OBJECTIVE A variety of symptoms may be associated with type 2 diabetes and its complications. Symptoms in chronic diseases may be described in terms of prevalence, severity, and trajectory and often co-occur in groups, known as symptom clusters, which may be representative of a common etiology. The purpose of this study was to characterize type 2 diabetes–related symptoms using a large nationwide electronic health record (EHR) database. Methods We acquired the Cerner Health Facts, a nationwide EHR database. The type 2 diabetes cohort (n = 1,136,301 patients) was identified using a rule-based phenotype method. A multistep procedure was then used to identify type 2 diabetes–related symptoms based on International Classification of Diseases, 9th and 10th revisions, diagnosis codes. Type 2 diabetes–related symptoms and co-occurring symptom clusters, including their temporal patterns, were characterized based the longitudinal EHR data. Results Patients had a mean age of 61.4 years, 51.2% were female, and 70.0% were White. Among 1,136,301 patients, there were 8,008,276 occurrences of 59 symptoms. The most frequently reported symptoms included pain, heartburn, shortness of breath, fatigue, and swelling, which occurred in 21–60% of the patients. We also observed over-represented type 2 diabetes symptoms, including difficulty speaking, feeling confused, trouble remembering, weakness, and drowsiness/sleepiness. Some of these are rare and difficult to detect by traditional patient-reported outcomes studies. Conclusion To the best of our knowledge, this is the first study to use a nationwide EHR database to characterize type 2 diabetes–related symptoms and their temporal patterns. Fifty-nine symptoms, including both over-represented and rare diabetes-related symptoms, were identified.

Measuring the population-level relationship between compromised mental health and diabetes care remains an important goal for clinicians and health care decision-makers. We evaluated the impact of self-reported unmet psychological need on health care resource utilization and total health care expenditure in people with type 2 diabetes. Patients who reported unmet psychological needs were more likely than those who did not to incur a higher annual medical expenditure, have greater resource utilization, and have a higher risk of all-cause mortality.

Telehealth has emerged as an evolving care management strategy that is playing an increasingly vital role, particularly with the onset of the coronavirus disease 2019 pandemic. A meta-analysis of 20 randomized controlled trials was conducted to test the effectiveness of home telemonitoring (HTM) in patients with type 2 diabetes in reducing A1C, blood pressure, and BMI over a median 180-day study duration. HTM was associated with a significant reduction in A1C by 0.42% (P = 0.0084). Although we found statistically significant changes in both systolic and diastolic blood pressure (−0.10 mmHg [P = 0.0041], and −0.07 mmHg [P = 0.044], respectively), we regard this as clinically nonsignificant in the context of HTM. Comparisons across different methods of transmitting vital signs suggest that patients logging into systems with moderate interaction with the technology platform had significantly higher reductions in A1C than those using fully automatic transmission methods or fully manual uploading methods. A1C did not vary significantly by study duration (from 84 days to 5 years). HTM has the potential to provide patients and their providers with timely, up-to-date information while simultaneously improving A1C.

Objective People with type 2 diabetes are likely to experience shame or guilt as they navigate through their disease. Previous research has shown that feelings of shame and guilt often exist within the clinician-patient relationship, often as a result of the complex care regimen required to achieve treatment goals. The purpose of this qualitative study was to explore patients’ experiences of shame and guilt in type 2 diabetes management and the impact their clinicians have on these experiences. Methods Semistructured interviews were used to explore patients’ experiences with shame and guilt. Interviews were audio-recorded, transcribed, and coded using directed content analysis. Demographic data were also obtained. Results We completed 20 interviews with people with type 2 diabetes (65% Black, 70% female). Participants exhibited feelings more consistent with guilt than with shame. All participants discussed how their clinicians affected these feelings. Patients who expressed feelings of guilt were able to recognize opportunities for behavior change without experiencing global devaluation, in which they linked their actions to an unchangeable aspect of their identity or personality, often describing their guilt as motivating of change. Unlike guilt, when patients experienced shame, they often exhibited global devaluation, in which they blamed their personality, experienced hopelessness, and increased maladaptive behaviors. Conclusion Our findings highlight a notable difference between shame and guilt in the context of type 2 diabetes management. We believe that incorporation of an understanding of these nuances, along with ideal responses to both shame and guilt, will enhance clinicians’ ability to provide high-quality patient-centered care to people with diabetes.

