Cut Points for Identifying Clinically Significant Diabetes Distress in Adolescents With Type 1 Diabetes Using the PAID-T: Results From Diabetes MILES Youth-Australia

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Observed collaborative and intrusive parenting behaviours associated with psychosocial outcomes of adolescents with type 1 diabetes and their maternal caregivers

AIMS

Maternal caregiver involvement is strongly associated with psychosocial and glycemic outcomes amongst adolescents with type 1 diabetes (T1D); however, previous studies have lacked detailed, objective examinations of caregiver involvement. We examined the relationship between observed parenting behaviors and psychosocial and glycemic outcomes amongst youth with T1D.

METHODS

Data collected from adolescents with T1D (age 11-17) and their female caregivers as a part of a randomized controlled trial were analyzed. These included structured, observation-based scores of adolescent-caregiver dyads engaged in videotaped interactions and selected psychosocial and glycemic outcome measures.

RESULTS

In adjusted analyses, higher levels of intrusive parenting behaviors during observed interactions were associated with higher diabetes distress in adolescents, but no difference in HbA1c. Associations between intrusive parenting behaviors and psychosocial outcomes were stronger for females compared to males for both diabetes distress and quality of life. Similarly, associations between collaborative parenting behaviors and quality of life were stronger for female adolescents than males. No associations were observed between collaborative parenting behaviors and glycemic outcomes. Consistent with previous work, we noted higher levels of adolescent-reported family conflict were associated with lower adolescent quality of life and higher diabetes distress with no significant difference between male and female adolescents.

CONCLUSION

These findings indicate that high levels of intrusive parenting behaviors, such as lecturing or over-controlling behaviors, are associated with lower levels of adolescent well-being, particularly among adolescent girls. This work suggests that interventions to reduce intrusive parenting by maternal caregivers could result in improved psychosocial outcomes for adolescents with T1D.

Teaching Adolescents With Type 1 Diabetes Self-Compassion (TADS) to Reduce Diabetes Distress: Protocol for a Randomized Controlled Trial

BACKGROUND

Adolescents living with type 1 diabetes (T1D) often experience diabetes distress (DD), a construct distinct from depression or anxiety that refers to the negative emotions that arise from living with and managing diabetes. Self-compassion, which involves being open to one's own suffering and treating oneself with the same care one would show to loved ones, is associated with better psychological and clinical outcomes among individuals with T1D. Self-compassion is a skill that can be taught and therefore represents an opportunity for intervention.

OBJECTIVE

The overall aim of this study is to assess the effectiveness of a web-based mindful self-compassion for teens (MSC-T) intervention on improving DD, anxiety, depression, diabetes-related disordered eating, and suicidal ideation experienced by youth with T1D (aged between 12 and 17 years) compared with a waitlist control group (standard of care). We will also explore (1) if the effect of the MSC-T intervention changes over time, (2) if the MSC-T intervention has a positive impact on measures of glycemic control, and (3) if the effect of the MSC-T intervention differs based on self-reported gender.

METHODS

We will conduct a single-center, parallel-group randomized controlled trial of 140 adolescents with T1D followed for 12 months. Participants will be randomly allocated (using hidden allocation) in a 1:1 ratio to either the MSC-T intervention or the waitlist control group. Our primary outcome is DD, as measured by the Problem Areas in Diabetes-Teen (PAID-T) version at 3 months. Secondary outcomes, assessed at 3 and 12 months, include anxiety (Generalized Anxiety Disorder 7-item [GAD-7] scale), depression (Patient Health Questionnaire-9 [PHQ-9]), diabetes-related disordered eating (Diabetes Eating Problem Survey-Revised [DEPS-R] version), and suicidal ideation (using 1 question from the PHQ-9).

RESULTS

Study recruitment began in October 2022 and was completed in March 2023, with a total of 141 participants enrolling. Data collection will be ongoing until March 2024. The first results are expected in June 2024.

CONCLUSIONS

This study will be the first randomized trial to assess the effectiveness of the web-based MSC-T intervention on adolescents with T1D. Given that adolescence is a period where individuals are typically required to assume more responsibility for their diabetes care, providing adolescents with the tools they need to better manage the stress that often accompanies T1D management is paramount.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05463874; https://clinicaltrials.gov/study/NCT05463874.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/53935.

The Effect of Do-It-Yourself Real-Time Continuous Glucose Monitoring on Glycemic Variables and Participant-Reported Outcomes in Adults With Type 1 Diabetes: A Randomized Crossover Trial

AIM

Real-time continuous glucose monitoring (rtCGM) has several advantages over intermittently scanned continuous glucose monitoring (isCGM) but generally comes at a higher cost. Do-it-yourself rtCGM (DIY-rtCGM) potentially has benefits similar to those of rtCGM. This study compared outcomes in adults with type 1 diabetes using DIY-rtCGM versus isCGM.

