. worries about hypoglycaemia and diabetes distress), general symptoms (e.g. fatigue and depression), functional status, general health perceptions and overall quality of life. Generic PROMs such as the 36-Item Short Form Health Survey (SF-36), WHO Disability Assessment Schedule (WHODAS 2.0), or Patient-Reported Outcomes Measurement Information System (PROMIS) measures could be considered to measure commonly relevant PROs, supplemented with disease-specific PROMs where needed. However, none of the existing diabetes-specific PROM scales has been sufficiently validated, although the Diabetes Symptom Self-Care Inventory (DSSCI) for measuring diabetes-specific symptoms and the Diabetes Distress Scale (DDS) and Problem Areas in Diabetes (PAID) for measuring distress showed sufficient content validity. Standardisation and use of relevant PROs and psychometrically sound PROMs can help inform people with diabetes about the expected course of disease and treatment, for shared decision making, to monitor outcomes and to improve healthcare. We recommend further validation studies of diabetes-specific PROMs that have sufficient content validity for measuring disease-specific symptoms and consider generic item banks developed based on item response theory for measuring commonly relevant PROs.

Diabetes distress in a Barbadian population with type 2 diabetes: A pilot test

One in five Barbadians has diabetes, suggesting that there is a severe burden of the disease.

Objective

To assess the psychometric properties of the Diabetes Distress Scale, in order to determine the feasibility, practicality, internal consistency and criterion validity of the instrument when used with Barbadians living with Type 2 Diabetes.

Methods

Patients with type 2 diabetes, (n = 106. 60% females, 40% males; mean age = 65.2, 11.3 years) attending a private clinic in Barbados were assessed for diabetes distress, depression, glycated hemoglobin (HbA1C) and blood pressure (BP).A self-report questionnaire that included: clinical and demographic questions; the Diabetes Distress Scale (DDS); the Patient Health Questionnaire (PHQ-9); and the Problem Areas In Diabetes (PAID-5) scale. Glycated haemaglobin (HbA1C) and Blood pressure (BP) were also measured.

Results

Of the 110 persons who participated, 106 persons completed the questionnaire. The Cronbach alpha coefficient of the PAID was 0.92 and the DDS was 0.92. Concurrent validity was demonstrated in a strong consistent relationship between the scores on the DDS and PAID-5, with a strong positive correlation, r = 0.70, n = 86, p < 0.001. There was a significant difference in the DDS scores between males (M = 1.26, SD = 0.37) and females (M = 1.50, SD = 0.73), t(73.31) = -1.99, p = 0.05 two tailed.

Conclusion

The DDS is shown to be a valid and reliable measure within this Caribbean context. Thus, researchers and clinicians desirous of a tool to assess Diabetes Distress may be assured of the strong psychometric properties demonstrated thus far.

Validation of the type 1 diabetes distress scale (T1-DDS) in a large Danish cohort: Content validation and psychometric properties

Aim

To validate the Type 1 Diabetes Distress Scale (T1-DDS) in a large sample of adults with Type 1 diabetes (T1D) from diabetes clinics in Denmark.

Methods

Altogether 40 adults with T1D were interviewed to explore the content of T1-DDS in a Danish setting and to validate the translation of the T1-DDS into Danish. Subsequently, a survey including T1-DDS, the Problem Areas In Diabetes scale (PAID-20), fear of hypoglycemia, social support, and diabetes duration was answered by 2201 people with T1D. Other person characteristics were collected from the National Patient Register. HbA1c was obtained from the Clinical Laboratory Information System. Data distribution, internal consistency, convergent and construct validity, factor structure, three weeks retest, and cut-points were explored.

Results

Interview data supported the relevance of all T1-DDS items for the assessment of diabetes distress among adults with T1D. The T1-DDS showed good content and acceptable construct validity, and the ability to detect high diabetes distress levels. A high correlation between T1-DDS and PAID-20 (rho = 0.91) was found. The retest scores showed a good reliability (all rho ≥0.68) with the highest variability in the Friends/Family Distress and Physician Distress subscales and the lowest variability in the Powerlessness and Eating Distress subscales of the T1-DDS. Qualitative findings pointed out relevant concerns of people with T1D, which were not included in the T1-DDS.

Conclusion

The study supports the use of the Danish T1-DDS, but also highlights that existing diabetes distress questionnaires including T1-DDS do not cover all potential diabetes stressors and worries.

A pilot evaluation of the Food as Medicine program for patients with type 2 diabetes

The objective of this study was to determine the effectiveness of the Food as Medicine Program (modified and adapted based on supporting research of the Fresh Food Farmacy™ program) that was implemented at a southeast regional hospital with voluntary participants with diabetes. It was hypothesized that participants would experience a decline in type 2 diabetes symptoms following the 12-month program of bi-monthly healthy groceries, nutritional guidance, educational sessions, and group health coaching. For this initial pilot study, four cohorts of patients were admitted consisting of 20 participants. The 12-month program included bi-monthly food pick-ups, nutritional recipes, and bi-monthly group educational and health coaching sessions for participants. They also completed pre- and post-program assessments, including a medical history questionnaire, biometric screening (HbA1c, weight, BMI, and blood pressure), and health behavior questionnaires. While there were not statistically significant differences from pre- to post-program, mean HbA1c slightly decreased from the time of the initial test (i.e., month 1) to follow-up testing (i.e., month 12). The pre- to post-program trends for diabetes self-care activities indicated improvements for general and specific diet maintenance, days of exercise per week, blood glucose testing per week, foot care, and smoking habits. Participants also exhibited a decrease in diabetes distress for emotional, physical, regimen, and interpersonal distress from pre- to post-program. This is very important as self-regulation of behaviors is necessary to successful management of diabetes. The results are discussed in relation to the limitations created by COVID-19, along with future implementation suggestions.

Comparison of diabetes distress and depression screening results of emerging adults with type 1 diabetes onset at different ages: findings from the German early-onset T1D study and the German Diabetes Study (GDS)

BACKGROUND

Diabetes distress is increasingly considered one of the most important psychosocial issues in the care of people with type 1 diabetes (T1D). We analyse whether diabetes distress and depression screening results of emerging adults are associated with the age at T1D onset.

