Time of Day When Type 1 Diabetes Patients With Eating Disorder Symptoms Most Commonly Restrict Insulin.

OBJECTIVE: Restricting insulin to lose weight is a significant problem in the clinical management of type 1 diabetes (T1D). Little is known about this behavior or how to effectively intervene. Identifying when insulin restriction occurs could allow clinicians to target typical high-risk times or formulate hypotheses regarding factors that influence this behavior. The current study investigated the frequency of insulin restriction by time of day. METHODS: Fifty-nine adults with T1D and eating disorder symptoms completed 72 hours of real-time reporting of eating and insulin dosing with continuous glucose monitoring. We used a generalized estimating equation model to test the global hypothesis that frequency of insulin restriction (defined as not taking enough insulin to cover food consumed) varied by time of day, and examined frequency of insulin restriction by hour. We also examined whether patterns of insulin restriction for 72 hours corresponded with patients' interview reports of insulin restriction for the past 28 days. RESULTS: Frequency of insulin restriction varied as a function of time (p = .016). Insulin restriction was the least likely in the morning hours (6:00-8:59 AM), averaging 6% of the meals/snacks consumed. Insulin restriction was more common in the late afternoon (3:00-5:59 PM), peaking at 29%. Insulin was restricted for 32% of the meals/snacks eaten overnight (excluding for hypoglycemia); however, overnight eating was rare. Insulin restriction was associated with higher 120-minute postprandial blood glucose (difference = 44.4 mg/dL, 95% confidence interval = 22.7-68.5, p < .001) and overall poorer metabolic control (r = 0.43-0.62, p's < .01). Patients reported restricting insulin for a greater percentage of meals and snacks for the past 28 days than during the 72 hour real-time assessment; however, the reports were correlated (Spearman's ρ = 0.46, p < .001) and accounted for similar variance in HbA1c (34% versus 35%, respectively). CONCLUSIONS: Findings suggest that insulin restriction may be less likely in the morning, and that late afternoon is a potentially important time for additional therapeutic support. Results also suggest that systematic clinical assessment and treatment of overnight eating might improve T1D management.

Impacts of Industrial Wind Turbine Noise on Sleep Quality: Results From a Field Study of Rural Residents in Ontario, Canada.

The objectives of this study were to determine whether grid-connected industrial wind turbines (IWTs) are a risk factor for poor sleep quality, and if IWT noise is associated with sleep parameters in rural Ontarians. A daily sleep diary and actigraphy-derived measures of sleep were obtained from 12 participants from an IWT community and 10 participants from a comparison community with no wind power installations. The equivalent and maximum sound pressure levels within the bedroom were also assessed. No statistically significant differences were observed between IWT residents and non-IWT residents for any of the parameters measured in this study. Actigraphy and sleep diaries are feasible tools to understand the impact of IWTs on the quality of sleep for nearby residents. Further studies with larger sample sizes should be conducted to determine whether the lack of statistical significance observed here is a result of sample size, or reflects a true lack of association.

Momentary Predictors of Insulin Restriction Among Adults With Type 1 Diabetes and Eating Disorder Symptomatology.

OBJECTIVE: Individuals with type 1 diabetes who restrict insulin to control weight are at high risk for diabetes-related complications and premature death. However, little is known about this behavior or how to effectively intervene. The aim of the current study was to identify predictors of insulin restriction in the natural environment that might inform new treatment directions. RESEARCH DESIGN AND METHODS: Eighty-three adults with type 1 diabetes and a range of eating disorder symptomatology completed 3 days of ecological momentary assessment. Participants reported emotions, eating, and insulin dosing throughout the day using their cellular telephone. Linear mixed models were used to estimate the effects of heightened negative affect (e.g., anxiety) before eating and characteristics of the eating episode (e.g., eating a large amount of food) on the risk of insulin restriction. RESULTS: Individuals who reported greater-than-average negative affect (general negative affect and negative affect specifically about diabetes) during the study period were more likely to restrict insulin. Momentary increases in anxiety/nervousness and guilt/disgust with self before eating (relative to an individual's typical level) further increased the odds of restricting insulin at the upcoming meal. Insulin restriction was more likely when individuals reported that they broke a dietary rule (e.g., "no desserts"). CONCLUSIONS: Results suggest that insulin restriction might be decreased by helping patients with type 1 diabetes respond effectively to heightened negative affect (e.g., anxiety, guilt) and encouraging patients to take a less rigid, punitive approach to diabetes management.

