Experiences of health care transition voiced by young adults with type 1 diabetes: a qualitative study

Objective: This qualitative study aimed to explore the experience of transition from pediatric to adult diabetes care reported by posttransition emerging adults with type 1 diabetes (T1D), with a focus on preparation for the actual transfer in care. Methods: Twenty-six T1D emerging adults (mean age 26.2±2.5 years) receiving adult diabetes care at a single center participated in five focus groups stratified by two levels of current glycemic control. A multidisciplinary team coded transcripts and conducted thematic analysis. Results: Four key themes on the process of transfer to adult care emerged from a thematic analysis: 1) nonpurposeful transition (patients reported a lack of transition preparation by pediatric providers for the transfer to adult diabetes care); 2) vulnerability in the college years (patients conveyed periods of loss to follow-up during college and described health risks and diabetes management challenges specific to the college years that were inadequately addressed by pediatric or adult providers); 3) unexpected differences between pediatric and adult health care systems (patients were surprised by the different feel of adult diabetes care, especially with regards to an increased focus on diabetes complications); and 4) patients’ wish list for improving the transition process (patients recommended enhanced pediatric transition counseling, implementation of adult clinic orientation programs, and peer support for transitioning patients). Conclusion: Our findings identify modifiable deficiencies in the T1D transition process and underscore the importance of a planned transition with enhanced preparation by pediatric clinics as well as developmentally tailored patient orientation in the adult clinic setting

Managing type 2 diabetes or prediabetes and binge eating disorder: a qualitative study of patients' perceptions and lived experiences

BACKGROUND: The overlap in prevalence between type 2 diabetes and binge eating disorder is substantial, with adverse physical and mental health consequences. Little is known about patients' efforts at managing these two conditions simultaneously. The research objective was to explore patients' experiences managing co-existing type 2 diabetes or prediabetes and binge eating disorder. METHODS: This is a qualitative descriptive study using semi-structured interviews. Participants included 21 women with type 2 diabetes or prediabetes (90% non-Hispanic White; mean age 49 ± 14.8 years, mean BMI 43.8 ± 8.4; 48% with type 2 diabetes and mean HbA1c was 8.4%). Interviews were analyzed using thematic analysis and NVivo software. RESULTS: Qualitative analysis revealed that participants reported binge episodes frequently started in childhood or adolescence and went undiagnosed for decades; notably, they recalled that diabetes diagnosis preceded the binge eating disorder diagnosis. They also described trying to lose weight throughout their lives and how feelings of deprivation, shame, and failure exacerbated binge eating. Participants further reported how binge eating made diabetes self-care and outcomes worse. Finally, participants observed that when binge eating disorder treatment and diabetes management were synergistically integrated, they experienced improvements in both binge eating and glycemic outcomes. This integration included reframing negative thoughts surrounding binge eating disorder and diabetes self-management and increasing their understanding of how the two disorders were inter-related. CONCLUSION: Findings highlight the importance of increasing healthcare providers' awareness of and screening for binge eating disorder in the treatment of diabetes and inform specific integrated interventions that address both diagnoses. From this study where we interviewed 21 women with binge eating disorder (BED) and type 2 diabetes/prediabetes, we learned how binge eating impacted diabetes management and how diabetes impacted BED. Most participants reported receiving the diabetes diagnosis before being diagnosed with BED despite the earlier onset of binge eating, pointing to the need for BED screening. Participants described trying to lose weight throughout their lives and reported feelings of failure and shame, which made binge eating worse. Binge eating made diabetes management harder, but when diabetes and BED treatment were aligned, participants experienced improvements in binge symptoms and diabetes outcomes.Dudley Allen Sargent Research FundPublished versio

A brief interactive training with medical students improves their diabetes knowledge about hypoglycemia

