Living with diabetes

Management of diabetes can be affected by emotional distress in two ways: directly, via the effect of stress on glycemic control, and indirectly via effects on self-care routines. Rational-emotive therapy, along with a number of other cognitive, emotive, and behavioral tools, is an important intervention for patients who have diabetes-related distress. The authors describe personal and professional examples of the application of these tools to living rationally with diabetes.Richard R. Rubin, Ph.D. is a staff member of the Diabetes Center and the Pediatric Diabetes Clinic at the Johns Hopkins Hospital. In addition, he has a private psychotherapy practice, substantially devoted to counseling and coping skills training for people with diabetes.Susan R. Walen, Ph.D. is an Associate Professor in the Department of Psychology, Towson State University and Director of the Baltimore Center for Cognitive Therapy. She is the coauthor ofA Practitioner's Guide to Rational-Emotive Therapy.Albert Ellis, Ph.D. is the founder of Rational Emotive Therapy and president of the Institute for RET in New York City. He is the author of more than 50 books and 600 journal articles on psychotherapy topics.     

Psycho-educational action for teenagers with diabetes

Twelve case-studies of teenagers with diabetes (aged between 14 and 18) were carried out in a Spanish hospital, which provided them with outpatient assistance, and in the secondary schools where they studied. The findings identify some features peculiar to the concurrent experience of adolescence and diabetes. Some suggestions are offered to counsellors and teachers working with students experiencing this condition.     

Illness perception clusters and relationship quality are associated with diabetes distress in adults with Type 2 diabetes

This report aims to augment what is already known about emotional distress in Type 2 diabetes, by assessing the predictive value of illness perception clusters and relationship quality on four subcategories of Diabetes Distress.162 individuals with Type 2 diabetes responded to a postal questionnaire assessing demographics, depression, diabetes distress, illness perceptions and relationship quality. Long-term blood glucose was retrieved from participants’ General Practitioner. Three illness perception clusters emerged from the data, capturing three subgroups of participants sharing similar illness perception schemas. Regression analyses were performed across each diabetes distress subscale, with demographics, illness perception clusters, and relationship variables entered into three blocks. Covariates explained 51.1% of the variance in emotional burden, 41% of the variance in regimen-related distress, 20% of the variance in interpersonal distress, and 8.6% of the variance in physician-related distress. Cluster membership was strongly associated with emotional burden, regimen-related distress, and to a lesser degree interpersonal distress, but was not associated with physician-related distress. Relationship quality most strongly predicted regimen-related distress. Illness perception schemas and interpersonal issues influence emotional adjustment in diabetes. This study provides direction for the content of a novel approach to identifying and reducing diabetes distress in people with Type 2 diabetes.     

Medication adherence and diabetes control in urban African Americans with type 2 diabetes.

In 181 urban African Americans with Type 2 diabetes, medication adherence was assessed using a measure designed specifically for an urban, impoverished sociodemographic population. Hemoglobin A-sub(1c), blood pressure and cholesterol levels, medication-related beliefs, and depression were assessed. Seventy-four percent of the sample reported adherence to diabetes medication. Adherence, adjusted for age, was associated with lower hemoglobin A-sub(1c). The specific behaviors associated with poorer diabetes control were forgetting to take medications and running out of medications. Knowledge of blood glucose goals differed for adherers and nonadherers. Blood pressure and cholesterol medication adherence rates were not associated with actual levels of blood pressure or lipids, respectively. These data suggest that specific medication-taking behaviors are important to diabetes control and constitute logical targets for interventions. ((c) 2005 APA, all rights reserved).     

Relations of diabetes intrusiveness and personal control to symptoms of depression among adults with diabetes.

