Ethnic differences in psychological outcomes among people with diabetes: USA results from the second Diabetes Attitudes, Wishes, and Needs (DAWN2) study

Diabetes Medical Group Visits and Type 2 Diabetes Outcomes: Mediation Analysis of Diabetes Distress

Background

Group-based diabetes care, both technology-enabled and in-person, can improve diabetes outcomes in low-income minority women, but the mechanism remains unclear.

Objective

We tested whether diabetes group medical visits (GMVs) reduced hemoglobin A1c (HbA1c) by mitigating diabetes distress (DD), an emotional response affecting nearly half of adults with type 2 diabetes in community settings.

Methods

We conducted a mediation and moderation analysis of data from the Women in Control 2.0 comparative effectiveness study, which showed that both technology-enabled and in-person diabetes GMVs improve HbA1c. We tested whether DD mediated the relationship between diabetes GMV engagement and reductions in HbA1c. We also tested whether this relationship was moderated by depressive symptoms and social support. Participants were 309 low-income and minority women. Diabetes GMV engagement was measured using the Group Climate Questionnaire. The mediator, DD, was measured using the Diabetes Distress Screening Scale. The outcome was the 6-month change in HbA1c. Social support was measured using the Medical Outcomes Study Social Support Survey.

Results

DD mediated the relationship between engagement and 6-month HbA1c. Specifically, group engagement affected HbA1c by reducing distress associated with the regimen of diabetes self-management (P=.04), and possibly the emotional burden of diabetes (P=.09). The relationship between engagement and 6-month HbA1c was moderated by depressive symptoms (P=.02), and possibly social support (P=.08).

Conclusions

Engagement in diabetes GMVs improved HbA1c because it helped reduce diabetes-related distress, especially related to the regimen of diabetes management and possibly related to its emotional burden, and especially for women without depressive symptoms and possibly for women who lacked social support.

Effect of an entry-to-care intervention on diabetes distress in individuals with newly diagnosed type 2 diabetes: a study protocol for a cluster-randomized trial

BACKGROUND

Diabetes distress (DD) affects at least 36% of T2DM patients and is often associated with insufficient support and care. This study examines an intervention that targets DD through enhanced cross-sectoral collaboration and treatment during the first 3 months following diagnosis. The intervention aims to improve care and self-management and to reduce DD.

METHODS AND INTERVENTION

The study is designed as a cluster-randomized trial with the intervention focusing on four key elements of diabetes care: effective cross-sectoral communication and information sharing, systematic care, a "one-stop-shop" health screening and start-up conversation at the municipality, and improving patient insights into own care. This study requires 32 clusters (16/arm) to achieve 80% power and a 5% significance cut-off, with 270 patients required. GP recruitment occurred from May to Dec 2022. Patient recruitment is ongoing from May 2022 to Aug 2023. GPs were randomized 1:1 using computer-generated blocks of six. Participating GPs are located in Southern Denmark and are not participating in other trials. Patients must be 18 + years of age, have a T2DM diagnosis, and be fluent in spoken and written Danish. DD is the primary outcome and will be measured at baseline, at four months, and again at a 12-month follow-up. Secondary outcomes include quality of care, self-management, quality of life, and clinical factors. Tertiary outcomes comprise depression, stress, resilience, sleep quality, and social network quality.

CONCLUSION

This study is among the first clinical trials exploring the development of DD from diagnosis to 12 months post-diagnosis. Many previous interventions did not directly target DD as the primary outcome. This research provides new insights into DD progression in patients newly diagnosed with T2DM and examines an intervention designed to lower DD in early diabetes stages, contributing to a better understanding of the development of DD and how this intervention affects patient well-being.

TRIAL REGISTRATION

ClinicalTrial.gov NCT05571306. Registered on 07 October 2022.

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

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSION

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

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.

Assessing depressive symptoms and diabetes distress in Type 1 diabetic adults: A comparison of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) users

This cross-sectional observational study assesses differences in depressive symptoms and diabetes-distress between adults with type 1 diabetes using continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) insulin delivery methods. Two-hundred and seventy-one adults with type 1 diabetes were recruited who used CSII (n = 104) or MDI (n = 167). Results show that, compared to CSII users, scores on the Severity Measure for Depression - Adult questionnaire and Management and Physician subscales on the Type 1 Diabetes Distress Scale were significantly greater in users of MDI. Thus, MDI users may require greater targetted support to improve these aspects of psychological wellbeing.

Effectiveness of an immersive telemedicine platform for delivering diabetes medical group visits for African American/ Black and Hispanic/ Latina women with uncontrolled diabetes: The Women in Control 2.0 non-inferiority randomized clinical trial (Preprint)

BACKGROUND

Medically underserved people with type 2 diabetes mellitus face limited access to group-based diabetes care, placing them at risk for poor disease control and complications. Immersive technology and telemedicine solutions could bridge this gap.

OBJECTIVE

The purpose of this study was to compare the effectiveness of diabetes medical group visits (DMGVs) delivered in an immersive telemedicine platform versus an in-person (IP) setting and establish the noninferiority of the technology-enabled approach for changes in hemoglobin A_1c (HbA_1c) and physical activity (measured in metabolic equivalent of task [MET]) at 6 months.

METHODS

This study is a noninferiority randomized controlled trial conducted from February 2017 to December 2019 at an urban safety net health system and community health center. We enrolled adult women (aged ≥18 years) who self-reported African American or Black race or Hispanic or Latina ethnicity and had type 2 diabetes mellitus and HbA_1c ≥8%. Participants attended 8 weekly DMGVs, which included diabetes self-management education, peer support, and clinician counseling using a culturally adapted curriculum in English or Spanish. In-person participants convened in clinical settings, while virtual world (VW) participants met remotely via an avatar-driven, 3D VW linked to video teleconferencing. Follow-up occurred 6 months post enrollment. Primary outcomes were mean changes in HbA_1c and physical activity at 6 months, with noninferiority margins of 0.7% and 12 MET-hours, respectively. Secondary outcomes included changes in diabetes distress and depressive symptoms.

RESULTS

Of 309 female participants (mean age 55, SD 10.6 years; n=195, 63% African American or Black; n=105, 34% Hispanic or Latina; n=151 IP; and n=158 in VW), 207 (67%) met per-protocol criteria. In the intention-to-treat analysis, we confirmed noninferiority for primary outcomes. We found similar improvements in mean HbA_1c by group at 6 months (IP: -0.8%, SD 1.9%; VW: -0.5%, SD 1.8%; mean difference 0.3, 97.5% CI -∞ to 0.3; P<.001). However, there were no detectable improvements in physical activity (IP: -6.5, SD 43.6; VW: -9.6, SD 44.8 MET-hours; mean difference -3.1, 97.5% CI -6.9 to ∞; P=.02). The proportion of participants with significant diabetes distress and depressive symptoms at 6 months decreased in both groups.