METHODS

In this crossover trial, adults with type 1 diabetes were randomized to use isCGM or DIY-rtCGM for eight weeks before crossover to use the other device for eight weeks, after a four-week washout period where participants reverted back to isCGM. The primary endpoint was time in range (TIR; 3.9-10 mmol/L). Secondary endpoints included other glycemic control measures, psychosocial outcomes, and sleep quality.

RESULTS

Sixty participants were recruited, and 52 (87%) completed follow-up. Glucose outcomes were similar in the DIY-rtCGM and isCGM groups, including TIR (53.1% vs 51.3%; mean difference -1.7% P = .593), glycosylated hemoglobin (57.0 ± 17.8 vs 61.4 ± 12.2 mmol/L; P = .593), and time in hypoglycemia <3.9 mmol/L (3.9 ± 3.8% vs 3.8 ± 4.0%; P = .947). Hypoglycemia Fear Survey total score (1.17 ± 0.52 vs 0.97 ± 0.54; P = .02) and fear of hypoglycemia score (1.18 ± 0.64 vs 0.97 ± 0.45; P = .02) were significantly higher during DIY-rtCGM versus isCGM. Diabetes Treatment Satisfaction Questionnaire status (DTSQS) score was also higher with DIY-rtCGM versus isCGM (28.7 ± 5.8 vs 26.0 ± 5.8; P = .04), whereas diabetes-related quality of life was slightly lower (DAWN2 Impact of Diabetes score: 3.11 ± 0.4 vs 3.32 ± 0.51; P = .045); sleep quality did not differ between the two groups.

CONCLUSION

Although the use of DIY-rtCGM did not improve glycemic outcomes compared with isCGM, it positively impacted several patient-reported psychosocial variables. DIY-rtCGM potentially provides an alternative, cost-effective rtCGM option.

Agenda-setting by young adults with type 1 diabetes and associations with emotional well-being/social support: results from an observational study

BACKGROUND

The Diabetes Psychosocial Assessment Tool (DPAT) was developed to assess the psychosocial well-being of young adults with type 1 diabetes in clinical practice. The DPAT includes three validated questionnaires (assessing diabetes distress, anxiety/depressive symptoms and emotional well-being) and an agenda-setting tool. It is currently used by the Queensland Statewide Diabetes Clinical Network (available at Clinical Excellence Queensland).

AIMS

To describe agenda items set by young adults with type 1 diabetes and investigate their association with emotional well-being/social support.

METHODS

The DPAT was completed by young adults attending routine diabetes outpatient appointments at the Mater Hospital (Brisbane) between November 2016 and January 2020. For the current analysis, data included responses on agenda-setting and outcomes from three validated questionnaires.

RESULTS

Responses of 277 young adults (15-26 years) were analysed. Ninety-four (34%) reported one to three agenda item(s). Common agenda items were diabetes technology and medications, but other topics raised included pregnancy, body image and eating concerns. Participants with moderate diabetes distress or anxiety symptoms were more likely to list at least one agenda item (P = 0.006; P = 0.002), as were females and older participants.

CONCLUSION

Several agenda items for young adults with type 1 diabetes were identified and were more likely to be raised by those with elevated diabetes distress and anxiety symptoms. The DPAT is a valuable and convenient tool that can be easily applied in routine clinical practice to enable clinicians to understand the concerns of the young adult population and deliver personalised medicine to optimise long-term outcomes.

Feasibility and acceptability of 'low-intensity mental health support via a telehealth-enabled network' for adults with type 1 and type 2 diabetes: the LISTEN pilot study

BACKGROUND

This study examined the feasibility and acceptability of the low-intensity mental health support via telehealth-enabled network (LISTEN) intervention, for adults with diabetes, facilitated by diabetes health professionals (HPs).

METHODS

LISTEN training. Three HPs participated in three half-day online workshops and applied their learnings during training cases (maximum four). Competency was assessed with a validated tool and achieved 'satisfactory' ratings for three consecutive sessions. LISTEN pilot. A single-group, pre-post study (up to four LISTEN sessions) with online assessments at baseline, post-intervention, and 4-week follow-up. Eligible participants were adults with type 1 or type 2 diabetes, with diabetes distress, but excluded if they had moderate/severe depressive and/or anxiety symptoms. Feasibility was assessed via recruitment and session completion rates. Acceptability was assessed with post-intervention self-report data. Changes in diabetes distress and general emotional well-being from baseline (T1) were explored at post-intervention (T2) and at 4-week follow-up (T3).

RESULTS

Two HPs achieved competency (median training case sessions required: 7) and progressed to deliver LISTEN in the pilot study. In the pilot, N = 16 adults (Med [IQR] age: 60 [37-73] years; 13 women) with diabetes participated (median sessions per participant: 2). Twelve participants (75%) completed the post-intervention assessment (T2): 92% endorsed the number of sessions offered as 'just right', 75% felt comfortable talking with the HP, and 67% were satisfied with LISTEN. Perceived limitations were the structured format and narrow scope of problems addressed. Diabetes distress scores were lower post-intervention.

