Experiences and Health Outcomes of Emerging Adults with Type 1 Diabetes: A Mixed Methods Study.

BACKGROUND: Emerging adults with type 1 diabetes are at risk of poorer diabetes-related health outcomes than other age groups. Several factors affecting the health and experiences of the emerging adults are culture and healthcare specific. OBJECTIVES: The aim of this study was to explore the experience of emerging adults living with type 1 diabetes in Lebanon, describe their diabetes self-care and diabetes-related health outcomes (HbA1c and diabetes distress), and identify the predictors of these outcomes. METHODS: A convergent mixed methods design was used with 90 participants aged 18-29 years. Sociodemographic, clinical data, and measures of diabetes distress, social support, and self-care were collected. Fifteen emerging adults participated in individual semi-structured interviews. Multiple linear regression was used to determine predictors of diabetes outcomes. Thematic analysis was used to analyze qualitative data. Data integration was used to present the mixed methods findings. RESULTS: The study sample had a mean HbA1c of 7.7% (SD = 1.36) and 81.1 % reported moderate to severe diabetes distress levels. The participants had good levels of diabetes self-care and high levels of social support. HbA1c was predicted by insulin treatment type, age at diagnosis, and diabetes self-care; while diabetes distress was predicted by diabetes knowledge, blood glucose monitoring approach, and diabetes self-care. "Living with type 1 diabetes during emerging adulthood: the complex balance of a chemical reaction" was the overarching theme of the qualitative data, with three underlying themes: "Breaking of bonds: changes and taking ownership of their diabetes", "The reactants: factors affecting the diabetes experience", and "Aiming for equilibrium". The integrated mixed methods results revealed one divergence between the qualitative and quantitative findings related to the complexity of the effect of received social support. DISCUSSION: The suboptimal health of the emerging adults despite good self-care highlights the importance of addressing cultural and healthcare specific factors such as diabetes knowledge and public awareness, social support, and availability of technology to improve diabetes health. Findings of this study can guide future research, practice, and policy development.

Type 1 Diabetes, Sleep, and Hypoglycemia.

PURPOSE OF REVIEW: To review the relationship between sleep and hypoglycemia, sleep characteristics, and their associations with glycemic control in persons with type 1 diabetes (T1D). The effects of sleep interventions and diabetes technology on sleep are summarized. RECENT FINDINGS: Nocturnal hypoglycemia affects objective and subjective sleep quality and is related to behavioral, psychological, and physiological factors. Sleep disturbances are common, including inadequate sleep, impaired sleep efficiency, poor subjective satisfaction, irregular timing, increased daytime sleepiness, and sleep apnea. Some have a bidirectional relationship with glycemic control. Preliminary evidence supports sleep interventions (e.g., sleep extension and sleep coach) in improving sleep and glycemic control, while diabetes technology use could potentially improve sleep. Hypoglycemia and sleep disturbances are common among persons with T1D. There is a need to develop sleep promotion programs and test their effects on sleep, glucose, and related outcomes (e.g., self-care, psychological health).

Computer-Controlled Virtual Humans in Patient-Facing Systems: Systematic Review and Meta-Analysis.

BACKGROUND: Virtual humans (VH) are computer-generated characters that appear humanlike and simulate face-to-face conversations using verbal and nonverbal cues. Unlike formless conversational agents, like smart speakers or chatbots, VH bring together the capabilities of both a conversational agent and an interactive avatar (computer-represented digital characters). Although their use in patient-facing systems has garnered substantial interest, it is unknown to what extent VH are effective in health applications. OBJECTIVE: The purpose of this review was to examine the effectiveness of VH in patient-facing systems. The design and implementation characteristics of these systems were also examined. METHODS: Electronic bibliographic databases were searched for peer-reviewed articles with relevant key terms. Studies were included in the systematic review if they designed or evaluated VH in patient-facing systems. Of the included studies, studies that used a randomized controlled trial to evaluate VH were included in the meta-analysis; they were then summarized using the PICOTS framework (population, intervention, comparison group, outcomes, time frame, setting). Summary effect sizes, using random-effects models, were calculated, and the risk of bias was assessed. RESULTS: Among the 8,125 unique records identified, 53 articles describing 33 unique systems, were qualitatively, systematically reviewed. Two distinct design categories emerged - simple VH and VH augmented with health sensors and trackers. Of the 53 articles, 16 (26 studies) with 44 primary and 22 secondary outcomes were included in the meta-analysis. Meta-analysis of the 44 primary outcome measures revealed a significant difference between intervention and control conditions, favoring the VH intervention (SMD = .166, 95% CI .039-.292, P=.012), but with evidence of some heterogeneity, I2=49.3%. There were more cross-sectional (k=15) than longitudinal studies (k=11). The intervention was delivered using a personal computer in most studies (k=18), followed by a tablet (k=4), mobile kiosk (k=2), head-mounted display (k=1), and a desktop computer in a community center (k=1). CONCLUSIONS: We offer evidence for the efficacy of VH in patient-facing systems. Considering that studies included different population and outcome types, more focused analysis is needed in the future. Future studies also need to identify what features of virtual human interventions contribute toward their effectiveness.

