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Psychosocial care in diabetes

Introduction

Effective management of diabetes requires constant effort from the patient. There is a growing recognition of the impact of psychosocial factors on the ability of patients to sustain this effort. Strong connections and effective communication with family members, physicians and other healthcare professionals, friends and peers and other people with diabetes are known to improve outcomes. A variety of interventions aiming to improve psychosocial factors affecting diabetes management and targeting patients, family members and healthcare providers have been trialled, with varying outcomes. However, this is a new area of research, which is hampered by the lack of consistency in methodology. Development of medical and communication technologies is expected to support further development of this field.

This themed collection comprises a selection of recent full-text articles and chapters from the Springer Nature portfolio, as well as links to selected articles sourced from other prominent publishers, that discuss this important subject. 

Contents

  1. Editorial
  2. Overview
  3. Adherence
  4. Diabetes distress and psychological comorbidities
  5. Disordered eating
  6. Quality of life
  7. Pyschosocial interventions
  8. Self management strategies
  9. Supplementary resource

Instructions

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Editorial

The central role of psychosocial care in diabetes management

Dr Jen Nash, a Clinical Psychologist who has been living with type 1 diabetes for 30 years, reflects on her psychological struggles with managing her condition and introduces this themed collection.


Overview

Psychosocial care for people with diabetes: A position statement of the American Diabetes Association

This article presents evidence-based guidelines for psychosocial assessment and care of people with diabetes.

Summary points
  • Psychosocial care should be integrated with medical care in order to optimize health outcomes and improve quality of life in people with diabetes.
  • People with diabetes should receive training in diabetes self-care skills and the use of technologies until they attain competence, and the diabetes care team should directly and regularly assess these behaviors.
  • Routine monitoring of people with diabetes for diabetes distress is recommended, particularly when treatment targets are not met and/or at the onset of diabetes complications.
  • Routine screening for depressive symptoms is indicated in this high-risk population. In addition, patients should be screened for anxiety if they exhibit worries that interfere with self-management behaviors, or if they express fear, dread, or irrational thoughts and/or show anxiety symptoms such as avoidance behaviours, excessive repetitive behaviours or social withdrawal. If necessary, such patients should be referred for treatment to a mental health specialist.
  • Screening for disordered or disrupted eating when hyperglycemia and weight loss are unexplained by self-reported behaviors is recommended.
  • In youth and emerging adults with diabetes, monitoring of social adjustment and assessment for generic and diabetes-related distress is recommended. 
  • In adults with diabetes, a discussion of life choices that could be affected by diabetes self-management, such as pregnancy and sexual functioning, should be conducted; high-quality relationships with intimate partners who are able to provide diabetes management support improve diabetes-specific and general quality of life, self-management behaviors and metabolic outcomes.
  • Older adults with diabetes are at an increased risk of all types of dementia; screening for mild cognitive impairment or dementia on an annual basis is indicated in this population.
  • People presenting for bariatric surgery should receive a comprehensive mental health assessment and, if psychopathology is evident, postponement of the procedure should be considered.
  • Physicians should take into consideration the lifestyle and emotional status of the individual with diabetes to ensure successful disease management.

Young-Hyman D et al. Diabetes Care. 2016; 39: 2126–2140. doi: 10.2337/dc16-2053

The ADA psychosocial statement: A UK perspective

Katharine Barnard

Medicine Matters diabetes advisory board member Katharine Barnard gives a UK perspective on the ADA's psychosocial position statement (3:11).


Adherence

Type 2 diabetes patients’ and providers’ differing perspectives on medication nonadherence: A qualitative meta-synthesis

This qualitative meta-synthesis examines the differences between patient and provider understandings of barriers to medication adherence for type 2 diabetes patients and highlights key discrepancies.