© 2019 The Author(s). Background: Hypoglycemia is a severe clinical problem with physical and psychosocial implications for people with type 1 and type 2 diabetes. Medical students would benefit from formal education on how to treat hypoglycemia as well as how to administer glucagon in case of a severe hypoglycemic emergency. The purpose of this study was to assess the effectiveness of a brief training to improve medical students\u27 knowledge and attitudes about diabetes, hypoglycemia, and glucagon administration. Methods: We conducted a feasibility study to assess the effectiveness of an interactive training session on diabetes education with an emphasis on hypoglycemia. We measured medical students\u27 knowledge and attitudes toward diabetes, hypoglycemia, and glucagon before and after the training. We performed Chi-Square tests, paired t-tests, determined effect sizes using Cohen\u27s d, and analyzed short answer responses via content and thematic analyses. Results: Two hundred and seventeen participants (age = 25.1 ± 2.3 years, 45.2% female, 78.3% white, 36.4% planned to pursue primary care, response rate of 94.3%) completed surveys. Following the training, participants\u27 total knowledge scores improved by five percentage points to 82.6 ± 11.0% (t-value = 7.119, p \u3c 0.001). We also observed positive improvements in the General Test scores to 82.3 ± 12.6% (t-value = 5.844, p \u3c 0.001) and Insulin Use Test scores to 82.4 ± 17.4% (t-value = 4.103, p \u3c 0.001). For the hypoglycemia test, participants averaged 55.7 ± 24.8% pre-training and 83.0 ± 22.4% post-training (t-value = 14.258, p \u3c 0.001). Lastly, participants scored 87.6 ± 18.5% on the glucagon test after the training session. In addition, we observed positive improvements in all five diabetes attitudes subscales after the training, with the largest magnitude of change in the Psychosocial impact of diabetes subscale (t-value = 9.249, p \u3c 0.001, Cohen\u27s d = 0.60). Qualitatively, more participants recognized the severity of hypoglycemia after the training. They also learned how to approach diabetes from the patient\u27s perspective and valued the clinically relevant and practical information provided during the training session, such as the 15-15 Rule. Conclusions: Medical students need to learn about patients\u27 everyday experiences of diabetes in order to have an understanding of and confidence to assess and treat hypoglycemia. These findings underscore the importance of training medical students on how to actively assess and manage the risk of hypoglycemia in people with diabetes

Women's perceptions of weight stigma and experiences of weight-neutral treatment for binge eating disorder: a qualitative studyResearch in context

Summary: Background: The detrimental effects of weight stigma are a growing concern as a contributor to negative physical and mental health outcomes, disparities in care, and healthcare avoidance. Research exploring the impact of weight-neutral healthcare is limited but suggests weight-neutral interventions are associated with positive psychological and behavioral outcomes. Little is known about patients’ lived experiences receiving weight-neutral healthcare. Methods: We conducted semi-structured interviews between Feb 5, 2019 and Feb 25, 2020 with 21 women (90% non-Hispanic white, mean age 49 ± 14.8 years) who had type 2 diabetes or prediabetes and high body weight (mean body mass index 43.8 ± 8.4, range: 30.2–63.9) and previously attended a specialized treatment program for binge eating disorder. We recruited individuals with type 2 diabetes or prediabetes who completed of >2 weeks of a specialized binge eating disorder treatment program with the ability to participate in an English-spoken interview and did not have cognitive impairment or severe psychopathology that would limit recall or engagement in the interview. Interviews were analysed using thematic analysis and Nvivo software. The main outcome we studied was patients’ lived experience in healthcare settings and in a weight-neutral eating disorder treatment program. Findings: Participants reported experiencing weight stigma in healthcare encounters and believed this decreased the quality of care they received. While participants frequently attempted to lose weight, they experienced embarrassment, internalized a sense of failure, and felt blamed for their weight and health conditions. In describing experiences within a weight-neutral paradigm, participants reported that helpful elements included consistency in the eating pattern (emphasizing adequate, varied, and nourishing intake), sufficient and specific education, and comprehensive support. Reported impacts included decreased binge episodes, experiencing less shame, and increased resiliency following treatment. Some participants experienced the weight-neutral treatment recommendations and the absence of the pursuit of weight loss as challenging. Interpretation: Weight-neutral treatment may improve psychological and behavioral outcomes regarding binge eating, and longitudinal, quantitative research is warranted. These findings are useful to decrease weight stigma in provider–patient interactions. Funding: The Dudley Allen Sargent Research Fund, Boston University

Understanding the meaning of food in people with type 2 diabetes living in Northern Appalachia

