Psychological determinants and self care in patients with type 1 diabetes

Diabetes is characterized by a number of metabolic disturbances. Self-management, that aims at normalizing these disturbances, constitutes the backbone of diabetes treatment. A number of factors may affect how patients take care of themselves. Knowledge of the current treatment guidelines is not sufficient alone, but must be translated into compliance. Also various psychological determinants, such as depression, may affect how patients take care of themselves. Sense of coherence (SOC), which refers to the extent to which individuals are able to use various resources to sustain and improve health, offers another kind of an approach to the issue of diabetes management. The aim of this thesis was to investigate the adherence with dietary recommendations in patients with type 1 diabetes, and to study the association between self-reported and measured compliance with recommendations. We also investigated the relevance of the SOC in diabetes self care, patients per-ceptions of their disease, and microvascular complications. Moreover the associations between depression and the metabolic syndrome and mortality were evaluated. The thesis is part of the Finnish Diabetic Nephropathy (FinnDiane) study. Compliance with dietary guidelines was highest for the intake of protein, alcohol, and sucrose. A substantial proportion of the participants consumed less carbohydrates, and fibre than recommended. Sodium chloride and saturated fatty acid intakes frequently exceeded the recommendations. Of the micronutrients, the recommendations for vitamin D, folate and iron were most frequently unmet. Self-reported compliance with dietary recommendations was reflected in more frequently meeting the recommendations for carbohydrates, total fat, saturated fatty acids, and alcohol intakes. Despite this, the observed frequencies of meeting the actual guidelines among these patients were, for many nutrients, only modest (e.g., 55% for carbohydrates and 35% for saturated fatty acids). In women, higher SOC score (indicating stronger SOC) was associated with more prudent food choices. In men, the SOC scores were positively associated with higher level of physical activity. Weak SOC was associated with higher HbA1c levels among women. In men, weak SOC was associated with the presence of diabetic nephropathy. Four factors were formed from the diabetes questionnaire (conceptions of HbA1c, complications, diabetes control, and hypoglycaemia). Higher factor scores describing less favourable self-reports were observed for conceptions of HbA1c and hypoglycaemia among those with weak SOC. Moreover, in men, weak SOC was associated with the complications factor. In women, the metabolic syndrome was a more frequent observation among those with symptoms of depression. Of the individual components of the metabolic syndrome, the BDI score was associated with the waist and triglyceride components in women. Purchases of antidepressant agents reduced the 10-year cumulative survival, mostly so among women with such purchases at around the baseline visit. The purchasers of antidepressant agents died mostly of chronic diabetic complications, while the predominant underlying cause of death among non-purchasers were cardiovascular diseases.Diabetekseen liittyy erilaisia aineenvaihdunnallisia häiriöitä joita pyritään normalisoimaan itsehoidon avulla. Erilaiset tekijät vaikuttavat kuitenkin siihen kuinka hyvin potilaat huolehtivat itsestään. Tieto vallitsevista suosituksista ei riitä, vaan oleellista on myös hoitomyöntyvyys, komplianssi. Myös erilaiset psyykkiset tekijät kuten masennus voi vaikuttaa haitallisesti itsehoitoon. Koherenssin tunne, jolla tarkoitetaan yksilön kykyä käyttää hyväkseen erilaisia voimavaroja terveyden ylläpitämiseksi, tarjoaa lisäksi toisenlaisen lähestymistavan diabeteksen itsehoidon tarkasteluun. Väitöskirjassa tutkittiin kuinka hyvin tyypin 1 diabetesta sairastavat noudattavat ravitsemussuosituksia, sekä selvitettiin itseraportoidun komplianssin yhteyttä suositusten noudattamiseen. Tutkimme myös koherenssin tunteen yhteyttä itsehoitoon, potilaiden mielikuviin sairaudestaan, sekä liitännäissairauksiin. Lisäksi selvitimme masennuksen yhteyttä metabolisen oireyhtymän esiintymiseen ja kuolleisuuteen. Väitöskirja on osa FinnDiane tutkimusta (the Finnish Diabetic Nephropathy study). Suurin osa tutkittavista saavutti proteiinin, alkoholin ja sakkaroosin saantisuositukset. Merkittävä osa tutkittavista sai ravinnosta suosituksia vähemmän hiilihydraatteja ja kuituja. Sen sijaan ruokasuolan ja tyydyttyneiden rasvahappojen saanti ylitti useilla suositukset. Mikroravintoaineista D-vitamiinin, folaatin ja raudan saannit jäivät usein suosituksia alhaisemmiksi. Itseraportoitu komplianssi oli positiivisesti yhteydessä hiilihydraattien, kokonaisrasvan, tyydyttyneiden rasvahappojen, sekä alkoholin saantisuositusten noudattamistiheyteen. Tästä huolimatta havaitut noudattamistiheydet jäivät myös näillä tutkittavilla useiden ravintoaineiden suhteen kuitenkin vain kohtuullisiksi (esim. 55% ja 35% saavutti hiilihydraattien ja tyydyttyneiden rasvahappojen saantisuositukset). Naisilla korkeammat koherenssin tunne -pisteet olivat yhteydessä ravitsemussuositusten noudattamiseen. Miehillä koherenssin tunne -pisteet olivat positiivisesti yhteydessä korkeampaan fyysiseen aktiivisuuteen. Heikko koherenssin tunne oli naisilla yhteydessä korkeampaan HbA1c -tasoon. Miehillä heikko koherenssin tunne oli yhteydessä diabeettiseen munuaistautiin. Diabeteskyselystä muodostui neljä faktoria (HbA1c:hen liittyvät mielikuvat, komplikaatiot, diabeteksen hoito ja hypoglykemia). Heikko koherenssin tunne oli yhteydessä epäsuotuisempiin mielikuviin HbA1c:stä sekä hypoglykemiasta. Lisäksi miehillä heikko koherenssin tunne oli yhteydessä komplikaatio -faktorin kanssa. Naisilla masennus oli yhteydessä metabolisen oireyhtymän esiintymiseen. Yksittäisistä metabolisen oireyhtymän komponenteista masennuspisteet olivat naisilla yhteydessä vyötärönympärys- ja triglyseridikomponentin esiintymiseen. Naisilla masennuslääkkeiden osto ensimmäisen tutkimuskäynnin aikoihin lisäsi kuolleisuutta 10 vuoden seurannan aikana. Masennuslääkkeiden ostajilla krooniset diabetekseen liittyvät komplikaatiot olivat yleisin kuolinsyy, kun taas niillä jotka eivät ostaneet masennuslääkkeitä yleisin kuolinsyy oli sydän- ja verisuonisairaudet

