Improvements In Diabetes Distress Research Articles

Effect of automated insulin delivery systems on person-reported outcomes in people with diabetes: a systematic review and meta-analysis

Conclusive evidence on the benefits of automated insulin delivery (AID) systems on person-reported outcomes (PROs) is missing. In this systematic review and meta-analysis, four databases (PubMed, PsycINFO, Cochrane, and GoogleScholar) were searched from inception up to August 7th, 2024. All types of studies were included if studies reported on PROs in people with diabetes using an AID system. All types of control groups in randomised controlled trials (RCT) were included. Summary data were extracted by three reviewers. Main outcomes focused on diabetes distress, fear of hypoglycaemia and quality of life. Meta-analyses were conducted for RCTs and observational studies separately. When five or more studies could be pooled, random-effects meta-analysis was used, otherwise common-effects meta-analysis was used. Risk of bias was evaluated with Cochrane tools. This study was registered with PROSPERO, CRD42022352502. A total of 62 studies (n=9253) were included reporting on 45 different questionnaires. Twenty-seven studies were RCTs and 25 were observational studies. RCT meta-analyses showed reduced diabetes distress (standardised mean difference [95% CI]:-0.159 [-0.309,-0.010], I2=23.0%), reduced fear of hypoglycaemia (-0.339 [-0.566,-0.111], I2=42.6%), and improved hypoglycaemia unawareness (-0.231 [-0.424,-0.037], I2=0.0%), quality of life in adults (0.347 [0.134, 0.560], I2=0.0%) and children/adolescents (0.249 [0.050, 0.448], I2=0.0%). Observational meta-analyses corroborated improvements in diabetes distress (-0.217 [-0.403,-0.031], I2=68.5%), fear of hypoglycaemia (-0.445 [-0.540,-0.349], I2=0.0%), hypoglycaemia unawareness (-0.212 [-0.419,-0.004], I2=0.0%), and showed improved sleep quality (-0.158 [-0.255,-0.061], I2=0.0%). We found low to moderate effect sizes indicating that AID therapy is associated with reduced burden and improved well-being in people with diabetes. Evidence comes from both RCTs and observational studies. However, for some PROs only a limited number of studies could be pooled with a large heterogeneity in questionnaires used. More research is needed with a more uniformed assessment of PROs to demonstrate the added value of AID therapy on psychosocial outcomes. None.

1056-P: Impact of Individualized HbA1c Target Setting on Diabetes-Distress, Self-Efficacy, Well-Being, and HbA1c

American Diabetes Association guidelines emphasize the importance of individualized HbA1c target setting in glycemic management, but little is known of the impact of target-setting on patient well-being. We randomized 50 adults (type 1 or 2) to receive HbA1c targets 5 mmol/mol (0.5%) above or below current value and evaluated impact on health-related quality of life: EQ-5D-5L, EQ-VAS, diabetes distress: Problem Areas in Diabetes, PAID, self-efficacy: Diabetes Empowerment Scale Long Form, DES-LF, well-being: Wellbeing Questionnaire-12, W-BQ12 and HbA1c (%) at baseline and 3 months; with thematic analysis of semi-structured interviews in a subset of 14 people. Tabulated results for 33 completers: We hypothesized that individualized target-setting, especially stretch targets, might worsen diabetes distress and compromise wellbeing. Multiple validated questionnaires and thematic analysis of semi-structured interviews showed no evidence of any significant deterioration. Indeed, the process of explicit individualized target setting was associated with improvements in all wellbeing measures except EQ-5D-5L and there were significant improvements in diabetes distress and psychosocial efficacy in the relaxed target group. Our data suggest that the process of setting explicit individualized HbA1c targets is a positive one, regardless of whether the target is ‘relaxed’ or ‘stretch’. Disclosure S.J.Westall: None. S.Watmough: None. R.Narayanan: None. G.Irving: Research Support; Graphnet, Takeda Pharmaceutical Co., Ltd. N.J.Furlong: None. G.A.Lewis: None. K.J.Hardy: Other Relationship; Sanofi, Speaker's Bureau; Napp Pharmaceuticals Limited.

