Diabetes distress in adults with type 1 diabetes: prevalence, incidence and change over time
Open accessAbstract
Aims To document the prevalence and 9-month incidence of elevated diabetes distress (DD) and the stability of DD over time using both single threshold and minimal clinically important differences (MCID) approaches.Methods Adults with type 1 diabetes (T1D) (N=224) completed the 28-item T1-Diabetes Distress Scale (T1-DDS) at baseline and 9months. A T1-DDS threshold was identified with spline analysis and MCID was calculated from the standard error of measurement.Results Analyses supported a cut-point of ≥2.0 for elevated DD. The prevalence and 9-month incidence of elevated DD was 42.1% and 54.4%, respectively. MCID was ±0.19 but varied by subscale (.26 to .50). Elevated DD was stable: only 20% crossed 2.0 over 9months. MCID analyses showed that change also occurred among those who remained either below or above 2.0 over time. Change varied by source of distress, with Powerlessness the most prevalent and stable. Using MCID, only participant age, gender and number of complications predicted change.Conclusions The prevalence, 9-month incidence and stability of elevated DD are high among adults with T1D, with change based on source of DD. We propose a combined cut-point/MCID framework for measuring change in DD, since each approach reflects unique characteristics of change over time.
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- Findingown data
Spline regression identified a knot at a T1-DDS score of 2.081 (R2 = .053).
“Results of spline regression procedures, specifying a linear relationship between T1-DDS and A1C along the full T1-DDS range, indicated a knot at the T1-DDS score of 2.081 (R2 = .053), with a positive linear coefficient for the slope in the first phase and a negative adjustment for the second phase (Figure 1).”
Quote in the paperNot a substantial claim - Findingown data
MCIDs for the T1-DDS subscales varied from 0.26 to 0.50.
“MCIDs for the subscales varied from 0.26 to 0.50: smaller values than for the total scale were expected, given that MCID was based in part on the number of scale items and alpha.”
Quote in the paperNot a substantial claim - Findingreasoning
Between 20% and 30% of participants became distressed or were no longer distressed over 9 months.
“Thus, elevated DD, when it occurred, was persistent over time, and between 20% and 30% of participants became distressed or were no longer distressed over 9 months.”
Quote in the paperSubstantial claim - Findingown data
The proportion of participants who were distressed at both baseline and 9 months differed across the seven T1-DDS subscales (Cochran's Q: χ2 = 320.79, p < .0001).
“However, the proportion of participants who were distressed at both at baseline and 9-months differed across the seven T1-DDS subscales (Cochran’s Q: χ2 = 320.79, p < .0001).”
Quote in the paperSubstantial claim - Findingown data
There was considerable variability in stability and change in MCID over time across the T1-DDS subscales (Cochran's Q: χ2(7) = 90.64, p < .0001).
“There was considerable variability in stability and change in MCID over time across the T1-DDS subscales (Cochran’s Q: χ2(7) = 90.64, p < .0001).”
Quote in the paperNot a substantial claim
- Findingown data
Among participants who scored ≥ 2.0 on the Powerlessness subscale at baseline, 90% scored similarly at 9 months.
“For example, 90% of participants who scored ≥ 2.0 on the Powerlessness subscale at baseline scored similarly at 9 months, whereas only 60% who scored at ≥ 2.0 at baseline on Physician Distress did so at 9 months.”
Quote in the paperNot a substantial claim - Findingown data
Among adults with T1D who were distressed at baseline (T1-DDS ≥ 2.0), 71% remained distressed at 9 months.
“Individuals who were distressed at baseline tended to remain distressed at 9 months (71%), and those who were not distressed at baseline tended to remain so at 9 months (81%) (Table 2).”
Quote in the paperSubstantial claim - Findingown data
The 9-month incidence of elevated DD (T1-DDS ≥ 2.0) among adults with T1D was 54.4%.
“The prevalence and 9-month incidence of elevated DD was 42.1% and 54.4%, respectively.”
