BMJ Open Diabetes Research & Care

AimsTo identify barriers and facilitators to physical activity (PA) in adults with type 1 diabetes (T1D) living in the United States (U.S.) and identify sociodemographic factors related to meeting recommended PA. MethodsWe conducted a cross-sectional online survey study of adults with T1D aged [≥]18 years recruited through online-based platforms. Quantitative questions related to exercise quantity and intensity, demographic characteristics, and exercise barriers and facilitators. Wilcoxon rank sum tests or independent t-tests were used to compare quantitative responses in individuals meeting or below target PA. Barriers and facilitators were also assessed qualitatively with open-ended questions. Logistic regression was performed to determine if the following characteristics were independently associated with meeting PA recommendations: age, sex, income level, and automated insulin delivery system use. ResultsOf 281 respondents who completed questions about exercise quantity, 162 (57.7%) were women, mean age 52.6 {+/-} 16.6 years, and 151 (53.7%) met PA guideline recommendations. Common barrier themes related to T1D included hypoglycemia, time, lack of knowledge about glycemic management, cost, and failure of available treatments to accommodate exercise. Common facilitator themes were insurance reimbursement of exercise program/facility, peer exercise groups, health/fitness advising, and T1D tailored fitness. Middle (vs. upper) income level was independently associated with lower odds of meeting PA recommendations (adjusted odds ratio 0.46, 95% CI: 0.27, 0.78, p = 0.004). ConclusionsIn this predominately U.S. cohort with T1D, financial factors were common novel themes related to PA. Further validation in more socioeconomically diverse cohorts and research examining PA reimbursement cost-efficacy are needed. Novelty statementO_ST_ABSWhat is already known?C_ST_ABSO_LIIn prior qualitative studies in type 1 diabetes, hypoglycemia is a commonly reported barrier to physical activity (PA) engagement. Most studies were conducted outside the United States (U.S.). C_LI What this study foundO_LIIn a predominately U.S. cohort of adults with type 1 diabetes, cost is a newly identified barrier to PA. C_LIO_LIInsurance reimbursement of PA programs/facilities was a reported facilitator. C_LIO_LIIndividuals with highest income were 54% more likely to achieve recommended PA compared to other income categories. C_LI What are the implications of the study?O_LICost-efficacy research examining PA programs/facility reimbursement in type 1 diabetes is needed. C_LI

This study investigates the challenges and enablers of self-management in type 2 diabetes, the role of primary care in diabetes management, and patients preferences for additional support services in Switzerland. Participants reported significant difficulties in sustaining behavioral changes and emphasized the need for more structured guidance to improve self-management. Many felt unsupported in primary care, stating that their general practitioners could have intervened earlier when they were at high risk but before an official diagnosis. Additionally, patients highlighted the lack of centralized, up-to-date diabetes resources in Switzerland, contrasting it with structured systems like the National Health Service in the United Kingdom. There was also a strong demand for a unified digital health platform to consolidate glucose readings, blood pressure data, and medication lists, ensuring seamless integration with healthcare providers. These findings underscore the need for patient-centered diabetes management strategies that integrate digital innovations, proactive primary care interventions, and accessible, evidence-based resources to enhance self-management.

ObjectivesExamine the characteristics of patient engagement (PE) practices in exercise-based randomized trials in type 1 diabetes (T1D), and facilitate T1D stakeholders in determining the top ten list of priorities for exercise research. DesignTwo methodological approaches were employed: a scoping review and a modified James Lind Alliance priority-setting partnership. MethodsPublished (Medline, Embase, CINAHL, and Central databases) and grey literature (www.clinicaltrials.gov) were searched to identify randomized controlled trials of exercise interventions lasting minimum four weeks and available in English. We extracted information on PE and patient-reported outcomes (PROMs) to identify if patient perspectives had been implemented. Based on results, we set out to determine exercise research priorities as a first step towards a patient-engaged research agenda. An online survey was distributed across Canada to collect research questions from patients, caregivers and healthcare providers. We qualitatively analyzed submitted questions and compiled a long-list that a twelve-person stakeholder steering committee used to identify the top ten priority research questions. ResultsOf 9,962 identified sources, 19 published trials and 4 trial registrations fulfilled inclusion criteria. No evidence of PE existed in any included study. Most commonly measured PROMs were frequency of hypoglycemia (n=7) and quality of life (n=4). The priority-setting survey yielded 194 submitted research questions. Steering committee rankings identified 10 priorities focused on lifestyle factors and exercise modifications to maintain short-term glycemic control. ConclusionRecent exercise-based randomized trials in T1D have not included PE and PROMs. Patient priorities for exercise research have yet to be addressed with adequately designed clinical trials.

