Structured type 1 diabetes education delivered within routine care: impact on glycemic control and diabetes-specific quality of life

Evaluation of Cardiovascular Risk in People with Type 1 Diabetes: A Comprehensive and Specific Proposed Practical Approach

People living with type 1 diabetes (T1D) have an increased risk of cardiovascular disease (CVD), and it is the leading cause of morbidity and mortality in this population. CVD risk increases with each uncontrolled risk factor, even in individuals with good glycaemic control. Recommendations for assessing CVD risk in the T1D population are extended from those for type 2 diabetes (T2D) even though the physiopathology and underlying mechanisms of atherosclerosis in T1D are poorly understood and differ from those in T2D. Unlike the assessment of microvascular complications, which is well established in T1D, this is far from being the case for the comorbidities and risk associated with CVD. Aside from classical cardiovascular comorbidities, carotid ultrasound can be useful to stratify CVD risk. The utilization of specific risk scales such as the Steno Type 1 Risk Engine can help to more accurately classify cardiovascular risk in these individuals. The cornerstones of the management of cardiovascular risk in T1D are the promotion of the Mediterranean diet, tight glycaemic control (glycated haemoglobin (HbA1c) < 7%), blood pressure < 130/80 mmHg in most patients, and low-density lipoprotein (LDL) cholesterol < 100 mg/dL in moderate-risk individuals, < 70 mg/dL in high-risk individuals, and < 55 mg/dL in very high-risk individuals. Conventional medical follow-up of patients with T1D should be individualized (approximately 2-3 visits per year), and a carotid ultrasound evaluation is recommended every 5 years in the absence of significant preclinical atherosclerosis or more often in those with severe preclinical atherosclerosis. Antithrombotic therapy is recommended in those receiving secondary prevention, those with stenosis > 50% in any arterial bed, and those with an impaired ankle-brachial index. This document is a proposal of a practical approach for the evaluation, classification, and management of CVD risk in individuals living with T1D.

Simplified integration of optimal self-management behaviors is associated with improved HbA1c in patients with type 1 diabetes

PURPOSE

Living with type 1 diabetes requires burdensome and complex daily diabetes self-management behaviors. This study aimed to determine the association between integrated behavior performance and HbA1c, while identifying the behavior with the most significant impact on HbA1c.

METHODS

A simple and feasible questionnaire was used to collect diabetes self-management behavior in patients with type 1 diabetes (n = 904). We assessed six dimensions of behavior performance: continuous glucose monitor (CGM) usage, frequent glucose testing, insulin pump usage, carbohydrate counting application, adjustment of insulin doses, and usage of apps for diabetes management. We evaluated the association between these behaviors and HbA1c.

RESULTS

In total, 21.3% of patients performed none of the allotted behavior, while 28.5% of patients had a total behavior score of 3 or more. 63.6% of patients with a behavior score ≥ 3 achieved HbA1c goal, contrasting with only 30.4% of patients with a behavior score of 0-1. There was a mean 0.54% ± 0.05% decrease in HbA1c for each 1-unit increase in total behavior score after adjustment for age, family education and diabetes duration. Each behavior was independently correlated with a lower HbA1c level, with CGM having the most significant effect on HbA1c levels.

CONCLUSIONS

Six optimal self-management behaviors, especially CGM usage, were associated with improved glycemic control, emphasizing the feasibility of implementing a simplified version of DSMES in the routine clinical care.

REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT03610984.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effectiveness of educational and behavioural interventions for reducing fear of hypoglycaemia among adults with type 1 diabetes: Systematic review and meta-analyses

AIMS

To summarize and critically appraise evidence regarding the effectiveness of educational and/or behavioural interventions in reducing fear of hypoglycaemia among adults with type 1 diabetes.

METHODS

Systematic searches of medical and psychology databases were conducted. Risk-of-bias was assessed using the Joanna Briggs Institute Critical Appraisal Tools. Data were synthesized using random-effects meta-analyses for randomized controlled trials (RCTs) and narrative synthesis for observational studies.

RESULTS

Five RCTs (N = 682) and seven observational studies (N = 1519) met the inclusion criteria, reporting on behavioural, structured education and cognitive-behavioural therapy (CBT) interventions. Most studies assessed fear of hypoglycaemia using the Hypoglycaemia Fear Survey Worry (HFS-W) and Behaviour (HFS-B) subscales. Mean fear of hypoglycaemia at baseline was relatively low across studies. Meta-analyses showed a significant effect of interventions on HFS-W (SMD = -0.17, p = 0.032) but not on HFS-B scores (SMD = -0.34, p = 0.113). Across RCTs, Blood Glucose Awareness Training (BGAT) had the largest effect on HFS-W and HFS-B scores, and one CBT-based program was as effective as BGAT in reducing HFS-B scores. Observational studies showed that Dose Adjustment for Normal Eating (DAFNE) was associated with significant fear of hypoglycaemia reductions.

CONCLUSIONS

Current evidence suggests that educational and behavioural interventions can reduce fear of hypoglycaemia. However, no study to date has examined these interventions among people with high fear of hypoglycaemia.

5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Analysis of Healthy Coping Feedback Messages from Diabetes Mobile Apps: Validation Against an Evidence-Based Framework

BACKGROUND

In this study, we focused on Healthy Coping, a key principle of ADCES7 Self-Care Behaviors^® (ADCES7^®) that enables people with diabetes to achieve health goals for self-care. We aimed to validate Healthy Coping-related feedback messages from diabetes mobile apps against the framework based on behavioral change theories.

METHODS

We searched apps using the search terms: "diabetes," "blood sugar," "glucose," and "mood" from iTunes and Google Play stores. We entered a range of values on 3 Healthy Coping domains: (1) diabetes-related measures including blood glucose, blood pressure, HbA1c, weight, (2) physical exercise/activity, and (3) mood to generate feedback messages. We used a framework by adopting validated behavioral change theory-based models to evaluate the feedback messages against 3 dimensions of timing, intention, and content (feedback purpose and feedback response). The feedback purposes in this study were categorized into 7 purposes; warning, suggestion, self-monitoring, acknowledging, reinforcement, goal setting, and behavior contract.

RESULTS

We identified 1,749 apps from which 156 diabetes mobile apps were eligible and generated 473 feedback messages. The majority of generated feedback messages were related to blood sugar measurement. Only feedback messages on blood sugar under diabetes-related measures and mood domains encompassed all 7 feedback purposes under the content dimension.

CONCLUSIONS

Many feedback messages neither supported Healthy Coping domains nor followed the behavioral theory-based framework. It is important that feedback messages be structured around the dimensions of the behavioral theory-based framework to promote behavior change. Furthermore, our framework had the generalizability that can be used in other clinical areas.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh

Objectives

Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).

Methods

Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children's hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).

Results

A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value  < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).