CONCLUSIONS

This pilot demonstrates the feasibility of training HPs to deliver LISTEN, and the acceptability and potential benefits of LISTEN for adults with diabetes. The findings highlight adaptations that may enhance the delivery of, and satisfaction with, LISTEN that will be tested in a hybrid type 1 effectiveness-implementation trial.

Diabetes distress and disordered eating behaviors in youth with type 1 diabetes: the mediating role of self-regulatory fatigue and the moderating role of resilience

BACKGROUND

Despite previous research on the association between diabetes distress and disordered eating behaviors (DEBs) among youth with type 1 diabetes (T1D), there is a lack of understanding regarding the underlying mechanisms. This study aimed to investigate the relationships between diabetes distress and DEBs, specifically examining whether self-regulatory fatigue mediated the relationship and whether resilience moderated this mediation.

METHODS

A cross-sectional study was performed among youth with T1D recruited from two diabetes centers in Nanjing, China. Measurement instruments included the problem areas in the diabetes-5 scale, the diabetes strengths and resilience measure for adolescents, the self-regulatory fatigue scale, and the Chinese version of diabetes eating problem survey-revised. Mediation and moderated mediation analyses were conducted.

RESULTS

A total of 185 youths with T1D were involved in the current study. The results indicated that diabetes distress positively predicted DEBs. Self-regulatory fatigue partially mediated the association between diabetes distress and DEBs, accounting for 50.88% of the overall effect. Additionally, the pathway from self-regulatory fatigue to DEBs was moderated by resilience.

CONCLUSION

The current study examined whether self-regulatory fatigue mediated the relationship between diabetes distress and DEBs and whether resilience moderated the connection between self-regulatory fatigue and DEBs. These findings add to the theoretical basis of how diabetes distress influences DEBs and help guide the incorporation of diabetes distress, self-regulatory fatigue, and resilience into DEBs reduction programs for youth with T1D.

Emotional well-being and HbA1c following the implementation of the Diabetes Psychosocial Assessment Tool (DPAT) in young adults with Type 1 Diabetes (T1DM): An observational study

AIMS

This observational study evaluated the implementation of the Diabetes Psychosocial Assessment Tool (DPAT), assessing emotional well-being of young adults with type 1 diabetes (T1DM) and the clinical congruency between DPAT-recommended and specialist-led referrals.

METHODS

Young adults with T1DM attending the clinic completed the DPAT on two occasions. The DPAT includes the PAID (diabetes distress), PHQ-4 (depression/anxiety) and WHO-5 (general well-being), a diabetes health audit and a referral pathway to (allied) health professionals. Demographic and clinical information was retrieved from medical records. Data was analyzed using descriptive statistics and generalized estimating equations.

RESULTS

115 people with T1DM, aged 16-25 years, were included in the analysis. Symptoms of moderate-severe diabetes distress were present in 29 (25%) participants, symptoms of depression/anxiety and impaired well-being in 21 (19%) and 26 (23%) participants, respectively. The odds of depression/anxiety symptoms was lower at the second timepoint compared to the first timepoint (OR 0.55, 95% CI 0.32-0.96, p=0.03). The odds of moderate-severe diabetes distress tended to be lower. No change was observed in general well-being or HbA1c. There was moderate concordance between DPAT and clinician referrals to psychologists (81%) and dieticians (70%).

CONCLUSIONS

Using the DPAT facilitates the conversation about emotional well-being during routine consultation and follow-up.

Sedentary Behavior and Physical Activity Associated with Psychosocial Outcomes in Adolescents with Type 1 Diabetes

Background

Adolescents with type 1 diabetes (T1D) are particularly vulnerable to poor psychosocial outcomes-high rates of diabetes distress and poor quality of life are common among this cohort. Previous work in the general population demonstrated positive associations between quality of life and increases in moderate-to-vigorous physical activity (MVPA), as well as decreased sedentary behavior. While survey-based assessments of young adults with T1D observed similar trends, these studies were limited by their use of subjective assessments of MVPA and sedentary behavior. The use of direct activity monitoring is needed to establish the association between psychosocial outcomes and MVPA and sedentary behavior among adolescents with T1D.

Objective

To explore the association between objectively measured MVPA and sedentary behavior on psychosocial outcomes among adolescents with T1D.

Subjects and Methods

The current study is a secondary analysis of baseline data collected for a pilot trial of sleep-promoting intervention for adolescents with T1D. Participants (n = 29, with a mean age of 15.9 ± 1.3 years) completed baseline surveys and wore an actigraph for a week following the baseline visit. We examined minutes per week of MVPA and proportion of awake time spent sedentary in relation to adolescents' diabetes distress, depressive symptoms, and diabetes-related quality of life.