IntroductionType 2 diabetes mellitus (T2DM) is a lifelong condition that has large societal, economic and clinical implications, and treatment should be supported by healthy lifestyle factors. Interventions for effective self-management are essential to the sustainability of treatment, however there is no standard approach. Research Design and MethodsSix hundred and five participants diagnosed with Type 2 Diabetes Mellitus were recruited from four countries (UK, France, Netherlands, Belgium) to complete the 12-week DWELL (Diabetes and WELLbeing) psychoeducational intervention. The programme was delivered at community and hospital-based settings and comprised of four key areas: education, nutrition, physical activity and wellbeing. Metabolic health (weight, waist size, BMI and HbA1c) and self-reported psychological measures were taken at four points: pre- and post-intervention, and two follow up points (at 6 and 12 months) to assess the impact of the programme. ResultsParticipants showed a significant reduction in all metabolic health measures, with improvements in both weight and BMI being maintained at 6-month follow-up. Participation in the programme also led to enhanced levels of participant empowerment, with significant improvements also seen in perceptions of diabetes, eating behaviours, mental and physical health, and self-care behaviours. ConclusionsThe study results demonstrated that an empowerment-based, holistic and flexible approach to diabetes self-management education programmes has a wider impact in improving longer term coping behaviours which help in achieving and sustaining positive metabolic and psychological changes. Key Messages What is already known on this topicDiabetes education has evolved from a compliance and knowledge-oriented approach to an empowerment and self-management-oriented approach. Yet, type 2 diabetes self-management education (DSME) programmes are mainly evaluated in relation to impact on metabolic (glycaemic) outcomes than on wider psychosocial outcomes. What this study addsParticipation in the DWELL programme led to significant improvements in metabolic health measures and produced significant positive changes across a range of psychological measures such as patient empowerment, illness perceptions, eating behaviours and self-care behaviours. How this study might affect research, practice or policyThe DWELL DSME programme which was co-designed with patients, healthcare professionals and family carers, focussed on patient empowerment and self-control, by offering flexibility and choice of options as well as peer support. Programme outcomes indicated that this approach led to positive changes in empowering and enabling health behaviour changes and improvements in metabolic health. The study adds to the body of knowledge of patient-led DSME practice with a holistic approach. Further research could shed light on the cultural and intersectional aspects of such approach that can inform more targeted programmes supporting T2DM patients with multiple co-morbidities such as serious mental health conditions.

AimsPeople with diabetes experience a significantly higher prevalence of mental health issues, particularly depression. This adversely affects their diabetes management and overall health. This scoping review aims to develop a conceptual framework for understanding the connection between depression and diabetes outcomes globally, specifically focusing on intermediary factors that may influence this relationship. MethodsPubMed, EMBASE, PsycINFO, and Global Index Medicus were searched using relevant keywords on 17th May 2024. The inclusion criteria encompassed peer-reviewed studies involving adults diagnosed with Type 2 diabetes that assessed depression and analysed its impact on diabetes outcomes through various pathways ResultsThe review identified 30 studies examining the association between depression and diabetes outcomes. Results indicate that while depression is linked to poorer diabetes outcomes, the mechanisms are complex and often mediated by factors such as self-efficacy, social support, and diabetes-related distress. Notably, self-efficacy emerged as a critical mediator in the relationship between depression and self-management behaviours. Furthermore, social support was identified as a protective factor that can reduce the adverse effects of depression on glycaemic control. ConclusionsAddressing mental health concerns in diabetes care is essential for improving patient outcomes. This review underscores the need for integrated interventions that consider psychosocial factors to enhance self-management and glycaemic control among individuals with Type 2 diabetes. Future research should focus on exploring these relationships in diverse populations to inform tailored strategies for effective diabetes management. {blacksquare}Individuals with diabetes experience higher rates of mental health issues, particularly depression, which negatively impacts diabetes management and health outcomes. {blacksquare}This scoping review identified 30 studies linking depression to poorer diabetes outcomes and developed a conceptual framework that highlights the complex mechanisms involved, including factors such as self-efficacy, self-management, illness perception and social support. {blacksquare}The findings emphasize the importance of addressing mental health in diabetes care