Conclusion

Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Dietitians' perspectives on challenges and prospects for group-based education to adults with type 1 diabetes - a qualitative study

BACKGROUND

Type 1 diabetes (T1DM) is an autoimmune disorder which can have short- and long-term adverse effects on health. Dietitians in diabetes offer specialist evidence-based advice to people with T1DM and provide education in either individual or group settings. The purpose of this study was to explore dietitians' perception of, and role in, group-based education as well as prospects for development.

METHODS

This was a qualitative descriptive study conducted in Sweden using a convenience sampling of dietitians working in adult diabetes care. Semi-structured interviews were conducted with participants and data were analysed using a content analysis approach.

RESULTS

Ten dietitians with a median experience of 14.5 years in diabetes care were interviewed. The informants were all appreciative of facilitating group-based education and perceived that it was beneficial for people with T1DM to be part of group processes, but the informants did also suggest that there were challenges for their professional role. The main challenges reported was to adjust the level of depth and complexity to the information provided and the lack of ability to individualize the education-sessions in a heterogenous group. None of the dietitians reported performing pre-assessment or follow-up audits on the group-based education.

CONCLUSION

There was a great engagement from the dietitians, but they identified a lack of framework that address challenges regarding group-based education. The dietitians experienced examples of person-centred care while facilitating group-based education, which may benefit people with T1DM. Based on the results, it would be valuable to explore the pedagogic training level of Swedish dietitians and potential barriers in their ability to facilitate group-based education. We suggest that a framework for group-based education should be explored together with patient representatives to optimize the care given to ensure cost-effectiveness, optimize clinical outcomes, quality of life and equally accessible care for people with T1DM.

Evaluating implementation of Diabetes Self-Management Education in Maryland County, Liberia: protocol for a pilot prospective cohort study

INTRODUCTION

Achieving glycaemic targets for people living with diabetes (PLWD) is challenging, especially in settings with limited resources. Programmes need to address gaps in knowledge, skills and self-management. Diabetes Self-Management Education (DSME) is an evidence-based intervention to educate and empower PLWD to improve self-management activities. This protocol describes a pilot study assessing the feasibility, acceptability and effect on clinical outcomes of implementing DSME in clinics caring for people living with insulin-dependent diabetes in Liberia.

METHODS AND ANALYSIS

Our protocol is a three-phased, mixed-methods, quasi-experimental prospective cohort study. Phase 1 focuses on (a) establishing a Patient Advisory Board and (b) training providers in DSME who provide care for PLWD. In phase 2, clinicians will implement DSME. In phase 3, we will train additional providers who interact with PLWD.We will assess whether this DSME programme can lead to increased provider knowledge of DSME, improvements in diabetes self-management behaviours, glycaemic control, diabetes knowledge and psychosocial well-being, and a reduction in severe adverse events. Primary outcomes of interest are implementation outcomes and change in frequency of self-management behaviours by patients. Secondary outcomes include change in haemoglobin A1c, psychosocial well-being, severe adverse events and change in provider knowledge of DSME.

ETHICS AND DISSEMINATION

Ethical approval was obtained from the University of Liberia Institutional Review Board (IRB) and the Brigham and Women's Hospital IRB. Findings from the study will be shared with local and national clinical and programmatic stakeholders and published in an open-access, peer-reviewed journal.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Socioeconomic deprivation is associated with reduced efficacy of an insulin adjustment education program for people with type 1 diabetes

BACKGROUND

The Dose Adjustment for Normal Eating (DAFNE) course teaches insulin dose adjustment to match dietary carbohydrates and improve glycaemic control in participants with type 1 diabetes mellitus (T1DM). We investigated the association between socioeconomic deprivation and reduction in HbA1c as a marker of sustained glycaemic control, after attending DAFNE education.

METHODS

This retrospective observational study identified adults with T1DM who attended DAFNE training in NHS Lothian, South East Scotland. We extracted age, sex, postcode-based Scottish Index of Multiple Deprivation (SIMD) quintiles and annual HbA1c measurements available four years before and after course attendance. We calculated mean HbA1c before (baseline) and after attendance at DAFNE, across four annual measurements. Change in mean HbA1c (mmol/mol) was categorised into three groups: decrease (≥ - 2.5), no change (<±2.5), increase (≥ + 2.5). We used multivariable ordinal logistic regression, with baseline mean HbA1c as a covariate, to investigate the association of SIMD quintile with reduction in mean HbA1c.

RESULTS

335 participants were included. Age and sex distribution were similar across SIMD quintiles (Mean age = 45, range 21-91, 59% women). Lower SIMD quintiles (greater deprivation) had higher baseline mean HbA1c (SIMD 1: 76.0, SIMD 5: 69.0). Higher SIMD quintiles (lower deprivation) were associated with lower odds of no change/increase in mean HbA1c (SIMD 5, odds ratio = 0.25, 95% confidence interval 0.10, 0.58, p = 0.001, multivariable analysis).

CONCLUSION

Socioeconomic deprivation was associated with higher baseline mean HbA1c and lower reduction in HbA1c following DAFNE education. Future research could explore causes and how best to support participants from deprived areas.

PREVIOUS SUBMISSIONS

This work has not been previously submitted to a journal. This work was presented as a poster at The ABCD Conference 2021 and the abstract (of no more than 300 words) from the meeting has been published: Innes CWD, Henshall DE, Wilson B, Poon M, Morley SD, Ritchie SA. Socioeconomic deprivation is associated with reduced efficacy of an insulin adjustment education programme for people with type 1 diabetes. Br J Diabetes. 2021; 21: 293-296.

A Telehealth Diabetes Intervention for Rural Populations: Protocol for a Randomized Controlled Trial

Background

Diabetes self-management education and support (DSMES) is a crucial component of diabetes care associated with improved clinical, psychosocial, and behavioral outcomes. The American Association of Diabetes Care and Education Specialists, the American Diabetes Association, and the American Academy of Family Physicians all recommend DSMES yet accessing linguistically and culturally appropriate DSMES is challenging in rural areas. The Diabetes One-Day (D1D) program is an established DSMES group intervention that has not been adapted or evaluated in rural communities.

Objective

The specific aims of this paper are (1) to adapt the existing D1D program for use in rural communities, called rural D1D (R-D1D); and (2) to conduct a patient-level randomized controlled trial to examine the effects of R-D1D and standard patient education, guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework.

Methods

This is a protocol for a pilot type II hybrid implementation-effectiveness trial of a culturally adapted virtual DSMES program for rural populations, R-D1D. We will use Boot Camp Translation, a process grounded in the principles of community-based participatory research, to adapt an existing DSMES program for rural populations, in both English and Spanish. Participants at 2 rural primary care clinics (4 cohorts of N=16 plus care partners, 2 in English and 2 in Spanish) will be randomized to the intervention or standard education control. The evaluation is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. Patient-level effectiveness outcomes (hemoglobin A_1c, diabetes distress, and diabetes self-care behaviors) will be assessed using patient-reported outcomes measures and a home A_1c test kit. Practice-level and patient-level acceptability and feasibility will be assessed using surveys and interviews.