Results

Participants engaged in a mean of 19.6 ± 22.4 minutes of MVPA per day and spent 68.6 ± 9.9% of their awake time sedentary. MVPA was associated with lower diabetes distress in unadjusted (-3.6; 95% CI: -6.4 to -0.8) and adjusted (-2.6; 95% CI: -5.0--0.3) analyses. Sedentary time was associated with higher diabetes distress in adjusted (6.3; 95% CI: 1.3-11.2) but not unadjusted (6.0; 95% CI: -5.6-12.6) analyses. In secondary analyses, we did not observe significant associations between quality of life or depressive symptoms with either MVPA or sedentary behavior.

Discussion

Our findings extend previous survey-based work demonstrating an association between decreased diabetes distress with greater weekly MVPA and lower sedentary time. The current study highlights the multifaceted benefits of physical activity in this population and provides preliminary evidence for developing interventions to reduce sedentary time as an alternative method to improve psychosocial outcomes in this at-risk population.

Internet-delivered eating disorders prevention program for adolescent girls with type 1 diabetes: Acceptable and feasible

BACKGROUND

Adolescents with type 1 diabetes are at significantly increased risk for eating disorders and few interventions exist.

OBJECTIVE

This study examined the feasibility, acceptability, and preliminary effects of an internet-based eating disorders prevention program adapted specifically for adolescent girls with type 1 diabetes.

PARTICIPANTS AND METHODS

Thirty-five girls (16.2 ± 1.1 years) participated Body Project (T1D Style), a 4-week program consisting of four adolescent sessions focused on promoting illness acceptance, challenging sociocultural body image pressures, increasing social support, and teaching assertive communication. Caregivers participated in one session focused on fostering body image positivity and a healthy relationship with food. Pre-intervention, post-intervention, and 3-month follow-up surveys assessed disordered eating, body dissatisfaction, thin-ideal internalization, diabetes acceptance, diabetes distress, and quality of life. Cohen's d effect sizes were calculated at post-intervention and follow-up. Program acceptability was assessed at post-intervention. Manual fidelity and homework completion were monitored.

RESULTS

High manual fidelity, retention, and homework completion were achieved. Quantitative and qualitative feedback from teens and caregivers suggested high acceptability. Large effects (d = 1.35-0.83) were observed for dieting, body dissatisfaction, diabetes distress, diabetes acceptance, and diabetes-related quality of life at post-intervention, with large-medium effects (d = 1.16-0.58) at follow-up. Medium-small effects (d = 0.49-0.78) at post-intervention were observed for diabetes-specific disordered eating and thin-ideal internalization, with effects maintained at follow-up.

CONCLUSIONS

Results support the acceptability and feasibility of this targeted eating disorders prevention program for adolescent girls with type 1 diabetes. Future clinical trials are warranted to determine its effectiveness compared to a control condition.

Glycemic control, depression, diabetes distress among adolescents with type 2 diabetes: effects of sex, race, insurance, and obesity

AIMS

To determine (1) differences in depression and distress scores between adolescents with type 1 (T1D) and type 2 diabetes (T2D), (2) how socioeconomic factors, obesity, race, and treatment regimen affect depression and diabetes distress in adolescent T2D, (3) the relationships between depression and diabetes distress scores in adolescents with T2D, and (4) how depression and diabetes distress scores relate to current and future glycemic control in adolescents with T2D.

BACKGROUND

Diabetes distress is a negative emotional reaction to diabetes complications, self-management demands, unresponsive providers, poor interpersonal relationships, and to diabetes itself. It is frequently mistaken for depression and the two are interrelated. Increases in both predict poor glycemic control in adolescents with T1D.

METHOD

Depression (PHQ-9) and diabetes distress (PAID-T) scores from self-administered tests were studied in 364 patients with diabetes between the ages of 13-17. Kruskal-Wallis test was used to assess differences between types of diabetes, sexes, races, and insurance status. Spearman correlations, and robust rank order multivariable regression analysis were used to assess relationships. Medical records were reviewed for follow-up hemoglobin A1c (HbA1c) levels over 3 years.

RESULTS

HbA1c was significantly lower in females with T2D than with T1D (p  =  0.019) but not in males. It, also, did not differ between females and males with T2D. Median PHQ-9 score in females with T2D was significantly greater than in females with T1D (p = 0.007) but did not differ between females and males with T2D. PHQ-9 scores did not differ between males with T2D and T1D. PAID-T scores, however, were higher in males with T2D than in males with T1D but did not differ between females. PHQ-9 scores and PAID-T scores were significantly related in T2D (r_s = 0.65, p < 0.001). Neither was related to HbA1c in T2D.

CONCLUSIONS

As in adolescents with T1D, depression and diabetes distress screening scores are closely related in adolescent T2D. However, unlike T1D, they are not related to glycemic control in T2D. Depression and diabetes distress may be more closely related to weight and lifestyle concerns.

Resilience and Diabetes Distress at 3 Months Following Diagnosis Predict A1C Trajectories in Youth With Type 1 Diabetes: An Argument for Early Intervention

OBJECTIVE

Youth and adolescents with type 1 diabetes (T1D) are at risk for poor health outcomes. Understanding if psychological factors shortly following diagnosis, such as diabetes distress and resilience, predict glycated hemoglobin (A1C) trajectories may help inform both optimal timing and content of psychosocial interventions for youth with T1D.

