Garry Welch

Assessment of diabetes-related distress

OBJECTIVE To describe a new measure of psychosocial adjustment specific to diabetes, the Problem Areas in Diabetes Survey (PAID), and to present initial information on its reliability and validity. RESEARCH DESIGN AND METHODS Before their routine clinic appointments, 451 female patients with type I and type II diabetes, all of whom required insulin, completed a self-report survey. Included in the survey was the PAID, a 20-item questionnaire in which each item represents a unique area of diabetes-related psychosocial distress. Each item is rated on a six-point Likert scale, reflecting the degree to which the item is perceived as currently problematic. A total scale score, hypothesized to reflect the overall level of diabetes-related emotional distress, is computed by summing the total item responses. To examine the concurrent validity of the PAID, the survey also included a series of standardized questionnaires assessing psychosocial functioning (general emotional distress, fear of hypoglycemia, and disordered eating), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for HbA1, within 30 days of survey completion and again ∼ 1–2 years later. Finally, long-term diabetic complications were determined through chart review. RESULTS Internal reliability of the PAID was high, with good item-to-total correlations. Approximately 60% of the subject sample reported at least one serious diabetes-related concern. As expected, the PAID was positively associated with relevant psychosocial measures of distress, including general emotional distress, disordered eating, and fear of hypoglycemia, short- and long-term diabetic complications, and HbA1, and negatively associated with reported self-care behaviors. The PAID accounted for ∼ 9% of the variance in HbA1. Diabetes-related emotional distress, as measured by the PAID, was found to be a unique contributor to adherence to self-care behaviors after adjustment for age, diabetes duration, and general emotional distress. In addition, the PAID was associated with HbA1 even after adjustment for age, diabetes duration, general emotional distress, and adherence to self-care behaviors. CONCLUSIONS These findings suggest that the PAID, a brief, easy-to-administer instrument, may be valuable in assessing psychosocial adjustment to diabetes. In addition to high internal reliability, the consistent pattern of correlational findings indicates that the PAID is tapping into relevant aspects of emotional distress and that its particular feature, the measurement of diabetes-related emotional distress, is uniquely associated with diabetes-relevant outcomes. These data are also consistent with the hypothesis that diabetes-related emotional distress, separate from general emotional distress, is an independent and major contributor to poor adherence. Given that the study was limited to female patients using insulin, further examination of the clinical usefulness of the PAID will need to focus on more heterogeneous samples.

The Problem Areas in Diabetes Scale: An evaluation of its clinical utility

OBJECTIVE To evaluate the reliability and concurrent and discriminant validity of the Problem Areas in Diabetes (PAID) scale, a new measure of emotional functioning in diabetes. RESEARCH DESIGN AND METHODS A battery of questionnaires, including the PAID, was completed by 256 volunteer diabetic outpatients. In our analyses, we examined the PAIDs internal structure and compared mean IDDM and NIDDM treatment group scores in regression analyses to explore its discriminant validity. We also evaluated concurrent validity from the correlations between the PAID and diabetes-specific measures of coping and health attitudes and HbA1c. RESULTS Principal component analyses identified a large emotional adjustment factor, supporting the use of the total score. Significant sizable correlations were found between the PAID and a range of selected health attitudinal measures. There were significant differences (with small-to-moderate effect sizes) in PAID scores between IDDM and NIDDM patients and between IDDM and NIDDM insulin- and tablet-treated subgroups; no differences were found between NIDDM insulin- and tablet-treated subgroups. CONCLUSIONS The study findings provided support for the construct validity of the PAID, including evidence for discriminant validity from its ability to detect differences between IDDM and NIDDM treatment groups expected to differ in the emotional impact of life with diabetes. Future studies should explore the PAIDs performance in nonspecialist treatment settings as well as its responsiveness to clinical change.

Responsiveness of the Problem Areas In Diabetes (PAID) questionnaire

Aim Responsiveness (sensitivity to change over time) is a key psychometric quality for an outcome measure. We examined the responsiveness of the Problem Areas In Diabetes (PAID) questionnaire, a measure of diabetes‐specific emotional distress.