METHODS

Data were taken from two cohort studies conducted at the German Diabetes Center, Düsseldorf, Germany. The 18-30-year-old participants had an age at onset either before the age of 5 years (childhood-onset long-term T1D study group, N = 749) or during adulthood (adult-onset short-term T1D study group from the German Diabetes Study (GDS), N = 163). Diabetes distress and depression screening were analysed by means of the 20-item Problem Areas in Diabetes (PAID-20) scale and the nine-item depression module from the Patient Health Questionnaire (PHQ-9). The average causal effect of age at onset was estimated by a doubly robust causal inference method.

RESULTS

The PAID-20 total scores were increased in the adult-onset study group [potential outcome mean (POM) 32.1 (95% confidence interval 28.0; 36.1) points] compared to the childhood-onset study group [POM 21.0 (19.6; 22.4) points, difference 11.1 (6.9; 15.3) points, p<0.001] adjusted for age, sex and haemoglobin A1c (HbA1c) levels. Moreover, more participants in the adult-onset group [POM 34.5 (24.9; 44.2) %] than in the childhood-onset group [POM 16.3 (13.3; 19.2) %] screened positive for diabetes distress [adjusted difference 18.3 (8.3; 28.2) %, p<0.001]. The PHQ-9 total score [difference 0.3 (-1.1; 1.7) points, p=0.660] and the proportion of participants with a positive screening result for depression [difference 0.0 (-12.7; 12.8) %, p=0.994] did not differ between the groups in the adjusted analyses.

CONCLUSIONS

Emerging adults with short-term type 1 diabetes screened positive for diabetes distress more often than adults with type 1 diabetes onset during early childhood when age, sex and HbA1c values were considered confounding factors. Accounting for age at onset or the duration of diabetes may help explain the heterogeneity in the data when psychological factors are examined.

Diabetes Distress Among Type 1 Diabetic Adolescents in a Tertiary Care Hospital in Pakistan

BACKGROUND AND AIM

 Diabetes distress, a term used to describe negative emotions associated with diabetes, is the key factor responsible for the elevated risk of psychological burden and compromised self-management. The aim of this study is to determine the prevalence of diabetes-related distress among adolescent patients with type 1 diabetes (T1D) and to ascertain various factors associated with it.

METHODOLOGY

In this cross-sectional study, 117 T1D patients with age 12-20 years visiting a diabetic clinic in the Department of Endocrinology and Metabolism, Services Hospital Lahore from February 2022 to August 2022 were enrolled. The patient's demographic and clinical details were noted in a pre-designed proforma. T1D distress scale (T1DDS) was utilized as the tool for measuring diabetes distress and distress was classified as severe, moderate, and no/little distress.

RESULTS

Of the total 117 T1D patients, 34.2% (n=40) had diabetes-related distress, out of which 31.6% had moderate and 2.6% had severe distress. The average total distress score was 1.73 ± 0.52 and higher mean scores were of powerlessness, negative social perception, and eating distress. Distress was higher among females, in those with the onset of diabetes in teens rather than in childhood. There is a significant impact of glycated hemoglobin (HbA1c) on the severity of diabetes distress as demonstrated by Pearson's correlation (r=.570, n= 117, p = <.001) Conclusion: The present study highlights the association of diabetes distress in adolescents with various factors, most significantly poor glycemic control, and therefore emphasizes the need for developing psychological interventional strategies in routine diabetes care to improve the mental well-being and self-management of diabetic patients.

Diabetes distress in adult patients with type 1 and type 2 diabetes

Background: Diabetes is a chronic and demanding condition, exposing patients to complex physical and mental challenges, and making them particularly vulnerable to distress. Diabetes distress related to disease in diabetic patients is a term encompassing challenges associated with the psychosocial adaptation required of these individuals. Aim of the study: To assess distress in patients with diabetes mellitus. Material and methods: This study was conducted among 107 patients with type 1 and 2 diabetes mellitus reporting for follow-up at a diabetes clinic. The Diabetes Distress Scale (DDS) was used for data collection. Results: Moderate and severe diabetes distress was found in 36.4% and 15% of respondents in the study group, respectively. The total mean score for the DDS was 2.19. The largest percentages of respondents with high levels of distress were observed in patients with a financial situation rated lower than good (30.6%), those having less than secondary education (28.0%), and those under 30 years of age (27.8%). Patients with type 1 diabetes (26.9%), a disease duration > 30 years (30.8%), those using insulin pump therapy (30%) or CGM (Continuous Glucose Monitoring) and FGM (Flash Glucose Monitoring) systems (50%), and those showing ≥ 3 chronic diabetic complications (37.5%) experienced severe distress. Conclusions: Overall, diabetic patients showed a moderate level of distress. The greatest inconveniences caused by the disorder were associated with regimen-related distress and emotional burden. Rural patients with a lower level of education and a lower financial status showed higher levels of distress. Patients experiencing chronic complications from diabetes and those with higher levels of glycated hemoglobin also presented with more severe distress.

Flexible inclusion of dialogue about psychosocial aspects of life with type 1 diabetes in routine consultations: A study of a questionnaire-based dialogue tool to promote person-centred support

AIMS

To explore (1) experiences among people with type 1 diabetes and diabetologists of using a questionnaire-based dialogue tool in routine consultations to identify and address psychosocial challenges and (2) experiences of person-centredness in this group compared with a group who did not use the tool.

METHODS

In all, 42 people with type 1 diabetes (mean age 54 years, mean diabetes duration 31 years and 60% women) were interviewed and completed an evaluation questionnaire following a routine consultation with the use of a dialogue tool including PAID-5, WHO-5 and open-ended questions. A comparison group of 42 people with type 1 diabetes attending routine consultations without the use of dialogue tools completed evaluation questionnaires. All consultations were audio recorded. Diabetologists were interviewed after completing all test consultations. Interviews were analysed using thematic text condensation. Evaluation questionnaires were analysed using descriptive statistics, chi square tests and Student's two-sided t-tests.

