ArticleLiterature Review

Fear, guilt feelings and misconceptions: Barriers to effective insulin treatment in type 2 diabetes

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Abstract

Diabetes self management education, the process of teaching individuals to manage their diabetes, has been considered the cornerstone of the clinical management of individuals with diabetes since the work of the Joslin Diabetes Center. The goals of self-management education are to optimize metabolic control, prevent acute and chronic complications, and optimize quality of life. The keystone to successful management is to involve the patient in his treatment. Clearly, factors other than knowledge and effective therapies affect the behaviors of patients and health care professionals and influence their ability to make optimal use of available treatments. The DAWN study has shown that both health care providers and patients may have a negative attitude toward starting insulin therapy. Patients with type 2 diabetes are very often reluctant to accept insulin therapy. The reasons most commonly encountered, for this negative attitude are: Patients blame themselves, for they consider that starting insulin therapy would indicate they had "failed" proper diabetes self-management. For some patients taking insulin means life will be more restricted or it means they have reached their last resort. Fear of hypoglycemia is a very common barrier for insulin therapy. Physicians may, unconsciously, negatively influence their patients. For some physicians putting his patient on insulin, means that he has failed to control his patient's diabetes on oral agents and now has to force him in a troublesome therapeutic regime. In order to overcome these barriers, health care professionals, rather than trying to "convince" their patients of the necessity of the treatment, should assess, by active listening, the precise reason for which his/her patient denies it.

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... In supporting this finding, insulin's side effects in Oman [48], and the fact that it is a life-long therapy in Malaysia [49] and Nigeria [50] have been cited as major barriers to insulin treatment. A study in United States of America (USA) also indicated that fear of hypoglycemia was one of the most common barriers to insulin treatment [51]. So, according to a forum for injection technique held in Malaysia, all persons with diabetes who are prescribed insulin treatment should be educated about the symptoms and early management of hypoglycemia. ...
... Patients in other countries have also reported that missed doses, [60], which should be addressed during routine medical checks with appropriate advice [61]. Misperceptions about insulin use were also mentioned as barriers by studies in USA [51] and Iran [62]. The insulin to be injected in the abdomen was thought to drain and collect in the penis's body, resulting in ED. ...
... Putting a patient on insulin, for some doctors, indicates that he has failed to control his diabetes with oral medications and now needs to force him into a difficult treatment regime. Instead of attempting to convince their patients of the treatment's necessity, health care practitioners should analyze the precise cause for his or her patients' denial of it through active listening [51]. ...
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Background Despite being the most effective treatment for advanced type 2 diabetes, the choice to start and maintain insulin therapy is based on a variety of criteria, including the patients' acceptance and willingness to adhere to it. The patients' beliefs and experiences, on the other hand, could not be revealed without a thorough exploration. Objectives This study investigated the barriers and facilitators to insulin treatment from the perspectives of patients with type 2 diabetes following treatment at Dessie Comprehensive Specialized Hospital, North-East Ethiopia. Methods A phenomenological study was conducted from July 2019 to January 2020. Twenty-four (11 males and 13 females) participants were recruited purposively. Data were collected through face-to-face in-depth interviews, lasted about 23 to 71 min, until theoretical saturation was reached, and then organized using QDA Miner Lite v2.0.9. The transcripts were thematically analyzed using narrative strategies and the themes that arose were discussed in detail. Results The most common facilitator of insulin treatment was its relative effectiveness, which was followed by its convenience (fewer gastrointestinal side effects, small needle size and ease of use), the concept of it is life, faith in doctors' decisions, family support, and health insurance membership. The most common impediments, on the other hand, were market failures (expensiveness and supply shortages), followed by its properties and patients' circumstances. Conclusions Market failures due to supply shortages and associated costs were identified to be the most significant barriers to insulin treatment, necessitating the availability of an effective pharmaceutical supply management strategy that targets on insulin supply and affordability. It is also strongly recommended that health insurance coverage be increased.
... To overcome this challenge, clinicians should actively listen to patients' concerns and/or fear regarding insulin therapy and explain that type 2 diabetes is a progressive disease and that β-cell failure is common. 31 For example, if the patient is concerned about insulin-induced hypoglycemia, the clinician can explain that newer longand short-acting insulin analogs are less likely to cause hypoglycemia compared with older insulin preparations and that severe hypoglycemia is seen mainly in patients with type 1 diabetes mellitus (T1DM). 31 ...
... 31 For example, if the patient is concerned about insulin-induced hypoglycemia, the clinician can explain that newer longand short-acting insulin analogs are less likely to cause hypoglycemia compared with older insulin preparations and that severe hypoglycemia is seen mainly in patients with type 1 diabetes mellitus (T1DM). 31 ...
... Although patient education is a time consuming task for physicians, 27 clinicians should give patients the time to express their fears and concerns about insulin therapy, thereby identifying preexisting misconceptions and addressing them accordingly. 31 For example, physicians often overestimate the patient's fear of injection pain, making a preemptive decision to delay or withhold insulin, whenin fact -one study showed that fear of pain ranked fairly low among patients. 50 The majority of PCPs agree that the potential for insulin to prevent or to delay complications far outweighs the risks of weight gain and hypoglycemia. ...
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Type 2 diabetes mellitus (T2DM) is a chronic illness that requires clinical recognition and treatment of the dual pathophysiologic entities of altered glycemic control and insulin resistance to reduce the risk of long-term micro- and macrovascular complications. Although insulin is one of the most effective and widely used therapeutic options in the management of diabetes, it is used by less than one-half of patients for whom it is recommended. Clinician-, patient-, and health care system-related challenges present numerous obstacles to insulin use in T2DM. Clinicians must remain informed about new insulin products, emerging technologies, and treatment options that have the potential to improve adherence to insulin therapy while optimizing glycemic control and mitigating the risks of therapy. Patient-related challenges may be overcome by actively listening to the patient's fears and concerns regarding insulin therapy and by educating patients about the importance, rationale, and evolving role of insulin in individualized self-treatment regimens. Enlisting the services of Certified Diabetes Educators and office personnel can help in addressing patient-related challenges. Self-management of diabetes requires improved patient awareness regarding the importance of lifestyle modifications, self-monitoring, and/or continuous glucose monitoring, improved methods of insulin delivery (eg, insulin pens), and the enhanced convenience and safety provided by insulin analogs. Health care system-related challenges may be improved through control of the rising cost of insulin therapy while making it available to patients. To increase the success rate of treatment of T2DM, the 2012 position statement from the American Diabetes Association and the European Association for the Study of Diabetes focused on individualized patient care and provided clinicians with general treatment goals, implementation strategies, and tools to evaluate the quality of care.
... In the past 20 years we have witnessed the transition from administering insulin syringes to pens which has improved the safety of insulin administration amongst older individuals with dexterity and visual impairment [58,59]. While newer innovations such as continuous glucose monitoring can potentially ease anxiety and provide peace of mind in insulin dependent people [60][61][62], it is important to ensure that such advances empower older adults, rather than generating anxiety over technical issues or promoting a hypervigilance of glucose levels. ...
... The second theme refers to supporting the social and emotional issues that insulin can bring in this population. Whilst experiencing negative emotions which create barriers to efficient insulin selfmanagement are common in all age groups [60,61] for older adults particularly, there can be a feeling of resignation and lack of motivation to manage their diabetes effectively. Older adults are also likely to find it more challenging to address diet and exercise habits which may have become ingrained over the years [62]. ...
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Background Type 2 diabetes mellitus is common in older people. Managing diabetes in older people can be challenging due to comorbidities and age-related disabilities, particularly in the context of insulin therapy. The purpose of this review is to explore older people’s experiences of insulin use and to consider how these experiences might inform healthcare delivery. Review methods A systematic review with thematic synthesis was conducted and reported in accordance with the PRISMA and ENTREQ statements. MEDLINE, Embase, PsycInfo, CINAHL and Web of Science were searched from 1985 to September 2019 with subsequent updates in December 2019 and June 2022. Included studies were quality appraised, findings tabulated, and results used to inform an integrated thematic synthesis. Results Fourteen studies that reported insulin experiences with 274 patients aged 60 years and over were included; nine of the studies were qualitative and five used questionnaires surveys. Seven themes emerged that were grouped into treatment-related factors (physical impact of insulin, physical capacity to administer insulin, insulin self-management behaviours) and person-centred factors (emotional factors, social factors, daily living, and personal knowledge/beliefs). Three analytical themes to guide clinical practice were derived from the data: addressing physical capacity and ability, supporting social and emotional issues and improving interactions with healthcare professionals. Conclusion The review indicates issues surrounding the technical aspects of insulin administration, side effects of treatment and reactions to insulin administration are common amongst older people. However, research evidence is limited, and there is an urgent need for empirical, participatory research with older insulin dependent adults with type 2 diabetes. Implications for practice Healthcare professionals need to ensure that older type 2 diabetes people on insulin are actively involved in their own care, to allow their insulin regimens to be personalised and aligned with their goals and expectations. Tailored educational interventions to reduce treatment hazards and promote physical and psychological wellbeing are also needed for this population.