CONCLUSIONS

In this noninferiority randomized controlled trial, immersive telemedicine was a noninferior platform for delivering diabetes care, eliciting comparable glycemic control improvement, and enhancing patient engagement, compared to IP DMGVs.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02726425; https://clinicaltrials.gov/ct2/show/NCT02726425.

Comparing the effectiveness of Family Support for Health Action (FAM-ACT) with traditional community health worker-led interventions to improve adult diabetes management and outcomes: study protocol for a randomized controlled trial

BACKGROUND

Diabetes self-management education and support (DSMES) programs have struggled to deliver sustainable, effective support for adults with diabetes (AWDs) to improve self-management behaviors, achieve glycemic goals, and reduce risk for complications. One largely untapped resource for this support is AWDs' social networks. Fifty to 75% of AWDs have an unpaid family member or friend ("support person") who provides ongoing help with diabetes management. However, DSMES interventions to date lack structured and effective approaches to directly engage support persons in AWDs' diabetes management.

METHODS

This parallel arm randomized trial is designed to determine the effectiveness of Family Support for Health Action (FAM-ACT), a novel community health worker (CHW)-delivered program focused on educating and supporting patients with type 2 diabetes (T2D) and their support persons (SPs), relative to an established, CHW-delivered, individual patient-focused DSMES and care management (I-DSMES) intervention. Both interventions were developed using a community-based participatory research (CBPR) approach. The study will be conducted in partnership with an urban Federally Qualified Health Center (FQHC) serving a low-income, Latino/a community, with target enrollment of 268 dyads consisting of an FQHC patient with T2D with high HbA1c and an SP. Patient-SP dyads will be randomized to receive FAM-ACT or I-DSMES over 6 months. The primary outcome is change in patient HbA1c from baseline to 6 months. Secondary patient outcomes include 12-month change in HbA1c, changes in patient blood pressure, diabetes self-management behaviors, diabetes distress, patient activation, diabetes self-efficacy, and perceptions of and satisfaction with SP support for diabetes. Secondary SP outcomes include self-efficacy for helping the patient with diabetes management and SP distress about the patient's diabetes. We also will assess the effect of the COVID-19 pandemic on patient's ability to manage diabetes.

DISCUSSION

This study will inform scalable, evidence-based approaches that leverage family support to help AWDs improve and sustain self-management strategies that underpin optimal management of multiple diabetes complication risk factors. The protocol is designed for and evaluated with a low-income and predominantly Latino/a community, which may increase applicability to other similar communities. The COVID-19 pandemic presented several challenges to study protocol and intervention delivery; modifications made to address these challenges are described.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03812614. Registered on 18 January 2019.

Effectiveness-implementation trial comparing a family model of diabetes self-management education and support with a standard model

BACKGROUND

Diabetes self-management education and support (DSMES) is an effective approach for improving diabetes self-care behaviors to achieve improved glycemic management and other health outcomes. Engaging family members may improve outcomes, both for the person with diabetes (PWD) and for the family members. However, family models of DSMES have been inconsistently defined and delivered. We operationalize Family-DSMES to be generalizable and replicable, detail our protocol for a comparative effectiveness trial comparing Standard-DSMES with Family-DSMES on outcomes for PWDs and family members, and detail our mixed-methods implementation evaluation plan.

METHODS

We will examine Family-DSMES relative to Standard-DSMES using a Hybrid Type 1 effectiveness-implementation design. Participants are ≥18 years old with type 2 diabetes mellitus and hemoglobin A1c ≥7.0%, recruited from rural and urban primary care clinics that are part of an academic medical center. Each participant invites a family member. Dyads are randomly assigned to Family- or Standard-DSMES, delivered in a small-group format via telehealth. Data are collected at baseline, immediately post-intervention, and 6-, 12-, and 18-months post-intervention. Outcomes include PWDs' hemoglobin A1c (primary), other biometric, behavioral, and psychosocial outcomes (secondary), and family members' diabetes-related distress, involvement in the PWD's diabetes management, self-efficacy for providing support, and biometric outcomes (exploratory). Our mixed-methods implementation evaluation will include process data collected during the trial and stakeholder interviews guided by the Consolidated Framework for Implementation Research.

CONCLUSION

Results will fill knowledge gaps about which type of DSMES may be most effective and guide Family-DSMES implementation efforts.

REGISTRATION

The trial is pre-registered at clinicaltrials.gov (#NCT04334109).

Effectiveness of an integrated primary care intervention in improving psychosocial outcomes among Latino adults with diabetes: the LUNA-D study

OBJECTIVE

To compare the effectiveness of usual care (UC) versus a culturally tailored integrated care model in improving mental health symptoms for Latino patients with Type 2 diabetes mellitus (T2DM).

METHODS

We conducted a two-arm randomized controlled trial from 2015 to 2019 at a federally qualified health center. Participants were 456 adults ages 23-80 years who had a previous diagnosis of T2DM and were not currently using insulin. Participants were randomly assigned to Integrated Care Intervention (ICI; including behavioral/mental healthcare, medical visits, health education and care coordination) or UC; standard of care including referrals for health education and behavioral/mental health care where appropriate. Intention-to-treat, multilevel models were used to compare group × time changes in depression and anxiety symptoms (PHQ-8; GAD-7) and perceived stress (PSS-10) across 6 months.

RESULTS

Participant mean age was 55.7 years, 36.3% were male, and 63.7% were primarily Spanish speaking. Baseline sociodemographic factors and mental health symptoms across study arms were balanced. Significant group × time interaction effects were observed for anxiety and depression symptoms (p < .05). Within the ICI and UC groups, mean depression symptom changes were -0.93 and -0.39 (p < .01); anxiety symptom changes were -0.97 (p < .01) and -0.11 (p = .35); and perceived stress changes were -1.56 and -1.27 (p < .01), respectively.

CONCLUSIONS

Although both ICI and UC showed decreases over time, the ICI group evidenced larger, statistically significant changes in both depression and anxiety. Adapted integrated models of behavioral and chronic disease management appear to be effective and could be considered for usual care practices.

CLINICALTRIALS.GOV IDENTIFIER

NCT03983499.

Comparison of Diabetes Mellitus Risk Factors in Mexico in 2003 and 2014

Objective

The prevalence of diabetes mellitus in Mexico is very high. This study aimed to compare the risk factors of diabetes mellitus in Mexican adults in 2003 and in 2014.

