Determinants of adherence to insulin and blood glucose monitoring among adolescents and young adults with type 1 diabetes in Qatar: a qualitative study

Background

Adherence to insulin and blood glucose monitoring (BGM) is insufficient in adolescents and young adults (AYAs) with type 1 diabetes (T1D) worldwide and in Qatar. Little is known about the factors related to being aware of suboptimal adherence and the beliefs related to suboptimal adherence in this group. This qualitative study investigated factors related to awareness of, and beliefs about suboptimal adherence, as well as the existence of specific action plans to combat suboptimal adherence using the I-Change model.

Methods

The target group was comprised of 20 Arab AYAs (17-24 years of age) with T1D living in Qatar. Participants were interviewed via semi-structured, face-to-face individual interviews, which were audio-recorded, transcribed verbatim, and analyzed using the Framework Method.

Results

Suboptimal adherence to insulin, and particularly to BGM, in AYAs with T1D was identified. Some AYAs reported to have little awareness about the consequences of their suboptimal adherence and how this can adversely affect optimal diabetes management. Participants also associated various disadvantages to adherence ( e.g., hypoglycemia, pain, among others) and reported low self-efficacy in being adherent ( e.g., when outside home, in a bad mood, among others). Additionally, goal setting and action-planning often appeared to be lacking. Factors facilitating adherence were receiving support from family and healthcare providers, being motivated, and high self-efficacy.

Conclusions

Interventions that increase awareness concerning the risks of suboptimal adherence of AYAs with T1D are needed, that increase motivation to adhere by stressing the advantages, creating support and increasing self-efficacy, and that address action planning and goal parameters.

Personalized Digital Health Information to Substantiate Human-Delivered Exercise Support for Adults With Type 1 Diabetes

OBJECTIVE

Pilot-test personalized digital health information to substantiate human-delivered exercise support for adults with type 1 diabetes (T1D).

DESIGN

Single-group, 2-week baseline observation, then 10-week intervention with follow-up observation.

SETTING

Community-based sample participating remotely with physician oversight.

PARTICIPANTS

Volunteers aged 18 to 65 years with T1D screened for medical readiness for exercise intervention offerings. N = 20 enrolled, and N = 17 completed all outcomes with 88% to 91% biosensor adherence.

INTERVENTION

Feedback on personalized data from continuous glucose monitoring (CGM), its intersection with other ecological data sets (exercise, mood, and sleep), and other informational and motivational elements (exercise videos, text-based exercise coach, and self-monitoring diary).

MAIN OUTCOME MEASURES

Feasibility (use metrics and assessment completion), safety (mild and severe hypoglycemia, and diabetic ketoacidosis), acceptability (system usability scale, single items, and interview themes), and standard clinical and psychosocial assessments.

RESULTS

Participants increased exercise from a median of 0 (Interquartile range, 0-21) to 64 (20-129) minutes per week ( P = 0.001, d = 0.71) with no severe hypoglycemia or ketoacidosis. Body mass index increased (29.5 ± 5.1 to 29.8 ± 5.4 kg/m 2 , P = 0.02, d = 0.57). Highest satisfaction ratings were for CGM use (89%) and data on exercise and its intersection with CGM and sleep (94%). Satisfaction was primarily because of improved exercise management behavioral skills, although derived motivation was transient.

CONCLUSIONS

The intervention was feasible, safe, and acceptable. However, there is a need for more intensive, sustained support. Future interventions should perform analytics upon the digital health information and molecular biomarkers (eg, genomics) to make exercise support tools that are more personalized, automated, and intensive than our present offerings.

Persons with Diabetes' Perceptions of Family Burden and Associated Factors

BACKGROUND

Families of a person with diabetes play a vital part in diabetes management since their support helps with regimen engagement in self-management behaviors. However, focal information on the family burden of diabetes is lacking. This study is aimed at, therefore, assessing the persons with diabetes' perceptions of family burden and associated factors at a university hospital.

METHODS AND MATERIALS

A facility-based cross-sectional study design was conducted from July 26 to September 26, 2021on 403 persons' with diabetes attending Jimma Medical Center diabetic clinic, the study sample was selected using a simple random sampling method. The data was collected using the Zarit burden questionnaire through face-to-face interviews. Descriptive statistics (mean, standard deviation, frequency, and percentages) were ordered logistic regression, and statistical significance was declared at P value ≤0.05. Results and Discussion. About 36.8% of the patient was in mild to moderate family burden of diabetes. Farmer (AOR 5.419; CI: 1.18, 24.872), living with partners and family (AOR: 0.110, CI: 0.018, 0.659), comorbidity (AOR 5.419; CI: 1.18, 24.872), oral hypoglycemic agent (AOR: 0.380, CI: 0.191, 0.758), and being never hospitalized before because of diabetes (AOR: 0.044, CI: 0.003, 0.571) was statistically associated with a family burden.

CONCLUSION

About one-fourth of diabetic patient-perceived mild to the moderate family burden of diabetes, persons with diabetes who work as farmers and have comorbidities have a higher opinion of family burden, whereas those who live with partners or family members, use oral hypoglycemic medications, and have never been hospitalized for diabetes have a lower view of family burden due to diabetes. The results of this study suggest that strategies for health promotion, intervention, and prevention of diabetes at the family level should consider the interaction between family member burden and the patient's sociodemographic and disease-related factors. A further large-scale study is required to validate these findings.

Cost-Effectiveness Analysis of Flash Glucose Monitoring System for People with Type 2 Diabetes Receiving Intensive Insulin Treatment

AIMS

For people with type 2 diabetes (T2D) on intensive insulin therapy, the use of flash continuous glucose monitoring ("flash monitoring") is associated with improved average glucose control and/or reduced hypoglycemic exposure. This study assessed the cost-effectiveness of flash monitoring versus traditional blood glucose monitoring (BGM) in people with T2D using intensive insulin in the United Kingdom (UK).