The generalizability of a model linking illness characteristics to psychosocial well-being was tested in a cross-sectional study of 237 adults with type 2 diabetes. It was hypothesized that diabetic complications increase illness intrusiveness, which in turn increases depressive symptomatology either directly or indirectly by reducing personal control over health outcomes. Illness intrusiveness was defined as the result of disruptions of valued activities and interests due to constraints imposed by the illness. An excellent fit of this model to the data was found using structural equation modeling. The model explained 65% of the variance in depressive symptomatology. Assessment of an alternative model excluding personal control suggested that the extent to which diabetes intrudes in life, rather than diabetic complications per se or personal control, is a key factor in relation to depressive symptomatology in individuals with diabetes.     

Glycosylated hemoglobin and psychological adjustment in adolescents with diabetes

The relationships between glycosylated hemoglobin levels as an index of metabolic control, life events occurring in the previous year, and general adjustment in the areas of attitude towards diabetes, independence, peer, school, and family relationships were investigated in 37 adolescents with insulin-dependent diabetes mellitus. The number or type of life events did not show a relationship with metabolic control. As measured by the Sullivan Diabetic Adjustment Scale, diabetic adolescents who were in better metabolic control reported more conflict regarding family relationships and issues of independence than did those in lesser control.     

Personality variables and metabolic control in children with diabetes

Insulin-dependent diabetic children and a group of their nondiabetic peers were compared on measures of self-concept, locus of control and health locus of control. A metabolic measure of long term diabetes control was also obtained on the children with diabetes. Data analyses revealed that metabolic control was not related to any of the personality measures in the diabetic sample. Diabetic and non-diabetic children did not differ on measures of locus of control and self-concept, but diabetics exhibited a health locus of control which was significantly more internal than that of control subjects. A possible explanation for these results was discussed and practical implications for health care providers working with young diabetics were presented.     

The effect of diabetes knowledge and attitudes on self-management and quality of life among people with type 2 diabetes

We examined the effect of diabetes knowledge and attitudes on self-management and quality of life (QoL) of people with type 2 diabetes mellitus (T2DM). We employed a cross-sectional study design. A total of 137 female and 129 male participants with T2DM completed the diabetes knowledge scale (DKN), Diabetes Integration Scale-19 (ATT19), Summary of Diabetes Self-care Activities (SDSCA) scale, and Diabetes Quality of Life (DQoL) scale, measuring diabetes knowledge, attitudes, self-management, and QoL respectively. The SDSCA scale measures diet, exercise, blood glucose monitoring, and foot care. The DQoL scale measures satisfaction and impact of QoL. An initial path model that tested the inter-relationships of the study variables was first identified based on previous research. Then, the path model was tested using Mplus 7.3. In the final model, diabetes knowledge was a significant predictor of attitudes and self-management in terms of blood glucose monitoring and foot care. Attitudes was a significant predictor of impact of QoL. Self-management in terms of blood glucose monitoring was a significant predictor of impact of QoL and diet was a significant predictor of satisfaction and impact of QoL. Exercise and foot care aspects of Self-management were significant predictors of satisfaction and impact of QoL respectively. The final model showed a good fit to the data: RMSEA = .045 (90% CI: .009, .071; Clfit = .601), CFI = .950, SRMR = .058. The findings suggest a theoretical basis to direct the development of appropriate health programs and interventions for improving QoL in people with T2DM and warrant replication in diverse samples.     

Children with recently diagnosed diabetes: interactions within their families

Cross-sectional findings drawn from the first year of a 4-year longitudinal study of preadolescent and early adolescent insulin-dependent diabetics and their families are presented. Using direct observation techniques and a specially designed coding system, the family interactions of 56 families with a recently diagnosed diabetic child are compared with those of 49 families with a child of similar age and sex, who has had a recent, serious acute illness. The two samples are contrasted in terms of each family member's (mother, father, and child) enabling and constraining interactions, controlling for social class differences. The findings reveal that the diabetic children and their parents expressed significantly more enabling (e.g., focusing, problem solving, active understanding) speeches than comparable members of the acute illness group. In addition, there are indications of particular constraining interactions (devaluing) occurring between fathers and diabetic children. Several alternative interpretations are offered to account for these results, together with plans for future research directions to investigate these hypothesized explanations.     

