There is value in treating elevated levels of diabetes distress: the clinical impact of targeted interventions in adults with Type 1 diabetes.

AIM: To compare the effect of targeted interventions to reduce high diabetes distress among adults with Type 1 diabetes with a comparison sample of similar but untreated individuals, and to document the stability of untreated diabetes distress over time. METHODS: A total of 51 adults with Type 1 diabetes with elevated baseline diabetes distress (distress score ≥ 2.0) and HbA1c levels (≥ 58 mmol/mol) were identified from a longitudinal, non-intervention study, and compared with a similar sample of 51 participants in an intervention study. Both groups completed the T1-DDS diabetes distress questionnaire at baseline and 9 months. RESULTS: Large and significant reductions in diabetes distress scores were recorded in the intervention group (mean ± sd change = -0.6 ± 0.6), while minimal change was found in the non-intervention group (-0.2 ± 0.6, group effect P = 0.002; effect size d = 0.67). Additional analyses using the established minimal clinically important difference for the T1-DDS showed that diabetes distress increased significantly (minimal clinically important difference ≥ 1) or persisted at high levels for 51% of participants in the non-intervention group, compared with 23.5% in the intervention group. CONCLUSION: Our results showed that targeted interventions led to dramatic reductions in diabetes distress compared with a lack of treatment. We also conclude that elevated diabetes distress, when left unaddressed, does not resolve over time and often remains chronic. (Clinical Trials Registry no.: NCT02175732).

Diabetes distress is linked with worsening diabetes management over time in adults with Type 1 diabetes.

AIM: To determine the cross-sectional and longitudinal associations between diabetes distress and diabetes management. METHODS: In a non-interventional study, 224 adults with Type 1 diabetes were assessed for diabetes distress, missed insulin boluses, hypoglycaemic episodes, and HbA1c at baseline and 9 months. RESULTS: At baseline, greater distress was associated with higher HbA1c and a greater percentage of missed insulin boluses. Longitudinally, elevated baseline distress was related to increased missed insulin boluses, and decreases in distress were associated with decreases in HbA1c . In supplementary analyses, neither depression symptoms nor a diagnosis of major depressive disorder was associated with missed insulin boluses, HbA1c or hypoglycaemic episodes in cross-sectional or longitudinal analyses. CONCLUSIONS: Significant cross-sectional and longitudinal associations were found between diabetes distress and management; in contrast, no parallel associations were found for major depressive disorder or depression symptoms. Findings suggest that elevated distress may lead to more missed insulin boluses over time, suggesting a potential intervention target. The covarying association between distress and HbA1c points to the complex and likely interactive associations between these constructs. Findings highlight the need to address distress as an integral part of diabetes management in routine care.

Prevalence of depression in Type 1 diabetes and the problem of over-diagnosis.

AIMS: To determine the prevalence of depression and diabetes distress in adults with Type 1 diabetes and the rate of false-positives when compared with rates of major depressive disorder. METHODS: The sample consisted of 368 individuals with Type 1 diabetes, aged > 19 years. Individuals completed: the eight-item Patient Health Questionnaire depression scale (PHQ8), which was coded using four scoring criteria (scores > 10, >12 and >15, and Diagnostic and Statistical Manual of Mental Disorders 5 (DSM) algorithm scores); the Type 1 Diabetes Distress Scale; and the Structured Clinical Interview for DSM Disorders (SCID) to assess major depressive disorder. RESULTS: The prevalence rates of depression according to the eight-item Patient Health Questionnaire were: score >10, 11.4%; score >12, 7.1%; score >15, 3.8%; and positive algorithm result, 4.6%. The prevalence of major depressive disorder was 3.5%; and the prevalence of at least moderate diabetes distress was 42.1%. Depending on the criterion used, the false-positive rate when using the Patient Health Questionnaire compared with the results when using the SCID varied from 52 to 71%. Of those classified as depressed on the PHQ-8 or Structured Clinical Interview for DSM Disorders, between 92.3 and 96.2% also reported elevated diabetes distress. No significant association was found between any group classed as having depression according to the PHQ8 or the SCID and HbA1c concentration. Depression was significantly associated with more other life stress, more complications and a lower level of education. CONCLUSIONS: We found an unexpectedly low rate of current depression and major depressive disorder in this diverse sample of adults with Type 1 diabetes, and a very high rate of false-positive results using the Patient Health Questionnaire. Considering the high prevalence of diabetes distress, much of what has been considered depression in adults with Type 1 diabetes may be attributed to the emotional distress associated with managing a demanding chronic disease and other life stressors and not necessarily to underlying psychopathology.

Impact of baseline patient characteristics on interventions to reduce diabetes distress: the role of personal conscientiousness and diabetes self-efficacy.

