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

First year national Swedish paediatric Hba1c data are at the level of several intervention studies: Results from a Swedish nationwide diabetes register study

AIMS/HYPOTHESIS

To study the progression of HbA1c after diagnosis of type 1 diabetes in children and adolescents during 2010-2019 with emphasis on HbA1c nadir 3-6 months after onset.

METHODS

Partial funding was secured for this study. The Swedish paediatric diabetes quality register SWEDIABKIDS has >95 % coverage of type 1 diabetes up to 18 years. A mixed model for repeated measurements was used to estimate differences in HbA1c between onset year periods.

RESULTS

We followed 6,891 patients over two years from onset (48,292 HbA1c values). We found a gradual decrease in mean HbA1c 24 months after onset from 56.0 mmol/mol (7.28 %) in 2010/11 to 50.5 mmol/mol (6.77 %) in 2018/19, which is at the level of several recent intervention studies. The initial drop in HbA1c from onset until 3 and 6 months has become more pronounced in recent years. There was a significant positive correlation between HbA1c at 3 and 6 months with 12, 18 and 24 months. Percentage of severe hypoglycaemic coma was higher (5.1 % vs 3.4 %; p = 0.023) in 2010/2011 than 2018/2019, but the absolute risk of ketoacidosis was essentially unchanged, (1.5 % to 0.8 %, p = 0.110) CONCLUSIONS/INTERPRETATION: There was a continuous decrease in HbA1c over the study period 2010-2019, which coincides in time with an increased use of diabetes technology and lowering the HbA1c target to 48 mmol/mol (6.5 %). The decrease in 2-year HbA1c was preceded by a lower HbA1c nadir, which may set the trajectories for coming HbA1c and be a modifiable factor for a long-term improvement in metabolic control.

Associations of clinical, psychological, and sociodemographic characteristics and ecological momentary assessment completion in the 10-week Hypo-METRICS study: Hypoglycaemia MEasurements ThResholds and ImpaCtS

INTRODUCTION

Reporting of hypoglycaemia and its impact in clinical studies is often retrospective and subject to recall bias. We developed the Hypo-METRICS app to measure the daily physical, psychological, and social impact of hypoglycaemia in adults with type 1 and insulin-treated type 2 diabetes in real-time using ecological momentary assessment (EMA). To help assess its utility, we aimed to determine Hypo-METRICS app completion rates and factors associated with completion.

METHODS

Adults with diabetes recruited into the Hypo-METRICS study were given validated patient-reported outcome measures (PROMs) at baseline. Over 10 weeks, they wore a blinded continuous glucose monitor (CGM), and were asked to complete three daily EMAs about hypoglycaemia and aspects of daily functioning, and two weekly sleep and productivity PROMs on the bespoke Hypo-METRICS app. We conducted linear regression to determine factors associated with app engagement, assessed by EMA and PROM completion rates and CGM metrics.

RESULTS

In 602 participants (55% men; 54% type 2 diabetes; median(IQR) age 56 (45-66) years; diabetes duration 19 (11-27) years; HbA1c 57 (51-65) mmol/mol), median(IQR) overall app completion rate was 91 (84-96)%, ranging from 90 (81-96)%, 89 (80-94)% and 94(87-97)% for morning, afternoon and evening check-ins, respectively. Older age, routine CGM use, greater time below 3.0 mmol/L, and active sensor time were positively associated with app completion.

DISCUSSION

High app completion across all app domains and participant characteristics indicates the Hypo-METRICS app is an acceptable research tool for collecting detailed data on hypoglycaemia frequency and impact in real-time.

'Didn't See the Need': Misperceptions about glucagon from the perspectives of people with diabetes and their caregivers

AIMS

Severe hypoglycaemia among people with diabetes who use insulin can be a life-threatening complication if left untreated. Although glucagon has been approved for treatment of hypoglycaemia since the 1960s, it has been underutilized. We aimed to understand the perceptions of people with diabetes and their caregivers about glucagon.

METHODS

We conducted in-depth, one-on-one telephone interviews with people with diabetes and their caregivers in the United States. The interviews included questions around general awareness of glucagon, reasons for owning or not owning glucagon, and suggestions for improving understanding of glucagon as treatment for severe hypoglycaemia. Initial synopsis and inductive codebook schema were used to analyse the responses by two independent researchers. Themes were developed from the codes, and codes were re-mapped back to the themes.

RESULTS

There were 60 dyads of people with diabetes and their caregivers (N = 120). Four themes developed from the interviews: (1) for most participants, the stated reasons for not owning or renewing a prescription for glucagon included unawareness of the medication, its advantages and its value; (2) misperceptions about glucagon occurred frequently; (3) caregivers often lacked confidence in administering reconstituted injectable glucagon; and (4) education and training from healthcare providers about glucagon would be welcomed.

