AIMS:To explore the prevalence and associated variables of diabetes distress in the adult Faroese type 1 diabetes (T1D) population. METHODS:This nationwide study involved the administration of an online questionnaire to adults diagnosed with T1D. A total of 119 participants (58% of the T1D population) completed the seven-item Type 1 Diabetes Distress Scale (T1-DDS-7) in an online survey conducted from June to August 2023. Logistic regression was used to examine the association between diabetes distress and potential associated variables. RESULTS:A total of 39% of the participants scored 14 or more in the T1-DDS-7, indicating diabetes distress. Multivariate logistic regressions identified five variables that were associated with diabetes distress: younger age, recent diabetes onset, being a smoker, having a lower self-estimated health, and being unsatisfied with the received information from healthcare professionals prior to start of diabetes treatment. CONCLUSIONS:More than one-third of Faroese adults with T1D experienced diabetes distress. Hence, additional targeted support might be necessary for a substantial part of adults with T1D. These findings underscore the significance of the understanding from healthcare professionals of the psychosocial dimensions of diabetes and the need to address diabetes distress as a fundamental component of routine diabetes management.

BackgroundPsychosocial challenges related to adult-onset type 1 diabetes are not systematically addressed in routine diabetes care. The Living with and Adapting to DiabetEs pRogramme (LADDER) was developed to support psychosocial adaptation to diabetes through two distinct interventions: 1) one-to-one consultations, and 2) group sessions. The LADDER interventions were tested in Denmark and the UK to evaluate the feasibility of 1) the research processes; 2) the delivery of the intervention; 3) collection of psychosocial and clinical outcomes and perceived benefits of participation; and to 4) identify key areas for improvement of the interventions.MethodsWe aimed to examine the feasibility of the one-to-one consultations via a controlled design with either non-random (Denmark) or random allocation (UK) to intervention or usual care and the group sessions via a wait-list randomised trial (UK). Psychosocial outcomes were collected through questionnaires, and clinical outcomes were obtained from electronic records. A concurrent process evaluation was conducted through interviews with participants and healthcare professionals.ResultsThe recruitment target was reached in Denmark. Due to a lower-than-expected number of participants, randomisation was abandoned in the UK. Questionnaire response rates were low, and clinical data were difficult to obtain. Due to uncontrolled study designs, small sample sizes, and high questionnaire attrition, quantitative comparisons between intervention and control groups were not feasible. Qualitative findings suggested that the LADDER interventions may support psychosocial adaptation by facilitating reflection, articulation of concerns, and shared understanding within supportive clinical and peer contexts.ConclusionConducting an evaluation of the LADDER interventions through a controlled study was not feasible, likely due to small study populations at each site, combined with changes in clinical working following COVID-19. We suggest using a realist evaluation approach for a future larger study to explore what aspects of LADDER works, for whom and in which contexts.

AIM:To gain insights into the experience of adults with type 1 diabetes (T1D) using a systematic screening method to assess and address diabetes distress (DD) in nurse-led routine diabetes care. METHODS:DD screening in 30 consultations incorporated the Type 1 Diabetes Distress Scale-7 (T1-DDS-7), a short-form, validated instrument capturing the most common sources of DD, and a dialogue model to support diabetes specialist nurses (DSNs) in addressing DD. Semi-structured interviews were conducted with 30 adults with T1D who participated in DD screening. Interviews were analysed using thematic text condensation. RESULTS:Participant mean age and diabetes duration were 47 and 26 years, respectively. Sixteen participants reported moderate to high DD (total T1-DDS-7 score ≥14). Participants described positive experiences discussing DD with DSNs during annual consultations. Three themes emerged from interviews: (1) an eye-opener that enhanced emotional support in adults with T1D, (2) meaningful conversations and personalised diabetes care and (3) increased satisfaction and engagement with diabetes care in adults with T1D. CONCLUSION:Systematically assessing and addressing DD in clinical consultations was both useful and acceptable. Participants reported high levels of satisfaction with the screening method, noting that DSNs used open-ended questions and active listening skills to support managing DD, reflecting good fidelity with the dialogue model. Future research should explore methods for implementing the screening tools to ensure consistent detection of DD in adults with T1D during consultations as well as timely referral to effective interventions.