- Also stated in: § 3.3 Prevalence, Incidence and Change in DD Over Time · plain
“The prevalence and 9-month incidence of DD, using the ≥ 2 threshold on the T1-DDS, was 42.1% and 54.4%, respectively.”
- Also stated in: § 4.0 DISCUSSION · boosted
“The point-prevalence and 9-month incidence of elevated DD among adults with T1D, based on the ≥ 2.0 cut-point, are strikingly high -- 42.1% and 54.4%, respectively.”
Quote in the paperSubstantial claim - Also stated in: § 3.3 Prevalence, Incidence and Change in DD Over Time · plain
- Findingown data
No baseline variable significantly predicted change from low to elevated DD over time across the ≥ 2.0 threshold.
“In the first set of analyses no variable significantly predicted change from low to elevated DD over time.”
Quote in the paperNot a substantial claim - Findingown data
The prevalence of elevated DD (T1-DDS ≥ 2.0) among adults with T1D was 42.1%.
“The prevalence and 9-month incidence of elevated DD was 42.1% and 54.4%, respectively.”
- Also stated in: § 3.3 Prevalence, Incidence and Change in DD Over Time · plain
“The prevalence and 9-month incidence of DD, using the ≥ 2 threshold on the T1-DDS, was 42.1% and 54.4%, respectively.”
- Also stated in: § 4.0 DISCUSSION · plain
“The point-prevalence and 9-month incidence of elevated DD among adults with T1D, based on the ≥ 2.0 cut-point, are strikingly high -- 42.1% and 54.4%, respectively.”
Quote in the paperSubstantial claim - Also stated in: § 3.3 Prevalence, Incidence and Change in DD Over Time · plain
- Findingown data
The MCID for the total T1-DDS score was 0.19.
“With a baseline T1-DDS total score mean of 1.96 (0.64), an alpha of 0.91 and a small effect size of 1.0, the MCID for the total T1-DDS score was 0.19 (Table 3).”
Quote in the paperSubstantial claim - Findingown data
There is a statistically significant change in slope between T1-DDS < 2.0 and T1-DDS ≥ 2.0 (B = −1.14, SE = .46, p = .01).
“There was also a statistically significant result for a change in slope from T1-DDS < 2.0 and T1-DDS ≥ 2.0 (B = −1.14 [SE = .46], Beta = −.38, t = −2.50, p = .01.).”
Quote in the paperSubstantial claim - Findingown data
Among adults with T1D who were not distressed at baseline (T1-DDS < 2.0), 81% remained not distressed at 9 months.
“Individuals who were distressed at baseline tended to remain distressed at 9 months (71%), and those who were not distressed at baseline tended to remain so at 9 months (81%) (Table 2).”
Quote in the paperSubstantial claim - Findingown data
Among participants who scored ≥ 2.0 on the Physician Distress subscale at baseline, 60% scored similarly at 9 months.
“For example, 90% of participants who scored ≥ 2.0 on the Powerlessness subscale at baseline scored similarly at 9 months, whereas only 60% who scored at ≥ 2.0 at baseline on Physician Distress did so at 9 months.”
Quote in the paperNot a substantial claim - Findingown data
MCID calculated using half-standard deviation units produced very similar results to those reported.
“Although not presented here, we also calculated MCID using half-standard deviation units and found very similar results.”
Quote in the paperNot a substantial claim - Findingown data
Overall, 76.8% of the total sample evidenced no change in DD across the 2.0 threshold.
“Overall, 76.8% of the total sample evidenced no change in DD across the 2.0 threshold.”
Quote in the paperSubstantial claim - Findingown data
Feelings of powerlessness are the most prevalent and persistent source of DD among those assessed.
“Feelings of powerlessness are the most prevalent and persistent source of DD among those assessed, pointing to the discouraging impact of varying and sometimes chaotic BG numbers over time, despite an individual’s best efforts.”
Quote in the paperSubstantial claim - Findingown data
Using MCID, only participant age, gender and number of complications predicted change.
“Using MCID, only participant age, gender and number of complications predicted change.”