METHODS

The IQVIA CORE Diabetes Model (IQVIA CDM; v9.0) was used to analyze the impact of flash monitoring versus BGM over a 40-year time horizon from the UK payer perspective. Model inputs included baseline characteristics, intervention effects, resource utilization, costs, and utilities, based on recently published literature and national databases. UK National Health Service reimbursed costs of flash monitoring and BGM were used. An intervention-related health utility was obtained from a time trade-off study. Alternative scenarios were explored to assess the impact of key assumptions on base case results.

RESULTS

In base-case analysis, flash monitoring compared with BGM resulted in an incremental cost of £5781 and an additional 0.47 quality-adjusted life years (QALYs). This provides an incremental cost-effectiveness ratio (ICER) of £12,309/QALY. HbA1c and the intervention-related health utility were the key drivers of differentiation. All scenario analyses, including different discount rates, time horizons, effects on HbA1c and on the intervention-related health utility, as well as glycemic emergencies, generated ICERs of less than £20,000 per QALY.

CONCLUSIONS

The consistent results across base case and a range of scenario analyses indicate that long-term flash glucose monitoring use is cost-effective compared with BGM in a UK population of T2D on intensive insulin therapy based on updated clinical effects and a cost-effectiveness threshold of £20,000-30,000 per QALY.

Factors Related to Diabetes Self-Management Among Patients with Type 2 Diabetes: A Chinese Cross-Sectional Survey Based on Self-Determination Theory and Social Support Theory

PURPOSE

Self-management behavior (SMB) plays a significant role in glycemic control. This study aimed to explore the factors related to SMB among patients with type 2 diabetes and how these factors interacted with each other.

PATIENTS AND METHODS

Patients diagnosed with type 2 diabetes were recruited from 18 community healthcare stations (CHSs) from six community healthcare centers (CHCs) in Beijing, China from April to May in 2017. Motivation, competence, autonomy support, social support, self-management skills, adherence to self-monitoring of blood glucose (SMBG) and haemoglobin A1c (HbA1c) measurement were tested by questionnaire. Correlation analysis and path analysis were performed so as to identify the factors associated with patients' SMB.

RESULTS

A total of 532 participants completed this study. Participants who have good compliance to SMBG got higher scores in social support (F = 7.68, p = 0.01), competence (F = 10.47, p = 0.01), and skills (F = 12.34, p < 0.01). Higher competence (β = 0.03, P < 0.001), higher social support (β = 0.01, P < 0.001), better skills(β = 0.01, P < 0.001) directly led to better adherence to SMBG. Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to SMBG. Better self-management skills directly led to better adherence to HbA1c measurement (β = 0.03, P < 0.001). Social support had a positive effect on autonomy support (β = 0.69, P < 0.001), motivation (β = 0.45, P < 0.001), competence (β = 0.28, P < 0.001), skills (β = 0.14, P < 0.001), which was also indirectly linked to better adherence to HbA1c measurement.

CONCLUSION

Self-determination theory and social support theory were practical in explaining SMB in Chinese population. Competence, motivation and social support played an important role in diabetic self-management. Paying attention to the promotion of individual's intrinsic motivation and self-efficacy may be able to help patients maintain self-management behavior in the long-term routine.

Factors Associated with Adherence to Self-Monitoring of Blood Glucose Among Young People with Type 1 Diabetes in China: A Cross-Sectional Study

BACKGROUND

Self-monitoring of blood glucose (SMBG) plays a crucial role in the maintenance of glycemic control in young people with type 1 diabetes mellitus (T1DM), but most of them do not perform SMBG as recommended. Few studies comprehensively explored factors that correlate with adherence to SMBG among this population on the basis of a framework. Hence, the aims of this study were to describe adherence to SMBG among young people with T1DM in China and explore its associating factors according to the Self and Family Management (SFM) framework.

METHODS

A cross-sectional study was conducted on young people with T1DM in Hunan Province of China from July to August 2020. Based on the SFM framework, self-reported questionnaires were organized for the collection of data on adherence to SMBG, socio-demographic and clinical factors, resources, health care system, and personal factors. Factors associated with adherence to SMBG were determined through multivariate logistic regression analysis.

RESULTS

A total of 165 young people were invited, of which 122 (73.9%) completed the questionnaires. The mean age was 12.41 years (SD = 3.18), and the proportion of young people who adhered to SMBG was 53.3%. Multivariate logistic regression analysis revealed that children aged 8-12 years (OR = 0.188, P = 0.002), from two-parent families (OR = 0.232, P = 0.019), and with better personal factors (eg, with more information of SMBG, OR = 1.072, P = 0.020; lower diabetes-related worry, OR = 0.917, P = 0.031; higher level of pain during SMBG, OR = 1.852, P = 0.001), had better adherence to SMBG.

CONCLUSION

Nearly half of the young people with T1DM were not adherent to SMBG in China. Clinicians need to pay more attention to adolescents from single-parent families with regard to their adherence to SMBG. Providing management strategies of SMBG, including delivering SMBG-related information, decreasing diabetes-related worry, and relieving pain related to SMBG, may improve adherence.

Barriers and facilitators of self-monitoring of blood glucose engagement among women with gestational diabetes mellitus in China: A mixed-methods study

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a crucial tool for maintaining glycemic control in women with gestational diabetes mellitus (GDM). However, to date, little is known about the current status of SMBG engagement among women with GDM in China.

OBJECTIVE

To describe the current status of SMBG engagement among women with GDM in China and identify its barriers and facilitators.

DESIGN AND SETTING

A mixed-methods design was conducted, comprising a cross-sectional survey and semi-structured interviews. The research data were collected in two tertiary hospitals in Hunan province, China.

PARTICIPANTS

A total of 323 women with GDM completed the survey from March 2018 to October 2018, and 11 of them participated in the interviews.

FINDING

In total, 35.6% of the participants actively engaged in SMBG. The participants who had an advanced maternal age (95% CI 0.253-0.947), did not own glucose meters (95% CI 0.054-0.364), did not receive SMBG-related information from health professionals (95% CI 0.232-.987), or received less SMBG information in general (95% CI 0.137-0.52) were less likely to engage in SMBG. Insufficient SMBG information and low awareness of SMBG were also summarized as the main barriers in the interview findings. Facilitators of SMBG engagement included SMBG-related social support (95% CI 1.573-6.135) and health concerns related to themselves and the unborn infant.

