Factors affecting glycosylated hemoglobin values in children with insulin-dependent diabetes

Codesigned Shared Decision-Making Diabetes Management Plan Tool for Adolescents With Type 1 Diabetes Mellitus and Their Parents: Prototype Development and Pilot Test

BACKGROUND

Adolescents with type 1 diabetes mellitus have difficulty achieving optimal glycemic control, partly due to competing priorities that interfere with diabetes self-care. Often, significant diabetes-related family conflict occurs, and adolescents' thoughts and feelings about diabetes management may be disregarded. Patient-centered diabetes outcomes may be better when adolescents feel engaged in the decision-making process.

OBJECTIVE

The objective of our study was to codesign a clinic intervention using shared decision making for addressing diabetes self-care with an adolescent patient and parent advisory board.

METHODS

The patient and parent advisory board consisted of 6 adolescents (teens) between the ages 12 and 18 years with type 1 diabetes mellitus and their parents recruited through our institution's Pediatric Diabetes Program. Teens and parents provided informed consent and participated in 1 or both of 2 patient and parent advisory board sessions, lasting 3 to 4 hours each. Session 1 topics were (1) patient-centered outcomes related to quality of life, parent-teen shared diabetes management, and shared family experiences; and (2) implementation and acceptability of a patient-centered diabetes care plan intervention where shared decision making was used. We analyzed audio recordings, notes, and other materials to identify and extract ideas relevant to the development of a patient-centered diabetes management plan. These data were visually coded into similar themes. We used the information to develop a prototype for a diabetes management plan tool that we pilot tested during session 2.

RESULTS

Session 1 identified 6 principal patient-centered quality-of-life measurement domains: stress, fear and worry, mealtime struggles, assumptions and judgments, feeling abnormal, and conflict. We determined 2 objectives to be principally important for a diabetes management plan intervention: (1) focusing the intervention on diabetes distress and conflict resolution strategies, and (2) working toward a verbalized common goal. In session 2, we created the diabetes management plan tool according to these findings and will use it in a clinical trial with the aim of assisting with patient-centered goal setting.

CONCLUSIONS

Patients with type 1 diabetes mellitus can be effectively engaged and involved in patient-centered research design. Teens with type 1 diabetes mellitus prioritize reducing family conflict and fitting into their social milieu over health outcomes at this time in their lives. It is important to acknowledge this when designing interventions to improve health outcomes in teens with type 1 diabetes mellitus.

Early risk stratification in pediatric type 1 diabetes

In the late 1980s all Danish children with type 1 diabetes were invited for a nationwide evaluation of glycemic control. Approximately 75% (n = 720) participated and have later been referred to as The Danish Cohort of Pediatric Diabetes 1987 (DCPD1987). The results were surprisingly poor glycemic control among these young patients which lead to a great emphasis on glycemic control in the Danish Pediatric Departments. In 1995 the participants were invited for yet another evaluation but this time with main focus on early signs of microvascular complications - 339 participated. The mean HbA1c had remained at high levels (9.6%) and 60% of the participants had some level of Diabetic Retinopathy (DR). However, as the patients with DR mostly had the very milder forms it was believed that stricter glycemic control would reverse or at least stop progression of the disease in accordance with results from the large intervention study DCCT. This was investigated further at follow-up in 2011. The first study in the present thesis aimed to describe the 16-year incidence, progression and regression of DR in 185 participants from the DCPD1987 cohort. The 16-year incidence of proliferative retinopathy (PDR), 2-step progression and regression of DR was 31.0, 64.4, and 0.0%, respectively. As expected, the participants with PDR at follow-up had significantly higher HbA1c-values at both baseline and follow-up than those without PDR. However; a significantly larger decrease in HbA1c was also observed in the group with PDR over the study period, which in accordance with DCCT should have prevented the development of PDR to some extent. A surprisingly high incidence of proliferative retinopathy amongst young patients with type 1 diabetes in Denmark was found despite improvements in HbA1c over time. The improvement in HbA1c was either too small or happened too late. This study highlights that sight-threatening diabetic retinopathy remain a major concern in type 1 diabetes and the importance of early glycemic control. Identifying high-risk patients at a very early stage is not only desired for prevention of diabetic retinopathy - neuropathy and nephropathy similarly remain frequent in type 1 diabetes. Early risk stratification will allow for timely implementation of effective interventions and for individualized screening and diabetes care. The second and third studies of this thesis provide the longest prospective studies to date on both retinal vessel calibers and retinal fractal dimensions and their predictive value on diabetic microvascular complications. Semi-automated computer software has been developed to measure smaller changes in the retinal vessels on retinal photographs. Two of the first parameters to be reliably estimated by these programs were retinal vessel calibers and retinal vascular fractal dimensions (a quantitative measure on vascular complexity). There is very limited knowledge on their predictive value on diabetic complications thus far. In the second and third study, a consistent relation between narrower retinal arteriolar calibers, wider retinal venular calibers, lower fractal dimensions and the 16-year incidences of diabetic neuropathy, nephropathy and proliferative retinopathy was found. This has never been shown before. The results on vessel analyzes provides indications of a common pathogenic pathway for diabetic microvascular complications and therefore a possibility of universal risk estimation for development of neuropathy, nephropathy and retinopathy in type 1 diabetes.

Diabetic control in children and adolescents: Psychosocial factors and therapeutic efficacy

Forty-two insulin-dependent latency and adolescent age diabetics were studied over a four-month period. Half of the population received a multicomponent intervention designed to enhance diabetic regulation. Psychological and demographic variables and glycosylation of hemoglobin were correlated in order to investigate the interaction between personality factors and metabolic control. Number of life event changes predicted initial values of glycohemoglobin, while ego development predicted the magnitude of improved diabetic control.

Long-term follow-up data may help manage patient and parent expectations for pediatric patients undergoing thyroidectomy

BACKGROUND

We investigated the incidence and impact of postoperative complications in children who underwent total thyroidectomy (TTx).

METHODS

The records of all pediatric patients undergoing TTx (2001-2011) at our institution were retrospectively reviewed for the occurrence of biochemical hypothyroidism (thyroid-stimulating hormone >10 mIU/mL), laboratory assessments, and medication nonadherence.

RESULTS

The 74 patients (median age, 12.5 years) had thyroid cancer (differentiated, n = 39; medullary, n = 16) or benign pathology (n = 19; 16 with multiple endocrine neoplasia type 2A). The median postoperative follow-up was 3.2 years; 46 patients (62%) had ≥ 1 year follow-up. Forty-one percent had ≥ 1 period of medication nonadherence; this was not associated with age at TTx (P = .30). Non-treatment-related hypothyroidism occurred in 33% of patients during postoperative year (POY) 1. The number of POY1 laboratory assessments among the 30% of patients with parathyroid dysfunction was more than twice that among patients with normal parathyroid function (median assessments per year 8 vs 3; P < .0001). Forty-four percent of patients/families reported behavioral or physiologic changes; 40% were concomitant with abnormal thyroid function.