Results

This study is supported by the National Institute of Nursing. The study procedures were approved, and the adaptation processes have been completed. Recruitment and enrollment started in July 2021.

Conclusions

To our knowledge, this will be the first study to evaluate both effectiveness and implementation outcomes for virtually delivered DSMES, culturally adapted for rural populations. This research has implications for delivery to other rural locations where access to specialty diabetes care is limited.

Trial Registration

ClinicalTrials.gov NCT04600622; https://clinicaltrials.gov/ct2/show/NCT04600622

International Registered Report Identifier (IRRID)

DERR1-10.2196/34255

Informing a Randomized Control Trial in Rural Populations: Adaptation of a Diabetes Self-Management Education and Support Intervention

BACKGROUND

Over 34 million people in the United States have diabetes, with 1.5 million diagnosed every year. Diabetes self-management education and support (DSMES) is a crucial component of treatment to delay or prevent complications. Rural communities face many unique challenges in accessing DSMES, including geographic barriers and availability of DSMES programs that are culturally adapted to rural context.

OBJECTIVE

Boot Camp Translation (BCT) is an established approach to community-based participatory research used to translate complex clinical and scientific information into concepts, messages, and materials that are understandable, meaningful, and relevant to community members and patients. This study aimed to utilize BCT to adapt an existing DSMES program for delivery in rural primary care for English- and Spanish-speaking people with diabetes.

METHODS

The High Plains Research Network (HPRN) Community Advisory Council (C.A.C.) partnered with researchers at the University of Colorado and University of Utah to use BCT to aid in translating medical jargon and materials from an existing DSMES program, called "Diabetes One Day (D1D)." BCT consisted of 10 virtual meetings over a 6-month period among the C.A.C., which included 15 diverse community stakeholders. Both English-speaking and bilingual Spanish-English-speaking C.A.C. members were recruited to reflect the diversity of the rural communities in which the adapted program would be delivered.

RESULTS

The BCT process guided adaptations to D1D for use in rural settings (R-D1D). R-D1D adaptations reflect both content and delivery to assure that the intervention is appropriate and likely to be accepted by rural English- and Spanish-speaking people with diabetes. Additionally, BCT informed the design of recruitment and program materials and identification of recruitment venues. During the BCT process, the importance of tailoring materials to reflect culture differences in English- and Spanish-speaking patients was identified.

CONCLUSIONS

BCT was an effective strategy for academic researchers to partner with rural community members to adapt an existing DSMES intervention for delivery in rural areas to both English- and Spanish-speaking patients with diabetes. Through BCT, adaptations to recruitment materials and methods, program content and delivery, and supplemental materials were developed. The need to culturally adapt Spanish materials with input from stakeholders rather than simply translate materials into Spanish was highlighted. The importance of increasing awareness of the connection between diabetes and depression or diabetes distress, adaptations to include local foods, and the importance of the relationship between people with diabetes and their primary care practices were identified.

Care Partner Support Following a Diabetes Self-Management Education and Support Intervention

PURPOSE

The purpose of the study was to understand care partner (CP) perceptions of an interdisciplinary diabetes self-management education and support (DSMES) intervention and explore how the interdisciplinary DSMES intervention influences diabetes-specific day-to-day interactions from the CP's perspective.

METHODS

A multiple-methods research design comprised of an online survey including demographics and supportive behaviors and a semistructured interview was conducted. The survey was completed by 16 CPs. Of the 16 CPs, 11 participated in semistructured interviews. Survey data were analyzed using descriptive statistics. Thematic analysis of semistructured interviews was conducted.

RESULTS

CPs provided support in 3 primary areas: (1) meal planning and preparation (87.5%), (2) participating in physical activity (56.3%), and (3) assisting with technology (43.8%). The main themes described by CPs include (1) the importance of diabetes education for caregivers, including the information they retained from the program, the acquisition of tools to support the person with diabetes, and the desire for more and ongoing education; (2) diabetes education enhances the CP's ability to provide social support and the challenges associated with support; and (3) partners described collaborative diabetes management such as finding middle ground and making changes together.

CONCLUSION

CPs play a significant role in patient diabetes self-management by providing social support and partnership. DSMES programs should seek to include CPs to enhance patient support.

SEE-Diabetes, a patient-centered diabetes self-management education and support for older adults: Findings and information needs from patients' perspectives

AIMS

This study identified the information needs of people with diabetes aged 65 and older through surveys and focus groups to inform the development of a patient-centered educational decision aid for diabetes care, SEE-Diabetes (Support-Engage-Empower-Diabetes).

METHODS

We conducted survey (N = 37) and three focus groups (N = 9). The survey collected demographics, diabetes duration, insulin usage, and clinic notes accessibility through a patient portal. In focus groups, participants evaluated the Assessment and Plan section of three selected deidentified clinic notes to assess readability and helpfulness for diabetes care.

RESULTS

The mean age of participants was 66 (24-82, SD = 12), and 22 were female (60%). The mean diabetes duration was 20.9 years (1-63, SD=15). Most participants (80%) read their clinical notes via patient portal. In the focus groups, the readability of clinic notes was noted as a primary concern because of medical abbreviations and poor formatting. Participants found the helpfulness of clinic notes was negatively impacted by vague or insufficient self-care information.

CONCLUSIONS

We found the high use of patient portal for reading clinic notes, which offers a use case opportunity for the proposed SEE-Diabetes educational aid. Feedback about the readability and helpfulness of clinic notes will be considered during the design process.

Diabetes Education and Support Tele-Visit Needs Differ in Duration, Content, and Satisfaction in Older Versus Younger Adults

BACKGROUND

Diabetes education and support are critical components of diabetes care. During the COVID-19 pandemic, when telemedicine took the place of in-person visits, remote Certified Diabetes Care and Education Specialist (CDCES) services were offered to address diabetes education and support. Specific needs for older adults, including the time required to provide education and support remotely, have not been previously reported.

METHODS

Adults with diabetes (primarily insulin-requiring) were referred to remote CDCESs. Utilization was individualized based on patient needs and preferences. Topics discussed, patient satisfaction, and time spent in each tele-visit were evaluated by diabetes type, age, sex, insurance type, glycosylated hemoglobin (HbA1c), pump, and continuous glucose monitor (CGM) usage. t-Tests, one-way analysis of variance, and Pearson correlations were employed as appropriate.