BACKGROUND:The impact of COVID-19-related changes in diabetes self-management and trajectories of HbA1c throughout COVID-19 is not fully understood. Here, we describe HbA1c trajectories, changes in diabetes self-management and their association before, during and after the COVID-19 pandemic (2019-2022). METHODS:During the spring of 2021, we invited 13,641 outpatients from diabetes clinics in the Region of Southern Denmark to complete a questionnaire regarding changes in diabetes self-management during COVID-19. We linked the questionnaire and registry HbA1c data from before, during and after the COVID-19 pandemic and conducted multivariable adjusted linear mixed-effect regression to assess the association between changes in diabetes self-management and HbA1c. RESULTS:5,581 (40.9%) people responded to the questionnaire (median age: 65 years, males: 59.7%). HbA1c decreased in people with type 2-diabetes and was unchanged for people with type 1-diabetes (interaction: p < 0.001). The majority of people reported unchanged diet (65-71%) and usual medication taking (89-90%). No changes in physical activity were reported by 43%, while 42% reported decreased physical activity. HbA1c trajectories did not differ according to change in physical activity and change in diet intake, while taking medication more regularly was associated with a decrease in HbA1c, from approximately 65/66 mmol/mol (8.1/8.2%) to 60/61 mmol/mol (7.6/7.7%) in both diabetes types. CONCLUSIONS:During COVID-19, HbA1c trajectories differed between diabetes types. Most of the sample maintained usual diabetes self-management, although some decreased physical activity levels. Improved medication taking was associated with decreased HbA1c. This information is crucial for health professionals, in order to provide support aimed at reducing HbA1c.

Background Although commercially developed automated insulin delivery (AID) systems have recently been approved and become available in a limited number of countries, they are not universally available, accessible, or affordable. Therefore, open-source AID systems, cocreated by an online community of people with diabetes and their families behind the hashtag #WeAreNotWaiting, have become increasingly popular. Objective This study focused on examining the lived experiences, physical and emotional health implications of people with diabetes following the initiation of open-source AID systems, their perceived challenges, and their sources of support, which have not been explored in the existing literature. Methods We collected data from 383 participants across 29 countries through 2 sets of open-ended questions in a web-based survey on their experience of building and using open-source AID systems. Narratives were thematically analyzed, and a coding framework was identified through iterative alignment. Results Participants consistently reported improvements in glycemia, physical health, sleep quality, emotional impact on everyday life, and quality of life. Knowledge of open-source AID systems was largely obtained through the #WeAreNotWaiting community, which was also the primary source of practical and emotional support. The acquisition of the components to build an open-source AID system and the technical setup were sometimes problematic. Conclusions The #WeAreNotWaiting movement represents a primary example of how informed and connected patients proactively address their unmet needs, provide peer support to each other, and obtain results through impactful, user-driven solutions. Alongside providing evidence on the safety and efficacy of open-source AID systems, this qualitative analysis helps in understanding how patients’ experiences and benefits range from psychosocial improvements to a reduction in the burden of managing diabetes. International Registered Report Identifier (IRRID) RR2-10.2196/15368

This study explores the perceived influence of social media on psychological wellbeing in young people living with type 1 diabetes. Young people aged 13-20 years (N = 19) with type 1 diabetes and caregivers (diabetes healthcare providers and parents) (N = 8) took part in an online focus group or interview. Thematic analysis was used to analyse the data. Participants reflected on social media's capacity to facilitate accessible peer learning and emotional support. Themes for young people centred on the emotional demand of perceiving diabetes products/diets, stigma, and 'filtered' peer profiles. Caregiver themes centred on the accuracy and trustworthiness of diabetes content. Caregivers perceive that young people find it difficult to be open about their condition online. Young people with type 1 diabetes reflected on how social media enables them to control their experience. Findings reflect the paradoxical nature of social media as a diabetes support aid, and practical implications of this are discussed.

