Patterns of self-management in pediatric type 1 diabetes predict level of glycemic control 2 years later

Association Between Psychosocial Acuity and Glycemic Control in a Pediatric Type 1 Diabetes Clinic

PURPOSE

The purpose of this study was to describe the frequency of psychosocial risk and its associations with glycemic levels in youth with type 1 diabetes (T1D) seen by social work staff during regular clinical care.

METHODS

A retrospective longitudinal analysis of observational clinical data was conducted. Individuals (1-26 years) with known T1D who were seen at a pediatric diabetes clinic in a US academic medical center between 2014 and 2021 were included. Variables included psychosocial acuity, A1C, and demographic characteristics. Chi-square tests, Wilcoxon rank sum tests, and mixed linear regressions were used to examine associations between demographic variables, psychosocial acuity, and A1C.

RESULTS

Of 966 patients, 513 (53.1%) were male, 76 (7.9%) were non-Hispanic Black, and 804 (83.2%) were non-Hispanic White. There was a mean of 6.9 annual social work encounters per patient, with 3 psychosocial domains measured at each visit. Results showed that as psychosocial acuity level increased, glycemic control decreased. There were significant differences in A1C according to race/ethnicity, insurance, age, and psychosocial acuity.

CONCLUSIONS

In a real-world clinical population, psychosocial acuity was associated with glycemic control. Presenting for psychosocial issues in their diabetes clinic was associated with reduced glycemic control among youth with T1D. There is an opportunity to connect pediatric patients with appropriate mental health services and psychosocial supports.

Mediterranean diet adherence and glycemic control in children and adolescents with type 1 diabetes

To effectively manage type 1 diabetes (T1D) insulin is essential, with dosages based on lifestyle. The Mediterranean diet has demonstrated its advantages in preventing and enhancing the management of chronic diseases. Our objective was to investigate the potential mediation of sensor activity on the relationship between adherence to the Mediterranean diet and glycemic control in children and adolescents. A total of 150 children and adolescents (mean age = 13.09, SD = 3.54; 44% female) with T1D were recruited. Adherence to the Mediterranean diet was assessed using the KIDMED questionnaire which evaluates 16 items and gives higher scores when adherence is higher. Glycemic control and the duration of sensor activity were evaluated with data from flash glucose monitoring. The data confirmed our hypothesis by revealing that adherence to the Mediterranean diet positively influenced glycemic control (direct effect = 1.505; P < 0.01) and that this relationship was mediated by the duration of sensor activity (indirect effect = 0.531; P < 0.01).  Conclusions: Our results support the increased utilization of glycemic control devices, as they contribute to improve glycemic control and mediate on the positive relationship between adherence to the Mediterranean diet and adequate glycemic control. Furthermore, our findings highlight the importance of incorporating Mediterranean diet recommendations to achieve better glycemic control in children and adolescents with T1D. What is Known: • The Mediterranean diet and glycemic control have proven benefits in improving cardiovascular health in the general population. Scarce evidence exists of these benefits among children and adolescents with T1D. What is New: • Adherence to the Mediterranean diet and greater use of glucose monitoring devices in children and adolescents with T1D are related to better glycemic control. These variables can be enhanced by psychoeducational interventions such as structured diabetes education programs or peer group-based sessions, which highlights the importance of focusing on these aspects.

Featured Article: Comparison of Diabetes Management Trajectories in Hispanic versus White Non-Hispanic Youth with Type 1 Diabetes across Early Adolescence

OBJECTIVE

Ethnic minority youth with type 1 diabetes (T1D) often have poorer glycemic control and lower rates of adherence compared to White Non-Hispanic (WNH) youth. Variables such as family conflict, autonomy support, and youth regimen responsibility have been shown to change over adolescence and impact diabetes management. However, these factors have been investigated in predominantly White samples. Few studies have examined potential differences in these variables and their trajectories for Hispanic youth over early adolescence.

METHODS

Youth with T1D (178 WNH and 33 Hispanic youth participants), as well as their maternal caregivers (174 WNH and 32 Hispanic maternal caregivers), completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency at 4 timepoints over a 3-year period.