CONCLUSION

More than 40% of pediatric patients were unable to fully adhere to postoperative medication regimens, and non-treatment-related hypothyroidism was common. Postoperative hypoparathyroidism doubled the number of laboratory assessments obtained. These data may help families better prepare for TTx sequelae.

Characteristics of children with type 1 diabetes and persistent suboptimal glycemic control

OBJECTIVE

This study aims to determine the relationship between the duration of persistent poor glycemic control in type 1 diabetes mellitus (T1DM) children and the likelihood of subsequent improvement.

METHODS

A retrospective cohort study was conducted on T1DM patients aged 6-18 years, followed for at least six visits at Children's National Medical Center (Washington, DC) with at least one hemoglobin A1c (HbA1c) ≥ 10% after the first year since the initial visit (n=151). Medical records of patients with subsequently improved glycemic control were reviewed (n=39).

RESULTS

Patients aged 12-18 years, females, and Medicaid patients were twice as likely to be in persistently poor control as patients aged 6-11 years, males, and privately insured patients, respectively. Each additional visit with HbA1c ≥ 10% and one percentage point increase in the mean HbA1c reduced the likelihood of subsequent improvement by 20% and 50%, respectively. Of the 39 patients with improved control, only 5 (13%) sustained their improvement for ≥ 2 years. Multiple contributing factors for improved control were identified, but no one factor explained improved control in > 25% of patients.

CONCLUSION

This study suggests that the longer the duration of poor control, the more difficult it is to reverse the underlying factors of poor diabetes management. Strategies to improve regular clinic attendance along with reinforcement of changes which resulted in improved control are critical. Adolescents, females, and Medicaid patients in particular should be targeted for sustained intervention.

Blue flash ERG PhNR changes associated with poor long-term glycemic control in adolescents with type 1 diabetes

PURPOSE

To investigate the relationship between long-term glycemic control and photopic negative response (PhNR) changes in the blue flash ERG in adolescents with type 1 diabetes (T1D) without diabetic retinopathy (DR).

METHODS

After light adaptation, ERG responses to 1.60 cd·s/m(2) blue (420 nm) flashes (blue flash ERG) and 3.0 cd·s/m(2) white flashes (LA 3.0 ERG) were recorded in 22 patients (age range, 12 to 19 years) and 28 age-similar control subjects. The primary outcome measure was the amplitude of the PhNR. Secondary outcome measures were the amplitude and implicit time of the a-wave and b-wave. Multiple regression analyses were conducted with glycated hemoglobin (HbA(1c)) values and the time since diagnosis of T1D as covariates.

RESULTS

Blue flash ERG PhNR amplitudes were reduced (P = 0.005) in patients compared with control subjects. Multiple regression analysis demonstrated that a 1-unit increase in HbA(1c) was associated with a 15% decrease in the blue flash ERG PhNR amplitude (r = 0.61, P = 0.003). Compared with controls blue flash ERG a-waves (P = 0.03) and b-waves (P = 0.02) were delayed in patients but were not significantly associated with HbA(1c) or time since diagnosis of T1D. None of the ERG measures in the LA 3.0 ERG were significantly different in patients compared with controls.

CONCLUSIONS

Poorer long-term glycemic control is associated with worsening inner retinal dysfunction involving short-wavelength cone pathways of adolescents with T1D and no clinically visible DR. Future studies are warranted to determine whether changes in the blue flash ERG PhNR are a predictive marker of subclinical DR.

Quality of life and glycemic control in adolescents with type 1 diabetes and the impact of an education intervention

OBJECTIVE

To assess quality of life (QoL) and glycemic control in adolescents with type 1 diabetes and to investigate the impact of an educational program.

METHODS

A quasiexperimental study with nonrandomized experimental and control groups was conducted in which a total of 503 adolescents with type 1 diabetes completed a questionnaire using the Diabetes Quality of Life Instrument for Youth. Adolescents were then assigned to experimental and control groups. The experimental group was subjected to four 120-minute sessions of an educational program over a period of 4 months. Extracted medical chart data included the duration of diabetes, insulin dosage, and most recent hemoglobin A1c levels. Analysis of covariance was used to detect the impact of intervention.

RESULTS

The overall mean QoL score (%) was 76.51 ± 9.79, with good QoL in 38% of all adolescents. Poorer QoL was significantly associated with older age (P < 0.001), more hospital admissions in the last 6 months (P = 0.006), higher levels of depression (P < 0.001), poor self-esteem (P < 0.001), and poor self-efficacy (P < 0.001). There was significant deterioration in all domains of QoL in the experimental group after intervention. However, this deterioration was significantly less severe than in the control group. Between-group effects on total knowledge, adherence to exercise, glucose monitoring, treatment, self-efficacy, family contribution to management, glycemic control, and satisfaction with life were significantly in favor of the experimental group.

CONCLUSION

Education intervention for adolescents with type 1 diabetes could be a safeguard against possible deterioration in QoL and glycemic control over time.

Multifocal ERG defects associated with insufficient long-term glycemic control in adolescents with type 1 diabetes

PURPOSE

To investigate the relationship between long-term glycemic control and localized neuroretinal function in adolescents with type 1 diabetes (T1D) without diabetic retinopathy (DR).

METHODS

Standard (103 hexagons) and slow-flash (61 hexagons) multifocal ERGs (standard mfERG and sf mfERG) were recorded in 48 patients and 45 control subjects. Hexagons with delayed responses were identified as abnormal. Negative binomial regression analysis was conducted with the number of abnormal hexagons as the outcome variable. Glycated hemoglobin (HbA(1c)) levels, time since diagnosis of T1D, age at diagnosis of T1D, age at testing, and sex were the covariates. Another model replacing HbA(1c) closest to the date of testing with a 1-year average was also generated.

RESULTS

There were more abnormal hexagons for mfOPs in patients than in control subjects (P = 0.005). There was no significant difference in the mean number of abnormal hexagons for standard mfERG responses between patients and control subjects (P = 0.11). Negative binomial regression analysis for the standard mfERG data demonstrated that a 1-unit increase in HbA(1c) was associated with an 80% increase in the number of abnormal hexagons (P = 0.002), when controlling for age at testing. Analysis using the 1-year HbA(1c) averages did not result in significant findings.

CONCLUSIONS

Poor long-term glycemic control is associated with an increase in areas of localized neuroretinal dysfunction in adolescents with T1D and no clinically visible DR. Stricter glucose control during the early stages of the disease may prevent neuroretinal dysfunction in this cohort.

Predictors of metabolic control among adolescents with diabetes: a 4-year longitudinal study

OBJECTIVE

To employ a risk and resistance framework to examine changes in metabolic control over early to middle adolescence.

