Personal and family factors associated with quality of life in adolescents with diabetes

Assessing adolescents with insulin-dependent diabetes mellitus: a multiple perspective pilot study using visual illness narratives and interviews

This study explored the illness experiences of adolescents with insulin-dependent diabetes mellitus (IDDM) using Video Intervention/Prevention Assessment (VIA). Five adolescents with IDDM were asked to videotape 8 hours of their lives over a 1-month period. At the conclusion of the study, the primary investigator interviewed each adolescent and their diabetes clinician. VIA visual illness narratives and follow-up interviews provided clinically important, previously unknown information about how adolescents live with diabetes, including the negative and positive influences of diabetes on the family unit and the individual, that parental involvement was associated with adolescents' diabetes control, and that gender may be a significant mediating factor in control.

Acceptability of the Schedule for the Evaluation of Individual Quality of Life-Direct Weight (SEIQoL-DW) in youth with type 1 diabetes

The purpose of this study was to assess the acceptability of the Schedule for the Evaluation of Individual Quality of Life-Direct Weight (SEIQoL-DW) in youth with diabetes. This measure asks respondents to assess the importance and satisfaction of domains that they nominate as being important to their own quality of life. Seventy-seven young people (age 8-17 years, M = 12.4) with type 1 diabetes were given the SEIQoL-DW. Data from 10 participants were deemed invalid due to respondents' inability to understand the task. Respondents whose data were deemed invalid were all under 12 years of age, M = 9.3. For participants with valid data, interviewers' ratings of participant boredom and fatigue were low. Time to complete the interview was reasonably short, M = 14.9 min. Of the 335 total QOL domains nominated by participants with valid data, only 19 domains (6%) were nominated with the assistance of a standard list. Forty-five participants nominated 'diabetes' as a life domain. Results indicate the SEIQoL-DW performed well with respondents over 12 years of age, is appropriate for samples with diabetes, and taps into diabetes-relevant domains. Further research with more diverse samples is needed before firm age cut-offs can be established for its use.

Age related differences in individual quality of life domains in youth with type 1 diabetes

Background

Investigating individual, as opposed to predetermined, quality of life domains may yield important information about quality of life. This study investigated the individual quality of life domains nominated by youth with type 1 diabetes.

Methods

Eighty young people attending a diabetes summer camp completed the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting interview, which allows respondents to nominate and evaluate their own quality of life domains.

Results

The most frequently nominated life domains were 'family', 'friends', 'diabetes', 'school', and 'health' respectively; ranked in terms of importance, domains were 'religion', 'family', 'diabetes', 'health', and 'the golden rule'; ranked in order of satisfaction, domains were 'camp', 'religion', 'pets', and 'family' and 'a special person' were tied for fifth. Respondent age was significantly positively associated with the importance of 'friends', and a significantly negatively associated with the importance of 'family'. Nearly all respondents nominated a quality of life domain relating to physical status, however, the specific physical status domain and the rationale for its nomination varied. Some respondents nominated 'diabetes' as a domain and emphasized diabetes 'self-care behaviors' in order to avoid negative health consequences such as hospitalization. Other respondents nominated 'health' and focused more generally on 'living well with diabetes'. In an ANOVA with physical status domain as the independent variable and age as the dependent variable, participants who nominated 'diabetes' were younger (M = 12.9 years) than those who nominated 'health' (M = 15.9 years). In a second ANOVA, with rationale for nomination the physical status domain as the independent variable, and age as the dependent variable, those who emphasized 'self care behaviors' were younger (M = 11.8 years) than those who emphasized 'living well with diabetes' (M = 14.6 years). These differences are discussed in terms of cognitive development and in relation to the decline in self-care and glycemic control often observed during adolescence.