Perceived Stress and Adherence to the Dietary Recommendations and Blood Glucose Levels in Type 1 Diabetes

Stress may negatively impact self-management of diabetes and thereby deteriorate glycaemic control. Eating is the most frequently reported stress-release method. In this study, we investigated the association between perceived stress (PS), dietary adherence, and glycaemic control. Data from participants in the FinnDiane Study with type 1 diabetes who had completed a diet questionnaire and Cohen's perceived stress scale (PSS) were included. In addition to using a continuous PSS score, participants were divided into three groups based on the PSS scores: the first PSS quartile, low levels of PS; second and third quartiles, moderate levels of PS; and fourth quartile, high levels of PS. A diet score reflecting the level of adherence to dietary recommendations was calculated. Analyses were conducted in the whole sample and in subgroups divided by body mass index (BMI = 25 kg/m(2)). In the whole sample, high PS and continuous stress score were negatively associated with the diet score and with adherence to fish, fresh vegetable, low-fat liquid milk product, and vegetable oil-based cooking fat recommendations. The stress score was negatively associated with the diet score both in lean and in those overweight or obese. However, fish and fresh vegetable recommendations were only affected in those with corpulence. PS was not associated with mean blood glucose concentrations in the whole sample. When divided by BMI status, worse glycaemic control was observed in lean subjects reporting stress. In individuals with overweight or obesity, instead, high glucose concentrations were observed regardless of the level of perceived stress. Interventions to improve stress management could improve dietary adherence and glycaemic control and could thereby have the potential to improve long-term health and well-being of individuals with type 1 diabetes.Peer reviewe

Meal timing, meal frequency, and breakfast skipping in adult individuals with type 1 diabetes - associations with glycaemic control