OBJECTIVE Approximately 200 million people worldwide use injectable therapies as part of diabetes management. There appears to be a significant gap between insulin injection technique recommendations and injection practice for many. We aimed to develop and validate a novel, brief, self-administered injection technique assessment questionnaire. RESEARCH DESIGN AND METHODS An iterative codesign process was conducted. Focus groups and interviews with adults (or parents of children) with type 1 or type 2 diabetes and health care providers (HCPs) elicited views and refined the tool for broader distribution to the target audience. Questions addressed ease of understanding; relevance; included items and potential missing questions; feelings about diabetes; and any discomfort or judgment felt when completing the tool. A user guide was developed with cognitive interviewing performed to ensure relevance, acceptability, readability, and understanding. Statistical analyses included propensity score matching to identify a subset of the Worldwide Injection Technique Questionnaire with similar characteristics. Boruta feature selection, Cramér’s V, and multiple correspondence analysis were conducted. RESULTS HCPs and 16 people with diabetes participated in the initial focus groups and interviews. Questions were reported as clinically relevant, simple to complete, “about the right length,” relevant, and easy to understand. A total of 267 participants completed the survey reviewing the questionnaire. A further 16 participants underwent cognitive interviews. The complete resource was then reviewed by another 23 people with diabetes as a final check for completeness and usability. Statistical analyses demonstrated high validity and reliability. CONCLUSION This novel resource is clinically relevant, acceptable, and easy to use as both a clinical tool and a self-assessment tool for people using injectable therapies for diabetes.

Researchers have recognized the role of social environment in diabetes management, with substantial attention directed toward spouses or romantic partners of people with diabetes. However, the specific ways in which partners are involved have not been articulated. This study, which included 207 couples in which one person was recently diagnosed with type 2 diabetes, used a mixed-methods approach to assess types of partner involvement in diabetes management. First, different types of partner involvement were qualitatively identified from audiotaped interviews, and links between qualitative findings and demographics were examined. Next, qualitative codes were compared with quantitative measures of partner involvement. Finally, relations of qualitative codes to relationship quality and diabetes outcomes were assessed. Qualitative analyses identified three ways in which partners were involved in diabetes management (support provision, collaboration, and controlling behavior) and two ways in which they were not involved (independent coping and disengagement on the part of the person with diabetes). Participants with diabetes perceived less partner involvement than their partners. Comparisons with quantitative measures revealed that collaboration was distinct from partner support. Reports from participants with diabetes of collaboration, but not partner support, were connected to higher relationship quality and lower A1C, whereas partner reports of collaboration were related to better self-care. Diabetes disengagement was associated with poorer relationship and behavioral outcomes. These findings underscore the varied ways in which partners are and are not involved in diabetes management and suggest that collaboration is more beneficial than social support in terms of relationship quality and diabetes outcomes.

Comorbid symptoms such as post-traumatic stress and pain are common barriers to optimal self-management among veterans with type 2 diabetes. Additionally, self-management behaviors occur in the context of veterans' daily routines and social environments. This study evaluated the feasibility and acceptability of ecological momentary assessment (EMA) among veterans with type 2 diabetes. Ten veterans with type 2 diabetes were asked to respond to random EMA surveys during pre-programmed intervals five times per day for 14 days. EMA surveys were delivered via a mobile application and assessed momentary physical location, activities, social interactions, mood, stress, and pain. The last survey of each day included additional items about daily post-traumatic stress symptoms, diabetes distress, social support, physical activity, self-management behaviors, and functioning. Participants completed interviews assessing their experience in the study and barriers to responding and indicated their likelihood of participating in similar studies. The mean survey response rate was 96%, providing 675 observations. The majority of participants completed the five momentary surveys in <1 minute and the daily EMA surveys in <5 minutes. Results revealed substantial individual day-to-day variability across symptoms and self-management behaviors that is not captured by aggregated means across all participants. Participants generally reported enjoying responding to surveys and experiencing few barriers. Nine of 10 participants reported being “extremely likely” to participate in a similar study. These pilot data suggest that intensive EMA designs are feasible and acceptable for veterans with type 2 diabetes and can inform the design of future larger studies.