People with diabetes often encounter stigma (ie, negative social judgments, stereotypes, prejudice), which can adversely affect emotional, mental, and physical health; self-care, access to optimal health care; and social and professional opportunities. To accelerate an end to diabetes stigma and discrimination, an international multidisciplinary expert panel (n=51 members, from 18 countries) conducted rapid reviews and participated in a three-round Delphi survey process. We achieved consensus on 25 statements of evidence and 24 statements of recommendations. The consensus is that diabetes stigma is driven primarily by blame, perceptions of burden or sickness, invisibility, and fear or disgust. On average, four in five adults with diabetes experience diabetes stigma and one in five experience discrimination (ie, unfair and prejudicial treatment) due to diabetes, such as in health care, education, and employment. Diabetes stigma and discrimination are harmful, unacceptable, unethical, and counterproductive. Collective leadership is needed to proactively challenge, and bring an end to, diabetes stigma and discrimination. Consequently, we achieved unanimous consensus on a pledge to end diabetes stigma and discrimination.

BACKGROUND:Diabetes distress refers to the negative emotional reaction to living with the demands of diabetes; it occurs in >40% of adults with type 1 diabetes (T1D). However, no interventions to reduce diabetes distress are specifically designed to be an integral part of diabetes care. OBJECTIVE:This study aims to modify and adapt existing evidence-based methods into a nurse-led group intervention to reduce diabetes distress among adults with T1D and moderate to severe diabetes distress. METHODS:The overall framework of this study was informed by the initial phase of the Medical Research Council's complex intervention framework that focused on undertaking intervention identification and development to guide the adaptation of the intervention. This study took place at 2 specialized diabetes centers in Denmark from November 2019 to June 2021. A total of 36 adults with T1D participated in 10 parallel workshops. A total of 12 diabetes-specialized nurses were interviewed and participated in 1 cocreation workshop; 12 multidisciplinary specialists, including psychologists, educational specialists, and researchers, participated in 4 cocreation workshops and 14 feedback meetings. Data were analyzed by applying a deductive analytic approach. RESULTS:The intervention included 5 biweekly 2.5-hour small group sessions involving adults with T1D and diabetes distress. Guided by a detailed step-by-step manual, the intervention was delivered by 2 trained diabetes specialist nurses. The intervention material included visual conversation tools covering seven diabetes-specific sources derived from the 28-item Type 1 Diabetes Distress Scale for measuring diabetes distress: (1) powerlessness, (2) self-management, (3) fear of hypoglycemia, (4) food and eating, (5) friends and family, (6) negative social perception, and (7) physician distress. The tools are designed to kick-start awareness and sharing of diabetes-specific challenges and strengths, individual reflections, as well as plenary and peer-to-peer discussions about strategies to manage diabetes distress, providing new perspectives on diabetes worries and strategies to overcome negative emotions. Diabetes specialist nurses expressed a need for a manual with descriptions of methods and detailed guidelines for using the tools. To deliver the intervention, nurses need increased knowledge about diabetes distress, how to support diabetes distress reduction, and training and supervision to improve skills. CONCLUSIONS:This co-design study describes the adaptation of a complex intervention with a strong evidence base, including detailed reporting of the theoretical underpinnings and core mechanisms.

• Young people alternate between perceiving diabetes as an integrated part of their internal identity, and as separated from their external identity. • Young people contain their condition within their internal identity as a means of maintaining a sense of control over the impression they make on others. • The formation of their identity is closely intertwined with concepts of normality and deviance, with the latter leading to negative self-perceptions and mental distress. • The management of diabetes can evoke feelings of empowerment or generate pressure, both of which have an impact on their overall psychological well-being.

There is broad consensus in the global diabetes community that diabetes education and psychosocial support are critical elements of care for all people with diabetes and their family members. Yet questions remain about the extent to which diabetes education effectively enhances self-management or addresses the psychosocial aspects of living with diabetes. The purpose of this chapter is to support enhanced competency in the delivery of self-management education and psychosocial support by clearly specifying the values, attitudes, and competencies that promote self-management. Diabetes education and support has the potential to empower people with diabetes to live well with diabetes. Diabetes is managed on a daily basis by the person with diabetes in the context of their sociocultural environment. Dialogue and participation enable the educator to shift from the expert (teach and tell) to collaboration (collaboration and empowerment).