CONCLUSION

About one-third of Chinese women with GDM engaged in SMBG. An accurate and complete description of how SMBG should be performed is needed from health professionals. Strategies to obtain more SMBG-related social support and a greater emphasis on health concerns are recommended to increase SMBG engagement among women with GDM in China.

The development of My Care Hub Mobile-Phone App to Support Self-Management in Australians with Type 1 or Type 2 Diabetes

Non-adherence to self-management poses a serious risk to diabetes complications. Digital behavioural change interventions have the potential to provide education and motivate users to regularly engage with self-management of diabetes. This paper describes the development of My Care Hub mobile phone application (app) aimed at supporting self-management in people with type 1 or type 2 diabetes. The development of My Care Hub involved a comprehensive process of healthy behavioural change identification, end users’ needs, expert consensus, data security and privacy considerations. The app translation was a highly iterative process accompanied by usability testing and design modification. The app development process included: (1) behaviour change strategy selection; (2) users’ involvement; (3) expert advisory involvement; (4) data security and privacy considerations; (5) design creation and output translation into a smartphone app and (6) two usability testings of the app prototype version. The app features include self-management activities documentation, analytics, personalized and generalized messages for diabetes self-management as well as carbohydrate components of common foods in Australia. Twelve respondents provided feedback on the usability of the app. Initially, a simplification of the documentation features of the app was identified as a need to improve usability. Overall, results indicated good user satisfaction rate.

The use of mobile technology to facilitate self-management in adults with type 1 diabetes: A qualitative explorative approach

AIMS

(a) To explore how mobile technology can support self-management in adults with type 1 diabetes (T1DM). (b) To inform a usability study in the design of a mobile application to facilitate self-management of T1DM.

DESIGN

Qualitative exploratory design.

METHODS

Semi-structured interviews were undertaken with adults with T1DM (N = 8). The data collected were analysed using a thematic analysis approach.

RESULTS

Mobile technology has the potential to support adults in their self-management of T1DM through facilitating their decision-making, saving time and enabling them to easily share their data with their healthcare professional. Participants identified four main visualization characteristics for technology to aid in decision-making; relationships between inputs, trends, graphs and colours, and identified essential features such as ease of use, convenience and connectivity.

The Cost-effectiveness of a Flash Glucose Monitoring System for Management of Patients with Type 2 Diabetes Receiving Intensive Insulin Treatment in Sweden

Flash glucose monitoring, an alternative to traditional self-monitoring of blood glucose (SMBG), prevents hypoglycaemic events without impacting glycated haemoglobin (REPLACE trial). Given the potential benefits, this study assessed the cost-effectiveness of using flash monitoring versus SMBG alone in patients with type 2 diabetes (T2D) receiving intensive insulin treatment in Sweden.Methods: This study used the IQVIA CORE Diabetes Model (IQVIA CDM, v8.5) to simulate the impact of flash monitoring versus SMBG over 40 years from the Swedish societal perspective. Baseline characteristics, intervention effects, and resource utilisation were derived from REPLACE; literature and Tandvårds-Läkemedelförmånsverket (TLV) sources informed utilities and costs. Scenario analyses explored the effect of key base case assumptions. Results: In base case analysis, direct medical costs for flash monitoring use were SEK1,630,586 (€158,523) versus SEK1,459,394 (€141,902) for SMBG use. Flash monitoring led to 0.56 additional quality-adjusted life years (QALYs; 6.21 versus 5.65 SMBG) for an incremental cost-effectiveness ratio (ICER) of SEK306,082/QALY (€29,762/QALY). ICERs for all scenarios remained under SEK400,000/QALY (€38,894/QALY). Conclusions: Hypoglycaemia and health utility benefits due to flash glucose monitoring may translate into economic value compared to SMBG. With robust results across scenario analyses, flash monitoring may be considered cost-effective in a Swedish population of T2D intensive insulin users.

Cost-effectiveness Analysis of a Flash Glucose Monitoring System for Patients with Type 1 Diabetes Receiving Intensive Insulin Treatment in Sweden

Flash glucose monitoring - an alternative to traditional self-monitoring of blood glucose (SMBG) - prevents hypoglycaemic events without impacting glycated haemoglobin (HbA1c).21 Given the potential benefits, this study assessed the cost-effectiveness of using flash monitoring versus SMBG alone in patients with type 1 diabetes (T1D) receiving intensive insulin treatment in Sweden. Methods: This study used the IQVIA CORE Diabetes Model (IQVIA CDM, v9.0) to simulate the impact of flash monitoring versus SMBG over 50 years from the Swedish societal perspective. Trial data informed cohort data, intervention effects, and resource utilisation; literature and Tåndvards-Läkemedelförmånsverket (TLV) sources informed utilities and costs. Scenario analyses explored the effect of key base case assumptions. Results: In base case analysis, direct medical costs for flash monitor use were SEK1,222,333 versus SEK989,051 for SMBG use. Flash monitoring led to 0.80 additional quality-adjusted life years (QALYs; 13.26 versus 12.46 SMBG) for an incremental cost effectiveness ratio (ICER) of SEK291,130/QALY. ICERs for all scenarios remained under SEK400,000/QALY. Conclusion: Hypoglycaemia and health utility benefits due to flash glucose monitoring may translate into economic value compared to SMBG. With robust results across scenario analyses, flash monitoring may be considered cost-effective in a Swedish population of T1D intensive insulin users.