Pilot Study of Caffeine Abstinence for Control of Chronic Glucose in Type 2 Diabetes.

BACKGROUND: A growing body of evidence suggests that caffeinated beverages may impair chronic glucose control in type 2 diabetes. This pilot study tested the chronic effects of caffeine abstinence on glucose control in type 2 diabetic patients who were daily coffee drinkers. METHODS: Twelve coffee drinkers (six males) with established type 2 diabetes participated. Seven (five males) completed 3 months of total caffeine abstinence. Measures of chronic glucose control, long-term (hemoglobin A1c [HbA1c]) and short-term (1,5-anhydroglucitol [1,5-AG]), were collected at baseline and during follow-up. Abstinence was established by diaries confirmed by saliva caffeine assays. RESULTS: Abstinence produced significant decreases in HbA1c and increases in 1,5-AG, both indicating improvements in chronic glucose control. Fasting glucose and insulin did not change, nor were changes in body weight observed. CONCLUSIONS: Although preliminary, these results suggest that caffeine abstinence may be beneficial for patients with type 2 diabetes. This hypothesis should be confirmed in larger controlled clinical trials.

Video-based coping skills to reduce health risk and improve psychological and physical well-being in Alzheimer's disease family caregivers.

OBJECTIVE: To determine whether video-based coping skills (VCS) training with telephone coaching reduces psychosocial and biological markers of distress in primary caregivers of a relative with Alzheimer's disease or related dementia (ADRD). METHODS: A controlled clinical trial was conducted with 116 ADRD caregivers who were assigned, alternately as they qualified for the study, to a Wait List control condition or the VCS training arm in which they viewed two modules/week of a version of the Williams LifeSkills Video adapted for ADRD family care contexts, did the exercises and homework for each module presented in an accompanying Workbook, and received one telephone coaching call per week for 5 weeks on each week's two modules. Questionnaire-assessed depressive symptoms, state and trait anger and anxiety, perceived stress, hostility, caregiver self-efficacy, salivary cortisol across the day and before and after a stress protocol, and blood pressure and heart rate during a stress protocol were assessed before VCS training, 7 weeks after training was completed, and at 3 months' and 6 months' follow-up. RESULTS: Compared with controls, participants who received VCS training plus telephone coaching showed significantly greater improvements in depressive symptoms, trait anxiety, perceived stress, and average systolic and diastolic blood pressures that were maintained over the 6-month follow-up period. CONCLUSIONS: VCS training augmented by telephone coaching reduced psychosocial and biological indicators of distress in ADRD caregivers. Future studies should determine the long-term benefits to mental and physical health from this intervention. TRIAL REGISTRATION: http://www.clinicaltrials.gov; #NCT00396825.

Plasma epinephrine predicts fasting glucose in centrally obese African-American women.

The high prevalence of diabetes in African-American (AA) women has been widely assumed to be related to the greater prevalence of obesity in this group. Catecholamine release acting on central adipose tissue has been proposed to be a contributing factor. The aim of this article was to examine the interaction of plasma catecholamines and central adiposity on fasting and nonfasting glucose levels in two separate samples. In both studies, the women were healthy, nondiabetic of similar age. In addition, both studies assessed plasma epinephrine (EPI) and norepinephrine (NOREPI) levels collected at three time points. In study 1, catecholamines were measured during a standardized laboratory mental stress task and in study 2, they were measured during the initial phase (10 min) of an intravenous glucose tolerance test (IVGTT). Results from both studies revealed significant effects of EPI on fasting glucose in the obese women. In study 1, mean EPI levels were significantly related to fasting glucose in AA women with high trunk fat (beta = 0.60, P < 0.001). Because high BMI was associated with high trunk fat in women, we used BMI >30 as a proxy for high trunk fat (>32%) in study 2. In study 2, EPI response to the glucose bolus was a strong predictor of fasting glucose in AA women with BMI >30 (beta = 0.75, P < 0.003). We conclude that the effect of central adiposity on fasting glucose may be moderated by plasma EPI. This suggests that adrenal medullary activity could play a role in the pathophysiology of type 2 diabetes.