Conclusions

Respondents nominated many non-diabetes life domains, underscoring that QOL is multidimensional. Subtle changes in conceptualization of diabetes and health with increasing age may reflect cognitive development or disease adjustment, and speak to the need for special attention to adolescents. Understanding individual quality of life domains can help clinicians motivate their young patients with diabetes for self-care. Future research should employ a larger, more diverse sample, and use longitudinal designs.

Adolescent quality of life: a school-based cohort study in Western Australia

BACKGROUND

Quality of life (QOL) has received increasing attention in pediatrics medicine recently. Improving QOL is the primary justification for many interventions, medications and therapies. The present study is a school-based longitudinal study which aims to investigate the factors affecting QOL of adolescents in Western Australia over a 6-month period.

METHODS

A generic self-reported questionnaire was administered twice to participants from 20 schools in Perth at 6 months apart. In addition to QOL scores and physical health status, demographic and other information was also collected. For the cohort of 363 students who participated in the initial survey, 300 of them completed the second questionnaire.

RESULTS

A significant change in QOL score between baseline and 6 months was observed. Results from fitting a hierarchical mixed regression model indicated that 55% of the variation in QOL was due to differences between individuals, and was significantly associated with age, control, opportunities and perceptions of physical health, while the remaining variance component could be attributed to within-individual changes. Improved control and opportunities appeared to have a significant positive impact on QOL, whereas increasing age and deterioration in physical health had the opposite effect.

CONCLUSIONS

The hierarchical regression analysis has enabled valid inferences to be made based on the observed longitudinal data. Perceptions of physical health, age, control and opportunities available are related to adolescent QOL. The findings have implications on evidence-based practices and childhood health issues.

Self-efficacy and its interrelation with family environment and metabolic control in Turkish adolescents with type 1 diabetes

OBJECTIVE

To explore the relationship between self-efficacy, family environment (cohesion and organization) and metabolic control.

RESEARCH DESIGN AND METHODS

A total of 100 adolescents with diabetes were assessed on a single occasion. Eligibility criteria were an age range of 11-18 yr, diagnosis of type 1 diabetes of at least 1 yr duration, and ability to complete the questionnaire unaided. Adolescents completed self-efficacy and family environment questionnaires. Metabolic control was assessed by HbA1c. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS) Version 10.0. Independent paired t-tests and Pearson's correlation coefficient were used as test methods.

RESULTS

Boys and girls were comparable on self-efficacy, and self-efficacy scores were quite satisfactory for both boys and girls. There was a significant positive correlation between self-efficacy and family cohesion in girls, but self-efficacy was not related to the family environment (cohesion and organization) and metabolic control in the total sample.

CONCLUSION

In the present study, there was no relationship between self-efficacy, family environment, and metabolic control in the total sample, but in girls, self-efficacy and family cohesion was positively correlated.

General quality of life in youth with type 1 diabetes: relationship to patient management and diabetes-specific family conflict

OBJECTIVE

To evaluate self-report and parent proxy report of child/teen general quality of life in youth with type 1 diabetes, compare their responses with those of a general pediatric population, and identify relationships between diabetes management, diabetes-related family behavior, and diabetes-specific family conflict with quality of life in youth with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Study participants included 100 children, 8-17 years of age (12.1 +/- 2.3), with type 1 diabetes for 0.5-6 years (2.7 +/- 1.6). Each child and a parent completed the Pediatric Quality of Life Inventory (PedsQL), completed the Diabetes Family Conflict Scale, and provided data on parent involvement in diabetes management. An independent measure of adherence to treatment assessed by the patient's clinician and a measure of glycemic control (HbA(1c)) were also collected.

RESULTS

PedsQL responses from youth with type 1 diabetes were stable over 1 year and similar to norms from a healthy standardization sample for all three scales of the PedsQL: total, physical, and psychosocial quality of life. After controlling for age, duration of diabetes, sex, HbA(1c), and family involvement, child report of diabetes-specific family conflict (P < 0.01) was the only significant predictor of child report of quality of life (model R(2) = 0.21, P < 0.02).

