Most patients with type 2 diabetes (T2D) have suboptimal adherence to recommended diet, physical activity, and/or medication. Current approaches to improve health behaviors in T2D have been variably effective, and successful interventions are often complex and intensive. It is therefore vital to develop interventions that are simple, well-accepted, and applicable to a wide range of patients who suffer from T2D. One approach may be to boost positive psychological states, such as positive affect or optimism, as these constructs have been prospectively and independently linked to improvements in health behaviors. Positive psychology (PP) interventions, which utilize systematic exercises to increase optimism, well-being, and positive affect, consistently increase positive states and are easily delivered to patients with chronic illnesses. However, to our knowledge, PP interventions have not been formally tested in T2D. In this paper, we review a theoretical model for the use of PP interventions to target health behaviors in T2D, describe the structure and content of a PP intervention for T2D patients, and describe baseline data from a single-arm proof-of-concept (
Health behavior adherence may be particularly important for patients with type 2 diabetes (T2D), a condition that affects 12% of American adults and is the 7th leading cause of death in the US [
Current approaches to improve health behaviors in T2D and other illnesses have demonstrated variable effectiveness [
In contrast to negative syndromes, positive psychological states may play a substantial and independent beneficial role in health outcomes. A meta-analysis of 26 studies (
These beneficial effects of positive psychological states may be mediated through health behaviors. Studies have consistently found links between increased positive psychological states and greater participation in health behaviors in medical populations. For example, Shepperd and colleagues [
Importantly, positive psychological states are not simply the flipside of depression. Constructs like optimism (
Given the empirical evidence identifying specific and prospective links between positive psychological states and health behaviors/outcomes and the multiple potential avenues (e.g., motivation, self-regulation, and concentration [
PP interventions may represent a promising strategy to increase positive psychological cognitions and emotions in patients with T2D and other chronic conditions. PP is a branch of clinical and research interventions that uses systematic exercises (e.g., gratitude letters, acts of kindness) to target positive cognitive and emotional states [
PP interventions have been used in over 4000 mostly healthy subjects and have been found to increase well-being and decrease depression [
As opposed to standard, disorder-based psychological interventions, a PP intervention can be delivered to the vast majority of patients who have T2D, rather than applying only to the subset of T2D patients with depression, anxiety disorders, or other clinical psychiatric conditions [
To our knowledge, PP interventions have never been tested in a T2D population, outside of a single small positive affect skills intervention trial that led to improvements in depressive symptoms [
Conceptual model outlining the proposed mediators between positive affect and improved health behaviors.
How might boosting positive affect, optimism, and psychological well-being lead to better health behavior adherence? We present a conceptual model of proposed mediation pathways from which additional empirical support is generated (Figure
Broadly, positive states are thought to improve people’s social, psychological, and physical resources [
Related constructs,
Positive psychological states and attributes can also increase
Aside from these five domains, other factors may also play a role in connections between psychological well-being and health. For example, positive states may improve energy and vitality [
Utilizing our experience with PP interventions in other populations, we created a PP intervention for patients with T2D that was designed to be tested in an initial proof-of-concept trial.
Week 1 (if initial exercise completed together with the interventionist rather than independently): (i) Provision and review of treatment manual (ii) Discussion of rationale for PP intervention and potential health benefits (iii) Introduction of initial exercise (Gratitude for Positive Events) (iv) Rating of optimism/positive affect (v) Completion of exercise, and recording of exercise and its effects in the manual (vi) Rating of optimism/positive affect and ease/utility of exercise post-completion (vii) Review of exercise with study trainer (viii) Assignment of second exercise (Personal Strengths) Week 2: (i) Participant independently completes tasks prior to phone session (a) Rating of optimism/positive affect immediately pre-completion (b) Completion of exercise and recording of details/effects (c) Ratings of optimism/positive affect, along with ease/utility of exercise (ii) Phone session with interventionists (a) Review of exercise with study trainer (b) Discussion of adapting skills to daily life, recording favorite skills (c) Assignment of third exercise (Gratitude Letter) Weeks 3-4: (i) Weekly exercise completion (independently) (ii) Weekly phone sessions (for review, skill building, and assignment of next exercise) Weeks 6–10: (i) Bi-weekly exercises (a) Weeks 8 and 10 can be choice from prior exercises and/or Acts of Kindness (ii) Bi-weekly phone sessions Week 12: (i) Review of final exercise (ii) Discussion of skills implementation into daily life with completion of 4-week plan
The 12-week intervention consists of 7 distinct PP exercises, to be completed weekly for the first 4 weeks and then biweekly over the next 8 weeks.