The Effect of Reduced Self-Monitored Blood Glucose Testing After Adoption of Continuous Glucose Monitoring on Hemoglobin A1c and Time in Range

The effectiveness of real-time continuous glucose monitoring (rtCGM) in adults with diabetes treated with insulin injections was evaluated in the 24-week DIAMOND clinical trial comparing rtCGM users to a control group using self-monitored blood glucose (SMBG) testing ( Clinicaltrials.gov : NCT02282397). All participants were instructed to use SMBG results for diabetes management decisions; however, SMBG testing frequency varied within the rtCGM group. This brief report evaluated how SMBG frequency changes in the rtCGM group were correlated with glycemic outcomes in the same trial. Baseline and end-of-study hemoglobin A1c (HbA1c) levels, percentages of CGM values in the 70-180 mg/dL target range (time in range [TIR]), mean of daily differences (MODD), and glycemic coefficients of variation (CVs) were compared. The rtCGM group analyzed included 175 participants-99 with type 1 diabetes (T1D) and 76 with type 2 diabetes (T2D). When comparing participants whose SMBG testing frequency decreased by >1/day versus ≤1/day, mean change in HbA1c was similar (-0.9 ± 0.7 percentage points in both groups, P = 0.59), as was change in TIR (+3.9 ± 14.3 vs. +5.7 ± 13.7 percentage points, respectively, P = 0.39). Likewise, when comparing participants in the highest and lowest quartiles of SMBG frequency reduction (≥2.2 vs. ≤0.4 fewer tests/day, respectively), changes in HbA1c (-0.8 ± 0.6 vs. -0.9 ± 0.6 percentage points, respectively, P = 0.52) and TIR (+4.8 ± 13.2 vs. +5.6 ± 12.7 percentage points, respectively, P = 0.98) were similar. The mean (standard deviation [SD]) change in MODD was -8.3 mg/dL (14.8) and -5.5 mg/dL (14.7) for participants who reduced their SMBG frequency by >1 test/day and ≤1 test/day, respectively; the mean (SD) change in CV was -3.6% (5.0) and -1.6% (5.1) for participants who reduced their SMBG frequency by >1 test/day and ≤1 test/day, respectively. These findings suggest that individuals who decrease the frequency of SMBG testing can effectively base some of their diabetes-related treatment decisions on glucose concentrations, trend information, and alarms provided by their rtCGM systems.

Self-monitoring of blood glucose in insulin-treated diabetes: a multicase study

OBJECTIVE

To explore how and why self-monitoring of blood glucose (SMBG) is carried out in a real-world context.

RESEARCH DESIGN AND METHODS

We conducted a multicase study among ten people with type 1 and insulin-treated type 2 diabetes mellitus in Scotland, alongside seven nominated support people and four healthcare professionals. All participants were interviewed in depth and six participants provided SMBG diaries. Stones' version of structuration theory informed the analysis.

RESULTS

People with diabetes were able to provide immediate motives for SMBG at particular times, often having different motives on different occasions. We identified six such motives, including routine, in response to symptoms, associated with a diabetes review, to facilitate lifestyle, when a 'good' result was expected, and higher level motives for longer term glycemic control. These motives were influenced by underlying attitudes toward diabetes that included level of engagement and responsibility for diabetes, a desire not to be controlled by diabetes, resistance to diabetes, diabetes education and relationship with the health service, fear of hypoglycemia, and prevention of diabetes complications. Five responses to test results were identified, depending on the immediate motive and underlying attitudes.

CONCLUSIONS

People with insulin-treated diabetes do not necessarily self-monitor with an explicit goal of improving long-term glycemic control, but may have other motives that are important to them. An individualized understanding is therefore needed to advise people with diabetes how SMBG can be optimized for them.

Association between mindfulness and interoceptive accuracy in patients with diabetes: Preliminary evidence from blood glucose estimates

OBJECTIVE

Mindfulness-based interventions, which increase dispositional mindfulness, may be useful adjunctive therapies for patients with chronic diseases, including diabetes. One way that mindfulness may benefit patients with diabetes is by fostering more accurate interoception, particularly in the form of blood glucose estimate accuracy. Many people with diabetes regulate their behavior based on estimates of their blood glucose levels from interoception, but they vary in estimate accuracy. Therefore, our objective was to conduct a preliminary test of the hypothesis that, in a sample of patients with diabetes, more mindful individuals would demonstrate greater blood glucose estimate accuracy.

METHODS

In a cross-sectional study, patients (N=28) with type 2 diabetes estimated their blood glucose levels immediately before their actual levels were assessed. Participants also completed two measures of mindfulness: one assessing general dispositional mindfulness and another assessing mindfulness specifically in the face of difficulty.

RESULTS

Although general dispositional mindfulness was unrelated to blood glucose estimate accuracy, individuals who reported more mindfulness during difficulties were approximately four times more likely to meet established accuracy criteria.

CONCLUSIONS

Mindfulness specifically during difficulties might play a role in disease-relevant interoception for patients with diabetes. Future research should aim to replicate this finding in larger and different samples, and to examine the potential role of mindfulness during difficulties in mindfulness-based interventions for patients with diabetes.

Effect of a Health Literacy-Considered Diabetes Self-Management Program for Older Adults in South Korea

The current randomized controlled study evaluated the effects of a health literacy-considered diabetes self-management program on diabetes-related parameters: diabetes self-management knowledge (DSK), diabetes health beliefs (DHB), diabetes self-efficacy (DSE), diabetes self-management behavior (DSMB), and diabetes biomarkers. Fifty-one Korean older adults with diabetes completed 12 weekly sessions that were developed based on their health literacy and health-related characteristics. The results indicate significant posttest differences between groups in DSK (p = 0.046), DSE (p = 0.046), DSMB (p = 0.012), and the DSMB self-monitored blood glucose subscale (p = 0.002). Significant pre-post changes between groups were observed in the DHB benefit subscale (p = 0.043), DSE (p = 0.006), DSMB (p = 0.008), DSMB diet (p = 0.029), and the self-monitored blood glucose subscale (p < 0.001). A significant pre-post difference was observed in the intervention group's HbA1c levels (p = 0.008). The program effectively improved participants' DSK, DHB, DSE, and DSMB values, which may be helpful for improving HbA1c levels. [Res Gerontol Nurs. 2017; 10(5):215-225.].

Type 1 diabetes mellitus care and education in China: The 3C study of coverage, cost, and care in Beijing and Shantou

AIMS

The paucity of data on Type 1 diabetes in China hinders progress in care and policy-making. This study compares Type 1 diabetes care and clinical outcomes in Beijing and Shantou with current clinical guidelines.