Perceptions of treatment control moderate the daily association between negative affect and diabetes problems among adolescents with type 1 diabetes

Perceived control over diabetes may serve to buffer the relationship between adolescents' experience of daily negative affect and daily problems with diabetes. In a daily diary study including 209 adolescents (ages 10.5-15.5) with type 1 diabetes, we examined how daily affect related to daily fluctuations in experience of diabetes problems, and whether perceptions of control moderated these daily associations. Using hierarchical linear modelling, we found that day-to-day experiences of negative affect were associated with more frequent daily diabetes problems. Perceptions of treatment control moderated associations between negative affect and number of problems; negative affect was more strongly associated with number of problems among teens perceiving lower versus higher treatment control over their illness. The same pattern of association was not apparent for personal control. Results suggest that perceived treatment control may help to buffer detrimental associations between negative affect and adolescents' ability to successfully manage their diabetes.     

Perceptions of treatment control moderate the daily association between negative affect and diabetes problems among adolescents with type 1 diabetes

Perceived control over diabetes may serve to buffer the relationship between adolescents’ experience of daily negative affect and daily problems with diabetes. In a daily diary study including 209 adolescents (ages 10.5–15.5) with type 1 diabetes, we examined how daily affect related to daily fluctuations in experience of diabetes problems, and whether perceptions of control moderated these daily associations. Using hierarchical linear modelling, we found that day-to-day experiences of negative affect were associated with more frequent daily diabetes problems. Perceptions of treatment control moderated associations between negative affect and number of problems; negative affect was more strongly associated with number of problems among teens perceiving lower versus higher treatment control over their illness. The same pattern of association was not apparent for personal control. Results suggest that perceived treatment control may help to buffer detrimental associations between negative affect and adolescents’ ability to successfully manage their diabetes.     

Anorexia nervosa in association with diabetes mellitus--a cognitive-behavioural approach to treatment

A case of anorexia nervosa occurring in a patient with diabetes mellitus is reported. The patient was successfully managed using a cognitive-behavioural treatment approach. The presence of diabetes necessitated certain modifications to the standard cognitive-behavioural treatment for anorexia nervosa, including self-monitoring of diabetic regimen behaviours, attention to the adequacy of glycaemic control, and advice about changes in insulin dosage. Cognitive restructuring techniques also had to address diabetes-related thoughts. The general applicability and cost-effectiveness of this type of approach for the treatment of patients with co-existing eating disorders and diabetes is discussed.     

Physical activity and psychological well-being in children with Type 1 diabetes

Physical activity and psychological well-being contribute to positive lifestyle and well-being in youngsters who have Type 1 diabetes. The aims of this study were to objectively assess the physical activity levels of children with Type 1 diabetes, and investigate associations between physical activity levels, psychological well-being and HbA(1c). Thirty-six children, mean age 12.8 years, participated in the investigation. Physical activity was assessed using heart rate monitoring over four days. Children further completed the Diabetes Quality of Life for Youths Questionnaire, the Physical Self-Perception Profile for Children and the Self-Efficacy for Diabetes Scale. Routine outpatient HbA(1c) measurements were recorded. There were no significant associations between psychological well-being and physical activity, or HbA(1c) and physical activity, thus suggesting physical activity does not directly relate to psychological well-being in children with Type 1 diabetes. It may be that the effect of physical activity differs from that in children without Type 1 diabetes because of the place of physical activity within diabetes management and the need to balance this with insulin dosage and dietary intake to maintain blood glucose levels.     

The health belief model and adolescents with insulin-dependent diabetes mellitus.