BackgroundAdults with type 1 diabetes mellitus (T1DM) have barriers to physical activity (PA), including physiological, psychological, emotional, and/or contextual. To complement prior quantitative work, we employed a qualitative study to explore momentary motivational states for movement and rest and to understand how internal and external factors shape these experiences among middle-aged adults with T1DM who had recently completed an exercise-support intervention. MethodsWe interviewed 23 middle-aged adults with T1DM (mean age 48, SD 11 years, 78% female, 91% non-Hispanic white, 35% overweight, and 26% obese), who recently completed an exercise intervention, using semi-structured interviews guided by the Wants and Aversions for Neuromuscular Tasks (WANT) model. This model addresses desires and aversions (i.e., fears) for movement and rest. We utilized directed content analysis to identify common themes, with both deductive and inductive coding. ResultsParticipants exhibited simultaneous desires to move and rest, opting for activities like yoga or outdoor walks for active recovery. Competing motivations also emerged, such as the internal drive to exercise conflicting with physical fatigue or glycemic levels necessitating rest. ConclusionsOur findings align with previous studies using the WANT model, underscoring the dynamic nature of motivation influenced by physiological parameters, aversive states, and recent activities. These insights gained can inform future interventions targeting psychological aspects of physical activity for this unique population.

BackgroundType 2 diabetes (T2DM) and cognitive impairment are common long-term chronic conditions affecting older people in hospital. Cognitive impairment can complicate glucose monitoring and lead to diabetes-related emergencies in T2DM. Traditionally, point of care test (POCT) measurements of capillary blood glucose are conducted in-hospital for T2DM while continuous glucose monitoring (CGM) is not widely used. AimTo understand the feasibility, acceptability and tolerability of using CGM in older in-patients with T2DM and cognitive impairment. MethodsThirty-two older people (mean age = 78.7 {+/-}6.7 years) with comorbid T2DM and cognitive impairment (AMT [≤]8/10 and Mini-ACE [≤]22/30) were recruited within a tertiary care hospital in the UK. All participants were naive to CGM and were asked to wear blinded Dexcom G7 sensors for up to 10 days. Participants were asked about feasibility, acceptability and tolerability questions at the point of sensor removal. ResultsTwenty-nine participants (96%) reported no pain during CGM fitting. All participants (100%) agreed that they did not notice wearing the sensor, and it did not affect their day-to-day hospital activities. All participants (100%) found it very easy or easy to have the sensor fitted and wearing it for 10 days, with 27 participants (90%) finding CGM convenient. Seventeen participants (57%) reported favourable perceptions of the subcutaneous sensor sensation. ConclusionCGM use in older in-patients with T2DM and cognitive impairment is highly feasible and acceptable for patients. Future studies and trials are now needed to evaluate the clinical use of CGM for glucose monitoring in hospitalised or community-dwelling older individuals with T2DM and cognitive impairment.

BackgroundDigital delivery of lifestyle interventions offers a potentially effective, affordable, and convenient option for patients to prevent and monitor type 2 diabetes (T2D) (Khan et al., 2019). Hemoglobin A1c (A1c) is a measure used to monitor T2D progression. Standard of care- based approaches to encourage lifestyle modification have been shown to decrease A1c, yet high healthcare costs and travel-related barriers limit the accessibility of these strategies. Rising T2D rates globally underscore the immediate need to identify the most comparably effective options that decrease A1c and address disease prevention and management. ObjectivesThis systematic review examines the effectiveness of digital delivery of lifestyle interventions in decreasing A1c among adults globally both overall and compared to standard ofcare and monitoring only based approaches. MethodsBased on application of the Navigation Guide systematic review methodology, 10 studies conducted in eight countries met the inclusion criteria and were evaluated for bias, quality, and strength of evidence. Conclusions were drawn from evaluating quantitative results. ResultsA systematic review of the literature demonstrated sufficient evidence of an association between digital delivery of lifestyle interventions and decreased A1c trends. Research did not show significant differences in A1c changes among the intervention groups when compared to the standard of care and monitoring only based control groups. ConclusionsThese results indicate that while the digital delivery of lifestyle interventions is effective in lowering A1c levels in T2D patients, these interventions do not outperform standard of care and monitoring only based approaches to prevent and manage T2D.