RESULTS

Adults (n = 982; mean age 48.4 years, 41.0% age ≥55 years) with type 1 diabetes (n = 846) and type 2 diabetes mellitus (n = 136, 86.0% insulin-treated), 50.8% female; 19.0% Medicaid, 29.1% Medicare, 48.9% private insurance; mean HbA1c 8.4% (standard deviation 1.9); and 46.6% pump and 64.5% CGM users had 2203 tele-visits with remote CDCESs over 5 months. Of those referred, 272 (21.7%) could not be reached or did not receive education/support. Older age (≥55 years), compared with 36-54 year olds and 18-35 year olds, respectively, was associated with more tele-visits (mean 2.6 vs. 2.2 and 1.8) and more time/tele-visits (mean 20.4 min vs. 16.5 min and 14.8 min; p < 0.001) as was coverage with Medicare (mean 2.8 visits) versus private insurance (mean 2.0 visits; p < 0.001) and lower participant satisfaction. The total mean time spent with remote CDCESs was 53.1, 37.4, and 26.2 min for participants aged ≥55, 36-54, and 18-35 years, respectively. During remote tele-visits, the most frequently discussed topics per participant were CGM and insulin pump use (73.4% and 49.7%). After adjustment for sex and diabetes type, older age was associated with lack of access to a computer, tablet, smartphone, or internet (p < 0.001), and need for more education related to CGM (p < 0.001), medications (p = 0.015), hypoglycemia (p = 0.044), and hyperglycemia (p = 0.048).

DISCUSSION

Most remote CDCES tele-visits were successfully completed. Older adults/those with Medicare required more time to fulfill educational needs. Although 85.7% of individual sessions lasted <30 min, which does not meet current Medicare requirements for reimbursement, multiple visits were common with a total time of >50 min for most older participants. This suggests that new reimbursement models are needed. Education/support needs of insulin-treated older adults should be a focus of future studies.

Patient education for people living with diabetes in the Philippines: A scoping review of information needs, diabetes knowledge and effectiveness of educational interventions

BACKGROUND AND AIMS

Despite the growing burden of diabetes in the Philippines, available evidence indicates that its care and control are far from optimal, including patient education. The aim of this scoping review was to synthesize information in the available literature to describe the state of science of patient education for people living with diabetes in the Philippines, specific to educational needs, diabetes knowledge, and effectiveness of educational interventions.

METHODS

Medline, Embase, Emcare, CINAHL, Pubmed and American Psychological Association PsycInfo were searched from data inception through July 2021. Studies of any methodology (qualitative/quantitative/mixed methods), sample size, and language were eligible for inclusion.

RESULTS

Of 2021 initial citations, 7 studies were included, with all being quantitative in design and with a median Critical Appraisal Skills Program score of 8/12. Information needs were described by one study and related to self-care abilities. Diabetes knowledge was measured in 6 studies and improved significantly after educational interventions. Overall, studies showed that educational interventions significantly impacted self-efficacy, anthropometric measures, hemoglobin A1c levels, utilization of care and routine programme and attitudes regarding their health.

CONCLUSIONS

The findings highlight the importance of a comprehensive and culturally appropriate educational intervention for this population. Further research is needed to develop such intervention and assess its effectiveness to change behaviour, such as increasing physical activity.

The Effects of Diabetes Self-Management Education on Quality of Life for Persons With Type 1 Diabetes: A Systematic Review of Randomized Controlled Trials

PURPOSE

It is well documented that chronic conditions, such as diabetes, impact quality of life (QoL). QoL assessment is essential when developing and evaluating diabetes self-management education support interventions. The aim of this systematic review was to evaluate the evidence and gaps in the research and the impact of diabetes self-management education (DSME) on QoL outcomes in persons with type 1 diabetes mellitus (T1DM).

METHODS

A systematic review of English language studies published between January 1, 2007, and March 31, 2020, was conducted using a modified Cochrane review method. Studies were included if they were randomized controlled trials (RCTs), participants had T1DM with or without caregivers, a DSME intervention alone or a component(s) of the ADCES7™ Self-Care Behaviors was described, and QoL was a primary or secondary outcome. A 3-tiered review process was utilized for selecting articles. Retained articles were assessed for risk of bias.

RESULTS

Nineteen articles, reporting on 17 RCTs, met inclusion criteria, of which 7 studies reported QoL as the primary outcome and 10 as a secondary outcome. Seven studies detected significant impact of DMSE on QoL outcomes in either the participants or family caregivers, which varied in participant populations, selection of QoL tools (generic vs diabetes-specific), intervention type, intervention length, and type of interventionist.

CONCLUSION

DSME has the potential to influence QoL outcomes in people with T1DM. Research using more standardized methods are needed to delineate impact on a broader range of factors that influence QoL for those living with T1DM across the life span and their caregivers.

Improving Quality Outcomes: The Value of Diabetes Care and Education Specialists

Given the growing prevalence and accelerating cost of diabetes, there is an urgent need to expand strategies in health care that improve access and outcomes and reduce the financial and human burden of the disease. Diabetes care and education specialists (DCESs) are well positioned to assist health care systems with delivery models that enhance diabetes care through evidence-based standards and quality improvement strategies. DCESs have increased opportunities to apply their competencies in primary, specialty, hospital, and acute care settings; accountable care organizations; community settings; research; and academia. Two national certification programs provide an evidence-based foundation for quality in the specialty, with updated competencies guiding practice. This article serves as a call to action for health care systems to integrate specialists in diabetes care and education into diabetes care delivery models and raise awareness of the positive impact these professionals have on the lives of people with diabetes.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Effects of physician's diabetes self-management education using Japan Association of Diabetes Education and Care Diabetes Education Card System Program and a self-monitoring of blood glucose readings analyzer in individuals with type 2 diabetes: An exploratory, open-labeled, prospective randomized clinical trial

AIMS/INTRODUCTION

This 6-month, single-center, prospective, open-labeled, randomized trial was designed to investigate whether physicians' diabetes self-management education using an education tool developed by the Japan Association of Diabetes Education and Care and a self-monitoring of blood glucose (SMBG) analyzer improves glycemic control in individuals with type 2 diabetes receiving insulin and SMBG.

MATERIALS AND METHODS

Participants were randomized into intervention (I) and control (C) groups. Both groups received physicians' diabetes self-management education at each hospital visit, whereas the Japan Association of Diabetes Education and Care education tool and the SMBG readings analyzer was used in group I, but not group C. All participants filled out a diabetes treatment-related quality of life form and an original questionnaire on SMBG use with five questions (Q1-Q5) before and after the study period.

RESULTS

A total of 76 individuals were recruited and randomized. Glycated hemoglobin (HbA1c) was significantly improved during the study period in group I, whereas no significant change was observed in group C. The change in HbA1c was greater in group I, although it did not reach statistical significance. The diabetes treatment-related quality of life total score was not changed in either group. Interestingly, the score of Q1 ("How important is SMBG to you?") in the SMBG questionnaire was unchanged in group I, whereas it was significantly decreased in group C. HbA1c change was independently associated with changes in insulin dose and SMBG Q1 score.

