Individual differences and day-to-day fluctuations in goal planning and type 1 diabetes management

Acceptability and feasibility of FAMS-T1D mHealth intervention to optimize self- and social regulation for emerging adults with type 1 diabetes

BACKGROUND

Among emerging adults with type 1 diabetes (T1D), self-regulation and social regulation skills can help avoid high A1c and diabetes distress. FAMS (Family/friend Activation to Motivate Self-care) is mobile phone-delivered intervention that supports development of these skills and is efficacious among adults with type 2 diabetes. However, the acceptability and feasibility of the FAMS intervention among emerging adults with T1D are unknown.

METHODS

Therefore, we adapted FAMS for in a new disease context and developmental stage and then conducted a 3-month mixed-methods pre-post pilot study. Participants were emerging adults with T1D and a friend/family member enrolled as a support person (optional). Feasibility/acceptability outcomes and associated progression thresholds were recruitment (≥ 70% eligible emerging adults), retention (≥ 85%), intervention engagement (≥ 70%), and satisfaction (≥ 70%). We also collected qualitative feedback to determine if the intervention addressed relevant needs and explored changes in outcomes of interest (family/friend involvement, self-efficacy, self-management, distress, A1c).

RESULTS

Recruitment rates indicate recruitment of emerging adults with T1D (n = 30) and their support persons (n = 20) is feasible - 79% of emerging adults who screened as eligible enrolled and 70% of enrolled emerging adults invited a support person. Emerging adults completed 98% of coaching sessions, and response rates to automated text messages were median 85% IQR [68%, 90%]. Changes in selected measures for outcomes of interest were in expected directions suggesting sensitivity to changes occasioned by the intervention in a future evaluative trial. Emerging adults said FAMS-T1D helped with setting realistic goals, motivated them to prioritize diabetes goals, and increased support, indicating acceptability of the intervention in this new disease and developmental context.

CONCLUSIONS

Findings suggest potential for FAMS-T1D to engage emerging adults and their support persons and feasibility for an evaluative trial examining effects on self-regulation (self-efficacy, self-management), social regulation (family/friend involvement), and outcomes (diabetes distress, A1c).

TRIAL REGISTRATION

We did not register this study on ClinicalTrials.gov because the purpose of the study was to assess the feasibility and acceptability of the intervention and study procedures and measures in preparation for a future trial. The purpose of that future trial will be to evaluate the effect of the intervention on health-related biomedical and behavioral outcomes, and that trial will be registered accordingly.

Goal change and goal achievement for emerging adults across the pilot FAMS-T1D intervention for type 1 diabetes

Objective

Interventions for emerging adults (EAs) with type 1 diabetes (T1D) focus on goal setting, but little is known about how goal achievement relates to intervention outcomes. We examined how goals change, how goal achievement relates to diabetes outcomes, and identified barriers and facilitators to goal achievement.

Method

EAs with T1D (N=29, M age=21.6 years, 57% female) were coached monthly to set a behavioral goal across a 3-month feasibility trial. Coaching notes were qualitatively coded regarding type, complexity, and changes in goals. Goal achievement was measured via daily responses to texts. HbA1c, self-efficacy, diabetes distress, and self-care were assessed pre- and post-intervention.

Results

EAs frequently set food goals (79%) in combination with other goals. EAs overwhelmingly changed their goals (90%), with most increasing goal complexity. Goal achievement was high (79% of days) and not affected by goal change or goal complexity. Goal achievement was associated with increases in self-efficacy and self-care across time. Qualitative themes revealed that aspects of self-regulation and social-regulation were important for goal achievement.

Conclusion

Meeting daily diabetes goals may enhance self-efficacy and self-care for diabetes.

Practice Implications

Assisting EAs to reduce self-regulation challenges and enhance social support for goals may lead to better diabetes outcomes.

Acceptability and Feasibility of FAMS-T1D mHealth intervention to optimize self- & social regulation for emerging adults with type 1 diabetes

Background

Among emerging adults with type 1 diabetes (T1D), self-regulation and social regulation skills can help avoid high A1c and diabetes distress. FAMS (Family/friend Activation to Motivate Self-care) is mobile phone-delivered intervention that supports development of these skills and is efficacious among adults with type 2 diabetes. However, the acceptability and feasibility of the FAMS intervention among emerging adults with T1D is unknown.