The greatest change in the treatment of people living with type 1 diabetes in the last decade has been the explosion of technology assisting in all aspects of diabetes therapy, from glucose monitoring to insulin delivery and decision making. Through screening of 835 peer-reviewed articles followed by systematic review of 70 of them (focusing on randomized trials and extension studies with [≥]50 participants from the past 10 years), we conclude that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c, time in range, and glycemic variability, while reducing hypoglycemia risk. Several studies included person-reported outcomes, allowing assessment of the burden or benefit of the technology in the lives of those with type 1 diabetes, demonstrating positive results or, at a minimum, no increase in self-care burden compared with standard care. Important limitations of the trials to date are their small size, the scarcity of pre-planned or powered analyses in sub-populations such as children, racial/ethnic minorities, people with advanced complications, and variations in baseline glycemic levels. In addition, confounders including education with device initiation, concomitant behavioral modifications, and frequent contact with the healthcare team are rarely described in enough detail to assess their impact. Our review highlights the potential of technology in the treatment of people living with type 1 diabetes and provides suggestions for optimization of outcomes and areas of further study for precision medicine-directed technology use in type 1 diabetes. Preface (Lay Abstract)We reviewed literature of the last decade to evaluate the impact of technology on the treatment of people living with type 1 diabetes. Screening of 835 articles and in-depth review of 70 showed that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c and time in range, while reducing hypoglycemia risk. Of importance, several studies showed a positive impact on person-reported outcomes, like quality of life or, at a minimum, no increase in self-care burden compared with standard care.

BackgroundDiabetes mellitus contributes increasingly to the Global Burden of Disease [GBD]; particularly in high and increasingly in low-and middle-income countries. Strategies to prevent and mitigate the impact are a public health priority. Painful diabetic neuropathy (PDN) is a syndrome of sensory disorders caused by both type 1 and type 2 diabetes mellitus. Available treatments include antidepressant medications and strong analgesics. These are often only partly effective and associated with significant side effect profiles. There is a need for effective treatments with low toxicity. Vitamin D has been proposed as potential therapeutic and biologically plausible agent. Non-randomised studies demonstrate benefit, but are subject to biases. There is a need for robust evidence derived from randomised data to inform patient care in this debilitating complication of diabetes. Review aimTo synthesise randomised controlled trials (RCTs) of Vitamin D supplementation and its effects on painful diabetic neuropathy. Review methodsA range of databases [Medline, EMBASE, Web of Science, Cochrane Library, CINHAL, EBSCO and Google Scholar] were searched from inception to March 2025, with backwards and forward citation searches to identify eligible studies. RCTs comparing Vitamin D with placebo in patients with diabetes [type 1 or 2] and PDN were sought. The primary outcome was pain as measured using a validated pain measure or measure of PDN. A fixed effects meta-analysis of continuous pain data was conducted, with standardisation between studies to calculate a standardised mean difference [SMD] between Vitamin D and placebo. Small study and publication bias was tested using an Egger plot, and study quality was assessed using the Cochrane Risk of Bias [RoB] tool. ResultsFour eligible studies were identified and three of these studies [comprising 260 participants] provided meta-analysable data. There was a statistically significant short-term benefit for vitamin D (pooled standardised mean difference =-0.70; 95%CI-0.95 to-0.45). There was moderate between study heterogeneity, and there was an intermediate level of heterogeneity (I = 54.9%). No studies reported medium-or long-term outcomes. The quality of studies was variable (either low or moderate risk of bias), with poor concealment of allocation as the most important design limitation. Two of the studies had been prospectively registered, making it difficult to check for bias in one study due to potential selective reporting of outcomes. Despite conducting an Egger Funnel Plot, it was not possible to exclude the influence of small study and selective publication bias. DiscussionBased on a meta-analysis of non-registered small size studies there was evidence of short-term reduction in pain symptoms in painful diabetic neuropathy. This benefit needs to be confirmed in fully powered RCTs with a longer duration of follow up. Vitamin D remains a viable low-cost treatment option for PDN, but more research is needed before this can confidently be recommended for routine patient care.

