The philosophers of antiquity and others through the ages recognized the connection of human emotion and thought with physiological processes and behavior (1). The relatively recent increases in the human life span and the prevalence of significant chronic illnesses have generated a greater appreciation of the relationship between human emotional, social, cognitive, and behavioral processes and health and wellness. However, understanding human behavior remains challenging, and in the presence of a significant chronic illness such as diabetes, that challenge becomes even more daunting. Specifically, the interaction of individual differences in emotional responses, attitudes, thought processes, preferences, beliefs, and social situations appear amplified with the increased complexities of new diabetes treatments. With the realization that other factors such as quality of life are equally important as physiological outcomes, the necessity of understanding behavioral and psychosocial processes is evident (2,3). Thus, the era of simply outlining a broad plan and sending it home for the patient to implement, if that era ever existed, is over. The era of placing the person with diabetes and family in the center of health care decisions and understanding their individual challenges and barriers has begun. Given the emerging concepts in the psychosocial aspects of diabetes, the editorial committee of Diabetes Care wanted to highlight this area in this issue.
This special issue of Diabetes Care presents nine articles that represent a broad spectrum of behavioral and psychosocial issues that can influence treatment success and quality of life for those living with diabetes. Central to this topic and serving as the cornerstone of the special issue is the publication of the first Position Statement from the American Diabetes Association (ADA) for the psychosocial care of people with diabetes (4). This is followed by the presentation of a collection of articles that represent important aspects of …
Background: Older adults with type 1 diabetes (T1D) face unique challenges, especially when their support structure is disrupted, as happened during the Covid-19 lockdown. We evaluated the clinical and psychological impact of this imposed isolation on the older population with T1D. Methods: We conducted semi-structured interviews with older adults with T1D who were part of an ongoing study, which was paused from March - August 2020. The interviews were performed between May - August 2020, and were transcribed, coded, and analyzed using content analysis to derive theme. A multidisciplinary team of 12 individuals coded the interviews to identify the themes and included geriatricians, endocrinologists, a nurse educator, infomaticists, an economist, a methodologist, and research assistants. Results: We have analyzed 12/35 interviews at this time; mean age 74±4 years, 50% female, 92% non-Hispanic white, mean duration of diabetes 37±18 years, and A1C 7.3±0.7%. Three main themes have emerged. The challenges related to diabetes care included fear of hypoglycemia, interruption in supply chain related to diabetes technology (insulin pump and continuous glucose monitoring (CGM) supplies), use of telehealth, diabetes-related distress, and adapting to new routines in self-care (diet and exercise). Challenges related to the Covid-19 pandemic included fear of getting Covid-19 infection, and a lack of reliable information on pandemic. The challenges related to psychological well-being included a feeling of isolation, loneliness, inability to spend time with family and friends, lack of in-person communication, and lack of recreational activity. Conclusion: The results of this qualitative study help to understand critical areas of need when social support structures are unavailable to older adults with T1D. Our results will help develop intervention strategies to overcome barriers in maintaining support for this vulnerable population. Disclosure M. Munshi: Consultant; Self; Sanofi. S. Neuwahl: None. S. Cummings: None. S. L. Brown: Stock/Shareholder; Self; Pfizer Inc., Siemens Corporation. K. Weinger: None. E. Toschi: Consultant; Self; Medtronic. C. Slyne: None. K. Sifre: None. D. J. Davis: None. R. Dewar: None. S. M. Sy: None. A. Atakov-castillo: None. A. Michals: None. S. N. Haque: None. Funding National Institutes of Health (1DP3DK112214-01)
The editorial by Perlmuter et al. (1) in the October 2008 issue of Diabetes Care commented on the long-term effects of severe hypoglycemia and raised concerns about our study (2), which reported that within the cohort of subjects who entered the Diabetes Control and Complications Trial (DCCT) during adolescence, there was no relationship between subsequent episodes of severe hypoglycemia and cognitive performance measured ∼20 years after study entry. Below, we outline their five major concerns and provide supporting information.
