Unn-Britt Johansson

Background: Regular physical activity is essential for preventing and managing type 2 diabetes. This study evaluates self-reported outcomes including depression, anxiety, stress, diabetes distress, and health-related quality of life during a 2-year pedometer-based intervention, with or without physical activity counseling, in people with prediabetes or type 2 diabetes. Methods: This study was a 3-armed parallel randomized controlled trial conducted in primary healthcare, involving people with prediabetes or type 2 diabetes. The 3 arms were: a multi-component intervention (self-monitoring of steps with counseling support), a single-component intervention (self-monitoring of steps without counseling support), and a control group (standard care). Secondary outcomes were measured using questionnaires for self-reported depression and anxiety (the Hospital Anxiety and Depression Scale [HADS]), stress (Perceived Stress Scale [PSS]), health-related quality of life (EuroQol, [EQ-5D 3L, and EQ-VAS] ), and diabetes distress (The Problem Areas in Diabetes questionnaire, [Swe-PAID-20]), at baseline and at months 3, 6, 12, 18, and 24. Intervention effects were evaluated by a robust linear mixed model. Results: In total, 188 patients (n = 64, 59, 65 in the respective group) were included. The mean (SD) age was 64.1 (7.7) years, 21% had prediabetes, 40% were female, and HbA1c was 49.9 (11.4) mmol/mol. The retention rate was approximately 91% of participants in the first year and 81% at the end of the second year. There were no significant within-group changes in self-reported outcomes from baseline up to 24 months. Moreover, there were no significant differences in outcomes between the interventions and control group at any time in any outcome. Conclusion: This 2-year, pedometer-based physical activity intervention, despite its effectiveness for other outcomes in previous studies, is likely insufficient on its own to improve psychological well-being or reduce diabetes distress in a primary care population with prediabetes or type 2 diabetes with generally well-managed mental health at baseline. The study offers methodological insights that can guide future research. It highlights the complexity of assessing mental health outcomes within practical, low-intensity physical activity interventions.

Background: Type 1 diabetes is a constraining disease due to the burden of its management, and diabetes outcome largely depends on the effectiveness of diabetes self-care. Digital health technology (DHT), which includes continuous glucose monitoring, insulin delivery devices, and related mobile health apps, can support diabetes self-care and thereby improve diabetes outcomes. In literature, experiences with the use of DHT vary widely among people with diabetes and are a less studied area among adults with type 1 diabetes. Objective: The study aimed to explore experiences of using DHT for diabetes self-care among adults with type 1 diabetes. Methods: A qualitative design with an inductive approach was used. Adults with type 1 diabetes who are users of DHT and could understand Swedish were included in the study. Participants were recruited primarily via digital advertisements through social media. A convenient sampling method was used. Data were collected through open-ended questions in a web-based survey (autumn 2022) and 2 digital group interviews (autumn 2024). The survey questionnaire and interview guide attempted to capture positive and negative experiences of using DHTs for diabetes self-care through personally relevant incidents and behavioral details. Data from a total of 161 participants (n=156 survey participants and n=5 interview participants), using 1 or more forms of DHTs, were included in the study. Data were analyzed using qualitative content analysis with an inductive approach as per Graneheim and Lundman. The data in this study generated 324 meaning units relevant to the aim. Results: The participants experienced using DHTs in diabetes self-care as a balancing act between feeling empowered and feeling exasperated. This is described under 5 categories: promoting autonomy in daily life, self-awareness through collaborative learning, feeling secure, tackling technical challenges and the need for support, and navigating the burden of psychosocial challenges. DHTs were experienced as empowering when they supported autonomy in daily life, enhanced self-awareness through collaborative learning, and fostered a sense of security. However, having to tackle technical challenges and the need for support, and navigating the burden of psychosocial challenges, led to feelings of exasperation. The exasperating experiences hindered participants from experiencing a full sense of empowerment with DHT use. Conclusions: This study sheds light on both positive and negative experiences of using DHTs for diabetes self-care in a real-life setting. The exasperating experiences may widen the digital health inequities and therefore are important to address. Improving technological literacy and ongoing support from health care or device manufacturers may help users to address exasperating experiences. Further studies are needed to validate our findings.