CONCLUSION

Greater HbA1c-lowering by physicians' diabetes self-management education using the Japan Association of Diabetes Education and Care education tool and SMBG analyzer in individuals with type 2 diabetes receiving insulin and SMBG was suggested, but not confirmed.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy

OBJECTIVE

This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP).

METHODS

We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health.

RESULTS

The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%.

CONCLUSIONS

CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up

OBJECTIVE

To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up.

METHODS

This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes.

RESULTS

162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03).

CONCLUSIONS

SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.

The Effect of Modified Diabetes Self-management Education and Support on Self-care and Quality of Life among Patients with Diabetic Foot Ulcers in Rural Area of Indonesia

BACKGROUND: Diabetes self-management education and support (DSMES) programs are patient-centered, holistic solution that enables it one of the best approaches for improving medication adherence enhanced coping, empowerment and self-efficacy, quality of life (QoL), and lower rates of depression, in people with type 2 diabetes mellitus (T2DM). In isolation, DSME strategies have not shown significant improvements to self-care and/or reduction of diabetic foot ulcer (DFU). AIM: This study sought to determine the effect of modified DSMES on self-care, DFU severity, and QoL in rural Indonesian patients with DFUs. METHODS: A quasi-experimental design with pre-test and post-test control group design, in Singkawang, West Kalimantan, Indonesia, with a total sample of 60 patients consisting of 30 patients in the intervention group and 30 patients in the control group. The DSMES has been adapted to cover 2 h of content for a period of 8 weeks and the eight-core components of DSMES. The curriculum was culturally adapted revised to incorporate culturally appropriate nature similarities, such as a prominent change to represent changes in glucose counts; to incorporate photos; to incorporate culturally relevant eating habits, such as fish and fruit; to communicate in detail the significance of medication adherence, with an emphasis on metformin’s organic, plant-based characteristics; and to emphasize engagement. Intention-to-treat analyses were conducted to determine the effect of modified DSMES on self-care, DFU severity, and QoL. RESULTS: The DSMES program improved outcomes in three of the three outcome indicators when compared to the control group at T1: In this study, (1) the DFU degree increased by 3.3% points (95% confidence interval [CI]: 0.018–0.194), (2) the diabetes foot self-care behavior score increased by a modest 8.8% points (95% CI: 0.021–0.203), and (3) the QoL increased by 32.7% points (95% CI: 00.075–0.689). The degree of DFU (difference-in-difference [DID] coef. 0.350, 95% CI 0.084–0.572), diabetes foot self-care behavior (DID coef. 0.085, 95% CI 0.065–0.405), and QoL (DID coef. 0.343, 95% CI 0.078–0.436) are all still significantly improved compared to the control at T2. CONCLUSION: The primary outcome analyses indicate that the adapted DSMES was more effective than standard care at improving self-care and QoL and decreasing DFU degree in this sample of Indonesians with DFU, both immediately after and 3 months after the intervention. As nurse educators, it is our responsibility to ensure that we evaluate all of the support options accessible to the patients in our care.

Effect of an Integrated, Multidisciplinary Nationwide Approach to Type 1 Diabetes Care on Metabolic Outcomes: An Observational Real-World Study

Objective: Achieving good metabolic control in people with type 1 diabetes (T1D) remains a challenge, despite the evolutions in diabetes technologies over the past decade. Here we investigate the evolution of metabolic control in people with T1D, where care is provided by specialized centers with access to technology, diabetes education, and regular follow-up. Methods: Data were cross-sectionally collected between 2010 and 2018 from more than 100 centers in Belgium. The evolutions over time of hemoglobin A1C (HbA1c), low-density lipoprotein (LDL) cholesterol, and systolic blood pressure (SBP) were investigated, together with the evolutions of use of insulin pump (continuous subcutaneous insulin infusion [CSII]), continuous glucose monitoring (CGM), and lipid-lowering and antihypertensive drugs. Association of HbA1c with gender, age, diabetes duration, and technology use was analyzed on the most recent cohort. Results: The study population contained data from 89,834 people with T1D (age 1-80 years). Mean HbA1c decreased from 65 mmol/mol (8.1%) in 2010-2011 to 61 mmol/mol (7.7%) in 2017-2018 (P < 0.0001, adjusted for gender, age, diabetes duration, and technology use). Respectively, mean LDL cholesterol decreased from 2.45 mmol/L (94.6 mg/dL) to 2.29 mmol/L (88.5 mg/dL) (P < 0.0001, adjusted for gender, age, and diabetes duration), and mean SBP remained stable. CGM usage increased, whereas the use of CSII and lipid-lowering and antihypertensive drugs remained stable. Gender, age, diabetes duration, and technology use were independently associated with HbA1c. Conclusions: Our real-world data show that metabolic and lipid control improved over time in a system where T1D care is organized through specialized multidisciplinary centers with emphasis on linking education to provision of technology, and its quality is monitored.

Diabetes Management Delivery and Pregnancy Outcomes in Women with Gestational Diabetes Mellitus during the First Wave of the 2020 COVID-19 Pandemic: A Single-Reference Center Report

OBJECTIVES

The COVID-19 pandemic has forced a rapid adaptation of healthcare services to secure care for many patient groups. This includes women with gestational diabetes mellitus (GDM). We evaluated the impacts of the first COVID-19 wave on parameters such as the GDM treatment, glycemic control, and pregnancy outcomes.

METHODS

In this retrospective study from a reference diabetes center (Krakow, Poland), we compared patient data from two different time periods: the first wave of the COVID-19 pandemic (March 2020-June 2020) and the preceding five months (October 2019-February 2020). Data was collected from the medical records and telephone surveys.

RESULTS

We included 155 consecutive women (group N1 = 73 and group N2 = 82 from the COVID-19 pandemic period and non-COVID-19 period, respectively). During the COVID-19 pandemic, almost half of all GDM women (N1 = 36, 49.3%) used telemedicine as a method of contacting their diabetic specialists while this tool was not utilized in the earlier period. Moreover, these patients reported difficulties in performing blood glucose self-control more often (N1 = 20, 27.4%, vs N2 = 7, 8.5%; p ≤ 0.01) and spent less time on diabetes education than the control group on average (N1 = 39, 53.4%, vs N2 = 9, 9.8% below 2 hours of training; p ≤ 0.01). Most analyzed glycemic parameters and pregnancy outcomes were similar. Differences were found with respect to the incidence of prolonged labor (N1 = 12, 16.4%, vs N2 = 3, 3.7%; p ≤ 0.01) and preeclampsia (N1 = 0 vs N2 = 7, 8.5%; p = 0.01).

CONCLUSION

In this single-center observational study, the first wave of the COVID-19 pandemic did not seem to have a negative impact on pregnancy outcomes in GDM women, despite the difficulties in diabetes management delivery.

