Abstract The overall goal of this K23 proposal is to provide Caroline Presley, MD, MPH the essential mentorship, career development, and research experience necessary to become an independent investigator whose patient- oriented research will contribute to improving emotional distress, self-management, and outcomes in vulnerable people with type 2 diabetes. Diabetes distress — the emotional burden of living with and managing diabetes on a daily basis — affects 36% of people with type 2 diabetes and is closely linked with poor adherence to diabetes self-management behaviors, as well as suboptimal glycemic control, the presence of cardiovascular disease risk factors, and diabetes complications. Low-income individuals are disproportionately affected by both diabetes and diabetes distress. Currently, interventions are lacking to simultaneously help adults with type 2 diabetes to improve their diabetes self-management and glycemic control, as well as to reduce diabetes distress. In this four-year K23 project, Dr. Presley plans to study Mindfulness-Based Diabetes Education — an intervention specifically adapted for adults with type 2 diabetes and elevated diabetes distress that targets stress reduction and improvement of diabetes self-management behaviors and outcomes. In safety-net healthcare clinics, she will conduct a pilot randomized controlled trial (RCT) comparing this intervention to standard Diabetes Self- Management Education (DSME) in low-income adults with suboptimally controlled type 2 diabetes and moderate-severe diabetes distress to assess feasibility and acceptability. Additionally, Dr. Presley will use mixed methods to evaluate key contextual factors related to intervention delivery and implementation obtaining input from provider and patient stakeholders. Assessing context is critical in designing for implementation and sustainability. These results will inform a future fully-powered efficacy study of the intervention in safety-net healthcare systems. We hypothesize that Mindfulness-Based Diabetes Education will be acceptable and feasible — tested through these specific aims. Aim 1: To conduct a pilot RCT of Mindfulness-Based Diabetes Education versus standard DSME to determine feasibility and acceptability among adults with suboptimally controlled type 2 diabetes and moderate-severe diabetes distress. Aim 2: To characterize the contextual factors relevant to delivery and implementation of Mindfulness-Based Diabetes Education using PRISM. Along with this mentored research experience, the career development plan has been created for Dr. Presley to gain skills and experience in 1) behavioral interventions and trials, 2) clinical application of mindfulness-based interventions, 3) mixed methods research and implementation science through expert mentorship, advanced trainings, coursework, and conferences, as well as opportunities for continued professional development. Upon completion of the project, Dr. Presley will be poised to conduct a fully-powered efficacy study of the Mindfulness-Based Diabetes Education intervention supported by an R-series grant.

Project Narrative Diabetes distress is common affecting over one-third of people with type 2 diabetes, negatively impacting self- management and outcomes, and disproportionately affecting low-income individuals. The proposed project will pilot test a Mindfulness-Based Diabetes Education intervention, specifically adapted for adults with type 2 diabetes and elevated diabetes distress, to assess feasibility and acceptability. Utilizing mixed-methods, this study will also characterize key contextual factors that relevant to intervention delivery and implementation setting the stage for a future, larger study in safety-net healthcare settings.