Objective: To explore mechanisms by which changes in diabetes distress (DD) can lead to reductions in Hemoglobin A1c among adults with type 1 diabetes over time in the context of a distress intervention.

Methods: In a two-arm randomized trial aimed at reducing DD (a DD-focused vs. an education/management intervention), 301 adults with type 1 diabetes [mean ± SD age was 45.1 ±15.0 years, baseline HbA1c 8.80% ± 1.12]. Individuals were assessed at baseline and at 9 month follow-up on DD, behavioral management, HbA1c and frequency of hypoglycemia (blood glucose < 70 mg/dl). Structural equation modeling tested for significant pathways between changes in DD, behavioral measures, and glycemic control; with separate pathways tested for both the education based and affective focused interventions.

Results: Reductions in management distress were associated with fewer missed insulin boluses, increased problem solving skills, increased diabetes knowledge and more frequent adjustments to insulin regimen in relation to diet (all p < .05). In turn, reductions in missed insulin boluses were linked with improved HbA1c; while increases in problem solving and diabetes knowledge were linked with reductions in frequency of hypoglycemia over a 9-month period. SEM model indices indicated good fit (Chi-square p = .01, CFI = .95, RMSEA = .04). An overall stronger set of linkages were noted for the DD-focused vs. the education/management intervention.

Discussion: In the context of an RCT to reduce DD, results point to significant pathways by which changes in Management Distress operate through changes in disease management and knowledge, which, in turn, drive changes in HbA1C and frequency of hypoglycemic episodes. These findings document the mechanisms through which DD is associated with glycemic control in type 1 diabetes and support the importance of integrating disease management with interventions to reduce DD to maximize improvements in glycemic control.


D.M. Hessler: Consultant; Self; Eli Lilly and Company. L. Fisher: None. U. Masharani: None. W. Polonsky: Advisory Panel; Self; Intarcia Therapeutics, Roche Diabetes Care. Consultant; Self; Abbott, Dexcom, Inc., Eli Lilly and Company, Insulet Corporation, Novo Nordisk Inc., Onduo, Sanofi US, Xeris Pharmaceuticals, Inc.


National Institute of Diabetes and Digestive and Kidney Diseases (R01DK094863)

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