CONCLUSIONS

Youth with type 1 diabetes report remarkably similar quality of life to a nondiabetic youth population. Greater endorsement of diabetes-specific family conflict predicted diminished quality of life for the child. As treatment programs focus on intensifying glycemic control in youth with type 1 diabetes, interventions should include efforts to reduce diabetes-specific family conflict in order to preserve the child's overall quality of life.

Psychological aspects of diabetes mellitus

Diabetes mellitus (DM) presents itself in two forms: insulin-dependent (type 1 DM) and non-insulin-dependent (type 2 DM). Although type 2 DM usually has an adult onset, in recent years there has been a significant rise in the number of children diagnosed with type 2 DM in the United States. Reasons for this increased frequency are believed to be a larger percentage of children who are overweight, a family history of diabetes, and a considerable increase in the use of psychotropic medication in children. The diagnosis of DM is a significant stressor not only for patients but also for their environment. Children with DM are sometimes stigmatized by their peers and relatives who do not understand the illness or are frightened by it. Some children also may need to alter several of their customary routines and are often scared to participate in activities in which they were previously engaged. The family's response to the diagnosis of DM may have a negative effect on glycemic control. Differences have been found in the way patients with type 1 DM and type 2 DM cope with and adapt to their diagnosis.

Associations of blood glucose control with self-efficacy and rated anxiety/depression in type II diabetes mellitus patients

We investigated the possible relations of hemoglobin A1c (HbA1c) level, a parameter of blood glucose control with scores on anxiety, depression, and self-efficacy for 113 outpatients (55 men and 58 women) with type II diabetes mellitus. The relation between the HbA1c level and the self-efficacy scores as well as with the ratings of anxiety and depression was evaluated. A significant relation was found for the HbA1c level with the scores; however, self-efficacy and anxiety and depression showed no association. These results suggest that HbA1c can be maintained at better levels by increasing self-efficacy of diabetic patients.

Diabetes self-care: lessons from research on the family and broader contexts

The foundation of diabetes management is the self-care behavior of the patient. All of the systems within which the person with diabetes interacts, as well as the media and broader social and cultural values, affect this self-care behavior. In this article I focus on recent research that has examined the link between relationships in the patient's intimate network (i.e., family and close friends) and in the patient's exchange network (i.e., patient-provider relationship, Internet support). The goal of this review is to identify relational targets associated with self-care behaviors that are potentially modifiable within the diabetes medical care setting. Evidence-based suggestions are made for points of intervention entry, and areas for future research are explored.

Depression in type 1 diabetes in children: natural history and correlates

The combination of diabetes and depression in children and adolescents is largely unstudied. The purpose of this article is to review the literature on the natural history and correlates of comorbid diabetes and depression in children and adolescents. Children with diabetes have a two-fold greater prevalence of depression, and adolescents up to three-fold greater, than youth without diabetes. Correlates of depression and diabetes include gender, poorer metabolic control, and family behaviors. Very little is known about treatment in these youth, and more studies are indicated.

Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome

This study describes pain characteristics, coping, depression, and functional disability in children with juvenile primary fibromyalgia syndrome (JPFS) and compares them with a group of children with nonmalignant chronic back pain (CBP). Subjects were 18 female subjects (9 to 19 years of age) diagnosed with JPFS and 18 matched control subjects with CBP. Visual Analog Pain Rating Scales, the Pain Coping Questionnaire, the Children's Depression Inventory, and Functional Disability Inventory were administered. Results indicated that both JPFS and CBP groups reported significant disruption in functional abilities and school attendance as a result of chronic pain. Both groups reported mildly elevated symptoms of depression overall, but there was a subgroup of JPFS subjects who reported severe levels of depression. The JPFS group had suffered from pain for significantly longer than the CBP group before being referred for specialty care. However, pain duration was not significantly related to depression, functional disability, or pain coping efficacy. The levels of functional disability were similar in both groups, but the JPFS group reported somewhat more school absences. The longer time to receive specialty care and identification of a subgroup of depressed subjects at risk for long-term psychosocial consequences are of particular concern in JPFS.