RESULTS

Most participants found questions in the dialogue tool relevant to discuss with the diabetologist, and two-thirds were satisfied with the time spent on that. Experiences of people with type 1 diabetes and diabetologists were related to three pathways: (1) the tool supported valuable conversations with the diabetologist, (2) conversations with the diabetologist were unchanged and (3) the tool derailed conversations. All participants reported high levels of person centredness; however, significantly more in the comparison group reported that the diabetologist made them feel at ease (80 vs. 55%) and discussed and planned specific changes with them (93 vs. 67%).

CONCLUSION

A questionnaire-based dialogue tool in consultations can support the discussion of psychosocial issues of people with type 1 diabetes. However, flexible and tailored use of the dialogue tool is crucial as consultations may otherwise be derailed.

User-driven open-source artificial pancreas systems and patient-reported outcomes: A missed opportunity?

AIM

This paper aims to highlight the attributes of engagement and urgency to act to control diabetes demonstrated by open-source artificial pancreas system users with the view that increased user involvement in research and practice can capitalize on these self-management traits; and to outline the challenges of researching outcomes in the context of unlicensed therapies.

METHODS

A group of technically minded people with type 1 diabetes have reverse-engineered commercially available diabetes devices to help them achieve the diabetes outcomes they desire. Although studies have reported improved biomedical outcomes with these artificial pancreas systems, there are only a few studies examining patient-reported outcomes.

RESULTS

The investigation of patient-reported outcomes for open-source artificial pancreas system users has been hampered by the rapid advances in the technology, the lack of randomized controlled trials and the ethical challenges of researching unregulated technologies. There is an on-going debate about the most appropriate types of measures to evaluate patient-related outcomes.

CONCLUSIONS

The early adopters of open-source artificial pancreas systems exhibit many of the characteristics that predict optimal diabetes outcomes through engagement and urgency regarding self-management. These qualities should be harnessed to improve research in this and other areas of diabetes management.

Psychometric validation of diabetes distress scale in Bangladeshi population

Diabetes Distress (DD)-an emotional or affective state arise from challenge of living with diabetes and the burden of self-care-negatively impact diabetes management and quality of life of T2DM patients. Early detection and management of DD is key to efficient T2DM management. The study aimed at developing a valid and reliable instrument for Bangladeshi patients as unavailability such a tool posing challenge in diabetes care. Linguistically adapted, widely used, 17-item Diabetes Distress Scale (DDS), developed through forward-backward translation from English to Bengali, was administered on 1184 T2DM patients, from four diabetes hospitals in Bangladesh. Psychometric assessment of the instrument included, construct validity using principal component factor analysis, internal consistency using Cronbach's α and discriminative validity through independent t-test and test-retest reliability using intraclass-correlation coefficient (ICC) and Kappa statistics. Factor analysis extracted 4 components similar to original DDS domains, confirms the construct validity. The scale demonstrated satisfactory internal consistency (α = 0.838), stability (test-retest ICC = 0.941) and good agreement across repeated measurements (Kappa = 0.584). Discriminative validity revealed that patients with complication (p < 0.001) and those are on insulin (p < 0.001) had significantly higher distress scores in all domains. Bengali version of DDS is a valid and reliable tool for assessing distress among Bangladeshi T2DM patients.

Association of the Coronavirus Disease 2019 Outbreak on the Diabetes Self-Management in Chinese Patients: An Analytical Cross-Sectional Study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak has seriously affected people's lives, especially those with chronic diseases. Diabetes self-management, which plays an important role in glycaemic control and reducing the risk of acute and long-term complications, may be discouraged by social distancing.

PURPOSE

To evaluate the level of self-management activities in Chinese patients with type 2 diabetes mellitus (T2DM) during the COVID-19 pandemic.

PATIENTS AND METHODS

A survey of with 872 patients with T2DM in the inpatient and outpatient departments through face-to-face interviews was conducted from 1 July, 2020 to 30 September, 2020. The main outcome measures were glycaemic control status and level of self-management activities during the pandemic.

RESULTS

In terms of glycaemic control, the data showed that patients with fasting plasma glucose (FPG) < 7.0 mmol/L (36.4%), postprandial plasma glucose (PPG) < 10.0 mmol/L (26.3%), or glycosylated haemoglobin (HbA1c) < 7.0% (18.6%) in our investigation has well-controlled blood glucose level, and 11.9% of patients experienced blood glucose <3.9 mmol/L during the outbreak. The diabetes self-management of Chinese patients decreased and the final diabetes self-management score of the Chinese patients was 3.4 ± 1.45. Patients with higher education, diabetes education, comorbidities, and online consultations had higher diabetes self-management scores (P <0.05). Adherence to diabetes self-management in the normal glycaemic control group was higher than that in the substandard glycaemic control group (P<0.05). Among all participants, 72.1% of the patients reduced the frequency of hospital visits, and 44.8% considered that they had diabetes-related stress during the pandemic. The mean anxiety level score rated by 286 patients was 5.3±2.8.

CONCLUSION

The COVID-19 pandemic has affected diabetes self-management, including substandard glycemic control, increased diabetes-related stress, limited exercise range and medical visits. Therefore, future interventions should focus on the online management of chronic diseases and support online consultation' development and promotion, which can overcome physical distance and provide personalized services conveniently.

Psychometric Evaluation of the Diabetes Distress Scale in Patients with Type 2 Diabetes in Turkey

The objective of the research was to evaluate the validity and reliability of the Diabetes Distress Scale in patients with type 2 diabetes in Turkey. Materials and Methods. Our study was conducted between September 2016 and January 2017 and included 170 patients with type 2 diabetes. The Personal Information Form and Diabetes Distress Scale were used as a data collection tool. Statistical analysis was performed using SPSS 23.0 and SAS package program. Results. According to the results of the research, Cronbach’s alpha reliability for the total scale was 0.91. The model fit indices for the revised confirmatory factor analysis model failed to meet the criteria for acceptability: the GFI was 0.8185, the CFI was 0.9316, the Bentler - Bonett (1980) NFI was 0.9005, and the RMSEA was 0.1067. In our study, exploratory factor analysis provided support for the three-factor model: [I] emotional and regimen-related distress, [II] health professional-related distress, [III] diabetes-related interpersonal distress. Conclusions. When the translation and cultural adaptation process have been considered, the Diabetes Distress Scale is a valid and reliable tool for the Turkish community. It is recommended to be used in the studies and clinical trials.