696-P: Evaluating REACHOUT—A Mobile App That Delivers Peer-Led Mental Health Support to Adults with Type 1 Diabetes

Introduction: Recent years have witnessed a dramatic shift toward digital health technologies for mental health care delivery. While research investigating digital interventions involving peer support for children and adolescents with type 1 diabetes (T1D) has been growing, few, if any studies, have examined peer support mental health interventions for adults with T1D. Methods: We recruited 46 adults with T1D (M age= 43.9, females=71.7%) living in rural and remote communities in British Columbia to participate in REACHOUT, a 6-month intervention utilizing a mobile app to deliver three modalities of support: one-on-one with a peer supporter, group-based text messaging, and video group sessions. Participants were invited to select their own peer supporter and encouraged to access any or all of the three modalities as frequently as desired. Assessments were conducted at baseline and six months and measured diabetes distress (and seven distress subscales), depressive symptomatology, and perceived support from family/friends, peers, and the health care team. Independent mixed-effects regression models were run to examine pre-post intervention changes. Results: Thirty-eight participants completed the intervention (attrition = 17%). At six months, reductions were observed for overall distress (p=0.007) and four subscales: powerlessness (p=0.009), management distress (p=0.001), negative social perceptions (p=0.023), and eating distress (p=0.032). For secondary outcomes, depressive symptoms decreased (p=0.009) while perceived support from family/friends (p=0.023) and peers (p<0.001) increased. Conclusions: Participation in REACHOUT was associated with improvements in diabetes distress as well as other psychosocial outcomes. By offering different modalities of support delivery over a digital platform, participants, especially those living in more geographically marginalized communities, can customize support to meet their own unique needs. Disclosure T.S.Tang: Research Support; Juvenile Diabetes Research Foundation (JDRF), Speaker's Bureau; Abbott Diabetes, Insulet Corporation. G.Klein: None. M.Görges: Research Support; Careteam Technologies, IDENTOS, Smile CDR Inc., SecureKey Technologies Inc., Thrive Health, Excelar Technologies. L.Fisher: Consultant; Abbott Diabetes, Eli Lilly and Company, Research Support; Ascensia Diabetes Care. W.H.Polonsky: Consultant; Abbott Diabetes, Boehringer Ingelheim and Eli Lilly Alliance, Eli Lilly and Company, Insulet Corporation, Intuity Medical, Inc., MannKind Corporation, Provention Bio, Inc., Sanofi-Aventis U.S., Vertex Pharmaceuticals Incorporated. D.M.Hessler: Consultant; Lilly. D.Taylor: None. Funding JDRF (2-SRA-2020-986-S-B)