Methods

This study had a repeated cross-sectional design. Data from the World Health Organization (WHO) Study on global AGEing and adult health (SAGE) from Mexico (Wave 0, 2003, and Wave 2, 2014) were compared. Self-reported diabetes mellitus (outcome) was evaluated with the yes/no question: "Have you ever been diagnosed with diabetes mellitus (high blood sugar)?" Bivariate analyses and multivariable logistic regression analyses adjusted for potential risk factors were conducted.

Results

In 11 years (2003-2014), the prevalence of self-reported diabetes mellitus in Mexican adults increased by 2.6 times in those younger than 50 years (2003: 2.1%; 2014: 5.5%) and by 1.9 times in those ≥50 years (2003: 12.7%; 2014: 24.2%). In 2003, the risk factors associated with diabetes mellitus were female sex (OR 1.344, 95% CI 1.176-1.536), age ≥50 years (OR 6.734, 95% CI 5.843-7.760), being overweight (OR 1.359, 95% CI 1.175-1.571), obesity (OR 1.871, 95% CI 1.583-2.211), and lower physical activity of <600 MET-minutes/week (OR 1.349, 95% CI 1.117-1.630). In 2014, the exposure characteristics significantly associated with diabetes mellitus were female sex (OR 1.244, 95% CI 1.025-1.511), older age ≥50 years (OR 4.608, 95% CI 3.260-6.515), being overweight (OR 1.649, 95% CI 1.305-2.083), obesity (OR 1.778, 95% CI 1.398-2.261), and in those who had not attended/completed primary school (OR 1.360, 95% CI 1.042-1.773).

Conclusion

The prevalence of diabetes mellitus in Mexico significantly increased from 2003 to 2014. Female sex, age older than 50 years, and being overweight or obese were significant risk factors in both 2003 and 2014. Not having completed primary school was a new significant risk factor in 2014. Public health policies and strategies should prioritize decreasing the high levels of overweight and obesity, and improve health literacy in Mexico.

Diabetes Distress in Young Adults With Youth-Onset Type 2 Diabetes: TODAY2 Study Results

OBJECTIVE

To assess the prevalence of high diabetes distress and associated factors in the Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY2) study cohort of young adults with youth-onset type 2 diabetes.

RESEARCH DESIGN AND METHODS

Participants completed the Diabetes Distress Scale (DDS) at end-of-study visits. Factors examined for association with high distress were demographic (sex, race/ethnicity, age, education, income), medical (HbA1c, BMI, complications), psychological (depressive and anxiety symptoms), and social (number in household, offspring, health care coverage, established with diabetes care provider). Univariate logistic regression identified factors associated with high distress that were controlled for in multivariate logistic regressions.

RESULTS

Of 438 participants, 66% were female (mean age 26.8 years, 18% non-Hispanic White, 37% non-Hispanic Black, 38% Hispanic). High distress (DDS ≥2) was reported by 105 (24%) participants. Subscales identified 40% with high regimen distress and 29.7% with high emotional burden. A greater percentage of those with high distress were female (P = 0.002), diagnosed with hypertension (P = 0.037) and retinopathy (P = 0.005), treated with insulin, had higher HbA1c, and had moderate to severe depressive and anxiety symptoms (all P < 0.001). In multivariate analyses, female sex (P < 0.001), HbA1c (P < 0.001), anxiety symptoms (P = 0.036), and lack of health care coverage (P = 0.019) were associated with high distress, after controlling for potential confounders. Moderate to severe depressive symptoms were associated with high regimen distress (P = 0.018) and emotional burden (P < 0.001); insulin treatment was associated with high emotional burden (P = 0.027).

CONCLUSIONS

Future research should identify modifiable factors associated with high diabetes distress in young adults with youth-onset type 2 diabetes that may inform distress interventions with this medically vulnerable group.

A Closer Look at Racial Differences in Diabetes Outcomes Among a Community Sample: Diabetes Distress, Self-care, and HbA1c

OBJECTIVE

Approximately 34 million people in the U.S. have diabetes. With this illness come substantial changes to psychological and physical health. However, type 2 diabetes disproportionately affects non-Hispanic Black compared with non-Hispanic White populations. The purpose of this study was to examine racial differences in psychological, behavioral, and physical health over time among individuals recently diagnosed with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were collected from a community sample of 193 adults recently diagnosed with type 2 diabetes (44% female; 45% Black). Measures of distress, self-care behaviors, and HbA1c were taken at an initial interview (time 1) and 6 months later (time 2). Individuals wore an Actical accelerometer to assess physical activity and participated in three 24-h dietary recall interviews to assess dietary intake within 2 weeks of the initial interview.

RESULTS

From time 1 to time 2, Black women showed the highest increase in depressive symptoms. There was a greater increase in regimen and physician distress among White compared with Black participants. White men and Black women reported a decline in medication adherence over time. There were no racial differences in changes in physical activity across 6 months. However, Black individuals had higher overall calorie consumption with greater protein, saturated fat, and cholesterol intake than White individuals. There were no race or sex differences in changes in glycemic stability.

CONCLUSIONS

Initial adjustment to a diagnosis of type 2 diabetes differentially influences Black and White men and women in terms of depressive symptoms, diabetes distress, and self-care.

Perceptions and correlates of distress due to the COVID-19 pandemic and stress management strategies among people with diabetes: a mixed methods study

Background

Greater risk of adverse health outcomes and public health measures have increased distress among people with diabetes during the coronavirus-2019 (COVID-19) pandemic. The objectives of this study were to explore how the experiences of people with diabetes during the COVID-19 pandemic differ according to sociodemographic characteristics and identify diabetes-related psychosocial correlates of COVID distress.

Methods

Patients with type 1 or 2 diabetes were recruited from clinics and community health centres in Toronto, Ontario, as well as patient networks. Participants were interviewed to explore the experiences of people with diabetes with varied sociodemographic and clinical identities, with respect to wellness (physical, emotional, social, financial, occupational), level of stress and management strategies. Multiple linear regression was used to assess the relationships between diabetes distress, diabetes self-efficacy and resilient coping with COVID distress.

Results

Interviews revealed that specific aspects of psychosocial wellness affected by the pandemic, and stress and illness management strategies utilized by people with diabetes differed based on socioeconomic status, gender, type of diabetes and race. Resilient coping (β=−0.0517; 95% confidence interval [CI], −0.0918 to −0.0116; p=0.012), diabetes distress (β=0.0260; 95% CI, 0.0149 to 0.0371; p<0.0001) and diabetes self-efficacy (β=−0.0184; 95% CI, −0.0316 to −0.0052; p=0.007) were significantly associated with COVID distress.

