Behavior change intervention and fear of hypoglycemia in type 1 diabetes

Introduction: Individuals with type 1 diabetes require lifelong insulin supply as well as behavioral adjustments for good treatment result. Only a minority reach the goal for glycemic control set in order to reduce the risk of severe long-term complications. Interventions based on cognitive behavior therapy (CBT) have been proposed to improve diabetes-management, but evidence for its efficacy in adults with poorly controlled type 1 diabetes is sparse. One common barrier to optimal diabetes-management is fear of hypoglycemia (FOH), especially in those who have experienced severe hypoglycemic episodes. Thus there is a need for a valid and reliable instrument to assess individuals who are affected by FOH. It is also vital to identify factors associated with FOH in order to find targets for interventions to reduce fear. Aim: The overall aims of this thesis were to evaluate a CBT intervention for poorly controlled individuals with type 1 diabetes and to explore fear of hypoglycemia in an effort to gain deeper knowledge of possible targets for interventions to reduce FOH. Methods: All four studies applied quantitative designs. Study I was a randomized controlled trial in which a cognitive behavioral intervention was evaluated on poorly controlled adult persons with type 1 diabetes. Study II was a psychometric evaluation of a Swedish version of the Hypoglycemia Fear Survey (HFS) in a survey study in adult persons with type 1 diabetes. Studies III and IV were cross-sectional survey studies employed on adults with type 1 diabetes exploring disease-specific, demographic, (studies III and IV) emotional and psychosocial factors (study IV) related to FOH. Results and conclusions: Study I: The intervention group receiving CBT showed significant improvements in HbA1c, diabetes related distress, well-being, FOH, perceived stress, anxiety and depression as well as frequency in self monitoring of blood glucose. Study II: A three- factor solution was found for the Swedish version of the HFS with the dimensions Worry, Behavior and Aloneness. Cronbach’s alpha for the total scale was 0.85 and varied between 0.63 – 0.89 in the subscales. Convergent validity was also supported with moderate correlation between Swe-HFS and Swe-PAID-20. The Swe-HFS seems to be a reliable and valid instrument to measure FOH in adults with type 1 diabetes. Study III: Seven hundred and sixty- four persons (55%) responded to the questionnaire. The HFS-Worry subscale was significantly associated with frequency of severe hypoglycemia, number of symptoms during mild hypoglycemia, gender, hypoglycemic symptoms during hyperglycemia and hypoglycemic unawareness. The HFS-Aloneness subscale was significantly associated with frequency of severe hypoglycemia, number of symptoms during mild hypoglycemia, gender, frequency of mild hypoglycemia, HbA1c, hypoglycaemic unawareness and visits to the emergency room because of severe hypoglycemia. FOH proved to be more prevalent in females. Frequency of severe hypoglycemia was identified as the most important factor associated with FOH. Study IV: A total of 469 (61%) persons responded to the questionnaire. The HFS was significantly associated with The Anxiety Sensitivity Index, the Anxiety subscale of Hospital Anxiety and Depression Scale and Social Phobia Scale. Together with the disease-specific factors the regression model explained 39% of the variance. Support for a positive association between FOH and anxiety was present and previously identified gender differences were confirmed. Differences between the subgroups on factors associated with FOH were found that may have implications in developing interventions

A longitudinal study of fear of hypoglycaemia in adults with type 1 diabetes

Aims: To  investigate  fear  of  hypoglycaemia  (FoH)  longitudinally  in  a  cross-  sectional  study  of  adult  patients  with  type  1  diabetes.  Specifically,  we  investigated  two  sub-groups of patients who over 4 years either showed a substantial increase or decrease in level of FoH to identify factors associated with changes in FoH. Methods: The Swedish version of the Hypoglycaemia Fear Survey (HFS) along with a questionnaire  to  assess  hypoglycaemia  history  was  sent  by  mail  to  764  patients  in  2010. The responders in 2010 (n =   469) received another set of the same two ques-tionnaires in 2014. HbA1c, insulin regimen, weight and creatinine from 2010 and 2014 were obtained from medical records. Those with an absolute difference in HFS scores ≥  75th percentile were included in   the    subgroup analyses. Statistical analyses included one- sample t tests, chi- square and McNemar’s test. Results: The absolute difference in the HFS total score (n =   347) between 2010 and 2014 was m =   ±7.6, SD ±   6. In the increased FoH group, more patients reported a high level of moderate hypoglycaemic episodes as well as impaired awareness of hypogly-caemia in 2014 compared with the decreased FoH group. There were more subjects in the  increased  FoH  group  with  insulin  pumps  in  2014  and  in  2010.  In  the  decreased  FoH group, more patients had a high frequency of daily self- monitoring of blood glu-cose (SMBG) in 2010 and in 2014. Conclusions: Fear of hypoglycaemia is stable across time for most patients. Changes in fear level are associated with changes in hypoglycaemia frequency. Thus, asking pa-tients about changes in hypoglycaemia experiences is of great importance

A novel approach for constructing personalized networks from longitudinal perceived causal relations