724-P: Baseline Findings from ACT1VATE—A Novel RCT for Diabetes Distress

Recent interventions for diabetes distress (DD) have achieved dramatic improvements in DD, but not A1c. Further, none have been rigorously tested in the healthcare settings where individuals receive their diabetes care. An in-progress RCT will compare diabetes education (DSME/S) to an Acceptance and Commitment Therapy group program (ACT1VATE) in improving glycemic management in N = 484 adults with type 1 diabetes, A1c ≥ 8, and significant DD. We predict that ACT1VATE will be superior to DSME/S in improving DD and glycemic management given its 1) goal to change one's relationship with difficult diabetes thoughts/emotions driving problematic health behaviors and 2) linkage of diabetes self-care behavior to one's personal values, thus eliciting intrinsic motivation for meaningful, lasting health behavior changes. Thus far, enrolled participants (N = 105) are predominantly female (65%), non-Hispanic (83%), and employed (63.8%), but heterogeneous in terms of education (49.5% completed college, 26.1% high school or less), household income (24% < $50k, 38% > $100k), and age (20 to 83; M = 45.9±16.1 years). Mean baseline A1c = 9.2±1.4 and Diabetes Distress Scale total = 2.8±0.9 (indicating “moderate/severe” distress). The Acceptance and Action Diabetes Questionnaire (AADQ) measured psychological processes targeted in ACT1VATE (psychological inflexibility, experiential avoidance). Consistent with our theoretical framework, at baseline, greater diabetes acceptance/action (higher AADQ) was significantly correlated with lower A1c (r = -.30) and diabetes distress (r = -.63), fewer missed insulin doses (r = -.38), healthier diet (r = .29) and better overall well-being (r = .55), ps < .01. As the first large scale DD RCT integrated in a real-world setting, this study will build on prior well-controlled efficacy trials and provide rich information about implementation. These findings will inform healthcare systems’ attempts to meet ADA recommendations to integrate DD screenings and interventions into routine care. Disclosure E.C.Soriano: None. A.L.Fortmann: Employee; Dexcom, Inc. H.Sandoval: None. M.G.Antrim: None. S.Guzman: Consultant; Abbott Diabetes. W.H.Polonsky: Consultant; Abbott Diabetes, Boehringer Ingelheim and Eli Lilly Alliance, Eli Lilly and Company, Insulet Corporation, Intuity Medical, Inc., MannKind Corporation, Provention Bio, Inc., Sanofi-Aventis U.S., Vertex Pharmaceuticals Incorporated. S.R.Spierling bagsic: None. A.Philis-tsimikas: Advisory Panel; Dexcom, Inc., Novo Nordisk A/S, Sanofi, Other Relationship; Medtronic, Research Support; Novo Nordisk A/S, Lilly, Viking Therapeutics, NIH - National Institutes of Health. Funding National Institutes of Health (1R01DK127491)

Effect of a Comprehensive Telehealth Intervention vs Telemonitoring and Care Coordination in Patients With Persistently Poor Type 2 Diabetes Control

Persistently poorly controlled type 2 diabetes (PPDM) is common and causes poor outcomes. Comprehensive telehealth interventions could help address PPDM, but effectiveness is uncertain, and barriers impede use in clinical practice. To address evidence gaps preventing use of comprehensive telehealth for PPDM by comparing a practical, comprehensive telehealth intervention to a simpler telehealth approach. This active-comparator, parallel-arm, randomized clinical trial was conducted in 2 Veterans Affairs health care systems. From December 2018 to January 2020, 1128 outpatients with PPDM were assessed for eligibility and 200 were randomized; PPDM was defined as maintenance of hemoglobin A1c (HbA1c) level of 8.5% or higher for 1 year or longer despite engagement with clinic-based primary care and/or diabetes specialty care. Data analyses were preformed between March 2021 and May 2022. Each 12-month intervention was nurse-delivered and used only clinical staffing/resources. The comprehensive telehealth group (n = 101) received telemonitoring, self-management support, diet/activity support, medication management, and depression support. Patients assigned to the simpler intervention (n = 99) received telemonitoring and care coordination. Primary (HbA1c) and secondary outcomes (diabetes distress, diabetes self-care, self-efficacy, body mass index, depression symptoms) were analyzed over 12 months using intent-to-treat linear mixed longitudinal models. Sensitivity analyses with multiple imputation and inclusion of clinical data examined the impact of missing HbA1c measurements. Adverse events and intervention costs were examined. The population (n = 200) had a mean (SD) age of 57.8 (8.2) years; 45 (22.5%) were women, 144 (72.0%) were of Black race, and 11 (5.5%) were of Hispanic/Latinx ethnicity. From baseline to 12 months, HbA1c change was -1.59% (10.17% to 8.58%) in the comprehensive telehealth group and -0.98% (10.17% to 9.19%) in the telemonitoring/care coordination group, for an estimated mean difference of -0.61% (95% CI, -1.12% to -0.11%; P = .02). Sensitivity analyses showed similar results. At 12 months, patients receiving comprehensive telehealth had significantly greater improvements in diabetes distress, diabetes self-care, and self-efficacy; no differences in body mass index or depression were seen. Adverse events were similar between groups. Comprehensive telehealth cost an additional $1519 per patient per year to deliver. This randomized clinical trial found that compared with telemonitoring/care coordination, comprehensive telehealth improved multiple outcomes in patients with PPDM at a reasonable additional cost. This study supports consideration of comprehensive telehealth implementation for PPDM in systems with appropriate infrastructure and may enhance the value of telehealth during the COVID-19 pandemic and beyond. ClinicalTrials.gov Identifier: NCT03520413.