© 2017 by the American Diabetes Association. Purpose. Food and eating convey memories and feelings and serve important functions in creating and maintaining relationships. Given the increasing rate of diabetes in the United States, research understanding the meaning of food may shed light on how patients negotiate everyday food choices while managing type 2 diabetes. The purpose of this qualitative study was to explore the meaning of food among adults with type 2 diabetes living in Northern Appalachia. Methods. In-depth, face-to-face interviews were conducted with type 2 diabetes patients. Interviews were coded and analyzed via thematic analysis. Results. Nineteen adults with type 2 diabetes (mean age 68.7 ± 10.6 years, mean A1C 7.4 ± 1.4%, mean diabetes duration 10.9 ± 11.9 years, 52.6% female, 100% white) participated in the study. Qualitative analysis revealed three themes: 1) Sustaining Life: Food and the Demands of Diabetes Management, in which participants described the role of food as operational and said that eating was dictated by time rather than hunger or pleasure; 2) Diabetes Feels Like a Yield Sign: Diabetes Changes Perceptions of Food, Enjoyment, and Social Relationships, in which most participants described a negative or ambivalent relationship with food after their diabetes diagnosis; and 3) Food is Everywhere; It\u27s Seducing: Struggling With Diabetes Management in a Fast-Food Culture, in which participants discussed how the American fast-food culture was in direct conflict with the demands of diabetes and described how they struggled to follow a healthful diet in a culture that advertised the opposite in many venues. Conclusion. Adults with diabetes may benefit from education that addresses both the personal and sociocultural factors that guide food choices

Specifying the Efficacy of Digital Therapeutic Tools for Depression and Anxiety: Retrospective, 2-Cohort, Real-World Analysis

BackgroundDepression and anxiety are the main sources of work and social disabilities as well as health-related problems around the world. Digital therapeutic solutions using cognitive behavioral therapy have demonstrated efficacy in depression and anxiety. A common goal of digital health apps is to increase user digital engagement to improve outcomes. However, there is a limited understanding of the association between digital platform components and clinical outcomes. ObjectiveThe aim of the study is to investigate the contribution of specific digital engagement tools to mental health conditions. We hypothesized that participation in coaching sessions and breathing exercises would be associated with a reduction in depression and anxiety. MethodsDepression and general anxiety symptoms were evaluated in real-world data cohorts using the digital health platform for digital intervention and monitoring change. This retrospective real-world analysis of users on a mobile platform–based treatment followed two cohorts of people: (1) users who started with moderate levels of depression and completed at least 2 depression assessments (n=519) and (2) users who started with moderate levels of anxiety and completed at least 2 anxiety assessments (n=474). Levels of depression (Patient Health Questionnaire-9) and anxiety (Generalized Anxiety Disorder-7) were tracked throughout the first 16 weeks. A piecewise mixed-effects model was applied to model the trajectories of the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 mean scores in 2 segments (1-6 weeks and 7-16 weeks). Finally, simple slope analysis was used for the interpretation of the interactions probing the moderators: coaching sessions and breathing exercises in both depression and anxiety cohorts. ResultsAnalysis revealed a significant decrease in depression symptoms (β=–.37, 95% CI –0.46 to 0.28; P≤.001) during the period of weeks 1-6 of app use, which was maintained during the period of 7-16 weeks. Coach interaction significantly moderated the reduction in depression symptoms during the period of weeks 1-6 (β=–.03, 95% CI –0.05 to –0.001; P=.02). A significant decrease in anxiety symptoms (β=–.41, 95% CI –0.50 to –0.33; P≤.001) was revealed during the period of 1-6 weeks, which was maintained during the period of 7-16 weeks. Breathing exercises significantly moderated the reduction in anxiety symptoms during the period of 1-6 weeks (β=–.07, 95% CI –0.14 to –0.01; P=.04). ConclusionsThis study demonstrated general improvement followed by a period of stability of depression and anxiety symptoms associated with cognitive behavioral therapy–based digital intervention. Interestingly, engagement with a coaching session but not a breathing exercise was associated with a reduction in depression symptoms. Moreover, breathing exercise but not engagement with a coaching session was associated with a reduction of anxiety symptoms. These findings emphasize the importance of using a personalized approach to behavioral health during digital health interventions

Glycemic Management by a Digital Therapeutic Platform across Racial/Ethnic Groups: A Retrospective Cohort Study