AIMS:To explore the feasibility and potential benefits of a peer support programme for adults with insulin-treated type 2 diabetes (T2D) starting continuous glucose monitoring (CGM). METHODS:This part of the Steno2tech study is an exploratory, single-centre, open-labelled, prospective, randomised controlled trial (RCT). A total of 60 participants were randomised 2:1 to 12 months of CGM with or without peer support. All participants received a 3-h diabetes self-management education course including a CGM part on how to use the CGM and interpret the CGM-derived data. Peer support consisted of three 3-h peer support meetings over the first 6 months of the study period with groups of three to six people. The exploratory outcomes included the acceptability and feasibility of the peer support intervention, and the between-group difference in change in several glycaemic, metabolic and participant-reported outcomes measured at baseline, 6 and 12 months. RESULTS:The peer support intervention was found acceptable and feasible. Participants shared their experiences of using and interpreting CGM data and its association with health behaviour. While both groups had improvements in glycaemic, metabolic and participant-reported outcomes, there were no significant between-group differences. CONCLUSIONS:Although feasible, we found no measured additional benefits when adding a peer support programme after starting CGM in this exploratory RCT including adults with insulin-treated T2D. Understanding the perceived effect of and preferences for a peer support intervention from the participants' points of view, including why individuals declined to participate, would be of value for future research.

OBJECTIVE:Binge eating has adverse health effects and may be 10 times more common in people with type 2 diabetes (T2D) than in the general population. Still, binge eating is not consistently addressed in diabetes treatment. People with T2D and binge eating may, therefore, seek guidance on the topic on social media. The study objective was to explore discussions about binge eating among members of a T2D-specific Facebook group. METHOD:Interactions among members of the Facebook group were observed over 8 months and supplemented by keyword searches within group content. The data were imported into NVivo12 and analyzed using Interpretive Description. RESULTS:The overarching theme described how group members exchanged guidance concerning co-existing T2D and binge eating based on personal experiences while trying to resolve co-members' misapprehensions regarding binge eating. Two subthemes were generated, describing frequently discussed topics relating to binge eating triggers and inhibitors. Triggers were confusion about the health impacts of carbohydrates and encounters with unsupportive clinicians, while inhibitors included the possibility of speaking openly about binge eating with peers and hunger cues being suppressed by glucagon-like peptide 1 receptor agonists. DISCUSSION:Social media may constitute an important source of support for people with T2D and binge eating, as the topic is typically not addressed in routine care. Besides being aware of the extent of binge eating in people with T2D and the health risks involved, clinicians should keep in mind that people with both conditions may seek information on social media that can affect diabetes management.

IntroductionThe study aimed to investigate independent and combined associations between insulin delivery method (insulin pump therapy (IPT) vs multiple daily injections (MDI)), glucose monitoring method (intermittently scanned continuous glucose monitoring (isCGM) and real-time continuous glucose monitoring (rtCGM) vs blood glucose metre (BGM)) and diabetes distress (DD) in adults with type 1 diabetes (T1D).Research design and methodsWe combined data from two Danish questionnaire-based surveys, the Steno Tech Survey (n=1591) and the Type 1 Diabetes Distress Scale (T1-DDS) validation survey (n=4205), in which individuals aged ≥18 years with T1D were invited to participate. The 28-item T1-DDS was used to measure DD and DD scores were categorised as little or no distress (score <2.0), moderate distress (2.0–2.9) and high distress (score ≥3.0). Associations between insulin delivery, glucose monitoring methods and DD were assessed using linear regression.ResultsAmong 2068 adults with T1D who responded to one of the surveys, the use of IPT was associated with a lower total T1-DDS score (−0.09, 95% CI 0.16 to −0.03) compared with MDI and adjusted for glucose monitoring method. The use of CGM was associated with a higher total T1-DDS score (0.11, 95% CI 0.05 to 0.18) compared with BGM and adjusted for the insulin delivery method. IPT was still associated with a lower T1-DDS score, regardless of being combined with BGM (−0.17, 95% CI −0.28 to −0.06) or CGM (−0.13, 95% CI −0.21 to −0.05), compared with MDI with CGM. No association was found between the type of CGM (isCGM vs rtCGM) and DD among either IPT or MDI users when restricting analysis to individuals using CGM.ConclusionsAmong Danish adults with T1D, the use of IPT was associated with lower levels of DD, while CGM use was associated with higher levels of DD. DD should be addressed when introducing people with T1D to diabetes technology, CGM in particular.Trial registration numberNCT04311164(Results).