... This in turn affects care relationships, potentially engendering feelings of guilt and inadequateness in physicians and consequently the urge to address patients' needs [36]. Indeed, previous studies have found a strong perceived responsibility in dealing with the emotional sufferance of patients with diabetes [8,12] as well as a sense of deficiency and personal failure [9,35] that can be overcome by using active listening and relational skills [13,29,37]. In this sense, both the fear of failure and the strive for achievement are strongly intertwined and underlie a motivation to derive satisfaction from the mastery of challenging tasks and effective care relationships [38]. ...
... The third factor deals with an anxiety pattern shaping the physician-patient interaction, characterized by insecure-ambivalent attachments. As reported by several pieces of research, physicians treating patients with diabetes experience feelings of anxiety [8,9,12,37], with specific regard to worries about patients' outcomes, fears of losing control over treatment and time constraints limiting individualized care. This may lead to feeling overwhelmed by social needs of patients as well as confused about one's professional role because of the risk of an excessively symbiotic relation with patients [8]. ...
Article
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Objective To explore the subjective experience of physicians working in diabetic settings about their care relationships in order to find some unique clues contributing to physician professional health and capacity to manage patients’ adherence. Research design and methods An interview-based exploratory study has been carried out involving 18 physicians (77.8% female) with at least 3 years of clinical practice in diabetes care. In-depth interviews about the emotional experience with patients with diabetes were conducted and audio recorded. Interviews transcripts were analyzed through a computer-based text analysis which allowed the identification of thematic domains (Cluster Analysis) and latent factors (Correspondence Analysis) viewed through a psychodynamic and constructivist lens. Results Six thematic domains emerged respectively referring to: Concern (8.43%), Control (14.42%), Ambivalence (22.08%), Devotion (22.49%), Guilt (19.29%) and Strive for Achievement (13.30%). Moreover, three latent dimensions were taken into account, which explained 69.20% of data variance: Affect Repression (28.50%), Tendency to Repair (22.70%) and Anxiety Pattern (18.00%). Conclusions Overall, the results of the present study confirm the challenging nature of diabetes care. In particular, physicians ongoing effort to restore patients’ psychological integrity in chronic condition constitute the most novel finding above all. In this regard, the need for emotional labor in physicians’ education and training is suggested in order to both prevent burnout symptoms (e.g. depersonalization) and promote shared decision making in care relationships. However, findings should be treated as preliminary given the convenience nature of the sample and its reduced size.
... Complications are more dangerous than diabetes itself, such as kidney disease, retinopathy, and neurological disorders. Diabetic patients commonly experience emotional stress when blood glucose management is neglected, such as anxiety, depression, and regret [1,2]. Mental stress and physical pain make the patient's quality of life worse when diabetes develops into a chronic disease. ...
... First, target heart rate (THR) is obtained from Karvonen's formula. The maximum heart rate is roughly estimated using Equation (1). The heart rate reserve (HRR) is obtained from subtracting resting heart rate, HRrest, from HRmax as Equation (2). ...
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Exercise enables continuous glycemic control for diabetic patients, and it is effective in preventing diabetic complications and maintaining emotional stability. However, it is difficult for diabetic patients to know the appropriate intensity and duration of exercise. Excessive exercise causes sudden hypoglycemia, and patients avoid therapeutic exercise or perform it conservatively owing to the repeated hypoglycemia symptoms. In this paper, we propose a new therapeutic exercise platform that supports type 2 diabetes patients to exercise regularly according to the exercise prescription received from the hospital. The proposed platform includes the following three significant contributions. First, we develop a hardware platform that automatically tracks and records all aerobic exercise performed by a patient indoors or outdoors using a wearable band and aerobic exercise equipment. Second, we devise a patient-specific exercise stress test to know whether the patient is exercising according to his or her usual exercise regimen. Finally, we develop a mobile application that informs patients in real-time whether they are exercising appropriately for their exercise regimen each time they exercise. For platform evaluation and future improvement, we received satisfaction ratings and functional improvements through a questionnaire survey on 10 type 2 diabetes patients and 10 persons without a diabetes diagnosis who had used the proposed platform for more than 3 months. Most users were (1) satisfied with automatic exercise recording, and (2) exercise time increased. Diabetics reported that their fasting blood glucose was dropped, and they were more motivated to exercise. These results prove that exercise must be combined with medication for blood glucose management in chronic diabetic patients. The proposed platform can be helpful for patients to continue their daily exercise according to their exercise prescription.
... This suggests that inquiring about and actively listening to patients' beliefs, concerns, and/or fear about insulin therapy may offer clinicians the opportunity to appropriately address the patients who will be reluctant to initiate insulin, as well as any preexisting misconceptions. [32][33][34] Of note, it has been stated that it is less likely that patients choose to be nonadherent and more likely that they struggle with the constraints placed by diabetes on their lifestyle. 35 Accordingly, increased awareness of patients about the progressive nature of type 2 diabetes with the eventual need of insulin therapy is as likely as enhanced flexibility of insulin therapy to enable better patient adherence and improved patient outcomes. ...
... 35 Accordingly, increased awareness of patients about the progressive nature of type 2 diabetes with the eventual need of insulin therapy is as likely as enhanced flexibility of insulin therapy to enable better patient adherence and improved patient outcomes. 1,[34][35][36] Lack of consensus among national guidelines and recommendations has been considered to be likely to induce the clinical inertia observed among clinicians. [37][38][39] Hence, given that more than two-thirds of continuers in our cohort had attended regular follow-up visits and that treatment discontinuation was based on a physician decision in 13.7% of discontinuers, the role of physician-related factors in insulin adherence should also be emphasized. ...
Article
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Objective: We aimed to evaluate adherence to insulin treatment in terms of treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetic patients initiating insulin therapy with basal (long acting), basal-bolus, and premixed insulin regimens in a tertiary endocrinology outpatient clinic. Methods: A total of 433 (mean age of 55.5±13.0 years; 52.4% females) insulin-naïve type 2 diabetic patients initiated on insulin therapy were included in this questionnaire-based phone interview survey at the sixth month of therapy. Via the telephone interview questions, patients were required to provide information about persistence to insulin treatment, self-reported blood glucose values, and side effects; data on demographics and diabetes characteristics were obtained from medical records. Results: Self-reported treatment withdrawal occurred in 20.1% patients, while 20.3% patients were nonadherent to daily insulin. Negative beliefs about insulin therapy (24.1%) and forgetting injections (40.9%) were the most common reasons for treatment withdrawal and dose skipping, respectively. Younger age (49.5±15.0 vs 56.4±12.0 years) (P=0.001) and shorter duration of diabetes (4.8±4.3 vs 8.8±6.3 years) (P=0.0008) and treatment duration (5.2±2.4 vs 10.7±2.4 months) (P=0.0001) were noted, respectively, in discontinuers vs continuers. Basal bolus was the most commonly prescribed insulin regimen (51.0%), while associated with higher likelihood of skipping a dose than regular use (61.3% vs. 46.0%, P=0.04). Conclusions: Persistence to insulin therapy was poorer than anticipated but appeared to be higher in patients with the basal bolus regimen. Negative perceptions about insulin therapy seemed to be the main cause for poor adherence in our cohort. Keywords: type 2 diabetes, insulin treatment adherence, basal-bolus insulin regimen, premixed insulin regimen
... Questionnaire Items from literature review [15,17,18,[20][21][22][23]27,30,[32][33][34][35]38,39] Reference Number Rating on Relevance* by Expert Experts in AgreementItem CVI ...
... Notwithstanding that insulin is a safe and effective drug for achieving glycaemic control [13,14], it is a global phenomenon that most T2DM patients resist starting insulin, predominantly because of psychological reasons (termed 'psychological insulin resistance') [15][16][17][18][19][20][21][22]. The decision to start insulin is often difficult and patients' reluctance may cause delays in initiating therapy, prolonging their sub-optimal glycaemic control [19]. ...
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To develop and evaluate the psychometric properties of a Chinese questionnaire which assesses the barriers and enablers to commencing insulin in primary care patients with poorly controlled Type 2 diabetes. Questionnaire items were identified using literature review. Content validation was performed and items were further refined using an expert panel. Following translation, back translation and cognitive debriefing, the translated Chinese questionnaire was piloted on target patients. Exploratory factor analysis and item-scale correlations were performed to test the construct validity of the subscales and items. Internal reliability was tested by Cronbach's alpha. Twenty-seven identified items underwent content validation, translation and cognitive debriefing. The translated questionnaire was piloted on 303 insulin naïve (never taken insulin) Type 2 diabetes patients recruited from 10 government-funded primary care clinics across Hong Kong. Sufficient variability in the dataset for factor analysis was confirmed by Bartlett's Test of Sphericity (P<0.001). Using exploratory factor analysis with varimax rotation, 10 factors were generated onto which 26 items loaded with loading scores > 0.4 and Eigenvalues >1. Total variance for the 10 factors was 66.22%. Kaiser-Meyer-Olkin measure was 0.725. Cronbach's alpha coefficients for the first four factors were ≥0.6 identifying four sub-scales to which 13 items correlated. Remaining sub-scales and items with poor internal reliability were deleted. The final 13-item instrument had a four scale structure addressing: 'Self-image and stigmatization'; 'Factors promoting self-efficacy; 'Fear of pain or needles'; and 'Time and family support'. The Chinese Attitudes to Starting Insulin Questionnaire (Ch-ASIQ) appears to be a reliable and valid measure for assessing barriers to starting insulin. This short instrument is easy to administer and may be used by healthcare providers and researchers as an assessment tool for Chinese diabetic primary care patients, including the elderly, who are unwilling to start insulin.
