We found that more than a third of our study sample had significant diabetes-related distress. Previous studies have shown that high diabetes-related distress affects 20-30% of people with T1D, with the difference in prevalence recorded across different populations and healthcare systems ranging from 8-65%5. Our results are consistent with the study in the United States which reported a prevalence of diabetes-related distress in T1D of 42.1%20. The same study showed that among those with high diabetes-related distress at baseline, 71% reported similarly high levels after nine months of follow-up. Interestingly, we found that disease duration did not predict diabetes-related distress. Several explanations are possible. For example, the source of distress may have changed over time, as in the example where duration is strongly associated with both complications and risk of hypoglycemia. Alternatively, it may indicate that coping with distress in people with T1D is not a matter of time, as a passive process, but requires the person to actively cope with the illness and accept the life changes associated with the occurrence of DM. For example, accepting their own fears of complications instead of denying them and not adhering to the diet, new healthy lifestyle, etc. This may indirectly indicate that psychosocial intervention may be needed to help the person cope with diabetes-related distress. This may be particularly important for people with prolonged distress, as it may predispose to problematic self-care behaviorseven. Indeed, severe diabetes-related distress increases the risk of poor treatment outcomes and the risk of diabetes-related complications.21. Of course, other factors such as general coping skills and life circumstances (eg, low socioeconomic status) not assessed in this study that are related to diabetes-related distress may explain these findings. .
The mean total PAID score in our study was 31.92 (21.14) and is comparable to the results of the SAGE study22.
The results of our study indicate that the presence of elevated HbA1c levels is a significant predictor of diabetes-related distress. This is consistent with findings from the T1 Exchange Clinic Registry in which HbA1c was one of the strongest predictors significantly associated with diabetes-related stress when adjusting for all other variables.15.
It is possible that uncontrolled diabetes, defined by high HbA1c levels, may increase patient distress, as patients may worry about the consequences of diabetes and lack of treatment success, especially over time . However, it is also possible that other characteristics, such as anxiety or overwhelming distress in life, may confer both increased diabetes-related stress and elevated HbA1c levels.
Consistent with our finding that the presence of elevated HbA1c levels is a significant predictor of diabetes-related distress, we also found that the presence of microvascular complications is also a significant predictor. First, we can assume that those with higher HbA1c levels will also have a higher likelihood of developing microvascular complications.23, indicating that (psychological) factors contributing to elevated HbA1c can lead to microvascular complications over time. Secondly, it is also possible that the acquisition of microvascular complications leads to an alteration in the functioning of the organs that the patient experiences through loss or alteration of functioning or limitation in daily life, and therefore the fear of disease and the potential impact on ability in the future as well as distress increase. No other significant predictors of higher diabetes-related distress among sociodemographic and disease characteristics were found. While associations between diabetes-related distress and gender, decreasing age and duration of diabetes have been demonstrated elsewhere15, the results of our study reveal no difference in the level of diabetes-related distress between genders and age groups. A possible explanation could be the higher average age of our study sample which was 48.11 (15.53) compared to 37.64 (16.33) in the T1 Exchange Clinic register. The second possibility is the different method of calculation, which in our study was Binary Logistic Regression, with the main variable classified as either above or below the threshold score, while the study mentioned used the original PAID score variable. continued. Interestingly, most of the participants in our study worried about complications (eg, neuropathy, retinopathy, and nephropathy) and hypoglycemia, which are described as the most common diabetes-specific fears among people with diabetes.24therefore intervention in patient education is warranted.
In our study, we found that certain individual items on the PAID questionnaire were highly rated by the majority of the study population, indicating moderate or severe distress regarding a particular topic.25. Worrying about the future and chronic complications and feeling guilty when diabetes management is off track were the top concerns, and these findings are comparable to results from a previous distress study. related to diabetes performed in the Croatian population with both type 1 and type 2 diabetic participants26. Interestingly, feeling guilty when not on track with management was the most prominent description of feelings associated with distress, followed by feeling exhausted from exertion. necessary to manage diabetes and to feel scared and depressed about living with diabetes and dealing with complications. and blood sugar levels, which may indicate the formation of the vicious cycle in which patients with diabetes are caught, trying and failing to “control” their disease and its future27. For example, their constant worry about the complication of diabetes due to non-optimal blood sugar levels and negative predictions about the future of their disease increasing their level of fear/anxiety can make patients feel burnt out by the constant effort required to manage diabetes. (to control their disease – blood sugar levels) – resulting in increased depression and fear of living with diabetes which then increases negative perceptions of the future forming the vicious cycle28. Alternatively, the constant worry about complications and negative predictions about the future of their disease, fear and depression can also lead to denial of the potential effects of chronic diabetes mellitus, which prevents them from adhering to a diet. /medication and leads to non-optimal blood sugar levels and ultimately an increase in the possibility of DM complications, followed by feelings of guilt when not on track with managing the diabetes29. This will further increase their concern about complications closing the vicious cycle. How diabetes distress manifests in the two different populations may be contextually different due to differences in age, predisposing conditions, treatment outcomes, and type of treatment. Our results on the elements of distress commonly perceived only in the T1D population could be a signal for clinicians on what to address during the clinical consultation.
The importance of psychosocial care and a call for improved psychosocial outcomes is recognized by the American Diabetes Association which has issued recommendations for integrating psychosocial care into patient-centered medical care, emphasizing that such care should be provided to all diabetic patients30. In addition, the recent consensus report on the management of T1D recognized ongoing psychosocial support as a relevant component of the management of T1D, as treatment outcomes are highly dependent on the self-management behavior of the patient. ‘a person.9. In particular, our results suggest that the availability of social support is perceived as very relevant by the participants in our study since more than 80% of the participants reported scores 31. Screening and monitoring for psychosocial issues using standardized and validated tools tailored to the patient is recommended at the initial visit and periodically thereafter if glycemic targets are not met and/or at the onset of complications of the diabetes. Although treating the psychological aspects of T1D may be as important as medical management in improving life with diabetes32the delivery method is not yet clear33.
Screening should be used to detect overall levels of diabetes-related distress, at the very start of treatment. According to PAID scores, several interventions should be offered, in addition to standard treatment, including education. For people with low to moderate levels of diabetes-related distress, education should be provided in an empathetic form by the diabetes healthcare team, as 67% of participants expressed satisfaction with from their diabetes physician. For highly distressed adults with T1D who have poor glycemic control, diabetes-related distress can be successfully addressed using educational and emotion-focused approaches34. In addition, psychological or psychiatric liaison consultations should be available.
Considerable strengths of the study are the inclusion of a representative sample of patients with T1D treated at secondary and tertiary centers in Croatia and the use of a standardized diabetes-specific measure that allows the results to be reproduced. ‘study. Our results performed only in patients with T1D provide a better understanding of this condition in specific patients. Finally, to our knowledge, this is the first study of its kind in Croatia.
Limitations of this study include a cross-sectional design that involves interpretation and clinical recommendations should be made with caution. The sample size is probably too small to confirm the absence of association between many variables. Other comorbidities or life events that might influence distress levels were not assessed in this study.