The Hypoglycemic Fear Syndrome: Understanding and Addressing This Common Clinical Problem in Adults With Diabetes.

Although a broad literature on fear of hypoglycemia and its impact on people with type 1 or type 2 diabetes has accumulated over the past three decades, there has been surprisingly little guidance concerning how best to tackle this problem in clinical care. The aim of this article is to begin filling this gap by describing the "hypoglycemic fear syndrome," which we define as hypoglycemic fear that has become so overwhelming that it leads to avoidance behaviors and chronically elevated glucose levels. We begin by presenting several illustrative cases, describing the syndrome and how it is most commonly presented in clinical care, and detailing its most common precipitants. We then offer practical, evidence-based strategies for clinical intervention, based on the literature and our clinical experience.

A Behavioral Perspective of Therapeutic Inertia: A Look at the Transition to Insulin Therapy.

From a behavioral perspective, therapeutic inertia can happen when obstacles to changing a diabetes treatment plan outweigh perceived benefits. There is a complex interaction of important treatment-related obstacles for people with diabetes (PWD), their treating health care professional (HCP), and the clinical setting in which they interact. Tipping the scales toward more effective action involve strategies that increase perceptions of the benefits of treatment intensification while addressing important obstacles so that treatment changes are seen by both PWD and HCPs as worthwhile and achievable.

Erratum: Stigma in People With Type 1 or Type 2 Diabetes. Clinical Diabetes 2017;35:27-34. DOI: 10.2337/cd16-0020.

[This corrects the article on p. 27 in vol. 35, PMID: 28144043.].

Stigma in People With Type 1 or Type 2 Diabetes.

IN BRIEF This study quantitatively measures diabetes stigma and its associated psychosocial impact in a large population of U.S. patients with type 1 or type 2 diabetes using an online survey sent to 12,000 people with diabetes. A majority of respondents with type 1 (76%) or type 2 (52%) diabetes reported that diabetes comes with stigma. Perceptions of stigma were significantly higher among respondents with type 1 diabetes than among those with type 2 diabetes, with the highest rate in parents of children with type 1 diabetes (83%) and the lowest rate in people with type 2 diabetes who did not use insulin (49%). Our results suggest that a disturbingly high percentage of people with diabetes experience stigma, particularly those with type 1 or type 2 diabetes who are on intensive insulin therapy. The experience of stigma disproportionately affects those with a higher BMI, higher A1C, and poorer self-reported blood glucose control, suggesting that those who need the most help are also the most affected by stigma.

EMBARK: A Randomized, Controlled Trial Comparing Three Approaches to Reducing Diabetes Distress and Improving HbA1c in Adults With Type 1 Diabetes.

OBJECTIVE: To compare the effectiveness of three interventions to reduce diabetes distress (DD) and improve HbA1c among adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: Individuals with T1D (n = 276) with elevated DD (a score >2 on the total Type 1 Diabetes Distress Scale) and HbA1c (>7.5%) were recruited from multiple settings and randomly assigned to one of three virtual group-based programs: 1) Streamline, an educator-led education and diabetes self-management program; 2) TunedIn, a psychologist-led program focused exclusively on emotional-focused DD reduction; or 3) FixIt, an integration of Streamline and TunedIn. Assessments of the primary outcomes of DD and HbA1c occurred at baseline and at 3, 6, and 12 months. RESULTS: All three programs demonstrated substantive and sustained reductions in DD (Cohen's d = 0.58-1.14) and HbA1c (range, -0.4 to -0.72) at 12-month follow-up. TunedIn and FixIt participants reported significantly greater DD reductions compared with Streamline participants (P = 0.007). Streamline and TunedIn participants achieved significantly greater HbA1c reductions than did FixIt participants (P = 0.006). CONCLUSIONS: DD can be successfully reduced among individuals with T1D with elevated HbA1c using both the educational/behavioral and emotion-focused approaches included in the study. Although both approaches are associated with significant and clinically meaningful reductions in DD and HbA1c, TunedIn, the emotion-focused program, had the most consistent benefits across both DD and HbA1c. The study findings suggest the overall value of group-based, fully virtual, and time-limited emotion-focused strategies, like those used in TunedIn, for adults with T1D.

Bringing an end to diabetes stigma and discrimination: an international consensus statement on evidence and recommendations.

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

The Emotional Impact of Negative Language in People With Diabetes: A Descriptive Study Using a Semantic Differential Scale.

