Diabetes-related Health Outcomes Research Articles

Do time preferences predict diabetes outcomes? A combined survey and register-based study.

Identifying determinants of heterogeneity in health outcomes continues to be a focus in the health economic literature. In this study, we analyze whether time preferences predict health outcomes in individuals with type 1 diabetes (T1D) who use insulin pump therapy to manage their condition. We collect data on time preferences using a hypothetical matching task and estimate aggregate as well as individual-level discounting parameters using the exponential, hyperbolic, and quasi-hyperbolic discounting models. These parameters are then regressed against essential diabetes-related health outcomes obtained from registries and medical records, including glycemic control, kidney function, BMI, and number of hospital contacts. Our analyses indicate that all three discounting models fit the data equally well. Except for hospital contacts, we find robust evidence that impatience, as reflected by higher discounting, predicts worse health outcomes. Additionally, present bias is associated with worse kidney function. Our findings suggest that time preferences can explain some of the heterogeneity in health among individuals with T1D and call for increased attention on the role of time preferences in the design of disease management programs for individuals with chronic conditions.

The Association of Multidimensional Sleep Health With HbA1c and Depressive Symptoms in African American Adults With Type 2 Diabetes.

Sleep is important for diabetes-related health outcomes. Using a multidimensional sleep health framework, we examined the association of individual sleep health dimensions and a composite sleep health score with hemoglobin A1c (HbA1c) and depressive symptoms among African American adults with type 2 diabetes. Participants (N = 257; mean age = 62.5 years) were recruited through local churches. Wrist-worn actigraphy and sleep questionnaire data assessed multidimensional sleep health using the RuSATED framework (regularity, satisfaction, alertness, timing, efficiency, duration). Individual sleep dimensions were dichotomized into poor or good sleep health and summed into a composite score. HbA1c was assessed using the DCA Vantage™ Analyzer or A1CNow® Self Check. Depressive symptoms were assessed using the Patient Health Questionnaire (PHQ-9). Regression models examined the association of individual sleep dimensions and composite sleep health with HbA1c and depressive symptoms. Higher composite sleep health scores were associated with a lower likelihood of having greater than minimal depressive symptoms (PHQ-9 ≥ 5) (odds ratio [OR] = 0.578, 95% confidence interval [CI] = 0.461-0.725). Several individual sleep dimensions, including irregularity (OR = 1.013, CI = 1.005-1.021), poor satisfaction (OR = 3.130, CI = 2.095-4.678), and lower alertness (OR = 1.866, CI = 1.230-2.833) were associated with a greater likelihood of having depressive symptoms. Neither composite sleep health scores nor individual sleep dimensions were associated with HbA1c. Better multidimensional sleep health is associated with lower depressive symptoms among African American adults with type 2 diabetes. Longitudinal research is needed to determine the causal association between multidimensional sleep health and depressive symptoms in this population. ClinicalTrials.gov identifier NCT04282395.

Independent Correlates of Glycemic Control among Adults with Diabetes in South Africa.

Globally, the prevalence of diabetes is increasing, especially in low- and middle-income countries (LMICs), including those in the sub-Saharan African region. However, the independent socioeconomic correlates of glycemic control as measured by hemoglobin A1C have yet to be identified. Therefore, the aim of this analysis was to understand the independent correlates of glycemic control in South Africa. Data from the 2016 South Africa Demographic and Health Survey on adults with diabetes were used for this analysis. The dependent variable, glycemic control, was defined using hemoglobin A1c (HbA1c). Independent variables included: age, gender, ethnicity, marital status, region, urban/rural residence, ability to read, education, insurance, wealth, occupation, and employment in the last year. Analysis of variance was used to test for differences in mean HbA1c for each category of all independent variables, and a fully adjusted linear regression model was used to identify independent correlates of glycemic control (HbA1c). Among the 772 people included in this analysis, there were significant differences in mean HbA1c by age (p < 0.001), ethnicity (p < 0.001), place of residence (p = 0.024), wealth index (p = 0.001), and employment in the last year (p = 0.008). Independent correlates of HbA1c included age, ethnicity, and wealth index. This study used data from a large diverse population with a high prevalence of diabetes in sub-Saharan Africa and provides new evidence on the correlates of glycemic control and potential targets for interventions designed to lower HbA1c and improve diabetes-related health outcomes of adults in South Africa.