Quality-of-life impact of lower urinary tract symptom severity: results from the Health Professionals Follow-up Study

OBJECTIVES To estimate the magnitude of the quality-of-life impact of lower urinary tract symptom (LUTS) severity using a large (n = 8406) sample of U.S. men participating in the Health Professionals Follow-up Study. METHODS Multiple regression modeling was used to estimate the relative quality-of-life burden of different levels of LUTS severity (defined using the American Urological Association Symptom Index as none-mild symptoms, 0 to 7; low moderate, 8 to 14; high moderate, 15 to 19; and severe, 20 to 35) and to compare these with age-matched U.S. male norms. A standardized and validated measure of both LUTS severity (the American Urological Association Symptom Index) and a widely used, standardized, multidimensional measure of quality of life (Short Form 36) were used. In addition, the relative impact of severe LUTS on the quality of life was compared with that experienced for other chronic illness conditions (diabetes, angina, hypertension, gout). RESULTS The results showed that high-moderate LUTS was associated with small to moderate deficits in anxious and depressed mood and poorer role functioning related to emotional problems arising from illness. Severe LUTS was associated with additional quality-of-life deficits related to vitality and the ability to work and carry out daily tasks as a result of illness. Comparisons of the severe LUTS patient group with four other chronic illness groups showed vitality/energy, in particular, but also role functioning and depressed and anxious feelings, to be poorer in the severe LUTS group. CONCLUSIONS Men with high-moderate and severe LUTS identified in a large U.S. cohort have a poorer health status in several important quality-of-life dimensions. The detection and effective treatment of LUTS may substantially improve the health status for these men in these dimensions.

Randomized Trial of a Literacy-Sensitive, Culturally Tailored Diabetes Self-Management Intervention for Low-Income Latinos: Latinos en Control

OBJECTIVE To test whether a theory-based, literacy, and culturally tailored self-management intervention, Latinos en Control, improves glycemic control among low-income Latinos with type 2 diabetes. RESEARCH DESIGN AND METHODS A total of 252 patients recruited from community health centers were randomized to the Latinos en Control intervention or to usual care. The primarily group-based intervention consisted of 12 weekly and 8 monthly sessions and targeted knowledge, attitudes, and self-management behaviors. The primary outcome was HbA1c. Secondary outcomes included diet, physical activity, blood glucose self-monitoring, diabetes knowledge and self-efficacy, and other physiological factors (e.g., lipids, blood pressure, and weight). Measures were collected at baseline and at 4- and 12-month follow-up. Change in outcomes over time between the groups and the association between HbA1c and possible mediators were estimated using mixed-effects models and an intention-to-treat approach. RESULTS A significant difference in HbA1c change between the groups was observed at 4 months (intervention −0.88 [−1.15 to −0.60] versus control −0.35 [−0.62 to 0.07], P < 0.01), although this difference decreased and lost statistical significance at 12 months (intervention −0.46 [−0.77 to −0.13] versus control −0.20 [−0.53 to 0.13], P = 0.293). The intervention resulted in significant change differences in diabetes knowledge at 12 months (P = 0.001), self-efficacy (P = 0.001), blood glucose self-monitoring (P = 0.02), and diet, including dietary quality (P = 0.01), kilocalories consumed (P < 0.001), percentage of fat (P = 0.003), and percentage of saturated fat (P = 0.04). These changes were in turn significantly associated with HbA1c change at 12 months. CONCLUSIONS Literacy-sensitive, culturally tailored interventions can improve diabetes control among low-income Latinos; however, strategies to sustain improvements are needed.

Glycemic control and major depression in patients with type 1 and type 2 diabetes mellitus

The current study evaluated the association of glycemic control and major depression in 33 type 1 and 39 type 2 diabetes mellitus patients. Type 1 patients with a lifetime history of major depression showed significantly worse glycemic control than patients without a history of psychiatric illness (t = 2.09; df = 31, p < 0.05). Type 2 diabetes patients with a lifetime history of major depression did not have significantly worse control than those with no history of psychiatric illness. Findings from this study indicate different relationships between lifetime major depression and glycemic control for patients with type 1 and type 2 diabetes. Treatment implications for glycemic control in type 1 and type 2 diabetes patients are discussed.