PURPOSE: Explore the emotional experience of people with diabetes as they encounter words and phrases that have been previously identified as problematic and evaluate potential differences in their emotional impact based on type of diabetes and demographic characteristics. METHODS: A cross-sectional descriptive study employing an online survey of 107 adults with type 1 diabetes and 110 adults with type 2 diabetes. A semantic differential scale was used to examine feeling states associated with negative diabetes language. Descriptive statistics including means, standard deviations, and frequencies were calculated for all study variables. For each target word, frequencies of participants who endorsed a positive, neutral, or negative affective response on the sematic differential scale are reported. RESULTS: People with diabetes reported feeling blamed, misunderstood, hopeless, judged, not motivated, and not trusting in response to "noncompliant," "unmotivated," "in denial," "preventable," "failed," "should," "uncontrolled," "what did you do wrong," and "you could end up blind or on dialysis." Participants who have type 1 diabetes and are female, White, more educated, and younger reported more negative feelings about the target words. CONCLUSION: People with diabetes experience highly negative affective responses when they read and hear previously identified words and phrases considered to be judgmental and unhelpful.

The AH-HA! Project: Transforming Group Diabetes Self-Management Education Through the Addition of Flash Glucose Monitoring.

Background: The majority of individuals referred to diabetes self-management education and support (DSMES) programs do not access this resource. Of those who do, attrition is high, with anecdotal reports pointing to the didactic and impersonal nature of these programs contributing to low utilization and completion rates. In an effort to develop a more engaging form of DSMES for adults with type 2 diabetes (T2D), we constructed a nondidactic "discovery learning"-based DSMES program centered on real-time flash glucose monitoring (FGM). Methods: In this single-arm pilot study, 35 adults with T2D duration 1-5 years, ages 21-75 years, not using insulin and HbA1c ≥8.0% were introduced to FGM and participated in five weekly group sessions. DSMES content was personalized, emerging from the concerns and questions arising from participants' FGM discoveries. The primary outcome was glycemic change as assessed by blinded FGM at baseline and month 3. Secondary outcomes included psychosocial and behavioral measures. Results: There was a significant gain in percentage time in range (% TIR) 70-180 mg/dL from baseline (55%) to month 3 (74%), and a parallel drop-in percentage time above range (TAR) >180 mg/dL from 44% to 25% (Ps = 0.01). Overall well-being rose significantly (P = 0.04), whereas diabetes distress showed a nonsignificant drop. Participants reported improvements in healthy eating (P < 0.001) and physical activity, although the latter did not reach statistical significance. Conclusions: These findings support a new approach to DSMES, a method that integrates FGM with a highly interactive and engaging patient-driven "discovery learning" approach to education.

Microwrinkled pH-sensitive hydrogel films and their role on the cell adhesion/proliferation.

In this work, hydrogels based on HEMA and DMAEMA (pH-sensitive monomer) were used to form biocompatible films which present microwrinkled patterns in their surface, with the focus of exploring the role of chemical composition on cell adhesion and proliferation. Three different pH (5.4, 7.4, and 8.3) were employed to prepare these hydrogels. The pre-polymerized hydrogel mixtures were deposited via spin coating, then exposed to vacuum for deswelling the films and finally, to UV-light to spontaneously generate the wrinkled pattern. By following this procedure, is possible to form a thin rigid layer on the top of the soft and incompletely polymerized hydrogel film which generates, in turn, a wrinkled pattern due to strain mismatch in the interface. FE-SEM and AFM micrographs allowed us to characterize the wrinkled pattern dimensions. The results evidenced that chemical composition is directly related to the surface pattern morphologies obtained, not so in the case of pH variation, which does not generate relevant changes in the pattern morphology. Interestingly, these pH variations resulted in significant alterations on the interface-cell interactions. More precisely, a premyoblastic cell monolayer was cultured over the wrinkled pattern, showing an optimal cell proliferation at neutral pH. Also, the variation of DMAEMA amount on the monomer feed composition employed for the preparation of the wrinkle surfaces revealed that a certain amount is required to favor cell attachment and growth.

Emotion regulation contributes to the development of diabetes distress among adults with type 1 diabetes.

OBJECTIVE: To demonstrate how maladaptive emotion regulation (ER) can lead to diabetes distress (DD), with subsequent effects on management and metabolic outcomes among adults with type 1 diabetes. METHODS: Data are based on pre-intervention assessment for a random controlled trial to reduce DD. Patients were recruited in California, Oregon, Arizona and Ontario, Canada. After screening and consent, patients completed an online assessment and released their most recent laboratory HbA1C. Structural equation modeling was used to define an ER measurement model and test for significant pathways. RESULTS: Three ER mechanisms combined into a single construct: emotion processing, non-judgment of emotions, non-reactivity to emotions. Models indicated a significant pathway from ER and cognitions to DD to disease management to metabolic control. CONCLUSIONS: As hypothesized, the three ER mechanisms formed a single, coherent ER construct. Patients with poor ER reported high DD; and high DD was linked to poor diabetes management and poor metabolic control. PRACTICE IMPLICATIONS: Identifying both the level of DD and the ER mechanisms that lead to high DD should be explored in clinical settings. Helping T1Ds to become more aware, less judgmental and less reactive behaviorally to what they feel about diabetes and its management may reduce DD.