Methods

Therefore, we adapted FAMS for in a new disease context and developmental stage then conducted a 3-month mixed-methods pre-post pilot study. Participants were emerging adults with T1D and a friend/family member enrolled as a support person (optional). Feasibility/acceptability outcomes and associated progression thresholds were recruitment (≥ 70% eligible emerging adults), retention (≥ 85%), intervention engagement (≥ 70%) and satisfaction (≥ 70%). We also collected qualitative feedback to determine if the intervention addressed relevant needs and explored changes in outcomes of interest (family/friend involvement, self-efficacy, self-management, distress, A1c).

Results

Recruitment rates indicate recruitment of emerging adults with T1D and their support persons is feasible - 79% of emerging adults who screened as eligible enrolled and 70% of enrolled emerging adults invited a support person. Emerging adults completed 98% of coaching sessions, and response rates to automated text messages were median 85% IQR [68%, 90%]. Changes in selected measures for outcomes of interest were in expected directions suggesting sensitivity to changes occasioned by the intervention in a future evaluative trial. Emerging adults said FAMS-T1D helped with setting realistic goals, motivated them to prioritize diabetes goals, and increased support, indicating acceptability of the intervention in this new disease and developmental context.

Conclusions

Findings suggest potential for FAMS-T1D to engage emerging adults and their support persons and feasibility for evaluation of effects on hypothesized intervention targets and outcomes in a subsequent evaluative trial.

Trial Registration

We did not register this study on clinicaltrials.gov because the purpose of the study was to assess the feasibility and acceptability of the intervention and study procedures and measures in preparation for a future trial. The purpose of that future trial will be to evaluate the effect of the intervention on health-related biomedical and behavioral outcomes and that trial will be registered accordingly.

Executive Functioning, Daily Self-Regulation, and Diabetes Management while Transitioning into Emerging Adulthood

BACKGROUND

Executive functioning (EF) predicts better Type 1 diabetes (T1D) management in the high-risk years after high school, but the daily self-regulation processes involved are unclear.

PURPOSE

To examine whether EF is associated with daily self-regulation that minimizes one's exposure or buffers adverse reactions to daily diabetes problems, and to determine whether these patterns become stronger during the transition out of high school.

METHODS

A measurement burst design with convenience sampling was used. Seniors in high school with T1D (N = 207; 66% female) completed self-report (i.e., Behavioral Rating Inventory of Executive Functioning) and performance measures of EF (i.e., Delis-Kaplan Executive Function System). A 14-day daily diary assessing self-regulation failures, diabetes problems, affect, and indicators of diabetes management was completed at baseline and 1 year later.

RESULTS

Correlations and multilevel modeling were conducted. Lower self-reported EF problems were associated with lower average levels of daily self-regulation failures, and these variables were associated with fewer daily diabetes problems. In contrast, better EF performance was unrelated to average daily self-regulation failures, and was unexpectedly associated with more frequent diabetes problems in year 2. Equally across years, on days participants reported lower than their average levels of daily self-regulation failures, they had fewer diabetes problems, regardless of EF. On days with lower than average diabetes problems, participants reported better diabetes management indicators. EF generally did not buffer daily associations in either year.

CONCLUSIONS

Regardless of EF, promoting daily self-regulation may prevent diabetes problems and promote T1D management in daily life at this high-risk transitional time.

Novel predictors of daily fluctuations in glycemia and self-management in adolescents and young adults with type 1 diabetes

AIMS

To understand morning biopsychosocial factors that predict glycemia, adherence, and goal attainment in adolescents and young adults (AYA) with type 1 diabetes (T1D) on a daily basis.

METHODS

Eight-eight AYA (mean 17.6 ± 2.6 years, 54% female, HbA1c 7.9 ± 1.4%, diabetes duration 8.5 ± 4.5 years) with T1D who use Continuous Glucose Monitoring (CGM) completed a 2-week prospective study. Participants chose a self-management goal to focus on during participation. For six days, participants prospectively completed a 25-item Engagement Prediction Survey to assess biopsychosocial factors to predict daily diabetes outcomes and an end-of-day Goal Survey. Lasso and mixed-model regression were used to determine items in the Engagement Prediction Survey most predictive of perceived goal attainment, CGM Time-in-Range (TIR, 70-180 mg/dl), sensor mean glucose, number of insulin boluses and hyperglycemia response (bolus within 30 min of high alert or glucose <200 mg/dl within 2 hours).