METHODS

The 3C Study was a cross-sectional study of the clinical practices and outcomes of people with Type 1 diabetes. The study sequentially enrolled 849 participants from hospital records, inpatient wards, and outpatient clinics. Data were collected via face-to-face interviews with patients and health professionals, the Summary of Diabetes Self-Care Activities, medical records, and venous blood samples. Care was audited using ISPAD/IDF indicators. Data underwent descriptive analysis and tests for association.

RESULTS

The median age was 22years (IQR=13-34years), and 48.4% of the sample had diabetes less than six years. The median HbA1c was 8.5% (69mmol/mol) (IQR 7.2-10.5%), with significant regional variance (p=0.002). Insulin treatment was predominantly two injections/day (45% of patients). The highest incidence of diabetic ketoacidosis was 14.4 events/100 patient years among adolescents. Of the 57.3% of patients with LDL-C>2.6mmol/L, only 11.2% received treatment. Of the 10.6% considered hypertensive, 47.1% received treatment. Rates of documented screening for retinopathy, nephropathy, and peripheral neuropathy were 35.2%, 42.3%, and 25.0%, respectively. The median number of days of self-monitoring/week was 3.0 (IQR=1.0-7.0). There were significant differences in care practices across regions.

CONCLUSIONS

The study documented an overall deficit in care with significant regional differences noted compared to practice guidelines. Modifications to treatment modalities and the structure of care may improve outcomes.

Behavioral Analysis of Chinese Adult Patients with Type 1 Diabetes on Self-monitoring of Blood Glucose

BACKGROUND

The information-motivation-behavioral skills (IMB) model of health behavior is an effective tool to evaluate the behavior of diabetes self-management. The purpose of this study was to explore behavioral factors affecting the practice of self-monitoring of blood glucose (SMBG) within the frame of IMB model of health behavioral among adult patients with type 1 diabetes in a single diabetes clinic in China.

METHODS

A questionnaire with three subscales on SMBG information, motivation, and behavioral skills based on IMB model was developed. Validity and reliability of the measures were examined and guaranteed. Adult patients with type 1 diabetes visiting our diabetes clinic from January to March 2012 (n = 55) were consecutively interviewed. The self-completion questionnaires were administered and finished at face-to-face interviews among these patients. Both descriptive and correlational analyses were made.

RESULTS

Fifty-five patients finished the questionnaires, with the median duration of diabetes 4.5 years and the median of SMBG frequency 2.00. Specific SMBG information deficits, motivation obstacles, and behavioral skill limitations were identified in a substantial proportion of participants. Scores of SMBG motivation (r = 0.299, P= 0.026) and behavioral skills (r = 0.425, P= 0.001) were significantly correlated with SMBG frequency. The multiple correlation of SMBG information, SMBG motivation, and SMBG behavioral skills with SMBG frequency was R = 0.411 (R2 = 0.169, P= 0.023).

CONCLUSIONS

Adult patients with type 1 diabetes in our clinic had substantial SMBG information deficits, motivation obstacles, and skill limitations. This information provided potential-focused education targets for diabetes health-care providers.

Patient perceptions of a comprehensive telemedicine intervention to address persistent poorly controlled diabetes

OBJECTIVE

We studied a telemedicine intervention for persistent poorly controlled diabetes mellitus (PPDM) that combined telemonitoring, self-management support, and medication management. The intervention was designed for practical delivery using existing Veterans Affairs (VA) telemedicine infrastructure. To refine the intervention and inform the delivery of the intervention in other settings, we examined participants' experiences.

METHODS

We conducted semistructured interviews with 18 Veterans who completed the intervention. We analyzed interview text using directed content analysis and categorized themes by hemoglobin A1c (HbA1c) improvement (<1% or ≥1%).

RESULTS

Participants generally reported greater awareness of their blood glucose levels; however, they described dissatisfaction with the telemonitoring interface and competing demands during the intervention. Participants with <1% HbA1c improvement reported that these challenges interfered with their engagement. Participants with ≥1% HbA1c improvement reported new self-management routines despite challenges.

CONCLUSION

Despite competing demands and frustration with the telemonitoring interface, many participants demonstrated intervention engagement and substantial improvement in HbA1c ($1%). Differences in engagement may reflect differing capacity to manage treatment burden. Because it relies on existing infrastructure, this intervention is a promising model for addressing PPDM within VA. Future work should focus on optimizing systems' telemedicine infrastructure; while reliance on existing infrastructure may facilitate practical delivery, and it may also limit intervention engagement by excessively contributing to treatment burden.

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Digital interventions to promote self-management in adults with hypertension systematic review and meta-analysis

OBJECTIVE

To synthesize the evidence for using interactive digital interventions (IDIs) to support patient self-management of hypertension, and to determine their impact on control and reduction of blood pressure.

METHOD

Systematic review with meta-analysis was undertaken with a search performed in MEDLINE, EMBASE, CINAHL, PsycINFO, ERIC, Cochrane Library, DoPHER, TROPHI, Social Science Citation Index and Science Citation Index. The population was adults (>18 years) with hypertension, intervention was an IDI and the comparator was usual care. Primary outcomes were change in SBP and DBP. Only randomized controlled trials and studies published in journals and in English were eligible. Eligible IDIs included interventions accessed through a computer, smartphone or other hand-held device.

RESULTS

Four out of seven studies showed a significantly greater reduction for intervention compared to usual care for SBP, with no difference found for three. Overall, IDIs significantly reduced SBP, with the weighted mean difference being -3.74 mmHg [95% confidence interval (CI) -2.19 to -2.58] with no heterogeneity observed (I-squared = 0.0%, P = 0.990). For DBP, four out of six studies indicated a greater reduction for intervention compared to controls, with no difference found for two. For DBP, a significant reduction of -2.37 mmHg (95% CI -0.40 to -4.35) was found, but considerable heterogeneity was noted (I-squared = 80.1%, P = <0.001).

CONCLUSION

IDIs lower both SBP and DBP compared to usual care. Results suggest these findings can be applied to a wide range of healthcare systems and populations. However, sustainability and long-term clinical effectiveness of these interventions remain uncertain.