BackgroundClinical guidelines for most adults with diabetes recommend maintaining hemoglobin A1c (HbA1c) [&le;]7.0% (<53 mmol/mol) to avoid microvascular and macrovascular complications. People with diabetes of different ages, sexes, and socioeconomic statuses may differ in their ease of attaining this goal. As a team of people with diabetes, researchers, and health professionals, we aimed to explore patterns in HbA1c results among people with type 1 or type 2 diabetes in Canada. Our research question was identified by people living with diabetes. MethodsWe used generalized estimating equations to analyze the effects of age, sex and socioeconomic status in 947,543 HbA1c results measured from 2010 to 2019 among 90,770 people living with type 1 or 2 diabetes in Canada. People living with diabetes reviewed and interpreted the results. ResultsHbA1c results at or below 7.0% represented 30.5% (male people living with type 1 diabetes), 21.0% (female people living with type 1 diabetes), 55.0% (male people living with type 2 diabetes) and 59.0% (female people living with type 2 diabetes) of results in each subcategory. We observed higher HbA1c values during adolescence and, for people living with type 2 diabetes, among people living in lower income areas. Among those with type 1 diabetes, female people tended to have lower HbA1c than male people during childbearing years but higher HbA1c than male people during menopausal years. Team members living with diabetes confirmed that the patterns we observed reflected their own life courses and suggested these results be communicated to health professionals and other stakeholders to improve treatment for people living with diabetes. InterpretationA substantial proportion of people with diabetes in Canada are insufficiently supported to maintain guideline-recommended glycemic control goals. Blood sugar management goals may be particularly challenging for people who are going through adolescence, menopause, or living with fewer financial resources. Health professionals should be aware of the challenging nature of glycemic management and policymakers in Canada should provide more support for people with diabetes to live healthy lives.

OBJECTIVESTo investigate whether there were important differences in uptake of NICE clinical guidelines according to diabetes mellitus type in England and Wales from 2013 to 2018, test the hypothesis that guidelines are more successfully implemented with T2DM than T1DM, and explore possible explanations for differences. DESIGNRetrospective cross-sectional analyses of aggregated patient level data from the National Diabetes Audit (NDA) dataset owned by NHS Digital and commissioned by Healthcare Quality Improvement Partnership. SETTINGDiabetes specialist services, primary care (GP surgeries submitting NDA data) across England and Wales. PARTICIPANTS1 739 175 patients with diabetes aged [&ge;]20 in England and Wales in 2013-14, 1 871 320 individual patients in 2014-15, 2 688 106 individual patients in 2015-16, 3 095 275 individual patients in 2016-17, and 3 357 055 individual patients in 2017-18. INTERVENTIONSRecommended care for diabetes mellitus as outlined in relevant NICE guidelines and delivered by either specialist clinicians or GPs. MAIN OUTCOME MEASURESThe recorded attainment of NICE treatment targets: HbA1c levels =<7.5% (58.5 mmol/mol), blood pressure <140/80mmHg, blood cholesterol <5mmol/l; and clinical processes: at least annual monitoring of HbA1c, blood pressure, cholesterol, albumin:creatinine ratio, smoking status, Body Mass Index. RESULTSAnnual collections (2013-14, 2014-15, 2015-16, 2016-17 and 2017-18) were individually analysed, testing associations between diabetes type and attainment of clinical targets or processes using a multivariable logistic regression model, adjusted for age and sex. Increased odds of meeting clinical targets if patients had T2DM compared with T1DM was consistent across the five years, except for cholesterol levels <5mmol/l where T2DM patients had lower odds (all associations p<.0001). Greatest differences in all five years between T1DM and T2DM was observed with patients meeting the HbA1c=<7.5% target, the largest being in 2015-16 (Odds Ratio 3.43, 95% confidence interval 3.39 to 3.47). CONCLUSIONSThe differences between T1DM and T2DM in HbA1c target attainment is key and potentially reflects challenges of managing T1DM with insulin but suggests a point of focus for that patient population. Other important elements for consideration could be specific setting for delivery (primary care versus secondary care) and duration of illness. O_TEXTBOXWHAT IS ALREADY KNOWN ON THIS TOPICNHS Digital publishes reports on the NDA every year, however much of this is descriptive rather than analytical. Very few published studies have explored NDA data and none have particularly compared clinical outcomes of T1DM and T2DM. WHAT THIS STUDY ADDSDifferences between age structures of T1DM and T2DM patient groups are adjusted and success in meeting NICE clinical processes and treatment targets are compared. This study highlights the different challenges faced by these different groups and conditions and raises questions about the suitability of applying identical targets to the diabetes subtypes given aetiological, clinical and therapeutic differences. C_TEXTBOX