A randomized control trial of the effect of negotiated telephone support on glycaemic control in young people with Type 1 diabetes

AIM

To evaluate changes in self-efficacy for self-management in young people with Type 1 diabetes participating in a "Negotiated Telephone Support" (NTS) intervention developed using the principles of problem solving and social learning theory.

METHODS

One-year RCT with 79 young people (male 39; mean age +/- sd 16.5 +/- 3.2 years, duration 6.7 +/- 4.4 years, HbA(1c) 8.6 +/- 1.5%) randomized into: Group 1 (control group), continued routine management, n = 28; Group 2, continued routine management with NTS, n = 25; Group 3, annual clinic with NTS, n = 26.

OUTCOME MEASURES

HbA(1c), self-efficacy, barriers to adherence, problem solving, and diabetes knowledge.

RESULTS

There were no differences between the groups at baseline. Participants in Groups 2 and 3 received an average of 16 telephone calls/year (range 5-19), median duration 9 min (2-30), with a median interval of 3 weeks (1-24) between calls. Significant correlations were found between age and average length of call (r = 0.44, P < 0.01) and frequency of contact (r = 0.36, P < 0.05). Social and school topics were discussed frequently. After 1 year, while the participants in the two intervention groups showed significant improvements in self-efficacy (P = 0.035), there was no difference in glycaemic control in the three groups. Barriers to insulin use adherence were a significant predictor of HbA(1c) (P < 0.001) after controlling for baseline.

CONCLUSIONS

NTS is an effective medium to deliver a simple theory-based psychological intervention to enhance self-efficacy for diabetes self-management. Reduced clinic attendance, combined with NTS, did not result in a deterioration of HbA(1c). Intensive personal support needs to be combined with intensive diabetes therapy to improve glycaemic control in this age group.

Assessing quality of life for adolescents in western Australia

This study investigates the quality of life (QOL) for adolescents residing in Perth, Western Australia. The Quality of Life Profile-Adolescent Version (QOLPAV), a generic self-reported questionnaire, was administered to 363 adolescents aged between ten and 18 years who were enrolled in 20 high schools within metropolitan Perth. Stepwise regression analysis of the data showed that age, control, opportunity and perceptions of health have significant associations with QOL. It was also found that adolescents with a chronic condition and those without have similar QOL scores. This suggests that, in terms of QOL, the chronically ill adolescents do not view themselves as different from their healthy counterparts.

Diabetes and behavioral medicine: the second decade

Diabetes management depends almost entirely on behavioral self-regulation. Behavioral scientists have continued a collaboration with other health systems researchers to develop a holistic approach to this disease. The authors summarized the literature in 4 major areas: self-management of diabetes, psychosocial adjustment and quality of life, neuropsychological impact, and psychobehavioral intervention development. Progress made in each of these areas over the past decade is highlighted, as are important issues that have not yet received sufficient scientific attention. Emerging areas likely to become central in behavioral research, such as diabetes prevention, are introduced. The future of behavioral medicine in diabetes is also discussed, including topics such as the changing role of psychologists in diabetes care, the urgent need for more and better intervention research, the growing importance of incorporating a health system-public health perspective, and obstacles to the integration of psychobehavioral approaches into routine health care delivery.

The network of psychological variables in patients with diabetes and their importance for quality of life and metabolic control

OBJECTIVE

The primary goals in treating patients with diabetes are maintaining blood glucose levels as close to normal as possible and making a relatively normal quality of life achievable. Both of these goals are influenced by a multitude of somatic and psychological factors that should be seen as building a complex network. We examined whether a mathematical model can be construed that can depict the relative significance of each factor for achieving these treatment goals.