The impact of socioeconomic factors, social determinants, and ethnicity on the utilization of glucose sensor technology among persons with diabetes mellitus: a narrative review.

Continuous glucose monitoring (CGM) usage has been shown to improve disease outcomes in people living with diabetes by facilitating better glycemic management. However, previous research has suggested that access to these devices can be influenced by nonmedical factors such as socioeconomic status and ethnicity. It is critical that equitable access to CGM devices is ensured as people from those groups experience poorer diabetes-related health outcomes. In this narrative review, we provide an overview of the various healthcare systems worldwide and how socioeconomic status, social context, and ethnicity shape device usage and the associated health outcomes. In general, we found that having a lower socioeconomic status and belonging to an ethnic minority group negatively impact CGM usage. While financial means proved to be an important mediator in this process, it was not the sole driver as disparities persisted even after adjustment for factors such as income and insurance status. Recommendations to increase CGM usage for people of a lower socioeconomic status and ethnic minorities include increasing the availability of financial, administrative, and educational support, for both patients and healthcare providers. However, recommendations will vary due to local country-specific circumstances, such as reimbursement criteria and healthcare ecosystems.

Pilot study to test the safety, tolerability and feasibility of dulaglutide during a low-energy diet for weight loss and improved glycaemic control

IntroductionDiabetes and obesity are significant public health concerns. Previous studies have demonstrated that low energy diets are effective in promoting weight loss and inducing diabetes remission. However, hunger is a...

A Digital Diabetes Storytelling Intervention for the Hmong Community: A Pilot Study

Hmong-Americans experience higher rates of diabetes and poorer diabetes-related health outcomes than their White peers. Traditional methods of diabetes education do not reach Hmong patients effectively due to known socioeconomic and literacy barriers. The purpose of this study is to examine the acceptability of a culturally informed diabetes self-management education video tool, using digital storytelling that was created using a community-engaged approach, administered in a single academic clinic that sees a large percentage of Hmong patients. The video tool was successful in the areas of acceptability, story transformation, and story identification; 96% of participants stated that the video felt like something from their community, 88% stated that they could identify with the story, 79% stated that they wanted to know what happened next, and 70% of participants reported that they were motivated to do something different after watching. New methods to improve diabetes education and improve health outcomes in Hmong communities are needed. Culturally informed digital storytelling is one tool, which may be used to improve diabetes health outcomes in this population.

Estimation of HbA1c after weight loss using a beta-regression for an economic evaluation of a behavioural weight management programme from the GLoW trial: a methodological study

BackgroundIn economic evaluations, average intervention effects are usually applied to a population. However, this fails to reflect the change in the distribution of HbA1c due to heterogeneous responses to weight loss. We aimed to investigate whether allowing heterogeneous treatment effects using a beta regression better represented the distribution of HbA1c after a weight-loss intervention, and how this affected cost effectiveness. MethodsThe Glucose Lowering through Weight Management (GLoW) trial evaluated the effectiveness of a diabetes education and weight-loss intervention against a standard diabetes education programme. Adults diagnosed with type 2 diabetes within 3 years were recruited from Clinical Commissioning Groups across 159 sites in England from July 20, 2018, to July 22, 2018. Ethics approval (18/ES/0048) and participant informed consent were obtained. Considering the between-treatment-arm difference in HbA1c after 12 months, we compared a mean-effect estimated from a mixed-effects regression to a heterogeneous effect estimated from a beta regression performed on 12-month HbA1c conditional on baseline HbA1c, gender, diabetes duration and intervention group. We used the School of Public Health Research (SPHR) Diabetes Treatment model to apply these treatment effects and evaluate the lifetime NHS costs and quality-adjusted life-years (QALYs), discounted at 3·5%. The microsimulation model estimated diabetes-related health outcomes using the UK Prospective Diabetes Study Outcomes Model 2 risk equations and risk factor trajectory equations, alongside estimating diabetes remission, osteoarthritis, and cancer. We calculated the incremental net benefit (INB) of the intervention using a £20 000 per QALY valuation, by deterministic analysis. The GLoW trial is registered with the ISRCTN Registry, ISRCTN18399564. FindingsThe trial recruited 577 participants (mean age 60 years; 278 [53%] female, 247 [47%] male; 474 [91%] white ethnic background). Applying heterogeneous HbA1c changes better reproduced the skewness in post-intervention HbA1c than applying a mean-effect (Kolmogorov-Smirnov test p=0·02 compared with p=0·0000007). The beta-regression method suggested the intervention was more cost-effective, estimating an INB of £736 per person, compared with £584 when applying the mean-effect. InterpretationAlternative regression specification methods should be considered when evaluating the cost-effectiveness of interventions if the key intervention outcomes are not normally distributed. However, this alternative method requires further investigation to conclude its appropriateness in evaluating cost-effectiveness in different contexts. FundingNational Institute for Health and Care Research (NIHR) Programme Grants for Applied Research Programme (Reference Number RP-PG0216-20010).