METHODS

Youth and adolescents (N = 34) with newly diagnosed T1D completed distress and resilience measures at baseline and 3 months following diagnosis. Using multilevel modeling, we predicted A1C trajectories up to 3 years following diagnosis.

RESULTS

We found that in separate models, higher 3-month diabetes distress and lower 3-month resilience predicted larger increases in A1C years 1-3 following diagnosis.

CONCLUSIONS

Our findings suggest that targeting resilience and diabetes distress within 3 months following diagnosis has implications for the yearly rate of A1C increase up to 3 years later.

The psychological profile of youth and young adults with type 1 diabetes in New Zealand

BACKGROUND

The psychological status of New Zealanders living with type 1 diabetes (T1D) is unknown. This study's purpose is to determine the prevalence of general wellbeing, diabetes-specific distress, and disordered eating, and explore their relationships with glycemic control.

METHODS

Participants were patients aged 15-24 years with T1D (N = 200) who attended their routine multidisciplinary clinic at the Waikato Regional Diabetes Service. They completed questionnaires including the World Health Organization Well-Being Index, the Problem Areas in Diabetes scales, and the Diabetes Eating Problem Survey-Revised. Clinical and demographic information were also collected.

RESULTS

Median age of participants was 19.3 years and 14% identified as Māori (indigenous people of Aotearoa New Zealand). Median HbA1c was 73 mmol/mol. One fifth of participants experienced low emotional wellbeing, including 7.5% who experienced likely depression. Diabetes distress was found in 24.1%, and 30.7% experienced disordered eating behaviors. Differences were identified between Māori and non-Māori in measures of diabetes distress and disordered eating, with Māori more likely to score in clinically significant ranges (50% vs. 19.9%; 53.6% vs. 26.7%, p < 0.05). Disordered eating was correlated with Hb_A1c , body mass index, and social deprivation; diabetes distress was associated with Hb_A1c and inversely with age (all p < 0.05).

CONCLUSIONS

This study is the first of its kind to determine that New Zealanders living with T1D experience significant psychological distress. Research with larger Māori representation is needed to more closely review identified inequities. Replication in other local clinics will help contribute to the ongoing development of normative data for Aotearoa New Zealand.

Depression and anxiety in adolescents with type 1 diabetes and their parents

BACKGROUND

Longitudinal studies including parental distress when examining adverse health outcomes in adolescents with type 1 diabetes are lacking. This study examined whether parental depression and anxiety predict adolescent emotional distress and glycated hemoglobin A_1c (HbA_1c) 1 year later and whether a relation between parental distress and HbA_1c is mediated by the level of parental involvement in diabetes care and by treatment behaviors.

METHODS

Longitudinal path modeling was applied to data from 154 adolescents and parents from diabetes centers participating in the Longitudinal study of Emotional problems in Adolescents with type 1 diabetes and their Parents/caregivers (Diabetes LEAP). At baseline and 1-year follow-up, participants completed measures of depression and anxiety. HbA_1c was extracted from medical charts. Responsibility and treatment behavior questionnaires were completed by adolescents at baseline.

RESULTS

Baseline parental depressive and anxiety symptoms were not associated with 1-year adolescent depressive symptoms, anxiety symptoms, and HbA_1c. Responsibility division and treatment behaviors did not mediate associations between parental emotional distress and 1-year HbA_1c.

CONCLUSIONS

Parental depressive and anxiety symptoms did not predict adolescent health outcomes 1 year later. Future studies may determine whether the link is present in case of mood/anxiety disorders or severe diabetes-specific distress, or whether adolescents are resilient in the face of parental distress.

IMPACT

Adolescents with T1D are a vulnerable group in terms of psychological and health outcomes. Whether parental emotional distress (i.e., depressive and anxiety symptoms) is prospectively associated with adolescent emotional distress and/or HbA_1c has been understudied. Our results show that parental distress was not related to adolescent distress or HbA_1c 1 year later. Responsibility division and treatment behaviors did not mediate associations between parental emotional distress and 1-year HbA_1c. Future studies could determine whether these links are present in case of mood/anxiety disorders or severe diabetes-specific distress, or whether adolescents are resilient in the face of parental distress.

Study protocol: Safety and efficacy of smart watch integrated do-it-yourself continuous glucose monitoring in adults with Type 1 diabetes, a randomised controlled trial

PURPOSE

Type 1 diabetes (T1D) management requires regular monitoring of glucose levels and judicious therapeutic administration of insulin to prevent both microvascular and macrovascular complications. Few people with diabetes are able to sustain the self-monitored blood glucose measurements needed for optimal care, and those that do, typically experience significant diabetes-related distress. Both intermittently scanned continuous glucose monitoring (isCGM) and continuous glucose monitoring (CGM) offer alternatives to reduce the overall burden, but both still have limitations. Given the expense of CGM, smart watch integrated do-it-yourself (DIY)-CGM has been developed as an alternative to commercial isCGM and CGM technologies. This study has been designed to evaluate the clinical efficacy of smart watch integrated DIY-CGM compared with isCGM in adults with T1D.