... Further, many are reluctant to start injectable therapies owing to fears of weight gain. Many persons with T2D perceive the need for injectable therapy as a personal failure to manage their disease, and/or because they fear the loss of control of their lifestyle [3,32,33]. In addition, comorbid depression can frequently reduce a patient's willingness or ability to initiate treatment [34][35][36], and can affect how individuals perceive the benefits of injectable therapy and how they participate in their own care. ...
Article
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Type 2 diabetes (T2D) progresses over time, and to achieve and maintain adequate glucose control, many people eventually require injectable therapies such as insulin. However, there can be significant barriers to the initiation of these medications, both from people living with T2D and from healthcare practitioners (HCPs). Misconceptions and misinformation relating to the potential risks and benefits of injectable therapies are common and can contribute to negative perceptions regarding their use. Additionally, HCPs are often unaware of the emotional burden associated with T2D. In particular, diabetes distress is a key contributory factor that needs to be addressed to alleviate fears before diabetes education can be successful. The onus is often on the HCP to initiate effective, individualized communication with each patient and make that person feel an active and equal participant in the management of their T2D. Shared decision-making has been demonstrated to improve understanding of the pathophysiology and treatment options, to increase risk awareness, adherence, and persistence, and to improve self-management behaviors (e.g., exercise, self-care) and patient satisfaction. While therapeutic inertia can result from both patient and HCP, HCPs need to bear the responsibility for escalating therapy when necessary. A proactive approach by the HCP, combined with shared decision-making and a patient-centric approach, are important for optimal T2D management; therefore, an open and effective relationship between the HCP and the person living with T2D is essential. This article is written by a person with T2D, a nurse practitioner/Certified Diabetes Care and Education Specialist, and a clinical endocrinologist, with the goal of providing a holistic view of the management experience, exploring patient needs and expectations, recognizing and avoiding HCP and patient barriers, and providing practical advice to HCPs to empower patients who would benefit from injectable therapy.Infographic and video abstract available for this article.
... 14 Besides health system barriers, patients may delay the initiation of insulin because they are afraid or anxious. 15 Feelings of anxiety may be exacerbated by the volume of information that people with diabetes must absorb in a short space of time. In South Africa, overburdened and overworked primary healthcare professionals are expected to dedicate enough time at every visit to educate and empower people living with diabetes. ...
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Objectives: A study was undertaken to assess the feasibility and safety of the Tshwane Insulin Project (TIP) intervention, describe patients’ and healthcare professionals’ experiences with the intervention, and determine preliminary treatment effects on glycaemic control. Design: This was a single-group feasibility study. Setting: The study was carried out in the City of Tshwane, South Africa. Subjects: People with type 2 diabetes on maximum oral drugs with suboptimal glycaemic control (HbA1c: 9–12%), and healthcare professionals who were involved in the implementation of the TIP intervention were included. Outcome measures: Implementation outcome measures included satisfaction, acceptability, appropriateness and safety; and efficacy by assessing change in HbA1c levels. Results: Healthcare professionals and patients were satisfied with the intervention. Healthcare professionals agreed that the intervention was acceptable and appropriate. No symptomatic or severe hypoglycaemic events were reported. Improved glycaemic control was recorded with 2.2% lowering of HbA1c values (95% CI, 1.6–2.8%). Conclusions: The TIP intervention was feasible and can be implemented with minor amendments. Most participants recommended scaling up the intervention. Lessons learned from this study include: (1) high rates of insulin refusal should be anticipated, and insulin resistance amongst people with type 2 diabetes in primary care should be addressed; and (2) the challenges of initiating and titrating insulin in primary care can be addressed through task sharing and by involving allied healthcare workers.
... In Japan, the prevalence of FoH in insulin-treated patients with T2D was 27.7% (Sakane et al., 2015). FoH not only influences the glycemic control of patients with T2D but also impairs their quality of life (McCoy et al., 2013), resulting in subsequent negative effects on physical and psychological consequences (Benroubi, 2011). Therefore, FoH is one of the crucial factors affecting the psychological health and self-management of patients with T2D. ...
Article
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Purpose: To explore the relationship between neuroticism and fear of hypoglycemia (FoH) among patients with type 2 diabetes (T2D), as well as the mediating effects of diabetes distress, anxiety, and cognitive fusion on the relationship between neuroticism and FoH. Methods: A total of 494 patients with T2D (39.9% females, n = 197) were analyzed using the neuroticism scale of the Eysenck Personality Questionnaire-Revised Short Scale (EPQ-RS), the Fear of Hypoglycemia-15 Scale (FH-15), the Diabetes Distress Scale (DDS), the Self-Rating Anxiety Scale (SAS), and the Cognitive Fusion Questionnaire (CFQ). The bootstrapping method was used to test the separate and parallel mediation models. Results: FoH was noted in 17.4% (n = 86) of patients. The correlations between neuroticism, diabetes distress, anxiety, cognitive fusion, and FoH were positive. Diabetes distress, anxiety, and cognitive fusion were significant mediators in the association between neuroticism and FoH in both separate and parallel mediation models. In the parallel mediation model, the mediating effect of anxiety was the highest, and the mediating effect of diabetes distress was the lowest, but no significant differences were found in the comparison of these three indirect effects. Conclusion: This study indicated that neuroticism not only directly affected FoH, but also indirectly influenced FoH via the increase of diabetes distress, anxiety, and cognitive fusion in patients with T2D. The results provide a theoretical basis for the development of intervention programs to ameliorate patients’ FoH directly and indirectly. Healthcare providers should be encouraged to develop appropriate programs based on improving diabetes distress, anxiety, and cognitive fusion to help patients with T2D improve FoH.
... 53 These insulin-treated patients may negatively affect insulin therapy and be compounded by a sense of guilt or failure for the additional medication treatment. 54 Nevertheless, patients with diabetes using glucose-lowering medication may have poorer glucose metabolism, glycemic control and worse health status than those not using these medications, which contributed to a higher incidence of mortality. Our study has some strengths, including the relatively large sample size of US adults and long length of followup. ...
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Aim: To examine the association of psychological distress with all-cause, cardiovascular disease (CVD) and cancer mortality in US adults, and verified whether the associations differed between participants with and without diabetes. Methods: A total of 485,864 adults (446,288 without diabetes and 39,576 with diabetes) who participated in the National Health Interview Survey from 1997 to 2013 were linked to the National Death Index through December 31, 2015. Psychological distress was measured by the Kessler 6 distress scale (K6). Multivariable Cox proportional hazards regression models were performed to estimate hazard ratios (HR) and 95% confidence intervals (95% CI) for the association between psychological distress and mortality. Results: We ascertained 11,746 deaths (mean follow-up, 7. 7 years) among people with diabetes and 51,636 deaths (9.9 years) among those without diabetes. Psychological distress was associated with higher all-cause, CVD, and cancer mortality. Compared to non-diabetic adults without psychological distress, HRs (95% CI) were 1.07 (1.04 to 1.09) for mild, 1.26 (1.22 to 1.30) for moderate and 1.46 (1.38 to 1.55) for severe psychological distress. Compared to the same reference group, in diabetic participants the HRs were 1.39 (1.33 to 1.44) for no psychological distress, 1.59 (1.53 to 1.66) for mild, 1.90 (1.80 to 2.00) for moderate and 1.98 (1.82 to 2.17) for severe psychological distress. Similar associations were also observed for CVD and cancer mortality but with non-statistically significant interaction. Conclusion: Psychological distress was associated with higher mortality, particularly in participants with diabetes. Strategies to ameliorate psychological distress may be important to reduce mortality in this population.
... Empowerment requires not only the acquisition of skills and knowledge, but also a psychologically safe environment that facilitates self-reflection and self-awareness. People with T2DM commonly experience feelings of guilt and shame and experience stigma, which may become barriers toward the management of T2DM such as with initiating insulin or making lifestyle changes (44)(45)(46). These feelings, as well as fear of being judged by medical doctors, may act as a barrier to effective communication within a consultation (47). ...