The Rationale for Continuous Glucose Monitoring-based Diabetes Treatment Decisions and Non-adjunctive Continuous Glucose Monitoring Use

Self-monitoring of blood glucose (SMBG) is now recognised as a core component of diabetes self-management. However, there are many limitations to SMBG use in individuals with diabetes who are treated with intensive insulin regimens. Many individuals do not test at the recommended frequencies. Additionally, because SMBG only provides a blood glucose reading at a single point in time, hypoglycaemia and hyperglycaemia can easily go undetected, limiting the user's ability to take corrective action. Inaccuracies due to user error, environmental factors and weaknesses in SMBG system integrity further limit the utility of SMBG. Real-time continuous glucose monitoring (CGM) displays the current glucose, direction and velocity of glucose change and provides programmable alarms. This trending information and 'around-the-clock' vigilance provides a significant safety advantage relative to SMBG. No published clinical studies have evaluated outcomes when CGM is used as a replacement for SMBG; however, recent in silico studies support this indication. This article reviews the limitations of SMBG and discusses recent evidence that supports CGM-based decisions as an effective approach to managing insulin-treated diabetes.

Adult-Onset Type 1 Diabetes: A Qualitative Study of Decision-Making Needs

INTRODUCTION

Type 1 diabetes is an autoimmune disease resulting from insulin deficiency and must be carefully managed to prevent serious health complications. Diabetes education and management strategies usually focus on meeting the decision-making needs of children and their families, but little is known about the decisional needs of people with adult-onset type 1 diabetes.

OBJECTIVE

The aim of this study was to explore the diabetes-related decision-making needs of people diagnosed with adult-onset type 1 diabetes.

METHODS

An interpretive descriptive qualitative study was conducted. Participants who self-identified as having adult-onset type 1 diabetes were interviewed using a semistructured interview guide. Transcripts were coded to identify needs, supports and barriers using thematic analysis.

RESULTS

Participating in the study were 8 adults (2 men, 6 women), ages 33 to 57, with type 1 diabetes for durations of 1 to 20 or more years. Their decision-making needs are summarized in 6 broad themes: 1) people diagnosed with type 1 diabetes are launched into a process of decision-making; 2) being diagnosed with type 1 diabetes means you will always have to make decisions; 3) knowledge is crucial; 4) personal preferences matter; 5) support is critical for decisions about self-care in type 1 diabetes; 6) living with type 1 diabetes means making very individualized decisions about daily life.

CONCLUSIONS

The findings describe the sudden and ubiquitous nature of type 1 diabetes decision-making and the need to tailor approaches for making care decisions in type 1 diabetes. People diagnosed with adult-onset type 1 diabetes require access to reliable information, support and opportunities for participation in decision-making.

8th Annual Symposium on Self-Monitoring of Blood Glucose (SMBG): April 16-18, 2015, Republic of Malta

International experts in the fields of diabetes, diabetes technology, endocrinology, mobile health, sport science, and regulatory issues gathered for the 8(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG) with a focus on personalized diabetes management. The aim of this meeting was to facilitate new collaborations and research projects to improve the lives of people with diabetes. The 2015 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.

Development and Validation of the Perception of Self-Monitoring of Blood Glucose Scale in Insulin-Treated Patients With Diabetes

Background and Purpose: The Perception of Self-Monitoring of Blood Glucose (P-SMBG) scale was developed and validated to assess perceptions of self-monitoring of blood glucose (SMBG) in insulin-treated patients with diabetes. Method: An initial 68-item version of the P-SMBG has been evaluated by a panel of professionals and patients. A sample of 375 patients tested the revised scale. Results: Factor analysis suggested a 19-item scale and a 2-factor structure, separating negatively and positively worded items. Cronbach’s alpha was .84 and .72, and the intraclass correlation coefficient was .66 and .57, respectively for both factors. Item–total correlations were in the range of .23–.66. Convergent/divergent validity was confirmed for the negatively worded items. Conclusions: The final P-SMBG scale (21 items) can be used to assess positive and negative perceptions of SMBG in insulin-treated patients with diabetes.

Intervention Mapping Protocol for Developing a Theory-Based Diabetes Self-Management Education Program

Development of behavior theory–based health promotion programs is encouraged with the paradigm shift from contents to behavior outcomes. This article describes the development process of the diabetes self-management program for older Koreans (DSME-OK) using intervention mapping (IM) protocol. The IM protocol includes needs assessment, defining goals and objectives, identifying theory and determinants, developing a matrix to form change objectives, selecting strategies and methods, structuring the program, and planning for evaluation and pilot testing. The DSME-OK adopted seven behavior objectives developed by the American Association of Diabetes Educators as behavioral outcomes. The program applied an information-motivation-behavioral skills model, and interventions were targeted to 3 determinants to change health behaviors. Specific methods were selected to achieve each objective guided by IM protocol. As the final step, program evaluation was planned including a pilot test. The DSME-OK was structured as the 3 determinants of the IMB model were intervened to achieve behavior objectives in each session. The program has 12 weekly 90-min sessions tailored for older adults. Using the IM protocol in developing a theory-based self-management program was beneficial in terms of providing a systematic guide to developing theory-based and behavior outcome–focused health education programs.

Pain reduction and financial incentives to improve glucose monitoring adherence in a community health center

Self-monitoring of blood glucose is a critical component of diabetes management. However, patients often do not maintain the testing schedule recommended by their healthcare provider. Many barriers to testing have been cited, including cost and pain. We present a small pilot study to explore whether the use of financial incentives and pain-free lancets could improve adherence to glucose testing in a community health center patient population consisting largely of non-English speaking ethnic minorities with low health literacy. The proportion of patients lost to follow-up was 17%, suggesting that a larger scale study is feasible in this type of setting, but we found no preliminary evidence suggesting a positive effect on adherence by either financial incentives or pain-free lancets. Results from this pilot study will guide the design of larger-scale studies to evaluate approaches to overcome the variety of barriers to glucose testing that are present in disadvantaged patient populations.

Testing versus guessing blood glucose values: impact on self-care behaviors in type 2 diabetes

OBJECTIVE

To assess differences between estimated blood glucose values and those measured on a blood glucose meter and the impact on self-care behavior in type 2 diabetes.