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

Introduction

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

Methodology

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

Results

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

Conclusion

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

Psychologische Herausforderungen bei Erwachsenen mit Typ-1-Diabetes

Menschen mit Typ-1-Diabetes müssen immer wieder verschiedene Anpassungsleistungen erbringen, um ihre Erkrankung und deren Therapie in den Alltag integrieren zu können. Gelingt dies nicht, können daraus Probleme beim Selbstmanagement der Krankheit resultieren. Doch trotz strukturierter Schulungsprogramme und leitliniengerechter, individuell zugeschnittener Therapieempfehlungen leben einige Menschen mit Typ-1-Diabetes mit chronisch erhöhten Blutzuckerwerten. Dabei scheint der Diabetes-Distress als Reaktion auf die erlebten Herausforderungen eine wichtige Rolle zu spielen und im Zusammenhang mit Problemen bei der glykämischen Kontrolle wie auch einer Therapievermeidung zu stehen. Um eine Chronifizierung des Diabetes-Distress zu verhindern, empfiehlt es sich daher, ein Screening auf diabetesbezogene Belastungen in der Versorgung von Menschen mit Typ-1-Diabetes zu etablieren. Dies kann mittels Fragebogen oder der Thematisierung im persönlichen Gespräch geschehen. Diabetesspezifische psychologische Interventionen können sowohl die diabetesbezogene emotionale Belastung als auch die glykämische Kontrolle verbessern, sind jedoch in Deutschland noch nicht in der Regelversorgung verfügbar.

Psychometric Properties of the Polish Version of the Diabetes Distress Scale (DDS)

Background

Type 2 diabetes is a disease that affects the functioning and life of both the patient and their family. It involves the constant treatment, self-care, monitoring of blood glucose levels and adherence to physical activity recommendations. As a result, it causes discomfort, distress and reduces the quality of life.

Aim

Due to the lack of a scale that would precisely evaluate the level of distress in patients with diabetes in Poland, we decided to linguistically adapt the DDS scale to the Polish population and investigate its psychometric properties in relation to Polish patients.

Material

The study group consisted of 336 individuals in total, including 156 females (46.43%) and 180 males (53.57%), aged 59.13±8.4 on average. The patients were under the care of a specialist diabetes clinic. The research tool was the Diabetic Stress Scale (DDS).

Results and Conclusion

Our analysis showed that the reliability of both the scale and its components was at a good level. Only the RD-related part was characterised by a lower Cronbach’s alpha coefficient of 0.614. The DDS scale can be successfully used for the assessment of distress in the Polish population of patients with type 2 diabetes.

Reductions in Management Distress Following a Randomized Distress Intervention Are Associated With Improved Diabetes Behavioral and Glycemic Outcomes Over Time

OBJECTIVE

To explore associations between reductions in diabetes distress (DD) and improvements in glycemic outcomes among adults with type 1 diabetes (T1D) in the context of a DD randomized clinical trial.

RESEARCH DESIGN AND METHODS

Adults with T1D (N = 301) participated in a two-arm trial aimed at reducing DD (DD-focused OnTrack group vs. education-oriented KnowIt group). Mean age was 45.1 years; mean baseline HbA_1c was 8.8% (73 mmol/mol). Individuals were assessed at baseline and 9 months later on DD, self-care, HbA_1c, and frequency of hypoglycemia. Structural equation models evaluated hypothesized pathways among changes in DD, self-care, and glycemic outcomes in the total sample and by intervention group.

RESULTS

Reductions in DD were significantly and independently associated with better self-care, including fewer missed insulin boluses, more frequent insulin adjustment, improved problem-solving skills, more blood glucose monitoring, and greater adoption of continuous glucose monitoring (all P < 0.05). In turn, better self-care was linked with better glycemic outcomes, including fewer episodes of hypoglycemia and improved HbA_1c over time. Fit indices indicated good fit of the model to the data (confirmatory fit index = 0.94, root mean square error of approximation = 0.05), with stronger and more meaningful associations for OnTrack than for KnowIt.

CONCLUSIONS

In the context of an intervention to reduce DD for adults with T1D, results indicate that reductions in DD do not affect glycemic outcomes directly but through improvements in self-care behavior. Findings support the importance of integrating disease management with DD interventions to maximize improvements in glycemic outcomes.

Distress and depression among patients with diabetes mellitus: prevalence and associated factors: a cross-sectional study

PURPOSE

This study aimed to validate the internal consistency of the Persian version of the diabetes distress scale-17 (DDS-17) and to investigate the prevalence of diabetes distress (DD), depression, and possible relevant factors.

METHODS

This was a cross-sectional study on 820 diabetes patients (62.4 % females) in Tehran, Iran between January and June 2017. The Ethics Committee of Shahid Beheshti University of Medical Sciences approved the protocol. Patients filled out a demographic and health survey, DDS-17, the Beck Depression Inventory Second Edition (BDI-II) and the Summary of Diabetes Self-Care Activities Measure (SDSCA). DDS-17 consist of emotional burden, and physician, regimen, and interpersonal related distress. The correlation between DDS subscales and association between DDS and BDI-II or SDSCA scores were assessed using SPSS.

RESULTS

The mean age was 58.91 ± 12.35 years. Majority of patients had high DD (37.2 %) and severe depression (38.7 %). The general and specific diets got the highest score in six SDSCA subscales. The Persian version of DDS-17 had excellent internal consistency with Cronbach's alpha coefficient of 0.924. The DDS score had significant relationship with socioeconomic level (p < .001), type of DM (p < .001), type of treatment (p < .001), glycemic control status (p < .001), complication (p < .001) and depression level (p < .001). The level of hemoglobin A1c was the most useful predictor of DDS score (p < .001).

CONCLUSIONS

High prevalence of depression and distress in patient with diabetes calls for greater emphasizes on the importance of enhanced physicians and patients' knowledge in these areas.