METHODS

We interviewed 70 girls and 62 boys (mean age 12 years) annually for 4 years. Risk and resistance factors, including demographics, disease-related variables, self-care behavior, and psychosocial variables were assessed. Hemoglobin A1c was obtained from medical records.

RESULTS

Multilevel modeling showed metabolic control deteriorated with age. Self-care behavior interacted with age to predict the decline, such that self-care was more strongly related to poor metabolic control for older adolescents. Eating disturbances, depression, and peer relations were related to poor metabolic control, whereas good family relations were related to better metabolic control for girls.

CONCLUSIONS

Independent risk factors for poor metabolic control included poor self-care, disturbed eating behavior, depression, and peer relations; parental support was an independent resistance factor for girls. Future research should examine mechanisms by which these relations emerge.

The HealthPia GlucoPack Diabetes phone: a usability study

BACKGROUND

Type I diabetes is a common chronic disease of childhood. Both the growing influence of peers and the shifting away from parental influence have been implicated as prime elements contributing to poor glycemic outcomes in adolescents. Mobile technology that can be directed towards providing self-management support and modifying potentially negative child parent interaction holds promise to improve control in adolescents with diabetes.

METHODS

HealthPia, Inc. (Palisades Park, NJ) has developed a prototype system, the HealthPia GlucoPack Diabetes Monitoring System, which integrates a small blood glucose monitoring device into the battery pack of a cell phone. A pilot study used mixed quantitative and qualitative methods to evaluate user satisfaction with the integrated system, including the potential of the device to transmit self-monitoring data to a website for review and analysis by clinicians, parents, and patients.

RESULTS

Adolescents in our study liked the integration of the two technologies and agreed that the glucometer was easy to use and that the tool was useful in the management of their diabetes.

CONCLUSIONS

Future work will focus on the utilization of the diabetes phone as a component of a care delivery system for adolescents with diabetes, including involvement of the health care team and enhancement of the web services that support the use of the phone.

Temporal trends in the treatment of pediatric type 1 diabetes and impact on acute outcomes

OBJECTIVE

To evaluate temporal trends in pediatric type 1 diabetes (T1DM) management and resultant effects on outcomes.

STUDY DESIGN

Two pediatric T1DM cohorts were followed prospectively for 2 years and compared; Cohort 1 (N = 299) was enrolled in 1997 and Cohort 2 (N = 152) was enrolled in 2002. In both cohorts, eligible participants were identified and sequentially approached at regularly scheduled clinic visits until the target number of participants was reached. Main outcome measures were hemoglobin A1c (A1c), body mass index Z score (Z-BMI), and incidence rate (IR; per 100 patient-years) of hypoglycemia, hospitalizations, and emergency room (ER) visits.

RESULTS

At baseline, Cohort 2 monitored blood glucose more frequently than Cohort 1 (> or = 4 times/day: 72% vs 39%, P < .001) and was prescribed more intensive therapy than Cohort 1 (> or = 3 injections/day or pump: 85% vs 65%, P < .001). A1c was lower in Cohort 2 than Cohort 1 at baseline (8.4% vs 8.7%, P = .03) and study's end (8.7% vs 9.0%, P = .04). The cohorts did not differ in Z-BMI (0.83 vs 0.79, P = .57) or IR of hospitalizations (11.2 vs 12.9, P = .38). Cohort 2 had lower IR of total severe hypoglycemic events (29.4 vs 55.4, P < .001) and ER visits (22.0 vs 29.3, P = .02).

CONCLUSIONS

T1DM management intensified during the 5 years between cohorts and was accompanied by improved A1c and stable Z-BMI. Along with improved control, IR of severe hypoglycemia and ER visits decreased by almost 50% and 25%, respectively.

What Adolescents With Type I Diabetes and Their Parents Want From Testing Technology

The presence of diabetes in an adolescent can significantly affect his/her normal development. Mobile technology may offer the ability to lessen this negative impact. We wished to learn from adolescents with diabetes and their parents how monitoring systems that incorporated mobile communication technology could potentially help to reduce hassles associated with testing, improve compliance, and ease adolescent-parent conflict about testing behavior. We recruited adolescents between the ages of 13 and 18 years, living with type 1 diabetes mellitus and their parents for focus groups. Qualitative analysis of the focus group data followed a set procedure. From the discussions, the following themes were identified: issues with blood glucose monitoring and desired technology. Elements of desired technology included hardware requirements, software requirements, communication, and miscellaneous requirements. The reported needs of this end-user group can help others to leverage maximally the capabilities of new and existing technology to care for children managing chronic disease.

The role of significant others in adolescent diabetes: a qualitative study

PURPOSE

The purpose of this study was to explore perceptions of how diabetes influences adolescents' perceptions of quality of life in general and their relationships with parents, peers, school, and their physician.

METHODS

The authors recruited adolescents between the ages of 13 and 18 years living with type 1 diabetes mellitus from a midwestern metropolitan area. Qualitative analysis of the focus group data followed a set procedure: (1) audio review of the tapes, (2) reading through the transcriptions, (3) discussions among investigators, (4) determination of conceptual themes, and (5) assignment of relevant responses to appropriate thematic constructs.

RESULTS

The 5 focus groups involved 31 adolescents. From the discussions that occurred within the 5 focus groups, the following themes were identified: personal perceptions of living with diabetes (which included living with diabetes, testing and injections, and blood sugar fluctuations), impact on relationships (which included relationships with their parents, their friends/peers, and their physician), and impact on school.

CONCLUSIONS

Diabetes in adolescence is fraught with equal and opposite demands. One consequence of this internal push/pull is that adolescents become more afraid to do appropriate developmental activities. This can have a significant impact on their normal progression to independence and adulthood, ironically at odds with the increased responsibility they have had to assume throughout their lives to care for their disease. Much of the clinical time and research still focuses on the devices of diabetes care: testing and treatment. While these are important tools in improving the outcomes of people with diabetes, they will have little impact on the adolescent until the developmental consequences of diabetes on their lives are simultaneously addressed.

Predictors of glucose control in children and adolescents with type 1 diabetes mellitus

AIMS

To evaluate the glucose control [(as measured by hemoglobin A1c (HbA1c)], the factors associated with glycemic control, and possible explanations for these associations in a sample of children and adolescents with type 1 diabetes.

METHODS

Data were collected on 155 children and adolescents, with type 1 diabetes mellitus, attending a multidisciplinary diabetes clinic in Portland, OR. Patients' hospital charts were reviewed to determine demographic factors, disease-related characteristics, and HbA1c level.