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Introduction: Type 2 diabetes (T2DM) is a major health concern with significant personal and healthcare system costs. There is growing interest in using shared medical appointments (SMAs) for management of T2DM. We hypothesize that adding mindfulness to SMAs may be beneficial. This study aimed to assess the feasibility and acceptability of SMAs with mindfulness for T2DM within primary care in Australia. Materials and methods: We conducted a single-blind randomized controlled feasibility study of SMAs within primary care for people with T2DM living in Western Sydney, Australia. People with T2DM, age 21 years and over, with HbA1c > 6.5% or fasting glucose >7.00 mmol/L within the past 3 months were eligible to enroll. The intervention group attended six 2-h programmed SMAs (pSMAs) which were held fortnightly. pSMAs included a structured education program and mindfulness component. The control group received usual care from their healthcare providers. We collected quantitative and qualitative data on acceptability as well as glycemic control (glycated hemoglobin and continuous glucose monitoring), lipids, anthropometric measures, blood pressure, self-reported psychological outcomes, quality of life, diet, and physical activity using an ActiGraph accelerometer. Results: Over a 2-month period, we enrolled 18 participants (10 females, 8 males) with a mean age of 58 years (standard deviation 9.8). We had 94.4% retention. All participants in the intervention group completed at least four pSMAs. Participants reported that attending pSMAs had been a positive experience that allowed them to accept their diagnosis and empowered them to make changes, which led to beneficial effects including weight loss and better glycemic control. Four pSMA participants found the mindfulness component helpful while two did not. All of the seven participants who contributed to qualitative evaluation reported improved psychosocial wellbeing and found the group setting beneficial. There was a significant difference in total cholesterol levels at 12 weeks between groups (3.86 mmol/L in intervention group vs. 4.15 mmol/L in the control group; p = 0.025) as well as pain intensity levels as measured by the PROMIS-29 (2.11 vs. 2.38; p = 0.034). Conclusion: pSMAs are feasible and acceptable to people with T2DM and may result in clinical improvement. A follow-up fully-powered randomized controlled trial is warranted. Clinical trial registration: Australia and New Zealand Clinical Trial Registry, identifier ACTRN12619000892112.
... Psychological stress is exacerbated when there is a need to escalate therapy, especially amongst people whose diabetes self-efficacy is low [9]. People with T2DM also often have strong negative attitudes towards insulin therapy [4,10]. Negative attitudes arise from doubts about the efficacy of insulin therapy in controlling diabetes, fear of injections, concerns about risks and side effects, difficulty in fitting insulin treatment around normal life and managing injections [4]. ...
Article
Aims To determine factors associated with ‘hypothetical willingness’ to start insulin among people with Type 2 diabetes (T2DM). Methods A quantitative cross-sectional study with insulin-naïve T2DM patients at 23 primary care facilities in the Tshwane Metropolitan Municipality. Data collected included demographic and clinical data, willingness to start insulin, attitudes and barriers to insulin therapy. Factors associated with unwillingness to start insulin therapy were explored using a multivariate logistic regression model. Results Of 468 T2DM study patients (mean age 57.2, SD = 11.3 years), more than half (51.9%) expressed unwillingness to starting insulin therapy. Unwillingness was associated with negative attitudes (OR = 1.32, 95% CI = 1.12-1.55, p = 0.001) and reluctance (OR = 1.41, 95% CI = 1.27-1.57, p < 0.001) rather than age, sex, education or diabetes duration. The strongest reasons for patient unwillingness were injection anxieties, fear of needles, insufficient knowledge of insulin, feeling unable to cope with insulin and concerns about out-of-pocket costs. Conclusions The prospect of insulin therapy disturbs patients’ sense of self and their psychological wellbeing. The high prevalence of psychological insulin resistance among these T2DM patients needs to be addressed for effective diabetes management.
... About 40%-70% of patients have psychological insulin resistances [10,11]. These resistances include viewing it as the last resort, fear of injection and/or pain, fear of hypoglycaemia and/or weight gain, poor self-efficacy about the skills required to administer insulin, etc [12]. Given that the start of insulin therapy needs most of patients to conquer their psychological resistances, it is reasonable to assume that adding-on insulin therapy may trigger some changes in patients' lifestyle pattern, such as physical activity, dietary pattern and smoking behaviour. ...
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Objectives: To evaluate the changes in diet, physical activity level and smoking status in insulin naïve patients with type 2 diabetes uncontrolled by oral antidiabetic drugs (OADs) after initiating basal insulins (BIs) for 6 months. Methods: Observational Registry of Basal Insulin Treatment (ORBIT) program is a 6-month, prospective study in China. Patients with type 2 diabetes uncontrolled on OADs (HbA1c ≥7%, 53 mmol/mol) and willing to initiate BI treatment were enrolled. Type and dose of BI were at the physician's discretion and patients' willingness. Interviews were conducted at baseline, month 3 and month 6. Daily diet consumption, frequency of physical activity and smoking status in past 7 days were collected. Patients who kept using BI during the 6 months were included for analysis. Results: Totally, 12 353 patients were included. Compared with the proportions at baseline, the proportion of patients with staple food of 0.4kg/day and above declined by 3%-4% at 6 th-month, whist the proportion of patients with moderate consumption (0.3kg/day) increased by 9.3%. The proportion of patients with 0.4kg/day vegetables increased by 4.2% and those with 0.2kg/day declined by 3.4% at 6 th-month. Proportion of patients with 0.2kg/day fruit and meat increased by 12.5% and 7.6% respectively at 6 th-month. Also, at 6 th-month, patients spent more days participating physical activities weekly (5.8 vs. 5.3days), and both proportion of patients with smoking (20.0% vs. 22.9%) and number of cigarettes smoked per day (14.7 vs. 17.4) declined. Conclusions: Adding-on BIs therapy is associated with positive lifestyle change including healthier diet consumption, more physical activities and less smoking behaviours in patients with type 2 diabetes.
... Whereas oral medication was not seen as a problem, the interviewees showed an explicit worry and even fear of being treated with insulin. Although this has been described before in previous studies [37] it was somehow surprising that almost all interviewees expressed this fear. This is very important information for both physicians and nurses when starting to discuss insulin treatment with the patient. ...
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Background To be diagnosed with type 2 diabetes is a challenge for every patient. There are previous studies on patients’ experience in general but not addressing the increased cardiovascular risk and multifactorial treatment. The aim of this study was to explore the thoughts, experiences and reactions of newly diagnosed patients with diabetes to this diagnosis and to the risk of developing complications. Methods Ten adults (7 men/3 women, aged 50–79) diagnosed with type 2 diabetes within the last 12 months were interviewed at a primary health care center in Sweden. An interview guide was used in the semi-structured interviews that were transcribed verbatim. The analysis was qualitative and inspired by systematic text condensation (Malterud). The text was read several times and meaning units were identified. Related meaning units were sorted into codes and related codes into categories during several meetings between the authors. Finally, the categories were merged and formed themes. Results We defined three main themes: Reaction to diagnosis, Life changes and Concerns about the future. Most patients reacted to the diagnosis without intensive feelings. Lifestyle changes were mainly accepted but hard to achieve. The patients’ major concerns for the future were the consequences for daily life (being able to drive and read) and concerns for relatives rather than anxieties regarding medical issues such as laboratory tests. There were considerable differences in how much patients wanted to know about their future risks. Conclusions The results of this study might help to focus doctor-patient communication on issues highlighted by the patients and on the importance of individualizing information and recommendations for each patient. Electronic supplementary material The online version of this article (10.1186/s12902-019-0380-5) contains supplementary material, which is available to authorized users.
... Furthermore, patients fear that switching to insulin treatment is a sign of progression to a more advanced stage with serious complications such as blindness, amputation, renal insufficiency, or of treatment failure. Finally, there is often patient reluctance to track plasma glucose levels (79)(80)(81). As an alternative to the initiation of basal insulin in such patients, treatment with a single dose of BIAsp 30 per day may be initiated and if necessary, switching to a two-dose daily regimen may help the patient get used to the treatment and improve compliance. ...
Article
The goals of Type 2 diabetes treatment are to eliminate the hyperglycemia resulting from insulin insufficiency and/or insulin resistance, delay beta cell damage/depletion, and prevent other metabolic co-morbidities and complications. In the current treatment algorithms, lifestyle changes (medical nutrition therapy, physical exercise) and oral anti-diabetics are followed by insulin therapy, which is considered a replacement therapy for Type 2 diabetes. Pre-mixed insulin preparations, which are an option for patients with poor blood glucose level control under oral anti-diabetics treatment, have been developed to meet both basal and prandial insulin needs by simulating the physiological changes in insulin levels. The consensus on the necessity of individualizing insulin therapy requires physicians to have a detailed knowledge of the various uses of insulin. Therefore, this comprehensive consensus statement has been prepared by a panel of expert endocrinologists from different regions of Turkey to help physicians use biphasic insulin aspart 30 in suitable patients at the right time. In this statement, expert panel opinions on (a) Recommendations for the appropriate initiation, titration, and intensification of insulin treatment, and (b) The treatment algorithms in initiation, titration, and intensification of biphasic insulin aspart 30 treatment and special conditions specific to changing treatment regimen are presented. © 2018 by Turkish Journal of Endocrinology and Metabolism Association.
... To fill the knowledge gap, people with pre-and type 2 diabetes can obtain information on their condition from healthcare professionals and also from less regulated sources such as the internet or from other people [9]. However, information obtained from unregulated sources can lead to misunderstanding, frustration and anxiety [10][11][12], poor compliance in treatment [12][13][14][15] and unnecessary food avoidance [12,16,17]. In questioning people with diabetes, there was confusion about the effect of macronutrients on glucose metabolism with carbohydrates being particularly misunderstood to the extent that some people were avoiding fruit due to the sugar content [17]. ...
