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Time With Diabetes Distress and Glycemia-Specific Distress: New Patient-Reported Outcome Measures for the Psychosocial Burden of Diabetes Using Ecological Momentary Assessment in an Observational Study

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posted on 25.05.2022, 18:41 authored by Dominic Ehrmann, Andreas Schmitt, Lilli Priesterroth, Bernhard Kulzer, Thomas Haak, Norbert Hermanns


To estimate time with diabetes distress using ecological momentary assessment (EMA) in people with type 1 diabetes and analyze its associations with glycemic management based on continuous glucose monitoring (CGM).

Research Design and Methods

We used EMA to assess diabetes distress in a sample of recently hospitalized adults with type 1 diabetes once a day for 17 consecutive days in an ambulatory setting (NCT03811132). Additionally, participants were asked daily about hypoglycemia distress (<70 mg/dl [3.9 mmol/l]), hyperglycemia distress (>180 mg/dl [10 mmol/l]), and variability distress (glucose fluctuations). Per person, the percentage of days with elevated distress was calculated (time with distress). Multilevel regression was used to analyze daily associations of distress ratings with CGM-derived parameters. EMA-derived associations between diabetes distress and glycemic management were compared to questionnaire-derived associations. 


Data of 178 participants were analyzed. Participants spent 24.1±29.7% of days in diabetes distress, 54.6±26.0% in hyperglycemia distress, 45.2±27.5% in variability distress, and 23.0±19.3% in hypoglycemic distress. In multilevel analyses, higher daily ratings of diabetes distress were significantly associated with hyperglycemia (β=0.41). Results showed high between-person variability as explanation of variance of the models ranged between 22.2% and 98.8%. EMA-derived diabetes distress showed a significant association with mean glucose (r=0.25), while questionnaire-based diabetes distress did not (r=0.10). Prospectively, time with diabetes distress was associated with HbA1c at the 3-month follow-up (r=0.27), while questionnaire-based distress showed no association (r=0.11).


Time with distress assessed by EMA showed a comparative advantage over questionnaire-based assessment of diabetes distress regarding associations with glycemic management.


This study was funded by the DZD (German Centre for Diabetes Research) under the grant number FKZ 82DZD1102A. The sponsor had no role in study design, collection, analysis, and interpretation of data nor in the writing of the report and in the decision to submit the paper for publication.