A comparison of the acceptability and psychometric properties of scales assessing the impact of type 1 diabetes on quality of life-Results of 'YourSAY: Quality of Life'

AIMS

To compare the acceptability, reliability and validity of five contemporary diabetes-specific quality of life (QoL) scales among adults with type 1 diabetes in the United Kingdom and Australia.

METHODS

Adults with type 1 diabetes (UK = 1139, Australia = 439) completed a cross-sectional, online survey including ADDQoL-19, DCP, DIDP, DSQOLS and Diabetes QoL-Q, presented in randomised order. After completing each scale, participants rated it for clarity, relevance, ease of completion, length and comprehensiveness. We examined scale acceptability (scale completion and user ratings), response patterns, structure (exploratory and confirmatory factor analyses) and validity (convergent, concurrent, divergent and known groups). To assess cross-country reproducibility, analyses conducted on the UK dataset were replicated in the Australian dataset.

RESULTS

Findings were largely consistent between countries. All scales were acceptable to participants: ≥90% completing all items, and ≥80% positive user ratings, except for DSQOLS' length. Scale structure was not supported for the DCP. Overall, in terms of acceptability and psychometric evaluation, the DIDP was the strongest performing scale while the ADDQoL-19 and Diabetes QoL-Q scales also performed well.

CONCLUSIONS

These findings suggest that the recently developed brief (7 items), neutrally worded DIDP scale is acceptable to adults with type 1 diabetes and has the strongest psychometric performance. However, questionnaire selection should always be considered in the context of the research aims, study design and population, as well as the wider published evidence regarding both the development and responsiveness of the scales.

A Social Marketing Intervention to Improve Treatment Adherence in Patients with Type 1 Diabetes

This research explores if a social marketing intervention model based on social representations theory and the health belief model can generate changes regarding treatment adherence and improve patient self-efficacy. As a pilot, a test-retest field quasi-experiment was designed to evaluate the intervention model with type 1 diabetes (T1DM) patients of families with 8- to 17-year-old children. The intervention model was designed to clarify misconceptions, increase awareness of the benefits of following doctors' treatments and improve patients' self-efficacy. In-depth interviews were carried out to gain a richer understanding of the intervention's effect. The pilot intervention generated a favourable change in shared misconceptions, individual health beliefs, glycaemic control and declared treatment adherence. This paper contributes to the social marketing literature and public health by providing early support for the theoretical assumptions regarding the role of shared misconceptions in physiological and behavioural outcomes for patients with T1DM. Contrary to previous studies, instead of only focusing on individual beliefs, this study incorporates shared beliefs between patients and caregivers, generating more comprehensive behavioural change.

The effectiveness of a comprehensive diabetes program for glycemic control and adherence, and the selection of candidates for sensor-augmented insulin pump therapy

OBJECTIVE

This study aimed to estimate the effectiveness of a comprehensive diabetes program (CDP) in terms of glycemic control, adherence, and the selection of candidates for sensor-augmented insulin pump therapy (SAP).

METHODS

We compared diabetes control before and 6 months after CDP. The program was based on disease management using a logical model dealing with the following: case management, education and coaching, nutritional assessment, and mental health.

RESULTS

The CDP improved glycemic control, HbA1c decreased by 0.56% (p-value=0.004; 95% CI: 0.14-0.98) and 19.1% of the patients reached the HbA1c goal without hypoglycemia. The CDP reduced by 52.4% the indication for SAP due to better glycemic control (36.4%) or non-adherence issues (63.6%); the remaining 47.6% persisted with poor glycemic control despite good adherence and were scaled to SAP. Among the 30 suitable candidates for SAP therapy, 60% did not reach the HbA1c goal and 40% had either hypoglycemic episodes (severe or persistent) or dawn phenomenon. The overall non-adherence rate was 33.3%.

CONCLUSIONS

CDP optimized the selection of suitable candidates for SAP by improving glycemic control and identifying adherence issues early. These results provide evidence of the impact of the implementation of patient selection and educational protocols in the real-life setting of a highly experienced clinic.

Comprehensive Care Models for Cardiometabolic Disease

PURPOSE OF REVIEW

The high burden of cardiovascular disease and the simultaneous obesity pandemic is placing an extraordinary strain on the health care system. In the current siloed care model, patients with cardiometabolic disease receive only fractionated care from multiple specialists, leading to insufficient treatment, higher costs, and worse outcomes.

RECENT FINDINGS

The imminent need for a new care model calls for the creation of a distinct cardiometabolic specialty in conjunction with a cardiometabolic outpatient clinic dedicated to the comprehensive cardiometabolic care. The cardiometabolic clinic would consist of a diverse range of professionals relevant to comprehensive treatment. The outpatient clinic we envision here would facilitate an interdisciplinary collaboration between specialists and deliver prevention-focused treatment to patients at risk/established cardiometabolic disease.

2017 National Standards for Diabetes Self-Management Education and Support

PURPOSE

The purpose of this study is to review the literature for Diabetes Self-Management Education and Support (DSMES) to ensure the National Standards for DSMES (Standards) align with current evidence-based practices and utilization trends.

METHODS

The 10 Standards were divided among 20 interdisciplinary workgroup members. Members searched the current research for diabetes education and support, behavioral health, clinical, health care environment, technical, reimbursement, and business practice for the strongest evidence that guided the Standards revision.

RESULTS

Diabetes Self-Management Education and Support facilitates the knowledge, skills, and ability necessary for diabetes self-care as well as activities that assist a person in implementing and sustaining the behaviors needed to manage their condition on an ongoing basis. The evidence indicates that health care providers and people affected by diabetes are embracing technology, and this is having a positive impact of DSMES access, utilization, and outcomes.

CONCLUSION

Quality DSMES continues to be a critical element of care for all people with diabetes. The DSMES services must be individualized and guided by the concerns, preferences, and needs of the person affected by diabetes. Even with the abundance of evidence supporting the benefits of DSMES, it continues to be underutilized, but as with other health care services, technology is changing the way DSMES is delivered and utilized with positive outcomes.

5. Facilitating Behavior Change and Well-being to Improve Health Outcomes: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Real-world effectiveness and safety of sensor-augmented insulin pump therapy in adults with type 1 diabetes: Long-term follow-up

OBJECTIVE

To evaluate the effectiveness and safety of sensor-augmented insulin pump therapy (SAP) in addition to a comprehensive diabetes program on glycated hemoglobin (HbA1c), severe hypoglycemia, ketoacidosis, and the hospital admission rate in patients with type 1 diabetes under real-world settings during a 2-year follow-up.