RESEARCH DESIGN AND METHODS

A total of 625 patients from 32 different treatment facilities were examined (224 type 1 and 401 type 2 diabetic patients) using HbA(1c) values (high-performance liquid chromatography), number of secondary illnesses, and standardized questionnaires with respect to health-related quality of life (World Health Organization Quality of Life questionnaire), coping behavior (Freiburger Illness-Coping Strategies questionnaire), diabetes-specific knowledge (Test of Diabetes-Specific Knowledge), doctor-patient relationship (Medical Interview Satisfaction Scale), and personality characteristics (Giessen Test and Assessment of Beliefs in Self-Efficacy and Optimism). The analyses were carried out by means of a structural equation model.

RESULTS

The model proved to be valid (chi(2) = 88.5, df = 76, P = 0.16), showing a sound fit (adjusted goodness of fit [AGFI] = 0.94). It explained 62% of the variance of the quality of life and 5% of the HbA(1c) values. Subjects characterized by strong beliefs in their self-efficacy and an optimistic outlook on life were more likely to be satisfied with their doctor-patient relationships. They demonstrated more active coping behavior and proved to have a higher quality of life. Active coping behavior was the only psychological variable significant for the HbA(1c) values.

CONCLUSIONS

It was possible to illustrate the various factors involved and their mutual dependency and significance for the treatment goals. Belief in self-efficacy and active coping behavior appear to have the greatest relevance for achieving the primary treatment goals.

Good metabolic control is associated with better quality of life in 2,101 adolescents with type 1 diabetes

OBJECTIVE

It is unclear whether the demands of good metabolic control or the consequences of poor control have a greater influence on quality of life (QOL) for adolescents with diabetes. This study aimed to assess these relations in a large international cohort of adolescents with diabetes and their families.

RESEARCH DESIGN AND METHODS

The study involved 2,101 adolescents, aged 10-18 years, from 21 centers in 17 countries in Europe, Japan, and North America. Clinical and demographic data were collected from March through August 1998. HbA(1c) was analyzed centrally (normal range 4.4-6.3%; mean 5.4%). Adolescent QOL was assessed by a previously developed Diabetes Quality of Life (DQOL) questionnaire for adolescents, measuring the impact of diabetes, worries about diabetes, satisfaction with life, and health perception. Parents and health professionals assessed family burden using newly constructed questionnaires.

RESULTS

Mean HbA(1c) was 8.7% (range 4.8-17.4). Lower HbA(1c) was associated with lower impact (P < 0.0001), fewer worries (P < 0.05), greater satisfaction (P < 0.0001), and better health perception (P < 0.0001) for adolescents. Girls showed increased worries (P < 0.01), less satisfaction, and poorer health perception (P < 0.01) earlier than boys. Parent and health professional perceptions of burden decreased with age of adolescent (P < 0.0001). Patients from ethnic minorities had poorer scores for impact (P < 0.0001), worries (P < 0.05), and health perception (P < 0.01). There was no correlation between adolescent and parent or between adolescent and professional scores.

CONCLUSIONS

In a multiple regression model, lower HbA(1c) was significantly associated with better adolescent-rated QOL on all four subscales and with lower perceived family burden as assessed by parents and health professionals.

Multidisciplinary teaming to promote effective management of type 1 diabetes for adolescents

Intensive diabetes therapy can reduce the long-term microvascular complications of Type 1 diabetes and improve glucose control. Managing the demands of intensive therapy however, often poses a burden on adolescents and their families. Through multidisciplinary teaming, the school health office can facilitate active participation in treatment, coordinate services, and maximize use of community resources. This paper presents a general overview of intensive diabetes therapy, psychosocial implications of chronic illness in adolescence, effects of chronic illness on the family, and behavior change strategies to improve adherence with disease management guidelines.

