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Articles by S. Heller
Total Records ( 14 ) for S. Heller
  T. C. Skinner , M. E. Carey , S. Cradock , H. M. Dallosso , H. Daly , M. J. Davies , Y. Doherty , S. Heller , K. Khunti and L. Oliver

Aims  To determine whether differences in the amount of time educators talk during a self-management education programme relate to the degree of change in participants` reported beliefs about diabetes.

Method  Educators trained to be facilitative and non-didactic in their approach were observed delivering the DESMOND self-management programme for individuals newly diagnosed with Type 2 diabetes. Observers used 10-s event coding to estimate the amount of time educators spoke during different sessions in the programme. Facilitative as opposed to didactic delivery was indicated by targets for levels of educator talk set for each session. Targets were based on earlier pilot work. Using the revised Illness Perceptions Questionnaire (IPQ-R) and the Diabetes Illness Representations Questionnaire (DIRQ), participants completed measures of: perceived duration of diabetes (timeline IPQ-R), understanding of diabetes (coherence IPQ-R), personal responsibility for influencing diabetes (personal responsibility IPQ-R), seriousness of diabetes (seriousness DIRQ) and impact on daily life (impact DIRQ), before and after the education programme.

Results  Where data from the event coding indicated educators were talking less and meeting targets for being less didactic, a greater change in reported illness beliefs of participants was seen. However, educators struggled to meet targets for most sessions of the programme.

Conclusion  The amount of time educators talk in a self-management programme may provide a practical marker for the effectiveness of the education process, with less educator talk denoting a more facilitative/less didactic approach. This finding has informed subsequent improvements to a comprehensive quality development framework, acknowledging that educators need ongoing support to facilitate change to their normal educational style.

  T. C. Skinner , M. E. Carey , S. Cradock , H. M. Dallosso , H. Daly , M. J. Davies , Y. Doherty , S. Heller , K. Khunti and L. Oliver
  Aims  To describe the course of depressive symptoms during the first year after diagnosis of Type 2 diabetes.

Methods Post hoc analysis of data from a randomized controlled trial of self-management education for 824 individuals newly diagnosed with Type 2 diabetes. Participants completed the Depression scale of the Hospital Anxiety and Depression Scale after diagnosis and at 4, 8 and 12 months follow-up. Participants also completed the Problem Areas in Diabetes scale at 8 and 12 months follow-up. We present descriptive statistics on prevalence and persistence of depressive symptoms. Logistic regression is used to predict possible depression cases, and multiple regression to predict depressive symptomatology.

Results  The prevalence of depressive symptoms in individuals recently diagnosed with diabetes (18-22% over the year) was not significantly different from normative data for the general population (12%) in the UK. Over 20% of participants indicated some degrees of depressive symptoms over the first year of living with Type 2 diabetes; these were mostly transient episodes, with 5% (1% severe) reporting having depressive symptoms throughout the year. At 12 months post diagnosis, after controlling for baseline depressive symptoms, diabetes-specific emotional distress was predictive of depressive symptomatology.

Conclusions  The increased prevalence of depressive symptoms in diabetes is not manifest until at least 1 year post diagnosis in this cohort. However, there are a significant number of people with persistent depressive symptoms in the early stages of diabetes, and diabetes-specific distress may be contributing to subsequent development of depressive symptoms in people with Type 2 diabetes.

  D. Rankin , D. D. Cooke , M. Clark , S. Heller , J. Elliott and J. Lawton
  Background  Conventional insulin therapy requires patients with Type 1 diabetes to adhere to rigid dietary and insulin injection practices. Recent trends towards flexible intensive insulin therapy enable patients to match insulin to dietary intake and lifestyle; however, little work has examined patients' experiences of incorporating these practices into real-life contexts. This qualitative longitudinal study explored patients' experiences of using flexible intensive insulin therapy to help inform the development of effective long-term support.