METHODS

This multicentre, randomised, crossover study will be conducted in New Zealand and aims to recruit 60 adults with established T1D who currently use isCGM. DIY-CGM will be compared to usual care with isCGM. Participants will be randomised to either arm of the study for 8 weeks followed by a 4-week washout period before crossing over to the other study arm for a further 8 weeks. The primary endpoint is glucose time in range (TIR) defined as percentage of time interstitial glucose is spent between 3.9 to 10 mmol/L for the entire intervention period. Secondary endpoints include diabetes-related quality of life, distress, and sleep quality in participants and their partners.

DISCUSSION

The results of this study will provide clinical trial data regarding smart watch integrated DIY-CGM versus isCGM for improving glycaemic control in adults with T1D, and also report a variety of key secondary outcomes, including changes in subjective outcome measures for both people with diabetes and their partners.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12621000648820,31 May 2021); World Health Organisation International Clinical Trial Registry Platform (U1111-1262-2784, 3rd December 2020).

Predictors of diabetes-related distress before and after FreeStyle Libre-1 use: Lessons from the Association of British Clinical Diabetologists nationwide study

AIM

To identify the baseline demographic and clinical characteristics associated with diabetes-related distress (DRD) and factors associated with improvement in DRD after initiating use of the FreeStyle Libre (FSL) in people living with type 1 diabetes (T1D).

METHODS

The study was performed using baseline and follow-up data from the Association of British Clinical Diabetologists nationwide audit of people with diabetes who initiated use of the FSL in the United Kingdom. DRD was assessed using the two-item diabetes-related distress scale (DDS; defined as the average of the two-item score ≥3). People living with T1D were categorized into two groups: those with high DRD, defined as an average DDS score ≥3 and those with lower DRD, defined as a DDS score <3. We used a gradient-boosting machine-learning (GBM) model to identify the relative influence (RI) of baseline variables on average DDS score.

RESULTS

The study population consisted of 9159 patients, 96.6% of whom had T1D. The median (interquartile range [IQR]) age was 45.1 (32-56) years, 50.1% were women, the median (IQR) baseline body mass index was 26.1 (23.2-29.6) kg/m² and the median (IQR) duration of diabetes was 20 (11-32) years. The two components of the DDS were significantly correlated (r²  = 0.73; P < 0.0001). Higher DRD was prevalent in 53% (4879/9159) of people living with T1D at baseline. In the GBM model, the top baseline variables associated with average DDS score were baseline glycated haemoglobin (HbA1c; RI = 51.1), baseline Gold score (RI = 23.3), gender (RI = 7.05) and fear of hypoglycaemia (RI = 4.96). Follow-up data were available for 3312 participants. The top factors associated with improvement in DDS score following use of the FSL were change in Gold score (RI = 28.2) and change in baseline HbA1c (RI = 19.3).

CONCLUSIONS

In this large UK cohort of people living with T1D, diabetes distress was prevalent and associated with higher HbA1c, impaired awareness of hypoglycaemia and female gender. Improvement in glycaemic control and hypoglycaemia unawareness with the use of the FSL was associated with improvement in DRD in people living with T1D.

Pivoting during a pandemic: lessons learned from transitioning a multisite randomized controlled trial to a remote protocol in response to COVID-19

THR1VE! is an ongoing multisite randomized clinical trial of a positive psychology intervention designed to treat diabetes distress and improve glycemic outcomes in teens with type 1 diabetes. Due to the COVID-19 pandemic restrictions on clinical research and changes in diabetes clinical care, THR1VE! was adapted from an in-person enrollment protocol to a remote protocol through a series of development and testing strategies. We discuss the process of transitioning the protocol and the demonstrated feasibility of ongoing recruitment, enrollment, and retention outcomes. These findings offer support for a remotely transitioned protocol that has larger applications for ongoing and future clinical research.

Prevalence and course of mood and anxiety disorders, and correlates of symptom severity in adolescents with type 1 diabetes: Results from diabetes LEAP

OBJECTIVES

We aim to determine the prevalence and the course of anxiety and mood disorders in Dutch adolescents (12-18 years old) with type 1 diabetes, and to examine correlates of symptom severity, including parental emotional distress.

METHODS

Participants were 171 adolescents and 149 parents. The Diagnostic Interview Schedule for Children-IV was used to assess current, past year and lifetime anxiety and mood disorders in adolescents. Symptom severity and diabetes distress were measured with validated questionnaires. Correlates of these symptoms were examined using hierarchical regression analyses and included demographics (adolescent sex and age), clinical factors (diabetes duration, treatment modality, most recent glycated hemoglobin A_1c ; all extracted from medical charts), adolescent diabetes distress, and parent emotional distress.