Contextual correlates of energy-dense snack food and sweetened beverage intake across the day in African American women: An application of ecological momentary assessment.

This study examined relationships between contextual factors and within-person variations in snack food and sweetened beverage intake in African American women (n = 79), aged 25-65 years living in metropolitan Chicago. For seven days, participants wore a global positioning system (GPS) logger and were signaled five times per day to complete an ecological momentary assessment (EMA) survey assessing behaviors and environmental, social, and other contextual factors via smartphones. Within-person associations between snack food and beverage intake and contextual factors were analyzed using three-level logistic regressions. Participants reported consuming a snack food at 38.4% of signals and a sweetened beverage at 17.9% of signals. Fast food restaurant and convenience store density within the daily activity space was not associated with either snack food or sweetened beverage intake. However, perceptions of close proximity to fast food restaurants and convenience stores making it easier to eat/drink, while accounting for one's usual proximity, were associated with increased odds of snack intake (O.R. 2.1; 95% C.I. 1.4, 3.0) but not sweetened beverage. We also found engaging in activities such as watching television (O.R. 1.8; 95% C.I. 1.2, 2.7) and talking (O.R. 1.7; 95% C.I. 1.1, 2.6) while eating were associated with higher snack intake. These factors were not related to sweetened beverage intake. Public health interventions addressing fast food restaurant and convenience store accessibility and food offerings and marketing within these outlets may help reduce snack food intake. Additionally, to reduce concurrent activities while eating, real-time interventions using smart technology could be used to enhance attentive eating in this population.

Associations between fatigue, sleep disturbance and eating style in adults with type 2 diabetes: A correlational study.

AIMS AND OBJECTIVES: To test the hypothesis that fatigue and sleep disturbance account for a significant amount of variation in eating styles among people with type 2 diabetes (T2D). BACKGROUND: Healthy eating is an important component of diabetes self-care but remains a major challenge. In people with T2D, symptoms of fatigue and sleep disturbance are pervasive. However, there is limited understanding of whether fatigue and sleep disturbance are associated with eating style in people with T2D. DESIGN: Correlational design. METHODS: This study was reported following the STROBE checklist. Data were collected between February 2017 and January 2018. A convenience sample of 64 T2D adults completed the Three-Factor Eating Questionnaire-R18V2 to measure eating style (e.g., emotional eating, cognitive restraint and uncontrolled eating). Diabetes distress, fatigue and sleep disturbance were measured using validated questionnaires. Hierarchical regression analyses were performed. RESULTS: Only age was a significant predictor (ß = -0.344) of cognitive restraint. Participant demographics, psychological factor and health-related factors contribute significantly to the model predicting emotional eating, but only diabetes distress was a significant predictor (ß = 0.433). Introducing fatigue and poor sleep quality explained an additional 12.0% of the variation in emotional eating. The final model explained 24.9% of the variation in emotional eating; both diabetes distress (ß = 0.294) and fatigue (ß = 0.360) were significant predictors. CONCLUSION: There is a strong, independent relationship of fatigue and diabetes distress with emotional eating T2D patients. The effect of improving fatigue and diabetes distress on eating style should be explored. RELEVANCE TO CLINICAL PRACTICE: In clinical practice, nurses are recommended to include a detailed assessment of fatigue and distress in patients with diabetes. Additional to the conventional nutrition therapy focusing on diet advice, eating style should also be incorporated in diet education by diabetes nurses.

Pathways of the relationships among eating behavior, stress, and coping in adults with type 2 diabetes: A cross-sectional study.