We tested the predictive utility of the health belief model (HBM) for adherence with a complex, ongoing medical regimen in the context of a chronically ill youthful population (56 adolescent outpatients with insulin-dependent diabetes mellitus; mean age = 14 years). A three-construct model of health beliefs was tested: Threat (perceived susceptibility combined with severity), Benefits-Costs, and Cues to seek treatment. Multiple indicators of compliance were used, and metabolic control was measured by glycosylated hemoglobin. The Benefits-Costs and Cues constructs were related to compliance in the theoretically expected positive direction. Threat interacted with Benefits-Costs in the prediction of compliance and with Cues in the prediction of metabolic control. The greatest compliance was achieved with low perceived Threat and high perceived Benefits-Costs. Poor metabolic control was associated with high Threat and Cues. As age increased, adherence to the exercise, injection, and frequency components of the regimen decreased.     

On structure of trauma-related stress reactions among people with diabetes mellitus

The factorial structure of trauma-related stress reactions was explored using the Purdue Posttraumatic Stress Disorder revised scale, in a sample of 106 adults with insulin-dependent diabetes mellitus. An exploratory factor analysis yielded 2 factors, (a) arousal and passive cognitive-affective avoidance reactions and (b) re-experiencing and active avoidance reactions. The 2-factor structure, however, may also be reflective of the scale format which limits its interpretative power.     

Mood changes associated with blood glucose fluctuations in insulin-dependent diabetes mellitus

Individuals with insulin-dependent diabetes mellitus (IDDM) and their healthcare practitioners believe that extreme blood glucose (BG) fluctuations are characterized by changes in subjective mood states and emotional behavior, as well as physical symptoms. This study examined relationships between BG levels and self-reported mood in a group of 34 IDDM adults. The method followed a within-subject, repeated-measures design employed in previous studies of physical symptoms associated with diabetic glucose. Four times each day, participants completed a mood/symptom checklist just prior to a self-measurement of BG until 40 checklists had been completed. Half the items on the checklist described physical symptoms and half described mood states. In addition, half the mood items described negative states and half described positive states. Within-subject correlations and regressions showed that moods were related to BG for the majority of participants and that, like physical symptoms, mood-BG relationships were highly idiosyncratic. Low BG levels tended to be associated with negative mood states, primarily self-reported "nervousness." Positive mood items were almost always associated with high BG. High BG levels also frequently correlated with negative mood states, although the negative mood items that tended to relate to high glucose (anger, sadness) differed from those that tended to relate to low BG. The implications of these findings for self-treatment and glucose perception in the IDDM individual are discussed.     

Agentic and communal traits and health: adolescents with and without diabetes

The authors examined whether agentic and communal traits are associated with relationship and health outcomes among adolescents with and without diabetes. They interviewed 263 teens (average age 12; 132 Type 1 diabetes; 131 healthy) on an annual basis for 5 years. The authors measured agency, communion, unmitigated agency, and unmitigated communion as well as parent and peer relationship quality, psychological distress, and diabetes health. In concurrent and lagged multilevel models, unmitigated communion and unmitigated agency were associated with poor relationship outcomes and greater psychological distress for those with and without diabetes. In lagged analyses, unmitigated communion predicted deterioration in diabetes health. Communion and agency were associated with positive relationship and health outcomes, with the former being stronger than the latter. These results underscore the need to focus on unmitigated agency and unmitigated communion when studying the implications of personality for health during adolescence.     

Cultural issues in disease management for chinese americans with type 2 diabetes

The purpose of this study is to highlight culturally unique experiences and responses to type 2 diabetes among Chinese immigrant families. Patient and spouse narratives from 16 different families were elicited in a series of group interviews on this topic. Using interpretive phenomenology, 5 primary cultural considerations in diabetes management emerged from the narratives: (1) conceptualization of diabetes, illness and health, (2) significance and meaning of food, (3) perceptions of Chinese and Western medicines, (4) exercise and physical activity, and (5) effects of the disease on family dynamics. The relation of these cultural considerations to an interdependent view of the self, collectivistic social orientation, Chinese cultural beliefs and norms, and acculturation processes are discussed. Clinical recommendations for culturally appropriate disease management strategies are outlined.