Background: There is a limited amount of evidence concerning the association between seasonal variation and the level of physical activity in individuals with chronic disease. This longitudinal observational study aimed to explore seasonal, monthly, and holiday variations in self-monitored step counts over two years among adults with prediabetes and type 2 diabetes in Sweden. Methods: Participants were recruited at primary care centers from 2013 to 2018 to take part in a physical activity intervention. Inclusion criteria included the following: an age of 40–80 years, having prediabetes or type 2 diabetes (≥1 year), and the ability to communicate in Swedish. Individuals with recent myocardial infarction, impaired renal function, diabetic ulcers, a limited capacity for physical activity, insulin onset (<6 months), recurrent or severe hypoglycemia, a high baseline for physical activity, or no internet access were excluded. In total, 120 participants wore step counters and recorded daily steps for two years. Linear mixed models adjusted for sex, age, and body mass index were applied. Results: Mean (95% CI) step counts were statistically significantly higher in summer (7825 [7762, 7889]) and spring (7805 [7757, 7853]) compared to winter (7098 [7052, 7145]) and fall (7422 [7349, 7490]). Highest step counts were registered in May (7993 [7904, 8071]), followed by June (7968 [7895, 8063]), and the lowest in January (6944 [6856, 7034]) and November (7208 [7113, 7289]). Step counts during holiday periods were statistically significantly lower than non-holiday periods across all seasons. Conclusion: Self-monitored daily steps varied over the seasons in this sample of individuals with prediabetes and type 2 diabetes. Declined physical activity levels in months with unfavorable weather conditions require attention in consultations and research.

Background: The use of digital health technology in diabetes self-care is increasing, making eHealth literacy an important factor to consider among people with type 1 diabetes. There are very few studies investigating eHealth literacy among adults with type 1 diabetes, highlighting the need to explore this area further. Objective: The aim of this study was to explore associations between eHealth literacy and demographic factors, disease-specific factors, and well-being among adults with type 1 diabetes. Methods: The study used data from a larger cross-sectional survey conducted among adults with type 1 diabetes in Sweden (N=301). Participants were recruited using a convenience sampling method primarily through advertisements on social media. Data were collected between September and November 2022 primarily through a web-based survey, although participants could opt to answer a paper-based survey. Screening questions at the beginning of the survey determined eligibility to participate. In this study, eHealth literacy was assessed using the Swedish version of the eHealth Literacy Scale (Sw-eHEALS). The predictor variables, well-being was assessed using the World Health Organization-5 Well-Being Index and psychosocial self-efficacy using the Swedish version of the Diabetes Empowerment Scale. The survey also included research group–developed questions on demographic and disease-specific variables as well as digital health technology use. Data were analyzed using multiple linear regression presented as nested models. A sample size of 270 participants was required in order to detect an association between the dependent and predictor variables using a regression model based on an F test. The final sample size included in the nested regression model was 285. Results: The mean Sw-eHEALS score was 33.42 (SD 5.32; range 8‐40). The model involving both demographic and disease-specific variables explained 31.5% of the total variation in eHealth literacy and was deemed the best-fitting model. Younger age (P=.01; B=–0.07, SE=0.03;95% CI –0.12 to –0.02), lower self-reported glycated hemoglobin levels (P=.04; B=–0.06, SE=0.03; 95% CI –0.12 to 0.00), and higher psychosocial self-efficacy (P<.001; B=3.72, SE=0.53; 95% CI 2.68-4.75) were found associated with higher Sw-eHEALS scores when adjusted for demographic and disease-specific variables in this model. Well-being was not associated with eHealth literacy in this study. Conclusions: The demographic and disease-specific factors explained the variation in eHealth literacy in this sample. Further studies in this area using newer eHealth literacy tools are important to validate our findings. The study highlights the importance of development and testing of interventions to improve eHealth literacy in this population for better glucose control. These eHealth literacy interventions should be tailored to meet the needs of people in varying age groups and with differing levels of psychosocial self-efficacy.

Introduction The management of type 1 diabetes, a non-preventable chronic disease, leads to a high physical and psychological burden on the individual. Digital health technology can improve a person’s psychosocial self-efficacy and thereby contribute to improved diabetes self-care. The aim of this study was to explore associations between psychosocial self-efficacy and demographic-, disease specific-, well-being as well as digital health technology (DHT) related factors among adults with type 1 diabetes. Methods A primarily web-based cross sectional survey was conducted among adults with type 1 diabetes in Sweden (n = 301). Psychosocial self-efficacy was assessed using the Swedish version of the Diabetes Empowerment Scale, Swe-DES-23. The survey also contained questions related to demographic-, disease specific-, well-being as well as digital health technology related variables. Results Higher well-being scores and lower HbA1c levels were associated with higher psychosocial self-efficacy in multiple linear regression analysis. In multivariate analysis, gender, body mass index, well-being scores, and HbA1c levels showed association with psychosocial self-efficacy. None of the DHT factors were found associated with psychosocial self-efficacy. Conclusions In this study, higher well-being score and lower self-reported HbA1c levels were associated with higher psychosocial self-efficacy in both univariate- and multivariate analysis and accounted for 30% of the variation in psychosocial self-efficacy in the regression model. Thus, measures to improve psychosocial self-efficacy in adults with type 1 diabetes may help maintain their psychological well-being and blood glucose control.