Methods  Semi-structured interviews were conducted with 30 adult patients with Type 1 diabetes following participation in a structured education programme on using flexible intensive insulin therapy, and 6 and 12 months post-course. Longitudinal data analysis used an inductive, thematic approach.

Results  Patients consistently reported feeling committed to and wanting to sustain flexible intensive insulin therapy. This regimen was seen as a logical and effective method of self-management, as patients experienced improved blood glucose readings and/or reported feeling better. Implementing and sustaining flexible intensive insulin therapy was enhanced when patients had stable routines, with more challenges reported by those working irregular hours and during weekends/holidays. Some patients re-crafted their lives to make this approach work for them; for instance, by creating dietary routines or adjusting dietary choices.

Conclusions  Clinical data have shown that flexible intensive insulin therapy can lead to improvement in glycaemic control. This study, drawing on patients' perspectives, provides further endorsement for flexible intensive insulin therapy by demonstrating patients' liking of, and their motivation to sustain, this approach over time. To help patients implement and sustain flexible intensive insulin therapy, follow-up support should encourage them to identify routines to better integrate this regimen into their lives.

  S. Brierley , C. Eiser , B. Johnson , V. Young and S. Heller
  Aims  Young adults with Type 1 diabetes experience difficulties achieving glucose targets. Clinic attendance can be poor, although health and self-care tend to be better among those who attend regularly. Our aims were to describe staff views about challenges working with this age-group (16-21 years).

Methods  Semistructured interviews were conducted with 14 staff from Sheffield Teaching Hospitals diabetes care team. Interviews were audio-recorded, transcribed and analysed using thematic analysis.

Results  Three main themes emerged. Unique challenges working with young adults included staff emotional burden, the low priority given to self-care by young adults and the complexity of the diabetes regimen. Working in a multidisciplinary team was complicated by differences in consultation styles, poor team cohesion and communication. An ideal service should include psychological support for the professional team, identification of key workers, and development of individualized care plans.

Conclusions  Staff differed in their views about how to achieve optimal management for young adults, but emphasized the need for greater patient-centred care and a range of interventions appropriate for individual levels of need. They also wanted to increase their own skills and confidence working with this age-group. While these results reflect the views of staff working in only one diabetes centre, they are likely to reflect the views of professionals delivering care to individuals of this age; replication is needed to determine their generalizability.

  D. Rankin , D. D. Cooke , S. Heller , J. Elliott , S. Amiel and J. Lawton
  Aims  Use of blood glucose targets is considered essential to help patients with Type 1 diabetes achieve tight glycaemic control following structured education. To foster effective use of blood glucose targets, we explored patients' experiences and views of implementing clinically recommended blood glucose targets after attending a structured education programme promoting intensive insulin treatment.

Methods  Repeat, in-depth interviews with 30 patients with Type 1 diabetes recruited from Dose Adjustment for Normal Eating (DAFNE) courses in the UK. Data were analysed using an inductive, thematic approach.

Results  Patients found use of blood glucose targets motivational. Targets enabled patients to identify problems with blood glucose control and prompted them to make insulin dose adjustments independently, or with assistance. However, patients tended to adapt or simplify targets over time to: make them more attainable and easy to remember; reduce risk of hypoglycaemia; and, mitigate feelings of failure when attempts to attain clinically defined targets were unsuccessful. Some patients were advised to use elevated targets to counter hypoglycaemia unawareness and required help from health professionals to determine when/if these should be reduced.

Conclusions  Although blood glucose targets are an important component of diabetes self-management, patients may adapt and personalize them over time, sometimes inadvertently, with a potentially detrimental impact on long-term glycaemic control. Blood glucose targets should be regularly revisited during clinical reviews and revised/new targets agreed to accommodate patients' concerns and difficulties. Other interventions may need to be considered to promote effective use of blood glucose targets.