RESULTS

A 7-item model (including current glucose, planning/wanting to manage diabetes, wanting to skip self-management, feeling good about self, health perception and support needs) explained 16.7% of the daily variance in TIR, 18.6% of mean sensor glucose, 2.1% of the number of boluses, 14% of hyperglycemia response, and 28.7% of goal attainment perceptions. The mean absolute change in day-to-day TIR was 16%, sensor glucose was 30 mg/dl, and the number of boluses was 2. AYA reported more positive Engagement Prediction Survey responses on mornings when they awoke with lower glucose levels.

CONCLUSIONS

Morning biopsychosocial state factors predict glycemic and adherence outcomes in AYA with diabetes and could be a novel intervention target for future behavioural interventions.

'La Vida Normal': Young people adapting to Type 1 diabetes in Bolivia

OBJECTIVES

To identify challenges and coping strategies of young people with Type 1 diabetes (T1D) and their families in Bolivia through qualitative analysis of interviews with beneficiaries of Centro Vivir con Diabetes (CVCD), a diabetes health center supported by the International Diabetes Federation Life for a Child (LFAC) program.

METHODS

Eighteen young people aged 14-33 and at least one caregiver participated in semi-structured interviews in five cities in Bolivia from May to June 2016. Interviews were recorded, transcribed, and analyzed using inductive thematic analysis.

RESULTS

Participants described needing guidance at diagnosis and facing stigma in communities. Young people expressed that life with T1D was 'la vida normal' (a normal life), although interpretations of normalcy varied. For some, 'la vida normal' meant resistance to T1D; for others it indicated acceptance.

DISCUSSION

Access to interdependent spheres of support allowed young people to form a new normal around T1D. Receiving supplies through the CVCD/LFAC partnership maintained family connection to clinical care, CVCD education helped families share in T1D management, and peer support mitigated stigma for young people. Programs like CVCD that combine supply-based aid with clinical education for whole families, create effective support for young people with T1D in low- and middle-income countries.

Cognitive Function in Adolescents and Young Adults With Youth-Onset Type 1 Versus Type 2 Diabetes: The SEARCH for Diabetes in Youth Study

OBJECTIVE

Poor cognition has been observed in children and adolescents with youth-onset type 1 (T1D) and type 2 diabetes (T2D) compared with control subjects without diabetes. Differences in cognition between youth-onset T1D and T2D, however, are not known. Thus, using data from SEARCH for Diabetes in Youth, a multicenter, observational cohort study, we tested the association between diabetes type and cognitive function in adolescents and young adults with T1D (n = 1,095) or T2D (n = 285).

RESEARCH DESIGN AND METHODS

Cognition was assessed via the National Institutes of Health Toolbox Cognition Battery, and age-corrected composite Fluid Cognition scores were used as the primary outcome. Confounder-adjusted linear regression models were run. Model 1 included diabetes type and clinical site. Model 2 additionally included sex, race/ethnicity, waist-to-height ratio, diabetes duration, depressive symptoms, glycemic control, any hypoglycemic episode in the past year, parental education, and household income. Model 3 additionally included the Picture Vocabulary score, a measure of receptive language and crystallized cognition.

RESULTS

Having T2D was significantly associated with lower fluid cognitive scores before adjustment for confounders (model 1; P < 0.001). This association was attenuated to nonsignificance with the addition of a priori confounders (model 2; P = 0.06) and Picture Vocabulary scores (model 3; P = 0.49). Receptive language, waist-to-height ratio, and depressive symptoms remained significant in the final model (P < 0.01 for all, respectively).

CONCLUSIONS

These data suggest that while youth with T2D have worse fluid cognition than youth with T1D, these differences are accounted for by differences in crystallized cognition (receptive language), central adiposity, and mental health. These potentially modifiable factors are also independently associated with fluid cognitive health, regardless of diabetes type. Future studies of cognitive health in people with youth-onset diabetes should focus on investigating these significant factors.