Quote in the paperSubstantial claim - Findingown data
Only those with good self-monitored BG adherence at baseline had T1-DDS scores below the cut-point at 9 months (82.0% vs. 69.9%, p < .001).
“In the second set of analyses, only those with good self-monitored BG adherence at baseline had T1-DDS scores below the cut-point at 9 months (82.0% vs. 69.9%, p < .001).”
Quote in the paperNot a substantial claim - Findingown data
MCID calculated with SEM using a large, diverse, national sample of 279 T1Ds produced results similar to those reported here.
“Furthermore, we calculated MCID with SEM using a large, diverse, national sample of 279 T1Ds and again found results similar to those reported here.”
Quote in the paperSubstantial claim - Findingown data
Across the entire T1-DDS score range, over twice as many individuals display a significant change using MCID than using the diagnostic criterion.
“Across the entire T1DDS score range, over twice as many individuals display a significant change using MCID than using the diagnostic criterion.”
Quote in the paperSubstantial claim - Findingown data
MCID analyses showed that change also occurred among those who remained either below or above 2.0 over time.
“MCID analyses showed that change also occurred among those who remained either below or above 2.0 over time.”
Quote in the paperNot a substantial claim - Interpretationown data
Based on MCID, the source of DD affected stability and change over time.
“Again, based on MCID, the source of DD affected stability and change over time.”
Quote in the paperSubstantial claim - Interpretationown data
Stability and change over time varied significantly as a function of the source of DD.
“Thus, stability and change over time varied significantly as a function of the source of DD.”
Quote in the paperSubstantial claim - Interpretationown data
Elevated DD, when it occurred, was persistent over time.
“Thus, elevated DD, when it occurred, was persistent over time, and between 20% and 30% of participants became distressed or were no longer distressed over 9 months.”
Quote in the paperSubstantial claim - Interpretationreasoning
An increase or decrease of at least 1 MCID in DD over time does not necessarily mean that the level of an individual's DD is no longer of concern.
“It is important to note, however, that an increase or decrease of at least 1 MCID in DD over time does not necessarily mean that the level of an individual’s DD is no longer of concern.”
Quote in the paperNot a substantial claim - Interpretationreasoning
The use of SEM for MCID can be better applied to diverse T1D populations.
“Thus, its use can be better applied to diverse T1D populations.”
Quote in the paperNot a substantial claim - Interpretationreasoning
Across the diabetes spectrum, even at relatively low levels of intensity, DD has significant implications for disease management and glycemic control.
“These findings suggest that across the diabetes spectrum, even at relatively low levels of intensity, DD has significant implications for disease management and glycemic control.”
Quote in the paperSubstantial claim - Interpretationown data
DD is a potent experience-even at low levels it displays a significant relationship with glycemic control.
“DD, therefore, is a potent experience—even at low levels it displays a significant relationship with glycemic control.”
Quote in the paperSubstantial claim - Interpretationown data
Including MCID into the analysis of change permits the detection of significant change even among those who score consistently high or low in DD over time, with implications for clinical care.
“Thus, including MCID into the analysis of change permits the detection of significant change even among those who score consistently high or low in DD over time, with implications for clinical care.”
Quote in the paperSubstantial claim - Premisecitation
The same 2.0 cut-point was demonstrated with A1C and diabetes management variables when a different scale to assess DD was administered to adults with T2D.
“Interestingly, the same 2.0 cut-point was demonstrated with A1C and diabetes management variables when a different scale to assess DD was administered to adults with T2D [17].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [17] source
Not checked in the free run.
- Interpretationown data
MCID analyses indicate that a far greater amount of meaningful change in DD occurs over time than is reflected by the use of a single score threshold.
“MCID analyses indicate that a far greater amount of meaningful change in DD occurs over time than is reflected by the use of a single score threshold.”
Quote in the paperSubstantial claim - Study design and conductnone given
The sample was not sufficiently large to enable subgroup analyses.
“Furthermore, our sample was not sufficiently large to enable subgroup analyses.”