Article
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Despite availability of diabetes and nutrition information for people with pre- and type 2 diabetes, the uptake and understanding of these resources may differ among ethnic groups. Our objective was to explore dietary knowledge and diabetes experiences amongst Māori, European, Pacific Island, Indian and East Asian people living in New Zealand with a focus on carbohydrate-containing foods. A registered diabetes dietitian led ethnic-specific discussions in groups involving 29 people with pre- or type 2 diabetes. Discussions were audio-recorded, fully transcribed and coded independently by two investigators. Themes were developed using deductive and inductive techniques. Five themes emerged: knowledge, concerns, achievements, simplicity and self-determination. Nutritional knowledge was lacking and a greater awareness of trustworthy dietary resources was needed. There were concerns about diabetes complications and appropriate carbohydrate-containing foods and portions. Contrary to this, people felt proud when achieving dietary goals and grateful for support from health care providers and family. Participants were willing to engage in self-care if advice from health professionals was given in plain language, and in a culturally appropriate manner. Given the desire to take an active role in diabetes self-management and willingness to use electronic devices, an ethnic-specific nutrition education resource could be a valuable tool.
... Nevertheless, subcutaneous injections could be associated with pain, discomfort and anxiety 3,4 . Needle phobia is, in fact, very common in children with type 1 diabetes and patients with a more intense fear of needles have higher HbA1c levels and less frequent blood sugar monitoring 5 ; furthermore, a great percentage of type 2 diabetic patients with poor control did not start insulin therapy at the appropriate time after failure of oral hypoglycemic agents because of fear of injection and its relationship with pain 6 . ...
Article
Objective: Insulin injection aspects, such as fear of injection and pain, directly affect glycemic control, patient adherence, and quality of life. Use of thinner and shorter needles could increase acceptance of injections. Aim of the study is to evaluate the non-inferiority of the new 34Gx3.5 mm needle compared to a 32GX4mm in patients with diabetes treated with insulin. Methods: This is an open, randomized, two-period cross-over, noninferiority trial. Every treatment period lasted 3 weeks. Patients with type 1 or type 2 diabetes, treated with multiple daily insulin injections insulin were randomly assigned to receive a 34Gx3.5 mm or a 32Gx4mm pen needle. Primary endpoint was the non-inferiority of the 34Gx3.5mm in comparison with the 32Gx4mm in terms of percentage absolute change of blood fructosamine (% |ΔFru|), using a non-inferiority margin of 20%. Results: overall 77 patients were randomized and 73 completed the study. Patients characteristics were: 52% male, 80.5% affected by type 1 diabetes, mean age 52 years (±14.6), mean BMI 24.5 kg/m² (±5.6), HbA1c 8% (±1.1) and baseline fructosamine level 350 µmol/l (±84). Mean fructosamine levels increased by 0.56µmol/l with the 34G needle, while a reduction of 7.29 μmol/l was documented with the 32G needle. The difference between the two groups (7.84 μmol/l) was not statistically significant (p = 0.27). The %|ΔFru| between the two groups was 7.55% (95% CI 5.67–9.44), meeting the non-inferiority criterion. Glycemic variability, expressed as standard deviation of fasting blood glucose and post-prandial glucose, was not different between the two treatment groups (p = 0.63 and p = 0.77, respectively). Conclusions: The 34Gx3.5 mm needle was non-inferior to the 32Gx4 mm needle regarding fructosamine levels and glycemic variability supporting the suitability of the 34Gx3.5 mm needle for insulin injection in patients with diabetes.
... People with T1DM require insulin upon diagnosis, but many people with type 2 diabetes manage diabetes with lifestyle adjustments and/or non-insulin regimens for a period of time [21], which may make adding insulin therapy more complex by comparison. Patients with type 2 diabetes may additionally experience a sense of guilt that they are responsible for the disease progression, which may be compounded by a sense of failure if they require insulin [10,22,23]. Furthermore, people with type 2 diabetes often have cooccurring conditions (ie hypertension, dyslipidemia, cardiovascular disease), which require additional medications [21]. ...
Article
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Objective: We hypothesized that diabetes-related distress would vary by type of diabetes and medication regimen [Type 1 diabetes (T1DM), Type 2 diabetes with insulin use (T2DM-i), Type 2 diabetes without insulin use (T2DM)]. Thus, the aim of this study was to identify groups with elevated diabetes-related distress. Methods: We administered the 17-item Diabetes-related Distress Scale (DDS-17) to 585 patients. We collected demographics, medications, and lab results from patient records. Results: Patients were categorized by type of diabetes and medication: T1DM (n = 149); T2DM-i (n = 333); and T2DM (n = 103). ANOVA revealed significant differences in sample characteristics. ANCOVA were conducted on all four DDS-17 domains [Emotional Burden (EB); Physician-related Distress (PD); Regimen-related Distress (RD); and Interpersonal Distress (ID)]; covariates included in the models were sex, age, duration of diabetes, BMI, and HbA1c. EB was significantly lower in T1DM than T2DM-i, p < 0.05. In addition, RD was significantly lower in T1DM than either T2DM-i, p < 0.05 and T2DM, p < 0.05. Conclusions: EB and RD are higher for those with type 2 diabetes. Thus, interventions to reduce EB and RD need to be considered for patients with type 2 diabetes. Implications: DDS-17 is useful in identifying diabetes-related distress in patients with diabetes. Efforts need to be made to reduce EB and RD.
... This indicates poor control of type 2 diabetes, leaving patients at risk of developing serious complications. Barriers such as fear (Benroubi, 2011) and negative perceptions have been identified among patient groups, including in Malaysia (Hassan et al., 2013). The lack of information on doctorpatient talk in the context of type 2 diabetes treatment in Malaysia, along with the gap in research on PDA use points to the need to investigate what happens during these critical conversations in the doctor's consultation room, and provides the justification for this study. ...
Article
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Patient decision aids (PDAs) are increasingly used to support treatment decision making in type 2 diabetes. However, research on PDAs generally involves quantitative analysis or focuses on physicians’ communicative practices, with limited data on how PDAs are used collaboratively in doctor-patient consultations. We apply discourse analytic methods to 11 recorded consultations during which a PDA on starting insulin was used. Purposive sampling was used to select participants from different healthcare settings and demographic profiles. Our analysis first addresses general questions on PDA use in the consultations, such as when it was used or mentioned in the consultation and by whom, before categorising the turns in which the PDA is mentioned or used by doctors and patients, according to the actions being performed. Next, we focus on consultations in which the patients have already read the PDA, and analyse the sequences of talk that occur after the doctor brings the PDA into the conversation. Our analysis shows that doctor talk on the PDA not only facilitated information provision, but also allowed doctors to elicit and explore the patient’s knowledge and perspectives. However, the kinds of questions that doctors asked tend to limit patient participation, and their focus on the PDA at times overshadowed patient contributions. More attention to doctors’ discursive choices can facilitate more patient-centred practices in using PDAs.
... No other study on this subject that included individuals diagnosed with a SMI along with diabetes was found. However, the studies that included individuals with diabetes only showed similarities to this finding (Benroubi, 2011;Chen & Tseng, 2012;Chlebowy et al., 2010;Mathew et al., 2012;Simmons et al., 2007). Polonsky, Fisher, Guzman, Villa-Caballero, and Edelman (2005) reported that 50.8% of the patients did not want to be injected every day, since they considered it a painful and torturous process (Polonsky et al., 2005). ...
Article
The aim of this study is to explore the beliefs and activities regarding diabetes self-care among individuals with type 2 diabetes and a comorbid severe mental illness, and those with type 2 diabetes only. This qualitative phenomenological study included 12 individuals diagnosed with both a severe mental illness and type 2 diabetes, and 14 individuals diagnosed with type 2 diabetes only. The data were collected using in-depth interviews through semi-structured questions, and analyzed using the content analysis method. The study examined the following three main themes: Living with diabetes, facilitators of compliance with diabetes barriers to compliance with diabetes The participants in both groups had difficulty in fulfilling their diabetes self-care. Nurses should plan initiatives that will support and motivate individuals in both patient groups in developing good self-care activities. Individuals with a severe mental illness need to be supported in coping with their psychiatric symptoms, and the side effects of the psychiatric drugs.
... Given the multitude of factors contributing to resistance to insulin treatment, a comprehensive approach is essential for overcoming these barriers. First, it is important to discuss in detail with the patient her/his concerns regarding insulin and to dispel common misconceptions [19]. It is important to inform the patient that initiation of insulin treatment not only improves glycemic control but was also shown to improve the quality of life, mostly due to improved glycemic control [20,21]. ...
... This is a phenomena that is overlooked in the diabetes self-management literature which focuses rather on HCP-driven self-management, looking at techniques that diabetes educators use, 14 success elements of education programmes, 15 and HCP behaviours. 16 The contributors in this paper, however, were taking the lead in self-managing their diabetes, and were discussing using sophisticated SMBG techniques to support this self-management. Most wanted to maintain a good working relationship with their HCPs, as this was seen as an important element of self-management. ...
