Practice Update: Endocrinology | Volume 1. Number 2. 2016

DIABETES

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EXPERT COMMENTARY Compassion vs empathy By Dr David Rakel “When a person feels accepted for who they are and what they do – no matter how unhealthy – it allows them the freedom to consider change rather than needing to defend against it.” T his quote by Steve Berg-Smith is true for treating oth-

had a moderate non-proliferative diabetic retinopa- thy. Diabetic retinopathy was proliferative in 0.3%. No cases of severe non-proliferative diabetic retin- opathy or diabetic maculopathy were found. Thirty (14.9%) of 202 and six (7.2%) of 83 individuals with and without concomitant arterial hypertension, re- spectively, had diabetic retinopathy (OR 2.54, 95% CI 1.06–7.14). Visual acuity did not differ between individuals with and without diabetic retinopathy. CONCLUSIONS/INTERPRETATION In this large European study, the prevalence of diabetic retinopathy in screening-detected type 2 diabetes was 13%. Only a very small proportion of participants with detected diabetic retinopathy needed treatment. Prevalence of diabetic retinopathy in screening- detected diabetes mellitus: RESULTS from the Gutenberg Health Study (GHS) . Diabetologia 2016 Jun 17;[Epub ahead of print], Ponto KA, Koenig J, Peto T, et al. Mindful self-compassion intervention improves depression, distress, and HbA1c in people with diabetes Diabetes Care Take-home message • This randomised controlled trial evalu- ated the effect of an 8-week mindful self-compassion program on depression, diabetes-related distress, and HbA 1c in patients with type 1 or type 2 diabetes mellitus. The results revealed that par- ticipants in the program had significantly fewer depressive symptoms, reduced distress, and improved HbA 1c during the study period and at follow-up. • This study suggests that promoting self- compassion improves overall emotional well-being as well as specific metabolic markers in diabetic patients. Abstract OBJECTIVE Mood difficulties are common among patients with diabetes and are linked to poor blood glucose control and increased complications. Evidence on psychological treatments that improve both mood and meta- bolic outcomes is limited. Greater self-compas- sion predicts better mental and physical health in both healthy and chronically ill populations. Thus, the purpose of this randomised con- trolled trial (RCT) was to evaluate the effects of self-compassion training on mood and meta- bolic outcomes among patients with diabetes. RESEARCH DESIGN AND METHODS This RCT tested the effects of a standardised 8-week mindful self-compassion (MSC) program (n = 32) relative to a wait-list control condition (n = 31) among patients with type 1 and type 2 diabetes. Measures of self-compassion, de- pressive symptoms, diabetes-specific distress, and HbA 1c were taken at baseline (preinter- vention), at week 8 (postintervention), and at 3-month follow-up. RESULTS Repeated-measures ANOVA using intention to treat showed that MSC training increased self-compassion and produced statistically and clinically significant reduc- tions in depression and diabetes distress in the intervention group, with results maintained at 3-month follow-up. MSC participants also averaged a clinically and statistically meaning- ful decrease in HbA 1c between baseline and follow-up of > 10 mmol/mol (nearly 1%). There were no overall changes for the wait-list con- trol group. CONCLUSIONS This initial report suggests that learning to be kinder to oneself (rather than being harshly self-critical) may have both emo- tional and metabolic benefits among patients with diabetes. Kindness matters: A randomised controlled trial of a mindful self-compassion interven- tion improves depression, distress, and HbA 1c among patients with diabetes. Diabe- tes Care 2016 Jun 22;[Epub ahead of print], Friis AM, Johnson MH, Cutfield RG, et al.

ers and ourselves. This study of type 1 and 2 diabetics showed that an 8-week mindfulness and self-compassion course reduced depression, diabe- tes-associated stress, and HbA 1c levels by almost 1% 3 months after enrolment in this 8-week course com- pared with a “usual care” control group.

Self-acceptance and kindness not only improves depression, coping, and diabetic control but can also reduce clinician burnout.

