Difficult conversations: adults with diabetes and the discussion of microvascular complications.

AIMS: To investigate the experiences among adults with diabetes of discussions of microvascular complications and provide recommendations for providers. METHODS: We performed a qualitative study in 148 adults with Type 1 and Type 2 diabetes (56% women, 95% white, mean age 60±13 years, 65% with Type 1 diabetes, 71% with ≥1 microvascular complication). Data were analysed using content analysis. RESULTS: At their first discussion of microvascular complications, 93% of participants (138/148) recalled providers using a preventative approach including clinical suggestions, factual information and warnings. At complication diagnosis, 78% of participants (82/105) perceived provider support through comprehensive interactive education, specific self-care guidance, reassuring messages, and referrals and follow-ups. In response to complication diagnosis, 48% (50/105) felt scared, 46% (48/105) had 'a wake-up call', and 86% (90/105) reported increasing ≥1 specific area of self-care. Participants recommended providers offer factual and complete information, specific self-care guidance, and positive honesty, with an individualized and collaborative approach that includes psychosocial assessment and referrals and lacks 'scare tactics' and blame. CONCLUSIONS: Adults with diabetes want to learn about diabetes microvascular complications and apply preventative strategies as early as possible. Paradoxically, the diagnosis of a diabetes microvascular complication in itself may represent a unique learning opportunity because 86% of participants improved diabetes self-care after this event. Recommendations offer providers simple but important clinical approaches to improve these difficult conversations and thus support necessary behaviour changes and psychosocial well-being. Training is needed to help providers discuss the threat of diabetes complications with honest but positive messages so that people with diabetes can be fully informed but also maintain hope in the face of complications.

Impact of continuous glucose monitoring on diabetes management and marital relationships of adults with Type 1 diabetes and their spouses: a qualitative study.

AIMS: To examine the impact of continuous glucose monitoring on diabetes management and marital relationships of adults with Type 1 diabetes and their spouses. METHODS: Nine younger (30-49 years) and 11 older (50-70 years) patients with Type 1 diabetes and 14 spouses participated in eight focus groups specific to age and role (patient or spouse). Audio-recorded data were transcribed, coded and analysed using thematic analysis and aided by NVivo software. RESULTS: Qualitative analysis revealed participants perceived continuous glucose monitoring as positively influencing hypoglycaemia management by decreasing spouses' anxiety, vigilance and negative experiences. Participants also described continuous glucose monitoring as promoting collaborative diabetes management and increasing spousal understanding of diabetes, especially when planning and managing pregnancy. Couples' conflicts occurred when (1) patients assumed sole responsibility for continuous glucose monitoring and/or did not respond to night-time glucose alarms and (2) spouses did not understand alarms and felt frustrated and helpless to assist patients. CONCLUSIONS: Our findings suggest that continuous glucose monitoring may positively impact collaborative diabetes management and marital relationships of patients with Type 1 diabetes and their spouses. However, reluctance to collaborate and lack of understanding may contribute to couples' conflicts around continuous glucose monitoring. Our findings have important implications for clinical care and point to the need for interventions that include spouses in continuous glucose monitoring training to increase their understanding of continuous glucose monitoring, minimize risk for spousal conflict and enhance collaborative diabetes management. Further studies are needed to explore these issues in more detail and depth with larger and more diverse populations.

Psychosocial factors associated with use of continuous glucose monitoring.

AIMS: To identify psychosocial factors associated with the use of continuous glucose monitoring by adults with Type 1 diabetes. METHODS: Twenty adult patients (aged 45 +/- 15 years, diabetes duration 25 +/- 19 years, 50% female) followed at our site in the multi-centre Juvenile Diabetes Research Foundation continuous glucose monitoring trial were divided into three groups: Glycated haemoglobin (HbA(1c)) Responders who demonstrated an improvement in glycaemic control with continuous glucose monitoring (baseline HbA(1c)> or = 7.0%, HbA(1c) reduction greater than or equal to 0.5%), Hypoglycaemia Responders (baseline HbA(1c) < 7.0%) who demonstrated decreased time < 3.9 mmol/l while remaining within target HbA(1c), and HbA(1c) Non-Responders (baseline HbA(1c)> or = 7.0%, HbA(1c) reduction less than 0.5%). Subjects participated in semi-structured interviews focusing on their psychosocial experiences with continuous glucose monitoring. RESULTS: Three major themes were identified that differentiated Responders (including both the HbA(1c) and Hypoglycaemia groups) from Non-Responders: (i) coping with frustrations-Responders used self-controlled rather than emotions-based coping when faced with continuous glucose monitoring frustrations; (ii) use of information-Responders used retrospective pattern analysis, not just minute-by-minute data analysis, in glycaemic management; (iii) 'significant other'/spousal involvement-Responders endorsed interest, encouragement and participation by their loved ones. Both Responders and Non-Responders expressed body image concerns when wearing continuous glucose monitoring devices. CONCLUSIONS: This qualitative study points to the importance of coping skills, retrospective review of data, and 'significant other' involvement in the effective use of continuous glucose monitoring. These findings will inform clinical initiatives to improve patient selection and training in the use of this new technology and have served as the basis for development of quantitative surveys to be used in clinical practice.

