This year's American Diabetes Association's Scientific Sessions were packed with research updates on interventions and insights to help people live well with their diabetes, and have the confidence to manage it. Here are some of the highlights.
Digging into diabetes distress
Diabetes doesn’t just affect someone physically. The relentless need to manage your condition and deal with everything diabetes throws at you affects mental health as well. Diabetes distress is a natural reaction to living with the condition. But higher levels of distress can be a problem and has been linked with higher HbA1c levels. However, we don’t yet understand what’s driving this relationship, or what direction it goes in. And without this understanding it’s difficult to know how to intervene.
Dr Danielle Hessler at the University of California sought to shed light on this. She ran a trial involving 301 people with type 1 diabetes who reported elevated levels of diabetes distress. They were randomly assigned to receive one of two different interventions designed to reduce distress.
- OnTrack – focuses on ways to help people deal with the emotional side of diabetes and how to develop emotion management techniques.
- KnowIt – focuses on teaching people about diabetes and self-management.
Dr Hessler found both interventions significantly reduced diabetes distress, but OnTrack seemed to help more. This suggests programmes which give people support for their emotions could be most effective. Dr Hessler then continued to follow participants over a 9-month period and tracked their diabetes self-management behaviours and blood sugar levels.
She found that reductions in diabetes distress drove changes in the participant’s diabetes management. They were less likely to skip insulin injections, had increased self-confidence to carb count and problem solve, monitored their blood sugar more often and reported a better understanding of diabetes. These behaviours in turn drove improvements in HbA1c and reduced hypos.
These insights are vital to figure out how to give people the right kind of support to help them cope with diabetes distress, and stay healthy now and into the future.
YES we can
Adolescence can be a really tricky time to manage type 1 diabetes. Young people are more likely to experience higher blood sugar levels and higher rates of DKA. Dr Dulmini Kariyawasam, at King's College London, described how emotional and social issues are likely to be key to this.
For this reason they developed the Youth Empowerment Skills programme (YES). It’s a new type of education tailored to the challenges of living with type 1 diabetes as a teenager. It was co-designed by young people with type 1, parents and healthcare professionals and has a focus on psychological and social aspects, such as relationships, attitudes to food and weight and taking insulin in front of friends. YES uses three main learning methods – simulation, group based learning and confidence building through physical activities. It’s delivered over three days in a non-hospital setting.
The researchers carried out a small study to test its feasibility. 49 young people with type 1 diabetes, from diverse ethnic and economic backgrounds tested the programme. Six weeks later the researchers interviewed the teenagers to get their feedback on what worked well and what didn’t, and followed them up one year on.
They saw some key themes emerge from their interviews. The teens reported that YES helped them to normalise their diabetes, gave them a more positive mindset, improved their knowledge of diabetes and gave them the confidence to share their experiences of diabetes with friends. The early results also indicated the programme could have some benefits for diabetes management. HbA1c was reduced by 0.7% and there was a 55% drop in hospitals admission due to DKA in year after YES, compared to the year before.
We’re now funding the YES research team to build on this early evidence to learn more about how well YES works compared to standard type 1 diabetes care to help adolescents feel more confident and in control.
Is diabetes education too boring?
While YES is innovating new ways to deliver diabetes education and support, Dr William Polonsky - recipient of the ADA's outstanding educator award - argued that current diabetes education courses are falling short. He told us over 400 studies have documented the huge impact structured education can make to people with diabetes. It can improve blood sugar levels, weight, diabetes knowledge and quality of life. But the people with diabetes who access and benefit from these courses are only the tip of the iceberg.
Dr Polonsky thinks we need to pay more attention to what's below the surface. Worldwide, only a minority of people newly diagnosed with diabetes are referred to education courses. For those who are referred, only somewhere between 10-30% show up. And if they do, most drop out before completing the whole programme. We urgently need to get to grips with what the barriers are for both healthcare professionals and people living with diabetes.
While there will be a number of factors contributing, Dr Polonsky’s view is that diabetes education is simply too boring. Too many people don’t feel engaged and it doesn’t seem meaningful to them. Educators are knowledgeable, passionate and want to make a difference. But with pressure to deliver too much information in a short space of time, it becomes difficult to make learning interactive or to personalise material to an individual’s needs and problems.
Dr Polonsky assured educators they don’t need to start making balloon animals. But we know why people learn and change, and it’s not typically because they’re lectured at. It’s through conversation, stories and personal discovery. He shared some recommendations for how diabetes education could be made more engaging.
- Acknowledge there is a problem. Educators should interview people who drop out and ask what was missing.
- Cut down on content. Answering concerns about medications is more important than explaining how each class of medications work, for example.
- Make programmes personally meaningful for each person with diabetes. Sessions should end with checking in on each person’s thoughts and asking how they might use the information to do things differently.
It’s so important we make sure education is there to benefit everyone with diabetes. And Dr Polonsky says shaking things up is the way to do it.
Sleep your way to safer blood sugars?
A good night’s sleep is critical for our physical and mental wellbeing. But evidence suggests that people living with diabetes may not get enough of it. Dr Susanna Patton, of the University of Kansas, described studies looking at sleep duration and disturbances. Adolescents with type 1 diabetes are six times more likely to not get enough sleep, compared to those without diabetes. And studies have shown there’s a relationship between sleep quality and blood sugar control and frequency of DKA.
But which comes first, bad sleep or higher blood sugars? Dr Patton described three models of sleep and type 1 diabetes that are trying to untangle this.
- Biological model. This suggests big variations in blood sugar levels causes our body to release the stress hormone, cortisol. This is turn leads to insulin resistance and sleep disturbances.
- Broad model of sleep and behaviour. This says sleep behaviours directly influence our cognitive functioning, like decision making and problem solving. And this impacts on diabetes self-management and, in turn, blood sugars.
- 24 hour model proposes that what happens at night affects day time outcomes and vice versa. Stress and poor mental wellbeing in day time cause poor sleep quality at night, which impacts on blood sugar control the next day. And all of this impacts on self-management.
There’s still work to be done to fully understand the mechanisms at play, but meanwhile, researchers are exploring if targeting sleep could be beneficial for people with diabetes.
Dr Michelle Perfect, from the University of Arizona, ran a small study with adolescents with type 1 diabetes. They were asked to either sleep for a fixed time each night, similar to their usual sleep length, or were able to extend their sleep. In the sleep extension group participants could spend at least 10 hours in bed and naturally extend their sleep over a week period. On average those in the extension group got 22 minutes more sleep a night than the fixed group.
The adolescents used continuous glucose monitors and at the start of the study there was no difference in HbA1c between groups. After the intervention, the researchers found the average HbA1c in extension group was 1.1% lower than the fixed group.
Bigger and longer studies are needed to understand more, but the results suggest reaching for the snooze button might not be a bad idea.