Article
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Background The benefit of self-monitoring of blood glucose by patients has been questioned, and UK policy is generally not to support this, although it is identified that there may be unidentified subgroups of people who would benefit from being supported to self-monitor. The purpose of this paper is to explore the self-management approaches of people with diabetes, and how self-testing of blood glucose contributes to self-management strategies.Methods This qualitative study of patients’ experiences drew data from contributors to online discussion boards for people living with diabetes. The principles of qualitative content analysis were used on posts from a sample of four Internet discussion boards.Results Contributors described how they were using self-testing within their selfmanagement strategies. Most saw it as a way of actively maintaining control of their condition. The amount of testing carried varied over time; more testing was done in the early days, when people were still learning how to stay in control of their diabetes. Some people had experienced a lack of support for self-testing from healthcare professionals, or had been expected to change their self-management to fit national policy changes. This was seen as unhelpful, demotivating, stressful, and harmful to the doctor–patient relationship.
... 15 In this regard, sequential (via four repeated follow-up interviews on days 15, 30, 60, and 90) rather than single (at day 90) telephonic interview seems to offer an option to enhance the flexibility of therapy, a better patient adherence, and ultimately, improved patient outcomes. 21,22 Initiation of premixed or basal insulin regimens was associated with improved glycemic control in our patients with reduction in HbA1c levels (from baseline levels of 10.5% [2.0%] in premixed and 9.7% [2.0%] in basal insulin regimens to 8.1% [1.5%] at 3 months for both) without causing weight gain within the course of 3 months. This seems consistent with data from treat-to-target studies concerning efficacy of insulin regimens 1,23,24 as well as the similar efficacy reported for basal insulin and premixed insulin in lowering HbA1c, while a lower rate of hypoglycemia with basal insulin in the literature. ...
Article
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Objective: The objective of this study is to evaluate the impact of sequential telephonic interviews on treatment persistence and daily adherence to insulin injections among insulin-naïve type 2 diabetes patients initiated on different insulin regimens in a 3-month period. Methods: A total of 1,456 insulin-naïve patients with type 2 diabetes (mean [standard deviation, SD] age: 56.0 [12.0] years, 49.1% were females) initiated on insulin therapy and consecutively randomized to sequential (n=733) and single (n=723) telephonic interview groups were included. Data on insulin treatment and self-reported blood glucose values were obtained via telephone interview. Logistic regression analysis was performed for factors predicting increased likelihood of persistence and skipping an injection. Results: Overall, 76.8% patients (83.2% in sequential vs 70.3% in single interview group, (P<0.001) remained on insulin treatment at the third month. Significantly higher rate for skipping doses was noted in basal bolus than in other regimens (27.0% vs 15.0% for premixed and 15.8% basal insulin, respectively, P<0.0001). Logistic regression analysis revealed sequential telephonic interview (odds ratio [OR], 1.531; 95% confidence interval [CI], 1.093-2.143; P=0.013), higher hemoglobin A1c levels (OR, 1.090; 95% CI, 0.999-1.189; P=0.049), and less negative appraisal of insulin therapy as significant predictors of higher persistence. Basal bolus regimen (OR, 1.583; 95% CI, 1.011-2.479; P=0.045) and higher hemoglobin A1c levels (OR, 1.114; 95% CI, 1.028-1.207; P=0.008) were the significant predictors of increased likelihood of skipping an injection. Conclusion: Our findings revealed positive influence of sequential telephonic interview, although including no intervention in treatment, on achieving better treatment persistence in type 2 diabetes patients initiating insulin.
... All over the world, insulin is under-utilized in older adults because of fear of hypoglycemia by the patient [63] and his family, [64,65] but also by the clinician. [66] They all think multi injections are too complicated and dangerous for an old person. ...
Article
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Diabetes mellitus (DM) frequency is a growing problem worldwide, because of long life expectancy and life style modifications. In old age (≥60-65 years old), DM is becoming an alarming public health problem in developed and even in developing countries as for some authors one from two old persons are diabetic or prediabetic and for others 8 from 10 old persons have some dysglycemia. DM complications and co-morbidities are more frequent in old diabetics compared to their young counterparts. The most frequent are cardiovascular diseases due to old age and to precocious atherosclerosis specific to DM and the most bothersome are visual and cognitive impairments, especially Alzheimer disease and other kind of dementia. Alzheimer disease seems to share the same risk factors as DM, which means insulin resistance due to lack of physical activity and eating disorders. Visual and physical handicaps, depression, and memory troubles are a barrier to care for DM treatment. For this, old diabetics are now classified into two main categories as fit and independent old people able to take any available medication, exactly as their young or middle age counterparts, and fragile or frail persons for whom physical activity, healthy diet, and medical treatment should be individualized according to the presence or lack of cognitive impairment and other co-morbidities. In the last category, the fundamental rule is "go slowly and individualize" to avoid interaction with poly medicated elder persons and fatal iatrogenic hypoglycemias in those treated with sulfonylureas or insulin.
... This is a phenomena that is overlooked in the diabetes self-management literature which focuses rather on HCP-driven self-management, looking at techniques that diabetes educators use, 14 success elements of education programmes, 15 and HCP behaviours. 16 The contributors in this paper, however, were taking the lead in self-managing their diabetes, and were discussing using sophisticated SMBG techniques to support this self-management. Most wanted to maintain a good working relationship with their HCPs, as this was seen as an important element of self-management. ...
Article
Full-text available
Background: The benefit of self-monitoring of blood glucose by patients has been questioned, and UK policy is generally not to support this, although it is identified that there may be unidentified subgroups of people who would benefit from being supported to self-monitor. The purpose of this paper is to explore the self-management approaches of people with diabetes, and how self-testing of blood glucose contributes to self-management strategies. Methods: This qualitative study of patients' experiences drew data from contributors to online discussion boards for people living with diabetes. The principles of qualitative content analysis were used on posts from a sample of four Internet discussion boards. Results: Contributors described how they were using self-testing within their self-management strategies. Most saw it as a way of actively maintaining control of their condition. The amount of testing carried varied over time; more testing was done in the early days, when people were still learning how to stay in control of their diabetes. Some people had experienced a lack of support for self-testing from healthcare professionals, or had been expected to change their self-management to fit national policy changes. This was seen as unhelpful, demotivating, stressful, and harmful to the doctor-patient relationship. Conclusions: The Internet is a valuable source of information about peoples' self-management behaviours. Patients who are using, or who wish to use, self-testing as part of their self-management strategy are one of the subgroups for whom self-testing is beneficial and who should be supported to do so.
... Improving patient education and empowering the patient to take some control over their disease are often very valuable tactics to improve both treatment outcomes [43,44] and treatment adherence, and therefore reduce the frequency of hypoglycemia454647. If the doctor can help the patient to clearly understand how their antidiabetic drugs and/or insulin work and impact their glucose levels in relation to their everyday activities, this will go a long way toward improving overall patient care [6,28,40,48,49]. " Patient empowerment " is an approach that emphasizes collaboration with patients in helping them to understand their disease, develop personal goals to manage it, and adapt their management as needed according to circumstances [45]. ...
Article
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Hypoglycemia continues to be a significant problem for patients with diabetes. The incidence remains high but patients may also be under-reporting hypoglycemic events for various reasons, including hypoglycemia unawareness and deliberate non-reporting. This restricts the ability of healthcare professionals to manage treatment effectively. The aim of this article is to focus specifically on the issues associated with hypoglycemia unawareness and undisclosed hypoglycemia. The article provides general practice teams with an overview of these problems and, through patient narratives, suggests ways to mitigate them.
Article
Aim: Examining perceptions about insulin may provide a deeper understanding of initiation to insulin therapy and guide healthcare professionals to develop suitable strategies to increase patient adherence. This study aimed to deeply elucidate perspectives of Turkish insulin-naive type 2 diabetes patients who were recently scheduled to receive insulin therapy. Material and Methods: A descriptive qualitative study design was utilized. The patient questionnaire and interview guide were used for data collection. Individual face-to-face interviews were performed (n=14). Mean, standard deviation, and percentages were utilized to define sample characteristics. A qualitative content analysis approach was employed to identify the key themes. Consolidated criteria for reporting qualitative research checklist were used as a guideline to report the study. Results: The mean age of the participants was 51.71 ± 9.78 years. Most participants were male (71.43%). The mean duration from diabetes diagnosis was 8.02 ± 5.06 years. The emerged themes included (i) facing the reality of insulin, (ii) attributions to dependence on insulin therapy, (iii) coming changes with the insulin in all aspects of life, and (iv) positive consequences of insulin. Conclusion: Patients had heavily negative perceptions regarding insulin and stated significant worries related to working and sexual life changes. On the other hand, starting insulin triggered patients to act for maintaining life in a healthier, better, and safer way. Investigating the expectations of patients with type 2 diabetes from health care providers at the beginning of insulin therapy is needed to better manage all aspects of the treatment process.
Book
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When you hear the word insulin, you may think of high blood sugar or diabetes. While insulin is involved in these conditions, the dangers of uncontrolled levels of insulin show to be more life-threatening. Insulin is a hormone that plays an essential role in digestion and metabolism because it allows glucose to enter the body’s cells to provide energy. It is also responsible for regulating the storage of excess glucose in the liver, muscles and fat cells. Driven by Canadian inventiveness in 1921 and carried across the globe, insulin is widely recognized as one of medicine’s greatest achievements. In this book, you will learn the story of insulin, including its discovery, development and continued innovation.