Hostility and fasting glucose in African American women.

OBJECTIVE: To examine whether the relationship of hostility (HOST) to fasting glucose indices is moderated by sex and race. HOST has been associated with abnormalities in glucose metabolism. Prior studies suggested that this association may be more prevalent in women and in African American (AA) individuals. METHODS: A total of 565 healthy AA and white (W) men and women (mean age = 33 +/- 6 years) were assessed. HOST was measured by the 27-item version of the Cook Medley HOST Scale. The moderating effects of sex and race were evaluated for the associations of HOST to fasting glucose, insulin, and insulin sensitivity (HOMA-IR). RESULTS: Analysis showed a moderating effect of sex and race on the association of HOST to fasting glucose (p = .03), but not for insulin (p = .12). Analysis of HOMA-IR revealed a trend (p = .06) for the interaction. Stratified analyses by race and sex revealed a positive association between HOST and fasting glucose only in AA women, which remained significant after controlling for age and body mass index. CONCLUSION: A relationship between HOST and fasting glucose was evident in AA women only, a group that has twice the risk of developing Type 2 diabetes compared with W women. Further studies are needed to elucidate the mechanisms by which HOST may affect glucose metabolism in AA women.

Hostility and minimal model of glucose kinetics in African American women.

OBJECTIVE: To explore the underlying physiology of hostility (HOST) and to test the hypothesis that HOST has a greater impact on fasting glucose in African American (AA) women than it does on AA men or white men or women, using an intravenous glucose tolerance test (IVGTT) and the minimal model of glucose kinetics. METHODS: A total of 115 healthy subjects selected for high or low scores on the 27 item Cook Medley HOST Scale underwent an IVGTT. Fasting nonesterified fatty acids (NEFA) levels were measured before the IVGTT. Catecholamine levels were measured 10 minutes into the IVGTT. RESULTS: Moderation by group (AA women versus others) of HOST was found for glucose effectiveness (Sg, p = .02), acute insulin response (AIRg, p = .02), and disposition index (DI, p = .02). AA women showed a negative association between HOST and both Sg (beta = -0.45, p = .04) and DI (beta = -0.49, p = .02), controlling for age and body mass index. HOST was also associated with changes in epinephrine (beta = 0.39, p = .05) and fasting NEFA (beta = 0.44, p = .02) in the AA women. Controlling for fasting NEFA reduced the effect of HOST on both Sg and DI. CONCLUSIONS: This study shows that HOST is related to decreased DI, a measure of pancreatic compensation for increased insulin resistance as well as decreased Sg, a measure of noninsulin-mediated glucose transport compared in AA women. These effects are partly mediated by the relationship of HOST to fasting NEFA.

Childhood socioeconomic status and serotonin transporter gene polymorphism enhance cardiovascular reactivity to mental stress.

OBJECTIVE: To test the hypothesis that low socioeconomic status (SES) and the 5HTTLPR L allele are associated with increased cardiovascular reactivity (CVR) to stress in a larger sample and that SES and 5HTTLPR genotypes interact to enhance CVR to stress. CVR to mental stress has been proposed as one mechanism linking stress to the pathogenesis of cardiovascular disease. The more transcriptionally efficient long (L) allele of a polymorphism of the serotonin transporter gene promoter (5HTTLPR) has been found associated with increased risk of myocardial infarction. We found the long allele associated with larger CVR to mental stress in a preliminary study of 54 normal volunteers. METHODS: Subjects included 165 normal community volunteers stratified for race, gender, and SES, who underwent mental stress testing. RESULTS: Childhood SES as indexed by Father's Education Level was associated with larger systolic blood pressure (SBP) (p < .05) and diastolic blood pressure (DBP) (p = .01) responses to mental stress. The L allele was associated with larger SBP (p = .04), DBP (p < .0001), and heart rate (p = .04) responses to mental stress compared with the short (S) allele. Subjects with the SS genotype and high Father's Education exhibited smaller SBP (5.2 mm Hg) and DBP (2.9 mm Hg) responses than subjects with LL genotype and low Father's Education (SBP = 13.3 mm Hg, p = .002; DBP = 9.7 mm Hg, p < .0001). CONCLUSIONS: Both the 5HTTLPR long allele and low SES, particularly during childhood, are associated with increased CVR to mental stress, which could account, at least in part, for the increased cardiovascular disease risk associated with these characteristics. If confirmed in further research, these characteristics could be used to identify persons who might benefit from preventive interventions.

