Disclosures: Lewinski reports receiving funds from Otsuka and PhRMA Foundation. The research was supported by was supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation grant and VA HSR&D grants. Please see the study for all other authors’ relevant financial disclosures.
January 14, 2022
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Consider military experience when assessing diabetes distress in veterans

Disclosures: Lewinski reports receiving funds from Otsuka and PhRMA Foundation. The research was supported by was supported by the Durham Center of Innovation to Accelerate Discovery and Practice Transformation grant and VA HSR&D grants. Please see the study for all other authors’ relevant financial disclosures.
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The military experience of veterans with type 2 diabetes may contribute to their diabetes distress and should be considered by providers when discussing diabetes self-management, according to study findings.

“Veterans have a unique set of life experiences that may impact their self-identity and interactions with other veterans, civilians and the health care system,” Allison Lewinski, PhD, investigator at the Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, and assistant professor in the school of nursing at Duke University, told Healio. “These in turn can influence their perception of type 2 diabetes and engagement in type 2 diabetes self-management. By better understanding domains and causes of diabetes distress for veterans, we can develop improved and more personalized models of care for veterans with type 2 diabetes.”

Allison Lewinski, PhD
Lewinski is an investigator at the Durham Center of Innovation to Accelerate Discovery and Practice Transformation, Durham Veterans Affairs Health Care System, and assistant professor in the school of nursing at Duke University.

Researchers conducted a qualitative study consisting of two rounds of cognitive interviews via telephone with 15 veterans with type 2 diabetes who received care with the Veterans Health Administration and had an HbA1c within 180 days of recruitment (73% men; mean age, 61 years). HbA1c, age, weight, comorbidities and medications were obtained through electronic medical records. The Diabetes Distress Scale was used to assess diabetes distress in the interview. Responses to each question were scored on a 6-point Likert scale, with 1 signifying the item was not a problem and 6 signifying a very serious problem.

Diabetes Distress Scale works well with veterans

The study cohort had an overall diabetes distress score of 2.5, indicating moderate distress. The subscale with the highest distress was emotional burden, with a mean score of 3. The cohort had a mean score of 2.6 for regimen and 2 for health care provider, signifying moderate distress. Interpersonal questions had the lowest distress score of 1.9.

Participants said the Diabetes Distress Scale accurately captured their emotions and feelings of living with type 2 diabetes and indicated self-management affected all aspects of their lives. There was some variation in responses to some questions, including confidence in day-to-day ability to managing diabetes, worry about ending up with serious long-term complications, and questions about whether their physician takes their concerns seriously, gives enough clear directions on diabetes management and can see them regularly enough. Veterans did not have any extreme negative emotional or physical reactions when completing the interview and were aware that type 2 diabetes could have serious long-term effects.

Additional areas of focus

There were several areas participants said they felt that the Diabetes Distress Scale did not address, including access to care, comorbidities, disruptions in routine, fluctuations in behavior, the lifelong nature of diabetes, mental health concerns, military culture, physical pain, personal characteristics, physical limitations, spirituality and stigma. Many veterans expressed frustration that they were asked to recall diabetes distress within the last month, saying it was a short timeframe.

After analysis of the data, the research team suggested adding additional questions for measuring diabetes distress in veterans, including measures to address stigma with the Stigma Scale of Chronic Illnesses and pain with the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference Scale, demographic questions about military experience, qualitative interview questions to address stigma, and probes to collect more information on physical pain, personal characteristics, mental health concerns, access to care and fluctuations in emotions and behaviors.

“We found diabetes distress in veterans to include domains not captured by the Diabetes Distress Scale, and so we added additional domains and questions to ask in our other research studies, which are currently ongoing,” Lewinski said. “Our future work includes using findings from this study, as well as findings from our other studies focused on diabetes distress, to help develop personalized interventions to reduce diabetes distress and improve type 2 diabetes self-management among veterans. Future research is warranted in developing and testing measures of additional domains of diabetes distress in other populations; future cognitive interviewing with diabetes distress measures should be completed with additional samples, such as women, transgender and/or younger veterans, at other health care institutions, and other geographic locations at longitudinal time points.”

For more information:

Allison Lewinski, PhD, can be reached at allison.lewinski@duke.edu.