To optimize interaction and engagement at the outset of the intervention, the interventionist may complete the first exercise (Gratitude for Positive Events) together with the participant (in person at enrollment or by phone at the first phone session), with the interventionist soliciting responses and encouraging elaboration by the participant. The participant can also choose to complete the first exercise independently with review of the exercise by phone. In either case, after discussion of the initial exercise, the subsequent week’s exercise is outlined and assigned, and a phone appointment is made for one week later.
Key themes discussed by interventionists across the weeks include (1) developing a greater and more nuanced vocabulary for describing positive thoughts and feelings, (2) learning to savor and “bookmark” positive feelings and experiences, (3) learning redirection toward positive thoughts/feelings if becoming distracted or dysphoric during an exercise, and (4) utilizing novelty in completing the exercises—the idea that performing tasks that they may not have normally completed in their daily lives can lead to even larger increases in positive affect.
We chose to develop a remotely delivered intervention to address the issue that patients with T2D may have significant functional limitations, transportation challenges, or insufficient time to attend in-person visits [
The PP treatment manual (see Boxes
For people with diabetes, it can be a real challenge to stick to a healthy diet, be physically active, and follow a medication plan. Research suggests that experiencing positive thoughts and feelings (like feeling hopeful, satisfied, or proud) can help people to stick to healthy behaviors. For this reason, we are trying to find ways to help people with diabetes experience more positive emotions in their daily lives. Positive psychology, a new approach to helping people, focuses on improving positive emotions and might help people to feel more hopeful, grateful, and happy. Positive psychology is an area of psychology that focuses on helping people to experience greater life satisfaction through specific, intentional activities. These include identifying and using your personal strengths, appreciating pleasant events during your day, performing kind acts for others, and using past successes to accomplish future goals. We have studied positive psychology exercises in patients with other medical illnesses, and these participants found the exercises easy and helpful. However, positive psychology has not been scientifically studied in people living with diabetes, and we want to learn more about whether they can help people with this condition to have happier and healthier lives.
We strongly believe that these exercises will help people like you who have diabetes—but we need your assistance to find out for sure! Based on our experience, we have specifically selected the positive psychology exercises that we think will be most helpful to people who are dealing with diabetes. We will ask you to complete and then write about your experience. Each week you will also speak with a study trainer by phone to review the exercise and learn about the next one.
Positive psychology is an area of psychology that is interested in helping people to experience more positive emotions and better mental health. This is done through specific, intentional activities that are designed to improve mood. These exercises include savoring pleasant events during your day, using your strengths, performing kind acts for others, or remembering past successes. There is an increasing amount of scientific research about the lasting power of positive psychology. At this stage, positive psychology exercises have been studied in over 4000 people, and we’ve found that they can improve mood, quality of life, and health.
Yes. It appears that almost half of a person’s happiness is directly under one’s own control (the rest is determined by genetics and life circumstances), and specific activities (like the ones you will perform in this study) can improve feelings of peace, happiness, and optimism. Like other activities that can benefit health, positive psychology exercises take practice, and there will be some exercises that may really be a great match for you, while others may be less effective. But with some effort, we believe that you will discover positive psychology activities that you will enjoy and that will provide you with lasting benefit.
It is normal to believe that if only something about the circumstances of our lives would change, then we would be happy. It can seem that finding a new roommate, getting a job, or having a life partner are required before one can experience more hope, happiness, or life satisfaction. Circumstances absolutely can have an impact on happiness. There is also no question that people can improve their level of happiness appears to have a more powerful effect on happiness than life events!
In this exercise, we will focus on identifying and re-experiencing three positive events that happened in the past week. It makes sense to analyze bad events so that we can learn from them and avoid them in the future. However, it can be easy to overdo this focus on the negative, and this can be a set-up for continued anxiety and depression. One way to keep this from happening is to develop our ability to think about the good in life. Most of us are not this is a skill that needs practice.
