Tackle Education and Mindset to Reduce Diabetes Distress

SAN DIEGO – Interventions that specifically address diabetes distress can not only improve patient mental health but can also cut costs, according to two new studies in patients with type 1 diabetes presented at the American Diabetes Association (ADA) 83rd Scientific Sessions.

Danielle Hessler Jones, PhD, presented findings from Behavioral Approaches to Reducing Diabetes Distress and Improving Glycemic Control (EMBARK), in adults with type 1 diabetes, during an oral session.

The three-arm randomized trial found that patients had the greatest improvements in feelings of powerlessness after a 3-month behavioral intervention that combined type 1 diabetes education plus specific attention to diabetes distress.

And in a late-breaking poster, "Do The Right Thing: Behavioral Intervention for At-Risk T1D Youth," David V. Wagner, PhD, showed that a behavioral intervention not only improved glycemic management but also reduced cost of care in disadvantaged youth.

"Diabetes distress is the emotional response to living with diabetes, the burden of relentless daily self-management, and the prospect of its long-term complications," said Hessler Jones, professor and vice chair for research in the Department of Family and Community Medicine at the University of California, San Francisco.

It is common, experienced by 20% to 58% of people with type 1 and type 2 diabetes, and is different from depression, as it is associated with glycemic control and disease management. It "is also chronic and does not disappear on its own without intervention," she stressed.

"It is the expected worries, concerns, and fears that are associated with struggling with a demanding and progressive chronic disease and its management," she added.

The findings from EMBARK "suggest that distress reductions are greatest when interventions integrate education alongside approaches to address the emotional side of diabetes" she said.

The group is also analyzing changes in A1c with the three different interventions in EMBARK, with results expected this fall.

Hessler Jones said they also just received funding for DDASSIST, which will answer the question: "How do I translate this into care in my clinic?" The aim of the clinic training program is to bring the intervention to the diabetes care team.

"Could this program be delivered by somebody else, other than a psychologist?" an audience member asked. They will be looking at this, she replied.

"Do the Right Thing"

For the late-breaking poster by Wagner and colleagues, researchers evaluated direct cost data from three healthcare systems provided for youth with type 1 diabetes who received an intensive behavioral health intervention, Novel Interventions in Children's Healthcare (NICH).

Youths were included in the analyses if they had type 1 diabetes and at least 1 year of cost data prior to and following NICH enrollment. Outpatient, emergency department, and inpatient costs were combined. The analysis included 53 youth with the following characteristics: mean age 14.2 years; 87% Medicaid; 58% female; 32% Black, 29% Non-Hispanic White, 28% Hispanic/Latinx, 7% Pacific Islander, 2% Asian, and 2% other racial and ethnic groups.

Average yearly costs significantly decreased from $20,400 per youth prior to NICH to $9500 per youth afterward, largely due to inpatient charges.

"These results highlight the benefits of providing access to intensive interventions to pediatric populations experiencing health disparities," said Wagner. "Investing early in the lives of youth experiencing health disparities is not only the right thing to do to improve patients' health but it could also have a positive economic impact down the road."

Three Interventions in 300 Adults With Type 1 Diabetes

Meanwhile, EMBARK recruited 300 patients with type 1 diabetes in the United States from clinics and community organizations who were aged 21 and older and had an elevated type 1 diabetes distress score (> 2.0) and A1c ≥ 7.5%.

Participants were a mean age of 46 years, 79% were female, and 89% were White. They had a type 1 diabetes distress score (T1DDS) of 2.8, a mean A1c of 8.3%, and 71% used an insulin pump and 79% used a continuous glucose monitor.

Participants were randomized to one of three interventions:

Streamline: A traditional diabetes educator-led education and management program.
Tuned-in: A psychologist-led program focused exclusively on reducing diabetes distress.
Fixit: An integration of the two programs.

Interventions were given virtually over 3 months to small groups of 8 to 12 individuals and included initial workshops, one-to-one phone calls, and follow-up group meetings. Participants were then followed for 8 months.

Researchers found statistically significant and substantial reductions in overall diabetes distress in all three interventions, with the greatest reductions in the combined intervention group, which were greater than in the educational approach alone group (P = .005).

The percentage of participants who no longer reported elevated diabetes distress at follow-up was 25% in Streamline, 37% in Tuned-in, and 42% in Fixit.

The percentage of participants who reported a minimal clinically important difference — the smallest change in a treatment outcome that an individual would identify as important — was also greatest in those in the Fixit intervention group (82%) than in the Tuned-in (74%) or Streamline (65%) interventions.

"Adding the Psychologist Is Where the Real Magic Happens"

"The certified diabetes care specialist (CDCS) intervention is really a very standard thing that most clinicians would have access to; they tend to focus on knowledge and problem solving and some of the psychosocial issues," Robert Gabbay, MD, PhD, chief scientific and medical officer for the ADA, told Medscape Medical News.

The EMBARK trial found a "graded response: CDCS alone, psychologist really focused on diabetes distress, and the two together, which would be the ideal practice model," he noted.

There are these validated ways of measuring diabetes distress using a diabetes distress survey tool, which is also underutilized.

"Adding the psychologist is really where the real magic happens in terms of diabetes distress," Gabbay said.

"As you can imagine, [if] somebody...feels powerless, it is going to be tough to manage their diabetes, and unlikely to be terribly successful," he observed. Often, these individuals are just not doing well. This study highlighted the importance of identifying this.

"I'm encouraged by the findings from the studies presented during this year's Scientific Sessions as we continue to seek out innovative, evidence-based solutions that support people living with diabetes when they need it the most," Gabbay concluded.

ADA 2023 Scientific Sessions. Presented on June 24, 2023.

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