Summary points
  • Non-adherence to medication regimens results in increased morbidity and mortality, reduced quality of life and higher healthcare costs.
  • Studies on the topic of barriers to medication adherence conducted in Canada, the USA, Europe, Australia and New Zealand in patients with type 2 diabetes and published from the 1st of January 2002 to the 10th of August 2013 were identified.
  • This analysis included 86 studies that involved 2797 patients with type 2 diabetes, 40 caregivers and 356 clinicians.
  • Seven categories of barriers and facilitators were identified: Emotional experiences as positive and negative motivators to adherence; intentional non-compliance; patient-provider relationship and communication; information and knowledge; medication administration; social and cultural beliefs; financial issues.
  • Positive emotions and social support can improve the ability to follow through with self-care. Negative emotions can raise adherence if patients become motivated by fear of symptoms returning, early death or potential complications, or they can lower adherence if patients become trapped in a “vicious circle of low motivation.” 
  • Most commonly, intentional non-compliance is motivated by the desire to avoid adverse effects, but can also result from the denial or incorrect beliefs about diabetes and medication. Healthcare providers attribute this behavior to cultural and financial motives, depression or poor cognitive ability, however, they fail to recognize avoiding adverse effects as a reason.
  • In the area of patient-provider relationship and communication, patients identify health care professionals’ support, collaboration and effective communication strategies as facilitators of adherence; while adherence is impeded by impractical or burdensome recommendations, perceived lack of support, cultural insensitivity and barriers to access. Providers recognize that a collaborative model of care has a positive impact; factors that can have a negative impact include poorly devised treatment regimens and incorrect assumptions about patient knowledge and understanding, among others. 
  • Administration requirements can constitute a barrier to adherence for patients due to fears associated with injectable medications or for those on complex treatment regimens. Providers recognize administration requirements as a barrier to adherence in patients with physical or cognitive impairments, comorbid conditions or those with fears related to treatments.
  • Patients’ social and cultural health beliefs may affect medication adherence, as well as their relationships with physicians. Providers identify aversion to insulin, fatalistic attitudes, the perception that fat is healthier and a desire to please the physician as health beliefs that can negatively impact adherence.
  • Patients identify various medical costs as barriers to adherence. Providers understand the financial barriers that patients may face, but commonly do not identify this issue as a barrier to adherence.
  • In general, healthcare providers tend to focus on clinical issues, while patients describe a much wider range of problems with medication adherence, including personal, social and practical challenges.

Brundisini F et al. BMC Health Serv Res 2015; 15: 516. doi: 10.1186/s12913-015-1174-8

Good cop, bad cop: Quality of parental involvement in type 1 diabetes management in youth

This review synthesizes the recent research on the effects of the involvement of caregivers (mostly mothers and fathers) in the disease management of youths with type 1 diabetes, with a focus on biopsychosocial outcomes.

Summary points
  • Parental involvement in diabetes management tasks can have different effects depending on the nature of intervention, whether it is the mother or the father who is involved and its appropriateness for the child’s age and level of maturity.
  • An indirect association has been demonstrated between general parental monitoring and diabetes outcomes through lower levels of externalizing behaviors, while a direct association with glycemic control through restriction of adolescents’ behavior has also been shown.
    • Diabetes-specific monitoring has been shown to directly correlate with better diabetes self-care, less family conflict and lower HbA1c levels.
  • A collaborative approach between caregivers and youths to diabetes management supports the development of youths and enhances their ability to self-manage, resulting in better outcomes.
  • Low-quality parental involvement is characterized by controlling, critical and restrictive behaviors; it is associated with lower adherence and suboptimal glycemic control, as well as lower health-related quality of life and greater family conflict.
  • Single parenthood and minority race/ethnicity are associated with poorer outcomes in youths with type 1 diabetes.
  • The relationship between parental involvement and distress is complex and bidirectional; promoting a balance of responsibility between both parents (in two-parent households) and/or other family members may help reduce parental distress.
  • The child’s behavior may affect the type, amount and quality of involvement.
  • Authors conclude that in the recent literature on the subject of parental involvement in diabetes management, a shift in focus has occurred from the amount of involvement to the type and quality.
  • To improve the quality of parental involvement in diabetes management of children with type 1 diabetes, the authors recommend gradually shifting responsibility to children in accordance with contextual factors and work collaboratively in order to achieve best outcomes.

Young MT et al. Curr Diab Rep 2014; 14: 546. doi: 10.1007/s11892-014-0546-5

A review of adolescent adherence in type 1 diabetes and the untapped potential of diabetes providers to improve outcomes

This review article includes discussions of barriers to adherence in adolescents with type 1 diabetes, interventions aiming to improve adherence, the role of providers and provides suggestions on future areas of research.