Exaggeration of postprandial hyperglycemia in patients with type 2 diabetes by administration of caffeine in coffee.

OBJECTIVE: To test whether caffeine administered in coffee increases postprandial hyperglycemia in patients with type 2 diabetes who are habitual coffee drinkers. METHODS: The study used a within-subject, double-blind, placebo-controlled experimental design. Twenty adult coffee drinkers (11 women and 9 men) with type 2 diabetes treated with diet, exercise, orally administered antidiabetic agents, or some combination of these factors completed two mixed-meal tolerance tests (MMTT) after an overnight fast. Before the MMTT, each study participant received 250 mg of caffeine in 16 oz (475 mL) of decaffeinated coffee or decaffeinated coffee alone, with the treatment order counterbalanced in the group. Fasting and 1-hour and 2-hour postprandial blood samples were collected for measurement of plasma glucose and insulin concentrations. RESULTS: Glucose and insulin responses to the MMTT were quantified by the incremental areas under the 2-hour concentration-time curves (AUC2h). Administration of caffeine in decaffeinated coffee increased postprandial glucose and insulin responses (both P = 0.02). The mean plasma glucose AUC2h was 28% larger and the mean plasma insulin AUC2h was 19% larger after administration of caffeine than after administration of placebo. CONCLUSION: Other constituents in coffee did not prevent the exaggeration of postprandial hyperglycemia by caffeine in these patients with type 2 diabetes, who were habitual coffee drinkers. Repeated on a daily basis, such effects could impair long-term glucose control in those patients with type 2 diabetes who habitually drink coffee or other caffeinated beverages.

Changes in depressive symptoms and glycemic control in diabetes mellitus.

OBJECTIVE: To investigate if changes in depressive symptoms would be associated with changes in glycemic control over a 12-month period in patients with Type 1 and Type 2 diabetes. METHODS: Ninety (Type 1 diabetes, n = 28; Type 2 diabetes, n = 62) patients having Beck Depression Inventory (BDI) levels of >10 were enrolled in the study. Of those 90 patients, 65 patients completed a 12-week cognitive behavioral therapy intervention. BDI was assessed at baseline and thereafter biweekly during 12 months. Hemoglobin (HbA1c) and fasting blood glucose levels were assessed at baseline and at four quarterly in-hospital follow-up visits. Linear mixed-model analysis was applied to determine the effects of time and diabetes type on depressive symptoms, HbA1c levels, and fasting glucose levels. RESULTS: Mean and standard deviation baseline BDI and HbA1c levels were 17.9 +/- 5.8 and 7.6 +/- 1.6, respectively, with no significant difference between patients with Type 1 and Type 2 diabetes. Mixed-model regression analysis found no difference between the groups with Type 1 and Type 2 diabetes in the within-subject effect of BDI score on HbA1c or fasting glucose levels during the study. Depressive symptoms decreased significantly (p = .0001) and similarly over a 12-month period in both patients with Type 1 and Type 2 diabetes, whereas HbA1c and fasting glucose levels did not change significantly over time in either group. CONCLUSION: Changes in depressive symptoms were not associated with changes in HbA1c or fasting glucose levels over a 1-year period in either patients with Type 1 or Type 2 diabetes.

Brief meditation training can improve perceived stress and negative mood.

