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Increased Risk of Depression, Anxiety and Disordered Eating for People with Diabetes--Psychosocial Care is Key

Posted: 14th June 2017 08:38
People with diabetes manage a complex and demanding treatment regimen, and are at increased risk for, depression, anxiety and disordered eating and have high incidence of diabetes distress which can all compromise health outcomes and quality of life. The behavioral and emotional challenges of diabetes—referred to as psychosocial aspects—are the focus of a 2016 Psychosocial Position Statement by the American Diabetes Association (Association) and within the Lifestyle Management section of the Association's 2017 Standards of Medical Care in Diabetes. Details of a new initiative focused on educating mental health providers on psychosocial care of people with diabetes and the results of two research studies focused on various psychosocial aspects of living with diabetes were highlighted at the American Diabetes Association's 77th Scientific Sessions® at the San Diego Convention Center.

The Mental Health Provider Diabetes Education Program

The Association recommends specific and comprehensive guidelines for psychosocial screening and assessments to support the care of people with diabetes. The recommendations propose that clinicians routinely screen patients with diabetes for psychosocial challenges, including mental health concerns, and that, when necessary, patients be referred to mental health providers with knowledge and experience in diabetes. However, as this screening becomes part of routine diabetes care, there are a limited number of mental health professionals with the knowledge and experience to provide diabetes-specific mental health care.

To help bridge this gap, the Association has partnered with the American Psychological Association (APA) on a joint initiative: the Mental Health Provider Diabetes Education Program, a two-part continuing education program for licensed mental health providers interested in further education to support in the psychosocial care of people with diabetes. The program consists of a seven-hour in-person course offered at the Association's 2017 Scientific Sessions or the APA 2017 Annual Meeting, and an additional five-hour online course. Upon successful completion of the program and knowledge course exams, providers will be eligible to be listed in the ADA Mental Health Provider Referral Directory, which will be freely accessible on the Association's website. This directory will list mental health providers who have additional education and experience in diabetes and will serve as a resource for patients and referring medical professionals.

"As more collaborative efforts like these take place, the psychosocial side of diabetes can be more adequately and appropriately addressed," said Korey Hood, PhD, professor of pediatric endocrinology, and professor of psychiatry and behavioral sciences at Stanford University; and co-author of the Association's Psychosocial Position Statement and member of the Mental Health Provider Diabetes Education Program development team. "People with diabetes need compassionate clinicians, who are aware of the lifelong challenges of living with diabetes and the impact mental health has on diabetes management. This initiative will have a positive impact on care and lead to optimal health outcomes for them, and at minimum, raise awareness of the psychosocial side of diabetes for clinicians administering care to people with diabetes. Beyond that, these programs offer practical solutions to providing psychosocially-minded diabetes care, screening for psychosocial needs, and making referrals or treating those needs. This will all lead to improved health and quality of life outcomes for people with diabetes."

Hood notes that additional research needs to be conducted to understand and solve real-world barriers of how best to implement psychosocial care for people with diabetes in both primary care and specialty care settings. Of note, psychosocial care models need to be mindful of insurance provider systems and how to be integrated with cost-effective diabetes care.

Program ACTIVE II: A Comparative Effectiveness Trial to Treat Major Depression in T2DM

Depression in patients with diabetes is associated with higher rates of difficulty in managing diabetes and has an impact on long-term health outcomes. This 12-week study, "Program ACTIVE II: A Comparative Effectiveness Trial to Treat Major Depression in T2DM" (376-OR), evaluated the effectiveness of talk therapy and physical exercise on depression and A1C levels among adults with type 2 diabetes diagnosed with clinical depression. The study included 140 adults, with an average age of 57, from three different states in the U.S., and from all levels of income and educational background.

The participants were randomly assigned to one of four groups to receive either: 12 weeks of exercise with a personal trainer (EXER); 10 individual talk therapy/cognitive behavioral therapy sessions (CBT); concurrent interventions of exercise combined with talk therapy over 12 weeks (CBT+EXER); or usual care (UC).

At the end of the 12-week intervention period, the EXER participants, CBT participants and CBT+EXER participants all showed significant improvements in depressive symptoms, diabetes-related distress and quality of life compared to those receiving UC. Participants in the EXER, CBT, and CBT+EXER groups reported fewer depressive symptoms (all p<.05); reduction in negative automatic thoughts (all p<.03), improved physical quality of life (all except CBT only p<.03); and decreased diabetes distress (p<.01), compared to the participants in the UC group.

After controlling for change in antidepressant medications, people assigned to the talk therapy (CBT group) were significantly more likely to be free of major clinical depression symptoms than people assigned to the UC group. Participants assigned to the exercise group were also significantly more likely to be free of major clinical depression symptoms compared to the participants who received usual care. And, participants assigned to the exercise group with a starting A1C level of 7.0 percent or greater showed a clinically meaningful reduction in their A1C of 0.7 percent at the end of the exercise intervention, compared to those receiving CBT or UC, after controlling for baseline education levels and changes in diabetes medications (p <.04).

"Depression occurs at higher rates in people with diabetes than in the general population and has significant implications for physical and mental health," said lead study author Mary de Groot, PhD, associate professor of medicine and acting director of the Diabetes Translational Research Center at Indiana University. "Our study is the first to demonstrate that exercise guided by a personal trainer and performed by participants in their communities is effective in treating both depression and diabetes, even after accounting for changes in diabetes medications. Exercise is also effective in managing blood sugar control in people who have depression and type 2 diabetes."