Summary points
  • Across the lifetime of a patient with type 1 diabetes, adolescence is characterized by the worst glycemic control and, therefore, represents a critical opportunity to avoid multiorgan complications later in life.
  • Adherence can be defined as “the degree to which patients follow the recommendations of their health professionals.”
  • In adolescents with type 1 diabetes, barriers to adherence can be psychosocial (family and parental care, peer support, presence of mood, anxiety and eating disorders), institutional (poor communication with healthcare providers, cost of treatment) or they can be associated with complex and burdensome treatment regimens.
  • A number of interventions aiming to improve adherence have been proposed in the recent literature, including motivational interviewing and text message-based approaches, approaches targeting diabetes adherence behaviors in the presence of peers and addressing health care utilization costs; the effectiveness of these approaches varies.
  • The role of healthcare providers in improving adherence has received relatively little attention; providers can improve adherence in several ways, such as by scheduling regular follow-up visits and improving communication between physicians, patients and caregivers.
  • The authors describe a number of suggestions for future research that include using consistent terminology to define adherence, a greater focus on the role of healthcare providers and investigating specific regimen-associated barriers to adherence.

Datye KA et al. Curr Diab Rep 2015; 15: 51. doi: 10.1007/s11892-015-0621-6


Diabetes distress and psychological comorbidities

Diabetes distress among adolescents with type 1 diabetes: A systematic review

This systematic review investigated the epidemiology of diabetic distress in adolescents with type 1 diabetes and interventions designed to address diabetic distress in this population.

Summary points
  • The prevalence and clinical significance of diabetes distress in adolescents with type 1 diabetes is not clear and information is sparse on effective interventions addressing diabetes distress in this patient group.
  • The study aimed to:
    1. Determine the prevalence of diabetes distress among adolescents with type 1 diabetes;
    2. Investigate the demographic, clinical, behavioral and psychosocial correlates of diabetes distress;
    3. Identify interventions targeting diabetes distress and determine common characteristics of successful interventions.
  • A search was performed for cross-sectional, observational or randomized controlled studies in which diabetes distress was assessed among adolescents with type 1 diabetes, and which were published in English after 1994.
  • Overall, 27 articles reporting on 16 studies were included in this review; participants’ ages ranged from 8 to 20 years.
  • With the exception of one study where the mean diabetes distress score was in the moderate range, on average, adolescents reported a low level of diabetes distress.
  • The proportion of patients experiencing severe diabetes distress was reported in three studies and ranged from 33% to 67%.

Hagger V et al. Curr Diab Rep 2016; 16: 9. doi: 10.1007/s11892-015-0694-2

Fear of hypoglycemia in children and adolescents and their parents with type 1 diabetes

This review provides a summary of the recent literature on fear of hypoglycemia in pediatric patients with type 1 diabetes.

Summary points
  • The term “fear of hypoglycemia” was coined to refer to the anxiety-like symptoms in individuals with diabetes or their families, which can manifest as worry about hypoglycemia and engagement in hypoglycemia avoidance behaviors, including overly vigilant blood glucose monitoring, maintaining elevated blood glucose levels by intentionally withholding insulin, and/or the premature or overtreatment of hypoglycemic events.
  • The prevalence of severe hypoglycemia, which is defined by seizure/loss of consciousness, in pediatric patients with type1 diabetes ranges from 5 to 12%.
  • Several questionnaires have been developed to assess fear of hypoglycemia in patients with type 1 diabetes, including hypoglycemia fear survey (HFS), HFS-II (both were developed for adults), HFS for parents (HFS-P), HFS for parents of young children (HFS-PYC), children’s hypoglycemia fear survey (HFS-C; a modification of HFS for 6 to 18 year-olds) and children’s hypoglycemia index (CHI).
  • Most studies fail to find a relationship between fear of hypoglycemia and glycemic control; the reasons for this are unclear.
  • All interventions addressing fear of hypoglycemia, such as cognitive behavioral therapy (individual or group), medical interventions and psychoeducation, have been designed for adults; however, these techniques can be used with children and adolescents with type 1 diabetes.
  • Several emerging technologies have the potential to reduce fear of hypoglycemia, including artificial pancreas, automated bolus calculators and continuous glucose monitoring.

Driscoll KA et al. Curr Diab Rep 2016; 16: 77. doi: 10.1007/s11892-016-0762-2


Disordered eating

Eating disorders in girls and women with type 1 diabetes: A longitudinal study of prevalence, onset, remission, and recurrence

This study describes the longitudinal course of disturbed eating behavior and eating disorders in a cohort of females with type 1 diabetes over 14 years.