The following exercise will ask you to identify three good things in your life that occurred in the past week. These positive events may have gone unnoticed in the difficulties and chaos of the past week. However, by looking back carefully and specifically for good things that may have happened, you may be surprised to find that there were small (or even large) positive events and blessings to be counted. This is a skill that takes practice, and after this exercise we will encourage you to keep working to “bookmark” and identify positive events. As a positive event happens, stop for a moment and allow yourself to experience it. Maintaining this focus on the present—being “mindful” of each moment—can really make a big difference. By working to stay present and aware of what is happening right now, you may find it much easier to appreciate a good thing that is happening—and easier to get out of a cycle of sadness, resentment, or disappointment. Life can feel richer, brighter, and more interesting as you get practice identifying and savoring good events. As you get skilled at focusing your attention on pleasant moments that happen during the day—a kind gesture from someone, a greatly-appreciated visit, good news about family or friends—you may even find it much easier to use these skills once the good things in your life are more obvious.
Take 10–15 minutes to complete this exercise. Use this time to write down three things that went well this week. Use the space below to write about the events—it is important that you have a physical record of what you wrote. The things you list can be relatively small in importance (“I enjoyed my lunch today”) or relatively large in importance (“My sister gave birth to a healthy baby boy”). As you write, follow these instructions: ( ( were involved, what they did or said. ( felt: Joy? Satisfaction? Relief? ( Some important tips: The goal of the exercise is to remember the good event the event itself in too much detail—the important thing here is being able to: (a) and then (b) possible—not just that you felt “good.” To help you describe the good feelings you experienced, refer to the list of focusing on negative feelings, turn your mind away from the negative thought. Instead, put your focus back on the good event and the positive feelings that came along with it. This can take effort, and you may have to bring your focus back again and again. But with continued practice this gets easier and can make a real difference in how you feel.
The manual contains a general introduction section that describes PP, outlines the use of systematic exercises to improve mood, optimism, and self-confidence, and describes potential connections between positive psychological states and improved self-management of T2D. The main portion of the manual contains sections representing the seven weekly exercises. Each exercise has a short introduction describing the rationale for the exercise and a formal set of instructions. Following the instruction pages, the manual contains space to record the exercise and its effects along with an area to provide feedback about the ease and utility of the exercise.
The final section of the manual contains two sections. First, the manual utilizes a grid to allow participants to schedule specific positive activities in the four weeks following the exercise to allow continuation of activities after intervention and encourage habitual use of the exercises. Second, the final pages of the manual are devoted to a “Favorite Skills” section in which activities that are particularly salient or useful can be recorded for easy access and use.
The study interventionist for the subsequent proof-of-concept trial (CD) was trained in several stages by staff (JH, CC) experienced in delivering PP interventions. First, she completed a guided review of the project’s provider manual that contains additional information on the rationale and procedures for each exercise, provides guidance for maintaining the focus of the interaction solely on the PP exercise and its review, and conveys specific advice to convey to participants to facilitate completion of the given exercise (e.g., methods of brainstorming).
The interventionist then viewed videos of sample PP sessions, completed PP background reading (book chapters and papers), and personally completed all PP exercises to be used in the intervention. Finally, she completed observed role plays with feedback to gain experience performing and reviewing each exercise. For quality control, sessions were reviewed by a multidisciplinary study team at weekly meetings, and specific feedback about intervention delivery and fidelity was provided in an ongoing manner.
Schedule of study events.
Event | Week | ||||||||
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Preenrollment | 1 | 2 | 3 | 4 | 6 | 8 | 10 | 12 | |
Adherence assessment |
X | X | X | ||||||
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Cognitive screening | X | ||||||||
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Chart review |
X | ||||||||
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PP exercise |
X | X | X | X | X | X | X |
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PP exercise ratings |
X | X | X | X | X | X | X |
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Psychological self-report measures |
X | X | X | ||||||
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Medical self-report measures |
X | X | X |
The PP exercises were selected based on their use in prior studies and their superior performance in our prior PP intervention studies. These included PP exercises tested in a broad variety of populations [
Week 12 is used to review the prior (Week 10) exercise and to create the plan/schedule for additional positive interventions over the following four weeks.
The intervention was then tested in a 12-week single-arm proof-of-concept study.
The goal of this small initial trial was to test logistics, show feasibility and acceptability, and adapt the intervention for future studies based on study outcomes and participant feedback. Institutional review board approval from our healthcare system was obtained prior to any study procedures. The study has completed enrollment, and study procedures and follow-up are ongoing.