Conclusions

Certain subgroups of people with diabetes have experienced a disproportionate amount of COVID distress. Assessing correlates of COVID distress among people with diabetes will help inform interventions such as diabetes self-management education to address the psychosocial distress caused by the pandemic.

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.

Latinos understanding the need for adherence in diabetes (LUNA-D): a randomized controlled trial of an integrated team-based care intervention among Latinos with diabetes

We developed and tested a culturally appropriate, team-based, integrated primary care and behavioral health intervention in low income, Spanish-speaking Latinos with type 2 diabetes, at a federally qualified health center. This pragmatic randomized controlled trial included 456 Latino adults, 23-80 years, 63.7% female, with diabetes [recruitment glycosylated hemoglobin (HbA1c) ≥ 7.0%/53.01 mmol/mol)]. The Special Intervention occurred over 6 months and targeted improvement of HbA1c, blood pressure, and lipids. The intervention included: (i) four, same-day integrated medical and behavioral co-located visits; (ii) six group diabetes self-management education sessions addressing the cultural dimensions of diabetes and lifestyle messages; (iii) and care coordination. Usual Care participants received primary care provider led standard diabetes care, with referrals to health education and behavioral health as needed. HbA1c and lipids were obtained through electronic health records abstraction. Blood pressure was measured by trained research staff. Multi-level models showed a significant group by time interaction effect (B = -0.32, p < .01, 95% CI -0.49, -0.15), indicating statistically greater improvement in HbA1c level over 6 months in the Special Intervention group (ΔHbA1c = -0.35, p = <.01) versus Usual Care (ΔHbA1c = -0.02, p = .72). Marginally significant group by time interactions were also found for total cholesterol and diastolic blood pressure, with significant improvements in the Special Intervention group (p < .05). This culturally appropriate model of highly integrated care offers strategies that can assist with self-management goals and disease management for Latinos with diabetes in a federally qualified health center setting.

Diabetes distress and HbA1c in racially/ethnically and socioeconomically diverse youth with type 1 diabetes

BACKGROUND

Diabetes distress, the emotional burden of caring for the chronic demands of diabetes, has not been well described in children and preadolescents with type 1 diabetes (T1D). This gap is particularly evident among youth of lower socioeconomic status (SES) and/or racial/ethnic minorities. Since these groups are more likely to have disparities in health outcomes and healthcare related to their diabetes, factors that could potentially improve glycemic and other diabetes-related outcomes should be studied closely.

OBJECTIVE

We hypothesized that (a) diabetes distress levels would be elevated in children with markers of lower SES and those of racial/ethnic minorities, and (b) higher HbA1c would be predicted by higher diabetes distress levels, when controlling for race/ethnicity, SES, and clinical covariates.

METHODS

One hundred and eighty-seven youth age 9 to 13 with T1D completed age-appropriate Problem Areas in Diabetes (PAID) questionnaires using a web-based portal during routine diabetes care visits.

RESULTS

PAID scores were significantly elevated in youth who had surrogate markers of lower SES and who were from racial/ethnic minority backgrounds. In multivariate models including race/ethnicity or the SES variables and controlling for clinical covariates, the factor most predictive of higher HbA1c was elevated PAID score.

CONCLUSIONS

Diabetes distress is elevated in a younger population of children with T1D who are from racial/ethnic minority backgrounds or have markers of lower SES. Interventions that target distress and/or expand the safety net in these populations could potentially improve glycemic outcomes.

Mobile-Enhanced Peer Support for African Americans with Type 2 Diabetes: a Randomized Controlled Trial

BACKGROUND

Peer support has been shown to improve diabetes self-management and control, but no standard exists to link peer support interventions to clinical care.

OBJECTIVE

To compare a community-based diabetes self-management education (DSME) plus mobile health (mHealth)-enhanced peer support intervention to community-based diabetes self-management education (DSME) alone for African American adults with poorly controlled type 2 diabetes.

DESIGN

A randomized controlled trial.

PARTICIPANTS

African American adults, age > 19 years, receiving care within a safety-net healthcare system in Jefferson County, Alabama, with a diagnosis of type 2 diabetes and a hemoglobin A1c (A1C) ≥ 7.5%.

INTERVENTIONS

Participants in the intervention group received community-based diabetes self-management education (DSME) plus 6 months of mHealth-enhanced peer support, including 12 weekly phone calls, then 3 monthly calls from community health workers, who used a novel web application to communicate with participants' healthcare teams. In the control group, participants received community-based DSME alone.

MAIN MEASURES

The primary outcome was A1C; secondary outcomes included diabetes distress, depressive symptoms, self-efficacy or confidence in their ability to manage diabetes, and social support. We used mixed models repeated measures analyses to assess for between-arm differences and baseline to follow-up changes.

KEY RESULTS

Of 120 participants randomized, 97 completed the study. Participants in intervention and control groups experienced clinically meaningful reduction in A1C, 10.1 (SD 1.7) to 9.6 (SD 1.9) and 9.8 (SD 1.7) to 9.1 (SD 1.9) respectively, p = 0.004. Participants in the intervention group experienced a significantly larger reduction in diabetes distress compared to the control, 2.7 (SD 1.2) to 2.1 (1.0) versus 2.6 (SD 1.1) to 2.3 (SD 1.0) p = 0.041.

CONCLUSIONS

Community-based DSME with and without peer support led to improved glycemic control. Peer support linked to clinical care led to a larger reduction in diabetes distress, which has important implications for the overall wellbeing of adults with type 2 diabetes.

Evaluating the Impact of Mobile Phone Technology on Health Outcomes for Latinos with Type 2 Diabetes

OBJECTIVES

To assess whether a Spanish-language text messaging program helps Latinos with diabetes better manage their disease.

METHODS

Spanish-speaking Latinos with type 2 diabetes and HbA1c ≥ 8% (N = 38) were recruited January 1, 2016-May 31, 2016, at a large integrated healthcare delivery system. Participants received 1-3 Spanish-language text messages about diabetes self-care per day for 3 months with an optional 3-month extension. The Wilcoxon signed-rank test for paired data was used to compare pre-post intervention HbA1c. The Wilcoxon-Mann-Whitney nonparametric test was used to compare changes in HbA1c across groups.

RESULTS

After 3 months, the median HbA1c reduction overall was 1.4 percentage points (IQR: 0.5-3.3, p < 0.01). Latinos having pre-intervention HbA1c > 10.0% had a greater reduction in median HbA1c (3.8, IQR: 0.5-5.3) compared with those having pre-intervention HbA1c ≤ 10.0% (0.9, IQR: 0.1-1.9, p < 0.05). This reduction in median HbA1c persisted after 6 months (1.3, IQR: 0.2-2.9, p < 0.01).

