Comparison of illness representations dimensions and illness representation clusters in predicting outcomes in the first year following diagnosis of type 2 diabetes: results from the DESMOND trial.

This article explores the utility of cluster analysis of illness representations, in comparison to analysing each dimension of the individual's illness representation, to predict an individual's response to diagnosis of type 2 diabetes. Participants in a large multi-centre randomised controlled trial of a self-management education intervention for people with type 2 diabetes, completed measures of illness beliefs (coherence, timeline, impact, seriousness, personal responsibility) and depression along with HbA1c and body mass index (BMI), at baseline 4, 8 and 12 months. The results of the cluster analysis were compared with an independent qualitative study of participants' responses to diagnosis and participation in the study. The quantitative analysis of 564 participants for whom complete data were available, identified four clusters of illness representations as the most parsimonious description of the data. The mean profiles of these clusters were comparable with groups identified by the independent qualitative analysis, and predicted the trajectory of illness outcomes over the 1-year follow-up. Combining illness beliefs into discrete clusters may be more useful in understanding patterns of responding to illness than using analysis of illness beliefs dimensions independently.

Depressive symptoms in the first year from diagnosis of Type 2 diabetes: results from the DESMOND trial.

AIMS: To describe the course of depressive symptoms during the first year after diagnosis of Type 2 diabetes. METHODS: Post hoc analysis of data from a randomized controlled trial of self-management education for 824 individuals newly diagnosed with Type 2 diabetes. Participants completed the Depression scale of the Hospital Anxiety and Depression Scale after diagnosis and at 4, 8 and 12 months follow-up. Participants also completed the Problem Areas in Diabetes scale at 8 and 12 months follow-up. We present descriptive statistics on prevalence and persistence of depressive symptoms. Logistic regression is used to predict possible depression cases, and multiple regression to predict depressive symptomatology. RESULTS: The prevalence of depressive symptoms in individuals recently diagnosed with diabetes (18-22% over the year) was not significantly different from normative data for the general population (12%) in the UK. Over 20% of participants indicated some degrees of depressive symptoms over the first year of living with Type 2 diabetes; these were mostly transient episodes, with 5% (1% severe) reporting having depressive symptoms throughout the year. At 12 months post diagnosis, after controlling for baseline depressive symptoms, diabetes-specific emotional distress was predictive of depressive symptomatology. CONCLUSIONS: The increased prevalence of depressive symptoms in diabetes is not manifest until at least 1 year post diagnosis in this cohort. However, there are a significant number of people with persistent depressive symptoms in the early stages of diabetes, and diabetes-specific distress may be contributing to subsequent development of depressive symptoms in people with Type 2 diabetes.

Key considerations around the risks and consequences of hypoglycaemia in people with type 2 diabetes.

Hypoglycaemia and its consequences represent a significant risk for many people who have type 2 diabetes, and hypoglycaemia is currently under-recognised and commonly avoidable. Current clinical guidelines recommend the targeting of tight glycaemic control and this strategy may also be associated with an increased risk of hypoglycaemia. Hypoglycaemia impacts on morbidity, mortality and quality of life of people with type 2 diabetes, and improved recognition of the symptoms of hypoglycaemia will allow effective treatment and reduce the risk of progression to more severe episodes. A common cause of hypoglycaemia in people with type 2 diabetes is glucose-lowering medication, in particular, those which raise insulin independently of ambient glucose concentration such as sulphonylureas and exogenous insulin. The recently published National Institute for Health and Clinical Excellence guideline recommends the use of Dipeptidyl peptidase-4 inhibitors or thiazolidinediones (glitazones) as alternative second-line therapy instead of a sulphonylurea in those patients who are at significant risk of hypoglycaemia and its consequences.

Effectiveness of the diabetes education and self management for ongoing and newly diagnosed (DESMOND) programme for people with newly diagnosed type 2 diabetes: cluster randomised controlled trial.