METHODS

This was a retrospective real-life study comparing diabetes control before and after SAP therapy initiation. Patients ≥18 years old with type 1 diabetes were included. They were followed for 2 years with clinical assessments at months 3, 6, 12, 18, and 24. Effectiveness was estimated by difference in medians of HbA1c from baseline and at each follow-up visit. Safety was assessed by comparing the annual rates of severe hypoglycemia, hyperglycemic crisis, and hospital admission related to diabetes.

RESULTS

162 patients were included, median age 32 years, women 73%). The main indication for SAP was poor metabolic control (51.2%). At 2 years HbA1c decreased from 8.4% to 7.5% (-0.9%, 95% CI: 0.5-1.2; p<0.0001), HbA1c ≤7% improved from 14.2% to 25.3% (11.1%, 95% CI: 19.7-2.5; p=0.006), and severe hypoglycemia decreased from 22.2% to 14.1% (-8.1%, 95% CI: -16.5 to 0.3; p=0.03).

CONCLUSIONS

SAP therapy improved glycemic control after the third month of use and for up to 2 years of follow-up, with lower rates of hospital admission and severe hypoglycemia. More studies are needed to assess the add-on impact of education programs and technologies for diabetes care.

Type 2 diabetes mellitus management in patients with chronic kidney disease: an update

Diabetes mellitus (DM) is a chronic multisystem disease. Diabetic nephropathy (DN) is one of its significant microvascular complications, associated with increased morbidity and mortality. The aim of this article is to review the literature regarding the latest advances in the management of type 2 DM (T2DM) in patients with chronic kidney disease (CKD). We initially refer to the screening guidelines, the diagnostic tests used, the need for novel biomarkers in DN, the recent advances in high-risk patient identification, the recommended glycemic targets, and concerns regarding the accuracy of HbA1c in these patients. Then, a detailed explanation of the appropriate medical management based on evidence from recent trials is presented, analyzed, and discussed. All patients with T2DM should be screened for albuminuria at initial diagnosis and annually thereafter. Proteomics and metabolomics today represent promising diagnostic tools. Optimal glycemic control, with individualized HbA1c targets, is fundamental for reduced onset or delayed progression of DN and microvascular complications, in general. This can be enhanced by lifestyle modifications and pharmacological interventions when needed. Metformin represents the first pharmacological step, with, recently, a broadened indication for patients with impaired renal function. If HbA1c remains above the target in patients with established CKD, SGLT2i or GLP-1 RA are the preferred second-line agents, as introduced in all new guidelines. This change was the result of recent landmark trials that highlighted the superiority of the two aforementioned medication categories in terms of both renal and cardiovascular outcomes.

Content Analysis: First-Time Patient User Challenges with Top-Rated Commercial Diabetes Apps

Background/Introduction: Using a mobile application (app) may improve diabetes self-management. However, the use of diabetes apps is low, possibly due to design and usability issues. The purpose of this study was to identify barriers to app use among adult patients with diabetes who were testing diabetes apps for the first time. Materials and Methods: We conducted a content analysis of observation notes and patient comments collected during the testing of two top commercially available diabetes apps as part of a crossover randomized trial. Participants were adult patients with type 1 or type 2 diabetes on insulin therapy. We analyzed field notes and transcriptions of audio recordings. Open coding derived categories of usability issues, which then were grouped into themes and subthemes on usability problem types. Results: A total of 92 adult Android smartphone users were recruited online (e.g., Facebook) and in-person postings. Three major themes described problems with data input, app report display and presentation, and self-learning options. Data entry modes were problematic because of overcrowded app screens, complicated "save data" steps, and a lack of data entry confirmation. The app icons, wording, entry headings, and analysis reports were not intuitive to understand. Participants wanted self-learning options (e.g., pop-up messages) during app use. Conclusions: Patient testing of top commercially available diabetes apps revealed key usability design issues in data entry, app report, and self-help learning options. Good app training for patients is necessary for both initial use and long-term use of diabetes apps to support self-management.

Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice

Purpose

Technology is rapidly evolving and has become an integral component of diabetes care. People with diabetes and clinicians are harnessing a variety of technologies, including connected blood glucose meters, continuous glucose monitors, insulin pumps, automated insulin delivery systems, data-sharing platforms, telehealth, remote monitoring, and smartphone mobile applications to improve clinical outcomes and quality of life. Although diabetes technology use is associated with improved outcomes, this is enhanced when the person using it is knowledgeable and actively engaged; simply wearing the device or downloading an app may not automatically translate into health benefits. The diabetes care and education specialist (DCES) has a central role in defining and establishing a technology-enabled practice setting that is efficient and sustainable. The purpose of this article is to describe the role of the DCES in technology implementation and to demonstrate the value of diabetes technology in both the care of the individual and as a tool to support population-level health improvements.

Conclusion

By following the recommendations in this article, DCESs can serve as technology champions in their respective practices and work to reduce therapeutic inertia while improving health outcomes and providing patient-centered care for the populations they serve.

A 2-Hour Diabetes Self-Management Education Program for Patients With Low Socioeconomic Status Improves Short-Term Glycemic Control

Diabetes self-management education (DSME) improves glycemic control, but patients with low socioeconomic status face institutional and personal barriers to receiving DSME. A retrospective single cohort study of a 2-hour group DSME program prioritizing accessibility and completion of a tightly focused curriculum was performed to determine if glycemic control improved and whether a longer, more comprehensive, prospective evaluation of the program is indicated. All patients who participated in the program from September 2017 to December 2018 were included in the analysis. The primary study endpoint was change in hemoglobin A1c (HbA1c) from baseline. A total of 58 out of 94 patients (61.7%) had paired measurements of HbA1c. Mean HbA1c improved from 9.8% ± 2.2% (83.5 ± 24.2 mmol/mol) to 8.3% ± 2.0% (67.7 ± 22.0 mmol/mol) at a median of 4 months after participation in the program (P<0.001). The proportion of patients with any improvement in HbA1c was 75.9% (44 of 58; P=0.003), and 65.5% of patients (38 of 58; P=0.066) had an improvement in HbA1c of ≥0.5%. These results demonstrate the benefit of highly targeted DSME for low-income patients and justify a longer-term and prospective evaluation of the program.

Barriers and facilitators to perceived diabetes self-management in Arab American patients with diabetes

AIMS

To assess perceptions surrounding diabetes self-management (DSM) behaviors in Arab American patients with diabetes.

METHODS

A 39-item survey was constructed from focus group discussions designed to better understand the impact of Arab American culture on DSM behaviors. The survey assessed perceptions about diet, adherence to medications, exercise, healthy lifestyle, and family support.

RESULTS

Two hundred Arab Americans with diabetes completed the survey via face-to-face interviews. Most patients were female (59%), over fifty years of age (79%), and immigrated from Lebanon (73%). Receiving instructions in Arabic, having family support, family understanding of food choices, and employment status were found to be important predictors of the perceived importance of DSM.