Qualitative analysis of helpful and unhelpful aspects of social relationships among young adults with type 1 diabetes

AIMS

Young adulthood is a high-risk time for type 1 diabetes management when individuals are managing diabetes within changing social contexts and new social relationships. This qualitative study examined helpful and unhelpful aspects of social relationships in the daily lives of young adults with type 1 diabetes.

METHODS

Semi-structured qualitative interviews with 29 young adults with type 1 diabetes (ages 22-24, mean = 23 years; 55% female) explored: (a) who in the past week was present when diabetes management occurred; (b) what others did that was helpful or unhelpful for diabetes management; (c) what made helpful and unhelpful aspects of social relationships more or less likely; and (d) what young adults disclosed to others about diabetes.

RESULTS

Romantic partners and parents were commonly present and helpful in giving reminders and offering instrumental support, but the presence of trusted individuals was also helpful to management. Co-workers and friends were present during episodes of diabetes management but were often unhelpful, especially when lacking knowledge about participants' diabetes or its management. Participants also discussed conflicting and spontaneous changes in schedules were unhelpful to management. Disclosing diabetes to others and planning for social context barriers were described as strategies to facilitate helpful and reduce unhelpful aspects of social relationships.

CONCLUSIONS

Young adults face social barriers to management if they are unable to utilize their relationships effectively. Interventions to promote disclosure to trusted others and planning to avoid social context-related barriers to diabetes management may facilitate more effective self-management at this high-risk time of development.

The Role of Individual and Dyadic Planning in Couples' Daily Goal Pursuits

Planning promotes progress toward goal achievement in a wide range of domains. To date, planning has mostly been studied as an individual process. In couples, however, the partner is likely to play an important role in planning. This study tested the effects of individual and dyadic planning on goal progress and goal-related actions. Two samples of couples (N = 76 and N = 87) completed daily diaries over a period of 28 and 21 days. The results indicate that individual and dyadic planning fluctuate on a daily basis and support the idea that dyadic planning is predominantly used as a complementary strategy to individual planning. As expected, individual and dyadic planning were positively associated with higher levels of action control and goal progress. In Sample 2, dyadic planning was only associated with goal progress on days in which individuals felt that they were dependent upon their partners' behaviors to achieve their goals.

The Relationship Between Executive Functioning, Type 1 Diabetes Self-Management Behaviors, and Glycemic Control in Adolescents and Young Adults

PURPOSE OF REVIEW

Understanding barriers to self-management behaviors and glycemic stability may inform specific needs for behavior change in adolescents and young adults with type 1 diabetes (T1D). The current review aims to systematically synthesize the literature on the relationships between executive functioning, self-management, and A1C in adolescents and young adults with T1D. Fifteen studies were retained in the current review. Study quality assessment for the majority of the studies were "Fair" or "Good."

RECENT FINDINGS

This review highlights several advances in research design, including use of longitudinal designs, data from multiple informants, and use of objective measures. Adolescents and young adults reported that more executive functioning weaknesses were related to decreased self-management behaviors and higher A1C. The current review demonstrated that self-perceived executive functioning weaknesses negatively impact self-management behaviors and A1C. Future research is needed to determine the utility of objective measures in assessing the relationships between executive functioning, T1D self-management, and A1C.

Executive functioning, caregiver monitoring, and medication adherence over time in adolescents with chronic kidney disease

OBJECTIVE

The purpose of this study was to evaluate associations between executive functioning and caregiver adherence monitoring with objective antihypertensive medication adherence over 24 months in adolescents with chronic kidney disease (CKD).

METHODS

Adolescents (N = 97, 11-20 years old) with CKD taking antihypertensive medication and their caregivers were recruited from three pediatric nephrology clinics. At baseline, adolescents and caregivers reported on adolescents' executive functioning and caregivers reported on their adherence monitoring. Antihypertensive medication adherence was objectively assessed via electronic monitoring at baseline and every 6 months after for 24 months. Associations between executive functioning, caregiver monitoring, and longitudinal adherence were evaluated with linear mixed models.