Association between initial continuity of care status and diabetes-related health outcomes in older patients with type 2 diabetes mellitus: A nationwide retrospective cohort study in South Korea

Background and aimTimely and continuous care is necessary for patients with diabetes to prevent hospitalization and complications. This study investigated the association between initial Continuity of Care Index (COCI) status after diagnosis of type 2 diabetes mellitus (T2DM) and short- and long-term diabetes-related health outcomes. MethodsIt targeted elderly patients aged 60 years and above diagnosed with T2DM and used the National Health Insurance Service Senior cohort data from 2008 to 2019. The outcome measures were diabetic avoidable hospitalization and diabetic complication incidence for a five-year period. The main independent variable was the first-year COCI status after T2DM diagnosis. Survival analyses were performed using the Cox proportional hazards model. ResultsParticipants with a good COCI status within the first year of being diagnosed with T2DM experienced a reduced risk of diabetes-induced avoidable hospitalization (five years: Hazard ratio (HR) 0.39, 95 % Confidence interval (CI) 0.27–0.57; overall period: HR 0.56, 95 % CI 0.43–0.72) and diabetic complications (five years: HR 0.74, 95 % CI 0.68–0.80; overall period: HR 0.77, 95 % CI 0.71–0.82). ConclusionsIn the short- and long-term, there is a need for early management and improved healthcare accessibility of diabetes to prevent diabetes-avoidable hospitalization and diabetes-related complications.

The impact of a pharmacist-led cultural competence training on provider perceived preparedness and clinical care in patients with diabetes of Asian descent

BackgroundPatients of Asian descent are under-represented in the U.S. health care system and provider cultural competence is inadequate in addressing Asian health disparities. ObjectivesThe purpose of this study was to evaluate the impact of the pharmacist-led cultural competence training on provider self-perceived preparedness and diabetes-related health outcomes in patients of Asian descent. MethodsThis study is a cross-sectional followed by a quasi-experimental design conducted in 2 phases in a primary care clinic. Phase one evaluated the association of providers’ cross-cultural care survey (CCCS) scores with patients’ diabetic health indices: hemoglobin A1c (HbA1C), systolic blood pressure (SBP), diastolic blood pressure, and body mass index. Phase 2 examined the impact of pharmacist-led cultural competence training on providers’ cross-cultural competency using survey analysis as well as pre- and post-training diabetic health indices in patients of Asian descent. ResultsPhase 1 CCCS results showed baseline cross-cultural competence of the providers is inadequate (N = 9 providers). Furthermore, a significant negative correlation was found between providers’ CCCS score and patients’ HbA1C (N = 49, P = 0.04). Phase 2 showed that cultural competence training significantly reduced providers’ self-perceived “un-preparedness” to care for patients of alternative cultures (N = 30 providers). Average diabetic health indices for all patients (N = 95) before and after the training were not significantly different. In the subset of patients with uncontrolled diabetes (HbA1C ≥ 7), SBP and HbA1C were significantly reduced after the training (P = 0.032 and P = 0.039, respectively). ConclusionsPharmacist-led cultural competence training had a positive impact on provider self-assessment and diabetic clinical outcomes in uncontrolled patients.

Development and Evaluation of the Delivery-Based HEALED Produce Rx Program for Uninsured Patients With Diabetes in Rural Eastern North Carolina.

