"It gets at engaging other healthcare team members in promoting a healthy lifestyle. If that comes from occupational therapists, who have their own approaches, sure. We often refer our patients to OT for physical issues and physical disabilities, but I think engaging them in chronic disease care is really innovative and novel," she commented.
Different Results in Type 1 and Type 2 Diabetes
The REAL study included young adults aged 18 to 30 years old of low socioeconomic status who had had either type 1 or type 2 diabetes for at least a year and an HbA1c of 8.0% or higher.
The intervention comprised 12 one-hour OT sessions delivered over 6 months in home or community settings. Content modules covered living with diabetes, access and advocacy, activity and health, social support, and emotional well-being. Each was individually tailored to the patient with the use of motivational interviewing.
Controls received informational pamphlets and were called by phone every 2 weeks to check whether they'd read the material and if they had questions.
A total of 81 patients were randomized. They had a mean age of 22.6 years, 63% were female, 78% were Hispanic/Latino,10% were African American, 10% white, and 23.8% were living below the federal poverty line.
Three-quarters had type 1 diabetes, and the rest had type 2. Overall diabetes duration was 9.7 years, and mean HbA1c for the entire group was 10.8%. Mean score for diabetes distress was 9.6 on a scale where greater than 8 reflects clinically significant distress. In all, 35 in the OT group and 37 in the control group completed the study and follow-up.
At 6 months, HbA1c had dropped by 0.57 percentage points in the OT group, while in the control group it rose by 0.36, a significant difference between groups (P = .01).
Unexpectedly, the response differed by diabetes type: Among the 56 patients with type 1 diabetes, HbA1c dropped by 0.84 vs 0.03 percentage points in the OT treatment and control groups, respectively (P = .04), while it actually rose in both treatment and control groups among the 19 with type 2 diabetes (0.2 vs 1.58 percentage points, P = .10).
The reason for this difference isn't clear. It may be that something about the intervention didn't resonate with the type 2 patients, or simply that it was a spurious finding given the small number in that group.
Moreover, Dr Pyatak noted that youth-onset type 2 diabetes is particularly difficult to control and little is known about the usual HbA1c trajectory in that population. "Is the 20s just a time you'd expect to see worsening? I'm still puzzling through this a bit," she said.
Overall for the entire group, significant improvements were also seen for the OT treatment compared with the controls in the Audit of Diabetes-Dependent Quality of Life (0.7 vs 0.15, P = .04) and for checking blood glucose in the Self-Reported Behavioral Automaticity Index, a measure of the extent to which the behavior had become a "habit" (3.94 vs 1.65, P = .05).
There were no other differences in overall effect by gender, ethnicity, diabetes type, or setting.
Dr Pyatak said her team has now received funding to implement the REAL intervention in a large Los Angeles County primary-care setting, and they're hoping to also launch a study of the intervention delivered via telehealth.
When Dr Baig was asked whether her Chicago center employs an occupational therapist as part of their diabetes team, she replied: "We don't. We should. I think we haven't engaged them in their full capacity."
The REAL study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases/National Institutes of Health. Dr Pyatak has no relevant financial relationships. Disclosures for the coauthors are listed in the abstract. Dr Baig has no relevant financial relationships.