AIMS: To improve patient-centred care by determining the impact of baseline levels of conscientiousness and diabetes self-efficacy on the outcomes of efficacious interventions to reduce diabetes distress and improve disease management. METHODS: Adults with Type 2 diabetes with diabetes distress and self-care problems (N = 392) were randomized to one of three distress reduction interventions: computer-assisted self-management; computer-assisted self-management plus problem-solving therapy; and health education. The baseline assessment included conscientiousness and self-efficacy, demographics, diabetes status, regimen distress, emotional burden, medication adherence, diet and physical activity. Changes in regimen distress, emotional burden and self-care between baseline and 12 months were recorded and ancova models assessed how conscientiousness and self-efficacy qualified the significant improvements in distress and management outcomes. RESULTS: Participants with high baseline conscientiousness displayed significantly larger improvements in medication adherence and emotional burden than participants with low baseline conscientiousness. Participants with high baseline self-efficacy showed greater improvements in diet, physical activity and regimen distress than participants with low baseline self-efficacy. The impact of conscientiousness and self-efficacy were independent of each other and occurred across all three intervention groups. A significant interaction indicated that those with both high self-efficacy and high conscientiousness at baseline had the biggest improvement in physical activity by 12 months. CONCLUSIONS: Both broad personal traits and disease-specific expectations qualify the outcomes of efficacious interventions. These findings reinforce the need to change from a one-size-fits-all approach to diabetes interventions to an approach that crafts clinical interventions in ways that fit the personal traits and skills of individual people.

A new perspective on diabetes distress using the type 2 diabetes distress assessment system (T2-DDAS): Prevalence and change over time.

AIMS: To establish cut-points and thresholds for elevated diabetes distress; document change over time; and define minimal clinically important differences (MCID) using the new Type 2 Diabetes Distress Assessment System (T2-DDAS). METHODS: A national sample of adults with type 2 diabetes completed the T2-DDAS CORE distress scale and the 7 T2-DDAS SOURCE distress scales at baseline and 6-months. Scores were computed separately for insulin- and non-insulin users. Spline regression models defined CORE cut-points and SEM formulas defined MCID. A rational "threshold" approach defined elevated SOURCE scores. RESULTS: 471 participants (205 insulin, 266 non-insulin) completed both assessments. Analyses yielded ≥2.0 as the cut-point for both elevated CORE and elevated SOURCE. Prevalence of elevated CORE was 61.8 % (69.9 % over 6 months). Elevated SOURCE scores varied from 30.6 % (Stigma/Shame) to 76.4 % (Management); 87.5 % indicated at least 1 elevated SOURCE score. Most (77.1 %) reported multiple elevated SOURCES. 81.8 % with elevated CORE distress at baseline remained elevated at 6 months. MCID analyses yielded +/- 0.25 as significant change. Few differences between insulin- and non-insulin users occurred. CONCLUSIONS: Elevated CORE distress is highly prevalent and persistent over time; most participants reported multiple SOURCES of distress. Findings highlight the need for comprehensive assessment of diabetes distress.

Personal-model beliefs and social-environmental barriers related to diabetes self-management.

OBJECTIVE: The specific aims of the present study were to report on the level of personal beliefs and social and environmental barriers across different regimen areas and patient subgroups and on the relationship of personal models and perceived barriers to the level of self-management. RESEARCH DESIGN AND METHODS: This study focused on several issues related to personal models (representations of illness) and perceived barriers to diabetes self-management among a large heterogeneous survey sample of 2,056 adults throughout the U.S. RESULTS: Respondents felt that diabetes was a serious disease and that their self-management activities will control their diabetes and reduce the likelihood of long-term complications. Most frequently reported barriers were related to dietary adherence, followed by exercise and glucose testing barriers. Both personal models and barriers significantly predicted level of self-management in all three regimen areas studied (diet, exercise, and glucose testing) after controlling for the influence of demographic and medical history factors. Regimen-specific models and barriers proved to be stronger predictors than more global measures. Differences on personal models and barriers were observed among different patient groups (e.g., age, health insurance, and insulin-taking status). Possible reasons for these differences and implications for intervention and future research are discussed. CONCLUSIONS: Both the personal-model and barriers scales had good internal consistency and predicted variance in each of the self-management variables after controlling for demographic and medical history factors. These brief self-report personal-model scales demonstrated good internal reliability and were as predictive of self-management as the lengthier interview-based measures in previous studies. The assessment of the treatment effectiveness component of personal models may be sufficient for most clinical purposes.

Preventive care practices for diabetes management in two primary care samples.