Diabetes is associated with self-critical thoughts such as, “I need to eat better, exercisemore, and lose weight.” This can lead to distress, depression, and worsening diabetic control. Compassion training has been associated with lower cortisol, increased heart rate variability, decreased IL-6 (inflam- mation), decreased stress, and lower HbA 1c levels. Compassion training also stimulates oxytocin (the love hormone) and natural endorphins. What is compassion training? Two main ingredients of the compassion training provided in this study were self-kindness (rather than self-criticism) and common hu- manity (rather than isolation). This second point is a key difference between empathy and compassion. Practicing empathy can lead to empathy distress or empathy fatigue because the training requires that we feel the suffering of another person where the two people involved are separate: me and you. Compassion training on the other hand teaches a common humanity, where two people are more one than separate. When I support you through your suffering, I support myself because we are both part of the same humanity (compassion) vs I feel your suffering (heavy) and I am going to help you through it (empathy). This may sound like psychological and philosophical babble, but there is promising evidence to back this up. In 2014, Klamicki and colleagues showed study participants videos of human suffering before and after empathy training (“I feel your pain”) and compassion training (loving-kindness training, for self and

others). The researchers looked at positive and negative affect and functional MRI after participants watched videos of human suffering. Negative affect worsened after empathy training and then improved after compassion training. Positive affect changed little after empathy training but went up significantly after compassion training. Functional MRI of the brains of these study participants showed that compassion training activated the centres associate with love, reward, and affiliation. Those activated with empathy were associated with pain. 2 Self-acceptance and kindness not only improves depression, coping, and diabetic control but can also reduce clinician burnout if we see our work as a service to all humanity in which we are an intricate part. References 1. Berg-Smith S. Heart of behavior change: Client-centered education. 2015; www. doh.wa.gov/portals/1/Documents/8100/HeartOfBehaviorChange.pdf . Accessed July 4, 2016. 2. Klimecki OM, Leiberg S, Ricard M, Singer T. Soc Cogn Affect Neurosci 2014;9:873–879.

Dr David Rakel is Associate Professor at the Department of Family Medicine and Director at the University of Wisconsin Integrative Medicine, University of Wisconsin School of Medicine and Public Health.

JOURNAL SCAN Prevalence of diabetic retinopathy in newly diagnosed type 2 diabetes Diabetologia Take-home message • In this observational population-based study, researchers investigated the prevalence of diabetic retinopathy (DR) at the time of diagnosis of type 2 diabetes. Of the 14,948 participants inves- tigated, 347 had newly diagnosed type 2 diabetes detected during the screening. Based on fundus photographs, researchers observed that 13% of participants with newly diagnosed type 2 diabetes had DR. The majority of DR in these participants was mild non-proliferative (12%), but 0.6% of participants had moderate DR and 0.3% had proliferative DR. • Up to 13% of individuals with type 2 diabetes have DR at the time of diagnosis, underscoring the importance of diabetes screening. Abstract

between 35 and 74 years. We determined the weighted prevalence of diabetic retinopathy by as- sessing fundus photographs. Screening-detected type 2 diabetes was defined as an HbA1c concen- tration of 6.5% (47.5 mmol/mol) or more, no medical diagnosis of diabetes and no intake of insulin or oral glucose-lowering agents. RESULTS Of 14,948 participants, 1377 (9.2%) had diabetes mellitus. Of these, 347 (25.2%) had newly diagnosed type 2 diabetes detected by the screen- ing. Overall, the weighted prevalence of screening- detected type 2 diabetes was 2.1%. Fundus photos were evaluable for 285 (82.1%) participants with newly diagnosed diabetes. The weighted preva- lence of diabetic retinopathy in screening-detected type 2 diabetes was 13.0%; 12% of participants had a mild non-proliferative diabetic retinopathy and 0.6%

determine the prevalence of diabetic retinopathy in patients with newly diagnosed (screening-detected) type 2 diabetes. METHODS The Gutenberg Health Study is a popu- lation-based study with 15,010 participants aged

AIMS/HYPOTHESIS Individuals with type 2 diabetes mellitus may experience an asymptomatic period of hyperglycaemia, and complications may already be present at the time of diagnosis. We aimed to

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