Psychosocial issues in pediatric diabetes

Although the majority of diabetic patients exhibit mild depression, anxiety, and somatic complaints at the time of diagnosis, these symptoms are usually temporary and resolve within 6 to 9 months. However, in some patients, depressive symptoms may increase with the duration of diabetes. Anxiety seems to increase and to be more prevalent in girls than in boys. Depression and self-esteem problems have a negative impact on the adaptation to diabetes and metabolic control. Patients' adjustment to diabetes shortly after diagnosis seems to predict adjustment later on. Family characteristics have major implications in the patient's adjustment to diabetes, self-management, and quality of life. Children and adolescents living in families with a high degree of conflict or that are less caring appear to have poorer metabolic control. Thus, the goal of achieving metabolic and psychological stability requires a diabetes team equipped to provide social and psychological support in addition to the development of technical skills. This includes very early assessment of family dynamics and psychological intervention.

Meaning of illness and health outcomes in type 1 diabetes

OBJECTIVE

To determine whether a relationship exists between the meaning attributed to type 1 diabetes and mental and physical health outcomes.

METHODS

The study sample consisted of 49 adults with type 1 diabetes. Each participant voluntarily agreed to complete the Meaning of Illness Questionnaire (MIQ), the Short Form-36 Health Survey (SF-36), and the Diabetes Health Survey. Multivariant analysis of covariance was used to determine the relationships among the MIQ and SF-36, a history of depression, hemoglobin A1c, and other demographic variables.

RESULTS

The meaning attributed to illness predicted health outcomes. Specifically, the impact of illness (MIQ subscale 1; P = 0.030) predicted SF-36 physical functioning, bodily pain, and general mental health; the degree of stress (MIQ subscale 3; P = 0.008) predicted SF-36 general physical health, vitality, and general mental health. Conversely, a history of depression (P = 0.014) and high hemoglobin A1c (P = 0.039) predicted a more negative meaning attributed to illness.

CONCLUSION

The meaning attributed to illness varies with physical and mental health. In addition, physical and mental health outcomes and hemoglobin A1c, a measure of mean blood glucose, affect the meaning attributed to diabetes. The findings in this study support a bidirectional relationship between the meaning attributed to illness and health outcomes in patients with type 1 diabetes.

Psychosocial therapies in diabetes: report of the Psychosocial Therapies Working Group

OBJECTIVE

To review key advances in the behavioral science literature related to psychosocial issues and therapies for persons with diabetes, to discuss barriers to research progress, and to make recommendations for future research.

RESEARCH DESIGN AND METHODS

Key findings from the literature on psychosocial research in diabetes are reviewed separately for children and adults. Specific issues covered include psychosocial adjustment and psychiatric disorders, neurocognitive functioning, quality of life, and psychosocial therapies. Barriers that must be addressed to allow research in this area to progress are discussed. Recommendations are then made concerning high-priority areas for advancing research in the field.

CONCLUSIONS

A substantial amount of behavioral science research has demonstrated that psychosocial factors play an integral role in the management of diabetes in both children and adults. Research has also shown the efficacy of a number of psychosocial therapies that can improve regimen adherence, glycemic control, psychosocial functioning, and quality of life. More research in this area is needed to develop psychosocial intervention programs for specific patient populations and to demonstrate the cost-effectiveness of these approaches.

Life with continuous subcutaneous insulin infusion (CSII) therapy: child and parental perspectives and predictors of metabolic control

OBJECTIVE

The purpose of this study was twofold (i): to evaluate metabolic control in patients receiving CSII therapy in a routine pediatric diabetes clinic by describing reasons for initiating therapy and daily management issues, including needle fear; and (ii) to assess the change in parental involvement and anxiety once their child initiated CSII therapy.

RESEARCH DESIGN AND METHODS

The study included 52 subjects (aged 7.6-23.6 yr) from a general pediatric diabetes clinic. Management issues were defined as diet, exercise, home blood glucose monitoring (HBGM) frequency, and self/staff assessment of needle fear. Characteristics were analyzed both according to a 0.5% change in HbA1c status (decreased vs. stable vs. increased) compared with pre-CSII therapy, and final HbA1c achieved (< or = 8.1 vs. > 8.1%).