Summary points
  • Teenage girls and women with type 1 diabetes are at significantly increased risk of disturbed eating behaviors, such as dieting, fasting, binge-eating and a range of other compensatory and purging behaviors, compared with their non-diabetic peers; disturbed eating behaviors can interfere with diabetes management.
  • Deliberately under-dosing or omitting insulin to induce hyperglycemia and loss of glucose in the urine to control weight is a purging behavior unique to individuals with type 1 diabetes; it is one of the mechanisms underlying the association between disturbed eating behavior and eating disorders and poor metabolic control.
  • A total of 126 girls with type 1 diabetes (disease duration of >6 months) aged 9 to 13 years (mean age: 11.8±1.5 years) were recruited at the Diabetes Clinic at The Hospital for Sick Children in Toronto between 1998 and 2001 and followed for 14 years.
  • Assessments were performed at baseline (time 1) and 1 (time 2), 2 (time 3), 3 (time 4), 5 (time 5), 8–10 (time 6) and 10–14 (time 7) years after time 1; at times 1–4, the children’s eating disorder examination (cEDE) was used, and at times 5–7, the eating disorder examination (EDE) was used.
  • At time 6 (age range: 17.3–23.2 years), 19.8% (16/81) suffered from a full-syndrome or sub-threshold eating disorder.
  • At time 7 (age range: 19.2–27.8 years), disturbed eating behavior was reported by 59.2% (42/71) of participants.
  • At time 6, HbA1c was significantly higher among women with a current eating disorder than in those without (10.06±1.5% [86±14 mmol/mol] vs 8.7±1.6% [72 ± 15 mmol/mol]; t=2.2, df=52, P=0.04, d=0.83).
  • At time 7, a trend towards higher HbA1c among those with an eating disorder compared with those without (9.0 ± 1.8% [75±17 mmol/mol] vs 8.2±1.3% [66±12 mmol/mol]; t=1.9, df=51, P=0.07, d=0.51).
  • Estimates of the cumulative probability of disturbed eating behavior onset remained reliable up to age 23 years; 79% experienced onset of disturbed eating behavior by this point.
  • Estimates of the cumulative probability of eating disorder onset remained reliable up to age 25 years; 60% experienced onset of an eating disorder by this point.
  • Both disturbed eating behavior and eating disorders tended to be persistent, with a mean time from observed onset to detected remission of 6.0 and 4.3 years, respectively, and significant estimated risk of recurrence.
  • Disordered eating is a common and serious concern among girls and young women with type 1 diabetes.

Colton PA et al. Diabetes Care 2015; 38: 1212. doi: 10.2337/dc14-2646

Treatment outcome of patients with comorbid type 1 diabetes and eating disorders

This study compared treatment outcomes, dropouts, eating disorder psychopathology and personality characteristics in individuals with eating disorders with comorbid type 1 diabetes and those without.

Summary points
  • Overall, 40 adult female patients diagnosed with eating disorders according to the DSM-IV were recruited at the Eating Disorder Unit of the Bellvitge Hospital (Barcelona, Spain) between April 1999 and June 2012, 20 with comorbid type 1 diabetes (disease duration >6 months; mean age: 25.3 years) and 20 controls (mean age: 28.0 years) matched for socio-demographic variables.
  • Patients received the following treatments:
    • 16 sessions of cognitive-behavioral therapy for those with bulimia nervosa, binge eating disorder and eating disorder not otherwise specified;
    • 3 months daytime hospitalization for anorexia nervosa patients.
  • Assessments included semi-structured interviews conducted by experienced psychologists and psychiatrists, a battery of psychological questionnaires, including the Temperament and Character Inventory–revised (TCI-R) and the Eating Disorders Inventory-2 (EDI-2) and a visual analogue scale to assess the motivational stage of change.
    • In patients with type 1 diabetes, HbA1c measured nearest to the interview was used as an indicator of glycemic control.
  • Age of onset of eating disorder was 19.5 years (SD=7.4) for patients with type 1 diabetes and 19.4 (SD=7.5) for controls.
  • The majority (90%, n=18) of patients with type 1 diabetes acknowledged skipping or reducing insulin doses to control weight.
  • Patients with type 1 diabetes were significantly less likely than controls to self-harm (p<0.012; d:1.03), have suicidal ideation (p<0.030; d:0.80) and suicidal behavior (p <0.039; d:0.79).
  • Patients with type 1 diabetes scored significantly lower on motivation to change and level of consciousness about their eating disorder, and had significantly lower persistence compared with controls.
  • Three quarters of patients in the control group (n=15) showed partial or full remission compared with 50% (n=10) of those with type 1 diabetes.
  • The number of dropouts was higher among patients with type 1 diabetes compared with controls and they stopped treatment significantly earlier (χ2=4.50, df=1, p=0.034).
  • Low levels of motivation to change and insulin abuse in patients with type 1 diabetes and eating disorders may suggest that in devising a treatment strategy aimed at this population, clinicians should consider the individual’s personality and role of insulin abuse in determining the appropriate intervention.