RESULTS

At baseline, Hispanic youth had significantly poorer glycemic control, more family conflict, and fewer blood glucose checks on average compared to WNH youth. Similar to WNH youth, Hispanic youth have increasing independence for regimen tasks and decreasing parent autonomy support during this developmental period. However, while Hispanic youth had worsening diabetes management during early adolescence (as did WNH youth), Hispanic parents reported a more gradual change in youth's diabetes management over early adolescence.

CONCLUSIONS

This study presents an important contribution to the existing literature on youth with T1D. Findings suggest potential strengths and targets for Hispanic youth navigating diabetes management during the adolescent period. It is important to continue to investigate the trajectories of ethnic minority youth with diabetes.

Psychological Considerations in Pediatric Chronic Illness: Case Examples

Despite significant gains in survival rates for pediatric patients and adolescents/young adults (AYA) with chronic illness, patients in this vulnerable age group are also at an increased risk for developing one or more adverse effects related to their disease, treatment, or maladaptive health behaviors. Maladaptive health behaviors ultimately increase the risk for developing adverse effects, including: increased rates of morbidity and mortality, impaired physical functioning, increased fatigue, obesity, increased psychological distress, and poor quality of life. With close attention including participation in preventive and therapeutic health promotion interventions, problematic health behaviors can be mitigated and ultimately prevented over time. It is well known that improved psychological functioning and adaptive coping can result in improved health status. The present paper provides four case examples illustrating various psychological interventions in pediatric chronic illness. As evidenced in the four case examples, pediatric psychologists provide comprehensive interventions for patients with acute and chronic medical conditions through the use of health promotion interventions, adherence and self-management promotion, cognitive behavioral therapy, behavioral therapy, medical coping, parent training, and motivational interviewing. Our case series demonstrates that for the most impactful behavior change to occur, a combination of interventions is often the most effective.

Patients with diabetes observing Ramadan: The experience of Muslims in the United States

BACKGROUND AND PURPOSE

Little is known about the experience of Muslims with diabetes while fasting during Ramadan in the United States. Providing quality care for Muslim patients requires being aware of Islamic beliefs and practices, particularly in regard to healthcare ramifications. Therefore, the aims of this study were to (a) explore the beliefs which influence the experience and practices of diabetes management among Muslims in the United States during Ramadan, and (b) explore perspectives of Muslims with diabetes on their experience with healthcare providers providing support during their fasting experience.

METHODS

Using an exploratory design, semi-structured interviews were conducted for qualitative analyses. A purposive sample of 14 Muslim patients with diabetes was recruited from mosques located across North Carolina.

RESULTS

Analyses revealed six subthemes on their "feelings" that were inherent to their experiences of managing diabetes while fasting during Ramadan. These were organized into two main themes: (1) having diabetes and fasting during Ramadan and (2) fasting challenges. Having diabetes and fasting during Ramadan focused on the experience of fasting and comprised four "feelings": (1) feeling spiritually connected, (2) feeling socially connected, (3) feeling physically healthy, and (4) feeling religiously obligated. The second theme focused on fasting challenges and included (1) feeling sick and dehydrated, and (2) feeling vulnerable and poorly understood by healthcare providers.

CONCLUSION

This is the first known study to explore the experience of Muslims with diabetes while fasting during Ramadan in the United States. Our findings offer important insights into how Muslims manage their diabetes while fasting and the missed opportunities for relevant conversations when partnering with healthcare providers during Ramadan. The importance of cultural competency across healthcare systems in the United States cannot be overemphasized. Healthcare providers need to hold conversations embracing shared decision-making to resolve healthcare dilemmas resulting from cultural differences, expand cultural knowledge, and adapt services to meet culturally-unique needs of their patients.

Autonomy support and responsibility-sharing predict blood glucose monitoring frequency among youth with diabetes

OBJECTIVE

Adolescence poses a number of special challenges for youth and their families managing the Type 1 diabetes medical regimen. Little is known on how family and youth factors and management of the regimen change over the course of early adolescence and predict adherence to the regimen during this developmental period.