Adolescent views of diabetes-related parent conflict and support: a focus group analysis.

PURPOSE: To increase understanding of adolescent-parent diabetes-related conflicts and supports in the management of type 1 diabetes by means of a focus group research approach. METHODS: Twenty-four adolescents (10 boys and 14 girls, age 13-15 years; 97% white) participated in three same-sex focus groups at two diabetes summer camps. The focus group leader used a prepared set of open-ended questions to guide the 90-minute sessions. Sessions were tape-recorded, transcribed, and analyzed by a set procedure for qualitative analysis to identify the adolescents' perspectives on parent-adolescent sources of diabetes-related conflict and support. RESULTS: Adolescents reported the following sources of diabetes-related conflict: parental worry and intrusive behaviors; parental lack of understanding and blaming behaviors, and the parents focus on the future vs. the adolescent focus on the present. With regard to diabetes-related support, the teens identified parental understanding of the demands of diabetes and parental provision of reassurance about their child's illness and normative functioning. CONCLUSIONS: Adolescents' perceptions of parental worry, lack of understanding, and resulting intrusive and blaming behaviors are major areas of conflict that need to be addressed in the management of type 1 diabetes.

Living with hypoglycemia.

OBJECTIVE: To increase understanding of the everyday experiences of hypoglycemia for patients with type 1 diabetes through the use of a narrative research approach. SETTING: Center for diabetes treatment and research. DESIGN: Cross-sectional assessment using a narrative research approach. PATIENTS/PARTICIPANTS: Twenty outpatients (aged 21-30 years) diagnosed with type 1 diabetes for at least 10 years. MEASUREMENTS AND MAIN RESULTS: Experiences of hypoglycemia were investigated during in-depth, semistructured interviews that were tape-recorded, transcribed, and analyzed to identify common themes. Self-report measures of depression (Revised Hamilton Rating Scale for Depression) and anxiety (State-Trait Anxiety Inventory) also were administered. Subjects reported the following common themes: interpersonal conflict including fears of dependency and loss of control and problems addressing concerns about hypoglycemia with significant others; difficulty making sense of their hypoglycemic behaviors in relation to their usual ways of functioning; and perceived lack of understanding by others, including physicians, about the emotional experiences of hypoglycemia. Subjects were neither clinically depressed nor anxious. CONCLUSIONS: These findings suggest that type 1 diabetes patients' experiences of hypoglycemia negatively affect their interpersonal relationships and views of themselves. Hypoglycemia also was described as an extremely private experience that was rarely discussed with others. Patient education and professional support in the treatment of hypoglycemia are recommended to enhance treatment decision making for patients with type 1 diabetes.

Short-term course of depressive symptoms in patients with eating disorders.

After inpatient treatment focused on aberrant eating behavior, six depressed normal-weight bulimic patients showed little improvement in depressive or eating symptoms. Four depressed anorexic patients with bulimic behavior improved in both areas, and five restricting anorexic patients had an intermediate response.

A follow-up study of thirty hospitalized bulimics.

Thirty normal-weight female bulimics were followed up 2-5 years following hospital admission using semistructured interviews and psychometric measures. Inasmuch as bulimia was only recently designated a distinct disorder, questions have emerged with regard to its clinical course and diagnostic validity. Results of this investigation suggest that bulimia displays a chronic but tractable course in that the majority of the patients continued to report bulimic behaviors at follow-up but the symptom intensity was greatly reduced from admission. The characterization of three bulimic outcome groups suggests that the outcome pattern of this disorder is heterogeneous, with some patients becoming symptom-free and others remaining severely afflicted. The durability of the symptoms and the failure of new psychiatric syndromes to emerge in the follow-up period is evidence that bulimia is a distinct diagnostic entity and not a variant of another underlying condition. The methodologic limitations of this study are addressed.

Depression in bulimia at 2- to 5-year followup.

Previous research has indicated a strong association between bulimia and affective disorder at the time of initial clinical assessment. To investigate this relationship from a long-term perspective, 30 normal weight female bulimics were evaluated 2 to 5 years posthospital admission with psychometric measures and clinical interviews. Contrary to previous reports, the depression scores of the bulimics were surprisingly low, even though 26 of the 30 continued to fulfill DSM-III criteria for bulimia. Higher depression scores were associated with more intense bulimic symptomatology and attitudes, and greater psychiatric disturbance at followup. Although these data demonstrate a relationship between bulimic symptomatology and depression at long-term followup, they do not support recent assertions that bulimia is a variant of an underlying affective disorder.