  K. D. Barnard , M. J. Campbell , C. Emery , A. J. Young and S. Heller
  Not available
  V. Young , C. Eiser , B. Johnson , S. Brierley , T. Epton , J. Elliott and S. Heller
  Aims  We report a systematic review to determine (1) prevalence of eating problems compared with peers and (2) the association between eating problems and glycaemic control in young adults with Type 1 diabetes.

Method  We conducted a systematic literature search via electronic databases and meta-analysis. Cohen's d (the mean difference score between Type 1 diabetes and comparison groups) was calculated for 13 studies that met inclusion criteria.

Results  Eating problems [both disordered eating behaviour (39.3 and 32.5%; d = 0.52, 95% CI 0.10-0.94) and eating disorders (7.0 and 2.8%; = 0.46, 95% CI 0.10-0.81)] were more common in adolescents with Type 1 diabetes compared with peers and both were associated with poorer glycaemic control (= 0.40, 95% CI 0.17-0.64). In restricted analyses involving measures adapted for diabetes, associations between eating problems and poorer glycaemic control remained (= 0.54, 95% CI 0.32-0.76). Disordered eating behaviour (51.8 and 48.1%; = 0.06, 95% CI −0.05 to 0.21) and eating disorders (6.4 and 3.0%; = 0.43, 95% CI −0.06 to 0.91) were more common in adolescents with Type 1 diabetes compared with peers, but differences were non-significant.

Conclusions  Eating problems are common among this age group. Future work in populations with Type 1 diabetes should develop sensitive measures of eating problems and interventions, and establish predictors of eating problems. Screening in clinics is recommended.

  B. Johnson , C. Eiser , V. Young , S. Brierley and S. Heller
  Aims  To determine: (1) prevalence of depression among young people with Type 1 diabetes compared with control groups or population norms; (2) implications of depression for HbA1c level; and (3) the relationship between history of depressive symptoms and future depressive symptoms.

Background  Among adults with Type 1 diabetes depression is higher than the general population, and has been associated with adverse implications for self-care and HbA1c level. The last published review of depression among young people with Type 1 diabetes only included studies up to 1999.

Method  Systematic searches were conducted for articles published from January 1999 to December 2011 including young people (up to 25 years old) with Type 1 diabetes.

Results  Twenty-three articles met the inclusion criteria. Of five studies that reported prevalence of depression compared with control groups, three found no differences. Of the three studies that investigated prevalence of depression making reference to population norms, all three showed higher rates of depressive symptoms. Fourteen of 15 studies found associations between more depressive symptoms and higher HbA1c level either cross-sectionally or longitudinally. Past depressive symptoms were associated with later depressive symptoms.

Conclusions  Current evidence is inconclusive about whether there is increased prevalence of depression among young adults with Type 1 diabetes, as established among adults, but those who are more depressed have higher HbA1c level. This review is limited by methodological problems and no identified work in the UK met the inclusion criteria. Given the adverse clinical outcomes, we conclude there is a case for routine mental health screening for young adults with Type 1 diabetes.

  J. Lawton , D. Rankin , D. D. Cooke , J. Elliott , S. Amiel and S. Heller
  Aims  Despite improvements in insulin therapy, hypoglycaemia remains an inevitable part of life for many people with Type 1 diabetes. Little attention has been paid to how individuals self-treat hypoglycaemia and their likes and dislikes of clinically recommended treatments. We explored participants' experiences of self-treating hypoglycaemia after attending a structured education programme for people with Type 1 diabetes. Our aims were: to identify treatments that are acceptable to people with Type 1 diabetes; and to provide recommendations for promoting self-treatment in line with clinical guidelines.

Methods  Thirty adults with Type 1 diabetes were recruited from the Dose Adjustment for Normal Eating (DAFNE) programme in the UK. Study participants were interviewed post-course and 6 and 12 months later, enabling their experiences to be explored over time.