Psychosocial Effects of the Loop Open-Source Automated Insulin Delivery System.

This study examined the psychosocial impact of Loop, an open-source automated insulin dosing system that has emerged from the diabetes technology "Do-It-Yourself" (DIY) movement. Subsamples of 239 adults, 115 children, and 243 parents completed data collection at the time of Loop initiation and 3 and 6 months later. Surveys collected demographic and clinical information, percent time-in-range, HbA1c, and validated psychosocial measures. Analyses included paired t tests and McNemar's tests to compare psychosocial functioning at 3 and 6 months and regression models to assess baseline predictors of psychosocial outcomes at 6 months. Adults reported significant improvements in diabetes distress (t = -7.20 P < .001; t = -8.01, P < .001), sleep quality (t = 6.81, P < .001; t = 2.98, P = .003), fear of hypoglycemia (t = -4.42, P < .001; t = -4.97, P < .001), and hypoglycemia confidence (t = 8.68, P < .001; t = 7.96 P < .001) from baseline to 3 months and 6 months, respectively. Significant improvements in parents' and children's sleep quality and parents' fear of hypoglycemia were also observed. Several baseline characteristics were associated with psychosocial outcomes at 6 months. The current findings support the broad and sustained benefits of Loop across multiple aspects of psychosocial well-being. Advancement and dissemination of such technologies has the potential to improve mental and physiological health among people living with type 1 diabetes.

The Influence of Baseline Hemoglobin A1c on Digital Health Coaching Outcomes in Adults With Type 2 Diabetes: Real-World Retrospective Cohort Study.

BackgroundDigital health coaching is an increasingly common diabetes self-management support strategy for individuals with type 2 diabetes and has been linked to positive mental and physical health outcomes. However, the relationship between baseline risk and outcomes is yet to be evaluated in a real-world setting.ObjectiveThe purpose of this real-world study was to evaluate trends in digital health coaching outcomes by baseline hemoglobin A1c (HbA1c) to better understand which populations may experience the greatest clinical and psychosocial benefit.MethodsA retrospective cohort study design was used to evaluate program effect in a convenience sample of participants in a 12-week digital health coaching program administered by Pack Health. Participants were referred through their health care provider, payer, or employer. The program included patient-centered lifestyle counseling and psychosocial support delivered via telephone, text, and/or email. Self-reported HbA1c and weight were collected at baseline and completion. Physical and mental health were assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Health Short Form and the Diabetes Distress Scale-2. Changes in HbA1c, weight, BMI, and physical and mental health were analyzed within three participant cohorts stratified by baseline HbA1c level.ResultsParticipants with complete HbA1c data sets (n=226) were included in the analysis. The sample population was 71.7% (162/226) female, with 61.5% (139/226) identifying as white and 34.1% (77/226) as black. Most participants (184/226, 81.4%) reported a baseline HbA1c ≥7%, and 20.3% (46/226) were classified as high risk (HbA1c >9%). Across HbA1c cohorts, the mean baseline BMI was 35.83 (SD 7.79), and the moderate-risk cohort (7% ≤ HbA1c ≤ 9%) reported the highest mean value (36.6, SD 7.79). At 12 weeks, patients reported a significant decrease in HbAlc, and high-risk participants reduced their levels by the greatest margin (2.28 points; P<.001). Across cohorts, BMI improved by 0.82 (P<.001), with the moderate-risk cohort showing the greatest reduction (−0.88; P<.001). Overall, participants reported significant improvements for PROMIS scores, with the greatest change occurring in the high-risk cohort for whom physical health improved 3.84 points (P<.001) and mental health improved 3.3 points (P<.001). However, the lowest-risk cohort showed the greatest improvements in diabetes distress (−0.76; P=.005).ConclusionsAcknowledging the limitations in this real-world study design, the results reported here suggest that adults with type 2 diabetes with a high baseline HbA1c or high BMI may benefit the most from patient-centered digital health coaching programs when compared to their lower risk counterparts. While all participants improved in physical and mental health categories, participants with high HbA1c experienced the greatest HbA1c reduction and individuals with the highest baseline BMI lost the most weight. These results may be used to inform referrals for patients who are more likely to benefit from digital health coaching.