T1-REDEEM: A Randomized Controlled Trial to Reduce Diabetes Distress Among Adults With Type 1 Diabetes.

OBJECTIVE: To compare the effectiveness of two interventions to reduce diabetes distress (DD) and improve glycemic control among adults with type 1 diabetes (T1D). RESEARCH DESIGN AND METHODS: Individuals with T1D (n = 301) with elevated DD and HbA1c were recruited from multiple settings and randomly assigned to OnTrack, an emotion-focused intervention, or to KnowIt, an educational/behavioral intervention. Each group attended a full-day workshop plus four online meetings over 3 months. Assessments occurred at baseline and 3 and 9 months. Primary and secondary outcomes were change in DD and change in HbA1c, respectively. RESULTS: With 12% attrition, both groups demonstrated dramatic reductions in DD (effect size d = 1.06; 78.4% demonstrated a reduction of at least one minimal clinically important difference). There were, however, no significant differences in DD reduction between OnTrack and KnowIt. Moderator analyses indicated that OnTrack provided greater DD reduction to those with initially poorer cognitive or emotion regulation skills, higher baseline DD, or greater initial diabetes knowledge than those in KnowIt. Significant but modest reductions in HbA1c occurred with no between-group differences. Change in DD was modestly associated with change in HbA1c (r = 0.14, P = 0.01), with no significant between-group differences. CONCLUSIONS: DD can be successfully reduced among distressed individuals with T1D with elevated HbA1c using both education/behavioral and emotion-focused approaches. Reductions in DD are only modestly associated with reductions in HbA1c. These findings point to the importance of tailoring interventions to address affective, knowledge, and cognitive skills when intervening to reduce DD and improve glycemic control.

The Use of Language in Diabetes Care and Education.

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators and the American Diabetes Association, convened to discuss language in diabetes care and education. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words, whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

The Use of Language in Diabetes Care and Education.

Language is powerful and can have a strong impact on perceptions as well as behavior. A task force, consisting of representatives from the American Association of Diabetes Educators (AADE) and the American Diabetes Association (ADA), convened to discuss language in diabetes care and education. This document represents the expert opinion of the task force. The literature supports the need for a language movement in diabetes care and education. There are effective ways of communicating about diabetes. This article provides recommendations for language used by health care professionals and others when discussing diabetes through spoken or written words-whether directed to people with diabetes, colleagues, or the general public, as well as research questions related to language and diabetes.

Are patients' initial experiences at the diagnosis of type 2 diabetes associated with attitudes and self-management over time?

UNLABELLED: Objective The purpose of this study was to investigate patients' experiences when diagnosed with type 2 diabetes and diabetes-related distress and self-management years later. Method One hundred seventy-nine adults with type 2 diabetes, 1 to 5 years after diagnosis, completed a questionnaire assessing what they were told and what was recommended at diagnosis as well as current diet, physical activity, and diabetes distress. RESULTS: Most patients (60%) expressed confidence in their health care provider (HCP) at diagnosis, but 30% reported that a clear action plan was not communicated. Current diabetes distress was significantly lower among those who reported being reassured at diagnosis that diabetes could be managed successfully and had developed a clearer action plan with their HCP. Patients' current dietary behaviors were significantly better among those receiving a clearer action plan at diagnosis. CONCLUSION: Patients' retrospective reports of reassuring HCP messages when diagnosed, along with the presentation of a clear action plan, are associated with less diabetes distress and better self-management at 1 to 5 years after diagnosis. Practical implications Findings suggest a long-lasting impact on patients' attitudes and behaviors when the diagnosis of type 2 diabetes is delivered clearly, a sense of hope is provided, and a specific care plan is put forward.

The contribution of negative and positive illness schemas to depression in patients with end-stage renal disease.

This research examined the role of negative and positive illness schemas as predictors of depression in 109 ESRD patients who were recruited from dialysis clinics throughout the San Diego area. Specifically, the model evaluated whether negative and positive illness schemas would mediate the relationship between disease severity and depression, and social support and depression, in a cross-sectional design. The model was tested with the Cognitive Depression Inventory (CDI), derived from the Beck Depression Inventory (BDI), and the full Beck as criterion variables. Hierarchical multiple regression analysis employing path-analytic procedures revealed that while disease severity was unrelated to depression, negative illness schema contributed to higher BDI and CDI scores, and positive illness schema contributed to lower BDI and CDI scores. Furthermore, positive illness schema mediated the relationship between social support and depression in both the BDI and CDI models. The results illustrate the important contribution of illness schemas to depression in this life-threatening disease.