Quote in the paperNot a substantial claim - Interpretationown data
Overall, very few participant baseline characteristics predicted a change across the DD threshold over time.
“Overall, very few participant baseline characteristics predicted a change across the DD threshold over time.”
Quote in the paperNot a substantial claim - Interpretationown data
These findings support the relative stability of MCID values across methods of calculation and samples of T1D adults.
“These findings, therefore, support the relative stability of MCID values across methods of calculation and samples of T1D adults.”
Quote in the paperSubstantial claim - Interpretationown data
Focusing exclusively on the presence or absence of elevated DD based on a score of ≥ 2.0 will miss the documentation of much meaningful change in DD over time.
“Thus, focusing exclusively on the presence or absence of elevated DD based on a score of ≥ 2.0 will miss the documentation of much meaningful change in DD over time.”
Quote in the paperSubstantial claim - Premisecitation
As found in other studies, without intervention few baseline demographic and diabetes-related variables predict significant change in DD over time.
“As found in other studies [8], without intervention few baseline demographic and diabetes-related variables predict significant change in DD over time.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [8] source
Not checked in the free run.
- Interpretationown data
Without intervention, elevated DD is relatively stable over time when using the ≥ 2.0 threshold.
“Without intervention, elevated DD is relatively stable over time when using the ≥ 2.0 threshold.”
Quote in the paperSubstantial claim - Study design and conductown data
There were no significant differences between those who completed the 9-month assessment and those who did not on any demographic or diabetes status variable tested.
“There were no significant differences between those who completed the 9-month assessment and those who did not on any demographic or diabetes status variable tested.”
Quote in the paperNot a substantial claim - Interpretationcitation
The point-prevalence and 9-month incidence of elevated DD among adults with T1D are similar to the 46.2% prevalence and 9-month 54.3% incidence of DD among adults with T2D, re-calculated from an earlier study (N = 502).
“These figures are similar to the 46.2% prevalence and 9-month 54.3% incidence of DD among adults with T2D, re-calculated from an earlier study (N = 502) [7].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [7] source
Not checked in the free run.
- May combine two claims. 25
- Classified as probably not a substantial claim. 11
May combine two claims.
Findingown dataIn piecewise regression, T1-DDS has a significant positive linear relationship with A1C below the 2.0 cut-point (B = .83, SE = .37, p = .02) but not above it (B = −.31, SE = .28, p = .26).
“In piecewise regression models using this cut-point, a significant linear relationship was found between T1-DDS and A1C below the cut-point (B = .83 [SE = .37], Beta = .05, t = 2.27, p = .02) but not above the cut-point (B = −.31 [SE = .28], Beta = −.02, t = −1.14, p = .26).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataAmong participants, 79.0% remained within one MCID over time on Physician Distress, whereas only 50.0% did so on Hypoglycemia Distress.
“For example, 79.0% of individuals remained within one MCID over time on Physician Distress, whereas only 50.0% did so on Hypoglycemia Distress.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataThe cut-point estimated in spline analyses was rounded to 2.0 and used to define two groups: T1-DDS < 2 and T1-DDS ≥ 2.
“The cut-point estimated in spline analyses, rounded to 2.0, was used to establish two patient groups: those with T1-DDS < 2 and those with T1-DDS ≥ 2.”
Quote in the paperSubstantial claimMay combine two claims.
FindingreasoningMore than twice as many individuals demonstrated a change of at least one MCID compared to a change across the single T1-DDS threshold of ≥ 2.0: 125 vs. 52, respectively (Cochran's Q: χ2(1) = 65.79, p < .0001).
“Because MCID is based on change along the entire scale distribution and not just on a single score cut-point, more than twice as many individuals demonstrated a change of at least one MCID compared to a change across the single T1-DDS threshold of ≥ 2.0: 125 vs. 52, respectively (Cochran’s Q: χ2(1) = 65.79, p < .0001).”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataIn MCID analyses, 27.7% of the sample increased by one or more MCIDs and 28.1% decreased, whereas 10.7% increased and 12.5% decreased across the 2.0 threshold.