Diabetes Distress and Glycemic Control in Type 2 Diabetes: Mediator and Moderator Analysis of a Peer Support Intervention.

BackgroundHigh levels of psychosocial distress are correlated with worse glycemic control as measured by glycosylated hemoglobin levels (HbA1c). Some interventions specifically targeting diabetes distress have been shown to lead to lower HbA1c values, but the underlying mechanisms mediating this improvement are unknown. In addition, while type 2 diabetes mellitus (T2D) disproportionately affects low-income racial and ethnic minority populations, it is unclear whether interventions targeting distress are differentially effective depending on participants’ baseline characteristics.ObjectiveOur objective was to evaluate the mediators and moderators that would inform interventions for improvements in both glycemic control and diabetes distress.MethodsOur target population included 290 Veterans Affairs patients with T2D enrolled in a comparative effectiveness trial of peer support alone versus technology-enhanced peer support with primary and secondary outcomes including HbA1c and diabetes distress at 6 months. Participants in both arms had significant improvements in both HbA1c and diabetes distress at 6 months, so the arms were pooled for all analyses. Goal setting, perceived competence, intrinsic motivation, and decisional conflict were evaluated as possible mediators of improvements in both diabetes distress and HbA1c. Baseline patient characteristics evaluated as potential moderators included age, race, highest level of education attained, employment status, income, health literacy, duration of diabetes, insulin use, baseline HbA1c, diabetes-specific social support, and depression.ResultsAmong the primarily African American male veterans with T2D, the median age was 63 (SD 10.2) years with a baseline mean HbA1c of 9.1% (SD 1.7%). Improvements in diabetes distress were correlated with improvements in HbA1c in both bivariate and multivariable models adjusted for age, race, health literacy, duration of diabetes, and baseline HbA1c. Improved goal setting and perceived competence were found to mediate both the improvements in diabetes distress and in HbA1c, together accounting for 20% of the effect of diabetes distress on change in HbA1c. Race and insulin use were found to be significant moderators of improvements in diabetes distress and improved HbA1c.ConclusionsPrior studies have demonstrated that some but not all interventions that improve diabetes distress can lead to improved glycemic control. This study found that both improved goal setting and perceived competence over the course of the peer support intervention mediated both improved diabetes distress and improved HbA1c. This suggests that future interventions targeting diabetes distress should also incorporate elements to increase goal setting and perceived competence. The intervention effect of improvements in diabetes distress on glycemic control in peer support may be more pronounced among White and insulin-dependent veterans. Additional research is needed to understand how to better target diabetes distress and glycemic control in other vulnerable populations.

Assessing Diabetes Distress and Sleep Quality in Young Adults with Type 1 Diabetes Using FreeStyle Libre: A Prospective Cohort Study.