RESULTS

Mean percent HbA1c was 9.3. Adolescents between the ages of 14 and 18 yr were in poorer metabolic control (adjusted mean percent HbA1c 0.56 higher than children 2-8 yr). Children who attended the clinic three to four times in the previous year were in better control (adjusted mean percent HbA1c 0.46 lower than those who visited two or fewer times and 1.11 lower than those who attended five or more times). Children with married parents were in better glycemic control than those of single, separated, or divorced parents (adjusted mean percent HbA1c 0.47 lower for children of married parents). This effect appeared to be mediated, in part, by the number of glucose checks performed per day.

CONCLUSIONS

This study suggests that adolescents should be targeted for improved metabolic control. Diabetes team members need to be aware of changing family situations and provide extra support during stressful times. Regular clinic attendance is an important component of intensive diabetes management. Strategies must be developed to improve accessibility to the clinic and to identify patients who frequently miss appointments.

Hypoglycemia prevalence in prepubertal children with type 1 diabetes on standard insulin regimen: use of continuous glucose monitoring system

OBJECTIVE

To determine hypoglycemia prevalence in prepubertal children on thrice (TID) and twice (BID) daily insulin regimens, using the Medtronic Minimed Continuous Glucose Monitoring System.

RESEARCH DESIGN AND METHODS

Twenty-eight children aged <12 years (median 9.8, range 6.9-11.8) wore the sensor for three consecutive days and nights. Hypoglycemia was defined as glucose <60 mg/dl for >15 min. Data are expressed as the percentage of time period spent hypoglycemic.

RESULTS

Hypoglycemia prevalence was 10.1% (mean 2.6 h. subject(-1) x day(-1)). Hypoglycemia was more common at night compared with daytime (18.81 vs. 4.4%, P < 0.001); 78 and 43% of subjects showed hypoglycemia on at least one night and two or more nights, respectively. Nocturnal episodes were prolonged (median 3.3 h) and asymptomatic (91% of episodes). Prevalence was greater between 0400 and 0730 h than between 2200 and 0400 h (25.5 vs. 15.4%, P < 0.001). On a TID compared with a BID regimen, nocturnal hypoglycemia prevalence was reduced, particularly between 0400-0730 h (22.9 vs. 27.4%, P = 0.005), whereas hypoglycemia the following morning (0730-1200 h) was greater (7.8 vs. 2.8%, P < 0.001). Nocturnal hypoglycemia risk was associated with decreasing age (by a factor of 0.6 for a year less in age), increased insulin dose (by 1.6 for an increase of 0.1 units. kg(-1) x day(-1)), insulin regimen (by 0.2 on a BID compared with a TID regimen), and increased weight standard deviation score (SDS) (by 2.7 for a one SDS rise).

CONCLUSIONS

Use of standard insulin regimens results in high prevalence and large intraindividual variation in hypoglycemia, particularly at night. Independent risk factors for nocturnal hypoglycemia were younger age, greater daily insulin dose, insulin regimen, and increasing weight.

Metformin as an adjunct therapy in adolescents with type 1 diabetes and insulin resistance: a randomized controlled trial

OBJECTIVE

To evaluate whether, in adolescents with type 1 diabetes, the addition of metformin to insulin and standard diabetes management results in 1) higher insulin sensitivity and 2) lower HbA1c, fasting glucose, insulin dosage (units per kilogram per day) and BMI.

RESEARCH DESIGN AND METHODS

This was a randomized, placebo-controlled 3-month trial of metformin therapy in 27 adolescents with type 1 diabetes, high insulin dosage (>1 unit. kg(-1). day(-1)), and HbA1c >8%, with measurements of insulin sensitivity (by frequently sampled intravenous glucose tolerance test [FSIGT]), HbA1c, insulin dosage, and BMI at the onset and end of treatment.

RESULTS

At t = 0, HbA1c was 9.2 +/- 0.9%, insulin dosage was 1.2 +/- 0.2 units. kg(-1). day(-1), fasting glucose was 10.6 +/- 2.4 mmol/l, and BMI was 24.2 +/- 3.9 kg/m2 (means +/- SD), with no difference between the metformin and placebo groups. At the end of the study, HbA1c was 0.6% lower in the metformin group than in the placebo group (P < 0.05). This was achieved at lower daily insulin dosages (metformin group -0.14 +/- 0.1 vs. placebo group 0.02 +/- 0.2 units. kg(-1). day(-1); P < 0.05), with no significant change in BMI. Fasting glucose levels improved significantly in the metformin group (P < 0.05). Change in insulin sensitivity, measured by FSIGT, was not significantly different between the two groups at study end. Mild hypoglycemia occurred more frequently in the metformin-treated than in the placebo subjects (1.75 +/- 0.8 vs. 0.9 +/- 0.4 events. patient(-1). week(-1); P = 0.03). There were no differences in frequency of severe hypoglycemic episodes or gastrointestinal complaints between the two groups.

CONCLUSIONS

Metformin treatment lowered HbA1c and decreased insulin dosage with no weight gain in teens with type 1 diabetes in poor metabolic control. Changes in insulin sensitivity were not documented in this study using the FSIGT. Long-term studies will determine whether these improvements are sustained and whether certain subgroups accrue greater benefit from this therapy.

Family conflict, adherence, and glycaemic control in youth with short duration Type 1 diabetes

AIMS

Behavioural support around diabetes management tasks is linked to glycaemic outcomes. In this study we investigated the relationship between diabetes-related parental behaviours (conflict around and involvement in treatment tasks), adherence to blood glucose monitoring (BGM), and glycaemic control in youth with short duration Type 1 diabetes mellitus (DM).

METHODS

In a cross-sectional study, 104 youth (aged 8-17 years, duration of Type 1 DM 0.5-6 years) along with a parent, completed the Diabetes Conflict Scale. Parental involvement in management tasks was assessed with structured interviews and the Diabetes Family Responsibility Questionnaire. Adherence to BGM was evaluated by family report and by independent clinician rating. Glycaemic control was assessed with glycosylated haemoglobin (HbA1c) (ref. range, 4-6%).

RESULTS

Children (8-12 years; n = 69) and adolescents (13-17 years; n = 35), respectively, had similar durations of diabetes (x +/- sd; 2.7 +/- 1.69, 2.4 +/- 1.32 years) and similar glycaemic control (8.3 +/- 1.1%, 8.4 +/- 1.1%). In both age groups, parental involvement was a significant predictor of adherence to BGM (P = 0.01). Multivariate analyses, controlling for age, sex, disease duration, and BGM adherence, revealed that higher diabetes conflict significantly related to poorer glycaemic control (HbA1c) (R2 = 0.17; P < 0.01).

CONCLUSIONS

These findings indicate that in this cohort, early in the course of diabetes, diabetes-specific conflict and adherence to BGM became strongly linked to the child's glycaemic control. This suggests that to insure optimal control, it may be beneficial to introduce targeted interventions to build positive family involvement and interaction around diabetes tasks early in the disease course, before negative behaviours become established.