Thesis
Le diabète de type 2 est une maladie très fréquente dans les pays développés, et s’avère particulièrement grave du fait de la sévérité de ses complications. Son histoire naturelle fait intervenir une carence progressive de la sécrétion en insuline. Aussi, la plupart des patients auront besoin d’un traitement insulinique. Les recommandations actuelles proposent de débuter une insulinothérapie basale dès lors que les traitements non insuliniques n’ont plus l’efficacité suffisante. Débuter une insulinothérapie basale peut être considéré comme un acte relevant des soins primaires en médecine générale. Pourtant, diverses études ont mis en évidence le retard à l’instauration de ce type de traitement. Ce travail effectué en médecine générale repose sur l’analyse triangulée d’entretiens semidirigés, réalisés chez 17 médecins généralistes choisis arbitrairement. L’objectif principal était de mettre en évidence les difficultés rencontrées en médecine générale pour débuter une insulinothérapie basale, c’est-à-dire les freins et les motifs d’inertie thérapeutique. L’analyse fine des 17 entretiens a permis d’objectiver un certain nombre de freins et de leviers, qui concernent à la fois les médecins et les patients. Parmi les freins identifiés, on retient essentiellement : la formation insuffisante des médecins et des infirmières, l’environnement et le profil du patient complexes ou peu favorables, les représentations et fausses croyances communes. Elle a permis également de mieux préciser les notions d’inertie thérapeutique, et finalement d’identifier les besoins des médecins généralistes et des patients pour faciliter l’instauration d’une insulinothérapie basale. Parmi ces facteurs : le développement de l’éducation thérapeutique grâce aux infirmières ASALEE et aux patients experts, une meilleure organisation des soins incluant des consultations spécialisées avancées et la mise en place de la télémédecine. La personnalisation des soins et la décision médicale partagée demeurent des points clés de la stratégie thérapeutique du diabète de type 2.
Article
Introduction: Type 2 diabetes mellitus (T2D) is a growing global epidemic. Due to the progressive nature of the disease, many people with T2D require insulin at some point, most commonly a long-acting (basal) insulin to assist with 24-hour control of glucose levels. Objective: This opinion paper provides an overview of considerations for primary care providers (PCPs) in intensifying the treatment regimen when basal insulin therapy is inadequate. Results: Control of mealtime hyperglycemia, in addition to fasting hyperglycemia, has been shown to be crucial in reaching A1c goals of <7.0%. However, initiating and optimizing mealtime insulin therapy can be challenging for both people with T2D and PCPs due to a perceived lack of efficacy and burden of insulin treatment, causing “psychological insulin resistance” in people with T2D and clinical inertia among PCPs. Successful implementation of mealtime insulin therapy requires not only choosing appropriate treatment strategies but also addressing patient-related behavioral and emotional barriers. Simplified treatment algorithms, combined with the use of advanced technology (devices such as insulin pens, pumps, and patches), and collaborative decision-making can help decrease barriers to effective mealtime insulin therapy. Conclusions: It is possible to implement an effective basal-bolus insulin regimen in people with T2D in a way that improves glucose control while minimizing negative effects on quality of life, treatment satisfaction, and psychological wellbeing.
Article
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Objective To investigate whether the use of apatient decision aid (PDA) for insulin initiation fulfils its purpose of facilitating patient-centred decision-making through identifying how doctors and patients interact when using the PDA during primary care consultations. Design Conversation analysis of seven single cases of audio-recorded/video-recorded consultations between doctors and patients with type 2 diabetes, using a PDA on starting insulin. Setting Primary care in three healthcare settings: (1) one private clinic; (2) two public community clinics and (3) one primary care clinic in a public university hospital, in Negeri Sembilan and the Klang Valley in Malaysia. Participants Clinicians and seven patients with type 2 diabetes to whom insulin had been recommended. Purposive sampling was used to select a sample high in variance across healthcare settings, participant demographics and perspectives on insulin. Primary outcome measures Interaction between doctors and patients in a clinical consultation involving the use of a PDA about starting insulin. Results Doctors brought the PDA into the conversation mainly by asking information-focused ‘yes/no’ questions, and used the PDA for information exchange only if patients said they had not read it. While their contributions were limited by doctors’ questions, some patients disclosed issues or concerns. Although doctors’ PDA-related questions acted as a presequence to deliberation on starting insulin, their interactional practices raised questions on whether patients were informed and their preferences prioritised. Conclusions Interactional practices can hinder effective PDA implementation, with habits from ordinary conversation potentially influencing doctors’ practices and complicating their implementation of patient-centred decision-making. Effective interaction should therefore be emphasised in the design and delivery of PDAs and in training clinicians to use them.
Article
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Although many patients with type 2 diabetes are initially managed through lifestyle modification, most eventually require insulin therapy. However, insulin initiation is often delayed because of factors such as patients’ resistance to insulin therapy and worries about injections. Such delays affect glycemic control, have a direct effect on patient encounters, and may affect medication adherence. Insulin pen delivery systems may address some of these concerns. This study had two phases. First, semi-structured qualitative interviews were conducted to identify the most important features of insulin delivery devices for prandial use from the perspective of patients (n = 8) and health care professionals (HCPs; n = 10). From phase 1, a 26-item questionnaire was developed. In phase 2, patients (n = 33 insulin naive, n = 78 pen users) and HCPs (n = 151) were asked to indicate the most important features to them in insulin delivery devices. Patients then simulated injection using three different pens (SoloSTAR, KwikPen, and FlexPen) and ranked them based on the same features. The most important features were knowing that the entire dose has been injected, ease of reading the dose correctly, and ease of correcting if the dose is over-dialed. In the simulation study, KwikPen and SoloSTAR scored significantly higher (paired t test, P < 0.05) than FlexPen on “knowing if you have injected the entire dose” (mean score out of 10: KwikPen, 8.9; SoloSTAR, 8.6; and FlexPen, 8.4). No other significant differences among the pens were noted in usability or design, and the mean ranking (from 1 to 3) of the pens was similar (KwikPen, 2.0; FlexPen, 2.1; and SoloSTAR, 1.9). By identifying which insulin delivery pens offer these features, HCPs can choose the most appropriate delivery device for patients, which may lead to earlier insulin initiation, greater patient adherence, and better clinical outcomes.
Article
Latin America faces a unique set of challenges in the treatment of type 2 diabetes mellitus (T2DM). This report identifies these challenges and provides a framework for implementation of the strategies, policies and education programs which are needed to optimize the management of this condition. In order to improve future diabetes care, it will be necessary to address existing problems such as limitation of resources, inadequate management of hyperglycemia, and inappropriate education of healthcare team members and people with diabetes. Achieving these goals will require collaborative efforts by many individuals, groups and organizations. These include policymakers, international organizations, healthcare providers, those responsible for setting medical school curricula, patients and society as a whole. It is anticipated that improved/continuing education of healthcare professionals, diabetes self-management education and development of a team approach for T2DM care will lead to optimization of patient-centered care. Implementation of multicentric demonstration studies and rational use of antidiabetic treatments will be necessary to demonstrate the long-term favorable impact of these strategies upon quality of care, prevention of chronic complications, mortality, healthcare costs and patient quality of life. (180 words)
Article
This quality improvement project evaluated the effectiveness of a monthly diabetes self-management education intervention on HbA1C and knowledge levels in patients with type 2 diabetes mellitus. A retrospective analysis evaluating 51 patients found no significant improvement in HbA1C levels; however, there was a significant improvement in knowledge levels. Race was an influential factor on HbA1C levels showing a significant elevation in mean HbA1C in African Americans, while there was a decrease in mean HbA1c in Caucasians over the 6-month evaluation period.
Article
Current medicine, including insulin therapy of type 1 and type 2 diabetes, emphasises "individualized" treatment approach. The basic requirements for such approach include: early initiation of insulin therapy, minimizing adverse drug reactions (hypoglycaemia, weight gain, poorer quality of life) and selection of the best insulin regimen. Therapy has to achieve long-term satisfactory diabetes control to prevent chronic vascular complications. Treatment should aim at reducing HbA(1c) levels as well as limiting postprandial glycaemia (fluctuations of glucose levels before and after food increase the risk of vascular complications). It has been confirmed that insulin therapy improves secretory function of beta-cells and insulin sensitivity. The requirement for early insulin initiation is based on the "metabolic memory" phenomenon; improved glycaemic compensation (even if it is followed by decompensation) has a positive effect on the risk of delayed complications. Novel agents and technologies are being developed: insulin inhalation and oral formulation, ultra-short and ultra-long insulin analogues as well as insulin-producing stem cells and artificial intelligence techniques.