Custal N et al. BMC Psychiatry 2014; 14: 140. doi: 10.1186/1471-244X-14-140


Quality of life

Physical activity in youth with type 1 diabetes: A review

This review article covers the recent literature on physical activity in children with type 1 diabetes with particular focus on young children, discusses the limitations of the current body of research and provides recommendations for objectively measured physical activity.

Summary points
  • Objective measures of physical activity are expensive and labor-intensive both to collect and to analyze, but subjective self- or parental report of child/adolescent physical activity may not be very reliable.
  • The American Academy of Pediatrics (AAP) recommends that all youth engage in 60–90 minutes of physical activity daily.
  • In healthy children, physical activity provides small but significant benefits in reducing depression, anxiety, psychological distress and emotional disturbance. Such activity may be particularly important for youths with type 1 diabetes, as this population is at an increased risk of depression and the association between depressive symptoms, poor glycemic control and diabetes-related health outcomes.
  • In a cross-sectional pilot study of young children with type 1 diabetes (n=10; age range; 3–7 years), those who engaged in moderate physical activity throughout the day trended to spend less time in blood glucose excursions than children who concentrated their physical activity at only one time of day.
  • Studies focusing on the physical activity of young children with type 1 diabetes are rare, with only six included in this review; three studies found no difference in glycemic control between the physical activity intervention group and controls, while in one other study, a 30-minute vigorous exercise program three times a week for 12 weeks improved their glycemic control and aerobic capacity.
  • Facilitators of physical activity in young children include preference for activity, positive modeling, environmental access to activities and social connectedness.
  • Barriers to physical activity include: safety concerns related to sun exposure and neighborhood, parental fear of hypoglycemia, time and financial constraints and family values prioritizing different activities such as education.
  • A review of relevant literature indicates that physical activity benefits physical health among youths with type 1 diabetes.
  • Healthcare providers should focus on promoting physical activity engagement in youths with type 1 diabetes.

Tully C et al. Curr Diab Rep 2016; 16: 85. doi: 10.1007/s11892-016-0779-6

The complex interplay between clinical and person-centered diabetes outcomes in the two genders

This secondary analysis of the data collected during the BENCH-D study (Benchmarking Network for Clinical and Humanistic Outcomes in Diabetes) assessed gender differences in diabetes-related distress, physical and psychological well-being, empowerment, perceived social support and other measures of satisfaction with treatment and care in people with type 2 diabetes.

Summary points
  • Data from the Annals of Associazione Medici Diabetologi has been used to suggest that, compared with men, the likelihood of reaching positive clinical outcomes is systematically lower for women with type 2 diabetes, especially in metabolic control (i.e. HbA1c > =8.0%).
  • A random sample of 2,335 patients with type 2 diabetes (men: 59.7%; women: 40.3%) was selected by from 26 diabetes outpatient clinics in Italy between January 2010 and July 2011.
  • Clinical data, including HbA1c, lipid profile, blood pressure and BMI, were extracted from electronic databases of these clinics; information on socio-demographic characteristics, quality of life, satisfaction and self-care behaviors and attitudes was collected using an ad hoc self-administered questionnaire that included 10 validated instruments.
  • Smaller proportions of women reached HbA1c levels of ≤7.0% (23.2% vs 27.8%; p=0.03), LDL-cholesterol <100 mg/dl (48.3 vs 57.8%; p=0.0005) and BMI <27 Kg/m2 (27.2 vs 31.6%; p=0.04) than men.
  • Compared with men, women scored significantly lower on:
    • Physical functioning;
    • Psychological well-being;
    • Self-care activities dedicated to physical activities;
    • Empowerment;
    • Diabetes-related distress;
    • Satisfaction with treatment;
    • Barriers to medication taking;
    • Satisfaction with access to chronic care and healthcare communication;
    • Perceived social support.
  • Moreover, 24.8% of women and 8.8% of men had WHO-5 score of ≤28 (likely depression) (p<0.0001), and 67.7% of women and 55.1% of men had PAID-5 score of > 40 (high levels of diabetes-related distress) (p<0.0001).
  • Multivariate analysis showed that the factors associated with an increased likelihood of having elevated HbA1c levels (≥8.0%) were different in men and women:
    • In men but not in women, the likelihood of having HbA1c ≥ 8.0% decreased as age increased (−3% for each additional 5 years) and was associated with the level of school education;
    • In women but not in men, high levels of diabetes related distress were associated with a higher likelihood of poor metabolic control.
  • Women with type 2 diabetes achieve poorer clinical and psychosocial outcomes than men.
  • Diabetes-related distress plays a role as a correlate of metabolic control in women but not in men.