Alleviating diabetes distress and improving diabetes self-management through health coaching in a primary care setting

Considering the rising global burden of diabetes and its complications, effective interventions for addressing barriers to diabetes self-management are needed. Diabetes distress, a psychological barrier to diabetes self-management, has become increasingly recognised in the literature, but effective and feasible ways of addressing it in routine primary care settings are not known. We present the case of a middle-aged non-Hispanic white American woman with poorly controlled diabetes (haemoglobin A1c (HbA1c): 13.9%) and elevated diabetes distress (baseline Diabetes Distress Scale Score: 2.53) who participated in a health coaching intervention. After the 5-month programme, which included eight 45 minute long sessions with a trained health coach, the patient achieved and sustained a 0.8-point reduction in diabetes distress, an improvement in insulin adherence and a 3.6-point reduction in HbA1c. This case demonstrates a novel approach to managing diabetes distress that entails providing patients a safe, nonjudgemental space to express their feelings and explore challenges with diabetes self-management.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSION

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

Psychosocial health in people with diabetes during the first three months of the COVID-19 pandemic in Denmark

AIMS

To analyze trajectories of psychosocial health among people with diabetes during the first three months of lockdowns and reopenings of the COVID-19 pandemic in Denmark.

METHODS

An online longitudinal survey of 2430 people with diabetes consisting of six questionnaire waves (Q1-Q6) was conducted between March 19 and June 25, 2020. Psychosocial outcomes assessed were COVID-19 worries, quality of life, feelings of social isolation, psychological distress, diabetes distress, anxiety, and general and diabetes-specific loneliness. Trajectories in psychosocial health were analyzed with linear multilevel mixed-effects models. Subgroup analyses were conducted.

RESULTS

In total, 1366 (56%) people with diabetes responded to the first questionnaire. COVID-19 worries, feelings of social isolation, psychological distress, anxiety and general loneliness had all improved at Q6 compared to Q1 (p < 0.001). In general, improvements in psychosocial health started after the first reopening phase (April 15); however, general loneliness increased up to the first reopening phase (p ≤  0.001) before decreasing, and quality of life decreased up to the first reopening phase (p = 0.002), with no improvements to follow. Subgroup analyses revealed that women had larger decreases in feelings of social isolation (p < 0.001) and in psychological distress (p = 0.035) and increases in quality of life (p < 0.001), between Q1 and Q6, compared to men.

CONCLUSIONS

Psychosocial health in people with diabetes improved following reopening of society. However, increases in loneliness and decreases in quality of life during lockdown indicates a potential need to mitigate the acute effects of such policies.

Psychological flexibility is associated with less diabetes distress and lower glycated haemoglobin in adults with type 1 diabetes

BACKGROUND

Diabetes distress, self-efficacy and health literacy are associated with diabetes self-management and health outcomes. Measures of coping styles and their impact on diabetes self-management and diabetes-related distress may add value in identifying those at risk of poorer health outcomes. Current evidence of associations between psychological flexibility/inflexibility and diabetes related health outcomes is limited.

AIMS

To measure associations of psychological flexibility, self-efficacy and health literacy with diabetes distress and HbA1c, in adults with type 1 diabetes.

METHODS

We surveyed 105 adults with type 1 diabetes attending a tertiary diabetes outpatient clinic (mean age 27±7.1 years, 53% men, duration of diabetes 12.6±8.5 years, HbA1c 72±22 mmol/mol, 8.7± 2.0 %, 34% using insulin pumps). We assessed psychological flexibility, self-efficacy, health literacy and diabetes distress. Regression models explored the relative contributions of different factors to diabetes distress and HbA1c.

RESULTS

The majority of health literacy scores were in the low risk range. Those with greater psychological flexibility had higher self-efficacy (r=0.34, p<0.01) and reported less diabetes distress (r=-0.54, p<0.001). In multiple regression analyses, psychological flexibility and self-efficacy accounted for 36% of the variance in distress score (p<0.001). Shorter duration of diabetes (p<0.001) and greater psychological flexibility (p<0.01) correlated with lower HbA_1c . A 10-point (one standard deviation) higher psychological flexibility score corresponded to a 0.5% lower HbA1c.

CONCLUSIONS

Greater psychological flexibility was associated with less diabetes distress and lower HbA1c_. The psychological flexibility construct may inform alternative interventional approaches aiming to improve wellbeing and glycaemic control. This article is protected by copyright. All rights reserved.

Diabetes-Related Distress and Its Associated Factors Among Patients with Diabetes in Vietnam

Background

Psychometric properties are regarded as one of the significant contributors related to diabetes treatment efficacy. Diabetes-related distress (DD) is one of the emotional burdens. The aims of this study were to investigate the prevalence of DD and to determine its associated factors among Vietnamese diabetic patients.

Methods

A cross-sectional study was conducted at a single medical center in the central of Vietnam. A total of 138 eligible DM outpatients were invited and a total of 112 patients who completed the questionnaire were utilized in this analysis using convenience sampling. DD was assessed using the diabetes distress scale (DDS). The participant’s sociodemographic and clinical information was obtained through face-to-face interviews and medical records. Multivariate logistic regression was used to determine independent factors associated with the presence of DD.

Results

Approximately, 12.5% of the patients experienced DD based on DDS self-administered questionnaire. The rates of mild/moderate and high distress were 8.0% and 4.5%, respectively. DD was found to be significantly higher in type 1 DM (p=0.04), insulin only in treatment regime (p=0.04), physical inactivities (p=0.02), times of mild hypoglycemia (time/month) (p=0.01), and fasting plasma glucose (mmol/l) (p=0.04). The occurrence of distress among DM patients was negatively correlated with their age and amount of physical exercise. Meanwhile, poor HbA1c control (HbA1c≥7%) was associated with an increased occurrence of diabetes distress.

Conclusion

The findings of single medical center in Vietnam highlights that DD is prevalent among DM patients. It should be of marked concerns, particularly the type 1 diabetic patients, younger age, and poor glycemic control patients.

The early impact of the COVID-19 pandemic on adults with type 1 or type 2 diabetes: A national cohort study

AIMS

To describe the effects of the COVID-19 pandemic on adults with T1D or T2D in the U.S.