“For example, whereas 10.7% of individuals display increases and 12.5% display decreases in DD across the 2.0 threshold, in MCID analyses 27.7% of the sample increased by one or more MCIDs and 28.1% decreased.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataA similar pattern of change occurred for patients who scored below 2.0 at both time points: some displayed significant reductions in DD, whereas others displayed significant increases.
“A similar pattern of change occurred for patients who scored below 2.0 at both time points: some displayed significant reductions in DD, whereas others displayed significant increases.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataChange varied by source of distress, with Powerlessness the most prevalent and stable.
“Change varied by source of distress, with Powerlessness the most prevalent and stable.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataElevated DD was stable: only 20% crossed 2.0 over 9 months.
“Elevated DD was stable: only 20% crossed 2.0 over 9 months.”
Quote in the paperSubstantial claimMay combine two claims.
Findingown dataUsing MCID, females (p < .03), younger adults (p < .07), and those with more complications (p < .03) displayed a higher probability of reduced DD ≥ 1 MCID over time than males, older adults, and those with fewer complications.
“Age, gender and number of complications either approached or reached statistical significance: females (p < .03), younger adults (p < .07) and those with more complications (p < .03) displayed a higher probability of reduced DD ≥ 1 MCID over time than males, older adults, and those with fewer complications.”
Quote in the paperNot a substantial claimMay combine two claims.
Findingown dataOf patients who scored above the 2.0 threshold at both time points (31% of the total sample), 32.9% demonstrated a reduction in DD of at least one MCID but stayed within the elevated range (≥ 2.0); 25.7% demonstrated an increase in DD of at least one MCID.
“For example, of the patients who scored above the 2.0 threshold at both time points (31% of the total sample), 32.9% demonstrated a reduction in DD of at least one MCID but stayed within the elevated range (≥ 2.0); and 25.7% demonstrated an increase in DD of at least one MCID.”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationown dataThe analyses support a T1-DDS total scale cut-point of 2.0 to identify elevated diabetes distress, because the relationship between T1-DDS and A1C is significantly linear until 2.0 and not significant after.
“Analyses supported a cut-point of ≥2.0 for elevated DD.”
- Also stated in: § 3.2 T1-DDS Scale Cut-Point · hedged
“These analyses suggested the viability of a T1-DDS total scale cut-point of 2.0 to identify elevated DD, since the relationship between T1-DDS and A1C was significantly linear until 2.0, after which no significant relationship occurred.”
- Also stated in: § 4.0 DISCUSSION · plain
“In summary, we find that a score of 2.0 serves as a useful cut-point to indicate elevated DD among adults with T1D.”
Quote in the paperSubstantial claim- Also stated in: § 3.2 T1-DDS Scale Cut-Point · hedged
Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).
Interpretationnone givenThe variability in MCID among the T1-DDS subscales might in part be accounted for by the underlying statistical robustness of the subscale itself.
“Fourth, the variability in MCID among the T1-DDS subscales might in part be accounted for by the underlying statistical robustness of the sub scale itself.”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
PremisecitationThe T1-DDS is a reliable and valid 28-item self-report instrument developed to identify specific sources of DD for adults with T1D and to provide an index of overall diabetes-related emotional distress.
“The Type 1 Diabetes Distress Scale (T1-DDS) is a reliable and valid 28-item self-report instrument developed to identify the specific sources of DD for adults with T1D and to provide an index of overall diabetes-related emotional distress for use in clinical and research settings [9].”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [9] source
Not checked in the free run.
May combine two claims.
InterpretationreasoningThe cut-point and MCID approaches each reflect unique characteristics of change over time.
“We propose a combined cut-point/MCID framework for measuring change in DD, since each approach reflects unique characteristics of change over time.”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationown dataThe prevalence, incidence and stability of DD over time vary significantly by the source of DD.
“The prevalence, incidence and stability of DD over time vary significantly by the source of DD.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationAmong type 2 adults, elevated DD is highly stable over time and the point prevalence of elevated DD is approximately 46%.