English-speaking adult patients who had (1)
Exclusion criteria were (1) cognitive impairment precluding consent or meaningful participation in the PP exercises, assessed using a six-item screen developed for research [
Participants were enrolled from the outpatient diabetes center and inpatient medical units of an urban academic medical center; we included both populations to capture both stable outpatients and those with more significant comorbid medical illness. In both locations, research staff introduced the study, assessed for inclusion and exclusion criteria, and obtained written informed consent. After enrollment, and prior to initiation of the intervention, participants completed baseline self-report measures of clinical outcomes (see below). Participants then completed a total of seven PP exercises and seven phone sessions over the 12 weeks, as described previously.
Feasibility and acceptability (the main aims of this proof-of-concept study) were assessed by examining rates of exercise completion among participants as recorded by study interventionists. In addition, participants rated their optimism and positive affect immediately prior to and after each exercise on a 1–10 Likert scale. Following the exercise, they also rate the ease and overall utility of the exercise on a 1–10 scale. At week 12, open-ended feedback about the overall intervention’s ease, utility, and applicability to T2D was also elicited from participants.
In addition, as a secondary aim, we explored pre-postchange in patient-reported clinical outcomes. At baseline, 6 weeks, and 12 weeks, noninterventionist study staff obtained the following validated measures (Table Life Orientation Test-Revised (LOT-R [ Gratitude Questionnaire-6 (GQ-6 [ Hospital Anxiety and Depression Scale (HADS [ Diabetes Distress Scale (DDS [ Patient-Reported Outcomes Measurement Information System 10-Item Scale (PROMIS-10 [ Summary of Diabetes Self-Care Activities Measure (SDSCA [ MOS SAS (health behavior adherence) items were also repeated at 6 and 12 weeks.
All analyses will be performed following completion of all follow-up assessments.
All statistical tests will be two-tailed and will be performed using Stata 11.2 (StataCorp, College Station, TX).
Treatment and trainers’ manuals were successfully developed for the feasibility trial, and study staff were successfully trained utilizing the above protocol. Figure
Flow diagram of enrollment.
Conceptual model for the combination of positive psychology and motivational interviewing to improve physical activity.
Table
Baseline sociodemographic and clinical characteristics.
Characteristics |
|
---|---|
Demographics and psychosocial characteristics | |
Age in years (mean (SD)) | 60.1 (8.8) |
Male | 6 (40) |
White | 14 (93.3) |
Medical history | |
Hypertension | 14 (93.3) |
Hyperlipidemia | 10 (66.7) |
Coronary artery disease | 3 (20) |
Current smoking | 1 (6.7) |
Body mass index | 31.03 (5.5) |
Hemoglobin A1c | 8.7 (1.6) |
Medications | |
Aspirin | 11 (73.3) |
ACE inhibitor/angiotensin II receptor blocker | 10 (66.7) |
Lipid-lowering agent (e.g., statin) | 13 (86.7) |
Insulin | 12 (80) |
Oral hypoglycemic agents | 9 (60) |
Antidepressants | 6 (40) |
Baseline psychological self-report measures (mean (SD)) | |
LOT-R (range 0–24, higher = greater optimism) | 13.0 (6.8) |
GQ-6 (range 6–42, higher = greater gratitude) | 35.7 (6.7) |
HADS-D (range 0–21, higher = more depression) | 7.0 (3.7) |
HADS-A (range 0–21, higher = more anxiety) | 7.9 (4.2) |
Baseline medical self-report measures (mean (SD)) | |
MOS SAS (range 3–18, higher = more adherent) | 11.4 (3.4) |
PROMIS-10 subscales (range 4–20, higher = better health) | |
Global Physical Health | 11.8 (3.2) |
Global Mental Health | 10.7 (1.9) |
DDS subscales (range 1–6, higher = more distress) | |
Emotional | 3.1 (1.4) |
Physical | 1.1 (0.1) |
Regimen | 3.0 (1.4) |
Interpersonal | 2.4 (1.7) |
SDSCA subscales (range 0–7, higher = better adherence) | |
Diet | 4.1 (1.8) |
Exercise | 1.3 (1.9) |
Blood sugar | 5.2 (2.4) |
Foot care | 2.7 (2.8) |
Overall, the mean age of participants was 60.1 ± 8.8 years, 9 (60%) were women, and the majority had one or more additional cardiovascular risk factors (e.g., hypertension and hyperlipidemia). Most participants were moderately nonadherent, with a mean MOS SAS score of 11.4 out of 18, consistent with a mean rating of 3.8 out of 6 for completion of each health behavior (diet, activity, and medication adherence).