CONCLUSIONS

Our findings suggest that there are multiple factors that dictate Arab American's perception of the importance of DSM. The survey that was constructed may serve as a valuable tool for providers to assess DSM perceptions in order to provide patient-centered care that will help to improve diabetes outcomes. This study supports the importance of integrating cultural influences into DSM education and support when providing care to a population with a strong cultural identity.

Health related quality of life and healthcare utilization among adults with diabetes and kidney and eye complications in the United States

BACKGROUND

One-third of adults with diabetes in the United States have chronic kidney disease (CKD), and 19% of them have eye complications (ECs). However, little is known about the Health-related Quality of Life (HRQoL) of adults with both of these diabetes-related complications. Therefore, the purpose of this study is to examine differences in the HRQoL, mental health, and healthcare utilization of adults with diabetes who have CKD, ECs, both or neither.

METHODS

A cross-sectional study design was implemented using data from multiple panels (2009-2015) of the Medical Expenditure Panel Survey. HRQoL was measured using the SF-12 Physical and Mental Component Summary (PCS & MCS) scores. The HRQoL, mental health, and healthcare utilization of four mutually exclusive groups: 1) diabetes with both CKD and ECs; 2) diabetes with CKD only; 3) diabetes with ECs only, and 4) diabetes with neither CKD nor ECs were compared. In all analyses, adults with neither CKD nor ECs were the reference group.

RESULTS

There were 8415 adults with diabetes who met the inclusion criteria. Approximately, 75% of the study sample had neither CKD nor ECs, 13.3% had ECs only, 5.7% had CKD only, and 5.5% had both CKD and ECs. In the adjusted analyses, adults with both CKD and/or ECs complications exhibited significantly lower HRQoL compared to those with neither CKD nor ECs. Mental illness and psychological distress were higher among adults with both CKD and ECs compared to those with neither CKD nor ECs. Furthermore, adults with CKD and/or ECs had higher polypharmacy, inpatient and emergency services use compared to those with neither CKD nor ECs.

CONCLUSIONS

The results indicate that the presence of both CKD and/or ECs was negatively associated with poor HRQoL, poor mental health, higher psychological distress and healthcare utilization in adults with diabetes. The findings emphasize the need for routine assessment and treatment for diabetes-related CKD and/or ECs complications to improve the quality of care for individuals with diabetes.

Establishment of a type 1 diabetes structured education programme suitable for Chinese patients: type 1 diabetes education in lifestyle and self adjustment (TELSA)

BACKGROUND

Various guidelines recommend that all adults diagnosed with type 1 diabetes (T1D) should be offered an evidence based, structured education programme (SEP) to optimize self-management care. China has a 13,000 annual increase in newly diagnosed T1D cases, of which 65% are adults. However, there is yet no validated SEP targeted to T1D patients in China. The purpose of this study is to establish a structured T1D self-management education programme-'Type 1 Diabetes Education in Lifestyle and Self Adjustment' (TELSA) that is adapted to medical and cultural practices in China.

METHODS

TELSA programme was developed based on the ADDIE model, following three steps: i) Semi-structured interviews were administered to 10 healthcare professionals (HCPs) and 13 T1D patients. Different topic guides, focusing on 4 dimensions including goals, contents, format of delivery, and quality assurance, were designed for either HCPs or patients. The interviews were recorded and analysed with thematic analysis. ii) Extracted themes were modified according to Delphi consultation. iii) Preliminary courses were conducted as pilot study to evaluate the effects of TELSA and optimization of the curriculum was finalized accordingly.

RESULTS

A total of 18 themes in 4 dimensions of the programme design were identified in the final version: i) goals: 'behaviour modification' and 'outcome improvement'; ii) contents: 'living with T1D', 'self-monitoring of blood glucose', 'knowing insulin', 'insulin dose adjustment', 'carbohydrates and carbohydrate counting', 'hypoglycaemia', 'complications of diabetes', 'managing psychological issues', 'physical activity', and 'question-and-answer'; iii) format: 'multidisciplinary team combined with peer support', 'face-to-face education followed by remote learning', and '2-day programme held on weekends'; and iv) quality assurance: 'after-class quiz', 'patients' feedback', and 'long-term evaluation on effectiveness'.

CONCLUSIONS

A type 1 diabetes structured education programme in China was set up and shown to be applicable under local medical, social, and cultural environment.

TRIAL REGISTRATION

NCT03610984. Date of registration: August 2, 2018.

Different Effects of Structured Education on Glycemic Control and Psychological Outcomes in Adolescent and Adult Patients with Type 1 Diabetes: A Systematic Review and Meta-Analysis

AIM

This systematic review aimed at investigating the effectiveness of structured education (SE) in improving glycemic control and psychological outcomes in adolescent and adult patients with type 1 diabetes.

METHODS

Electronic databases (EMBASE, Medline, PubMed, and the Cochrane Library) and the reference lists of included studies were searched from the beginning of the database through April 2019. Randomized controlled trials comparing SE with a control condition and reporting a change in glycosylated hemoglobin (HbA1c) level were included. The primary outcome was glycemic control measured by HbA1c. Secondary outcomes were diabetes-related distress, well-being, depression, and quality of life.

RESULTS

Eighteen studies representing 2759 patients were included. Twelve studies targeted adolescents and six targeted adults. Adolescent patients who were randomized to the intervention group did not show significant improvement of HbA1c in the short (SMD = -0.04; 95% CI: -0.14 to 0.06; P=0.41), medium (SMD = -0.03; 95% CI: -0.13 to 0.07; P=0.41), medium (SMD = -0.03; 95% CI: -0.13 to 0.07; P=0.41), medium (SMD = -0.03; 95% CI: -0.13 to 0.07; P=0.41), medium (SMD = -0.03; 95% CI: -0.13 to 0.07; P=0.41), medium (SMD = -0.03; 95% CI: -0.13 to 0.07.

CONCLUSIONS

Development of more efficient SE programs according to the patients' personal characteristics is needed.

Clinical guidelines for type 1 diabetes mellitus with an emphasis on older adults: an Executive Summary

We present a summary of a guideline produced by an international group of experts for managing type 1 diabetes in adults with an emphasis on the special needs of older people with this condition. The rationale for delivering high-quality diabetes care for adults with type 1 diabetes, why it is important to include older people in our considerations, and the key underpinning principles of the guideline are included. The structure of the recommendations given is described and consists of 'general' recommendations followed by 'specific' recommendations according to three categories depending on the characteristics of adults addressed, such as functional level or self-management ability. Recommendations are provided in the areas of: clinical diagnosis, establishing management plans and glucose regulation, diabetes self-management education, nutritional therapy, physical activity, exercise and lifestyle modification, insulin treatments and regimens, use of technology in diabetes management, hypoglycaemia, managing cardiovascular risk, management of microvascular risk, and inpatient management of type 1 diabetes and ketoacidosis.