OBJECTIVES: To test a brief, non-sectarian program of meditation training for effects on perceived stress and negative emotion, and to determine effects of practice frequency and test the moderating effects of neuroticism (emotional lability) on treatment outcome. DESIGN AND SETTING: The study used a single-group, open-label, pre-test post-test design conducted in the setting of a university medical center. PARTICIPANTS: Healthy adults (N=200) interested in learning meditation for stress-reduction were enrolled. One hundred thirty-three (76% females) completed at least 1 follow-up visit and were included in data analyses. INTERVENTION: Participants learned a simple mantra-based meditation technique in 4, 1-hour small-group meetings, with instructions to practice for 15-20 minutes twice daily. Instruction was based on a psychophysiological model of meditation practice and its expected effects on stress. OUTCOME MEASURES: Baseline and monthly follow-up measures of Profile of Mood States; Perceived Stress Scale; State-Trait Anxiety Inventory (STAI); and Brief Symptom Inventory (BSI). Practice frequency was indexed by monthly retrospective ratings. Neuroticism was evaluated as a potential moderator of treatment effects. RESULTS: All 4 outcome measures improved significantly after instruction, with reductions from baseline that ranged from 14% (STAI) to 36% (BSI). More frequent practice was associated with better outcome. Higher baseline neuroticism scores were associated with greater improvement. CONCLUSIONS: Preliminary evidence suggests that even brief instruction in a simple meditation technique can improve negative mood and perceived stress in healthy adults, which could yield long-term health benefits. Frequency of practice does affect outcome. Those most likely to experience negative emotions may benefit the most from the intervention.

Psychosocial benefits of three formats of a standardized behavioral stress management program.

OBJECTIVE: Psychosocial factors are associated with increased morbidity and mortality in healthy and clinical populations. Behavioral interventions are needed to train the large number of people in the community setting who are affected by stressors to use coping skills that will reduce these risk factors. The aim of the current study was to evaluate the efficacy of three forms of delivery of a standardized, behavioral intervention-the Williams LifeSkills program-designed to reduce levels of psychosocial risk factors in nonclinical populations. METHODS: One hundred ninety-six participants screening positive for elevated psychosocial distress were randomized to either a waitlist control group or one of three intervention groups: the LifeSkills Workshop, the LifeSkills Video, or the LifeSkills Video and Workshop combined. Psychosocial risk factors were evaluated at baseline and at 10 days, 2 months, and 6 months after the training/wait period. RESULTS: At 10 days follow up, the workshop + video and video-only groups showed significant improvements over control subjects in trait anxiety and perceived stress. Moreover, the workshop + video group maintained benefit over control subjects throughout 6 months follow up in both of these measures, whereas the video-only group maintained benefit in trait anxiety. CONCLUSIONS: Because the psychosocial well-being of two of the treated groups improved over that of the control group, it appears that the Williams LifeSkills program accelerates and maintains a normal return to low distress after a stressful time. This is the first study to show that a commercially available, facilitator- or self-administered behavioral training product can have significant beneficial effects on psychosocial well-being in a healthy community sample.

Treatment regimen determines the relationship between depression and glycemic control.

UNLABELLED: Several recent studies have suggested that depression is related to poorer glycemic control in patients with type 1 diabetes, but not in type 2 diabetes. We hypothesize that complexity of self-care regimen rather than the type of diabetes, is more important in determining this relationship of depression to glycemic control. METHODS: One thousand thirty-four adults with diabetes were recruited for the study. These patients were treated with: diet and exercise, oral medications, oral medications and insulin, 1-2 daily injections of insulin, and > or =3 daily injections. All participants completed the Beck depression inventory (BDI) and had a hemoglobin A(1c) (HbA(1c)) performed as part of routine clinical care. RESULTS: Pearson correlations between BDI scores and HbA(1c) were low and insignificant in all groups (0.015< or =r< or =0.066) except for those administering three or more daily shots of insulin (r=0.284; p=0.034). DISCUSSION: The results of this study clearly show that while depressive symptoms are significantly correlated to glycemic control in patients taking three or more insulin injections per day, there is no relationship in patients who are taking fewer than three injections per day.

Beneficial effects of noetic therapies on mood before percutaneous intervention for unstable coronary syndromes.

