Background Although maintaining near normal glycemia delays onset and slows progression of diabetes complications, many diabetes patients and their physicians struggle to achieve glycemic targets. 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, 53±12 years old, 18±12 years duration, hemoglobin A1c=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) 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 post-intervention hemoglobin A1c levels (primary), 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 improved hemoglobin A1c (p<0.001). However, the structured behavioral arm improved more than group and individual control arms (3-month HbA1c change: −0.8% versus −0.4% and −0.4%; groupXtime interaction p-value=0.04). Further, type 2 participants improved more than type 1 participants (type of diabetesXtime interaction p-value=0.04). 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 two control interventions in improving glycemia in adults with long-duration diabetes. Educators can successfully utilize modified psychological and behavioral strategies. (ClinicalTrail.gov registration number: NCT000142922)

Aims To identify psychosocial factors associated with the use of continuous glucose monitoring by adults with Type 1 diabetes.Methods Twenty adult patients (aged 45 AE 15 years, diabetes duration 25 AE 19 years, 50% female) followed at our site in the multi-centre Juvenile Diabetes Research Foundation continuous glucose monitoring trial were divided into three groups: Glycated haemoglobin (HbA 1c ) Responders who demonstrated an improvement in glycaemic control with continuous glucose monitoring (baseline HbA 1c ‡ 7.0%, HbA 1c reduction greater than or equal to 0.5%), Hypoglycaemia Responders (baseline HbA 1c < 7.0%) who demonstrated decreased time < 3.9 mmol ⁄ l while remaining within target HbA 1c , and HbA 1c NonResponders (baseline HbA 1c ‡ 7.0%, HbA 1c reduction less than 0.5%). Subjects participated in semi-structured interviews focusing on their psychosocial experiences with continuous glucose monitoring.Results Three major themes were identified that differentiated Responders (including both the HbA 1c and Hypoglycaemia groups) from Non-Responders: (i) coping with frustrations-Responders used self-controlled rather than emotions-based coping when faced with continuous glucose monitoring frustrations; (ii) use of information-Responders used retrospective pattern analysis, not just minute-by-minute data analysis, in glycaemic management; (iii) 'significant other' ⁄ spousal involvement-Responders endorsed interest, encouragement and participation by their loved ones. Both Responders and Non-Responders expressed body image concerns when wearing continuous glucose monitoring devices.Conclusions This qualitative study points to the importance of coping skills, retrospective review of data, and 'significant other' involvement in the effective use of continuous glucose monitoring. These findings will inform clinical initiatives to improve patient selection and training in the use of this new technology and have served as the basis for development of quantitative surveys to be used in clinical practice.

One of the most challenging diabetes-related behavior changes is adhering to a healthful diet. Drawing on the social cognitive theory and social support literature, this qualitative study explores how spousal support influences dietary changes following a diagnosis of type 2 diabetes in middle-aged and older adults. The purpose of this study was to determine how aspects of the spousal relationship translate into behavior changes, specifically adherence to a healthful diet. Analyses revealed five core themes related to dietary adherence: control over food, dietary competence, commitment to support, spousal communication, and coping with diabetes. The themes can be categorized within two key social cognitive theory constructs: reinforcement and self-efficacy. Implications from the focus group data can inform the development of more effective, targeted nutrition messages and programs to provide specific knowledge and skills.

Our findings suggest that continuous glucose monitoring may positively impact collaborative diabetes management and marital relationships of patients with Type 1 diabetes and their spouses. However, reluctance to collaborate and lack of understanding may contribute to couples' conflicts around continuous glucose monitoring. Our findings have important implications for clinical care and point to the need for interventions that include spouses in continuous glucose monitoring training to increase their understanding of continuous glucose monitoring, minimize risk for spousal conflict and enhance collaborative diabetes management. Further studies are needed to explore these issues in more detail and depth with larger and more diverse populations.

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Aims To explore older patients’ perceived impact of chronic co-morbid conditions on Type 2 diabetes self-management. Methods We used purposive sampling to select 32 mentally alert community-dwelling adults, aged 60 years or older, diagnosed with Type 2 diabetes and at least one other chronic health condition to participate in focus groups. We summarized the discussions following each focus group and identified codes to describe the overarching themes. Results We conducted eight 90-min focus groups, each consisting of two to six patients. Three themes emerged. (i) Diabetes complications as a motivator: managing co-morbid conditions made health an important focal point in the lives of older patients. Most patients acknowledged the positive effect complications had on their diabetes self-management by motivating them to pay greater attention to their diabetes to diminish the progression of these complications. (ii) Prioritizing health conditions: patients reported prioritizing health conditions and selectively attending to the management of those conditions based on perceived severity or importance. Further, many patients perceived some conditions as more serious than others and admitted to prioritizing another health condition over their diabetes. (iii) Emotional impact of co-morbidity management: patients described feeling frustrated, confused, and overwhelmed in response to conflicting treatment recommendations, particularly for diet, physical activity and medication regimens. Conclusions Complications and co-morbidities may have differential impacts on the diabetes self-management of older patients. Addressing the perceived impact of co-morbidity on diabetes self-management may improve patients’ outcomes; however, the most effective method of utilizing this information in clinical practice needs to be examined.

Objective Diabetes self-care is challenging and requires effective patient-provider communication to achieve optimal treatment outcomes. This study explored perceptions of barriers and facilitators to diabetes self-care communication during medical appointments. Design Qualitative study using in-depth interviews with a semi-structured interview guide. Participants 34 patients with type 2 diabetes and 19 physicians who treat type 2 diabetes. Results Physicians described some patients as reluctant to discuss their self-care behaviors primarily because of fear of being judged, guilt, and shame. Similarly, patients described reluctant communication resulting from fear of being judged and shame, particularly shame surrounding food intake and weight. Physicians and patients recommended trust, non-judgmental acceptance, open/honest communication, and providing patients hope for living with diabetes as important factors for improving self-care communication. Further, patients stressed the clinical benefits of physicians directly addressing poor self-care behaviors while physicians described having few strategies to address these difficulties. Conclusions Physician-patient self-care communication barriers included patients' reluctance to discuss self-care behaviors and physicians’ perceptions of few options to address this reluctance. Treatment recommendations stressed the importance of establishing trusting, non-judgmental and open patient-provider communication for optimal diabetes treatment. Medical education is needed to improve physicians' strategies for addressing self-care communication during medical appointments.

Adhering to increased exercise is often reported as one of the greatest challenges facing adults living with diabetes, a perception shared by the married middle-aged and older adults living with diabetes who participated in this study. Understanding how that challenge can best be met is both research and program relevant. Drawing on the social cognitive theory and social support literature, this qualitative study explored the powerful couple relationship in Type 2 diabetes management. The overarching goal of this paper was to illuminate the potentially key role of collective efficacy in exercise adherence in order to develop and test interventions that provide more effective supports for adults living with diabetes. Analyses revealed three core themes used by the couples to describe their perceived beliefs: 'Collective support', 'Collective motivation' and 'Collective responsibility'. Our findings provide insights regarding how collective beliefs of spousal support may influence the adoption and maintenance of an exercise program. As health educators look for approaches to improve exercise adherence in diabetes management, it is important to understand how couples can be empowered to assume responsibility for their management.