We assessed meal timing, meal frequency, and breakfast consumption habits of adult individuals with type 1 diabetes (n = 1007) taking part in the Finnish Diabetic Nephropathy Study, and studied whether they are associated with glycaemic control. Data on dietary intake and blood glucose measurements were retrieved from food records. HbA(1c) was measured at the study visit. In the whole sample, four peaks of energy intake emerged. Energy intake was the greatest in the evening, followed by midday. Altogether 7% of the participants reported no energy intake between 05:00 and 09:59 (breakfast skippers). While breakfast skippers reported lower number of meals, no difference was observed in the total energy intake between those eating and omitting breakfast. In a multivariable model, skipping breakfast was associated with higher mean blood glucose concentrations and lower odds of good glycaemic control. A median of 6 daily meals was reported. Adjusted for confounders, the number of meals was negatively associated with HbA(1c), and the mean of the blood glucose measurements, but positively associated with the variability of these measurements. Our observations support the habit of a regular meal pattern, including consumption of breakfast and multiple smaller meals for good glycaemic control in adults with type 1 diabetes. However, an increase in the blood glucose variability may additionally be expected with an increase in the number of meals eaten.Peer reviewe

Nut Consumption Is Associated with Lower Risk of Metabolic Syndrome and Its Components in Type 1 Diabetes

Although nut consumption has been associated with several health benefits, it has not been investigated in individuals with type 1 diabetes. Therefore, our aim was to assess nut consumption and its association with metabolic syndrome in adult individuals with type 1 diabetes taking part in the Finnish Diabetic Nephropathy Study. The nut intake of the 1058 participants was assessed from 3-day food records that were completed twice, and the number of weekly servings, assuming a serving size of 28.4 g, was calculated. Metabolic syndrome was defined as the presence of ≥3 of the cardiovascular risk factors: central obesity, high blood pressure (≥130/85 mmHg or use of antihypertensive medication), high triglyceride concentration (≥1.70 mmol/L or use of lipid-lowering medication), low HDL-cholesterol concentration (7.5%) was used as a criterion for suboptimal glycaemic control. Of the 1058 (mean age 46 years, 41.6% men) participants, 689 (54.1%) reported no nut intake. In the remaining sample, the median weekly nut intake was 40.8 g. In the adjusted models, higher nut intake, as the continuous number of weekly servings and the comparison of those wit

The Self-reported Use of Probiotics is Associated with Better Glycaemic Control and Lower Odds of Metabolic Syndrome and its Components in Type 1 Diabetes

Peer reviewe

Dietary patterns reflecting healthy food choices are associated with lower serum LPS activity

Gram-negative bacteria-derived lipopolysaccharides (LPS) are associated with various negative health effects. Whether diet is associated with LPS, is an understudied phenomenon. We investigated the association between diet and serum LPS activity in 668 individuals with type 1 diabetes in the FinnDiane Study. Serum LPS activity was determined using the Limulus Amoebocyte Lysate assay. Diet was assessed with a food frequency questionnaire (FFQ) section of a diet questionnaire and a food record. The food record was used to calculate energy, macronutrient, and fibre intake. In a multivariable model, energy, macronutrient, or fibre intake was not associated with the LPS activity. Using factor analysis, we identified seven dietary patterns from the FFQ data ("Sweet", "Cheese", "Fish", "Healthy snack", "Vegetable", "Traditional", and "Modern"). In a multivariable model, higher factor scores of the Fish, Healthy snack, and Modern patterns predicted lower LPS activity. The validity of the diet questionnaire was also investigated. The questionnaire showed reasonable relative validity against a 6-day food record. The two methods classified participants into the dietary patterns better than expected by chance. In conclusion, healthy dietary choices, such as consumption of fish, fresh vegetables, and fruits and berries may be associated with positive health outcomes by reducing systemic endotoxaemia.Peer reviewe

Symptoms of depression are associated with reduced leisure-time physical activity in adult individuals with type 1 diabetes

Aims Here, we investigated the association between depressive symptoms and leisure-time physical activity (LTPA) in type 1 diabetes. Methods Data from adult individuals with type 1 diabetes without evidence of diabetic kidney disease or macrovascular complications, participating in the Finnish Diabetic Nephropathy Study, were included. Based on a questionnaire, weekly LTPA as metabolic equivalent of task hour was calculated. Activity levels (inactive, moderately active, active), weekly frequencies ( 2), intensities (low, moderate, high), and single session durations ( 60 min) were assessed. Depressive symptomatology was evaluated using the Beck Depression Inventory (BDI). We calculated a continuous BDI score and divided participants into those with (BDI score >= 16) and without (BDI score < 16) symptoms of depression. For sensitivity analyses, we additionally defined symptoms of depression with antidepressant agent purchases within a year from the study visit. Results Of the 1339 participants (41.7% men, median age 41 years), 150 (11.2%) reported symptoms of depression. After adjustments, both higher BDI scores and depressive symptomatology were associated with more inactive lifestyle, and lower frequency and intensity of the LTPA. The BDI score was additionally associated with shorter single session duration. For antidepressant purchases, lower odds were observed in those with higher intensity and longer single session duration of LTPA. Conclusions Depressive mood is harmfully related to LTPA in type 1 diabetes. In order to improve the long-term health of individuals with type 1 diabetes, efforts to increase both mental well-being and physical activity should be taken.Peer reviewe