IntroductionThe burden of diabetes, its potential complications, and related self-care activities can induce negative psychosocial effects in patients with type 1 diabetes mellitus (T1DM). This prospective cohort study investigated the psychosocial benefits associated with 3 months of FreeStyle Libre (FSL) flash glucose monitoring use in young adults with T1DM in Saudi Arabia.MethodsPatients completed the Diabetes Distress Scale (DDS) and the Pittsburgh Sleep Quality Index (PSQI) questionnaires at baseline and 3 months. HbA1c, number of confirmed hypoglycemia episodes per month, and frequency of blood glucose testing were also collected at baseline and 3 months.ResultsOf 95 patients analyzed, significant reductions were observed in mean DDS (3.8 vs. 2.5; p < 0.001) and PSQI (8.7 vs. 3.9; p < 0.001) scores from baseline to 3 months. Furthermore, HbA1c and confirmed hypoglycemia episodes per month also decreased from baseline to 3 months (HbA1c 8.3 vs. 7.7% [67 vs. 61 mmol/mol], p < 0.001; hypoglycemia episodes 3.0 vs. 2.3, p < 0.001). In contrast, mean frequency of blood glucose testing per day increased from baseline to 3 months (2.5 vs. 5.2; p < 0.001).ConclusionThese data demonstrate improvements in diabetes distress and sleep quality as well as glycemic outcomes following 3 months’ FSL use in young adults with T1DM.

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

To explore the auxiliary psychosocial effects of a monetary reinforcement intervention targeting self-monitoring of blood glucose among young people with Type 1 diabetes. Sixty young people with Type 1 diabetes, HbA1c 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). 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. 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.

Building Infrastructure for Diabetes Self-Management Support in Church-Based Settings—Results of a 15-Month Cluster-Randomized Controlled Trial

Diabetes self-management support (DSMS) is not a covered benefit in the U.S. health system, and little is known about the infrastructure needed to provide effective DSMS in organizations without existing diabetes self-management education (DSME) programs. The Praise study is a 15-month cluster-randomized controlled trial in 9 African American (AA) churches in metro-Detroit, as a conduit to build infrastructure for DSMS in low-resource communities. From 2013-2015, Praise examined the effects of peer-led DSMS on A1C and diabetes distress (DD) at 3, 9, and 15 months. CDEs trained peer leaders (PL) (n=12) and parish nurses (PN) (n=3) on goal setting, skills development, and group facilitation. Following professionally-delivered DSME, 6 monthly DSMS groups were independently planned and facilitated by 12 PL (mean age: 61.9 years, 100% AA, 25% male), followed by an additional 6 months of ongoing support to assess the logistical feasibility of sustaining DSMS efforts. Churches (and their participants, n=94) were randomized to 3 parallel groups: 1) PL only DSMS (n= 28), 2) PN + PL DSMS (n= 36), or 3) enhanced usual care (n= 30). Over time, a significant increase in A1C (p=.03) was observed across groups overall, but not within study groups. After adjusting for multiple factors, younger age (β=-.04; p=.004) and lower levels of DD (p=.04) were associated with improvements in A1C over time, while insulin use (p= .032) was associated with increases in A1C. A marked improvement in DD was observed (p=.04) overall. PL only (p= .003), PL+PN (p=.01), and A1C (p=.02) were significantly associated with improvements in DD. Results suggest DD is a significant indicator of improvement in A1C levels. DD levels also improved following a faith community-based DSME intervention and were sustained by using the PL and PN DSMS infrastructure of the church. Opportunities to expand the DSMS infrastructure beyond churches and into other community organizations is needed. Disclosure N.J. Koscielniak: None. M. Funnell: Advisory Panel; Self; Sanofi US, Intarcia Therapeutics, Inc.. G. Piatt: None.

Outcomes at 18 Months From a Community Health Worker and Peer Leader Diabetes Self-Management Program for Latino Adults.

