Type 2 Diabetes Self-Management Interventions: Does the Rubber Meet the Road?

Purpose: Type 2 diabetes (T2D) is a major cause of global disability, suffering and death. It is a well-known cause of cardiovascular disease, kidney failure, and lower extremity amputations. [1] Less focus is given to its significant impact on cognitive and affective impairments. Depression is twice as common in people with T2D [2] and brain functional abnormalities have been associated with significant consequences for cognition. [3] Precision health approaches or patient-centered therapy have been hypothesized as a contemporary approach to bridge the rising tide of disability and need for patient-focused self-management. Precision health approaches might improve the effectiveness of self-management interventions by tailoring the intervention towards clinically significant characteristics (or phenotypes) unique to subgroups of individuals. A wide range of self-management interventions for cognitive and affective symptoms in individuals with T2D have been developed and tested but little is known about the extent to which these interventions allow for precision health approaches.

The purpose of this integrative review was to describe the empirical literature on cognitive and affective self-management interventions for T2D and appraise its fit with precision health concepts. Our aims were as follows: 1. Summarize and analyze the state of the science on self-management interventions for adults with T2D that focus on cognitive and affective responses; 2. Examine precision health related factors and how they affect intervention outcomes; 3. Evaluate the level of investment needed to implement these interventions into clinical practice.

Methods: The empirical literature published between 1994-2018 was searched to identify self-management interventions for cognitive and affective symptoms in patients with T2D. Searches were initially conducted in April 2014 and updated in July 2018. PubMed, CINAHL, and PsycINFO databases were searched using a combination of terms including: Type 2 Diabetes, Cognitive, Affective, Self-management, and Interventions. Searches were limited to research studies in English. Inclusion Criteria: (1) Populations including adults with T2D; (2) Cognitive and affective symptoms a major focus of the intervention study; (3) Self-management of T2D as a key focus, outcome, or intervention; and (4) Published from 1994 through present. Exclusion Criteria were:

(1) A diagnosis of type 1 diabetes or LADA (latent autoimmune diabetes of adults).

1. T2D sample not separately analyzed and reported.

(2) T2D used as a co-variate and not as the primary sample characteristic.

(3) No reporting of cognitive/affective variables.

(4) A pregnancy with pre-existing diabetes and gestational diabetes.

Exclusion Criteria were:

(1) Focus on type 1 diabetes or LADA (latent autoimmune diabetes of adults).

a. T2D sample not separately analyzed and reported.

(2) T2D used as a co-variate and not as the primary sample characteristic.

(3) No reporting of cognitive/affective variables.

(4) Focus on pregnancy with pre-existing diabetes and gestational diabetes.

Results: We identified 68 studies that met inclusion criteria. The studies were published between 2002 and 2018; 46 of 68 studies were conducted in the United States. Study designs were mostly experimental (n=54) with 10 quasi-experimental studies and 4 mixed methods. The sample sizes ranged from 16 to 5145.

Seven questions guided our analysis and organization of the finding. They were as follows:

1) What were the main categories of interventions outcomes?

2) How was self-management utilized in the study?

3) How were cognitive and affective concepts utilized in the study?

4) Was a theoretical framework used to guide study design?

5) Who delivered the intervention?

6) Was the intervention targeted or tailored?

7) What level of investment would be required to implement the intervention in clinical practice?

Conclusion: This review demonstrates that most intervention studies for self-management of cognitive and affective symptoms of T2D do not utilize precision health approaches that are conducive to tailoring or targeting interventions to specific subgroups. While many studies included predictor variables, moderator analyses were not conducted in order to allow the determination of “precision” variables for tailoring. [4] Importantly, most interventions were rated as requiring moderate to high levels of resources to implement in clinical or community settings and therefore, there should be more of a focus on sustainability and translatability in the future. [5] People living with T2D and other chronic conditions often experience cognitive and affective symptoms, necessitating a focus on addressing these symptoms in an effective, generalizable way in future research and implementation science initiatives.