Rossi MC et al. Health Qual Life Outcomes 2017; 15: 41. doi: 10.1186/s12955-017-0613-0


Psychosocial interventions

Diabetes and behavioral learning principles: Often neglected yet well-known and empirically validated means of optimizing diabetes care behavior

This review article discusses the basic behavioral principles and common barriers to implementation, relevant interventions and presents several examples of applications in clinical settings.

Summary points
  • The authors propose that behavioural learning principles are the key to the vast majority of empirically supported interventions that have demonstrated effectiveness in improving adherence and other aspects of diabetes care.
  • Operant conditioning focuses on the ability of reinforcement and punishment to shape human behavior.
    • Positive reinforcement increases the likelihood of a behavior occurring by adding something to the environment that the individual finds rewarding.
    • Negative reinforcement increases the likelihood of a behavior by removing an adverse stimulus from the environment.
    • Punishment decreases the frequency of a behavior by either adding something undesirable to the environment or removing something rewarding.
  • Often, a discrepancy exists between patients’ knowledge of desired healthcare and consistently engaging in the behavior necessary to accomplish the healthcare tasks; clinical efforts are often directed at increasing knowledge and ignore the behavioral aspect.
  • Examples of behavioral interventions include reinforcement, self-monitoring, contracting and environmental change; existing literature suggests that approaches founded in behavioral learning principles are associated with positive patient and family outcomes.
  • Diabetes burnout occurs “when an individual with diabetes has the information (education) necessary to manage diabetes well, yet his or her psychological and emotional state(s) have become barriers to adequately engaging in the behavior necessary to effectively manage diabetes.”
  • Positive patient/provider interactions and satisfaction with medical care are critical for effective diabetes management.
  • Shaping of the clinical culture in such a way that it values quality engagement in the provision of healthcare may can help to reduce the likelihood of physician burnout.
  • The authors offer the following recommendations:
    • View regular patient interactions as opportunities for the purposeful application of learning principles, specifically positive reinforcement;
    • Emphasize health behaviors, not outcomes;
    • Take the punishment out of diabetes care;
    • Educate the patient and family about behavioral principles;
    • Encourage the continued integration of behavioral health interventions into standard diabetes care delivery.

Stoeckel M, Duke D. Curr Diab Rep 2015; 15: 39. doi: 10.1007/s11892-015-0615-4

Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions

This study evaluated the Brief Behavioural Activation intervention in patients with chronic conditions and recurrent depression.

Summary points
  • Practice nurses in primary care facilities are in a position to contribute to the management of patients with chronic conditions and recurrent depression.
  • A service development project with a nested qualitative study was conducted to:
    • Train practice nurses to deliver a brief behavioral activation intervention to patients with depression and one or more long-term health conditions;
    • Evaluate the patients and clinicians perspectives and experiences of receiving and delivering the intervention.
  • Healthcare professionals (n=10; nurses, general practitioners and a mental health gateway worker) and patients (n=4) were recruited from eight practices in one Primary Care Trust in England.
  • Semi-structured qualitative interviews were conducted and four Normalisation Process Theory concepts of coherence, cognitive participation, collective action and reflexive monitoring were used to explore how this intervention could be implemented in practice.
  • Both general practitioners and practice nurses found the intervention acceptable in terms of its simplicity and its workability in the long-term management of patients with chronic conditions and recurrent depression.
  • Patients believed that the fact that practice nurses were available to listen was valuable.
  • The greatest barriers to the implementation of the Brief Behavioural Activation intervention in routine primary care were:
    • Competing practice priorities;
    • Perceived lack of time and resources;
    • Lack of engagement by the whole practice team.
  • Lack of understanding of, participation in and support from the whole practice team in the collaborative care model exacerbated the pressures perceived by practice nurses.