Results  Study participants described a poor knowledge of how to self-treat hypoglycaemia correctly pre-course. Post-course, individuals often struggled to adhere to clinically recommended guidelines because of: panic, disorientation, hunger sensations and consequent difficulties ingesting fixed quantities of fast-acting carbohydrate; use of sweets to manage hypoglycaemia; reversion to habituated practices when cognitive impairment as a result of hypoglycaemia supervened; difficulties ingesting dextrose tablets; and other people's anxieties about under-treatment.

Conclusions  Historical experiences of hypoglycaemia and habituated practices can influence present self-treatment approaches. Professionals need to be aware of the range of difficulties individuals may experience restricting themselves to fixed quantities of fast-acting carbohydrate to manage hypoglycaemia. There may be merit in developing a more acceptable range of treatments tailored to people's own preferences, circumstances and needs.

  L. Grant , J. Lawton , D. Hopkins , J. Elliott , S. Lucas , M. Clark , I. MacLellan , M. Davies , S. Heller and D. Cooke


Study aims were to (1) describe and compare the way diabetes structured education courses have evolved in the UK, (2) identify and agree components of course curricula perceived as core across courses and (3) identify and classify self-care behaviours in order to develop a questionnaire assessment tool.


Structured education courses were selected through the Type 1 diabetes education network. Curricula from five courses were examined and nine educators from those courses were interviewed. Transcripts were analysed using framework analysis. Fourteen key stakeholders attended a consensus meeting, to identify and classify Type 1 diabetes self-care behaviours.


Eighty-three courses were identified. Components of course curricula perceived as core by all diabetes educators were: carbohydrate counting and insulin dose adjustment, hypoglycaemia management, group work, goal setting and empowerment, confidence and control. The broad areas of self-management behaviour identified at the consensus meeting were carbohydrate counting and awareness, insulin dose adjustment, self-monitoring of blood glucose, managing hypoglycaemia, managing equipment and injection sites; and accessing health care. Specific self-care behaviours within each area were identified.


Planned future work will develop an updated questionnaire tool to access self-care behaviours. This will enable assessment of the effectiveness of existing structured education programmes at producing desired changes in behaviour. It will also help people with diabetes and their healthcare team identify areas where additional support is needed to initiate or maintain changes in behaviour. Provision of such support may improve glycaemia and reduce diabetes-related complications and severe hypoglycaemia.

  J. Kruger , A. Brennan , P. Thokala , H. Basarir , R. Jacques , J. Elliott , S. Heller and J. Speight


To estimate the cost-effectiveness of training in flexible intensive insulin therapy [as provided in the Dose Adjustment for Normal Eating (DAFNE) structured education programme] compared with no training for adults with Type 1 diabetes mellitus in the UK using the Sheffield Type 1 Diabetes Policy Model.


The Sheffield Type 1 Diabetes Policy Model was used to simulate the development of long-term microvascular and macrovascular diabetes-related complications and the occurrence of diabetes-related adverse events in 5000 adults with Type 1 diabetes. Total costs and quality-adjusted life years were estimated from a National Health Service perspective over a lifetime horizon, discounted at a rate of 3.5%. The treatment effectiveness of DAFNE was modelled as a reduction in HbA1c that affected the risk of developing long-term diabetes-related complications. Probabilistic and structural sensitivity analyses were conducted.


DAFNE resulted in greater life expectancy and reduced incidence of some diabetes-related complications compared with no DAFNE. DAFNE was found to generate an average of 0.0294 additional quality-adjusted life years for an additional cost of £426 per patient, leading to an incremental cost-effectiveness ratio of £14 400 compared with no DAFNE. There was a 54% probability that DAFNE would be cost-effective at a willingness-to-pay threshold of £20 000 per quality-adjusted life year.


The results of this study suggest that DAFNE is a cost-effective structured education programme for people with Type 1 diabetes and support its provision by the National Health Service in the UK.