Personalized networks of psychological symptoms aim to advance therapy by identifying treatment targets for specific patients. Statistical relations in such networks can be estimated from intensive longitudinal data, but their causal interpretation is limited by strong statistical assumptions. An alternative is to create networks from patient perceptions, which comes with other limitations such as retrospective bias. We introduce the Longitudinal Perceived Causal Problem Networks (L-PECAN) approach to address both these concerns. 20 participants screening positive for depression completed 4 weeks day of brief daily assessments of perceived symptom interactions. Quality criteria of this new method are introduced, answering questions such as “Which symptoms should be included in networks?”, “How many datapoints need to be collected to achieve stable networks?”, and “Does the network change over time?”. Accordingly, about 40% of respondents achieved stable networks and only few respondents exhibited network structure that changed during the assessment period. The method was time-efficient (on average 7.4 min per day), and well received. Overall, L-PECAN addresses several of the prevailing issues found in statistical networks and therefore provides a clinically meaningful method for personalization.</p

Acceptance and commitment therapy (ACT) for adult type 1 diabetes management : study protocol for a randomised controlled trial

INTRODUCTION: Integrating diabetes self-management into daily life involves a range of complex challenges for affected individuals. Environmental, social, behavioural and emotional psychological factors influence the lives of those with diabetes. The aim of this study is to evaluate the impact of a stress management group intervention based on acceptance and commitment therapy (ACT) among adults living with poorly controlled type 1 diabetes. METHODS AND ANALYSIS: This study will use a randomised controlled trial design evaluating treatment as usual (TAU) and ACT versus TAU. The stress management group intervention will be based on ACT and comprises a programme divided into seven 2-hour sessions conducted over 14 weeks. A total of 70 patients who meet inclusion criteria will be recruited over a 2-year period with follow-up after 1, 2 and 5 years.The primary outcome measure will be HbA1c. The secondary outcome measures will be the Depression Anxiety Stress Scales, the Swedish version of the Hypoglycemia Fear Survey, the Swedish version of the Problem Areas in Diabetes Scale, The Summary of Self-Care Activities, Acceptance Action Diabetes Questionnaire, Swedish Acceptance and Action Questionnaire and the Manchester Short Assessment of Quality of Life. The questionnaires will be administered via the internet at baseline, after sessions 4 (study week 7) and 7 (study week 14), and 6, 12 and 24 months later, then finally after 5 years. HbA1c will be measured at the same time points.Assessment of intervention effect will be performed through the analysis of covariance. An intention-to-treat approach will be used. Mixed-model repeated measures will be applied to explore effect of intervention across all time points. ETHICS AND DISSEMINATION: The study has received ethical approval (Dnr: 2016/14-31/1). The study findings will be disseminated through peer-reviewed publications, conferences and reports to key stakeholders. TRIAL REGISTRATION NUMBER: NCT02914496; Pre-results

A Novel Approach for Constructing Personalized Networks from Longitudinal Perceived Causal Relations

Introduction The network approach to psychopathology aims to solve problems with heterogeneity and comorbidity, as well as advance psychiatric precision medicine. Statistical relations in networks can be estimated from intensive longitudinal data, but causal interpretations of such networks are limited by strong statistical assumptions and the frequency of assessments heavily influences which relations can be discovered. Objective An alternative is to create networks from patient perceptions, which comes with other limitations such as retrospective bias. As a synthesis, we introduce the Longitudinal Perceived Causal Relations (L-PCR) approach. Methods 20 participants screening positive for depression completed up to 28 days of brief assessments of experienced symptoms and perceived symptom-symptom influences. Quality criteria of this new method are introduced via a bootstrapping algorithm, answering questions such as “Which symptoms should be included in networks?”, “How many datapoints need to be collected to achieve stable networks?”, and “Does the network change over time?”. Results To achieve stability, networks had to be created using only a core of frequently experienced symptoms, i.e. symptoms experienced during at least a third of days. About 40% of respondents achieved stable networks and only a few respondents exhibited changes in network structure across time. The method was time efficient (on average 7.4 minutes per day) and well received by participants. Conclusions Future directions of L-PCR include individualized core symptoms in a controlled clinical population, as well as additional assessment types such as counterfactual questions. Overall, L-PCR addresses several of the prevailing issues found in statistical networks and therefore provides a clinically-meaningful method for personalized analysis

Beliefs and experiences of fear of hypoglycemiaand use of uncooked cornstarch before bedtime in persons with type 1-diabetes

Introduction: Among persons living with type 1-diabetes hypoglycemia and fear of hypoglycemia remain limiting barriers for achieving optimal glucose control and a good quality of life. Fear of hypoglycemia has been found stable over time if not treated. Uncooked cornstarch has been found to reduce the risk of hypoglycemia but has not been studied in relation to fear of hypogly-cemia. The aims of this study were to through clinical data, self-reported measures and clinical interviews explore subjects’ experience of using un-cooked cornstarch before bedtime and their beliefs and experiences of fear of hypoglycemia. Methods: Mixed methods with both quantitative and qualita-tive data were used. Self-reported measures of hypoglycemia and fear of hy-poglycemia were compared to subjects’ responses during a clinical interview. The interviews were analyzed with a functional behavior analytical approach. Results: A total of five subjects took part in the study. One subject perceived the uncooked cornstarch helpful in reducing hypoglycemia. Several subjects could recall frightening hypoglycemic episodes triggering their fear. Three out of the five subjects reported avoidance behaviors such as excessive self-monitoring of blood glucose or overeating related to fear of hypoglyce-mia. Conclusions: The uncooked cornstarch was found appetizing but was not perceived as having an effect on BG or hypoglycemia frequency. The clinical interviews confirmed previous research regarding experience of hy-poglycemia and fear of hypoglycemia