This study evaluated the effectiveness of a community health worker (CHW) diabetes self-management education (DSME) program, followed by two different approaches to maintain improvements in HbA1c and other clinical and patient-centered outcomes over 18 months. The study randomized 222 Latino adults with type 2 diabetes and poor glycemic control from a federally qualified health center to 1) a CHW-led, 6-month DSME program or 2) enhanced usual care (EUC). After the 6-month program, participants randomized to the CHW-led DSME were further randomized to 1) 12 months of CHW-delivered monthly telephone outreach (CHW-only) or 2) 12 months of weekly group sessions delivered by peer leaders (PLs) with telephone outreach to those unable to attend (CHW+PL). The primary outcome was HbA1c. Secondary outcomes were blood pressure, lipid levels, diabetes distress, depressive symptoms, understanding of diabetes self-management, and diabetes social support. Assessments were conducted at baseline and at 6, 12, and 18 months. Participants in the CHW intervention at the 6-month follow-up had greater decreases in HbA1c (-0.45% [95% CI -0.87, -0.03]; P < 0.05) and in diabetes distress (-0.3 points [95% CI -0.6, -0.03]; P < 0.05) compared with EUC. CHW+PL participants maintained HbA1c improvements at 12 and 18 months, and CHW-only participants maintained improvements in diabetes distress at 12 and 18 months. CHW+PL participants also had significantly fewer depressive symptoms at 18 months compared with EUC (-2.2 points [95% CI -4.1, -0.3]; P < 0.05). Participants in CHW-led DSME had significant improvements in diabetes social support and in understanding of diabetes self-management at 6 months relative to EUC, but these intervention effects were not sustained at 18 months. This study demonstrates the effectiveness of a 6-month CHW intervention on key diabetes outcomes and of a volunteer PL program in sustaining key achieved gains. These are scalable models for health care centers in low-resource settings for achieving and maintaining improvements in key diabetes outcomes.

Potential positive impact of group-based diabetes dialogue meetings on diabetes distress and glucose control in people with type 1 diabetes

ObjectiveTo evaluate the effect of group-based diabetes dialogue meetings (DDMs) on diabetes distress, perceived competence and glycaemic control. MethodsPatients with type 1 diabetes (T1D) were invited to DDMs with peers and healthcare professionals. The impact of participation was evaluated by change in diabetes distress measured by Problem Areas in Diabetes (PAID), diabetes competence measured by Perceived Competence in Diabetes (PCD), change in HbA1c before and one year after the DDMs. Results120 patients with T1D participated in at least one DDM: 75% female, mean age 50 years (range 21–76), mean diabetes duration 23 years (range 0–64); 39% of all participants had a baseline PAID score≥33, indicating high levels of distress. After one year, both PAID (from 30.4±16.6 to 27.4±17.1; n=81, p=0.03), and mean HbA1c (61.6±10.2 to 58.8±9.9; n=120, p<0.0001) had improved significantly. PCD showed no change. Meanwhile, the benefit from participating was rated high with a median of four out of five and the major gain being the possibility to share experiences with peers. ConclusionGroup-based DDMs were highly appreciated by participants and associated with significant improvements in diabetes distress and HbA1c. Practice implicationsDDMs target a large group of patients using few staff resources.

The detection and management of diabetes distress in people with type 1 diabetes.

Diabetes distress (DD) represents a significant clinical burden in which levels of DD are related to both glycated haemoglobin (HbA1c) and some self-management behaviours. DD is related to, but different from, depression. Differences in DD experienced in people with type 1 and type 2 diabetes have been observed. Commonly measured using the Problem Areas in Diabetes Scale (PAID) and the Diabetes Distress Scale (DDS), rates of elevated DD in research study participants range from 20 to 30%. Risk factors for elevated DD in type 1 diabetes are longer duration of diabetes, severe hypoglycaemia, younger age and being female. A systematic review of intervention studies assessing DD identified eight randomised controlled trials (RCTs) and nine pre-post design studies. Only three studies targeted DD with the intervention. Intervention types were diabetes self-management education (DSME), psychologically informed self-management and devices. DSME pre-post studies, namely the Dose Adjustment For Normal Eating (DAFNE) programme, produced more consistent improvements in DD and HbA1c at follow-up. Psychologically informed self-management was more heterogeneous, but several RCTs were effective in reducing DD. Group interventions offered the greatest benefits across intervention designs.