Produce prescription (PRx) programs have emerged as a preventive treatment to subsidize the cost of fruits and vegetables for people with lower income and have shown promise in improving diet quality and diabetes-related health outcomes (eg, glycated hemoglobin A1c). Researchers from the Department of Nutrition Science at East Carolina University worked with the Wayne Action Teams for Community Health (WATCH) Clinic, a safety-net clinic in rural Eastern North Carolina, and a local research farm to develop a PRx program for rural patients with type 2 diabetes and no health insurance. Preliminary patient surveys identified high levels of interest in a PRx program and a desire for recipes to accompany the produce. Formative evaluation results via telephone interviews with eligible patients identified transportation barriers to participation and the desire for complementary nutrition education and culinary resources. These results led to a delivery-based PRx program implemented from June through November 2021. Patients received weekly home delivery of an average of 4.7 pounds of fruits and vegetables and complementary nutrition and health education materials and culinary resources (cookbook, recipes). The level of patient satisfaction with the program was high; the reported level of consumption of produce, including unfamiliar produce, was high; educational resources were associated with increased knowledge and motivation to make healthful lifestyle changes, and glycemic control significantly improved. Ensuring that patients have a voice in the design and implementation of PRx programs is crucial to success. Ongoing use of rigorous formative and process evaluations can ensure appropriateness, use, and a positive effect of PRx programs, and they are needed to establish best practices for implementation.

An integrated approach to address diabetes in the context of food insecurity: Delivering health study protocol

BackgroundDiabetes self-management education and support (DSMES) interventions among food insecure individuals with type 2 diabetes (T2D) have found modest improvements in nutrition and health outcomes but are limited by barriers to attendance and retention. This study applies a community-based participatory research approach, engaging community members at all levels of intervention planning, development, implementation, and dissemination, to deliver a plain-language DSMES curriculum to food insecure community members with T2D. MethodsThis is a single-arm, pre-post design assessing the efficacy of a 12-week home-delivered DSMES curriculum and T2D-appropriate food box intervention to improve the nutrition and health outcomes of food insecure individuals with T2D. The intervention consists of a weekly food box delivery and handout with video links on key DSMES topics, developed and refined using community advisor feedback. Up to 100 English-, Spanish-, or Marshallese-speaking adult participants with T2D (HbA1c ≥ 7%) and food insecurity are being recruited from food pantries in northwest Arkansas. Data is collected at pre-intervention and immediately post-intervention. The primary study outcome is change in HbA1c. Secondary measures include diet quality (Healthy Eating Index-2015, calculated from 3 24-h dietary recall interviews via phone), body mass index, blood pressure, skin carotenoids, food security, T2D self-management behaviors, T2D self-efficacy, and T2D-related distress. ResultsRecruitment began in August 2021 and enrollment is anticipated to be complete in March 2023. ConclusionFindings from this study will provide a rich understanding of diabetes-related health outcomes and dietary patterns of individuals with food insecurity and T2D and inform future food-focused DSMES interventions in this setting.

The indirect impact of the COVID-19 pandemic on people with type 2 diabetes mellitus and without COVID-19 infection: Systematic review and meta-analysis

BackgroundThe effect directly from the coronavirus disease 2019 (COVID-19) infection on health and fatality has received considerable attention, particularly among people with type 2 diabetes mellitus (T2DM). However, evidence on the indirect impact of disrupted healthcare services during the pandemic on people with T2DM is limited. This systematic review aims to assess the indirect impact of the pandemic on the metabolic management of T2DM people without a history of COVID-19 infection. MethodsPubMed, Web of Science, and Scopus were systematically searched for studies that compared diabetes-related health outcomes between pre-pandemic and during-pandemic periods in people with T2DM and without the COVID-19 infection and published from January 1, 2020, to July 13, 2022. A meta-analysis was performed to estimate the overall effect on the diabetes indicators, including hemoglobin A1c (HbA1c), lipid profiles, and weight control, with different effect models according to the heterogeneity. ResultsEleven observational studies were included in the final review. No significant changes in HbA1c levels [weighted mean difference (WMD), 0.06 (95% CI −0.12 to 0.24)] and body weight index (BMI) [0.15 (95% CI −0.24 to 0.53)] between the pre-pandemic and during-pandemic were found in the meta-analysis. Four studies reported lipid indicators; most reported insignificant changes in low-density lipoprotein (LDL, n = 2) and high-density lipoprotein (HDL, n = 3); two studies reported an increase in total cholesterol and triglyceride. ConclusionsThis review did not find significant changes in HbA1c and BMI among people with T2DM after data pooling, but a possible worsening in lipids parameters during the COVID-19 pandemic. There were limited data on long-term outcomes and healthcare utilization, which warrants further research. Systematic review registrationPROSPERO CRD42022360433.