METHODS

Participants, recruited from the Taking Control of Your Diabetes Research Registry, were ≥19 years old and diagnosed with either T1D or T2D for ≥12 months. Participants completed an online survey on a HIPAA-protected platform.

RESULTS

Completed surveys were received from 763 T1Ds and 619 T2Ds. Average T1D age was 53.3 (SD = 15.3); average T2D age was 64.9 (SD = 10.3). Both samples were predominantly female, non-Hispanic white and well-educated. Average self-reported HbA1c was 6.9 (SD = 1.0; 52 mmol/mol) for T1Ds and 7.1 (SD = 1.1; 54 mmol/mol) for T2Ds. About 40% of respondents reported that all of their diabetes healthcare appointments at the time were cancelled or postponed, 40% reported a switch to telehealth appointments and almost half reported lower overall satisfaction with these visits (compared to pre-pandemic). There were widespread increases in general and diabetes-related stress and social isolation, and negative effects on disease management. About 25% reported increases in highs, lows, and glucose variability in both groups.

CONCLUSION

There has been a substantive increase in level of diabetes-related and general life stress and social isolation due to the pandemic, with a significant impact on disease management.

Diabetes and COVID-19: psychosocial consequences of the COVID-19 pandemic in people with diabetes in Denmark-what characterizes people with high levels of COVID-19-related worries?

AIM

To map COVID-19-specific worries and overall psychosocial health among people with diabetes in the initial phase of the COVID-19 pandemic in Denmark, and to explore characteristics of people with diabetes and high levels of worries related to the COVID-19 pandemic.

METHODS

A cross-sectional survey was conducted by distributing online questionnaires to 2430 adult members (> 18 years) of two user panels consisting of people with diabetes who have volunteered to share information about their life with diabetes. The questionnaire included items on COVID-19-specific worries as well as such worries related to diabetes, sociodemographic and health status, social relations, diabetes-specific social support, diabetes distress and changes in diabetes-specific behaviours. Responses were analysed with descriptive statistics and logistic regressions.

RESULTS

People with diabetes have COVID-19-specific worries related to their diabetes. More than half were worried about being overly affected due to diabetes if infected with COVID-19, about one-third about being characterized as a risk group due to diabetes and not being able to manage diabetes if infected. Logistic regressions showed that being female, having type 1 diabetes, diabetes complications and diabetes distress, feeling isolated and lonely, and having changed diabetes behaviours were associated with being more worried about COVID-19 and diabetes.

CONCLUSION

People with diabetes have COVID-19-specific worries related to their diabetes which is associated with poorer psychosocial health. These worries should be addressed through support targeting specific questions and needs of individuals with diabetes as well as frequent updates on new knowledge regarding COVID-19 and diabetes.

Addressing a Care Gap in Type 1 Diabetes Management: Using the Diabetes Distress Scale in a Community Care Setting to Address Diabetes-Related Treatment Challenges

OBJECTIVES

To bridge the gap between existing clinical evidence and recommendations around screening for diabetes-related distress (DD) and the observation of a low level of adoption of these suggestions in everyday clinical practice. We focused on the use of the Diabetes Distress Scale (DDS) by adult diabetes care specialists.

METHODS

We conducted a survey of endocrinologists and diabetes educators in our clinics, examining the use of DD screening and assessment tools, including DDS-2, DDS-17 and T1-DDS-28.

RESULTS

Our results indicated that very few practitioners surveyed are currently using the DD questionnaires, and highlighted their perceptions of the primary barriers to doing so.

CONCLUSIONS

We discuss the results of our survey of colleagues' use of the DDS and provide suggestions about how to incorporate this tool, and tips about how to address the various facets of DD. We argue that integrating the assessment of DD in clinical practice, with the use of standardized and validated self-report questionnaires, is a necessary and very feasible step towards achieving further improvements in the health and quality of life of people living with type 1 diabetes.

Depression and Diabetes Distress in South Asian Adults Living in Low- and Middle-Income Countries: A Scoping Review

OBJECTIVES

In this study, we conducted a scoping review to identify the prevalence of both depression and diabetes distress in patients with type 2 diabetes in low- and middle-income countries in South Asia.

METHODS

This scoping review was grounded in the methodology of Arksey and O'Malley by searching for relevant studies using Ovid MEDLINE, PsycINFO and Cumulative Index of Nursing and Allied Health Literature databases, as well as grey literature sources and hand searches. Two reviewers independently screened and extracted data from articles that met the inclusion criteria.

RESULTS

A total of 46 studies were included, with only 1 addressing both depression and diabetes distress. We present 42 total articles on depression and 5 on diabetes distress. The prevalence of type 2 diabetes and elevated depressive symptoms ranged from 11.6% to 67.5%, whereas the prevalence of diabetes distress ranged from 18.0% to 76.2%.

CONCLUSIONS

The prevalence of elevated depressive symptoms was found to be much higher than that reported in data from high-income countries and in data on South Asians living in high-income countries. Diabetes distress was found to be lower compared with other studies; however, the scarcity of data makes this observation inconclusive. Variations in depression inventories, lack of culturally tailored inventories and the focus on urban clinic-based populations are identified as limitations and areas requiring further research. Our review provides evidence for the need of increased mental health screening and treatment in diabetes care in South Asian countries.

How Do the Challenges of Emerging Adulthood Inform our Understanding of Diabetes Distress? An Integrative Review

PURPOSE OF REVIEW

Emerging adulthood (ages 18-29) presents many emotional, social, and developmental challenges that can contribute to an increased sense of burden when managing type 1 diabetes (T1D). Diabetes distress (DD) is the concept that captures the emotional burden, frustrations, and worries resulting from living with T1D. This integrative review sets out to examine the impact of developmental context by answering this question: How do the challenges of emerging adulthood inform our understanding of DD?

RECENT FINDINGS

DD is highly prevalent in emerging adults and occurs at higher rates than in other age groups. Qualitative studies reveal that DD is embedded within the developmental challenges specific to living with T1D during this stage. Quantitative studies reveal the prevalence and correlates of DD in this age group, and qualitative studies augment these findings by capturing the scope and complexity of the emotional burden of living with T1D as an emerging adult.