IntroductionThe adoption of digital tools in diabetes care has transformed the way people with diabetes (PwD) and healthcare professionals (HCPs) manage the condition. Digital tools allow for remote management, improved accuracy in blood glucose readings, and enhanced education for patients. This paper presents the results of a 12-month service evaluation of the Roche Diabetes Care Platform, a diabetes data management platform that was implemented into a primary care network (PCN). The aim of the implementation of the RocheDiabetes Care Platform was to address the current challenges faced by clinicians and PwD in diabetes care, such as reducing complications, improving diabetes education, and the delivery of health care to PwD. Semi-structured interviews were conducted virtually to capture the views of HCPs on their experiences with these digital tools. MethodologyInterviews were conducted with individuals in a range of roles, intrinsic to the diabetes service management in the Leicester PCN, at each stage of implementation. This included pre-implementation, implementation, and post-implementation phases. The data was analysed using thematic analysis. ResultsThe use of the RocheDiabetes Care Platform in the Leicester PCN has advanced HCPs management of PwD, demonstrably improving patient outcomes and enhancing interactions. There were two themes identified in the pre-implementation stage, including pre-appointment activities and challenges, and appointment activities and challenges. A further six themes were identified in the post-implementation results, including the optimisation of appointments, time and cost savings, enhanced engagement with PwD, the centralisation of resources, challenges in the PCNs pathway of care that the RocheDiabetes Care Platform addressed and the future vision of the PCN with the RocheDiabetes Care Platform. Overall, available and accessible data helped to reduce the number of appointments efficiency. Additionally, where PwD were onboarded onto the RocheDiabetes Care Platform, and there was no specific need for the PwD to attend the practice, the number of face-to-face appointments was reduced, improving overall clinic efficiency. Over the period of the evaluation there were no (0) Did Not Attend (DNAs).

Aims: to identify and compare barriers and enablers influencing physical activity (PA) in adults and children with type 1 diabetes in the UK. Methods: A cross-sectional, national survey was distributed via BreakthroughT1D (formerly JDRF) networks between December 2022 and January 2023. The survey included closed and open-ended questions on PA behaviours and influencing factors. Responses were collected from adults with T1D and parents of children with type 1 diabetes. Quantitative data were analysed using descriptive statistics and two-proportion z-tests. Free-text responses were analysed thematically. Barriers and enablers were synthesised using the COM-B model and socioecological framework to identify behavioural determinants and intervention targets. Results: 311 responses were analysed (182 adults; 129 parent proxies for children). Stigma and negative comments were reported by nearly three-quarters of both groups. Adults more frequently reported clinical and motivational barriers: fear of hypoglycaemia (53%) and lack of motivation (39%). Adults reported significantly less healthcare provider support for physical activity (24%) compared to children (57%), revealing a critical care gap. Children more frequently reported external barriers, including lack of education among coaches (31%). Conclusion: this is the first UK-wide study to comprehensively compare barriers and enablers across age groups. Stigma in physical activity and sports settings emerges as a major, under-recognised barrier requiring urgent attention. Multi-level interventions are required, targeting individual knowledge and motivation alongside systemic changes. These should include mandatory diabetes education for coaches and teachers, policy enforcement to address discrimination, and enhanced healthcare provider support for physical activity.

Background & AimsA fasting-mimicking programme in primary care demonstrated metabolic benefits for persons with type 2 diabetes (T2D). This study evaluated the feasibility of this approach. MethodsPersons with T2D who used metformin or no medication for glycemic control, were randomly assigned to monthly 5-day fasting-mimicking diet (FMD) cycles plus usual care (n=51) or usual care alone (n=49) for one year. In this mixed method study, feasibility of following an FMD was evaluated by combining quantitative data, including reasons for discontinuation, serum ketone levels, and treatment satisfaction, and qualitative data from focus group discussions. ResultsIn the FMD group, 61% of the participants completed the FMD programme, 31% discontinued the programme due to diet-related issues, and 8% discontinued the programme for other reasons. Ketone levels were consistently higher in the FMD group than in the control group (p<0.01). Treatment satisfaction did not differ between the groups. Focus groups (n=20) revealed facilitators of adherence, including convenience, short FMD cycles, not feeling hungry, internal motivation, believing in beneficial effects, experiencing health effects and social support. Barriers included taste, quantity, and frequency of the FMD, environmental temptations, and lack of social support. ConclusionsThe implementation of periodic FMD cycles appears feasible for T2D patients in primary care, supported by adherence rates, ketone levels, and treatment satisfaction. Adherence might be enhanced by addressing identified facilitators and barriers. Trial registrationClinicalTrials.gov; NCT03811587. Registered 22 January 2019.

