Katie Weinger

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.

Frequent hypoglycemia among elderly patients with poor glycemic control.

BACKGROUND Episodes of hypoglycemia are particularly dangerous in the older population. To reduce the risk of hypoglycemia, relaxation of the standard hemoglobin A(1c) (HbA(1c)) goals has been proposed for frail elderly patients. However, the risk of hypoglycemia in this population with higher HbA(1c) levels is unknown. METHODS Patients 69 years or older with HbA(1C) values of 8% or greater were evaluated with blinded continuous glucose monitoring for 3 days. RESULTS Forty adults (mean [SD] age, 75 [5] years; HbA(1C) value, 9.3% [1.3%]; diabetes duration, 22 [14] years; 28 patients [70%] with type 2 diabetes mellitus; and 37 [93%] using insulin) were evaluated. Twenty-six patients (65%) experienced 1 or more episodes of hypoglycemia (glucose level <70 mg/dL). Among these, 12 (46%) experienced a glucose level below 50 mg/dL and 19 (73%), a level below 60 mg/dL. The average number of episodes was 4; average duration, 46 minutes. Eighteen patients (69%) had at least 1 nocturnal episode (10 pm to 6 am). Of the total of 102 hypoglycemic episodes, 95 (93%) were unrecognized by finger-stick glucose measurements performed 4 times a day or by symptoms. CONCLUSIONS Hypoglycemic episodes are common in older adults with poor glycemic control. Raising HbA(1C) goals may not be adequate to prevent hypoglycemia in this population.

The role of resilience on psychological adjustment and physical health in patients with diabetes

OBJECTIVE This study used a longitudinal design to investigate the buffering role of resilience on worsening HbA(1c) and self-care behaviours in the face of rising diabetes-related distress. METHOD A total of 111 patients with diabetes completed surveys and had their glycosylated haemoglobin (HbA(1c)) assessed at baseline and at 1-year follow-up. Resilience was defined by a factor score of self-esteem, self-efficacy, self-mastery and optimism. Diabetes-related distress and self-care behaviours were also assessed. RESULTS Baseline resilience, diabetes-related distress and their interaction predicted physical health (HbA(1c)) at 1 year. Patients with low, moderate and high resilience were identified. Those with low or moderate resilience levels showed a strong association between rising distress and worsening HbA(1c) across time (r=.57, .56, respectively). However, those with high resilience scores did not show the same associations (r=.08). Low resilience was also associated with fewer self-care behaviours when faced with increasing distress (r=-.55). These correlation coefficients remained significant after controlling for starting-points. CONCLUSION In patients with diabetes, resilience resources predicted future HbA(1c) and buffered worsening HbA(1c) and self-care behaviours in the face of rising distress levels.

Cognitive function in patients with insulin-dependent diabetes mellitus during hyperglycemia and hypoglycemia

BACKGROUND To determine the impact of glycemic control, gender, and other relevant parameters on cognitive function during exposure to different blood glucose levels in patients with insulin-dependent diabetes mellitus (IDDM), we examined neuropsychologic function during experimentally induced periods of hyperglycemia and hypoglycemia. METHODS We studied 20 men and 22 women, aged 18 to 44 years, with IDDM duration of 3 to 14 years and HbA1 values ranging from 5.8% to 18.0% (nondiabetic range 5.4% to 7.4%). We used a controlled experimental setting involving tests of sensory perceptual processing, simple motor abilities, attention, learning and memory, language, and spatial and constructional abilities at plasma glucose levels of 2.2, 5.6, 8.9, 14.4, and 21.1 mmol/L. Patients were blind to the glucose level. Tests used at each glucose level included reaction time (simple and choice), digit vigilance, trail making part B, word recall, digit sequence learning, and verbal fluency. RESULTS All aspects of neuropsychologic function were diminished at 2.2 mmol/L when compared with basal levels of performance at 8.9 mmol/L, whereas no alterations were observed at 14.4 or 21.1 mmol/L. Tests involving associative learning, attention, and mental flexibility were the most affected during hypoglycemia. Glycemic control was not correlated with neuropsychologic function at any glucose level. Women demonstrated less of an impairment in neuropsychologic function than men at 2.2 mmol/L. CONCLUSIONS Cognitive function in IDDM patients was generally well-preserved even at substantially elevated blood glucose levels. Deficits in all relevant areas of cognitive function occurred during hypoglycemia (2.2 mmol/L), irrespective of prior glycemic control, and women with IDDM were less cognitively impaired than men with IDDM during hypoglycemia.

Psychosocial and quality of life correlates of glycemic control during intensive treatment of type 1 diabetes

To identify emotional and attitudinal barriers to improved glycemic control (HbA1c) during intensive diabetes treatment, 55 patients attending a 4-5 month intensive diabetes medical/education clinic were followed. Subjects completed a battery of psychological surveys, had HbA1c and body mass index measured, and rated their attitude toward weight gain and the extent of problems with specific self-management behaviors before and after the medical intervention. Although HbA1c improved on average, 29% had only modest improvement and 16% showed no improvement. The number of diabetes-related annoyances, worry about hypoglycemia, and diabetes-related emotional distress diminished. Only the satisfaction subscale of the Diabetes Quality of Life survey, diabetes-related emotional distress, and problems with self-management behaviors correlated with HbA1c. Treatment-related frustration and emotional distress may initially act as motivators to improve glycemia but can later become barriers to that goal. Interventions designed to help patients overcome attitudinal barriers should be incorporated into medical programs geared toward improving glycemia.