RESULTS

Up to 38% of adolescents had elevated executive functioning scores indicating more severe impairments, with rates varying by scale and reporter (adolescent vs. caregiver). Caregiver monitoring showed a significant, negative association with adherence, but adolescents' executive functioning was not significantly associated with adherence. Neither variable was associated with the rate of change in adherence over time.

CONCLUSIONS

Given that adolescents' executive functioning was not associated with antihypertensive medication adherence or changes in adherence over time, adherence to daily pill-form medications may involve less cognitive effort than more complex medical regimens. Higher levels of caregiver monitoring were unexpectedly associated with lower adherence levels. This unanticipated finding may reflect increased caregiver monitoring efforts when faced with adolescents' medication nonadherence, but this finding warrants further investigation. Adolescents with CKD who are nonadherent may benefit from medication adherence-promoting strategies beyond increasing caregiver monitoring. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Executive Cognitive Functions and Behavioral Control Differentially Predict HbA1c in Type 1 Diabetes across Emerging Adulthood

OBJECTIVES

To examine the contributions of two aspects of executive functioning (executive cognitive functions and behavioral control) to changes in diabetes management across emerging adulthood.

METHODS

Two hundred and forty-seven high school seniors with type 1 diabetes were assessed at baseline and followed up for 3 years. The baseline assessment battery included performance-based measures of executive cognitive functions, behavioral control, IQ estimate (IQ-est), and psychomotor speed; self-report of adherence to diabetes regimen; and glycated hemoglobin (HbA1c) assay kits as a reflection of glycemic control.

RESULTS

Linear and quadratic growth curve models were used to simultaneously examine baseline performance on four cognitive variables (executive cognitive functions, behavioral control, IQ, and psychomotor speed) as predictors of indices of diabetes management (HbA1c and adherence) across four time points. Additionally, general linear regressions examined relative contributions of each cognitive variable at individual time points. The results showed that higher behavioral control at baseline was related to lower (better) HbA1c levels across all four time points. In contrast, executive cognitive functions at baseline were related to HbA1c trajectories, accounting for increasingly more HbA1c variance over time with increasing transition to independence. IQ-est was not related to HbA1c levels or changes over time, but accounted instead for HbA1c variance at baseline (while teens were still living at home), above and beyond all other variables. Cognition was unrelated to adherence.

CONCLUSIONS

Different aspects of cognition play a different role in diabetes management at different time points during emerging adulthood years.

The association between individual differences in executive functioning and resting high-frequency heart rate variability

Both resting high-frequency heart rate variability (HF-HRV) and executive functioning (EF) are individual differences implicated in vulnerability to a wide range of adverse outcomes. The overlapping set of associations, along with theoretical models positing connections between the brain regions subserving the executive functions and the parasympathetic nervous system, suggest that the two factors should be correlated. Seeking to address limitations in prior research, the current study examined the association between EF, measured comprehensively with individually-administered neuropsychological tests and controlling for lower-order cognitive processes, and resting physiology, measured with impedence cardiography, in healthy, community participants (68% female; mean age = 27, SD = 6.5). Results confirmed a significant association between EF and resting HF-HRV, but no association with resting state sympathetic nervous system activation (pre-ejection period). These findings may inform future investigation of transdiagnostic mechanisms related to these two individual difference factors.

The effect of type 1 diabetes on the developing brain

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues.

Self- and Social-Regulation in Type 1 Diabetes Management During Late Adolescence and Emerging Adulthood

PURPOSE OF REVIEW

This paper aims to examine how self-regulation (i.e., cognition, emotion) and social-regulation (i.e., parents, friends, romantic partners) are interrelated risk and protective factors for type 1 diabetes management during late adolescence and emerging adulthood.

RECENT FINDINGS

Problems in cognitive (e.g., executive function) and emotional (e.g., depressive symptoms) self-regulation are associated with poorer management, both at the between- and within-person levels. Better management occurs when parents are supportive and when individuals actively regulate the involvement of others (e.g., seek help, minimize interference). Friends both help and hinder self-regulation, while research on romantic partners is limited. Facets of self- and social-regulation are important risk and protective factors for diabetes management during emerging adulthood. At this time when relationships are changing, the social context of diabetes may need to be regulated to support diabetes management. Interventions targeting those with self-regulation problems and facilitating self- and social-regulation in daily life may be useful.