IntroductionThere is a growing prevalence of diabetes and related chronic complications in Uganda. We conducted a systematic review and meta-analysis to document the prevalence and predictors of five microvascular and macrovascular diabetes complications in adult Ugandans with diabetes. Materials and MethodsWe searched Medline, EMBASE, CINAHL, Cochrane Library, and Africa Journal Online databases. We included studies on the prevalence and predictors of any chronic microvascular or macrovascular diabetes complications of interest. We conducted a random effect meta-analysis to determine the pooled prevalence of each diabetes complication. A narrative review was used to describe the significant predictors. ResultsA total of 20 studies involving 11,400 participants were included. The pooled mean (standard deviation) age of the participants was 54.8 (3.6) years, with the majority being female (pooled proportion of 61.1%, 95% confidence interval [CI] 57.1-65.2). For the microvascular diabetes complications, the pooled prevalence of diabetic neuropathy, retinopathy, and nephropathy was 56.8% (95% CI 44.9-68.7, I2 = 98.56%, p<0.001), 19.5% (95% CI 3.9-35.2, I2 = 99.60%, p<0.001), and 17.7% (95% CI 7.3-28.0, I2 = 99.36%, p<0.001), respectively. For the macrovascular diabetes complications, the pooled prevalence of peripheral arterial disease and diabetic foot disease was 32.2% (95% CI 15.8-48.7, I2 = 97.67%, p<0.001) and 5.5% (95% CI 1.7-9.2, I2= 90.22%, p<0.001), respectively. Hypertension comorbidity, physical inactivity, family history of diabetes, body mass index [&le;]30 kg/m2, and pregnancy were predictors of diabetic nephropathy in three studies. In two studies, a history of a foot ulcer and age >60 years were predictors of diabetic neuropathy while female sex, hypertension comorbidity, and use of glibenclamide were predictors of peripheral arterial disease. DiscussionChronic diabetes complications are very common in adult Ugandans with diabetes, especially diabetic neuropathy and peripheral arterial disease. Regular screening and optimal management of diabetes and its complications should be emphasised in Uganda.

Type 2 diabetes (T2D) has been occurring at younger ages of onset around the world. Indias population accounts for nearly 20% of the global disease burden. This study investigated the occurrence of depressive symptoms and qualitatively explored the lived experiences of 20 young adults living with T2D under the age of 35. We conducted a convergent mixed-methods study with the Patient Health Questionnaire (PHQ-9) and semi-structured interviews from June 2022 to July 2022 in Mysore district, India. Guided by the World Health Organizations Commission on Social Determinants of Health conceptual framework and biopsychosocial frameworks, areas of inquiry included knowledge and perception about T2D, accessibility of healthcare resources, T2D-related self-care activities, and the impact of the condition on their daily life. Interviews were debriefed by the research team and analyzed thematically using NVivo 12. Participants were aged between 21 and 35 (mean: 30.8, SD: 4.2) and the majority were female (75%). Overall, 55% reported mild depression symptoms, 15% reported moderate to moderately severe depression symptoms; 5 participants (25%) reported suicidality. Sex, living in rural Mysore district, socioeconomic status, T2D duration, family history of T2D, T2D-induced complications, and T2D-related self-care behaviors were associated with depressive symptoms. Thematic analysis revealed 1) low knowledge about T2D, 2) substantial interpersonal and internalized stigma for having T2D at a young age, 3) financial and time constraints to seek and receive care, 4) self-perception as burdens to family members due to the cost and stress of living with T2D, 5) competing priorities with work and family, and 6) the power of social support in managing T2D. These themes were consistent across the sample, regardless of severity of depressive symptoms. Awareness campaigns and peer support programs may help reduce depressive symptoms and increase self-efficacy in this population.

IntroductionHomelessness poses unique barriers to diabetes management. Population-level data on the risks of diabetes outcomes among people experiencing homelessness are needed to inform resource investment. The aim of this study was to create a population cohort of people with diabetes with a history of homelessness to understand their unique demographic and clinical characteristics and improve long-term health outcomes. MethodsOntario residents with diabetes were identified in administrative hospital databases between 2006 and 2020. A history of homelessness was identified using a validated algorithm. Demographic and clinical characteristics were compared between people with and without a history of homelessness. Propensity score matching was used to create a cohort of people with diabetes experiencing homelessness matched to comparable non-homeless controls. ResultsOf the 1,455,567 patients with diabetes who used hospital services, 0.7% (n=8,599) had a history of homelessness. Patients with a history of homelessness were younger (mean: 54 vs 66 years), more likely to be male (66% vs 51%) and more likely to live in a large urban centre (25% vs 7%). Notably, they were also more likely to be diagnosed with mental illness (49% vs 2%) and be admitted to a designated inpatient mental health bed (37% versus 1%). A suitable match was found for 5219 (75%) people with documented homelessness. The derived matched cohort was balanced on important demographic and clinical characteristics. ConclusionPeople with diabetes experiencing homelessness have unique characteristics that may require additional supports. Population-level comparisons can inform the delivery of tailored diabetes care and self-management resources.