“Recent studies have indicated that among type 2 adults (T2D) elevated DD is highly stable over time and that the point prevalence of elevated DD is approximately 46%, suggesting a widespread clinical problem in this population [7].”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [7] source
Not checked in the free run.
Classified as probably not a substantial claim.
InterpretationreasoningThe scale response options indicate that significant DD occurs when respondents report even a "slight problem" on average across all 28 items.
“The scale response options indicate that significant DD occurs when respondents report even a “slight problem” on average across all 28 items.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationcitationThe prevalence/incidence of elevated DD in adults with T1D is substantially higher than the reported prevalence/incidence of clinical depression or elevated depression symptoms in this population.
“They are also substantially higher than the reported prevalence/incidence of clinical depression or elevated depression symptoms in this population [18, 19].”
Quote in the paperNot a substantial claim0 of 2 sources checkedClassified as probably not a substantial claim.
InterpretationreasoningMCID provides a yardstick for observing change even among patients who remain above or below the threshold over time.
“MCID, therefore, provides an yardstick for observing change even among patients who remain above or below the threshold over time.”
Quote in the paperSubstantial claimMay combine two claims.
InterpretationreasoningIndividuals with initially low DD (< 2.0) may increase one or more MCIDs over time but still fail to cross the threshold for elevated DD; individuals with initially high DD (≥ 2.0) may demonstrate a reduction of at least one MCID and still not cross the threshold.
“Individuals with initially low levels of DD (< 2.0) may increase one or more MCIDs over time but still fail to cross the threshold for elevated DD; and individuals with initially high levels of DD (≥ 2.0) may demonstrate a reduction of at least one MCID and still not cross the threshold.”
Quote in the paperSubstantial claimMay combine two claims.
Study design and conductnone givenThe study included a diverse, community sample of adults with T1D, permitted a careful comparison of different approaches to change, included assessment of several potential predictors of change, and allowed for a sufficiently long time interval to detect meaningful change.
“This study has several strengths: it included a diverse, community sample of adults with T1D, permitted a careful comparison of different approaches to change, included assessment of several potential predictors of change, and allowed for a sufficiently long time interval to detect meaningful change.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
InterpretationreasoningThe cut-point and MCID approaches each make a unique contribution to documenting change in DD over time.
“We suggest a two-stage approach that includes both methods, since each makes a unique contribution to the documentation of change.”
Quote in the paperSubstantial claimMay combine two claims.
Interpretationown dataUnlike depression, elevated DD does not appear to be episodic, ebbing and flowing over time; instead, when it occurs, without intervention it is generally persistent and continuous.
“Thus, unlike depression [7], elevated DD does not appear to be episodic, ebbing and flowing over time; instead, when it occurs, without intervention it is generally persistent and continuous.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [7] source
Not checked in the free run.
Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningThe study included a 9-month time frame with only two assessments; patterns of stability and change may vary based on the time intervals and multiple assessments.
“Second, the study included a 9-month time frame with only two assessments. Patterns of stability and change may vary based on the time intervals and multiple assessments.”
Quote in the paperNot a substantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
Study design and conductreasoningThe study was observational and no intervention was included to stimulate change, thus reducing the opportunity to identify important predictors of change.
“Third, the study was observational and no intervention was included to stimulate change, thus reducing the opportunity to identify important predictors of change.”
Quote in the paperNot a substantial claimMay combine two claims.
Interpretationown dataThe prevalence, 9-month incidence and stability of elevated DD is high among adults with T1D, with change based on source of DD.
“The prevalence, 9-month incidence and stability of elevated DD is high among adults with T1D, with change based on source of DD.”
Quote in the paperSubstantial claimClassified as probably not a substantial claim.
Study design and conductreasoningSEM was selected to calculate MCID because it is a property of the scale and not a property of a particular sample's T1-DDS score distribution.
“SEM was selected to calculate MCID because it is a property of the scale and not a property of a particular sample’s T1-DDS score distribution.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.
PremisecitationDD is directly linked with poor glycemic control and problematic self-care behaviors, unlike depression.