Stress is related to eating behavior, and eating behavior is important in diabetes treatment. The aim of this study was to examine the relationships among perceived stress, diabetes-related stress, coping strategies, and eating behaviors in adults living with type 2 diabetes (T2DM). Adults with type 2 diabetes (n = 183) were recruited from a large metropolitan area in the Midwest United States. Stress factors and coping strategies associated with eating behaviors were measured using validated questionnaires. Structural equation modeling was used to investigate the relationships among perceived stress, diabetes-related stress, coping strategies, and eating behaviors. The final model showed that emotion-oriented coping partially mediated the effect of stress on eating behaviors. Specifically, emotion-oriented coping partially mediated the effect of diabetes-related stress on restrained eating behavior (r = 0.318, p < .001) and emotional eating behavior (r = 0.399, p < .001); emotion-oriented coping partially mediated the effect of perceived stress on external eating behavior (r = 0.276, p < .001). Emotion-oriented coping was found to be a partial mediator in the path model between stress and eating behaviors in people with type 2 diabetes. Knowledge of the association of stress with eating behaviors may prove important for health care providers in treatment and care of people with type 2 diabetes.

Endothelial Dysfunction is Related to Glycemic Variability and Quality and Duration of Sleep in Adults With Type 1 Diabetes.

BACKGROUND: Elevated cardiovascular disease risk in people with type 1 diabetes (T1DM) is incompletely understood. Glycemic control, glycemic variability, and sleep quality and duration may relate to cardiovascular disease risk in this population via endothelial dysfunction. OBJECTIVE: The aim of this study was to examine relationships among glycemic control, glycemic variability, sleep quality and duration, and endothelial function in adults with T1DM. METHODS: Endothelial function was measured using flow-mediated dilation. Glycemic control and glycemic variability were measured using A1C and a continuous glucose monitor, respectively; sleep quality and duration were measured with the Pittsburgh Sleep Quality Index. RESULTS: Twenty subjects were recruited. Reduced flow-mediated dilation and higher glucose levels were associated with poorer sleep quality (r = -0.51, P = .01; r = 0.52, P = .03). Subjects with shorter sleep duration had greater glycemic variability. CONCLUSIONS: Endothelial dysfunction (a precursor to cardiovascular disease) relates to glycemic control, glycemic variability, and sleep quality in T1DM.

Poor sleep quality is associated with nocturnal glycaemic variability and fear of hypoglycaemia in adults with type 1 diabetes.

AIMS: To examine sleep quality and its associations with glycaemic control, glycaemic variability (GV), and fear of hypoglycaemia (FOH) in adults with type 1 diabetes. BACKGROUND: Poor sleep quality has negative health consequences and is a frequent complaint among adults with type 1 diabetes. Sleep quality in adults with type 1 diabetes is likely affected by glucose levels as well as stressors associated with managing a chronic condition. DESIGN: A retrospective secondary analysis of pooled data from two previous cross-sectional studies was conducted. METHODS: We examined subjective sleep quality, FOH; objective measures of glycaemic control (HbA1c); and GV (3-day continuous glucose monitoring) in 48 men and women aged 18-45 years with type 1 diabetes. The data were collected over 3 years in 2013-2016. RESULTS/FINDINGS: Poor sleep quality was reported by 46% of patients. Those with poor sleep quality had significantly greater nocturnal GV and FOH. Nocturnal GV and FOH were significantly associated with poor sleep quality. The interaction effect of GV and FOH was significant. CONCLUSION: These findings suggest that glycaemic control and FOH are targets for intervention to improve sleep quality in those with type 1 diabetes.

Health-Related Stigma in Young Adults With Type 1 Diabetes Mellitus.

Young adults with type 1 diabetes mellitus (T1DM) often exhibit poor treatment adherence and suboptimal glucose control. Health-related stigma may adversely influence diabetes self-management behavior. The aim of the current study was to explore health-related stigma among young adults with T1DM using qualitative descriptive methods in focus groups. Data were collected from a purposive sample of 14 young adults ages 20 to 34 with T1DM. Using content analysis, transcripts from two focus groups were analyzed, and five main themes were identified: (a) Desire to be Seen as a Person, Not a Disease; (b) Wanting to be "Normal"; (c) Feeling Ashamed Managing Diabetes in Public; (d) Struggling to Overcome Anger and Distress; and (e) Feeling Distrusted by Others to Manage Their Condition. Young adults with T1DM reported experiencing a high degree of stigma in their daily lives, which negatively influenced their self-management and psychological well-being. Stigma led to delaying blood glucose monitoring and insulin dosing and feelings of anger and distress. Young adults with T1DM require strategies to help cope with stigma and the anger and distress they experience. [Journal of Psychosocial Nursing and Mental Health Services, 56(10), 44-51.].