The study researchers plan to evaluate the long-term effects of both talk therapy and exercise on depression and A1C to determine if the improvements that were observed in this trial can be sustained over an additional 12-months beyond treatment. Research is also being conducted to evaluate the cost-effectiveness of each intervention to further understand the extent to which these treatments can reduce health care costs.

Disordered Eating Behaviors in Youth and Young Adults with Type 1 and Type 2 Diabetes: The SEARCH for Diabetes in Youth Study

Young people with type 1 diabetes (T1D) and type 2 diabetes (T2D) are at increased risk for developing disordered eating primarily because of the intense focus on diet and weight control that accompanies the management of diabetes. This study, "Disordered Eating Behaviors in Youth and Young Adults with Type 1 and Type 2 Diabetes: The SEARCH for Diabetes in Youth Study" (802-P), investigated the occurrence of disordered eating behaviors in youth and young adults with diabetes, and was focused on defining the characteristics associated with disordered eating, including age, body mass index (BMI) and health outcomes.

Using data obtained from SEARCH for Diabetes in Youth, a population-based observational study conducted at five sites in the United States, data on 2,156 youth with T1D (average age of 17.7 years) and T2D (average age of 21.8 years) was analyzed. The participants included in the analysis were diagnosed with diabetes between 2002 and 2008, and had two or more study visits, including a "Cohort" visit between 2011 and 2015. During the Cohort visit, the participants had a brief exam, blood and urine samples were collected, and questionnaires completed, including the Diabetes Eating Problem Survey – Revised (DEPS-R).

Results indicated that disordered eating behaviors (DEPS-R score ≥ 20) were observed in 21.2 percent of the study participants with T1D and 52.2 percent of the participants with T2D. Disordered eating behaviors were more common in females with T1D and in those who were overweight. Higher DEPS-R scores (DEPS-R score ≥ 20) were associated with higher BMI, in both the participants with T1D (p<0.01) and the participants with T2D (p<0.01). Approximately 20 percent of the T1D participants reported skipping insulin for weight control, and more than 20 percent of all of the participants indicated they faced challenges in maintaining a healthy weight while managing diabetes. Some of the participants with T1D (12.4 percent) and some with T2D (34.2 percent) indicated they had a desire to be "thin at the expense of good diabetes control." Overall, the participants with disordered eating had poorer health outcomes, including higher A1C levels, more depressive symptoms and poorer quality of life.

"Disordered eating behaviors are often under-recognized among patients with diabetes, and this may complicate their diabetes management, glucose control and overall general health," said lead study author Angel Siu Ying Nip, MD, fellow in pediatric endocrinology at the University of Washington. "It is paramount to raise the awareness among health providers, as well as among families and patients, to identify at-risk patients early, and to offer appropriate counseling and treatment if necessary. Providers should educate patients and families to make sustainable healthful lifestyle choices rather than focus on a specific weight-loss goal."

To speak with Dr. Hood, Dr. de Groot or Dr. Nip, please contact the Association's media relations team on-site at the San Diego Convention Center on June 9 -13, by phone at 619-525-6250 or by email at

The American Diabetes Association's 77th Scientific Sessions, to be held June 9-13, 2017, at the San Diego Convention Center, is the world's largest scientific meeting focused on diabetes research, prevention and care. During the five-day meeting, health care professionals have exclusive access to more than 2,500 original research presentations, participate in provocative and engaging exchanges with leading diabetes experts, and can earn Continuing Medical Education (CME) or Continuing Education (CE) credits for educational sessions. The program is grouped into eight interest areas: Acute and Chronic Complications; Behavioral Medicine, Clinical Nutrition, Education and Exercise; Clinical Diabetes/Therapeutics; Epidemiology/Genetics; Immunology/Transplantation; Insulin Action/Molecular Metabolism; Integrated Physiology/Obesity; and Islet Biology/Insulin Secretion. Brenda Montgomery, RN, MSHS, CDE, President of Health Care and Education[1], will deliver her address on Saturday, June 10, and Alvin C. Powers, MD, President of Medicine and Science, will present his address on Sunday, June 11. Eight abstracts were selected by the Scientific Sessions Meeting Planning Committee to be presented on Tuesday, June 13, in the President's Oral Session. These abstracts represent important research being conducted in the field of diabetes today. In total, the 2017 Scientific Sessions includes 378 abstracts in 49 oral sessions; 2,152 poster presentations including 50 moderated poster discussions; and 360 published-only abstracts. Join the Scientific Sessions conversation on Twitter, #2017ADA. 

About the American Diabetes Association
More than 29 million Americans have diabetes, and every 23 seconds another person is diagnosed with diabetes. The American Diabetes Association (Association) is the global authority on diabetes and since 1940 has been committed to its mission to prevent and cure diabetes and to improve the lives of all people affected by diabetes. To tackle this global public health crisis, the Association drives discovery in research to treat, manage and prevent all types of diabetes, as well as to search for cures; raises voice to the urgency of the diabetes epidemic; and provides support and advocacy for people living with diabetes, those at risk of developing diabetes and the health care professionals who serve them. For more information, please call the American Diabetes Association at 1-800-DIABETES (1-800-342-2383) or visit Information from both of these sources is available in English and Spanish. Find us on Facebook (American Diabetes Association), Twitter (@AmDiabetesAssn) and Instagram (@AmDiabetesAssn).

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