  K. Ridge , S. Thomas , P. Jackson , S. Pender , S. Heller , J. Treasure and K. Ismail


To describe the development of an intervention for parents and carers of young people with Type 1 diabetes and assess the feasibility, acceptability and emerging clinical themes.


Participants were carers of young persons aged 10-18 years with a diagnosis of Type 1 diabetes of more than 12 months' duration in two inner-city South London hospitals. Carers were invited to attend six sessions of a group workshop where they received emotional support, diabetes education and were taught motivational interviewing techniques to support their child.


Out of 106 eligible participants, carers of 31 young people with Type 1 diabetes were recruited, 17 of whom ‘completed’ the intervention (attending four or more sessions). Participants discussed a variety of themes in session, including the increasing difficulty of diabetes management as children grow older, parenting techniques for managing diabetes in the home and the emotional challenges of having a child with a chronic illness.


Engaging parents in a carer intervention for Type 1 diabetes was a challenge, but parents who participated appeared to value the programme. Future interventions for carers need to take account of carers' wishes and expectations in order to maximize user uptake.

  B. Johnson , J. Elliott , A. Scott , S. Heller and C. Eiser


To assess medical and psychological outcomes among young people with Type 1 diabetes and to compare medical outcomes with a previous audit.


An observational study in two diabetes clinics for young adults (aged 16-21 years) in Sheffield, UK. Young people (n = 96: 81.4% response rate) with Type 1 diabetes (diagnosed > 6 months) completed measures of depressive symptoms, anxiety and disordered eating and consented for their medical records to be consulted.


Mean HbA1c (86 ± 23 mmol/mol; 10.0 ± 2.1%); was comparable with that reported previously and considerably higher than recommended (< 58 mmol/mol or 7.5%). Screening rates were improved and non-attendance was lower than previously reported, but levels of non-proliferative retinopathy have increased. Microvascular complications are present in 46.9% of those diagnosed more than 7 years. Elevated levels of disordered eating were reported by 35.1%. Those scoring above cut-off levels for clinical anxiety (26.6%) and depression (10.9%) are comparable with other work with young people with Type 1 diabetes.


Despite technological advances and improvements to delivery of care, HbA1c remain above recommended levels in a significant proportion of young people, many of whom already have microvascular complications. We need to learn from European centres who achieve better results, improve transition from paediatric care, integrate mental health support with diabetes care provision and take into account young people's views about clinic.

  P. Thokala , J. Kruger , A. Brennan , H. Basarir , A. Duenas , A. Pandor , M. Gillett , J. Elliott and S. Heller


To build a flexible and comprehensive long-term Type 1 diabetes mellitus model incorporating the most up-to-date methodologies to allow a number of cost-effectiveness evaluations.


This paper describes the conceptual modelling, model implementation and model validation of the Sheffield Type 1 Diabetes Policy Model (version 1.0), developed through funding by the UK National Institute for Health Research as part of the Dose Adjustment for Normal Eating research programme. The model is an individual patient-level simulation model of Type 1 diabetes and it includes long-term microvascular (retinopathy, neuropathy and nephropathy) and macrovascular (myocardial infarction, stroke, revascularization and angina) diabetes-related complications and acute adverse events (severe hypoglycaemia and diabetic ketoacidosis). The occurrence of these diabetes-related complications in the model is linked to simulated individual patient-level risk factors, including HbA1c, age, duration of diabetes, lipids and blood pressure. Transition probabilities were modelled based on a combination of existing risk functions, published trials, epidemiological studies and individual-level data from the Dose Adjustment for Normal Eating research programme.


The model takes a lifetime perspective, estimating the impact of interventions on costs, clinical outcomes, survival and quality-adjusted life years. Validation of the model suggested that, for almost all diabetes-related complications predicted, event rates were within 10% of the normalized rates reported in the studies used to build the model.


The model is highly flexible and has broad potential application to evaluate the Dose Adjustment for Normal Eating research programme, other structured diabetes education programmes and other interventions for Type 1 diabetes.

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