This article outlines how social and health care determinants can affect young adults with diabetes. The authors provide a detailed description of each determinant’s influence on diabetes self-management and offer solutions to help mitigate these harmful effects.

Antidiabetic medications that improve glycemic control as well as cardiovascular outcomes will be the mainstay of treatment for type 2 diabetes moving forward. This article reviews the beneficial effects of the thiazolidinedione pioglitazone of ameliorating hyperglycemia and improving cardiovascular risk factors. While the newer sodium–glucose cotransporter 2 inhibitor and glucagon-like peptide 1 receptor agonist drug classes have confirmed cardiovascular benefits, pioglitazone also has been shown to reduce major adverse cardiovascular events, in both people with type 2 diabetes and nondiabetic subjects with insulin resistance. Adverse effects associated with pioglitazone can be mitigated by its use at a lower dose and in combination with antidiabetic agents from other drug classes.

The cardiovascular (CV) safety of glucagon-like peptide 1 (GLP-1) receptor agonists has been established in robust cardiovascular outcomes trials (CVOTs) in patients with type 2 diabetes at high CV risk. The GLP-1 receptor agonists liraglutide, dulaglutide, and injectable semaglutide demonstrated a significant CV benefit in these trials and now have indications to reduce the risk of major adverse CV events, including CV death, myocardial infarction, and stroke in adult patients with type 2 diabetes and established cardiovascular disease or high CV risk (dulaglutide). The dipeptidyl peptidase 4 inhibitors have also demonstrated CV safety in dedicated CVOTs but have not been associated with any CV benefit. Guidelines for the treatment of type 2 diabetes have evolved from a glucocentric focus to one that now focuses on reducing overall CV risk by personalizing therapy and using drugs such as GLP-1 receptor agonists with proven CV benefits.

Diabetes is a known risk factor for the development of cardiovascular and chronic kidney disease. Sodium–glucose cotransporter 2 inhibitors are glucose-lowering medications that have been demonstrated to improve clinical cardiovascular and renal outcomes. This article reviews recent large clinical trials involving these medications and explains their impact on type 2 diabetes treatment guidelines.

Diabetic kidney disease (DKD) accounts for about half of individuals entering end-stage renal disease programs. Patients with DKD frequently have associated microvascular complications and are at very high risk for developing macrovascular complications. Comprehensive treatment involves slowing or preventing the decline in glomerular filtration rate (GFR) and preventing macrovascular and further microvascular complications. Maintaining an A1C <6.5% represents primary prevention; in established DKD, tight blood pressure control is essential. ACE inhibitors/angiotensin receptor blockers (ARBs) and sodium–glucose cotransporter 2 (SGLT2) inhibitors can be used in combination to slow the rate of decline in GFR. This article reviews the general approach to DKD treatment and summarizes renal outcomes in four cardiovascular outcomes trials of SGLT2 inhibitors. Together, these trials provide conclusive evidence that SGLT2 inhibitors, added to an ACE inhibitor or ARB, slow the progression of DKD.