Subclinical and Clinical Eating Disorders in IDDM Negatively Affect Metabolic Control

OBJECTIVE To characterize the relationship of subclinical and clinical eating disorders to HbA1c values in women with IDDM. RESEARCH DESIGN AND METHODS Ninety women with IDDM (18–46 years of age) were recruited from diabetes clinics throughout Connecticut and Massachusetts. Subjects were categorized into one of three groups according to the Diagnostic Statistical Manual of Mental Disorders (DSM-III-R) criteria for eating disorders as follows: the clinical group (n = 14), the subclinical group (partially fulfilling the diagnostic criteria; n = 13), and the control group (n = 63). Group differences in the degree of dietary restraint, binge eating, and bulimic behaviors and weight, shape, and eating concerns were assessed with the Eating Disorder Examination (EDE) and the Bulimia Test Revised (BULIT-R). RESULTS Women with subclinical and clinical eating disorders had clinically elevated HbA1c results and more diabetes-related complications, compared with the control subjects. The severity of bulimic behaviors, weight concerns, reduced BMI, and decreased frequency of blood glucose monitoring were associated with elevated HbA1c. CONCLUSIONS HbA1c may have clinical utility in the identification of eating disorder behavior in females with IDDM. Health care professionals should be aware of the potent effect of subclinical and clinical eating behaviors including insulin misuse in weight-conscious women with IDDM who have poor glycemic control.

The BULIT-R: its reliability and clinical validity as a screening tool for DSM-III-R bulimia nervosa in a female tertiary education population

The Bulimia Test (BULIT) has been updated to accommodate the DSM-III-R criteria for bulimia nervosa. Therefore, in this study, we evaluated the psychometric properties of the BULIT-R using a sample of young women at a tertiary educational institute. The results showed all 28 BULIT-R items correlated highly with the total test score (average = .59) and the internal reliability was high (.92). In terms of its concurrent validity, the BULIT-R correlated highly (.90) with the Bulimia Investigatory Test Edinburgh (BITE), a screening measure argued to detect bulimia nervosa. In terms of criterion-related validity, the optimal cutoff for the BULIT-R as a screening measure was 98 with this sample, using a semistructured DIS-III R interview administered by experienced clinicians who specialize in eating disorders. At this cutoff, the sensitivity was 100%, the specificity 99.0%, the negative predictive value 100%, and the positive predictive value 71.3%.

The Association of Lifetime Psychiatric Illness and Increased Retinopathy in Patients With Type I Diabetes Mellitus

Forty-nine patients with Type I diabetes mellitus were assessed to examine the relationship between lifetime prevalence of psychiatric illness and retinopathy severity. The subjects with a history of psychiatric illness had significantly worse retinopathy than the subjects without psychiatric illness. Eighty-nine percent of the subjects with severe nonproliferative retinopathy or proliferative retinopathy had a history of psychiatric illness, predominantly affective illness. In addition, the subjects with a history of psychiatric illness had significantly higher current glycohemoglobin levels than those with no psychiatric history. This studys findings suggest that psychiatric illness may be a risk factor for development of retinopathy in Type I diabetic patients.

Nurse diabetes case management interventions and blood glucose control: results of a meta-analysis.

We conducted a meta-analysis of studies reporting diabetes case management interventions to examine the impact of case management on blood glucose control (HbA1c). Databases used for the search included Medline, PubMed, Cochrane EPOC, Cumulative Index to Nursing & Allied Health Literature database guide (CINAHL), and PsychInfo. A composite estimate of effect size was calculated using a random effects model and subgroup analyses were conducted. Twenty-nine salient studies involving 9397 patients had sufficient data for analysis. Mean patient age was 63.2 years, 49% were male, and ethnicity/race was 54% White. Type 2 diabetes was the focus in 91% of studies. Results showed a large overall effect size favoring case management intervention over controls or baseline values on HbA1c (ES=0.86, 95%CI: 0.52-1.19, Z=5.0, p<0.001). This corresponds to a mean HbA1c reduction of 0.89 (95%CI: 0.63-1.15). Subgroup analyses showed clinical setting, team composition, and baseline HbA1c were important predictors of effect size, but not diabetes self-management education which was poorly described or absent in most diabetes case management interventions examined. Nurse-led case management provides an effective clinical strategy for poorly controlled diabetes based on a meta-analysis of clinical trials focusing on blood glucose control.