•Young people perceive diabetes as an integrated part of their internal identity, and as separated from their external identity.•Young people attempt to control the impression they ake of themselves in relation to diabetes on others.•The formation of identity is intertwined with concepts of normality and deviance, with the latter leading to mental distress.•Diabetes care evoke feelings of empowerment or generate pressure, which have an impact on overall psychological well-being.

Up to 25% of people with type 2 diabetes (T2D) may binge eat which is almost 10 times as many as in the general population. Binge eating is associated with depression, anxiety, and social isolation. Moreover, binge eating may increase the risk of obesity and high blood glucose levels, both of which can accelerate the onset of complications to diabetes and death in people with T2D. Still, little is known about the experiences, needs, and preferences of people with T2D and binge eating that can inform and develop current and future treatment efforts. The aim of the study was therefore to gain in-depth insights into the experiences and biopsychosocial support needs of women and men with T2D and binge eating. Twenty semi-structured individual interviews (65% with females) were conducted and analyzed according to the methodology of Interpretive Description. Four themes were identified: (a) T2D and binge eating: Feeling trapped in a vicious circle; (b) Unwanted outcasts: Responding to continuous criticism; (c) Biomedical relief: Blaming and adjusting the body; and, (d) Silent struggles: Wanting to cease the secrecy. Pertinent to all themes were the guilt, shame, and worries about developing complications that the participants experienced when binge eating despite having T2D. Although binge eating triggered emotional distress, binge eating was at the same time a way of coping with such distress. Implications for treatment and future research are discussed, including the need to systematically assess and address binge eating in routine T2D care.

Objectives To construct and test patient-reported outcome measures (PROMs) for identifying diabetes support needs of adults with co-existing diabetes and severe mental illness (SMI) provided by mental health professionals at psychiatric outpatient clinics.Methods Design thinking was used to identify, select, and modify PROMs in collaboration with 18 adults with type 1 or type 2 diabetes and SMI and 10 healthcare experts. The PROMs were then tested with 86 adults with diabetes and SMI recruited from eight psychiatric outpatient clinics in Denmark. Data were analysed using systematic text condensation (questionnaire construction) and descriptive statistics (testing).Results Four principles for PROMs were identified: (a) be modified to be relevant for the target group, (b) be concise and simple to complete, (c) have a clear and unambiguous wording, and (d) be designed to measure topics that are perceived as meaningful. Test of the questionnaire contained 49 items in four domains. Missing response rates in the test were 1.2-4.7% in three domains and 4.7-11.6% in a domain addressing potential sources of diabetes support.Discussion PROMs can successfully be constructed in collaboration with this vulnerable population that yield low rates of missing responses.

Aim: To validate the Type 1 Diabetes Distress Scale (T1-DDS) in a large sample of adults with Type 1 diabetes (T1D) from diabetes clinics in Denmark. Methods: Altogether 40 adults with T1D were interviewed to explore the content of T1-DDS in a Danish setting and to validate the translation of the T1-DDS into Danish. Subsequently, a survey including T1-DDS, the Problem Areas In Diabetes scale (PAID-20), fear of hypoglycemia, social support, and diabetes duration was answered by 2201 people with T1D. Other person characteristics were collected from the National Patient Register. HbA1c was obtained from the Clinical Laboratory Information System. Data distribution, internal consistency, convergent and construct validity, factor structure, three weeks retest, and cut-points were explored. Results: Interview data supported the relevance of all T1-DDS items for the assessment of diabetes distress among adults with T1D. The T1-DDS showed good content and acceptable construct validity, and the ability to detect high diabetes distress levels. A high correlation between T1-DDS and PAID-20 (rho = 0.91) was found. The retest scores showed a good reliability (all rho >= 0.68) with the highest variability in the Friends/Family Distress and Physician Distress subscales and the lowest variability in the Powerlessness and Eating Distress subscales of the T1-DDS. Qualitative findings pointed out relevant concerns of people with T1D, which were not included in the T1DDS. Conclusion: The study supports the use of the Danish T1-DDS, but also highlights that existing diabetes distress questionnaires including T1-DDS do not cover all potential diabetes stressors and worries.