Social Determinants of Health and Impact on Screening, Prevalence, and Management of Diabetic Retinopathy in Adults: A Narrative Review.

Diabetic retinal disease (DRD) is the leading cause of blindness among working-aged individuals with diabetes. In the United States, underserved and minority populations are disproportionately affected by diabetic retinopathy and other diabetes-related health outcomes. In this narrative review, we describe racial disparities in the prevalence and screening of diabetic retinopathy, as well as the wide-range of disparities associated with social determinants of health (SDOH), which include socioeconomic status, geography, health-care access, and education.

The Effect of Food is Medicine Interventions on Diabetes-related Health Outcomes Among Low-income and Food-insecure Individuals: A Systematic Review and Meta-analysis

ObjectiveIn this study, we aim to review the current evidence of Food is Medicine interventions on diabetes outcomes among low-income or food-insecure individuals. MethodsSeven databases were searched from January 1, 2000 to October 26, 2021 for full-text articles written in English. The studies included experimental studies of any duration and design which addressed the effect of Food is Medicine interventions on fruit and vegetable (F&V) intake and glycated hemoglobin (A1C) levels among low-income or food-insecure populations with prediabetes or diabetes of any age group. Only direction of effect of interventions on F&V intake were ascertained due to high variability in outcome measurement. A1C results were pooled using generic inverse variance with a fixed-effects model. Heterogeneity was assessed using Cochran’s Q and quantified by I2. ResultsSixteen studies were included. Five of the 8 studies reported a significant increase in F&V intake. Seven of the 14 studies reported a significant decrease in A1C levels. A meta-analysis of 5 randomized controlled trials (n=843) resulted in clinically meaningful reductions in A1C compared with control (mean difference, −0.47%; 95% confidence interval, −0.66 to −0.29, I2=88%, p<0.0001). Half (n=8) of the studies have a high risk of bias due to missing data, detection bias, and confounding. ConclusionsFood is Medicine interventions are effective in increasing F&V intake and reducing A1C levels of the target population. More randomized controlled studies are needed to validate the results.

Racial disparities in healthcare utilization and costs in pharmacologically treated medicaid enrollees with developmental disabilities and Type 2 diabetes

Objective: Adults with developmental disabilities have higher prevalence of chronic disease conditions such as diabetes, obesity, high blood pressure, arthritis, CVD and chronic pain. They also have poor healthcare utilization and are screened less for chronic disease conditions. Very few studies have looked at the diabetes related health outcomes in developmentally disabled adults, where distinct racial differences in medication use behaviors have been observed. The objective of this study was to examine the association of race with healthcare utilization and costs in pharmacologically treated Medicaid enrollees with developmental disabilities (DD) and type 2 diabetes. Methods: This was a retrospective cohort study that identified adults with DD and type 2 diabetes from the MarketScan® Multi-State Medicaid Database. Enrollees aged 18-64 years who received new medications for type 2 diabetes from January 1, 2004 and December 31, 2006 were included. An index diagnosis date was assigned to each patient and adults with a continuous enrollment for at least 12 months were included. Probabilities of type 2 diabetes related healthcare utilization (inpatient, outpatient and emergency department visits) in adults with DD were computed using multivariate logistic regression models. Multivariate negative binomial regression was used to measure the rate of change in type 2 diabetes related healthcare utilization in patients with DD. Multivariate linear regression with log-transformation was used to determine type 2 diabetes related healthcare costs in Medicaid enrollees with DD. Results: This study had a sample size of 1529 patients. After controlling for all the covariates, compared to Caucasians with DD, African Americans with DD were more likely to have type 2 diabetes related inpatient (OR=1.71; 95% CI, 1.02-2.85) and emergency department visits (OR, 1.67; 95% CI, 1.02-2.73). African Americans with DD and type 2 diabetes had significantly higher healthcare costs compared to Caucasians with DD and type 2 diabetes. Conclusion: Racial disparities exist in healthcare utilization in Medicaid patients with DD and type 2 diabetes. African Americans were more likely to have inpatient and ER visits respectively. Also, African Americans were more likely to have higher type 2 related healthcare costs compared to Caucasians.