Effectiveness of the Freestyle Libre Flash Glucose Monitoring System on Diabetes Distress Among Individuals with Type 1 Diabetes: A Prospective Study

AIM

To study and explore the intervention of the flash glucose monitoring system (FGMS) on diabetes-related distress (DRD) in children and adolescents with type 1 diabetes (T1D).

METHODS

A 12-week prospective study was performed from March 2019 to July 2019 involving 187 children and adolescents (age range 13-19 years; 56.7% female) with T1D who were self-testing their glucose levels using the conventional fingerprick method. At the time of the baseline visit, FGMS sensors were fixed by a trained diabetes educator onto each patient in the study population. A trained interviewer also administered the 28-item T1-Diabetes Distress Scale (T1-DDS) questionnaire to each participant at the baseline visit and again after 12 weeks to determine the T1-DDS score.

RESULTS

Comparison of the baseline (fingerprick) data with data collected at 12 weeks after the patients had switched to the FGMS revealed a significant decrease in the subdomains of the T1-DDS as follows: powerlessness (p = 0.0001); management distress (p = 0.0001); hypoglycemia distress (p = 0.0001); negative social perceptions (p = 0.0001); eating (p = 0.0001); physician distress (p = 0.0001); friend/family distress (p = 0.0001); and total T1-DDS score (p = 0.0001). Similarly, analysis of the data revealed that there was also a substantial drop from baseline to 12 weeks after initiation of the intervention in the clinical variables assessed, such as glycosylated hemoglobin; specifically, there was a considerable decrease after 12 weeks in the frequency of hypoglycemia. Interestingly, the frequency of glucose monitoring also showed an upswing among users of the FGMS.

CONCLUSION

The outcomes of this study clearly demonstrate that once the patients had been switched from the fingerprick method to FGMS, the DRD and related clinical parameters showed remarkable improvement. However, further studies are necessary to determine whether the continued and consistent use of the FGMS will achieve better results.

Twenty-five years of diabetes distress research

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

High Diabetes Distress Among Ethnic Minorities Is Not Explained by Metabolic, Cardiovascular, or Lifestyle Factors: Findings From the Dutch Diabetes Pearl Cohort

OBJECTIVE

Diabetes distress among patients from ethnic minorities is still poorly understood. We investigated the association between ethnicity and diabetes distress among ethnic minority groups of people with type 2 diabetes in the Netherlands, focusing on the possible effects of glycemic control, lifestyle factors, cardiovascular risk factors, and diabetes complications.

RESEARCH DESIGN AND METHODS

Cross-sectional data from the Dutch Diabetes Pearl cohort included people with type 2 diabetes from primary, secondary, and tertiary diabetes care programs. We used the 20-item Problem Areas in Diabetes Survey (PAID) scale to assess diabetes distress; a score ≥40 is considered to represent high distress. Ethnicity was estimated on the basis of country of birth. Sociodemographic and lifestyle data were self-reported; cardiovascular and metabolic data were retrieved from medical charts. Logistic regression analysis determined the association between ethnicity and diabetes distress, with Caucasians as the reference group.

RESULTS

Diabetes distress scores and ethnicity were available for 4,191 people with type 2 diabetes: 3,684 were Caucasian, 83 were Asian, 51 were Moroccan, 92 were African, 134 were Latin American, 46 were Turkish, and 101 were Hindustani-Surinamese. Overall, participants in minority groups had worse health outcomes than those of Caucasian descent, and diabetes distress was more prevalent (ranging from 9.6 to 31.7%, compared with 5.8% among Caucasians), even after adjusting for age, sex, education level, alcohol use, smoking, BMI, lipid profile, HbA_1c, medication use, and the presence of diabetes complications.

CONCLUSIONS

Among people with type 2 diabetes in the Netherlands, ethnicity is independently associated with high diabetes distress. Further research is warranted to explain the higher prevalence of diabetes distress in minority groups and to develop effective interventions.

Depression and diabetes distress in adults with type 2 diabetes: results from the Australian National Diabetes Audit (ANDA) 2016

This study explores the prevalence of, and factors associated with, likely depression and diabetes distress in adults with type 2 diabetes in a large, national sample. Australian National Diabetes Audit data were analysed from adults with type 2 diabetes attending 50 diabetes centres. The Brief Case find for Depression and Diabetes Distress Score 17 were administered to screen for likely depression and diabetes-related distress, respectively. A total of 2,552 adults with type 2 diabetes participated: (mean ± SD) age was 63 ± 13 years, diabetes duration was 12 ± 10 years, and HbA1c was 8 ± 2%. Twenty-nine percent of patients had likely depression, 7% had high diabetes distress, and 5% had both. Difficulty following dietary recommendations, smoking, forgetting medications, and diabetes distress were all associated with greater odds of depression whereas higher own health rating was associated with lower odds (all p < 0.02). Female gender, increasing HbA1c, insulin use, difficulty following dietary recommendations and depression were all associated with greater odds of diabetes distress & older age, higher own health rating and monitoring blood glucose levels as recommended were associated with lower odds (all p < 0.04). Depression was associated with sub-optimal self-care, while diabetes distress was associated with higher HbA1c and sub-optimal self-care.

Evaluating the relationships of hypoglycaemia and HbA1c with screening-detected diabetes distress in type 1 diabetes

AIMS

To explore the relationship between diabetes distress, glucose control and awareness of hypoglycaemia in adults with type 1 diabetes.

METHODS

We performed a cross-sectional study using data collected from 280 consecutive type 1 diabetes patients who used a routine clinic consultation tool that recorded HbA1c, hypoglycaemia awareness (measured using the Gold score) and diabetes distress (measured using the Diabetes Distress Scale 2 [DDS2]). We assessed correlations between DDS2 and HbA1c and DDS2 and Gold score and performed an ordinal regression analysis to identify factors contributing to distress.