CONCLUSION

A Spanish-language text messaging program was an effective way to improve glycemic control for Latinos with type 2 diabetes.

POLICY IMPLICATIONS

Culturally and linguistically tailored text messaging programs for managing diabetes should be considered.

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.

Innovative Diabetes Interventions in the U.S. Hispanic Population

IN BRIEF In the United States, Hispanics have a 66% greater risk of developing type 2 diabetes and, once diagnosed, exhibit worse outcomes than non-Hispanic whites. It is therefore imperative to ensure that interventions meet the specific needs of this at-risk group. This article provides a selective review of the evidence on innovative, real-world approaches (both live and technology-based) to improving behavioral, psychosocial, and clinical outcomes in underserved Hispanics with type 2 diabetes. Key aspects of successful live interventions have included multimodal delivery, greater dosage/attendance, and at least some in-person delivery; effective technology-based approaches involved frequent but intermittent communication, bi-directional messaging, tailored feedback, multimodal delivery, and some human interaction. Across modalities, cultural tailoring also improved outcomes. Additional research is needed to address methodological limitations of studies to date and pinpoint the most efficacious components and optimal duration of interventions. Future efforts should also attend to variability within the U.S. Hispanic population to ensure acceptability and sustainability of interventions in this diverse group.

The association between diabetes and depressive symptoms varies by quality of diabetes care across Europe

Background

Depressive symptoms are more common in adults with diabetes and may arise from the physical and psychosocial burden of disease. Better quality of diabetes care may be associated with a reduced disease burden and fewer depressive symptoms.

Methods

This cross-sectional study included 34 420 participants from 19 countries in the European Social Survey Round 7 (2014-2015). Countries were grouped into quartiles based on their quality of diabetes care as measured in the Euro Diabetes Index 2014. Individual-level depressive symptoms were measured using the 8-item Center for Epidemiologic Studies-Depression Scale. Negative binomial regression was used to compare the number of depressive symptoms between adults with and without diabetes in each quartile of diabetes care quality. Analyses included adjustment for covariates and survey weights.

Results

In countries with the highest quality of diabetes care, having diabetes was associated with only a 3% relative increase in depressive symptoms (95% CI 1.00-1.05). In countries in the second, third and fourth (lowest) quartiles of diabetes care quality, having diabetes was associated with a 13% (95% CI 1.08-1.17), 13% (1.08-1.19) and 22% (1.14-1.31) relative increase in depressive symptoms, respectively.

Conclusion

The association between diabetes and depressive symptoms appears stronger in European countries with lower quality of diabetes care. Potential pathways for this association include the financial aspects of diabetes care, access to services and differential exposure to the social determinants of heath. Further research is needed to unpack these mechanisms and improve the quality of life of people with diabetes across Europe.

Sex, race, and the role of relationships in diabetes health: intersectionality matters

Previous research has seldom used an intersectionality framework to consider how sex and race affect diabetes health, nor has it examined the role of sex and race in the well-established link between romantic relationship quality and health. This study targeted 200 adults with type 2 diabetes (46% Black; 45% female) and examined whether sex, race, and the interaction between sex and race predicted behavioral and psychological health, or moderated the link between relationship quality and health outcomes. Black women reported poorer diabetes self-care and lower self-efficacy compared to other groups. Relationship quality was associated with better self-care, increased self-efficacy, and lower depressive symptoms. The association between relationship quality and medication adherence was stronger for Black women, and the association between relationship quality and self-efficacy was stronger for both Black women and White men. Results suggest that Black women with diabetes experience more health disadvantages than other groups, but some of these disadvantages might be attenuated by supportive romantic relationships.

Effectiveness of Diabetes Self-Management Education Programs for US Latinos at Improving Emotional Distress: A Systematic Review

PURPOSE

This systematic review examined whether diabetes self-management education (DSME) interventions for US Latino adults improve general emotional distress (eg, depression symptoms) and/or health-specific emotional distress (eg, diabetes distress). The topic is important given the high prevalence of type 2 diabetes (T2DM), concomitant distress, and worse health outcomes among Latinos and considering the barriers that distress poses for effective diabetes self-management.

METHODS

Following PRISMA guidelines, a search of the online databases PsycINFO, CINAHL, PubMed, and CENTRAL was conducted from database inception through April 2018. A comprehensive search strategy identified trials testing DSME interventions for US Latinos with T2DM that reported on changes in general or health-specific emotional distress. Risk of bias was assessed using the EPHPP Quality Assessment Tool. Raw mean differences ( D) and effect sizes ( d) were computed where possible.

RESULTS

Fifteen studies were included in the review. Six of 8 studies that examined depression symptoms reported significant symptom reduction. Of 10 studies that examined health-specific emotional distress, 6 reported significant symptom reduction. Effect sizes ranged from -0.20 to -3.85. Null findings were more readily found among studies with very small sample sizes (n < 30) and studies testing interventions without specific psychosocial content, with little cultural tailoring, with less frequent intervention sessions, and with support sessions lacking concurrent diabetes education. Most studies (11) received a weak rating of evidence quality.

CONCLUSIONS

There is an absence of strong evidence to support that DSME programs tailored for Latino adults with T2DM are beneficial for improving emotional distress. Methodologically robust studies are needed.

US Ethnic Group Differences in Family Member Support for People With Diabetes in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) Study

Purpose

The purpose of the study was to describe the perceptions of family members (FM) and people with diabetes (PWD) regarding the frequency and helpfulness of FM support for PWD, including differences among US ethnic groups.

Methods

The US 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) substudy was a survey of independent samples of 238 adult FM and 540 adult PWD. Outcome measures included ratings by FM and PWD of the frequency and perceived helpfulness of 7 FM support behaviors and composite scores for frequency and helpfulness.

Results

Ratings of individual FM support behaviors were strongly correlated between FM and PWD but significantly different among behaviors. FM and PWD reported most frequent support for listening, assisting, and doing activities with PWD and reporting PWD was doing poorly least frequently. Both groups reported listening, assisting, and reporting PWD was doing well as most helpful; reporting PWD was doing poorly was least helpful. PWD rated support and helpfulness of most behaviors lower than FM. Composite measures of support frequency and helpfulness were strongly correlated for both FM and PWD. Ethnic minority PWD and FM reported most support behaviors as more frequent and more helpful than non-Hispanic white Americans.