One concern of Perlmuter et al. was the exclusion of potential participants from the DCCT if they had a history of severe hypoglycemia, thus limiting generalizability. However, a history of severe hypoglycemia was not an absolute exclusion criterion for participation in the DCCT. Indeed, 24% of the 175 participants had previously experienced 1–5 episodes of severe hypoglycemia with loss of consciousness before entry …
In Brief Mental health concerns and family dynamics. Specific psychosocial challenges can be a barrier to effective diabetes self-management and should not be ignored.
Neural substrates for low cognitive performance and depression, common long-term central nervous system–related changes in patients with type 1 diabetes mellitus, have not yet been studied.
Objective
To investigate whether prefrontal glutamate levels are higher in patients with type 1 diabetes and whether an elevation is related to lower cognitive performance and depression.
Design
Cross-sectional study.
Setting
General clinical research center.
Participants
One hundred twenty-three patients with adult type 1 diabetes with varying degrees of lifetime glycemic control and 38 healthy participants.
Main Outcome Measures
With the use of proton magnetic resonance spectroscopy, prefrontal glutamate–glutamine–γ-aminobutyric acid (Glx) levels were compared between patients and control subjects. Relationships between prefrontal Glx levels and cognitive function and between Glx levels and mild depressive symptoms were assessed in patients with type 1 diabetes.
Results
Prefrontal Glx concentrations were 9.0% (0.742 mmol/L;P = .005) higher in adult patients with type 1 diabetes than in healthy control subjects. There were positive linear trends for the effects of lifetime glycemic control on prefrontal Glx levels (Pfor trend = .002). Cognitive performances in memory, executive function, and psychomotor speed were lower in patients (P = .003, .01, and <.001, respectively) than in control subjects. Higher prefrontal Glx concentrations in patients were associated with lower performance in assessment of global cognitive function (0.11 change inzscore per 1-mmol/L increase in Glx) as well as with mild depression.
Conclusions
The high prefrontal glutamate levels documented in this study may play an important role in the genesis of the low cognitive performance and mild depression frequently observed in patients with type 1 diabetes. Therapeutic options that alter glutamatergic neurotransmission may be of benefit in treating central nervous system–related changes in patients with adult type 1 diabetes.
BACKGROUND Background: The COVID-19 lockdown imposed a sudden change in lifestyle with self-isolation and a rapid shift to the use of technology to maintain clinical care and social connections. OBJECTIVE Objective: In this mixed-methods study, we explored the impact of isolation during the lockdown on the use of technology in older adults with Type 1 Diabetes (T1D) METHODS Methods: Older adults (age ≥65 years) with T1D using continuous glucose monitoring (CGM) participated in semi-structured interviews during the COVID-19 lockdown. A multidisciplinary team coded the interviews. In addition, CGM metrics from a subgroup of participants were collected before and during the lockdown. RESULTS Results: We evaluated 34 participants (age 71±5 years). Three themes related to technology use emerged from the thematic analysis regarding the impact of isolation on: 1) insulin pump and CGM use to manage diabetes including timely access to supplies, and changing Medicare eligibility regulations; 2) technology use for social interaction, and 3) telehealth use to maintain medical care. The CGM data from a subgroup (n=19; age 74±5 years) showed an increase in time in range (57±17 vs 63±15%; p= 0.001), a decrease in hyperglycemia (>180 mg/dL) (41±19 vs 35±17; p< 0.001), and no change in hypoglycemia (<70 mg/dL) (0.7% vs 1.1%) during the lockdown, compared to before. CONCLUSIONS Conclusion: These findings show our cohort of older adults successfully used technology during isolation. Participants provided positive and negative perceptions of technology use. Clinicians can benefit from our findings by identifying barriers to technology use during times of isolation and developing strategies to overcome these barriers. CLINICALTRIAL Clinicaltrials.gov NCT03078491
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