PURPOSE: To assess the level of physician performance on American Diabetes Association Provider Recognition Program (PRP) measures in two samples of primary care patients, as well as to identify patient, physician, and office characteristics related to performance levels. METHODS: In the two studies, we surveyed 435 Type 2 diabetes patients, cared for by 47 different physicians, on their receipt of PRP preventive care activities. RESULTS: Overall, patients in the two samples reported receiving 74% and 64% of recommended services. In both samples, performance of microvascular/glycemic control activities and cardiovascular lab checks (84% and 74%) was significantly higher than behavioral self-management/patient-focused activities (61% and 48%) (p<0.001). From a set of patient, physician, and practice setting characteristics, only the use of community resources for chronic illness management support was associated with service performance. CONCLUSIONS: We found considerable variability in the levels of performance in providing PRP-recommended activities. Greater attention should be focused on self-management and patient-focused activities, given that these are delivered less frequently than medical/laboratory checks.

Smoking-specific weight gain concerns and smoking cessation in a working population.

Smoking cessation rates, progression in stage of change for smoking cessation, and serious quit attempts were examined over 2 years in a cohort of 242 men and women smokers (mean age 39.7 years, mean body mass index [BMI] 26.3) as a function of expressing concern about gaining weight because of quitting smoking. Participants were employees of 25 companies who were in a worksite health promotion program aimed at reducing risk factors for cardiovascular disease. Multivariate odds ratios (controlled for age, education, job class, sex, and BMI) for quitting smoking, attempting to quit smoking, and progressing in stage of change for smoking cessation as a function of weight concern were not significant. Interactions between sex and weight concern, and BMI and weight concern were also not significant. These findings, in a working, predominantly blue-collar population, and those of other studies, suggest that concern about gaining weight is, at best, a weak predictor of change in smoking behavior among most smokers.

Concern about weight gain associated with quitting smoking: prevalence and association with outcome in a sample of young female smokers.

This study investigated the relationship between weight gain concern and outcomes of a large-scale smoking cessation study among 506 young female smokers attending Planned Parenthood clinics. Results of this prospective study did not support the clinical importance of weight gain concerns. Using an index of weight concern that was predictive in previous research, baseline weight concern was unrelated to smoking cessation efforts, whether participants made a quit attempt, reduced the number of cigarettes they smoked, or reported a change in self-efficacy for stopping smoking. Both the overall level of concern expressed in this sample of predominantly White young women and the lack of relationship between weight gain concern and smoking cessation outcomes suggest that weight gain concern may not be a critical factor for cessation programs targeting similar female smokers.

Awareness and barriers to use of cancer support and information resources by HMO patients with breast, prostate, or colon cancer: patient and provider perspectives.

This study assessed patient awareness and use--as well as obstacles to use--of HMO- and community-based psychosocial support services designed for cancer patients. Participants were a randomly selected group of patients from a large Northwest HMO, with breast (N=145), prostate (N=151), or colon cancer (N=72), and their oncology and urology providers (N=29). Patient awareness was highest for HMO-based services (68-90%) and lower for community- (33%) or Internet-based (10-14%) services, and use rates were low across all services (range 2-8%). Providers reported referring 70% of their patients to HMO cancer support services, but their estimates of actual patient use of these services (40%) were inflated. Providers reported few barriers to referring patients to support services. The most commonly reported patient barriers to using such services were already having adequate support, lack of awareness of the service, and lack of provider referral. Results of regression analyses suggest that education, physician referral, social support, and spirituality may be important influences on use of cancer support services. This study takes a first step toward understanding patient use of existing cancer support services and suggests ways to increase participation in these services.

Lifestyle change in women with coronary heart disease: what do we know?

Coronary heart disease (CHD) is the leading cause of death among women in the United States, yet few studies have specifically targeted women who have CHD, and still fewer have examined how behavior and psychosocial factors affect lifestyle change. This article reviews what is known about lifestyle change, with an emphasis on psychosocial factors related to change, in women with CHD. Studies exploring individual lifestyle improvement areas--exercise, nutrition, smoking, and social support--as well as studies of comprehensive lifestyle changes are reviewed. Strong conclusions were precluded because of the paucity of studies, widely variable and inconsistent findings, flawed methodologies, and inadequate reporting of results. Future research is advised to develop and test intervention programs for women with CHD, addressing barriers to participation, lifestyle change patterns, psychosocial and quality of life outcomes, and physiologic change.

Risk and protective factors influencing adolescent problem behavior: a multivariate latent growth curve analysis.

This study examined the dynamic relations between adolescent problem behaviors (alcohol, marijuana, deviance, academic failure) over time and predictors of these behaviors. Data from the National Youth Survey (1) included 1,044 adolescents (53.5% male; mean age at year 1 = 13.20). Dependent measures were adolescent alcohol use, marijuana use, deviance, and academic failure, assessed annually over 4 years. Independent measures included age, gender, marital status, income, family time, family support, time with friends, friend deviance, knowledge of friends, activities, and neighborhood problems. An associative latent growth modeling (LGM) analysis showed significant increases and relations between the four behaviors in both initial status and development. Second-order multivariate LGM analyses indicated that the four behaviors could be modeled by a higher-order problem behavior construct. Significant effects on the common problem behavior intercept or slope included time with friends, deviant friends, age, marital status, family time, and support. Additional effects were found to be specific to the initial status and slopes of individual problem behaviors. Overall, results indicate the importance of assessing the relations between adolescent problem behaviors as they change over time and identifying the risk and protective factors that have both common and individual influences on these behaviors.