CONCLUSIONS

This study emphasizes the need for healthcare providers to discuss hypoglycaemia prevention and events at each clinical visit, including the use of glucagon in the case of severe hypoglycaemia. Healthcare providers are encouraged to assess the knowledge of people with diabetes and their caregivers regarding treatment and prevention of hypoglycaemia.

Psychometric properties of an innovative smartphone application to investigate the daily impact of hypoglycemia in people with type 1 or type 2 diabetes: The Hypo-METRICS app

INTRODUCTION

The aim of this study was to determine the acceptability and psychometric properties of the Hypo-METRICS (Hypoglycemia MEasurement, ThResholds and ImpaCtS) application (app): a novel tool designed to assess the direct impact of symptomatic and asymptomatic hypoglycemia on daily functioning in people with insulin-treated diabetes.

MATERIALS AND METHODS

100 adults with type 1 diabetes mellitus (T1DM, n = 64) or insulin-treated type 2 diabetes mellitus (T2DM, n = 36) completed three daily 'check-ins' (morning, afternoon and evening) via the Hypo-METRICs app across 10 weeks, to respond to 29 unique questions about their subjective daily functioning. Questions addressed sleep quality, energy level, mood, affect, cognitive functioning, fear of hypoglycemia and hyperglycemia, social functioning, and work/productivity. Completion rates, structural validity, internal consistency, and test-retest reliability were explored. App responses were correlated with validated person-reported outcome measures to investigate convergent (rs>±0.3) and divergent (rs<±0.3) validity.

RESULTS

Participants' mean±SD age was 54±16 years, diabetes duration was 23±13 years, and most recent HbA1c was 56.6±9.8 mmol/mol. Participants submitted mean±SD 191±16 out of 210 possible 'check-ins' (91%). Structural validity was confirmed with multi-level confirmatory factor analysis showing good model fit on the adjusted model (Comparative Fit Index >0.95, Root-Mean-Square Error of Approximation <0.06, Standardized Root-Mean-square Residual<0.08). Scales had satisfactory internal consistency (all ω≥0.5), and high test-retest reliability (rs≥0.7). Convergent and divergent validity were demonstrated for most scales.

CONCLUSION

High completion rates and satisfactory psychometric properties demonstrated that the Hypo-METRICS app is acceptable to adults with T1DM and T2DM, and a reliable and valid tool to explore the daily impact of hypoglycemia.

Self-reported Severe and Nonsevere Hypoglycemia in Type 1 Diabetes: Population Surveillance Through the BETTER Patient Engagement Registry: Development and Baseline Characteristics

OBJECTIVES

The BETTER (BEhaviors, Therapies, TEchnologies and hypoglycemic Risk in Type 1 diabetes) registry is a type 1 diabetes population surveillance system codeveloped with patient partners to address the burden of hypoglycemia and assess the impact of new therapies and technologies. The aim of this report was to describe the baseline characteristics of the BETTER registry cohort.

METHODS

A cross-sectional baseline evaluation was performed of a Canadian clinical cohort established after distribution of an online questionnaire. Participants were recruited through clinics, public foundations, advertising and social media. As of February 2021, 1,430 persons ≥14 years of age and living with type 1 diabetes or latent-autoimmune diabetes (LADA) were enrolled. The trial was registered on ClinicalTrials.gov (NCT03720197).

RESULTS

Participants were (mean ± standard deviation) 41.2±15.7 years old with a diabetes duration of 22.0±14.7 years, 62.0% female, 92.1% Caucasian and 7.8% self-reporting as LADA, with 40.9% using a continuous subcutaneous insulin infusion (CSII) system and 78.0% using a continuous glucose monitoring (CGM) system. The most recent glycated hemoglobin ≤7% was reported by 29.7% of participants. At least 1 episode of hypoglycemia <3.0 mmol/L (level 2-H) in the last month was reported by 78.4% of participants, with a median (interquartile range) of 5 (3, 10) episodes. The occurrence of severe hypoglycemia (level 3-H) in the last 12 months was reported by 13.3% of participants. Among these, the median number of episodes was 2 (1, 3).

CONCLUSIONS

We have established the first surveillance registry for people living with type 1 diabetes in Canada relying on patient-reported outcomes and experiences. Hypoglycemia is a highly prevalent burden despite a relatively wide adoption of CSII and CGM use.

The experience of a severe hypoglycaemic event from the perspective of people with diabetes and their caregivers: "What am I going to do?"

