Identifying and Addressing the Complex, and Costly, Interplay of Stress and Diabetes

Dr. Bimal Shah


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Using real-time “feeling tags” to identify and intervene against diabetes-related stress

For the more than 30 million Americans living with diabetes, managing their condition involves a daily regimen of healthy eating, exercise, self-monitoring of blood glucose (BG), medication adherence, and more. Staying on top of these tasks while dealing with day-to-day life challenges can be a stressful experience. In fact, 18% to 35% of people with diabetes experience high levels of “diabetes distress,” or stress or anxiety derived from living with and managing their condition. We also know that people with diabetes are 2 to 3 times more likely than others to have depression and 20% more likely to experience anxiety. As studies have shown, these added stresses and coping deficits have a compounding effect, leading to poor BG control and greater risk for diabetes complications such as vision problems, kidney disease, vascular diseases, stroke and heart attacks.

Despite these well-known mind-body connections, traditional medicine tends to treat these tightly intertwined conditions in isolation from each other. With mental health professionals in short supply in much of the U.S., it’s estimated that roughly half of behavioral health issues go undiagnosed and untreated. In primary care visits, people with diabetes may not discuss feelings of stress, anxiety or depression due to the associated stigma. For those fortunate enough to see a therapist weekly, the direct connection between day-to-day diabetes self-management and feelings of stress can too easily go undetected and unaddressed.

A First-of-Its-Kind Study

At Livongo, we are committed to breaking down these silos and focusing on the whole person by integrating diabetes self-management tools and behavioral health skills and support on the same platform. As the COVID-19 pandemic ratchets up stress and anxiety for all Americans — and especially for people with diabetes who are at risk of serious complications from the virus — it’s more important than ever to understand the complex, multi-directional relationships among diabetes, stress, and self-management so we can optimize our interventions to address our Members’ real-world needs.

With these goals in mind, Livongo’s clinical research team recently conducted a first-of-its-kind study based on a unique data set drawn from Members enrolled in our digital diabetes self-management program, the results of which were presented at the Society for Behavioral Medicine’s virtual conference in April 2020.

Each time Livongo Members take a reading with their BG meter, they’re prompted to select from a set of “feeling tags” that best reflect their in-the-moment emotional or mental state — choices include “I feel fine”; “I don’t feel well”; “Light-headed”; “Stressed out.” This type of ecological momentary assessment (EMA) — a well-established method for measuring psychosocial stress in real time with accuracy that greatly exceeds retroactive ratings based on recall and reflection — allows us to accurately and immediately record the lived experience of people managing diabetes. Livongo is the only company collecting such real-time tags and using them to tailor and target just-in-time adaptive interventions.

The study included 3,263 Members with diabetes age 65 and younger who had access to Livongo between June 2015 and August 2018. For each participant, in addition to feeling tags data and detailed demographics, we also had data on a set of other key measures:

  • Glucose Control. (hemoglobin A1c - HbA1c)

  • Diabetes Distress. (Diabetes Distress Scale (DDS2), which screens for the presence of diabetes distress, e.g. feeling overwhelmed by the demands of living with diabetes).

  • Diabetes Empowerment. (Diabetes Empowerment Scale (DES), which assesses self-efficacy in people with diabetes, e.g. the degree to which they feel able to effectively manage their diabetes).

  • Behavioral Health Diagnosis and Healthcare Utilization. (Medical claims data).

The results revealed stress to be a common experience for people living with diabetes, and one that is directly associated with worse emotional and physical health. Our feeling tag data showed that over half (55%) of all participants experienced stress at the time of at least one BG reading — and that stress was associated with greater Diabetes Distress, lower Diabetes Empowerment, greater insulin use, and poorer glucose control over time.

We also found that over half (52%) of participants who reported stress had at least one behavioral health diagnosis or had received some kind of behavioral health intervention in their medical claims. Compared to those who neither reported stress nor received a behavioral health diagnosis/intervention, these participants also had higher BMI and longer duration of diabetes at the time of enrollment.

Addressing the Whole Person Through Applied Health Signals

This study demonstrates the accuracy and untapped potential of digital tools — and Applied Health Signals — for understanding and addressing the relationship between people’s physical and emotional health. With Livongo’s Applied Health Signals platform, integrating diabetes self-management with our behavioral health solution, we are able to take a whole-person approach to addressing the needs of Members whose experience of stress or other behavioral health issues may compromise self-management and compound the effects of their condition.

As Livongo Members identify feelings of stress, we can be responsive in real-time, offering mindfulness or other stress-management exercises and resources available through our integrated solution. Beyond one-off acute stress management, as our Applied Health Signals platform identifies behavioral trends and triggers — such as experiences of stress every morning — we can begin to anticipate Member needs and proactively intervene with targeted Health Nudges™. Depending on whether the Member completed a recommended exercise — and if so, how much it helped — we can continuously refine future interventions. Or, if we identify patterns suggesting chronic anxiety, depression, insomnia, or another significant behavioral health issue, we can escalate Members into a more intensive clinical program.

The COVID-19 pandemic and its economic aftershocks have only heightened the demand for this kind of integrated, in-the-moment approach to understanding and managing stress in the context of other chronic conditions. Over the past month, we’ve seen a 10% uptick in utilization across our devices and mobile app. In that same period, the number of Members who have tagged “stress” during BG checks has nearly doubled and we’ve seen increased responsiveness to our stress-related Health Nudges. We’ve been able to respond to this demand with additional digital coaching and tailored “Coping During COVID-19” resources.

In the years ahead, every study shows diabetes continuing to rise here in the U.S. By 2030, it’s projected that it will affect nearly 55 million Americans, lead to 385,800 deaths per year, and cost the U.S. healthcare system $622 billion. As we learn more about the intricate interplay of diabetes and behavioral health — and specifically the way experience of stress compromises the efficacy of diabetes self-management — it’s clear that we can’t properly address one without the other. Through ongoing research and learning on Livongo’s digital Applied Health Signals platform, we can better understand these relationships in a real-world context and design interventions that drive better outcomes not just for one condition or another, but for the whole person.

This study was a collaborative effort among a number of Livongo researchers including Jessica Yu, PhD, Tong Xu, MS, Roberta James, MStat, Wei Lu, PhD, and Julia Hoffman, PsyD.

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