RESULTS

Twenty-four (14%) adolescents met the criteria for ≥1 disorder(s) in the previous 12 months. Anxiety disorders were more prevalent than mood disorders (13% vs. 4%). Lifetime prevalence of anxiety and mood disorders was 29% (n = 49). The presence of any of these disorders earlier in life (from 5 years old up to 12 months prior to assessment) was associated with disorders in the past 12 months (OR = 4.88, p = 0.001). Higher adolescent diabetes distress was related to higher symptoms of anxiety (b = 0.07, p = 0.001) and depression (b = 0.13, p = 0.001), while demographics, clinical characteristics, and parental emotional distress were not related.

CONCLUSIONS

Anxiety and mood disorders are common among adolescents and related to earlier disorders. Higher diabetes distress was related to higher symptom severity. Clinicians are advised to address past psychological problems and remain vigilant of these problems.

Our language matters: Improving communication with and about people with diabetes. A position statement by Diabetes Australia

The words used about diabetes affect the physical and emotional health of people living with diabetes. They also affect how individuals and society view people living with, or at risk of, diabetes. People with diabetes, their families, and people at risk of diabetes, need and deserve communications that are clear and accurate, respectful and inclusive, and free from judgement and bias. The aim of this position statement is to help bring about positive change in the language used about diabetes. It is based on 30+ years of research into the experiences of people with diabetes. Changing thelanguage of diabetes can make a powerful and positive difference to the emotional well-being, self-care and health outcomes of people affected by diabetes. It also affects community and government support for funding diabetes care, prevention and research. Diabetes Australia encourages everyone communicating about diabetes, or about people affected by diabetes, to choose and use their words carefully to support all people affected by diabetes. This position statement is intended as a guide for people working in healthcare, the media, government and policy, academia, industry, as well as employers and the community. It may also be helpful for the family and friends of people with diabetes.

Profiles of Depressive Symptoms and Diabetes Distress in Preadolescents With Type 1 Diabetes

OBJECTIVES

Diabetes distress and depressive symptoms are common psychosocial concerns for people with diabetes. These are related, yet distinct, mood states, which have each been related to diabetes management and glycated hemoglobin (A1C) among adolescents and adults with diabetes. However, they have not been examined concurrently in preadolescents with type 1 diabetes. Understanding the overlaps and distinctions between diabetes distress and depressive symptoms in youth would help guide decisions about psychosocial screening in diabetes clinical practice. In this study, we aimed to categorize preadolescents based on clinical cutoffs of concurrently administered measures of depressive symptoms and diabetes distress, and identify clinical and demographic characteristics of each group.

METHODS

One hundred eighty youth (age range, 9 to 13 years; age [mean ± standard deviation], 11.3±1.3 years; 55% female; 56% Caucasian; mean A1C, 8.4±1.6% [68 mmol/mol]) completed measures of diabetes distress, depressive symptoms and quality of life. Daily blood glucose monitoring frequency was calculated from meter download. A1C values were obtained from electronic medical records.

RESULTS

Depressive symptoms and diabetes distress each significantly correlated with A1C and quality of life. Although most (69%) participants had no clinically significant elevations in either diabetes distress or depressive symptoms, 14% had elevated depressive symptoms only and 17% had elevated distress without concurrent elevated depressive symptoms. Groups differed based on A1C, quality of life and insurance status.

CONCLUSIONS

Routine assessment of both depressive symptoms and diabetes distress may help to identify preadolescents with type 1 diabetes who require psychosocial support.

THR1VE! Positive psychology intervention to treat diabetes distress in teens with type 1 diabetes: Rationale and trial design

Adolescents with type 1 diabetes (T1D) experience high rates of diabetes distress, which negatively influence self-management and glycemic control. Building on effective positive psychology interventions to improve adherence in adults, as well as our pilot work to adapt these interventions for adolescents, we developed a positive psychology intervention for adolescents with T1D. The goal of THR1VE! is to reduce diabetes distress in adolescents with T1D and improve their diabetes outcomes. This multi-site randomized controlled trial compares a Diabetes Education + text-message-based Positive Affect intervention, to a Diabetes Education control condition. In the ongoing trial, we are evaluating the effects of the intervention on adolescents' diabetes distress, self-management, and glycemic control. This paper describes the rationale, trial design, and methodology of the THR1VE! Study.

Monetary reinforcement for self-monitoring of blood glucose among young people with type 1 diabetes: evaluating effects on psychosocial functioning

AIMS

To explore the auxiliary psychosocial effects of a monetary reinforcement intervention targeting self-monitoring of blood glucose among young people with Type 1 diabetes.

METHODS

Sixty young people with Type 1 diabetes, HbA_1c concentrations between 58 and 119 mmol/mol (7.5-13.0%), and average self-monitoring of blood glucose <4 times per day were randomized to either enhanced usual care or a 24-week intervention of monetary rewards for self-monitoring of blood glucose and associated behaviours (e.g. uploading glucose meters). Data were collected from the young people and their parents at baseline, during the intervention (6, 12 and 24 weeks) and after the intervention (36 weeks).