Exploring associations in developmental trends of adolescent substance use and risky sexual behavior in a high-risk population.

This study examined associations between the development of adolescent alcohol, cigarette, and marijuana use and risky sexual behavior, over time, using latent growth modeling methodology. Gender differences in the development and relationships between use of substances and risky sexual behavior were also examined. Participants were 257 adolescents (mean age = 15.96 years) assessed at three time points over an 18-month period. The intercepts of marijuana with cigarettes and alcohol, and all three substances with risky sexual behavior were significantly related. Development of the three substances showed similar patterns and development of cigarette use covaried with development of risky sexual behavior. There were no significant differences for boys and girls in these relationships. Results are discussed in relation to the need for greater understanding of nonsexual and sex-related problem behaviors and for analyses examining development and change in these behaviors during adolescence.

A social-ecologic approach to assessing support for disease self-management: the Chronic Illness Resources Survey.

We report on the development and validation of an instrument to assess support and resources for chronic illness management (the Chronic Illness Resources Survey; CIRS). The 64-item full instrument and the 29-item Brief CIRS are based on a social-ecologic model, designed to apply across chronic diseases, and assess support and resources at each of seven levels (e.g., family and friends, physician and health care team, neighborhood/community). A prospective evaluation with 123 patients having heart disease, arthritis, diabetes, and/or COPD revealed that the overall instrument, as well as subscales and the brief instrument, had acceptable internal consistency, moderate to high test-retest reliability, good construct validity, and moderate concurrent and prospective criterion validity. We discuss potential uses of the CIRS for assessment, feedback, tailoring intervention, and evaluation and make recommendations for future research.

Tobacco policy rating form: a tool for evaluating worksite and tribal smoking control policies.

OBJECTIVE: To report on the development and validation of a rating scale to code the various components of written tobacco policies. DESIGN: A one-page Tobacco Policy Rating Form (TPRF) was developed to apply to written policies in both worksites and American Indian tribes. Fifteen worksite and 24 tribal tobacco policies from a diverse set of companies and tribes of varying size and economic status were rated on the TPRF by two separate sets of experienced and inexperienced raters. Kendall's coefficient of concordance (W) was computed to measure inter-rater agreement. RESULTS: The scale was found to produce a high level of agreement when used by both experienced and inexperienced raters on both tribal and worksite policies. For experienced raters, W = 0.92, P < 0.0001 for tribal policies and W = 0.97, P < 0.0001 for worksite policies; for inexperienced raters, W = 0.89, P < 0.0001 for tribal policies and W = 0.96, P < 0.0001 for worksite policies. CONCLUSIONS: The TPRF seems worthy of future use as a tool to rate the strength and comprehensiveness of written tobacco policies. It may be extended to other settings such as schools and municipalities, or used by investigators studying behavioural or economic consequences of smoking policies. Those interested in policy change may find the TPRF useful as a way of describing existing policies and as a quantitative measure of change.

Take Heart II: replication of a worksite health promotion trial.

The purpose of this study was to evaluate the effects of a revised worksite health promotion program that featured an employee steering committee/menu approach to intervention. The "Take Heart II" program was evaluated using a quasi-experimental matched-pair design with worksite as the unit of analysis. Experimental and control worksites did not differ on baseline organizational or employee demographic variables or on baseline levels of dependent variables. Outcome and process results revealed consistent, but modest effects favoring intervention worksites on most measures. Cross-sectional analyses generally failed to produce statistically significant intervention effects, but cohort analyses revealed significant beneficial effects of the Take Heart II intervention on eating patterns, behavior change attempts, and perceived social support. Neither analysis detected a beneficial effect of intervention on cholesterol levels.

Modifying dietary and tobacco use patterns in the worksite: the Take Heart Project.

This article describes the conceptual basis, design, and intervention approach for a worksite-based heart disease risk reduction project. Baseline characteristics of the 26 moderate size worksites participating in the Take Heart Project are also described. The trial is designed to produce changes at both the organization and employee level on tobacco use, dietary fat intake, and serum cholesterol. A key feature of the intervention is creation of employee steering committees to enhance ownership and involvement. From a menu of brief, low-intensity health education and environmental change activities, these committees select activities best suited to their worksite. The baseline characteristics of organizations randomized to intervention and control conditions were similar, and indicated a relatively high level of worksite activity related to cholesterol and smoking.