RESULTS

Diabetes distress was significantly correlated with HbA1c (r = .319, P < .001) and Gold score (r = .258, P < .001) independently and with synergistic effect. Female gender was also associated with diabetes distress, while age, BMI, duration of diabetes, severity of complications and use of CSII pumps were not. Occurrence of severe hypoglycaemia (SH) episodes increased with Gold score in a linear manner throughout the scale.

CONCLUSIONS

This study has identified new evidence of a significant, independent relationship between diabetes distress measured by the DDS2 and reduced awareness of hypoglycaemia in people with type 1 diabetes. It also demonstrates that diabetes distress is significantly associated with HbA1c and female gender independently. The DDS2 identifies distress associated with both hypo- and hyperglycaemia and can be a useful creening tool. Additionally, the occurrence of SH increases with increasing Gold score.

Adolescent life with diabetes-Gender matters for level of distress. Experiences from the national TODS study

OBJECTIVE

To examine the relationship between diabetes distress and gender, and the association with glycemic control, social support, health behaviors, and socio-economic status.

METHODS

All adolescents, aged 15 to 18 years, in the national, pediatric diabetes registry SWEDIABKIDS with type 1 diabetes were invited to complete an online questionnaire. A total of 2112 teenagers were identified.

RESULTS

453 complete responses were valid for analyses. Young women scored significantly higher on the distress-screening instrument DDS-2. Almost half of the female respondents exhibited moderate to severe diabetes distress-more than twice the proportion than among male respondents (44% vs 19%). Females reported twice as high scores on the fear of hypoglycemia scale (P < 0.0001) and had a higher HbA1c value than males (P < 0.0001). Gender was highly correlated with distress level even when controlling for multiple factors that may affect distress (parameter_female  = 0.4, P = 0.0003). Particular social problems were highly significant, that is, those who trust that their parents can handle their diabetes when necessary were significantly less distressed than others (P = 0.018). Higher HbA1c levels were associated with higher distress scores (P = 0.0005 [female], P = 0.0487 [male]).

CONCLUSIONS

Diabetes-related distress is a great burden for adolescents living with diabetes. Actively involved family and friends may reduce diabetes distress, but female adolescents appear to be particularly vulnerable and may need extra focus and support. Our findings indicate that pediatric diabetes teams working with teenagers must intensify the care during this vulnerable period of life in order to reduce the risk of both psychological and vascular complications in young adults.

Psychosocial aspects of diabetes management: dilemma of diabetes distress

Diabetes mellitus (DM) is a debilitating chronic illness with complex pathophysiological, psychological, and quality of life (QoL) implications creating a constant state of turbulence. Some of these interconnections are apparent to healthcare providers and are easily addressed in a routine diabetic clinical care. However, a large number of these hidden factors that interplay with each other and impact on the physical outcomes of DM goes unnoticed by health care providers. This is a frustrating and lonely predicament for DM patients making it very difficult for them to manage their illness well. At times these patients are mislabeled as "difficult patients". In other cases they are considered to have and unnecessarily treated for psychiatric illness like depression, other mood or anxiety spectrum disorders which they may not need. In recent years clinical researcher are making strides in understanding the emotional distress a DM patient may feel and the factors contributing or perpetuating diabetes distress. This article focuses on understanding the diabetes distress and how it impacts our patients, how to screen, assess, treat and eventually prevent it from happening. The paper also attempt to bring out the major differences between diabetes distress and common psychiatric comorbidities of DM including but not limiting to major depressive disorder and other depression spectrum disorders.

Diabetes distress is linked with worsening diabetes management over time in adults with Type 1 diabetes

AIM

To determine the cross-sectional and longitudinal associations between diabetes distress and diabetes management.

METHODS

In a non-interventional study, 224 adults with Type 1 diabetes were assessed for diabetes distress, missed insulin boluses, hypoglycaemic episodes, and HbA_1c at baseline and 9 months.

RESULTS

At baseline, greater distress was associated with higher HbA_1c and a greater percentage of missed insulin boluses. Longitudinally, elevated baseline distress was related to increased missed insulin boluses, and decreases in distress were associated with decreases in HbA_1c . In supplementary analyses, neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA_1c or hypoglycaemic episodes in cross-sectional or longitudinal analyses.

CONCLUSIONS

Significant cross-sectional and longitudinal associations were found between diabetes distress and management; in contrast, no parallel associations were found for major depressive disorder or depression symptoms. Findings suggest that elevated distress may lead to more missed insulin boluses over time, suggesting a potential intervention target. The covarying association between distress and HbA_1c points to the complex and likely interactive associations between these constructs. Findings highlight the need to address distress as an integral part of diabetes management in routine care.

Translation, Revision, and Validation of the Diabetes Distress Scale for Indonesian Type 2 Diabetic Outpatients with Various Types of Complications

OBJECTIVES

To translate, revise, and validate the Diabetes Distress Scale (DDS) instrument for Indonesian type 2 diabetes mellitus (T2DM) outpatients with various complications.

METHODS

Participants were recruited from four hospitals and two primary health care centers. The study was performed with forward and backward translations, an adaptation testing with a small subset of participants, and validation analysis. Factor analysis with maximum likelihood estimation and promax rotation was then used to investigate the instrument structure. Internal consistency among the items was estimated using Cronbach α for each domain of the DDS.

RESULTS

In total, 324 participants (246 from the hospitals and 78 from the primary health care centers) were involved in this study. To improve participant comprehension of the exact meaning of questions, examples of daily activities for patients with T2DM (e.g., diet, exercise, and adherence to therapy) were added to some questions after the translation and revision procedures. The factor analysis revealed a correlation among the four factors ranging from 0.40 to 0.67. The factor loadings of selected items from the four factors ranged from 0.41 to 0.98. The order of the four factors in the factor analysis was as follows: interpersonal distress, emotional burden, physician distress, and regimen distress. The internal consistency for the four domains ranged from 0.78 to 0.83. The instrument resulting from this study was labeled "DDS17 Bahasa Indonesia."

CONCLUSIONS

The DDS17 Bahasa Indonesia provides an initial psychometric validation study, factor structure, and internal consistency for assessing the distress of Indonesian T2DM outpatients. Use of this instrument in future research and clinical trials is recommended for the Indonesian context.