BACKGROUND: Many common medical, surgical, and diagnostic procedures performed for conscious patients can be accompanied by significant anxiety. Mind-body-spirit interventions could serve as useful adjunctive treatments for the reduction of stress. OBJECTIVE: To evaluate the effects of stress management, imagery, touch therapy, remote intercessory prayer, and standard therapy on mood in patients awaiting percutaneous interventions for unstable coronary syndromes as part of the Monitoring and Actualization of Noetic Training (MANTRA) trial, which explored the feasibility and efficacy of noetic interventions on clinical outcomes in a randomized clinical trial. METHODS: A total of 150 patients were randomized to one of the five treatment conditions. Stress management, imagery, and touch therapy were administered in 30-minute treatment sessions immediately before the cardiac intervention. Intercessory prayer was not necessarily contemporaneous with these treatments. Mood was assessed by a set of visual analog scales before and after treatment for a similar length of time for the standard therapy and prayer groups. RESULTS: Analysis of complete data from 108 patients showed that stress management, imagery, and touch therapy all produced reductions in reported worry, as compared with standard therapy, whereas remote intercessory prayer had no effect on mood. The ratings of other similar moods were not affected, perhaps because of the relatively positive emotional state observed in the participants before treatment. CONCLUSIONS: The results suggest that at least some noetic therapies may have beneficial effects on mood in the course of medical and surgical interventions. Administration of these interventions was feasible even in the hectic environment of the coronary intensive care unit. Given their relatively low cost and limited potential for adverse effects, these interventions merit further study as therapeutic adjuncts.

Correlations between preprocedure mood and clinical outcome in patients undergoing coronary angioplasty.

We studied the relationship between mood and mood shift immediately before percutaneous coronary intervention (PCI) and 3 end points: total ischemic burden during PCI, adverse cardiac end points (ACE) after PCI, and death by 6-month follow up. Patients (n = 119) with unstable angina or myocardial infarction completed a visual analog scale (VAS) twice before PCI; before and after a session of stress relaxation, imagery, or touch; or approximately 30 minutes apart for patients assigned to prayer or to standard care. VAS included happiness, satisfaction, calm, hope, worry, shortness of breath, fear, and sadness. We observed a significant correlation between higher hope score before PCI and lower ischemic burden. Patients who experienced ACE had significantly lower hope and happiness scores than those who did not. Patients who survived to 6 months had significantly greater increases in worry and in hope. Our data suggest correlations between simple mood assessments before PCI and clinical outcomes during and after the procedure. More study is needed to understand whether attempts to alter patient mood can affect clinical outcomes.

Caffeine affects cardiovascular and neuroendocrine activation at work and home.

OBJECTIVE: This study investigated the effects of moderate doses of caffeine on ambulatory blood pressure and heart rate, urinary excretion of epinephrine, norepinephrine, and cortisol, and subjective measures of stress during normal activities at work and at home in the evening. METHODS: Healthy, nonsmoking, habitual coffee drinkers (N = 47) participated in 3 days of ambulatory study. After a day of ad lib caffeine consumption, caffeine (500 mg) and placebo were administered double-blind in counter-balanced order on separate workdays. Ambulatory blood pressure and heart rate were monitored from the start of the workday until bedtime. Urinary excretion of catecholamines and cortisol was assessed during the workday and evening. RESULTS: Caffeine administration significantly raised average ambulatory blood pressure during the workday and evening by 4/3 mm Hg and reduced average heart rate by 2 bpm. Caffeine also increased by 32% the levels of free epinephrine excreted during the workday and the evening. In addition, caffeine amplified the increases in blood pressure and heart rate associated with higher levels of self-reported stress during the activities of the day. Effects were undiminished through the evening until bedtime. CONCLUSIONS: Caffeine has significant hemodynamic and humoral effects in habitual coffee drinkers that persist for many hours during the activities of everyday life. Furthermore, caffeine may exaggerate sympathetic adrenal-medullary responses to the stressful events of normal daily life. Repeated daily blood pressure elevations and increases in stress reactivity caused by caffeine consumption could contribute to an increased risk of coronary heart disease in the adult population.