Webster LAD et al. BMC Nurs 2016; 15: 71. doi: 10.1186/s12912-016-0190-2

The psychosocial challenges and care of older adults with diabetes: “Can’t do what I used to do; can’t be who I once was”

This review discusses the current literature on diabetes in older adults, with a focus on psychological and medical challenges and interventions needed to address them.

Summary points
  • Older adults with diabetes have higher rates of diabetes-related complications and are more likely to present with comorbid conditions, which are associated with worsening glycemic control and may interfere with the performance of self-care behaviors.
  • Older adults with diabetes experience disproportionately high rates of depression (14–28%) and depressive symptoms.
  • Diabetes distress affects 18–35% of older adults and is associated with worsening glycemic control, reduced self-care and increased morbidity; however, only a few validated treatments are available.
  • Many people with diabetes and depression also have comorbid anxiety disorders; anxiety disorders and elevated anxiety symptoms have been shown to be associated with increased diabetes complications, worsened blood glucose levels, reduced quality of life, increased depression, increased body mass index and greater disability.
  • In older adults with diabetes, quality of life is negatively affected by comorbidity and hypoglycemia; more research into this area is required.
  • Older people experience major life challenges whose impact may be exacerbated by diabetes; interventions that include family members and friends can be effective in addressing these challenges.
  • The majority of adults over 65 who have diabetes have at least one comorbid condition; the presence of comorbid conditions often presents challenges in the management of diabetes.
  • Type 1 and type 2 diabetes and increased age are independent risk factors for cognitive impairment. Older adults with severe hypoglycemia are at greater risk for cognitive impairment; regular screening is recommended.
  • Older adults are more vulnerable to hypoglycemia due to diminished counter-regulatory responses and changes in pharmacokinetics and pharmacodynamics; early recognition and treatment of hypoglycemic symptoms, as well as education of patients and family members can help reduce the impact of hypoglycemia in this population.
  • Polypharmacy is particularly dangerous in older adults with diabetes due to age-related physiological changes than have an effect on pharmacokinetic and pharamcodynamic parameters.
  • Providers should recognize the interdependency of medical, social and mental health issues in the treatment of older patients with diabetes.

Beverly EA et al. Curr Diab Rep 2016; 16: 48. doi:10.1007/s11892-016-0741-7


Self management strategies

Social support for diabetes self-management via eHealth interventions

This review discusses the applications of eHealth technologies in providing social support to adult patients with type 2 diabetes.

Summary points
  • eHealth technologies can be defined as health information or services delivered through the Internet or related technologies, and include phone, text, telehealth, web-based and virtual technologies.
  • Phone-based support interventions described in the reviewed literature included video conferences with nurses, consultations about lab values and telehealth monitoring of various clinical parameters.
  • Web-based support interventions used discussion boards, email, text, online chats, voice communication and web-conferencing to monitor patient data, provide feedback and communicate with peers.
  • Many eHealth interventions used a combination of technologies to deliver support.
  • The majority of eHealth interventions employed healthcare professionals to provide support (most commonly advanced practice nurses), while others also recruited people with type 2 diabetes.
  • While most studies were able to demonstrate short-term improvements in glycemic control and, sometimes, other biomarkers, long-term effectiveness varied; in studies that compared different interventions, generally, their effects on glycemic control were not significantly different.
  • Many eHealth interventions, most commonly phone-based interventions, were successful in improving behavioral outcomes, such as medication adherence, glucose monitoring, foot care, exercise, healthy eating, healthy coping and problem solving.
  • Psychosocial outcomes, such as diabetes distress, depression and quality of life, were commonly improved with the use of eHealth interventions.
  • The frequency and duration of eHealth interventions varied widely; the frequency of contact generally declined over time, as did patient participation.
  • Studies describing eHealth interventions often fail to clearly document the impact on social support.

Vorderstrasse A et al. Curr Diab Rep 2016; 16: 56. doi: 10.1007/s11892-016-0756-0

When does personalized feedback make a difference? A narrative review of recent findings and their implications for promoting better diabetes self-care

This review examined the recent literature on the effectiveness of feedback in eight health-related areas, including those specific to diabetes care, as well as others which were more general, in order to identify how personalized health-related feedback is most effectively designed and delivered.