METHODS

Youth with Type 1 diabetes (n = 239) and their maternal caregivers completed measures of diabetes-specific autonomy support, diabetes-related family conflict, regimen responsibility, and blood glucose monitoring frequency (BGMF) at 4 timepoints over a 3-year period.

RESULTS

Autonomy support and BGMF significantly decreased over time and responsibility for the diabetes regimen shifted from the caregiver toward youth over time. Significant changes in perceived family conflict over time differed depending on the reporter. Baseline BGMF, changes in caregiver autonomy support, and changes in responsibility for the regimen significantly predicted changes in BGMF over time.

CONCLUSIONS

This study documents changes in autonomy support, youth responsibility for the diabetes regimen, and BGMF during the transition into early adolescence. Higher levels of caregiver autonomy support preserve BGMF during a developmental period in which BGMF typically deteriorates.

The Relationship between Self-Management and Glycemic Control in a Cohort of Children with Type 1 and Type 2 Diabetes

AIM

Self-management of diabetes improves glycemic control. The development of a quick, objective questionnaire in the clinic setting may provide data to the clinician caring for the patient in overall evaluation.

OBJECTIVE

We developed a 23 question tool (clinic preparedness score) and administered it to type 1 and 2 (T1DM & T2DM) diabetes patients. Clinicians of patients were surveyed to determine their perception of adherence by patients. A total of 350 T1DM patients and families and 137 T2DM families were administered the questionnaire. Additionally, HbA1C was correlated to the various parameters that are related to improved glycemic control such as having a meter, carrying glucose tablets for hypoglycemia, and downloading/ writing blood sugars in log book in T1DM and T2DM.

RESULTS

T1DM subjects had a lower HbA1C with better clinic preparedness (8.2 ± 1.3 vs. 9.4 ± 1.9%) However, this did not hold true for T2DM (p NS). If T1DM subjects adjusted their insulin dose and reported that their parent was involved they had better HbA1C than those that did not change insulin dose and if parent was uninvolved in the care. Clinicians of patients were able to accurately predict that appropriate dose adjustments resulted in good glycemic control.

CONCLUSIONS

Pediatric T2DM adherence measures do not mirror similar characteristics of T1DM in childhood. The variability in glucose monitoring, medication and insulin administration may affect T2DM differently than T1DM.

Identification and prediction of group-based glycemic control trajectories during the transition to adolescence

OBJECTIVE

To identify trajectories of glycemic control over a period of 3 years in a pediatric sample of youth diagnosed with Type 1 diabetes transitioning to adolescence. A second aim was to examine a set of modifiable individual and family level baseline predictors of glycemic control group membership.

METHODS

This multisite, prospective study included 239 children and adolescents (ages 9-11 years at baseline) diagnosed with Type 1 diabetes and their caregivers. Glycemic control was based on hemoglobin A1c (HbA1c) collected at 6-month intervals over a period of 3 years. Predictors of glycemic control membership included baseline global executive functioning, diabetes self-management, diabetes-specific family conflict, blood glucose monitoring frequency, and relevant individual and family level covariates.

RESULTS

Group-based trajectory analyses were used to describe patterns of glycemic control from baseline to 36 months and 3 trajectories were identified: low risk (42.9%), elevated risk (44.6%), and high risk (12.1%) subgroups. Baseline maternal-reported family conflict, blood glucose monitoring frequency, and gender were significant predictors of glycemic control group membership. Higher levels of baseline family conflict, lower frequency of blood glucose monitoring, and female gender were associated with elevated and high-risk group membership.

CONCLUSIONS

These findings underscore the importance of examining trajectories of HbA1c across time. These results suggest that problematic trajectories of glycemic control are evident during the transition to adolescence. Furthermore, there are modifiable individual and family level characteristics that predict group membership and hence could be targeted in interventions to ensure adequate glycemic control is maintained over time and that risks for diabetes-related complications are reduced.