OBJECTIVE: To evaluate the effectiveness of a structured group education programme on biomedical, psychosocial, and lifestyle measures in people with newly diagnosed type 2 diabetes. DESIGN: Multicentre cluster randomised controlled trial in primary care with randomisation at practice level. SETTING: 207 general practices in 13 primary care sites in the United Kingdom. PARTICIPANTS: 824 adults (55% men, mean age 59.5 years). INTERVENTION: A structured group education programme for six hours delivered in the community by two trained healthcare professional educators compared with usual care. MAIN OUTCOME MEASURES: Haemoglobin A(1c) levels, blood pressure, weight, blood lipid levels, smoking status, physical activity, quality of life, beliefs about illness, depression, and emotional impact of diabetes at baseline and up to 12 months. MAIN RESULTS: Haemoglobin A(1c) levels at 12 months had decreased by 1.49% in the intervention group compared with 1.21% in the control group. After adjusting for baseline and cluster, the difference was not significant: 0.05% (95% confidence interval -0.10% to 0.20%). The intervention group showed a greater weight loss: -2.98 kg (95% confidence interval -3.54 to -2.41) compared with 1.86 kg (-2.44 to -1.28), P=0.027 at 12 months. The odds of not smoking were 3.56 (95% confidence interval 1.11 to 11.45), P=0.033 higher in the intervention group at 12 months. The intervention group showed significantly greater changes in illness belief scores (P=0.001); directions of change were positive indicating greater understanding of diabetes. The intervention group had a lower depression score at 12 months: mean difference was -0.50 (95% confidence interval -0.96 to -0.04); P=0.032. A positive association was found between change in perceived personal responsibility and weight loss at 12 months (beta=0.12; P=0.008). CONCLUSION: A structured group education programme for patients with newly diagnosed type 2 diabetes resulted in greater improvements in weight loss and smoking cessation and positive improvements in beliefs about illness but no difference in haemoglobin A(1c) levels up to 12 months after diagnosis. TRIAL REGISTRATION: Current Controlled Trials ISRCTN17844016 [controlled-trials.com].

'Educator talk' and patient change: some insights from the DESMOND (Diabetes Education and Self Management for Ongoing and Newly Diagnosed) randomized controlled trial.

AIMS: To determine whether differences in the amount of time educators talk during a self-management education programme relate to the degree of change in participants' reported beliefs about diabetes. METHOD: Educators trained to be facilitative and non-didactic in their approach were observed delivering the DESMOND self-management programme for individuals newly diagnosed with Type 2 diabetes. Observers used 10-s event coding to estimate the amount of time educators spoke during different sessions in the programme. Facilitative as opposed to didactic delivery was indicated by targets for levels of educator talk set for each session. Targets were based on earlier pilot work. Using the revised Illness Perceptions Questionnaire (IPQ-R) and the Diabetes Illness Representations Questionnaire (DIRQ), participants completed measures of: perceived duration of diabetes (timeline IPQ-R), understanding of diabetes (coherence IPQ-R), personal responsibility for influencing diabetes (personal responsibility IPQ-R), seriousness of diabetes (seriousness DIRQ) and impact on daily life (impact DIRQ), before and after the education programme. RESULTS: Where data from the event coding indicated educators were talking less and meeting targets for being less didactic, a greater change in reported illness beliefs of participants was seen. However, educators struggled to meet targets for most sessions of the programme. CONCLUSION: The amount of time educators talk in a self-management programme may provide a practical marker for the effectiveness of the education process, with less educator talk denoting a more facilitative/less didactic approach. This finding has informed subsequent improvements to a comprehensive quality development framework, acknowledging that educators need ongoing support to facilitate change to their normal educational style.

Patient and professional accuracy of recalled treatment decisions in out-patient consultations.