Conclusions

FM more frequently engage in the support behaviors they view as most helpful, but PWD perceive support to be less frequent and less helpful than FM. FM support differs across ethnic groups, with ethnic minorities reporting higher support frequency and helpfulness. Diabetes care providers should consider ethnic group differences in FM support for PWD.

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.

Effects of stress management and relaxation training on the relationship between diabetes symptoms and affect among Latinos

OBJECTIVE

Stress management and relaxation (SMR) interventions can reduce symptoms of chronic disease and associated distress. However, there is little evidence that such interventions disrupt associations between symptoms and affect. This study examined whether SMR dampened the link between symptoms of hyperglycemia and proximal levels of affect. We predicted that during periods of increased hyperglycemia, individuals receiving SMR training, relative to controls, would demonstrate smaller increases in negative affect.

DESIGN

Fifty-five adult Latinos with type 2 diabetes were randomised to either one group session of diabetes education (DE-only; N = 23) or diabetes education plus eight group sessions of SMR (DE + SMR; N = 32). After treatment, participants reported five diabetes symptoms and four affective states twice daily for seven days using a bilingual telephonic system.

RESULTS

Mean age = 57.8 years, mean A1c = 8.4%, and ¾ was female with less than a high school education. Individuals receiving DE + SMR, compared to DE-only, showed a weaker positive within-person association between daily diabetes symptoms and nervous affect. Groups also differed on the association between symptoms and enthusiasm. Age moderated these associations in most models with older individuals showing less affect reactivity to symptoms.

CONCLUSIONS

Findings provide partial support for theorised mechanisms of SMR.

US ethnic group differences in self-management in the 2nd diabetes attitudes, wishes and needs (DAWN2) study

AIMS

Understanding the relationship between ethnicity and self-management is important due to disparities in healthcare access, utilization, and outcomes among adults with type 2 diabetes from different ethnic groups in the US.

METHODS

Self-reports of self-management and interest in improving self-management from US people with diabetes (PWD) in the 2nd Diabetes Attitudes, Wishes and Needs (DAWN2) study, a multinational, multi-stakeholder survey, were analyzed, including 447 non-Hispanic White, 241 African American, 194 Hispanic American, and 173 Chinese American PWD (>18 years).

RESULTS

Overall, self-management behavior was highest for medication taking and lowest for physical activity. Non-Hispanic Whites had lowest physical activity and highest adherence to insulin therapy. Chinese Americans had lowest foot care and highest healthy eating. Overall, interest was highest for improving healthy eating and physical activity. Chinese Americans and Hispanic Americans were more interested than non-Hispanic Whites in improving most self-management behaviors. Chinese Americans were more interested than African Americans in improving most self-management behaviors. Healthcare providers telling PWD that their A1c needs improvement was associated with lower self-rated glucose control, which was associated with higher PWD interest in improving self-management behaviors.

CONCLUSIONS

Diabetes care providers should use patient-centered approaches and consider ethnicity in tailoring self-management support.

The effect of diabetes self-management education on HbA1c and quality of life in African-Americans: a systematic review and meta-analysis

Background

Type 2 diabetes presents a major morbidity and mortality burden in the United States. Diabetes self-management education (DSME) is an intervention associated with improved hemoglobin A1c(HbA1c) and quality of life(QOL), and is recommended for all individuals with type 2 diabetes. African-Americans have disproportionate type 2 diabetes morbidity and mortality, yet no prior meta-analyses have examined DSME outcomes exclusively in this population. This systematic review and meta-analysis examined the impact of DSME on HbA1c and QOL in African-Americans compared to usual care.

Methods

Randomized controlled trials, cluster-randomized trials, and quasi-experimental interventions were included. 352 citations were retrieved; 279 abstracts were reviewed, and 44 full-text articles were reviewed. Fourteen studies were eligible for systematic review and 8 for HbA1c meta-analysis; QOL measures were too heterogeneous to pool. Heterogeneity of HbA1c findings was assessed with Cochran’s Q and I².

Results

HbA1c weighted mean difference between intervention and usual care participants was not significant: − 0.08%[− 0.40–0.23];χ² = 84.79 (p < .001), I² = 92%, (n = 1630). Four of five studies measuring QOL reported significant improvements for intervention participants.

Conclusions

Meta-analysis results showed non-significant effect of DSME on HbA1c in African-Americans. QOL did show improvement and is an important DSME outcome to measure in future trials. Further research is needed to understand effectiveness of DSME on HbA1c in this population.

Trial registration

PROSPERO registration: CRD42017057282.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3186-7) contains supplementary material, which is available to authorized users.

Diabetes-related complications: Which research topics matter to diverse patients and caregivers?

BACKGROUND

Diabetes is a chronic disease with increasing prevalence worldwide. Although research has improved its treatment and management, little is known about which research topics matter to people living with diabetes, particularly among under-represented groups.

OBJECTIVES

To explore the importance of research topics among a diverse range of people living with any type of diabetes or caring for someone living with any type of diabetes.

METHODS

We used a convergent mixed-method design with quantitative and qualitative aspects. We surveyed a national sample of people living with diabetes and caregivers of people with diabetes, asking them to rate the importance of 10 predetermined important research topics. We also held three focus groups in two major cities to explore research concerns of people who are under-represented in research.

RESULTS

469 adults (57% men, 42% women) in Canada completed the online survey, indicating that all 10 areas of research mattered to them, with the highest ratings accorded to preventing and treating kidney, eye and nerve complications. Fourteen individuals participated in three focus groups and similarly noted the importance of research on those three complications. Additionally, focus group participants also noted the importance of research around daily management. No new topics were identified.

CONCLUSIONS

This study confirmed the importance of research topics among a population of people living with or caring for someone with diabetes. Findings from this study were used to inform the vision for Diabetes Action Canada-a pan-Canadian Strategy for Patient-Oriented Research (SPOR) Network on diabetes and its complications.

HRQOL in Diverse Ethnic Groups with Diabetes: Findings from the 2014 BRFSS

OBJECTIVE

The study's objective is to examine differences in mental and physical health-related quality of life (HRQOL) in non-Hispanic White, non-Hispanic Black, and Hispanic adults with diabetes.

DESIGN

A secondary analysis of 2014 Behavioral Risk Factor Surveillance System (BRFSS) data was conducted. A total of 26 states participated in the 2014 BRFSS core and optional diabetes models (n = 17,923). HRQOL was measured by the number of mentally and physically unhealthy days during the past month, respectively. A series of regression models were developed to assess differences in HRQOL without and with inclusion of demographic (age, marital status, income, gender, and education) and diabetes-related (depression, sleep time, insulin use, complications, age of diabetes diagnosis, BMI, smoking, and exercise) factors.