Perceived Stress and Adherence to the Dietary Recommendations and Blood Glucose Levels in Type 1 Diabetes

Stress may negatively impact self-management of diabetes and thereby deteriorate glycaemic control. Eating is the most frequently reported stress-release method. In this study, we investigated the association between perceived stress (PS), dietary adherence, and glycaemic control. Data from participants in the FinnDiane Study with type 1 diabetes who had completed a diet questionnaire and Cohen's perceived stress scale (PSS) were included. In addition to using a continuous PSS score, participants were divided into three groups based on the PSS scores: the first PSS quartile, low levels of PS; second and third quartiles, moderate levels of PS; and fourth quartile, high levels of PS. A diet score reflecting the level of adherence to dietary recommendations was calculated. Analyses were conducted in the whole sample and in subgroups divided by body mass index (BMI = 25 kg/m(2)). In the whole sample, high PS and continuous stress score were negatively associated with the diet score and with adherence to fish, fresh vegetable, low-fat liquid milk product, and vegetable oil-based cooking fat recommendations. The stress score was negatively associated with the diet score both in lean and in those overweight or obese. However, fish and fresh vegetable recommendations were only affected in those with corpulence. PS was not associated with mean blood glucose concentrations in the whole sample. When divided by BMI status, worse glycaemic control was observed in lean subjects reporting stress. In individuals with overweight or obesity, instead, high glucose concentrations were observed regardless of the level of perceived stress. Interventions to improve stress management could improve dietary adherence and glycaemic control and could thereby have the potential to improve long-term health and well-being of individuals with type 1 diabetes

Dietary intake in type 1 diabetes at different stages of diabetic kidney disease

Aim Diet plays an important role in the kidney health of individuals with type 1 diabetes. However, not much is known about dietary practices at different stages of diabetic nephropathy. We aimed at investigating food intake, dietary patterns, and nutrient intakes in individuals with type 1 diabetes differing in renal status. Methods Data were available from 1874 individuals with type 1 diabetes (45% men, age 48 ± 13 years). Diet was assessed at the levels of food items and diet patterns (diet questionnaire), and energy and nutrient intakes (food record). Six groups were formed based on the eGFR or dialysis and transplantation status. Results Reductions in liquid-milk product and salt consumption, and increase in special diet adherence were observed at the early stages of eGFR decline. Reduced coffee consumption was observed after eGFR wasPeer reviewe

The serum uric acid concentration is not causally linked to diabetic nephropathy in type 1 diabetes

Previous studies have shown a relationship between uric acid concentration and progression of renal disease. Here we studied causality between the serum uric acid concentration and progression of diabetic nephropathy in 3895 individuals with type 1 diabetes in the FinnDiane Study. The renal status was assessed with the urinary albumin excretion rate and estimated glomerular filtration rate (eGFR) at baseline and at the end of the follow-up. Based on previous genomewide association studies on serum uric acid concentration, 23 single nucleotide polymorphisms (SNPs) with good imputation quality were selected for the SNP score. This score was used to assess the causality between serum uric acid and renal complications using a Mendelian randomization approach. At baseline, the serum uric acid concentration was higher with worsening renal status. In multivariable Cox regression analyses, baseline serum uric acid concentration was not independently associated with progression of diabetic nephropathy over a mean follow-up of 7 years. However, over the same period, baseline serum uric acid was independently associated with the decline in eGFR. In the cross-sectional logistic regression analyses, the SNP score was associated with the serum uric acid concentration. Nevertheless, the Mendelian randomization showed no causality between uric acid and diabetic nephropathy, eGFR categories, or eGFR as a continuous variable. Thus, our results suggest that the serum uric acid concentration is not causally related to diabetic nephropathy but is a downstream marker of kidney damage.Peer reviewe