Bias adjustment in analysing longitudinal data with informative missingness

The recent biostatistical literature contains a number of methods for handling the bias caused by 'informative censoring', which refers to drop-out from a longitudinal study after a number of visits scheduled at predetermined intervals. The same or related methods can be extended to situations where the missing pattern is intermittent. The pattern of missingness is often assumed to be related to the outcome through random effects which represent unmeasured individual characteristics such as health awareness. To date there is only limited experience with applying the methods for informative censoring in practice, mostly because of complicated modelling and difficult computations. In this paper, we propose an estimation method based on grouping the data. The proposed estimator is asymptotically unbiased in various situations under informative missingness. Several existing methods are reviewed and compared in simulation studies. We apply the methods to data from the Wisconsin Diabetes Registry Project, a longitudinal study tracking glycaemic control and acute and chronic complications from the diagnosis of type I diabetes.

Comparison of single-mother and two-parent families on metabolic control of children with diabetes

OBJECTIVE

To understand the impact of family structure on the metabolic control of children with diabetes, we posed two research questions: 1) what are the differences in sociodemographic, family, and community factors between single-mother and two-parent families of diabetic children? and 2) to what extent do these psychosocial factors predict metabolic control among diabetic children from single-mother and two-parent families?

RESEARCH DESIGN AND METHODS

This cross-sectional study included 155 diabetic children and their mothers or other female caregivers. The children were recruited if they had been diagnosed with diabetes for at least 1 year, had no other comorbid chronic illnesses, and were younger than 18 years of age. Interviews and self-report questionnaires were used to assess individual, family, and community variables.

RESULTS

The findings indicate that diabetic children from single-mother families have poorer metabolic control than do children from two-parent families. Regression models of children's metabolic control from single-mother families indicate that age and missed clinic appointments predicted HbA1c levels; however, among two-parent families, children's ethnicity and adherence to their medication regimen significantly predicted metabolic control.

CONCLUSIONS

This study suggests that children from single-mother families are at risk of poorer metabolic control and that these families have more challenges to face when raising a child with a chronic illness. Implications point to a need for developing strategies sensitive to the challenges of single mothers.

Coping behaviors at diagnosis and in adjustment one year later in children with diabetes

The aim of this investigation was to determine the contributions of coping behaviors used at diagnosis to medical (metabolic control) and psychosocial adjustment (self-perceived competence; adjustment) 1 year later. A total of 89 children (8 to 14 years of age; 48% male; 59% White) received follow-up quarterly from diabetes diagnosis to 1 year later. Findings indicated that, in general, although metabolic control worsened over the first year, psychosocial status and coping behaviors were stable. Boys had worse metabolic control than girls. Multiple regression analysis indicated that self-worth at 1 year postdiagnosis was associated with less use of spirituality (beta = -.44), more use of humor (beta = .28), and more positive self-care (beta = .28); and self-care was less likely to be positive in older children (r = .32). These variables accounted for 47% of the variance (39% adjusted) in general self-worth when entry self-worth was controlled. Poorer overall adjustment at 1 year postdiagnosis was associated with more use of avoidance behaviors (beta = -.47) and poorer self-care (beta = -.71); and more use of avoidance was associated with older age. These variables accounted for 62% of the variance (58% adjusted) in adjustment when adjustment at diagnosis was controlled. Poorer metabolic control was associated with more use of avoidance (beta = .30) and female gender (beta = .39), and avoidance behaviors were more common in older children (beta = .12). This model predicted 33% of the variance (25% adjusted) in metabolic control 1 year after diagnosis.

Glycemic control and transfer of health care among adolescents with insulin dependent diabetes mellitus

PURPOSE

To describe glycemic control among older adolescents with insulin dependent diabetes mellitus (IDDM) as they move from pediatric to adult-focused health care.

METHODS

Prospective cohort study conducted in a university medical center. Participants included 82 consecutive adolescents (50 males and 32 females) with IDDM transferred from a pediatric to an adolescent/young adult diabetes clinic. Main outcome measures were the levels of total stable glycosylated hemoglobin (HbA1) obtained at each visit for up to one year before and after the transfer.

RESULTS

The average age of transfer to the young adult clinic was 17.3 +/- 0.8 years. Mean age at onset of IDDM was 9.6 +/- 4.2 years (1.2 to 17.3) with duration of 7.7 +/- 3.9 years (0.7 to 16.1). Glycemic control remained unchanged following transfer (9.9% +/- 1.8 vs 10.2% +/- 1.9; t = 1.6; p = 0.125). Following transfer, both males and females maintained similar levels of glycemic control (9.8% +/- 1.7 and 10.7% +/- 1.8 respectively); although the difference between males and females was significant (t = -2.0; p = 0.048) following transfer, there was no difference in the degree of change by gender (t = -2.0; p = 0.8). In both pediatric and young adult clinics, there was no relationship between duration of IDDM (< 5 vs > or = 5 years) and HbA1.

CONCLUSIONS

Transfer to an adult-focused diabetes program appears to have no negative impact on glycemic control.

Illness characteristics and psychosocial and demographic correlates of illness severity at onset of insulin-dependent diabetes mellitus among school-age children

To verify empirically the most prevalent physical signs and symptoms of diabetes at onset among school-age children, document the distribution of illness-severity, and examine psychosocial and demographic correlates of initial illness severity, the authors analyzed data on 95 school-age children whose diabetes had been newly diagnosed. The most common presenting symptoms were generally consistent with descriptions in the clinical literature. Only 22% of the children presented with severe illness on admission. Children who lived in single-parent households tended to be more ill on admission than children who lived in two-parent households.

The management of diabetes in adolescents and young adults: a preliminary case study

This paper describes one part of a first-stage study concerned with the care received by a group of adolescents and young adults with insulin-dependent diabetes mellitus (IDDM) in one district health authority. The paper reports findings from a self-selected sample of 30 patients aged between 15 and 25. Each of the 30 patients was interviewed during a routine appointment at a diabetes clinic. The patients' doctor at the clinic and one of the diabetes specialist nurses also filled in a short questionnaire for each of the patients interviewed. The main finding was that although all 30 patients interviewed reported that their diabetes control was at least moderately good, a significant number of patients had blood glucose levels above the recommended norm. The study lends support to the widely held belief that young adults with diabetes have particular difficulties in maintaining blood glucose levels within a normal range. It is suggested that processes within the current mode of care may be contributing to this poor level of control. Recommendations for a controlled trial of specialist nurse versus doctor care are made.

Eating disorders and maladaptive dietary/insulin management among youths with childhood-onset insulin-dependent diabetes mellitus

OBJECTIVE

To determine the prevalence of DSM-III eating disorder and the conjoint symptoms of maladaptive dietary/insulin management (irrespective of eating disorder) and their psychiatric and biomedical correlates among youths with childhood-onset insulin-dependent diabetes mellitus (IDDM).