RESULTS

In the fully adjusted models (inclusion of demographic and diabetes-related factors), non-Hispanic Whites had more mentally (β = 0.88, p = 0.03) and physically (β = 1.35, p = 0.01) unhealthy days per month compared to Hispanics. Non-Hispanic Blacks (β = 1.42, p < 0.01) also had more mentally unhealthy days per month in relation to Hispanics when adjusting for demographic and diabetes-related factors. Depression emerged as a potent predictor of mentally (β = 8.60; p < 0.0001) and physically (β = 4.43; p < 0.0001) unhealthy days in the multivariate models.

CONCLUSION

Non-Hispanic Black and White adults with diabetes may be more vulnerable to poor HRQOL compared to their Hispanic counterparts. Increased, widened application of diabetes interventions targeting depression appears warranted to improve HRQOL outcomes.

Mean Levels and Variability in Affect, Diabetes Self-Care Behaviors, and Continuously Monitored Glucose: A Daily Study of Latinos With Type 2 Diabetes

OBJECTIVE

This study investigated between- and within-person associations among mean levels and variability in affect, diabetes self-care behaviors, and continuously monitored glucose in Latinos with type 2 diabetes.

METHODS

Fifty participants (M [SD] age = 57.8 [11.7] years, 74% women, mean [SD] glycosylated hemoglobin A1c = 8.3% [1.5%]) wore a "blinded" continuous glucose monitor for 7 days, and they responded to twice daily automated phone surveys regarding positive affect, negative affect, and self-care behaviors.

RESULTS

Higher mean levels of NA were associated with higher mean glucose (r = .30), greater percent hyperglycemia (r = .34) and greater percentage of out-of-range glucose (r = .34). Higher NA variability was also related to higher mean glucose (r = .34), greater percent of hyperglycemia (r = .44) and greater percentage of out-of-range glucose (r = .43). Higher positive affect variability was related to lower percentage of hypoglycemia (r = -.33). Higher mean levels of self-care behaviors were related to lower glucose variability (r = -.35). Finally, higher self-care behavior variability was related to greater percentage of hyperglycemia (r = .31) and greater percentage of out-of-range glucose (r = -.28). In multilevel regression models, within-person increases from mean levels of self-care were associated with lower mean levels of glucose (b = -7.4, 95% confidence interval [CI] = -12.8 to -1.9), lower percentage of hyperglycemia (b = -0.04, 95% CI = -0.07 to -0.01), and higher percentage of hypoglycemia (b = 0.02, 95% CI = 0.01 to 0.03) in the subsequent 10-hour period.

CONCLUSIONS

Near-to-real time sampling documented associations of glucose with affect and diabetes self-care that are not detectable with traditional measures.

Ethnic Minorities with Diabetes Differ in Depressive and Anxiety Symptoms and Diabetes-Distress

Objective. To determine the association between ethnicity, diabetes-distress, and depressive and anxiety symptoms in adult outpatients with diabetes. Research Design and Methods. Diabetes-distress (Problem Areas in Diabetes Scale, PAID5), depressive and anxiety symptoms (Extended Kessler-10, EK10), and quality of life (Short-Form 12, SF12) were assessed in an ethnic diverse diabetes outpatient population of a teaching hospital in Amsterdam. Descent of one's parents and self-classified ethnicity were obtained to define ethnicity. HbA1c, clinical data, and socioeconomic status were derived from the medical charts. Based on established cut-offs for PAID5- and EK10-scores, emotional distress was dichotomized for the purpose of logistic regression analyses. Results. Of 1007 consecutive patients approached, 575 participated. Forty-nine percent were of non-Dutch ethnicity and 24.7% had type 1 diabetes. Diabetes-distress was reported by 12.5% of the native Dutch patients and by 22.0%, 34.5%, and 42.6% of the Surinamese, Turkish, and Moroccan patients, respectively. Prevalence of depressive symptoms was 9.4% in native Dutch patients and 20.4%, 34.5%, and 27.3% in the other groups mentioned. Diabetes-distress and Moroccan origin were significantly associated (OR = 3.60, p < .01) as well as depressive symptoms and Turkish origin (OR = 4.23, p = .04). Conclusions. Different ethnic minorities with diabetes vary in their vulnerability for emotional distress, warranting clinical attention. Future research should elucidate explanatory factors and opportunities for tailored interventions.

Acculturation and bicultural efficacy effects on Chinese American immigrants' diabetes and health management

The primary goal of this study was to examine effects of bicultural efficacy, or perceived confidence in dealing with bicultural acculturation stressors, on type 2 diabetes management and health for first-generation, Cantonese-speaking, Chinese American immigrants (N = 162) recruited for a larger community-based diabetes intervention study (Chesla et al. in Res Nurs Health 36(4):359-372, 2013. doi: 10.1002/nur.21543 ). The current study also tested whether a new Bicultural Efficacy in Health Management (BEFF-HM) scale is a more robust predictor of diabetes and health outcomes than proxy (years in the U.S.) and general acculturation measures. Hierarchical regression analyses of cross-sectional data revealed that high BEFF-HM was significantly related to positive outcomes on five of six diabetes and health measures as hypothesized after accounting for participant characteristics, proxy and general acculturation measures, and social support. Proxy and general acculturation measures failed to predict any study outcome supporting our secondary hypothesis that BEFF-HM is a better predictor of Chinese American immigrants' diabetes and health management. An immigrant-focused research approach advances understanding of acculturation and bicultural efficacy effects on health by identifying key acculturation domains for study.

Do pre-existing diabetes social support or depressive symptoms influence the effectiveness of a diabetes management intervention?

OBJECTIVE

Examine influences of diabetes-specific social support (D-SS) and depressive symptoms on glycemic control over time, among adults randomized to a diabetes self-management education and support (DSME/S) intervention or usual care.

METHODS

Data were from 108 African-American and Latino participants in a 6-month intervention trial. Multivariable linear regression models assessed associations between baseline D-SS from family and friends and depressive symptoms with changes in HbA1c. We then examined whether baseline D-SS or depression moderated intervention-associated effects on HbA1c.

RESULTS

Higher baseline D-SS was associated with larger improvements in HbA1c (adjusted ΔHbA1c -0.39% for each +1-point D-SS, p=0.02), independent of intervention-associated HbA1c decreases. Baseline depressive symptoms had no significant association with subsequent HbA1c change. Neither D-SS nor depression moderated intervention-associated effects on HbA1c.

CONCLUSIONS AND PRACTICE IMPLICATIONS

Diabetes self-management education and support programs have potential to improve glycemic control for participants starting with varying levels of social support and depressive symptoms. Participants starting with more support for diabetes management from family and friends improved HbA1c significantly more over 6 months than those with less support, independent of additional significant DSME/S intervention-associated HbA1c improvements. Social support from family and friends may improve glycemic control in ways additive to DSME/S.