Association between the quality of primary care, insurance coverage, and diabetes-related health outcomes in a cohort of older adults in China: results from the China Health and Retirement Longitudinal Study

ObjectiveThis study aims to identify the association between diabetes diagnosis, health outcomes, insurance scheme, and the quality of county-level primary care in a cohort of older Chinese adults.Design and settingData...

Projected Impact of the Medicare Part D Senior Savings Model on Diabetes-Related Health and Economic Outcomes Among Insulin Users Covered by Medicare.

The Medicare Part D Senior Savings Model (SSM) took effect on 1 January 2021. In this study we estimated the number of beneficiaries who would benefit from SSM and the long-term health and economic consequences of implementing this new policy. Data for Medicare beneficiaries with diabetes treated with insulin were extracted from the 2018 Medical Expenditure Panel Survey. A validated diabetes microsimulation model estimated health and economic impacts of the new policy for the 5-year initial implementation period and a 20-year extended policy horizon. Costs were estimated from a health system perspective. Of 4.2 million eligible Medicare beneficiaries, 1.6 million (38.3%) would benefit from the policy, and out-of-pocket (OOP) costs per year per beneficiary would decrease by 61% or $500 on average. Compared with non-White subgroups, the White population subgroups would have a higher proportion of SSM enrollees (29.6% vs. 43.7%) and a higher annual OOP cost reduction (reduction of $424 vs. $531). Among the SSM enrollees, one-third (605,125) were predicted to have improved insulin adherence due to lower cost sharing and improved health outcomes. In 5 years, the SSM would 1) avert 2,014 strokes, 935 heart attacks, 315 heart failure cases, and 344 end-stage renal disease cases; 2) gain 3,220 life-years and 3,381 quality-adjusted life-years (QALY); and 3) increase insulin cost and total medical cost by $3.5 billion and $2.8 billion. In 20 years, the number of avoided clinical outcomes, number of life-years and QALY gained, and the total and insulin cost would be larger. The Medicare SSM may reduce the OOP costs for approximately one-third of the Medicare beneficiaries treated with insulin, improving health outcomes via increased insulin adherence. However, the SSM will also increase overall Medicare spending for insulin and overall medical costs, which may impact future premiums and benefits. Our findings can inform policy makers about the potential impact of the new Medicare SSM.

Use and Impact of Type 2 Diabetes Prevention Interventions

RCTs have found that type 2 diabetes can be prevented among high-risk individuals by metformin medication and evidence-based lifestyle change programs. The purpose of this study is to estimate the use of interventions to prevent type 2 diabetes in real-world clinical practice settings and determine the impact on diabetes-related clinical outcomes. The analysis performed in 2020 used 2010‒2018 electronic health record data from 69,434 patients aged ≥18 years at high risk for type 2 diabetes in 2 health systems. The use and impact of prescribed metformin, lifestyle change program, bariatric surgery, and combinations of the 3 were examined. A subanalysis was performed to examine uptake and retention among patients referred to the National Diabetes Prevention Program. Mean HbA1c values declined from before to after intervention for patients who were prescribed metformin (-0.067%; p&lt;0.001) or had bariatric surgery (-0.318%; p&lt;0.001). Among patients referred to the National Diabetes Prevention Program lifestyle change program, the type 2 diabetes postintervention incidence proportion was 14.0% for nonattendees, 12.8% for some attendance, and 7.5% for those who attended ≥4 sessions (p&lt;0.001). Among referred patients to the National Diabetes Prevention Program lifestyle change program, uptake was low (13% for 1‒3 sessions, 15% for ≥4 sessions), especially among males and Hispanic patients. Findings suggest that metformin and bariatric surgery may improve HbA1c levels and that participation in the National Diabetes Prevention Program may reduce type 2 diabetes incidence. Efforts to increase the use of these interventions may have positive impacts on diabetes-related health outcomes.

Psychological flexibility is associated with less diabetes distress and lower glycated haemoglobin in adults with type 1 diabetes.