RESULTS

The primary recommendation source for CSII use was most often the physician/diabetes team (48.1%), followed by a combination of the former with a personal referral source (32.7%). The most common reason (71.2%) for CSII initiation was a combination of wanting to achieve better metabolic control, dislike of insulin injections, and/or increased flexibility in daily living. Over one-quarter (26.9%) of subjects were identified as being needle-fearful, and this characteristic was predictive of final metabolic control (3/25 subjects </= 8.1% vs. 11/27 subjects > 8.1%, p = 0.03). On CSII therapy, dietary carbohydrate consistency was highly variable, and most subjects (65.3%) exclusively used an insulin to carbohydrate ratio for insulin bolus dosage calculation. The most common adjustment strategy (63.5%) for exercise was a combination of decreasing the insulin basal rate, disconnecting the pump, and/or eating extra carbohydrates. For the total cohort, the frequency of HBGM significantly increased on CSII therapy (4.31-4.85 tests/day, p = 0.02). Females did not have a significant change in HBGM frequency, while the youngest subjects had the highest HBGM frequency. Parental involvement and anxiety primarily stayed the same or decreased, regardless of the child's age (< or = 18 vs. > 18 yr) or metabolic control.

CONCLUSIONS

Analyses of the various characteristics identified only needle fearfulness as being predictive of poor metabolic control. Interestingly, poor control with CSII therapy did not result in a significant increase in parental involvement and/or anxiety.

Clinical and psychosocial factors associated with achievement of treatment goals in adolescents with diabetes mellitus

PURPOSE

To examine the following questions with regard to the initiation of a new intensive management program for adolescents with Type 1 diabetes mellitus: (a) What clinical and psychosocial factors are associated with achievement of metabolic control treatment goals after 1 year? and (b) What baseline clinical and psychosocial factors are associated with improvement in the quality of life after 12 months?

METHODS

Eighty-one subjects (of 83 who began; aged 14.3 +/- 2.0 years at entry; 48 females, 33 males; 95% white; diabetes duration 8.9 +/- 3.9 years) with Type 1 diabetes completed 12 months of follow-up in a study of intensified treatment of diabetes. Assessments at baseline and at 12 months used the Diabetes Quality of Life for Youth scale, the Self-efficacy for Diabetes Scale, the Children's Depression Inventory, the Issues in Coping with Diabetes Scale, and the Diabetes Family Behavior Scale. Data were analyzed using multiple and logistic regression.

RESULTS

From a baseline of >9%, HbA1c levels decreased to a mean of 7.8 +/- 0.7%, with 30% of the subjects achieving our treatment goal of <or=7.2%. Logistic regression demonstrated that achievement of goal levels of HbA1c were associated with better metabolic control at study entry (p = .05), participation in coping skills training (p = .003), and more parental participation in guidance and control (p = .05). Multiple regression analysis demonstrated that participation in coping skills training with lower impact of diabetes on quality of life at baseline and less depression at baseline contributed significantly to the variance (0.57) in quality of life at 12 months.

CONCLUSIONS

Providers need to pay particular attention to adolescents with poorer metabolic control and impact of diabetes on quality of life when they intensify their treatment because they are less likely to reach treatment goals. Furthermore, behavioral interventions such as coping skills training may help teens achieve their goals.