RESEARCH DESIGN AND METHODS

Subjects ≥18 years with type 2 diabetes (N = 297) attending a Taking Control of Your Diabetes conference were asked questions about diabetes management and to estimate their current blood glucose. Study staff tested subjects' blood glucose on a meter. After seeing the result, subjects were again asked questions on diabetes management.

CLINICAL TRIAL REGISTRATION

NCT01453413.

MAIN OUTCOME MEASURE

The percentage of subject blood glucose estimations that were outside ISO 15197:2003 accuracy criteria (>±15 mg/dL or >±20% of meter glucose values).

RESULTS

Nearly half (46%) of subjects estimated blood glucose values outside ISO 15197:2003 accuracy criteria. Time since last blood glucose test, time since last meal, testing frequency, and A1C did not have an effect on differences between estimated blood glucose values and meter results. In the questionnaire before blood glucose testing, most subjects strongly agreed, agreed, or neither agreed nor disagreed that 'I make decisions about my diabetes, such as my food intake or my insulin dose even when I do not test my blood sugar' (71%) and 'My body tells me without testing if my blood sugar is low or high' (77%). After blood glucose testing, 99% of subjects strongly agreed, agreed, or neither agreed nor disagreed that 'Knowing my blood sugar by checking could help me make different diabetes decisions'.

CONCLUSIONS

Self-monitoring of blood glucose is an important component of diabetes self-management. Testing rather than guessing blood glucose values is important to obtain accurate results and inform people with type 2 diabetes to make effective, appropriate diabetes management decisions. A potential limitation of this study is that the subject population may not be representative of the general population of people with diabetes; however, the conference setting may attract a more motivated population, which could underestimate the magnitude of the results.

Individual differences and day-to-day fluctuations in perceived self-regulation associated with daily adherence in late adolescents with type 1 diabetes

OBJECTIVE

To examine whether individual differences and intraindividual (within-person day-to-day) fluctuations in late adolescents' self-regulation were associated with daily adherence to the type 1 diabetes regimen. 

METHODS

 110 school seniors (M age = 17.78 years) and their mothers assessed adolescents' skills underlying self-regulation (executive function, attention, self-control, behavioral inhibition and activation, emotion regulation) and adherence, with glycosylated hemoglobin from medical records. Teens completed daily diaries reporting self-regulation failures surrounding monitoring blood glucose, adherence, and number of blood glucose checks each day for 14 days. 

RESULTS

 Hierarchical Linear Models indicated that better daily adherence was associated with teen and mother reports of better self-regulation skills and teens' reports of fewer daily self-regulation failures. Daily adherence was unrelated to temperamental differences in behavioral inhibition and activation. 

CONCLUSIONS

 Results indicate that both individual and intraindividual differences in self-regulation contribute to daily adherence highlighting the importance of daily self-regulatory challenges to adherence.

Everyday living with diabetes described by family members of adult people with type 1 diabetes

The aim of this study was to explore family members' experiences of everyday life in families with adult people living with type 1 diabetes. The grounded theory method was used to gather and analyse data from the interviews of nineteen family members. Six concepts describing the family members' views on everyday living with diabetes were generated on the basis of the data. Everyday life with diabetes is described as being intertwined with hypoglycemia. Becoming acquainted with diabetes takes place little by little. Being involved in the management and watching self-management from the sidelines are concepts describing family members' participation in the daily management of diabetes. The family members are also integrating diabetes into everyday life. Living on an emotional roller-coaster tells about the thoughts and feelings that family members experience. Family members of adult people with diabetes are involved in the management of the diabetes in many ways and experience many concerns. The family members' point of view is important to take into consideration when developing education for adults with diabetes.

Value and utility of self-monitoring of blood glucose in non-insulin-treated patients with type 2 diabetes mellitus

Self-monitoring of blood glucose (SMBG) levels provides important information regarding glycemic control for patients with diabetes, and is recommended by European and American diabetes organizations as an essential adjunct to periodic glycated hemoglobin (HbA1c) level monitoring. The benefits of SMBG in improving glycemic control in patients with type 1 diabetes and those with type 2 diabetes (T2DM) who are being treated with insulin are well recognized. In contrast, the potential role of SMBG in patients with T2DM not treated with insulin remains controversial, which may lead to underutilization of SMBG in this population. Structured SMBG, introduced as part of a treatment intervention, has been associated with modest but significant improvements in HbA1c levels in patients with T2DM who are not taking insulin as part of their management plan. Patient-obtained readings provide valuable real-time feedback on glucose responses to meals and exercise, and provide the patient with guidance on the day-to-day management of their diabetes. Studies have shown that when patients perform self-monitoring as part of their treatment interventions, support through appropriate educational initiatives is critical to ensure that patients understand the rationale for SMBG. Patients should be trained in correct testing technique and data recording for SMBG, as well as target blood glucose and goal HbA1c levels so that they will know when their SMBG readings are out of range. Technology has a potential role in facilitating SMBG-based interventions by improving patient-physician communication and optimizing glycemic control through the use of remote data uploading, data analysis tools, and, perhaps, even text messaging. This review outlines the benefits of SMBG in the management of patients with T2DM not treated with insulin, and highlights strategies for improving the effectiveness of SMBG-based treatment interventions in this population.

Active assistance technology reduces glycosylated hemoglobin and weight in individuals with type 2 diabetes: results of a theory-based randomized trial

BACKGROUND

Type 2 diabetes is an individual health challenge requiring ongoing self-management. Remote patient reporting of relevant health parameters and linked automated feedback via mobile telephone have potential to strengthen self-management and improve outcomes. This research involved development and evaluation of a mobile telephone-based remote patient reporting and automated telephone feedback system, guided by health behavior change theory, aimed at improving self-management and health status in individuals with type 2 diabetes.

SUBJECTS AND METHODS

This research comprised a randomized controlled trial. Inclusion criteria were diagnosis of type 2 diabetes, elevated glycosylated hemoglobin (HbA1c) levels (range, 6.5-11%) or use of oral diabetes medication, and 30-70 years of age. Intervention subjects (n=24) participated in remote patient reporting of health status parameters and linked health behavior change feedback. Control participants (n=24) received standard of care including diabetes education and healthcare provider counseling. Patients were followed for approximately 10 months.