AIMS

Among people with diabetes using insulin, severe hypoglycaemia (SH) can be a life-threatening complication, if untreated. The personal experiences during an SH event from the perspectives of people with diabetes and their caregivers are not well-characterized. This study assessed the perceptions of the event and the decision making processes of people with diabetes (T1D n = 36; T2D n = 24) and their caregivers during SH events.

METHODS

In-depth one-on-one telephone interviews were conducted with dyads of people with diabetes and caregivers in the United States (n = 120). An initial synopsis and inductive codebook schema were used to analyse the data with two independent coders (kappa = 0.87-0.89). Themes were developed from the codes, and codes were re-mapped to the themes.

RESULTS

Four themes were formed: (1) Caregivers scramble to do the right thing and support people with diabetes in treating SH; (2) Decision making capacity is impaired during an SH event, often a panicked time; (3) People learn to manage SH events through their own experiences and frequently make lifestyle changes to prevent and treat future events; and (4) Discussion with healthcare providers about SH, and particularly SH treatment, is limited.

CONCLUSIONS

SH events are stressful and often evoke emotional reactions that can impair decision making. Thus, advance treatment planning of SH events needs to occur. Much of the knowledge about SH treatment derives from prior experience rather than healthcare provider guidance, suggesting a need for healthcare providers to initiate proactive discussions about SH treatment.

Factors Associated with Diabetes-Related Distress in Type 2 Diabetes Mellitus Patients

BACKGROUND

Diabetes-related distress is a unique emotional problem that is directly related to the burden and anxieties felt by type 2 diabetes mellitus (T2DM) patients. Diabetes-related distress may lead to pessimism and lower self-efficacy which resulted in a deficiency of self-treatment compliance and can cause further bad glycemic control. Knowing the associated factors of diabetic-related distress and solving them may help T2DM patients improve their glycemic control.

METHODS

This study is an analytical study with cross-sectional design conducted at Sanglah General Hospital from January to April 2021. The data were taken using the consecutive sampling method; 124 samples were collected according to inclusion and exclusion criteria. The participants filled Diabetes Distress Scale questionnaire (DDS17 Bahasa Indonesia). The data analysis was done using univariate (descriptive), bivariate (chi-square) and multivariate (logistic regression) analysis.

RESULTS

Seventy-five subjects out of 124 (60.5%) had diabetes-related distress. The associated factors of diabetes-related distress one among others are the insulin usage as diabetic therapy (OR= 8.30, 95% CI 2.24-30.72; p = 0.002), had a hypoglycaemia in last 3 months (OR=44.59, 95% CI 4.36-455.51; p = 0.001), had diabetes-related retinopathy (OR=10.28, CI 95% 1.54-68.70; p=0.016), and lack of family support (OR=44.791, 95% CI 10.02-200.22; p < 0.001).

CONCLUSION

Our present study revealed that diabetes distress prevalence is predominantly and associated among in type 2 diabetes mellitus. We suggest diabetes-related distress screening and regular health promotion which focus on relationship between diabetes and psychological may be a great potential action to improve public health and patient outcomes.

Quality of life, burden of treatment, safety, and avoidance of future events (QBSAfe) protocol: a pilot study testing an intervention to shift the paradigm of diabetes care

Background

Diabetes care has been traditionally focused on targeting certain levels of glycemic control. This narrow emphasis may impose burdens on patients, including high treatment costs, illness-related work, or side effects from medications, while leaving other patient needs and goals under-addressed. The authors aim to shift the paradigm of care for people with diabetes, to focus on quality of life, burden of treatment, safety, and avoidance of future events: the QBSAfe domains.

Methods

We describe a single-arm pilot study to assess the feasibility and acceptability of using the QBSAfe agenda setting kit (ASK) during routine clinical visits. The set of 14 conversation aid cards was co-developed with patients, family caregivers, and clinicians. The ASK will be used in the context of a clinic visit, which will be recorded by members of the study team to identify patterns of clinician-patient conversations. Feasibility will be measured by the number of participants recruited, time to goal accrual, and completeness of data collection; acceptability will be assessed using post-visit surveys of patients and clinicians. A subgroup of patients will be invited to participate in post-visit qualitative semi-structured interviews for additional feedback. This study will be conducted across three medical centers in the Midwest and East Coast of the USA.

Discussion

Current healthcare infrastructure and associated demands and pressures on clinicians make changes in care difficult. However, this intervention has the potential to shift conversations during clinical encounters so they can address and directly respond to patient needs, symptoms, and capacity. As part of the QBSAfe ASK, the authors are also actively collaborating with a variety of stakeholders to create tools to help clinicians respond more effectively to patient concerns as they are raised during the clinical encounters. Additional insights about the use of the QBSAfe approach in the virtual space will be gathered during the process of our study due to restrictions imposed upon face to face visit during the COVID-19 pandemic.

