Living with Diabetes

Short English summary This dissertation focuses on understanding the psychological challenges faced by adults with diabetes, including diabetes distress, fatigue, disordered eating behaviour, and coping strategies. It also examines ways to identify and manage these challenges, including the development of a diabetes-specific self-help intervention for adults with type 1 diabetes (T1D). Part I includes three studies on psychological challenges associated with living with T1D, and Part II includes three studies on strategies for identifying, coping with, and managing these challenges. Chapter 1 discusses diabetes and its management, followed by the emotional impact. It reviews literature on diabetes distress, emotion regulation, disordered eating, and self-help interventions for adults with T1D, and describes the outline of the dissertation. Chapter 2 used network analysis to examine relationships between individual symptoms of diabetes distress, emotional well-being, and fatigue in adults with T1D. Results showed strong internal connectivity within each construct, with some symptoms, like food-related worries, appearing isolated. Few bridge symptoms were found between constructs, with emotional well-being as a primary bridge between distress and fatigue. No significant associations were found between diabetes distress and fatigue, suggesting that tailored, symptom-specific interventions may be needed. Future research should explore symptom networks longitudinally to personalise interventions. Chapter 3 investigated the relationships between diabetes distress, emotional self-awareness, and emotion regulation strategies (expressive suppression, cognitive reappraisal, mood repair). Emotional self-awareness allows individuals to modify, accept, and tolerate emotions. Clarity of feelings was associated with less diabetes distress; the more adults could identify and discriminate between their emotional states, the less distress they experienced. Increased clarity of feelings was also associated with increased mood repair, highlighting the importance of emotional awareness and regulation in interventions. Chapter 4 studied associations between disordered eating behaviour (DEB), diabetes distress, and emotion regulation strategies. DEB prevalence was 27.1% in adults with T1D. Risk factors included younger age, higher BMI, higher HbA1c, and lower TIR. DEB was associated with more diabetes distress, cognitive reappraisal with less distress, and expressive suppression with more DEB. The study underlines the importance of identifying and addressing DEB and strengthening adaptive emotion regulation strategies in interventions. Chapter 5 examined the psychometric properties of the Dutch DEPS-R, a diabetes-specific screening tool for DEB. The DEPS-R showed acceptable to good internal consistency and construct validity. Both single-factor and three-factor structures were supported: “perspectives on weight,” “diabetes-related maladaptive behaviour,” and “binge eating and compensatory behaviours.” Attention should be paid not only to total scores but also to individual items. Chapter 6 examined coping strategies used by adults with T1D and T2D to manage diabetes distress. Problem-focused strategies (e.g., taking care of diabetes, eating healthy, having a routine) were used more frequently and considered more useful than emotion-focused strategies (e.g., attention exercises, writing, therapy). Differences in strategy use between individuals with low and high diabetes distress were limited, but more adaptive strategies were used by those with lower distress. Factors such as type of diabetes, age, gender, and A1C may also influence coping. Chapter 7 investigated uptake and usage of a self-help intervention (MyDiaMate) over nearly 2 years. A total of 1,008 accounts were created (≈1% of adults with T1D in the Netherlands). Participation varied by module length, and most participants reported low emotional well-being and high distress and fatigue. 78.1% were not receiving psychological treatment, indicating unmet need. No evidence suggested that more severe profiles reduced participation. MyDiaMate shows potential as a supplementary tool to improve coping and mental health. Finally, Chapter 8 summarizes the findings, discusses results, evaluates strengths and limitations, and highlights future research directions and clinical implications.