Significant racial/ethnic disparities in healthcare and diabetes technology use have been observed in Type 2 diabetes mellitus (T2DM), which are associated with nonengagement in diabetes self-management and out-of-range glycemia. This study aimed to assess whether there were differences in the blood glucose levels achieved by several racial/ethnic groups using the same digital tool. Study objectives were to determine whether engagement with the digital tool and blood glucose levels differ among ethnic groups, and to determine whether any differences in the in-target-glycemia are related to engagement levels. The retrospective real-world analysis followed a group of 1000 people with Type 2 diabetes who used the DarioTM digital therapeutic platform over 12 months. Participants included in the study had a blood glucose average > 180 mg/dL (hyperglycemia, high-risk) in their first month. The differences between/within the groups’ average blood glucose level (Avg.bg) and glycemic variability were evaluated. Furthermore, three general linear models were constructed to predict the Avg.bg by the number of blood glucose measurements (Bgm) in Model 1 (with the moderator White persons (WP)/people from racial and ethnic minority groups (REM)) and by the frequency of measurements by months (F.m) within REM and WP in Model 2 and Model 3, respectively. The Avg.bg was significantly reduced in each group over a year with no differences between REM/WP users. Blood glucose measurements in Model 1 and frequency of measurements by months in Model 2 and Model 3 predicted the Avg.bg (β1 = −0.20, p = 0.045; β2 = −4.38, p = 0.009; β3= −3.77, p < 0.001, respectively). Findings indicate a positive association between digital engagement and glycemia, with no differences between REM and WP participants

Diabetes in Appalachia: Providers\u27 perspectives

© 2020 The Author(s). Background: Southeastern Appalachian Ohio has more than double the national average of diabetes and a critical shortage of healthcare providers. Paradoxically, there is limited research focused on primary care providers\u27 experiences treating people with diabetes in this region. This study explored providers\u27 perceived barriers to and facilitators for treating patients with diabetes in southeastern Appalachian Ohio.Methods: We conducted in-depth interviews with healthcare providers who treat people with diabetes in rural southeastern Ohio. Interviews were transcribed, coded, and analyzed via content and thematic analyses using NVivo 12 software (QSR International, Chadstone, VIC, Australia).Results: Qualitative analysis revealed four themes: (1) patients\u27 diabetes fatalism and helplessness: Providers recounted story after story of patients believing that their diabetes was inevitable and that they were helpless to prevent or delay diabetes complications. (2) Comorbid psychosocial issues: Providers described high rates of depression, anxiety, incest, abuse, and post-traumatic stress disorder among people with diabetes in this region. (3) Inter-connected social determinants interfering with diabetes care: Providers identified major barriers including lack of access to providers, lack of access to transportation, food insecurity, housing insecurity, and financial insecurity. (4) Providers\u27 cultural understanding and recommendations: Providers emphasized the importance of understanding of the values central to Appalachian culture and gave culturally attuned clinical suggestions for how to use these values when working with this population.Conclusions: Evidence-based interventions tailored to Appalachian culture and training designed to increase the cultural competency and cultural humility of primary care providers may be effective approaches to reduce barriers to diabetes care in Appalachian Ohio

Understanding Physicians ’ Challenges When Treating Type 2 Diabetic Patients’ Social and Emotional Difficulties

OBJECTIVE—To explore physicians ’ awareness of and responses to type 2 diabetic patients’ social and emotional difficulties. RESEARCH DESIGN AND METHODS—We conducted semistructured interviews with 19 physicians. Interviews were transcribed, coded, and analyzed using thematic analysis. RESULTS—Three themes emerged: 1) physicians ’ awareness of patients ’ social and emotional difficulties: physicians recognized the frequency and seriousness of patients ’ social and emotional difficulties; 2) physicians ’ responses to patients ’ social and emotional difficulties: many reported that intervening with these difficulties was challenging with few treatment options beyond making referrals, individualizing care, and recommending more frequent follow-up visits; and 3)the impact of patients ’ social and emotional difficulties on physicians: few available patient treatment options, time constraints, and a perceived lack of psychological expertise contributed to physicians’ feeling frustrated, inadequate, and overwhelmed. CONCLUSIONS—Recognition and understanding of physicians ’ challenges when treating diabetes patients ’ social and emotional difficulties are important for developing programmatic interventions