Trial registration

ClinicalTrials.gov, NCT04514523. Registered 17 August 2020—retrospectively registered.

The impact of hypoglycaemia on the quality of life of family members of adults with type 1 or type 2 diabetes: A qualitative systematic review

AIM

To summarize and critically appraise the recent qualitative evidence regarding the impact of hypoglycaemia on the quality of life of family members of adults with type 1 or type 2 diabetes.

METHODS

Four databases were searched systematically (MEDLINE, PsycINFO, CINAHL and Cochrane Library), and results were screened for eligibility. Article quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Qualitative Research. Data were extracted, coded and analysed using thematic analysis. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Enhancing transparency in reporting of qualitative research (ENTREQ) guidelines.

RESULTS

Eight qualitative studies were included in the final review. The majority of participants were partners or spouses of adults with type 1 diabetes. Thematic synthesis resulted in six analytical themes: 'Hypoglycaemia alters everyday life, reducing freedoms and increasing disruptions', 'Hypoglycaemia has an adverse impact on sleep', 'Hypoglycaemia negatively changes the relationship with the person with diabetes', 'Hypoglycaemia negatively impacts emotional well-being', 'The detection, prevention, and treatment of hypoglycaemia consumes time and energy' and 'Family members have unmet needs for informational and emotional support regarding hypoglycaemia'. Across the six analytical themes, family members described how hypoglycaemia has a severe negative impact on different aspects of their lives, including daily living, personal relationships and emotional well-being.

CONCLUSIONS

Family members experience the impact of hypoglycaemia as a major recurrent challenge in their lives. The unmet needs of family members need further attention in research and clinical practice.

Economic burden of diabetes-related hypoglycemia on patients, payors, and employers

The economic and psychological consequences of diabetes-related hypoglycemic events are multifold and shared across various parties, including patients and their family or caregivers, payors, and employers. Hypoglycemic events contribute to increased morbidity, mortality, and a substantial portion of diabetes economic burden. Both severe and non-severe hypoglycemic episodes contribute to economic and psychological burden, and can have short-term consequences, such as emergency services, hospitalization, clinic visits, and increased use of diabetes supplies. Severe hypoglycemic events also generate additional follow-up costs, and are likely to occur again. Left untreated, hypoglycemia can have long-term consequences including, death, cardiovascular events, and cognitive issues. Costs vary geographically based on the treatment protocols which focus on outpatient treatment versus increased in-patient hospitalization. Certain types of medications are also associated with increased hypoglycemia, which requires closer monitoring of the patient, such as with basal insulin initiation. Some individuals with diabetes may be more vulnerable to hypoglycemia, such as the elderly, postoperative bariatric patients, and adolescent females. Measures to mitigate hypoglycemia are essential to ease the economic burden of these events. Medication management, optimal glucose control, lifestyle modifications and frequent glucose monitoring are some interventions which may help prevent hypoglycemia.

Spouse's Diabetes Status and Incidence of Depression and Anxiety: An 18-Year Prospective Study

OBJECTIVE

We investigated the risk of depression and anxiety in people whose spouse did or did not have diabetes. We also examined associations between depression and anxiety and severity of spouse's diabetes.

RESEARCH DESIGN AND METHODS

We analyzed prospective self-reported data about diagnosed depression/anxiety and diabetes in cohabiting couples in the national Panel Study of Income Dynamics (PSID) during 1999-2017 (n = 13,500, 128,833 person-years of follow-up, median follow-up 8.1 years). We used Poisson models to estimate incidence and incidence rate ratios (IRRs) of depression/anxiety, according to spouse's diabetes status overall and by severity of diabetes.

RESULTS

Age-, sex-, and race-adjusted incidence of depression/anxiety was 8.0/1,000 person-years (95% CI 6.5, 9.6) among those whose spouse had diabetes and 6.5/1,000 person-years (95% CI 6.0, 6.9) among those whose spouse did not have diabetes. Those whose spouse had diabetes had higher risk of depression/anxiety (IRR 1.24 [95% CI 1.01, 1.53]). Those whose spouse had diabetes-related limitations in daily activities (IRR 1.89 [95% CI 1.35, 2.67]) and diabetes combined with other chronic conditions (IRR 2.34 [95% CI 1.78, 3.09]) were more likely to develop depression/anxiety, while those whose spouse had diabetes with no limitations or additional chronic conditions had incidence of depression/anxiety similar to that of subjects whose spouses did not have diabetes.