Article
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The Diabetes Attitudes, Wishes, and Needs (DAWN) program is an international partnership effort to improve outcomes of diabetes care by increasing the focus on the person behind the disease, especially the psychosocial and behavioral barriers to effective diabetes management. DAWN was initiated by an international survey of > 5,000 people with diabetes and almost 4,000 diabetes care providers. The DAWN program has facilitated a number of concrete initiatives to address the gaps in diabetes care identified by the DAWN study. Diabetes is one of the major world health problems. Recent estimates from the World Health Organization predict that if current trends continue, the number of people with diabetes will more than double, from 176 to 370 million people by 2030.1 Diabetes is already the single most costly health care problem in Westernized countries. Among those diagnosed with the disease, at least half still do not achieve satisfactory glycemic control, despite the availability of effective treatments.2 As a consequence, millions of people with diabetes are at elevated risk of suffering needlessly from serious complications of the disease. With the growing number of people with diabetes, there is an urgent need to find better ways of curbing the human and economic burden of this chronic progressive disease, through prevention, detection, and treatment. A review of the literature suggests several important areas that have the potential to address these problems. Suboptimal diabetes self-management has been identified by several studies as one of the possible causes of poor outcomes of diabetes care in general practice.3,4 A multitude of research studies, mainly in the Western world and with relatively small patient samples, has indicated the potential importance of a multitude of psychological, social, and behavioral factors for patient self-management.5,6Access to patient-centered self-management support and education has …
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To examine the effects of type I and type II diabetes on patient perceptions of their quality of life and compare the psychometric properties of a generic versus a diabetes-specific quality of life measure. Consecutive outpatients (n = 240) from a large multispecialty diabetes clinic were studied on a single occasion using two measures of quality of life--Diabetes Quality of Life Measure (DQOL) and the Medical Outcome Study Health Survey 36-Item Short Form (SF-36). No interventions were performed. This study examines three issues: 1) the reliability (internal consistency) of the two measures; 2) the relationship between the DQOL and SF-36 scales; and 3) the influence of clinical patient characteristics, such as number and severity of diabetes complications, on quality of life. Examination of this issue provides information about the construct validity of the two quality of life measures. The estimates of internal consistency (Cronbach's alpha) for the DQOL and SF-36 subscales ranged from 0.47 to 0.97. These values were very similar to the published findings from previous studies. The subscales of the two measures were variably correlated with one another (range of correlations: -0.003 to 0.60), indicating that the areas of functioning addressed by the DQOL and SF-36 overlapped only to a modest degree. Examination of the relationship of demographic factors to the DQOL measures suggests that they are not generally confounded by factors such as education, sex, or duration of diabetes. Health-related quality of life is affected by the marital status of both type I and type II diabetic patients, with separated and divorced individuals generally experiencing lower levels of quality of life. The quality of life measures were sensitive to clinical characteristics, such as frequency and severity of complications. Even after factors such as marital status and, among type II diabetic patients, type of treatment, patients' severity of diabetes complications was a significant predictor of both the diabetes-related and the more broad-based measure of quality of life. For type II diabetic patients, insulin treatment was associated with lower levels of satisfaction with diabetes and greater impact of diabetes on quality of life. This study provides evidence for the reliability and validity of two measures of quality of life. The two measures examine quality of life from different but complimentary perspectives. The DQOL seems more sensitive to lifestyle issues and contains special questions and worry scales oriented toward younger patients, whereas the SF-36 provides more information about functional health status. Thus, the measures may be used usefully in combination in studies of both type I and type II diabetic patients.
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Newer insulin therapies, including the concept of physiologic basal-prandial insulin and the availability of insulin analogues, are changing clinical diabetes care. The key to effective insulin therapy is an understanding of principles that, when implemented, can result in improved diabetes control. To systematically review the literature regarding insulin use in patients with type 1 and type 2 diabetes mellitus (DM). A MEDLINE search was performed to identify all English-language articles of randomized controlled trials involving insulin use in adults with type 1 or type 2 DM from January 1, 1980, to January 8, 2003. Bibliographies and experts were used to identify additional studies. Studies were included (199 for type 1 DM and 144 for type 2 DM, and 38 from other sources) if they involved human insulins or insulin analogues, were at least 4 weeks long with at least 10 patients in each group, and glycemic control and hypoglycemia were reported. Studies of insulin-oral combination were similarly selected. Twenty-eight studies for type 1 DM, 18 for type 2 DM, and 48 for insulin-oral combination met the selection criteria. In patients with type 1 DM, physiologic replacement, with bedtime basal insulin and a mealtime rapid-acting insulin analogue, results in fewer episodes of hypoglycemia than conventional regimens. Rapid-acting insulin analogues are preferred over regular insulin in patients with type 1 DM since they improve HbA1C and reduce episodes of hypoglycemia. In patients with type 2 DM, adding bedtime neutral protamine Hagedorn (isophane) insulin to oral therapy significantly improves glycemic control, especially when started early in the course of disease. Bedtime use of insulin glargine results in fewer episodes of nighttime hypoglycemia than neutral protamine Hagedorn regimens. For patients with more severe insulin deficiency, a physiologic insulin regimen should allow lower glycemic targets in the majority of patients. Adverse events associated with insulin therapy include hypoglycemia, weight gain, and worsening diabetic retinopathy if hemoglobin A1C levels decrease rapidly. Many options for insulin therapy are now available. Physiologic insulin therapy with insulin analogues is now relatively simple to use and is associated with fewer episodes of hypoglycemia.
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To examine the correlates of patient and provider attitudes toward insulin therapy. Data are from surveys of patients with type 2 diabetes not taking insulin (n = 2,061) and diabetes care providers (nurses = 1,109; physicians = 2,681) in 13 countries in Asia, Australia, Europe, and North America. Multiple regression analysis is used to identify correlates of attitudes toward insulin therapy among patients, physicians, and nurses. Patient and provider attitudes differ significantly across countries, controlling for individual characteristics. Patients rate the clinical efficacy of insulin as low and would blame themselves if they had to start insulin therapy. Self-blame is significantly lower among those who have better diet and exercise adherence and less diabetes-related distress. Patients who are not managing their diabetes well (poor perceived control, more complications, and diabetes-related distress) are significantly more likely to see insulin therapy as potentially beneficial. Most nurses and general practitioners (50-55%) delay insulin therapy until absolutely necessary, but specialists and opinion leaders are less likely to do so. Delay of insulin therapy is significantly less likely when physicians and nurses see their patients as more adherent to medication or appointment regimens, view insulin as more efficacious, and when they are less likely to delay oral diabetes medications. Patient and provider resistance to insulin therapy is substantial, and for providers it is part of a larger pattern of reluctance to prescribe blood glucose-lowering medication. Interventions to facilitate timely initiation of insulin therapy will need to address factors associated with this resistance.
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To describe the characteristics at baseline of patients with type 2 diabetes mellitus who are initiating insulin. Prospective, observational multi-centre, open-label study in five European countries of patients with type 2 diabetes who were initiating insulin as part of their usual care. A total of 1172 patients were enrolled, with mean age 63.3 years and body mass index 29.9 kg/m(2). The majority (90%) of patients were taking one or more oral anti-diabetic agents; the percentage not taking anti-diabetic medication in the previous four weeks was highest in Germany (23.4%) and Spain (15.1%). The prevalence of microvascular diseases (range: 16.1%-36.1%) varied considerably between countries but for macrovascular (30.4%-38.6%) and other diabetes-related diagnoses (72.6%-76.6%) such as hypertension and dyslipidaemia the differences were less pronounced. In Germany, reported use of lipid-lowering (26.7%) and anti-platelet (27.1%) therapies was much less than in other countries (ranges: 53.2%-78.1% and 48.3%-61.1%, respectively). The majority of evaluable patients in each country had demonstrated poor control over a long period of time. Prior to initiating insulin, the most recent mean (+/-SD) HbA1(c) was 9.58 +/- 1.81%, fasting plasma glucose was 12.18 +/- 4.32 mmol/L and 78.5% had metabolic syndrome. IDF targets for HDL- and LDL-cholesterol, and blood pressure were met in 76.8%, 33.1% and 18.9% of patients, respectively. Insulin treatment was only initiated after HbA1(c) values were considerably higher than recommended in treatment guidelines for a sustained period of time.
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Many forces within and outside patient education have influenced the development and current status of this field. This paper traces the historic growth of patient education from the Formative era through the Contemporary period. The analysis sheds light on the important issues and controversies which patient education advocates are facing during the current period of growing cost containment, privatization and conglomeration of health care, excess supply of physicians and hospital beds, and consumer activism.
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Quality of life is an important health outcome in its own right, representing the ultimate goal of all health interventions. This paper reviews the published, English-language literature on self-perceived quality of life among adults with diabetes. Quality of life is measured as physical and social functioning, and perceived physical and mental well-being. People with diabetes have a worse quality of life than people with no chronic illness, but a better quality of life than people with most other serious chronic diseases. Duration and type of diabetes are not consistently associated with quality of life. Intensive treatment does not impair quality of life, and having better glycemic control is associated with better quality of life. Complications of diabetes are the most important disease-specific determinant of quality of life. Numerous demographic and psychosocial factors influence quality of life and should be controlled when comparing subgroups. Studies of clinical and educational interventions suggest that improving patients' health status and perceived ability to control their disease results in improved quality of life. Methodologically, it is important to use multidimensional assessments of quality of life, and to include both generic and disease-specific measures. Quality of life measures should be used to guide and evaluate treatment interventions.
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