“Although often confused with depression, unlike depression DD is directly linked with poor glycemic control and problematic self-care behaviors [2–6].”
Quote in the paperNot a substantial claim0 of 5 sources checkedMay combine two claims.
Study design and conductown dataOf 348 eligible individuals, 305 completed the baseline survey (87.0%) and 224 completed the follow-up assessment 9 months later (73%).
“Of 348 eligible individuals identified from the four clinics, 305 completed the baseline survey (87.0%) and 224 completed the follow-up assessment 9 months later (73%).”
Quote in the paperNot a substantial claimClassified as probably not a substantial claim. May combine two claims.
InterpretationreasoningThe MCID findings indicate that a full explication of change requires additional, more fine-grained analyses; otherwise, important aspects of change among those who score consistently high or consistently low over time will be missed and an increase in the risk of type 1 error will occur.
“Second, the MCID findings indicate that a full explication of change requires additional, more fine-grained analyses; otherwise, important aspects of change among those who score consistently high or consistently low over time will be missed and an increase in the risk of type 1 error will occur - not documenting a significant change when in fact one occurred.”
Quote in the paperSubstantial claim
The paper relies on this without support.
No systematic analysis of the prevalence, incidence, and stability of diabetes distress over time among adults with type 1 diabetes had been conducted before this study.
“To date, however, no systematic analysis of the prevalence, incidence and stability of DD over time among adults with type 1 diabetes (T1D) has occurred.”
The paper relies on this without support.
Diabetes distress is important with respect to quality of life and disease management.
“Given the importance of DD with respect to quality of life and disease management, one important but often neglected question is: How much change in DD among adults with T1D over time should be considered meaningful?”
Claims other papers make about this one
Each is checked against this paper’s own text: does it say what the citing paper says it does?
Diabetes distress is prevalent among adults with type 1 diabetes and is associated with poor clinical outcomes.
“Diabetes distress (DD) is a prevalent concern among people with type 1 diabetes (T1D) and is linked to poor clinical outcomes.”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [4]
An estimated 42% of adults with type 1 diabetes report clinically significant diabetes distress.
“As DD is highly prevalent, with an estimated 42% of adults with type 1 diabetes (T1D) reporting clinically significant DD (4)”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [4]
Currently, no available interventions have been shown to significantly reduce both diabetes distress and HbA1c.
“Although DD is highly prevalent (4) and consistently related to self-management behavior and glycemic outcomes among people with diabetes (1–3), currently, no available interventions have been shown to significantly reduce both DD and HbA1c.”
From Addressing emotional distress to improve outcomes in adults with type 1 diabetes: Protocol for ACT1VATE randomized controlled trial (2024) · cites this paper as [4]
About 42% of adults with type 1 diabetes have elevated diabetes distress.
“Approximately 42% of adults with T1DM manifest elevated diabetes distress.4”
From Economic costs of implementing group interventions to reduce diabetes distress in adults with type 1 diabetes mellitus in the T1-REDEEM trial (2019) · cites this paper as [4]
Diabetes distress has been shown to be relatively stable over time, unless some form of intervention takes place.
“Diabetes distress has been shown to be relatively stable over time, unless some form of intervention takes place (19).”
From Observed Glycemic and Psychosocial Benefits in the Prospective Bigfoot Unity Real World Study: A 6-Month Analysis (2025) · cites this paper as [19]
Comparing the average improvement in the current study with the MCID suggests that for the majority of participants, there may have been clinically meaningful improvement.
“To place context around these results, note that the estimated minimally clinically important difference (MCID) for the 28-item T1-DDS total score is 0.19 in an insulin-requiring T1D population (19); comparing the average improvement in the current study with the MCID suggests that for the majority of participants, there may have been clinically meaningful improvement.”
From Observed Glycemic and Psychosocial Benefits in the Prospective Bigfoot Unity Real World Study: A 6-Month Analysis (2025) · cites this paper as [19]
The estimated minimally clinically important difference (MCID) for the 28-item T1-DDS total score is 0.19 in an insulin-requiring T1D population.