Impact of diabetes and its treatment on cognitive function among adolescents who participated in the Diabetes Control and Complications Trial.

OBJECTIVE—The purpose of this study was to evaluate whether severe hypoglycemia or intensive therapy affects cognitive performance over time in a subgroup of patients who were aged 13–19 years at entry in the Diabetes Control and Complications Trial (DCCT). RESEARCH DESIGN AND METHODS—This was a longitudinal study involving 249 patients with type 1 diabetes who were between 13 and 19 years old when they were randomly assigned in the DCCT. Scores on a comprehensive battery of cognitive tests obtained during the Epidemiology of Diabetes Interventions and Complications follow-up study, ∼18 years later, were compared with baseline performance. We assessed the effects of the original DCCT treatment group assignment, mean A1C values, and frequency of severe hypoglycemic events on eight domains of cognition. RESULTS—There were a total of 294 reported episodes of coma or seizure. Neither frequency of hypoglycemia nor previous treatment group was associated with decline on any cognitive domain. As in a previous analysis of the entire study cohort, higher A1C values were associated with declines in the psychomotor and mental efficiency domain (P < 0.01); however, the previous finding of improved motor speed with lower A1C values was not replicated in this subgroup analysis. CONCLUSIONS—Despite relatively high rates of severe hypoglycemia, cognitive function did not decline over an extended period of time in the youngest cohort of patients with type 1 diabetes.

The effect of a structured behavioral intervention on poorly controlled diabetes: a randomized controlled trial.

BACKGROUND Although maintaining nearly normal glycemia delays onset and slows progression of diabetes complications, many patients with diabetes and their physicians struggle to achieve glycemic targets. The best methods to support patients as they follow diabetes prescriptions and recommendations are unclear. METHODS To test the efficacy of a behavioral diabetes intervention in improving glycemia in long-duration, poorly controlled diabetes, we randomized 222 adults with diabetes (49% type 1) (mean [SD] age, 53 [12] years; mean [SD] disease duration 18 [12] years; mean [SD] hemoglobin A(1c) [HbA(1c)] concentration, 9.0% [1.1%]) to attend (1) a 5-session manual-based, educator-led structured group intervention with cognitive behavioral strategies (structured behavioral arm); (2) an educator-led attention control group education program (group attention control); or (3) unlimited individual nurse and dietitian education sessions for 6 months (individual control). Outcomes were baseline and 3-, 6-, and 12-month postintervention HbA(1c) levels (primary) and frequency of diabetes self-care, 3-day pedometer readings, 24-hour diet recalls, average number of glucose checks, physical fitness, depression, coping style, self-efficacy, and quality of life (secondary). RESULTS Linear mixed modeling found that all groups showed improved HbA(1c) levels (P < .001). However, the structured behavioral arm showed greater improvements than the group and individual control arms (3-month HbA(1c) concentration changes: -0.8% vs -0.4% and -0.4%, respectively (P = .04 for group × time interaction). Furthermore, participants with type 2 disease showed greater improvement than those with type 1 (P = .04 for type of diabetes × time interaction). Quality of life, glucose monitoring, and frequency of diabetes self-care did not differ by intervention over time. CONCLUSIONS A structured, cognitive behavioral program is more effective than 2 control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully use modified psychological and behavioral strategies. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT000142922.

The effects of type 1 diabetes on cerebral white matter

Aim/hypothesisStudies investigating the structure, neurophysiology and functional outcomes of white matter among type 1 diabetes patients have given conflicting results. Our aim was to investigate the relationship between type 1 diabetes and white matter hyperintensities.MethodWe assessed white matter integrity (using magnetic resonance imaging), depressive symptoms and neuropsychological function in 114 type 1 diabetes patients and 58 age-matched non-diabetic controls.ResultsOnly Fazekas grade 1 and 2 white matter hyperintensities were found among 114 long-duration, relatively young diabetes patients; the severity of lesions did not differ substantially from 58 healthy controls. White matter hyperintensities were not associated with depressive history or with clinical characteristics of diabetes, including retinopathy, severe hypoglycaemia or glycaemia control.Conclusions/interpretationOur data do not support an association between diabetes characteristics and white matter hyperintensities among relatively young type 1 diabetes participants.

Driving Mishaps Among Individuals With Type 1 Diabetes A prospective study

OBJECTIVE Hypoglycemia-related neuroglycopenia disrupts cognitive-motor functioning, which can impact driving safety. Retrospective studies suggest that drivers with type 1 diabetes experience more collisions and citations than their nondiabetic spouses. We present the first prospective data documenting the occurrence of apparent neuroglycopenia-related driving performance impairments. RESEARCH DESIGN AND METHODS We completed the initial screening of 452 drivers from three geographically diverse centers who then reported monthly occurrences of driving “mishaps,” including collisions, citations, losing control, automatic driving, someone else taking over driving, and moderate or severe hypoglycemia while driving. RESULTS Over 12 months, 52% of the drivers reported at least one hypoglycemia-related driving mishap and 5% reported six or more. These mishaps were related to mileage driven, history of severe hypoglycemia, and use of insulin pump therapy. CONCLUSIONS Many individuals with type 1 diabetes report hypoglycemia-related driving events. Clinicians should explore the recent experiences with hypoglycemia while driving and the risk of future events.