Aims: We aimed to estimate effects of insulin pump therapy (IPT) on HbA1c level, HbA1c variability, and risk of hospitalised diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH), compared with multiple daily insulin injections (MDI).Methods: We identified a cohort of all adults with type 1 diabetes in Denmark using national registry data and assigned each individual to either IPT (treatment) or MDI (control) from 2010 to 2020. We estimated average treatment effects on the treated (ATT) and treatment effects among population subgroups using treatment-staggered difference-in-differences.Results: The cohort consisted of 26,687 individuals with a collective 243,601 person-years of observation; 38,823 (16 %) were IPT person-years. We identified an ATT for HbA1c of-0.33 % (95 % CI-0.39 to-0.27;-3.6 mmol/ mol [95 % CI-4.2 to-2.9]). ATTs were larger among women and individuals who were older, had highest baseline HbA1c, and used continuous glucose monitoring. ATT for HbA1c variability (-0.016 % [-0.028 to-0.0041);-0.17 mmol/mol [95 % CI-0.30 to-0.045]) corresponded to a 6.5 % decrease in the standard deviation of HbA1c. ATTs for DKA and SH corresponded to 0.52 additional and 0.11 fewer hospitalisations per 1,000 person-years, respectively.Conclusions: IPT significantly reduced HbA1c level and variability, compared with MDI. However, it also marginally increased the risk of hospitalised DKA.

Aims: People with type 2 diabetes experience a range of negative work-related outcomes at a time when people are expected to remain active within the labour market for longer. This study sought to identify the work-related challenges faced by people with type 2 diabetes and ways to address them.Methods: Recruitment was undertaken in two contexts and focussed on people living with type 2 diabetes of working age (18-67). A further inclusion criterion for participants was that they were registered as having at least one diabetes-related complication. Qualitative data was gathered via semi-structured interviews and interactive workshops and analysed using systematic text condensation.Results: Three themes were identified. The first theme highlighted that participants did not generally believe that their diabetes caused them any problems in the context of work, though this was not fully supported in their own accounts. The second theme pointed to the positive value attached to work, simultaneously indicating that work could negatively impact diabetes management and general health. The final theme highlighted the ways that both participants and their healthcare providers considered diabetes in isolation from other aspects of life, potentially delaying remedial actions.Conclusions: Epidemiological data indicate that there are serious issues linked to living with type 2 diabetes and work-related outcomes. The extent to which these issues are recognized and understood may be obfuscated or contained by the value which people attach to work-life. More needs to be done to tease out work-related challenges for people with type 2 diabetes to better initiate timely remedial actions.

Aim: To pilot-test an intervention, co-designed with people with type 1 diabetes (T1DM) and diabetes specialist nurses, to reduce diabetes distress (DD) in adults with T1DM and moderate-to-severe DD. Methods: A group-based programme to reduce DD in people with T1DM and moderate-to-severe DD (REDUCE) was pilot-tested in four groups with five bi-weekly two and a half-hour meetings facilitated by two trained diabetes specialist nurses. Data collection included baseline and post-intervention questionnaires measuring DD and psychosocial outcomes and semi-structured interviews with participants post-intervention (n = 18). Data were analysed using descriptive statistics and systematic text condensation. Results: Twenty-five adults with T1DM participated in the study. The median age and diabetes duration of participants were 50 (IQR: 32;57.5) years and 26 (IQR: 18;45) years, respectively. Seventeen (68%) were women. The pilot study showed a significant reduction in DD (measured by Type 1 Diabetes Distress Scale) between baseline and post-intervention from 2.6 +/- 0.7 to 1.9 +/- 0.6 (mean +/- SD) (p < 0.001). The largest reductions were seen on the subscales: powerlessness 1.2 +/- 1.1, eating distress 0.9 +/- 1.2 and fear of hypoglycaemia 0.8 +/- 1.0 (mean +/- SD). Significant improvements were also seen for quality of life, diabetes empowerment and emotion regulation. Qualitative data showed that REDUCE supported participants in verbalizing emotions and seeing worries in a more constructive perspective. Acknowledgement of negative diabetes experiences eased negative self-judgments. Sharing experiences among peers increased relatedness and reduced loneliness. Conclusion: Participation in REDUCE was associated with significant reduction in DD and significant increase in quality of life. Larger scale studies are planned to determine sustained effectiveness of REDUCE.