Summary points
  • Personalized health-related feedback is defined as the provision of personal information that has been derived from some type of assessment procedure to prompt or maintain positive behavioral change.
  • Health-related feedback often has beneficial effects on patient behavior and clinical outcomes, but feedback is sometimes no better than no feedback and may occasionally be harmful.
  • Although provision of health-related feedback is typically considered a single, uniform type of intervention, it varies dramatically in form, duration, frequency and content from one study to another.
  • Authors identified five factors that influence the impact of health-related feedback:
    • Clarity;
    • Personal meaningfulness;
    • Frequency;
    • Guidance and support;
    • Patient interpretation.
  • Clarity of health-related feedback can be improved by providing a good summary of complex data and by making it relatable by providing real-world comparators.
  • Personal meaningfulness of health-related feedback can be improved by comparing the recipient’s data to a relevant peer group, demonstrating the connection between health outcomes and targeted behavior, describing the ways feedback can be applied and by providing it promptly.
  • Generally, frequent feedback is more effective, however, the frequency of feedback should be appropriate to the message and the characteristics of the behavior/biomarker for which the feedback is given.
  • Better outcomes tend to be achieved:
    • When the patient is guided to interpret feedback as encouraging rather than discouraging, in the absence of blaming and shaming;
    • In an atmosphere of trust and collaboration and when there is collaborative decision-making regarding how best to respond to the presented results.
  • In order to make sure that the patient interprets the feedback correctly, the following factors should be considered: affective state, health beliefs, interest or readiness to receive feedback and demographics.
  • The authors identify several common limitations in the literature on health-related feedback examined in this review:
    • Dearth of studies that evaluate the effect of repeated episodes of feedback over time;
    • Common use of a “one-size-fits-all” approach to the delivery of feedback;
    • Lack of comprehensiveness and perspective when considering the frequent inconsistent or contradictory findings across studies.

Polonsky WH, Fisher L. Curr Diab Rep 2015; 15: 50. doi: 10.1007/s11892-015-0620-7

Self-management and self-management support outcomes: A systematic review and mixed research synthesis of stakeholder views

This systematic review discusses published empirical evidence to determine the outcomes of self-management valued by key stakeholder groups (patients, their families, health professionals and those who commission self-management services) in one of three conditions: colorectal cancer, diabetes and stroke.

Summary points
  • A variety of approaches aiming to improve self-management in people with chronic conditions have been trialled, including those led by laypersons or professionals, generic or disease specific, delivered in group or individual setting and most often based on Social Cognition Theory.
  • Research tools that measure the impact of self-management interventions most frequently focus upon self-efficacy, health status, mood and quality of life, however, more than 70 different variables used to evaluate self-management programs have been identified.
  • A systematic search of Allied and Complimentary Medicine database (AMED), British Nursing Index (BNI), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Medline, Psychinfo and Web of science electronic databases was conducted in order to find empirical studies of self-management interventions in adult patients with diabetes, stroke or colorectal cancer published in English between 1995 and June 2014
  • In total, 41 studies (individual interviews, n=18, 45%; focus groups, n=10, 25%; quasi-experimental and survey, both n=4, 10%) met the search criteria and were analyzed using the method of mixed research synthesis and NVivo 10 software.
  • Gaining applicable knowledge was an important self-management outcome for health professionals involved in the treatment of diabetes, who valued knowledge that was focused around the diabetes disease process and prevention of deterioration.
  • Patients with all three conditions valued independence, usually understood as having control over and responsibility for managing the condition.
  • From the patients’ perspective, a positive social network is an important factor enabling successful self-management. The perspectives of health professionals and families were not presented in the reviewed literature.
  • People with diabetes expressed a strong desire to ‘‘be normal,” which was frequently challenged by the burden of managing blood glucose levels.
  • Health professionals involved in diabetes management felt that patient motivation was a key requisite of successful self-management. Across all conditions, patients identified the need to develop skills in managing emotions and stress in order to maintain health and well-being.
  • The findings of this review indicate that while there was a general consensus on outcomes, different stakeholders often interpreted the same outcomes in different ways and valued different aspects of the same outcomes.

Boger E et al. PLoS ONE 2015; 10: e0130990. doi: 10.1371/journal.pone.0130990


Supplementary resource

Diabetes and Mood Information Prescription

Developed by Diabetes UK, the Diabetes and Mood Information Prescription is a tool that gives people with diabetes the information they need to understand and improve their diabetes management and emotional wellbeing by setting goals and talking about how they feel. Healthcare professionals can easily incorporate this tool into routine care, enabling them to have this conversation in a more structured approach. The link above takes you to the Information Prescription on the Diabetes UK website (external link).

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