Background: Many studies have identified key factors affecting the rates of engagement in physical activity in older adults with chronic disease. Environmental conditions, such as weather variations, can present challenges for individuals with chronic diseases, such as type 2 diabetes when engaging in physical activity. However, few studies have investigated the influence of weather on daily steps in people with chronic diseases, especially those with prediabetes and type 2 diabetes. Objective: This study investigated the association between weather variations and daily self-monitored step counts over two years among individuals with prediabetes and type 2 diabetes in Sweden. Methods: The study is a secondary analysis using data from the Sophia Step Study, aimed at promoting physical activity among people with prediabetes and type 2 diabetes, which recruited participants from two urban primary care centers in Stockholm and one rural primary care center in southern Sweden over eight rounds. This study measured physical activity using step counters (Yamax Digiwalker SW200) and collected self-reported daily steps. Environmental factors such as daily average temperature, precipitation, and hours of sunshine were obtained from the Swedish Meteorological and Hydrological Institute. A robust linear mixed-effects model was applied as the analysis method. Results: There was no association found between weather variations and the number of steps taken on a daily basis. The analysis indicated that only 10% of the variation in daily steps could be explained by the average temperature, precipitation, and sunshine hours after controlling for age, gender, and BMI. Conversely, individual factors explained approximately 38% of the variation in the observations. Conclusion: This study revealed that there was no association between weather conditions and the number of daily steps reported by individuals with prediabetes and type 2 diabetes taking part in a physical activity intervention over two years. Despite the weather conditions, women and younger people reported more steps than their male and older counterparts.

Introduction High HbA1c levels in type 1 diabetes (T1D) are associated with increased risk of micro- and macrovascular complications and severe diabetes distress. A more comprehensive understanding of the adult perspective of living with T1D can improve the quality of care. We aimed to describe experiences of living with T1D as an adult with prolonged elevated HbA1c. Methods Thirteen adults with T1D and HbA1c > 60 mmol/mol (7.6%) for at least 1 year were individually interviewed via a digital platform. The interviews were transcribed verbatim and analyzed using qualitative content analysis. Results The analysis identified an overarching theme, “a lifelong follower”, and generated two main categories describing study participants’ experience: constraining and manageable. Constraining experiences were explained in obligated control, loss of control, environmental impact, and consequences of diabetes. Manageable experiences were described in everyday life, approach to diabetes, and support in life. Diabetes knowledge in health care and in the general public, and individualized care were important factors in feeling understood, safe, and supported. Conclusions The findings revealed the diverse experiences of adults with prolonged elevated HbA1c. Living with T1D, a lifelong non-chosen follower, could be perceived as constraining but manageable in different degrees. A person-centered care approach addressing both dimensions may be beneficial. Experiences of living with and managing diabetes are multifaceted and intertwined with life context and medical prerequisites.

Background: People with prediabetes or type 2 diabetes (T2D) need to be physically active, including moderate-to-vigorous intensity physical activity (MVPA) and light-intensity physical activity (LIPA) and reduce time in sedentary behaviour (SB). Few studies have evaluated the effect of randomised controlled trials taking all movement behaviours into account. This study aimed to investigate the effects of a 2-year pedometer-based intervention in people with prediabetes or T2D on relative time in movement behaviours. Methods: Secondary analysis of longitudinal data on individuals with prediabetes or T2D from a three-armed randomised controlled trial, the Sophia Step Study, was conducted. The three groups were (1) a multi‑component group (self‑monitoring of steps with a pedometer plus counselling), (2) a single‑component group (self‑monitoring of steps with a pedometer, without counselling), and (3) a standard care group (control). The three behaviours MVPA, LIPA and SB during waking hours were measured with an ActiGraph GT1M accelerometer at baseline, 6, 12, 18 and 24 months. Relative time in MVPA, LIPA and SB for each participant at each time point was calculated and used as outcome measures. Linear mixed models assessed the effect of the intervention over time. Results: In total 184 participants with mean (SD) age 64.3 (7.6) years and 41% female was included. In the multi-component group, compared to the control group, a significant group-by-time interaction effect for relative time in all three behaviours was found at 6 and 18 months and for MVPA and SB at 24 months. In the single-component group, compared to the control group, an effect occurred in the MVPA and SB behaviours at 6 months and MVPA and LIPA at 24 months. The estimated marginal means ranged from 0.9 to 1.5% of more MVPA, 1.9–3.9% of less LIPA and from 0.5% of less SB to 1.7 more SB in the intervention groups compared to the control group. Conclusions: The findings show a beneficial effect on all behaviours over time in the two intervention groups compared to the control group. A more pronounced effect occurred in the multi-component intervention compared to the single-component intervention, implicating the importance of counselling in pedometer-based interventions. Trial registration ClinicalTrials.gov, NCT02374788