“To place context around these results, note that the estimated minimally clinically important difference (MCID) for the 28-item T1-DDS total score is 0.19 in an insulin-requiring T1D population (19); comparing the average improvement in the current study with the MCID suggests that for the majority of participants, there may have been clinically meaningful improvement.”
From Observed Glycemic and Psychosocial Benefits in the Prospective Bigfoot Unity Real World Study: A 6-Month Analysis (2025) · cites this paper as [19]
Evidence from longitudinal studies indicates that diabetes distress levels can remain relatively stable for up to nine months.
“Yet evidence from a longitudinal study that recruited adults with type 1 diabetes [27] and a longitudinal study that recruited parents of youth with type 1 diabetes [28] indicate that diabetes distress levels can remain relatively stable for up to nine months”
From A nonrandomized pilot of a group, video-based telehealth intervention to reduce diabetes distress in parents of youth with type 1 diabetes mellitus (2022) · cites this paper as [27]
Statistics recomputed
Every reported test result, recomputed from its test statistic and degrees of freedom. A result shows as not adding up only once an independent check has confirmed it.
- Consistentχ²(1) = 65.79reported p < .0001 · recomputed p < .001
“χ2(1) = 65.79, p < .0001”
- Consistentχ²(7) = 90.64reported p < .0001 · recomputed p < .001
“χ2(7) = 90.64, p < .0001”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Summary adds BG testing to the MCID predictors
MajorThe abstract says only age, gender, and complications predicted MCID change, whereas the final summary also lists BG testing.
“Using MCID, only participant age, gender and number of complications predicted change.”
“Last, few variables predict change over time, with only age, gender, number of complications and frequency of BG testing predicting change beyond one MCID.”
Subscale MCIDs are described as smaller than the total-scale MCID
MinorEvery value in the stated subscale range exceeds the reported total-scale MCID of 0.19, contrary to the description that the subscale values are smaller.
“MCIDs for the subscales varied from 0.26 to 0.50: smaller values than for the total scale were expected”
“the MCID for the total T1-DDS score was 0.19 (Table 3).”
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“12 Emotional stress related to the management of diabetes, diabetes distress, persists over time 13 and is present among 20%–30% of people with type 1 diabetes.”
BackgroundWorking people with type 1 diabetes in the Finnish population
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- Authors
- Fisher, L., Hessler, D., Polonsky, W., Strycker, L., Masharani, U., & Peters, A.
- Affiliations
- University of California, San Francisco (US)
- University of California San Diego (US)
- Oregon Research Institute (US)
- University of Southern California (US)
- Corresponding author
- Fisher, Lawrence
- Venue
- Journal of Diabetes and its Complications
- Publisher
- Elsevier BV
- Published
- 2016-08
- Volume
- 30
- Issue
- 6
- Pages
- 1123-1128
- ISSN
- 0891-6632 (ISSN-L)
- 1056-8727
- PMC
- PMC4949147
- OpenAlex
- W2324027622
- Cited by
- 208
- References
- 17
- Citations by year
- 2026: 27 · 2025: 29 · 2024: 25 · 2023: 20 · 2022: 28 · 2021: 24 · 2020: 19 · 2019: 13 · 2018: 12 · 2017: 10 · 2016: 1
- FWCI
- 12.04
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Diabetes and its Complications (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- eScholarship (California Digital Library) (submittedVersion)
- Funders
- Ministerul Cercetării, Inovării şi Digitalizării
- National Institute of Diabetes and Digestive and Kidney Diseases (R01DK094863)
- Topics
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Education
- Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
- Health Sciences › Medicine › Oncology › Cancer survivorship and care
- Keywords
- diabetes distress, type 1 diabetes, adults, prevalence, incidence, minimal clinically important difference, cut points, powerlessness, temporal stability, diabetes complications
- MeSH terms
- Adult, Diabetes Mellitus, Type 1, Emotions, Female, Humans, Male, Middle Aged, Stress, Psychological, Incidence, Prevalence
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