Participants had relatively low baseline optimism (LOT-R = 13.0 ± 6.8, compared to general population mean of 15.2 ± 3.8 [
Thus far it appears that recruitment and enrollment for a proof-of-concept study of a PP intervention in T2D is feasible in both inpatient and outpatient settings, and phone delivery of the intervention has been straightforward. It is not yet clear whether PP exercises will be effective in boosting positive psychological states and modifying health behaviors in patients with T2D. Controlled studies of PP interventions have led to increased positive psychological well-being in a wide variety of populations [
PP interventions may overlap to some degree with other commonly used psychological interventions. One such intervention is mindfulness-based stress reduction (MBSR), which has been successful in improving symptoms in a variety of medical conditions [
PP is distinct in important ways. In contrast to MBSR, PP exercises are briefer and can be completed independently, and in-person sessions are not required. The provider training process (completed via a training manual, role play, and audiotaped practice sessions for PP) is much simpler than that required for MBSR, improving applicability to real-world settings. Finally, as opposed to a focus on mindfulness, PP specifically targets behaviors (e.g., leveraging past success) and positive attributes (e.g., positive affect and optimism) that have been associated with increased participation in health behaviors and superior medical outcomes [
MI is a patient-centered method for enhancing intrinsic motivation to change and facilitating behavior change [
MI and related interventions have several appealing characteristics. First, MI can be used with patients at any stage of change, from those who feel that they currently are not motivated to increase their activity to those who are highly motivated to increase activity but have failed on prior attempts [
All of these factors make MI attractive to T2D patients who are poorly adherent to key health behaviors. By being adaptable to patients at any stage of change, it can apply to a large number of patients. Furthermore, as with PP, the ability to deliver MI remotely is very well suited to T2D patients, who may have functional, time, financial, or transportation barriers that preclude frequent inpatient visits.
MI has been successfully used to target physical activity and other health behaviors in T2D patients in several studies [
Fortunately, MI and MET have been successfully combined with additional interventions in numerous populations, including interventions targeting weight control or health behaviors in those with medical illness. For example, in a comparative effectiveness trial, MET alone was not effective in improving outcomes in patients with type 1 diabetes, but when combined with a second intervention it did result in improved clinical outcomes [
A novel health behavior intervention that combines MI and PP in T2D may be very effective. Physical activity may be an ideal target for such an intervention, given that positive states may be most linked with physical activity among the health behaviors [
Figure
Furthermore, MI itself leads to decreased ambivalence, greater intention to change, and increased feelings of control (pathway C1) [
This combination of a psychological component (that can boost optimism, confidence, and positive experiences) alongside a more tightly focused, goal-oriented, and cognitive MI component may be much more powerful in this complex and vulnerable population than either approach alone. Prior attempts to combine health behavior interventions with psychological interventions have been successful in T2D but thus far have been designed only for minority of patients with clinical depression [
PP interventions, alone or combined with other behavioral interventions, have several limitations. Not all patients may be interested in activities to boost their affect and well-being, and, despite the exercises’ straightforward nature, not all patients may be willing or able to complete positive activities on a regular basis. Furthermore, though there is ample data linking positive psychological states to health behaviors, there is less evidence regarding the impact of PP interventions on physiologic outcomes (e.g., inflammation) important to health. Overall, this line of work is still in very early stages and PP interventions (alone or combined) are far from established health-promoting interventions. Limitations of our specific proof-of-concept trial also include the use of only a single inpatient and a single outpatient site in an academic medical center and the fact that the majority of participants were white; these factors may limit generalizability of findings.
In sum, there is evidence to suggest that higher levels of positive affect, optimism, and well-being can lead to improved health behavior adherence (and outcomes) in patients with chronic illnesses like T2D. In addition, PP interventions appear to reliably increase these positive states, have been well accepted in other populations, and are distinct from other behavioral interventions in their ease of administration, high acceptability, and specific focus on promoting positive psychological well-being.
However, we have just begun to test PP interventions in patients with T2D and suboptimal health behavior adherence, and it is likely that additional customization of the intervention more specifically to T2D will be useful. Utilizing the Rounsaville model [
Adapted Rounsaville model of behavioral intervention development.
The authors have no conflict of interests to report.
This work was supported in part by NIH Grant R01HL113272 to Dr. Jeff Huffman.