Background and objectivesType 1 diabetes (T1D) is a largely self-managed condition that requires ongoing daily tasks and decisions. Many people living with T1D in Canada manage it alone, which can feel very isolating and negatively affect physical and mental health. Connecting with other people in similar situations may help to reduce the potential burden associated with managing this health condition. We aim to co-develop and evaluate a virtual peer support program called CommuniT1D, led by people with T1D, to improve the overall wellbeing of people across Canada whose lives are affected by T1D. Methods and analysisUsing a community-based participatory design and action research approach and a realist evaluation framework, we will first co-develop CommuniT1D by working together as a group of people with T1D, researchers, and clinicians. Over two thirds of steering committee members live with T1D (their own or their childs.) This collective lived expertise is complemented by experts in mental health, social support, health services research, and other relevant fields. Once the program is ready to welcome members, we will work with our partner organizations, networks, and use tailored ads to recruit CommuniT1D peer leaders and members. We will then form virtual peer support groups of people with shared lived experience. Within the program, we will hold monthly small group meetings led by peer leaders via an online platform. We will also hold monthly large webinars open to all CommuniT1D members and other interested people. To evaluate CommuniT1D, we will conduct surveys at baseline and every 6 months, collecting data about diabetes distress, life challenges, quality of life, wellbeing, management indicators, and access and use of management tools and services. We will analyze quantitative data using repeated measures analysis of variance. We will also conduct individual interviews with CommuniT1D members and peer leaders at two time points. We will analyze interview data thematically, and create a logic model by triangulating results from qualitative and quantitative analyses, applying a realist evaluation lens. DiscussionPeer support may help people with T1D feel less alone and better supported. This protocol outlines the design of a virtual peer support program called CommuniT1D to improve the wellbeing of people whose lives are affected by T1D in Canada. We hope that this program will help better equip people with T1D to cope with T1D-related stressors, thus improving the lives of people with T1D in Canada.

BackgroundDiabetic foot complications are a leading cause of morbidity, disability, and healthcare costs worldwide, yet they are largely preventable through proper self-care. In Palestine, evidence on patient adherence to recommended practices is scarce. This study aimed to assess the knowledge, attitudes, and practices of foot self-care among adults with diabetes in the West Bank and to identify factors associated with adherence. MethodsA cross-sectional study was conducted among 300 diabetic patients attending primary care clinics across the West Bank. Data were collected using a structured and validated questionnaire covering knowledge, attitudes, and practices. Statistical analyses included reliability testing, factor analysis, bivariate correlations, and multivariable regression models to identify independent predictors of adherence. ResultsAdherence to recommended foot care practices was generally low, with only 13% of participants reporting daily engagement in all recommended behaviors. While daily foot washing was widely practiced (80.9%), preventive measures were less consistent: 33.1% inspected their feet daily, 45.1% dried between toes, and 40.3% inspected shoes. Risky practices were also common, including foot soaking (28.6%), barefoot walking (20.2%), and wearing shoes without socks (15.9%). Reliability testing of the foot care scale revealed poor internal consistency (Cronbachs alpha = 0.39), suggesting a multidimensional structure. Multivariable regression showed that higher education (adjusted B = -4.05 for no schooling vs. undergraduate, p = 0.049), higher income (B = +3.91, p = 0.028), and longer diabetes duration (B = +1.02 per 5 years, p = 0.035) were associated with better adherence. Male sex was linked to lower adherence (OR 0.46, p = 0.017). Exposure to structured education and professional foot examinations also strongly predicted improved practices. ConclusionAdherence to preventive foot self-care among diabetic patients in the West Bank is suboptimal, particularly in practices directly related to ulcer prevention. Socioeconomic disparities, health literacy, and limited clinical reinforcement emerged as key barriers. Culturally tailored education, structured provider counseling, and policy-level interventions are urgently needed to reduce the burden of diabetic foot disease in Palestine.