CONCLUSIONS

People living with a spouse with diabetes are at higher risk of developing depression/anxiety than people whose spouse does not have diabetes; this risk is driven by the severity of the spouse's diabetes. Strategies to address the impacts of diabetes on families need to be devised and tested.

Differences in Importance Attached to Drug Effects Between Patients With Type 2 Diabetes From the Netherlands and Turkey: A Preference Study

Objective: The aim of this study was to compare the importance that patients with type 2 diabetes mellitus from the Netherlands and Turkey attach to certain drug effects of oral anti-diabetic drugs. Methods: Data were collected through a cross-sectional survey containing demographic questions and a discrete choice experiment assessing preferences for oral anti-diabetic drugs. Adults from the Netherlands and Turkey were included if they had type 2 diabetes mellitus and had received a prescription of an oral anti-diabetic drug in the last 4 months. The oral anti-diabetic drugs in the discrete choice experiment were described in terms of six attributes: effects on HbA1c, cardiovascular diseases, weight change, gastrointestinal adverse drug events hypoglycemic events, and bladder cancer. Multinomial logit models with country as an interaction factor were fitted. Results: In total, 381 patients were included, 199 from the Netherlands and 182 from Turkey. Patients' preferences toward drug effects varied between the countries. Turkish patients attached the highest importance to reducing the risk of cardiovascular diseases (relative weight: 0.51, 95% CI 0.45-0.55), followed by reducing hypoglycemic events (relative weight: 0.16, 95% CI 0.11-0.22), and reducing gastrointestinal adverse drug events (relative weight: 0.11, 95% CI 0.07-0.18). Patients from the Netherlands attached the highest importance to gastrointestinal ADEs (relative weight: 0.22, 95% CI 0.14-0.39), followed by reducing hypoglycemic events (relative weight: 0.22, 95% CI 0.16-0.25), and reducing the risk of cardiovascular diseases (relative weight: 0.20, 95% CI 0.13-0.23). Conclusion: Patient preferences may differ across countries. Such differences should be acknowledged in regulatory decisions and clinical practice.

Family Members: The Forgotten Players in the Diabetes Care Team (The TALK-HYPO Study)

INTRODUCTION

The objective of this study was to establish the burden of hypoglycemia on family members of people with diabetes (PWDs) and to gain an understanding of how conversations about hypoglycemia can contribute to diabetes care.

METHODS

This was a multinational cross-sectional study of family members of people with type 1 or type 2 diabetes taking insulin and/or secretagogues for ≥ 12 months who voluntarily completed an online questionnaire.

RESULTS

Overall, 4300 family members of PWDs (type 1 [29%], type 2 [46%], unknown [25%]) were surveyed. Two in three family members (66%) reported thinking about the hypoglycemia of the PWD at least monthly, and 64% felt worried or anxious about the PWD's risk for hypoglycemia. There was general agreement among family members that more conversations about hypoglycemia would have a positive impact on the PWD's life (76%).

CONCLUSIONS

Hypoglycemia can present a burden on the lives of family members of PWDs. Conversations about hypoglycemia, facilitated by a healthcare professional, may reduce this burden and hypoglycemia risk.

FUNDING

Novo Nordisk A/S.

Type D personality and social relations in adults with diabetes: results from diabetes MILES - The Netherlands

OBJECTIVE

To examine whether individual differences in Type D personality (combination of negative affectivity (NA) and social inhibition (SI)) could explain heterogeneity in perceived social support and relationship adjustment (intimate partner relationship) among people living with diabetes.

DESIGN

In the Diabetes MILES-The Netherlands survey, 621 adults with type 1 or type 2 diabetes (54% female, age: 56 ± 14 years) completed measures of Type D personality (DS14), perceived social support and relationship adjustment. We used established DS14 cut-off scores to indicate Type D personality, high NA only, high SI only and reference groups.

RESULTS

Participants from the Type D and NA only groups perceived lower levels of social support (Welch[3,259] = 37.27, p < 0.001), and relationship adjustment (Welch[3,191] = 14.74; p < 0.01) than those from the SI only and reference groups. Type D was associated with lower social support (lowest quartile; adjusted OR = 8.73; 95%CI = 5.05 ∼ 15.09; p < 0.001) and lower relationship adjustment (lowest quartile; adjusted OR = 3.70; 95%CI = 2.10 ∼ 6.53; p < 0.001). Type D was also associated with increased levels of loneliness.

CONCLUSION

Participants with Type D and participants with high NA only tend to experience less social support and less relationship adjustment. Type D personality was also associated with more loneliness. Experiencing lower social support and relationship adjustment may complicate coping and self-management in people with diabetes.