METHOD

Forty-four girls and 35 boys, 8 to 13 years old at IDDM onset, were repeatedly interviewed during an interval of up to 14 years (mean = 9 years) to ascertain psychiatric disorders and behaviors related to diabetes care. Metabolic control and IDDM-related hospitalizations also were monitored.

RESULTS

By the mean age of approximately 21 years, 3.8% of the sample had DSM-III eating disorders and 11.4% had "eating problems," defined as the conjoint symptoms of severe dietary indiscretion and repeated insulin omission (irrespective of eating disorders). Youths with "eating problems" were nine times more likely to have had a psychiatric disorder than the rest of the patients, and they had a significantly higher rate of pervasive noncompliance with medical treatment. No between-group differences were found in metabolic control and rates of multiple hospitalizations.

CONCLUSIONS

The diabetes-specific symptom-pair of serious dietary indiscretion and repeated insulin omission appears to identify youths who have had other problems as well. The association of eating problems with psychiatric disorders (other than eating disorders) suggests that a subgroup of diabetic youths have various difficulties in coping with the medical illness and require close monitoring and psychosocial intervention.

A longitudinal study of biomedical and psychosocial predictors of multiple hospitalizations among young people with insulin-dependent diabetes mellitus

The aim of the present study was to estimate the cumulative probability of multiple diabetes-related hospitalizations and identify associated risk factors in a sample of 92 school-age children, newly diagnosed with insulin-dependent (Type 1) diabetes mellitus, who were followed longitudinally for up to 14 years (mean: 9 years). 'Multiple hospitalizations' as a variable was defined as three or more admissions. Altogether 26 young patients (28%) had multiple admissions (with a total of 158 hospitalizations), yielding an estimated cumulative probability for this outcome of 0.33 by 10 years after onset of diabetes. Multivariate longitudinal analyses revealed that at any given point in time, four variables significantly increased the risk of multiple admissions: higher levels of glycosylated haemoglobin reflecting poorer metabolic control, higher levels of externalizing symptoms reflecting greater behaviour problems, younger age at diagnosis, and lower socio-economic status. According to the results of post hoc analyses, however, the aforementioned risk factors do not appear to be specific to multiple hospitalizations, and can serve to identify groups that are generally vulnerable to-readmissions.

Year-long weight loss treatment for obese patients with type II diabetes: does including an intermittent very-low-calorie diet improve outcome?

PURPOSE

To evaluate a year-long behavioral weight control program, used with and without an intermittent very-low-calorie diet (VLCD) in the treatment of type II diabetes mellitus.

PATIENTS AND METHODS

Subjects (n = 93) were randomly assigned to 50-week treatment programs that used either a balanced low-calorie diet (LCD) of 1,000 to 1,000 kilocalories (kcal) per day throughout or included 2 12-week periods of a VLCD of 400 to 500 kcal per day alternating with the balanced LCD. Weight, glycemic control, blood pressure, and lipids were assessed at baseline, at the end of the year-long treatment, and at 2-year follow-up.

RESULTS

Subjects in the VLCD program lost significantly more weight than did LCD subjects at the end of the 50-week program (14.2 kg versus 10.5 kg; P = 0.057) and remained off diabetes medication longer (P < 0.05). These benefits of the VLCD were due primarily to the first 12 weeks of the diet; the second diet maintained, but did not increase, these effects. Subjects in both groups experienced marked improvements in glycemic control and cardiovascular risk factors over the year-long program, but attendance declined in the latter weeks of treatment and weight was regained. There was also marked recidivism in both groups in the year following treatment.

CONCLUSIONS

The intermittent VLCD improved weight loss and glycemic control, but these effects were quite modest and do not appear to justify the clinical use of an intermittent VLCD. Moreover, lengthening treatment to a full year did not prevent relapse. Thus, further research is needed to develop a successful approach to long-term weight control.

Biomedical and psychosocial predictors of early rehospitalization among children with insulin-dependent diabetes mellitus: a longitudinal study

The purpose of the present study was to determine the cumulative probability of the first diabetes-related rehospitalization within the initial 2.5 years after the onset of insulin-dependent diabetes mellitus (IDDM) among newly diagnosed children, and to identify risk factors that can be determined shortly after IDDM-onset. The sample consisted of 88 children, 8 to 13 years old at the onset of IDDM, who had been participating in a longitudinal study. In this sample, there was a 0.25 cumulative probability of an early readmission. Poor control was the most frequent reason for readmissions. Four variables significantly increased the risk of early rehospitalization: severity of child's externalizing symptoms at IDDM-onset, lower socio-economic status, younger age at onset of IDDM, and higher levels of glycosylated haemoglobin, reflecting poorer metabolic control. Because externalizing symptoms and poor control are amenable to change, some early rehospitalizations can potentially be prevented. Furthermore, information about the risk of early rehospitalization should be part of initial diabetes education in order to better prepare families for the possibility of such an event.

Teaching assertive communication skills to adolescents with diabetes: evaluation of a camp curriculum

Diabetes management requires consistently implementing adherence behaviors in a variety of settings. For some adolescents, consistency may be difficult due to problems in communication and assertiveness. The purpose of the present study was to evaluate the impact of a camp curriculum to teach assertive communication skills to adolescents with diabetes. The curriculum included didactic information, sharing of personal experiences, and role playing. Results showed a significant increase in adolescents' perceptions of their assertiveness from before to after the camp experience, an increase that was still apparent at a 3-month follow-up. No changes were reported in parental perceptions of their adolescents' degree of openness in communicating or in communication problems. In contrast, adolescents reported a significant decrease in their degree of openness in communicating with fathers, with a similar trend for mothers. These results suggest that the curriculum was successful in meeting the primary goal of enhancing the adolescents' assertive communication skills but had a questionable impact on their general communications with parents.

Prevalence and predictors of pervasive noncompliance with medical treatment among youths with insulin-dependent diabetes mellitus

School-age children were assessed longitudinally for up to 9 years, after the onset of their insulin-dependent diabetes mellitus (IDDM), to determine the time-dependent risk of the psychiatric diagnosis of noncompliance with medical treatment and to examine protective and risk factors. The cumulative risk for this diagnosis over the 9 years was .45. Noncompliance tended to emerge in middle adolescence and was found to be protracted. Social competence, self-esteem, and aspects of family functioning at IDDM onset and initial psychiatric status did not predict noncompliance. However, noncompliance was associated with having major psychiatric disorder later in the course of IDDM.