AIMS: To test the assumption that professional recall of consultation decisions is valid and more accurate than patient recall of consultation decisions. METHODS: One hundred and thirty-four consultations between diabetes specialist nurses and diabetes specialist dietitians in an adult out-patient diabetes service were audiotaped. Patients and professionals were asked to recall the treatment decisions made immediately after the consultation. Patient participants were also asked to complete the Health Care Climate Questionnaire (HCC). Recalled decisions, by patient and professional participants, were then compared with those extracted from the audio tapes, and with each other. RESULTS: The mean duration of consultations was 27 min. Patients recalled a mean of 2.5 (SD 1.4) decisions per consultation, and professionals a mean of 3.2 (SD 1.6) decisions per consultation. A mean of 2.2 (SD 1.1, range 0-4) decisions per consultation were identified on the audiotapes. Patients recalled a mean of 2.3 (SD 1.4, range 0-6) decisions per consultations that could not be found on the tapes, with professionals recalling a mean of 1.7 (SD 1.2, range 0-6) decisions per consultation that could not be found on the tape. More autonomy, as measured by the HCCQ, was correlated with better professional recall (r = 0.17; P < 0.05). CONCLUSIONS: Both patients and professionals have poor recall of decisions made in diabetes out-patient consultations. Although the mean professional recall is marginally better than that of the patients, they recall a vast number of unmade decisions and the implications of these being recorded in patients' notes is substantial.

Helping patients to improve self management of diabetes.

Research suggests that people with diabetes are poorly compliant with dietary and exercise recommendations, and that primary non-compliance with medication is common. Local research has shown that patients' beliefs about diabetes suggest little understanding of the seriousness of the disease in terms of increased mortality. Portsmouth Primary Care Trust, in collaboration with Portsmouth Hospitals NHS Trust, is developing a range of structured self management programmes to assist in helping people be clearer about how they can make changes that will reduce their risk of diabetes complications and cardiovascular disease. These programmes are delivered to groups of patients, rather than on a single patient basis.

Behavioral interventions for adolescents with type 1 diabetes: how effective are they?

OBJECTIVE: To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature. RESEARCH DESIGN AND METHODS: The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated. RESULTS: The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P<0.05, 1-tailed). CONCLUSIONS: Research to date indicates that these interventions are moderately effective. Several methodological weaknesses to be avoided in future studies are noted. It is also recommended that investigators use the reach, efficacy, adoption, implementation, and maintenance (RE-AIM) framework to guide the design of future studies, which should result in more disseminable interventions. RE-AIM assesses the intervention's reach, or percent or representativeness of patients willing to participate; efficacy across a range of outcomes; adoption, or the percent and representativeness of settings willing to implement the intervention; implementation, or the consistency of the delivery of the intervention as intended; and maintenance, or the extent to which delivery of the intervention becomes a routine part of health care in the medical setting.

Nurse prescribing in diabetes.

The adjustment of diabetes medication is vital for the prevention of complications. Insulin dose adjustment by diabetes specialist nurses is common practice but its legality is questionable. Two surveys were undertaken to identify common practice. The results were used to establish the basis for an effective multiprofessional protocol for nurse administration of diabetes medication.

The role of exercise in diabetes management.

Monitor blood glucose level before, during and for up to 24 hours after exercise. Ensure refined carbohydrate snack is taken prior to exercise. Reduce insulin dosage if possible. Inject insulin away from any exercising muscle. Remember that glycogen stores are replenished in two phases: immediately after the exercise and two to three hours later. These are the key risk times for hypoglycaemia. If blood glucose control is poor (14 mmol/litre or higher) prior to exercise, the 'stress' effect of the exercise may cause further increases in the blood sugar level unless control is achieved.

Assessing the impact of diabetes on female sexuality.

Sexual dysfunction in men is well recognised but the effects of diabetes on women's sexual health is less researched and understood. Few women seek help for sexual problems and yet effective treatments may be available. Some genito-urinary diseases are more common in diabetes and the community nurse should consider this as part of the patient's assessment. Women with diabetes should be given appropriate advice on pregnancy. Community nurses have a major role to play in helping women with diabetes to talk freely about their sexuality and sexual health problems.

Blood glucose monitoring by people with diabetes.

Blood glucose monitoring can be a valuable tool in the management of diabetes. It has two different roles: as a patient self-management tool and as a professional monitoring tool. Recent studies have shown limitations in its use as a patient self-management tool. For blood glucose monitoring to be used as a successful self-management tool, a different professional approach may be required.