Health-related quality of life measurement in type 2 diabetes

Type 2 diabetes has significant adverse effects on health-related quality of life (HRQoL). A vast array of questionnaires has been used to measure HRQoL in diabetes patients, contributing to the difficulty of selecting instruments for future research. To systematically evaluate these measures, a literature search was undertaken to identify relevant publications. This paper summarizes the generic, diabetes-specific, and psychological measures utilized to evaluate persons with type 2 diabetes, and highlights related findings. Generic instruments demonstrate significant reductions in health status compared with other chronic disease populations and healthy controls. Multiple diabetes-specific measures are available to assess domains affected by the disease, including symptoms, worries, self-care, locus of control, functional ability, social support, and sexual functioning. Psychological measures show that type 2 diabetes is frequently associated with adverse psychological effects, particularly depression. Since much of this research has been cross-sectional in nature, little is known about responsiveness of many of the HRQoL measures to clinical change and treatment effects. It is clear that HRQoL results are influenced by multiple patient and disease factors, particularly age, gender, and the presence and severity of disease complications and comorbid conditions. These factors should be considered in the design and analysis of HRQoL evaluations in type 2 diabetes patients. Selection of instruments for future research will therefore require careful evaluation of study design and objectives, population characteristics, the presence of disease-related factors, and outcomes of interest.

Motivation and dietary self-care in adults with diabetes: are self-efficacy and autonomous self-regulation complementary or competing constructs?

This study examined constructs drawn from social-cognitive theory (A. Bandura, 1986) and self-determination theory (E. L. Deci & R. M. Ryan, 1985, 1991) in relation to dietary self-care and life satisfaction among 638 individuals with diabetes. A motivational model of diabetes dietary self-care was proposed, which postulates direct links between self-efficacy/autonomous self-regulation, and adherence/ life satisfaction. Structural equation modeling showed that both self-efficacy and autonomous self-regulation were associated with adherence (betas = .54 and .21, respectively) and with life satisfaction (betas = .15 and .34, respectively). Constraint analyses confirmed that self-efficacy was significantly more associated with adherence, whereas autonomous self-regulation was significantly more associated with life satisfaction. According to the model, interventions for dietary self-care and life satisfaction should focus on increasing self-efficacy and autonomous self-regulation.

Key issues in chronic illness research: lessons from the study of children with diabetes

Issues and controversies in chronic illness research are discussed, with data and examples from a program of research dealing with children and adolescents with diabetes. The key differences that demand consideration include prevalence, developmental issues, measurement, cultural issues, the lack of viable models, use of controls, the importance of the family, and ethical concerns.

Use of lispro insulin and quality of life in adolescents on intensive therapy

PURPOSE

This study examined the metabolic and quality-of-life effects of using lispro insulin in teenagers.

METHODS

Teenagers on multiple daily injections who had not reached metabolic treatment goals were offered the opportunity to use lispro insulin as part of a larger ongoing study of intensive management in youth. Of the 51 who were eligible, 35 used lispro and were followed for 12 months; the remaining 16 had reached treatment goals, were not offered lispro, and comprised the control group.

RESULTS

After 12 months, the teens who received lispro insulin achieved equivalent levels of metabolic control to those achieved by teens in the control group, without differences in total daily dose, insulin regimen, or adverse events. Those who received lispro found coping with diabetes less difficult than those who continued on regular insulin, and they reported less negative impact of diabetes on quality of life and fewer worries about diabetes. Both groups were equally satisfied with their diabetes treatment.

CONCLUSIONS

Lispro insulin is a safe alternative for youth on intensive regimens, may assist youth in coping with diabetes, and may improve their quality of life.

A summer vacation from diabetes: evidence from a clinical trial

PURPOSE

This study examined the metabolic trend and factors associated with an unexpected rise in HbA1c levels during the summer, with a return to baseline when school resumed, in 40 intensively treated adolescents with type 1 diabetes.

METHODS

Psychosocial data were collected using a variety of diabetes evaluation instruments. HbA1c was measured monthly.

RESULTS

HbA1c values increased by a mean of .73% from May to July and decreased by a mean of .75% from August to October. Lack of consistency in summer routines compared with school days was associated with a worsening in metabolic control during the summer months. Other factors associated with the summer increase in HbA1c included lower guidance scores on the Diabetes Family Behavior Scale, and higher impact and worry scores on the Diabetes Quality of Life for Youth Scale.

CONCLUSIONS

Interviews suggested that teenagers need to take a vacation from intensive diabetes care during the summer.