Change in glycemia in a four-year interval in younger-onset insulin-dependent diabetes

Hyperglycemia is an important risk factor for the development of retinopathy and nephropathy in people with diabetes mellitus. There are few population-based data on changes in glycemia over time. The purpose of this study was to examine changes in glycemia, as measured by glycosylated hemoglobin in 1980 to 1982 and in 1984 to 1986, in a large population-based study of people who were diagnosed to have diabetes before the age of 30 years and who used insulin (n = 697). Glycosylated hemoglobin was measured by a microcolumn technique at both examinations. There was a significant (P < .001) fall in the mean glycosylated hemoglobin from 10.8 to 10.1% over the 4-year interval of the study. In contrast, there was no change in the glycosylated hemoglobin (6.2%) in a similarly aged nondiabetic comparison group over the same period. The decrease in mean glycosylated hemoglobin over the 4-year period in the diabetic group was associated with several characteristics of diabetes management. These include changes in the insulin regimen (going from intermediate- or long-acting insulin only to combinations with short-acting insulin), an increase in the number of doses of insulin per day, and a higher frequency of self-monitoring of blood glucose level. It was also associated with an increased number of reported insulin reactions. These data suggest that recent changes in treatment and management of diabetes may be related to a significant decrease in glycemia.

Metabolic control and diet in Finnish diabetic adolescents

The effects of dietary, clinical and demographic factors on metabolic control in 105 diabetic adolescents were studied. All patients had diabetes for longer than two years and a daily insulin dose greater than 0.5 IU/kg body weight. Low body mass index, high social class, high number of daily eating occasions, high day-to-day variation in energy intake, high number of urine tests and a long interval between insulin injection and eating were associated with good metabolic control. Many of these determinants reflect also the general compliance with the diabetic regimen. The results stress the importance of good coordination between insulin injections and eating habits.

Familial and sporadic insulin-dependent diabetes: evidence for heterogeneous etiologies?

Heterogeneity within insulin-dependent diabetes mellitus (IDDM) has been hypothesized, but few studies have focused on differences which may exist between familial and sporadic IDDM cases. Presenting characteristics for 330 white, newly diagnosed IDDM cases were evaluated. Familial cases were older (10.2 +/- 5.1 years vs 7.9 +/- 4.2 years, P = 0.010) and had, on average, less severe metabolic disturbances at presentation, as demonstrated by lower mean hemoglobin A1 (12.6 +/- 2.4% vs 14.4 +/- 2.6%, P = 0.001) and mean insulin dose at discharge (0.62 +/- 0.35 U/kg/day vs 0.85 +/- 0.29 U/kg/day, P less than 0.001), and higher mean plasma bicarbonate concentrations (19.3 +/- 3.9 mmol/l vs 15.8 +/- 5.9 mmol/l, P = 0.023) and mean plasma C-peptide levels (0.35 +/- 0.36 pmol/ml vs 0.14 +/- 0.15 pmol/ml, P less than 0.001). Further analyses on a subset of IDDM cases (n = 100) indicated that initial differences in metabolic indices observed at diagnosis were no longer apparent at one-year post-diagnosis. These results suggest that the etiology of familial and sporadic IDDM is similar and that the less severe presentation observed at diagnosis in the familial cases may be due to earlier identification of the disease, reflecting increased parental knowledge of diabetic symptoms and/or frequent testing for diabetes.

Internalizing and externalizing symptoms and attributional style in youth with diabetes

The psychiatric functioning of 28 youths with insulin-dependent diabetes mellitus was examined. Measures of psychological functioning were related to age at onset, duration of diabetes, and metabolic control, as assessed by HgbAlC. Children diagnosed with insulin-dependent diabetes mellitus at a later age were considered by teachers to have more behavioral problems. Children who had better metabolic control tended to hold themselves responsible for negative events. It is worthwhile to develop interventions to teach diabetic children a realistic balance between taking appropriate responsibility for controllable negative events without taking undue blame for uncontrollable negative events associated with the disease.

Eating disorders and intentional insulin undertreatment in adolescent females with diabetes

Intentional undertreatment with insulin was found to be a common method of inducing weight loss or preventing weight gain in female adolescents with insulin-dependent diabetes mellitus (IDDM) and eating disorders. More than half of those with eating disorders intentionally omitted insulin to produce hyperglycemia and weight loss. Individuals with eating disorders were also less compliant with other aspects of IDDM management and had poorer metabolic control than the rest of the sample. It is suggested here that intentional undertreatment with insulin in some individuals with IDDM may be regarded as an equivalent to purging, with similar purpose and consequences.

A nation-wide cross-sectional study of glycosylated haemoglobin in Danish children with type 1 diabetes

A nation-wide screening for HbA1c was carried out in Denmark. Twenty-one paediatric departments treating children with Type 1 diabetes participated. During a period of 4 months 884 children were included, 93% of all those followed at these centres, representing approximately 70-80% of all children and adolescents with Type 1 diabetes in Denmark. Among the children 351 were less than or equal to 12 years and 533 were adolescents between 12 and 18 years. Children less than or equal to 12 years had a HbA1c concentration of 8.9 +/- 1.5 (+/- SD)% and an insulin dose of 0.71 +/- 0.3 U kg-1 24-h-1. For adolescents HbA1c was significantly higher 9.7 +/- 2.0% (p less than 0.001) and insulin dose significantly increased 0.85 +/- 0.3 U kg-1 24-h-1 (p less than 0.001). Normal range for HbA1c is 4.0-6.5 (mean 5.3)% of total haemoglobin. Boys and girls less than or equal to 12 years had similar HbA1c, but girls received 13% more insulin (p less than 0.001). In the group of adolescents, girls had a HbA1c 4% higher than boys (9.9 +/- 2.0 vs 9.5 +/- 2.0%, p less than 0.025), received 11% more insulin (p less than 0.001), and had 6% higher body mass index (p less than 0.001). A weak correlation was found between insulin dose and the HbA1c level (r = 0.29, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Exercise in a behavioural weight control programme for obese patients with Type 2 (non-insulin-dependent) diabetes

Two studies were conducted to determine whether adding exercise to a diet programme promotes weight loss or glycaemic control in Type 2 (non-insulin-dependent) diabetic subjects. In Study 1, 25 subjects were randomly assigned to diet plus moderate exercise or diet plus placebo exercise. All subjects exercised twice a week as a group and once a week on their own; the diet plus moderate exercise group walked a 3-mile route at each session while the diet plus placebo exercise group did very low intensity exercises such as stretching and light calisthenics. All subjects followed a calorie-counting diet and were taught behaviour modification strategies. Weight losses and improvements in glycaemic control did not differ significantly between the two treatment groups at the end of the 10-week treatment or at 1-year follow-up. In Study 2, more extreme conditions were compared: a diet only group and a diet plus exercise group. The diet plus exercise group walked a 3-mile route with the group 3 times/week and once a week on their own, while the diet only group was instructed to maintain their current low level of activity. Both groups received comparable diet and behaviour modification instruction and therapist contacts. The diet plus exercise group had significantly (p less than 0.01) better weight losses than the diet only condition at the end of the 10 week programme (-9.3 kg vs -5.6 kg) and at 1 year follow-up (-7.9 kg vs -3.8 kg).(ABSTRACT TRUNCATED AT 250 WORDS)