The relationship between depressive symptoms, diabetes symptoms, and self-management among an urban, low-income Latino population

OBJECTIVE

To investigate the prevalence of depression symptoms among Latinos with diabetes following transition from hospital to home and the relationship of depressive symptoms to diabetes symptom severity and self-management activities.

METHODS

203 Latino patients with diagnosed diabetes completed a survey assessing depressive symptoms (PHQ-9), diabetes symptom severity, and diabetes self-management activities (SDSCA). Characteristics and diabetes outcomes between patients with and without probable major depression were compared. Associations between PHQ-9 scores and diabetes outcomes were assessed. Multivariate regression models evaluated the relationship between depressive symptoms and diabetes outcomes and exercise after controlling for patient characteristics.

RESULTS

31.5% of participants indicated probable major depression (PHQ-9≥10). More severe diabetes symptoms and less reported exercise were associated with higher PHQ-9 scores. Regression models showed no relationship between self-management and depression. More severe diabetes symptoms were significantly associated with being female, married, and having probable major depression. Odds of exercising were reduced by 6% for every one-unit increase in PHQ-9 score.

CONCLUSIONS

The prevalence of probable depressive symptoms is high in this population. Having depressive symptoms is an indicator of poorer diabetes symptoms. Screening for depressive symptoms may help identify individuals who need additional support with diabetes symptom and self-management.

Associations of Social Support and Self-Efficacy With Quality of Life in Older Adults With Diabetes

Older adults are disproportionately affected by diabetes, which is associated with increased prevalence of cardiovascular disease, decreased quality of life (QOL), and increased health care costs. The purpose of the current study was to assess the relationships between social support, self-efficacy, and QOL in a sample of 187 older African American and Caucasian individuals with diabetes. Greater satisfaction with social support related to diabetes (but not the amount of support received) was significantly correlated with QOL. In addition, individuals with higher self-efficacy in managing diabetes had better QOL. In a covariate-adjusted regression model, self-efficacy remained a significant predictor of QOL. Findings suggest the potential importance of incorporating the self-efficacy concept within diabetes management and treatment to empower older adults living with diabetes to adhere to care. Further research is needed to determine whether improving self-efficacy among vulnerable older adult populations may positively influence QOL.

Community health workers assisting Latinos manage stress and diabetes (CALMS-D): rationale, intervention design, implementation, and process outcomes

Latinos have high rates of diabetes and mental distress, but lack appropriate services. A study was designed to compare enhanced standard diabetes care with enhanced standard care plus community health worker (CHW) delivered stress management for Latinos with type 2 diabetes. This paper reports intervention design and process outcomes. A formative process was used to develop and implement an eight-session, group stress management intervention. One hundred twenty-one participants completed baseline assessments; n = 107 attended diabetes education and were then randomized. Recruits reported high credibility and treatment expectancies. Treatment fidelity was high. Participants reported high treatment satisfaction and therapeutic alliance and their diabetes knowledge and affect improved over the short term. Retention and attendance at group sessions was challenging but successful relative to similar trials. This comprehensive and culturally sensitive stress management intervention, delivered by a well-trained CHW, was successfully implemented.

Race and referral to diabetes education in primary care patients with prediabetes and diabetes

PURPOSE

The purpose of the study was to determine whether there are any race-related disparities in the prevalence of provisions for diabetes education in primary care clinics for patients with diabetes and prediabetes.

METHODS

A retrospective cross-sectional study of 3967 patients aged 14 to >89 years with prediabetes and diabetes. Medical record data from patient encounters within primary care clinics at a large academic medical health system between July 1, 2008, and July 31, 2013, were used to determine rates of referral for diabetes education by race. Multivariate logistic regression models were used to assess associations between race and referral to diabetes education. Separate regression models were computed for patients who were prediabetic and diabetic. Adjusted models included age, sex, A1C, health care utilization, smoking, and diagnosis for depression, hyperlipidemia, hypertension, vascular disease, and obesity.

RESULTS

Compared to that of white patients, a significantly higher prevalence of African American patients with prediabetes were referred to diabetes education, and this association was also observed in patients with diabetes. In fully adjusted models, white patients with prediabetes were significantly less likely to be referred.

CONCLUSIONS

Being African American independently increased the likelihood of referral for diabetes education in patients with prediabetes and patients with diabetes. After adjusting for patient comorbidities and risk factors, this association remained significant for patients with prediabetes. Additional research is needed to determine if provider beliefs and attitudes regarding race and diabetes education account for this association.

Ethnic differences in family member diabetes involvement and psychological outcomes: results from the second Diabetes Attitudes, Wishes and Needs (DAWN2) study in the USA

OBJECTIVE

To assess differences among USA ethnic groups in psychological status of adult family members (FMs) and their involvement with the diabetes of another adult.

RESEARCH METHODS

Data are from the FM survey of the USA DAWN2 study, including 105 White non-Hispanics, 47 African Americans, 46 Hispanic Americans and 40 Chinese Americans. All FMs lived with and cared for an adult with diabetes. Analysis of covariance controlled for respondent and patient characteristics to assess ethnic group differences (P < 0.05). Multiple regression analyses identified significant (P < 0.05) independent correlates of psychological outcomes.

MAIN OUTCOME MEASURES

FM psychological outcomes measured include well-being, quality of life (QoL), impact of diabetes on life domains, diabetes distress, and burden.

CLINICAL TRIAL REGISTRATION

NCT01507116.

RESULTS

White non-Hispanics reported less diabetes burden and distress, more negative life impact, and lower well-being than FMs from ethnic minority groups. African Americans reported the highest well-being and lowest negative life impact, Chinese Americans reported the most diabetes burden, Hispanic Americans reported the highest distress. There were no ethnic group differences in QoL. Ethnic minority FMs reported having more involvement with diabetes, greater support success, and more access to a diabetes support network than White non-Hispanics. Higher FM diabetes involvement was associated with negative psychological outcomes, while diabetes education, support success and diabetes support network size were associated with better psychological outcomes. Potential limitations are the sample sizes and representativeness.

CONCLUSIONS

Minority ethnic FMs experienced both advantages and disadvantages in psychological outcomes relative to each other and to White non-Hispanics. Ethnic minority FMs had more involvement in diabetes care, support success and support from others, with the first associated with worse and the latter two with better psychological outcomes. Additional studies are needed with larger samples and broader representation of ethnic groups to better understand these associations and identify areas for intervention.