RESULTS

Linear mixed models were used to evaluate the intervention effects on psychosocial outcomes, adjusting for corresponding baseline levels and potential moderation by baseline level. The intervention reduced diabetes distress at week 6 among young people who had average and high baseline distress. It also reduced diabetes distress at weeks 12 and 24 among those with low baseline distress. The intervention also reduced young person-reported diabetes-related family conflict and diabetes-related interference among those with high baseline scores in these areas; however, the intervention worsened young person-reported diabetes interference among those with low baseline interference. Effects were medium-sized and time-limited.

CONCLUSIONS

Findings indicate predominantly positive impacts of monetary reinforcement interventions on psychosocial outcomes, although effects varied by outcome and time point. Whereas early improvements in diabetes distress were observed for all who received the intervention, improvements in other areas varied according to the level of psychosocial challenge at baseline. Incorporating psychosocial interventions may bolster and maintain effects over time.

Acceptability of Continuous Glucose Monitoring in Elderly Diabetes Patients Using Multiple Daily Insulin Injections

Background: Integrative diabetes care is lifelong and encompasses patient-reported outcome measures (PROMs). Understanding older adults' perceptions of continuous glucose monitoring (CGM) benefits and potential annoyances is important to assist with introducing it in this population. The aim of this study was to investigate PROMs and effectiveness of CGM introduction in elderly multiple daily injection (MDI) users with well-controlled diabetes. Methods: MDI-treated elderly (n = 25, mean age 67.6 ± 1.2 years, HbA1c = 7.1% ± 0.2%, 56% type 1 diabetes) were instructed to use a CGM device. PROMs were measured by questionnaires. CGM-recorded glycemic control metrics (time in range [TIR], time in hypoglycemia, coefficient of variation [CV]) were compared during blinded CGM and real-time CGM. Results: Satisfaction with CGM use was high; with perceived advantages as "very common" (4.22 out of 5) and annoyances as "modest" (1.82 out of 5). In total 95% of participants expressed improved sense of security with CGM use, 68% reported of improved sleep quality, and 82% were willing to use a CGM device after finishing the study protocol. CGM introduction did not impose additional diabetes-related distress (measured by the Problem Areas in Diabetes questionnaire). Significant improvements in TIR (3.9-10.0 mmol/L) (66.3% ± 2.6% vs. 76.9% ± 3.0%; P < 0.001), time in hypoglycemia (9.6% ± 2.1% vs. 5.2% ± 1.1%; P = 0.041), as well as reduced glycemic variability (%CV) (37.3 ± 11.1 vs. 32.9 ± 6.3; P < 0.001) were observed. Conclusion: Introduction of CGM in elderly patients with well-controlled diabetes resulted in high satisfaction without imposing additional diabetes distress. Furthermore, an added benefit in glucose control with stabilizing glycemia in target range was proven.

Diabetes distress is more strongly associated with HbA1c than depressive symptoms in adolescents with type 1 diabetes: Results from Diabetes MILES Youth-Australia

BACKGROUND

Glycated hemoglobin (HbA1c) is higher during adolescence than at any other life stage. Some research among adolescents indicates that depressive symptoms are associated with suboptimal HbA1c. However, research among adults suggests diabetes distress is a stronger predictor of HbA1c than depressive symptoms.

OBJECTIVE

To determine the relative contributions of depressive symptoms and diabetes distress to explain the variance in HbA1c among adolescents with type 1 diabetes.

PARTICIPANTS AND METHODS

Diabetes MILES Youth Study respondents aged 13 to 19 years completed questionnaires assessing depressive symptoms (Patient Health Questionnaire for Adolescents: PHQA-8), diabetes distress (Problem Areas in Diabetes-Teen version: PAID-T), and self-reported socio-demographic and clinical variables, including their most recent HbA1c. Stepwise hierarchical multiple regression was conducted to examine the contributions of depressive symptoms and diabetes distress to HbA1c.

RESULTS

Participants (N = 450) had a (mean ± SD) age of 15.7 ± 1.9 years; diabetes duration of 6.9 ± 4.3 years; and 38% (n = 169) were male. Twenty-one percent (n = 96) experienced moderate-to-severe depressive symptoms (PHQA-8 ≥ 11) and 36% (n = 162) experienced high diabetes distress (PAID-T > 90). In the final regression model, HbA1c was explained by: diabetes duration (β = .14, P = .001), self-monitoring of blood glucose (β = -.20, P < .001), and diabetes distress (β = .30, P < .001). Following the addition of diabetes distress, depressive symptoms were no longer significantly associated with HbA1c (P = .551). The final model explained 18% of the variance in HbA1c.

CONCLUSIONS

Consistent with evidence from studies among adults, diabetes distress mediated the relationship between depressive symptoms and HbA1c among adolescents with type 1 diabetes. These findings suggest that clinicians need to be aware of diabetes distress.