Diabetes distress, self-efficacy and health literacy are associated with diabetes self-management and health outcomes. Measures of coping styles and their impact on diabetes self-management and diabetes-related distress might add value in identifying those at risk of poorer health outcomes. Current evidence of associations between psychological flexibility/inflexibility and diabetes-related health outcomes is limited. To measure associations of psychological flexibility, self-efficacy and health literacy with diabetes distress and glycated haemoglobin (HbA1c) in adults with type 1 diabetes. We surveyed 105 adults with type 1 diabetes attending a tertiary diabetes outpatient clinic (mean age 27 ± 7.1 years; 53% men; duration of diabetes 12.6 ± 8.5 years; HbA1c 72 ± 22 mmol/mol, 8.7 ± 2.0%; 34% using insulin pumps). We assessed psychological flexibility, self-efficacy, health literacy and diabetes distress. Regression models explored the relative contributions of different factors to diabetes distress and HbA1c. The majority of health literacy scores were in the low-risk range. Those with greater psychological flexibility had higher self-efficacy (r = 0.34; P < 0.01) and reported less diabetes distress (r = -0.54; P < 0.001). In multiple regression analyses, psychological flexibility and self-efficacy accounted for 36% of the variance in distress score (P < 0.001). Shorter duration of diabetes (P < 0.001) and greater psychological flexibility (P < 0.01) correlated with lower HbA1c. A 10-point (one standard deviation) higher psychological flexibility score corresponded to a 0.5% lower HbA1c. Greater psychological flexibility was associated with less diabetes distress and lower HbA1c. The psychological flexibility construct might inform alternative interventional approaches aiming to improve well-being and glycaemic control.

IDF21-0259 Development of a self-care program for older people with type 2 diabetes attending community health centers

Background: Diabetes is a growing problem globally, with the major impact being experienced in low and middle-income countries. In South Africa, diabetes is a major cause of morbidity and mortality and a burden to the overstretched health services, community, family, and people with the disease. Self-care management is a cornerstone of diabetes care. Aim: To inform the development of a self-care management program for older people attending public sector primary health care services in Cape Town, South Africa by using the PRECEDE planning model. Method: (1) This research study is based on the theoretical framework of the PRECEDE-PROCEED model (PPM). (2) In the PPM, a complete needs assessment involving phases should be made before planning a health promotion intervention. Results: This research study incorporates five interlinked studies, The first was a systematic review of studies that assessed the prevalence of type 2 diabetes mellitus among older people in African countries conducted between 2000 and 2015 with the objective of providing data for the monitoring of future trends. the overall prevalence of diabetes was 13.7% (95% CI 11·3–16·3) and was twofold higher in studies based on the oral glucose tolerance test than in those using fasting plasma blood glucose. The second is a secondary analysis of the Study on global AGEing and adult health (SAGE) South Africa Wave 1 data that examined the prevalence of self-reported diabetes and the association between diabetes and each health-related quality of life and disability amongst South Africa’s older adults. The results were that diabetes was associated with lower quality of life and greater disability. The third, a cross-sectional survey, examines the knowledge of older people with diabetes attending primary care clinics. Its major finding is that there was a lack of knowledge about the complications of diabetes, suggesting that the available diabetes educational opportunities have not been effective. Importantly, however, social support was positively associated with both knowledge and a number of self-care aspects. The fourth is a qualitative study consisting of a documentary review. This found that generally older persons face numerous barriers in managing their condition. Further, there are multiple efforts to re-orientate the healthcare system to focus more effectively on non-communicable diseases for the population which would benefit older patients with diabetes. Finally, the study includes a systematic review of peer and non-professional health worker-led diabetes self-management programmes (COMP-DSMP) in low and middle-income country primary health care settings, and also examines the implementation strategies and associated diabetes-related health outcomes This found equivocal evidence supporting the use of COMP-DSMP for people with diabetes in these countries and suggested that the models of a peer/CHW-led programme need to be further explored, especially given the inevitability of a professional healthcare workforce shortage in LMICs Discussion: This research alerts policymakers and clinicians to some of the specific issues considered to be pertinent and important in the care and management of older persons with diabetes. Many of these would also be applicable to older individuals with other chronic conditions.