RESULTS

Intervention participants achieved, compared with controls and controlling for baseline, a significantly greater mean reduction in HbA1c of -0.40% (95% confidence interval [CI] -0.67% to -0.14%) versus 0.036% (95% CI -0.23% to 0.30%) (P<0.03) and significantly greater weight reduction of -2.1 kg (95% CI -3.6 to -0.6 kg) versus 0.4 kg (95% CI -1.1 to 1.9 kg). Nonsignificant trends for greater intervention compared with control improvement in systolic and diastolic blood pressure were observed.

CONCLUSIONS

Sophisticated information technology platforms for remote patient reporting linked with theory-based health behavior change automated feedback have potential to improve patient outcomes in type 2 diabetes and merit scaled-up research efforts.

Pilot study of a prototype minimally invasive intradermal continuous glucose monitor

INTRODUCTION

The purpose of this study was to assess point accuracy, rate-of-change accuracy, and safety of a prototype, minimally invasive continuous glucose monitoring (CGM) device over a 12 h in-clinic study. The CGM system consisted of a wireless electronics module with a disposable glucose sensor attached to the bottom. The electronics module was affixed to the abdomen using an adhesive pad on the bottom of the disposable sensor housing.

METHODS

Two CGM sensors were inserted into the abdominal tissue (left and right) of 15 adults aged 26-67 years, 5 with normoglycemia, 5 with type 1 diabetes, and 5 with type 2 diabetes. Over a 12 h period, each participant was fed three meals. Reference venous blood samples were drawn at periodic intervals (12.4 ± 5.3 min), and glucose was measured at the bedside using a laboratory reference method. For each participant, a single plasma equivalent glucose concentration was used for retrospective sensor calibration.

RESULTS

A total of 1082 paired data points were obtained from 15 subjects and 25 of 30 sensors. Statistical analysis yielded a mean absolute relative difference of 12.6% and a mean absolute difference of 16.0 mg/dl. Continuous glucose error grid analysis showed the combined point and rate-of-change accuracy was 97.4% in zone A and 1.5% in zone B (98.9% A+B), with 1.1% erroneous readings.

CONCLUSIONS

The prototype CGM system provided clinically accurate results 98.9% of the time and was well tolerated by participants, with little or no pain and no adverse events.

Advanced meter features improve postprandial and paired self-monitoring of blood glucose in individuals with diabetes: results of the Actions with the CONTOUR Blood Glucose Meter and Behaviors in Frequent Testers (ACT) study

BACKGROUND

This study evaluated whether education and use of the advanced meter features of the CONTOUR(®) (Bayer HealthCare LLC, Diabetes Care, Tarrytown, NY) blood glucose monitoring system (BGMS) affect the frequency and pattern of blood glucose testing in insulin-using subjects with diabetes who routinely perform self-monitoring of blood glucose (SMBG).

SUBJECTS AND METHODS

Insulin-using subjects with type 1 or type 2 diabetes were enrolled in this 6-month, multicenter, prospective study and randomized to one of two groups. The basic meter features group (BMF group) received basic instruction in the use of the BGMS, whereas the advanced meter features group (AMF group) also received training in the use of advanced features, including the meal marker and audible reminder, and were instructed to use these features. Both groups received education on the importance of postprandial testing.

RESULTS

The AMF group (n=105) had significantly greater average weekly postprandial blood glucose testing than the BMF group (n=106) at each follow-up visit (P<0.001) and significantly increased the frequency of paired blood glucose testing (P<0.001) as well. In both groups, glycated hemoglobin decreased significantly as postprandial testing frequency increased (P<0.05). Subject reports indicated that use of advanced features made postmeal SMBG considerably easier to remember, helped them better understand how to make decisions on their own, and increased their confidence in meal choices.

CONCLUSIONS

Study findings showed that advanced features of the CONTOUR BGMS increased structured testing as measured by postprandial and paired SMBG and were perceived as useful by patients.

Perspectives of patients with type 1 or insulin-treated type 2 diabetes on self-monitoring of blood glucose: a qualitative study

Background

Self-monitoring of blood glucose (SMBG), including self-regulation, is an important tool to achieve good glycemic control. However, many patients measure their glucose concentrations less often than is recommended. This study investigates patients' perspectives of SMBG and all relevant aspects influencing SMBG in patients with type 1 and insulin-treated type 2 diabetes.

Methods

In depth interviews were conducted with 13 patients with type 1 diabetes from an outpatient clinic and 15 patients with type 2 diabetes from general practices. All interviews were transcribed verbatim and analyzed using the Grounded Theory approach.

Results

A wide variety of SMBG was encountered. Perceptions, goals of SMBG and personal and contextual factors were identified, influencing the respondents' perspective of SMBG, and leading to this variety. Respondents experienced a discrepancy between their own and the professionals' perceptions and goals. Respondents' perception of SMBG ranged along a continuum from 'friend' to 'foe'. With respect to the goals, the respondents experienced tension between achieving good glycemic control and quality of life, and deliberately made their own choices. The performance of SMBG was tailored to their perceptions and personal goals. Personal and contextual factors such as hypo- or hyper (un)awareness, knowledge, and contact with professionals acted as either facilitating factors or as barriers to SMBG, depending on the respondents' perspective. A SMBG model was developed providing a representation of the factors and their interrelations.

Respondents with type 1 diabetes seemed more resigned to their situation and SMBG was more integrated into their lives.

Conclusions

From the patients' perspective, professionals positively present SMBG as a 'friend' in order to achieve strict glycemic control. Whereas patients can also perceive SMBG as a 'foe'. They primarily seek a personal balance between achieving glycemic control and quality of life, leading them to deliberately make other choices regarding SMBG performance than was recommended. Gaining insight and discussing all factors affecting SMBG will help professionals and patients come to mutually agreed goals and to tailor the performance of SMBG to the individual patient. This should result in a more optimal use of SMBG, an improved quality of life, and improved clinical parameters.