An epidemiologic approach to the study of retinopathy: the Pittsburgh diabetic morbidity and retinopathy studies

Diabetic retinopathy was studied in two cohorts of insulin-dependent diabetics (IDDs) from the Children's Hospital of Pittsburgh. The first cohort (n = 696) consisted of IDDs of long duration. Severe retinopathy was self-reported in 70% of this cohort by 30 years duration of diabetes. Associations between severe retinopathy, hypertension and smoking were observed. In order to examine the relationship between metabolic control and early diabetic retinopathy, a second cohort of adolescent IDDs (n = 58) were referred for standardized fluorescein angiography. Sixty-four percent had early retinopathy. None had proliferative changes. Significant differences in individual mean whole blood glycosylated hemoglobin (GHb), averaged over 3 years before angiography, were consistently seen between those with and without early retinopathy. Also, the number of microaneurysms was positively correlated with individual mean GHb. Before the advent of GHb testing, those IDDs who later had retinopathy were more likely to have experienced at least one hospitalization for diabetic ketoacidosis. These observations provide strong support that poor metabolic control preceded the development of diabetic retinopathy. Results are consistent with the hypothesis that improvement of metabolic control early in the course of IDDM may prevent or delay the development of the early changes of diabetic retinopathy.

Behaviour problems in children with diabetes as a function of sex and age of onset of disease

Twenty-seven children with early onset (less than or equal to 3 years) diabetes (EOD), 24 with late onset (greater than or equal to 4 years) diabetes (LOD) and 30 sibling controls were compared on measures of psychosocial adjustment. These included parent rating scales of behaviour problems and temperament; direct measures of self-esteem, body image and school achievement; and indices of diabetic control. Results indicated that LOD boys showed increased incidence of behaviour problems, 83% of whom could be assigned a diagnostic classification and more distortions of body image. The results were not related to any indices of diabetic control.

Puberty decreases insulin sensitivity

Puberty is commonly associated with an increase in insulin requirement in patients with insulin-dependent diabetes. To investigate whether this pubertal increase in insulin requirement is confined to diabetic subjects, we examined insulin responses during oral glucose tolerance testing with glucose loads per unit weight (1.75 g/kg) or unit surface area (55 g/m2), and insulin sensitivity via euglycemic-hyperinsulinemic clamp in prepubertal and pubertal children without diabetes. Irrespective of glucose dose, glucose tolerance testing elicited a threefold greater insulin response, but equivalent euglycemia, in pubertal versus prepubertal children (P less than 0.05). As assessed by the clamp procedure, prepubertal children were approximately 30% more sensitive than their pubertal counterparts (P less than 0.01). Insulin sensitivity correlated inversely with body mass index (r = -0.49, P less than 0.02), serum dehydroepiandrosterone sulphate concentration (r = -0.57, P less than 0.01), and log somatomedin C/insulinlike growth factor I (r = -0.45, P less than 0.05). We conclude that puberty is associated with decreased sensitivity to insulin that normally is compensated for by increased insulin secretion. Thus, in patients with insulin-dependent diabetes, an approximately 30% increase in insulin dosage should be anticipated with the onset of puberty.

Does self-monitoring of blood glucose levels improve dietary compliance for obese patients with type II diabetes?

Self-monitoring of blood glucose levels is currently being recommended for obese patients with type II diabetes to improve weight loss and glycemic control. To determine whether self-monitoring of blood glucose levels improves dietary compliance in these patients, 50 obese patients with type II diabetes were randomly assigned either to a standard behavioral weight control program or to a weight control program that included self-monitoring of blood glucose levels and focused on the weight-blood glucose relationship. Both groups lost significant amounts of weight and maintained their losses for at least one year; reductions in medication could be made for 70 percent of patients. These data suggest that the behavioral weight control used in this study may be of benefit to patients with type II diabetes. However, there was no evidence that the addition of self-monitoring of blood glucose levels to the treatment program improved the outcome in terms of weight loss, reduction in medication, dietary compliance, or mood state.

Evaluation of glycosylated hemoglobin in the management of young patients with insulin-dependent diabetes mellitus

Serial glycosylated hemoglobin (HbA1) concentrations were measured in 146 children and young adults with insulin-dependent diabetes mellitus. Patients were randomly divided into two groups. The HbA1 results were made available to the physicians and patients of group A but they were withheld from group B for 12-16 months. The groups were then alternated for an equal time period, with group A being blinded and group B unblinded. When the patients were further subdivided into those with initial HbA1 levels above or below the group mean (12.7%), it was found that the metabolic control of subjects with high HbA1 concentrations tended to improve when the values were made available and to remain unchanged when the results were withheld. Knowledge of HbA1 concentrations by physician and patient/parent appears to be beneficial in patients with relatively poor control. In contrast, no improvement was noted in patients with initial HbA1 less than 12.7% whether or not the results were available to the physician and patient/parent.

Eating disorders in female adolescents with insulin dependent diabetes mellitus

Recent case reports have suggested an association between anorexia nervosa and/or bulimia with insulin-dependent diabetes mellitus (IDDM). Fifty-eight females aged fifteen to twenty-two with IDDM for more than one year were assessed for the presence of eating disorders. Patients were screened for eating and weight pathology using the Eating Disorder Inventory (EDI) and Eating Attitudes Test-26 (EAT-26). Glycosylated hemoglobin (HbA1) was measured to assess metabolic control. Subjects who scored above the cut-off points associated with eating and weight pathology were interviewed. Clinically significant eating and weight pathology was found in 20.7 percent of the population. Of these subjects, anorexia nervosa was found in 6.9 percent and the syndrome of bulimia, based on DSM-III criteria, was found in 6.9 percent. In patients with bulimia, there was a strong inverse correlation between bulimic symptoms and metabolic control. These findings suggest that anorexia nervosa may be more common in female adolescents with IDDM than in nondiabetic populations and that bulimic symptoms may be a risk factor for poor metabolic control.

The effects of diabetes mellitus on the school attendance and school achievement of adolescents

This study examined the relationship between school absences and neuropsychological functioning in a group of adolescents who developed diabetes mellitus after the age of 5 years, and a demographically-similar group of non-diabetic teenagers. The diabetic group missed significantly more school, performed more slowly on a series of visuomotor tasks, and obtained lower scores on tests of reading, spelling, and arithmetic achievement. Multiple regression analyses demonstrated that the cognitive measures were differentially affected by the demographic and school attendance variables. Achievement test performance was best predicted by measures of school attendance, whereas visuomotor test performance was best predicted by demographic characteristics (grade and sex). These results imply that the somewhat lower scores earned by many diabetic youngsters on tests of general knowledge may have a psychosocial basis.