Type 2 diabetes management continues to increase in complexity as more pharmacologic medication classes become available and high-quality clinical trials are completed. Because many antihyperglycemic agents could be appropriate for a given patient, expert treatment guidance is indispensable. Algorithms can help to guide clinicians toward initiating more evidence-based therapy and critically thinking about patient-centered factors that may influence their medication choices. High-quality cardiovascular, renal, and heart failure outcomes trials completed in the past several years have changed the paradigm of how we think about antihyperglycemic agents. Considerations for atherosclerotic cardiovascular disease, heart failure, and renal insufficiency now figure prominently in treatment algorithms for type 2 diabetes, and the results of recent outcomes trials have significantly transformed algorithmic guidelines published by diabetes, endocrinology, and cardiology associations.

Background ACHIEVE Control, a prospective, open-label, randomized, pragmatic, real-life study in insulin-naive people with type 2 diabetes (A1C 8.0–11.0%), demonstrated superiority of insulin glargine 300 units/mL (Gla-300) versus first-generation standard-of-care basal insulin (SOC-BI; glargine 100 units/mL or insulin detemir) in achieving individualized A1C targets without documented symptomatic (glucose ≤3.9 mmol/L [≤70 mg/dL] or <3.0 mmol/L [<54 mg/dL]) or severe hypoglycemia (American Diabetes Association level 3) at 6 months. Noninsulin antihyperglycemic background therapies are commonly used; however, sulfonylureas may increase hypoglycemia risk. This post hoc analysis assessed outcomes according to background therapy. Methods Subgroup analyses were performed per concomitant use/nonuse of sulfonylureas, glucagon-like peptide-1 receptor agonists, dipeptidyl peptidase 4 inhibitors, or sodium–glucose cotransporter 2 (SGLT2) inhibitors. End points (6 and 12 months) included A1C target attainment without documented symptomatic or severe hypoglycemia, A1C target attainment, and absence of documented symptomatic or severe hypoglycemia. Results Odds ratios (ORs) at 12 months mostly favored Gla-300 versus SOC-BI across subgroups except in analysis of SGLT2 inhibitors, in which ORs were similar. Among sulfonylurea users, ORs at 12 months strongly favored Gla-300 versus SOC-BI for all end points, particularly A1C target achievement without documented symptomatic hypoglycemia (glucose ≤3.9 mmol/L [≤70 mg/dL]; OR 1.25, 95% CI 1.02–1.53) or severe hypoglycemia and achievement of no documented symptomatic hypoglycemia (glucose <3.0 mmol/L [<54 mg/dL]; OR 1.25, 95% CI 1.02–1.52) or severe hypoglycemia. Conclusion The results suggest that, in insulin-naive people with type 2 diabetes, Gla-300 is effective with a risk of hypoglycemia that is lower than or similar to that of SOC-BI regardless of background medication. Individuals receiving concomitant sulfonylureas were more likely to remain without symptomatic or severe hypoglycemia with Gla-300.

Objective The purpose of this literature review was to identify educational approaches addressing low health literacy for people with type 2 diabetes. Low health literacy can lead to poor management of diabetes, low engagement with health care providers, increased hospitalization rates, and higher health care costs. These challenges can be even more profound among minority populations and non-English speakers in the United States. Methods A literature search and standard data extraction were performed using PubMed, Medline, and EMBASE databases. A total of 1,914 articles were identified, of which 1,858 were excluded based on the inclusion criteria, and 46 were excluded because of a lack of relevance to both diabetes management and health literacy. The remaining 10 articles were reviewed in detail. Results Patients, including ethnic minorities and non-English speakers, who are engaged in diabetes education and health literacy improvement initiatives and ongoing follow-up showed significant improvement in A1C, medication adherence, medication knowledge, and treatment satisfaction. Clinicians considering implementing new interventions to address diabetes care for patients with low health literacy can use culturally tailored approaches, consider ways to create materials for different learning styles and in different languages, engage community health workers and pharmacists to help with patient education, use patient-centered medication labels, and engage instructors who share cultural and linguistic similarities with patients to provide educational sessions. Conclusion This literature review identified a variety of interventions that had a positive impact on provider-patient communication, medication adherence, and glycemic control by promoting diabetes self-management through educational efforts to address low health literacy.