Adherence in adolescents with Type 1 diabetes: strategies and considerations for assessment in research and practice

Device-Related Skin Reactions Increase Emotional Burden in Youths With Type 1 Diabetes and Their Parents

BACKGROUND

Skin reactions due to technological devices pose a significant concern in the management of type 1 diabetes (T1D). This multicentric, comparative cross-sectional study aimed to assess the psychological impact of device-related skin issues on youths with T1D and their parents.

METHODS

Participants with skin reactions were matched in a 1:1 ratio with a control group. Diabetes-related emotional distress was evaluated using the Problem Areas in Diabetes-Teen version (PAID-T) for participants aged 11 to 19 years and the Problem Areas in Diabetes-Parent Revised version (PAID-PR) completed by parents. In addition, glucose control was assessed through glycated hemoglobin (HbA1c) values and continuous glucose monitoring (CGM) metrics.

RESULTS

A total of 102 children and adolescents were consecutively recruited. Adolescents with skin issues had higher PAID-T scores compared to those without (79.6 ± 21.1 vs 62 ± 16.8; P = .004). Parents of youths with skin reactions also reported higher PAID-PR scores than the control group (34.0 ± 11.0 vs 26.9 ± 12.3; P = .015). No differences were observed in HbA1c levels (6.9 ± 0.8% vs 6.8 ± 0.8%, P = .555) or CGM glucose metrics between the two groups. Remarkably, 25.5% were forced to discontinue insulin pumps and/or glucose sensors (21.5% and 5.9%, respectively).

CONCLUSIONS

Our study highlighted the increased emotional burden experienced by youths with T1D and their parents due to device-related skin reactions, emphasizing the need for further research and interventions in this crucial aspect of diabetes management.

Evaluating usability of and satisfaction with mHealth app in rural and remote areas-Germany GIZ collaboration in Bosnia-Herzegovina to optimize type 1 diabetes care

Background

Type 1 diabetes mellitus (T1DM) management in children and adolescents requires intensive supervision and monitoring to prevent acute and late diabetes complications and to improve quality of life. Digital health interventions, in particular diabetes mobile health apps (mHealth apps) can facilitate specialized T1DM care in this population. This study evaluated the initial usability of and satisfaction with the m-Health intervention Diabetes: M app, and the ease of use of various app features in supporting T1DM care in rural and remote areas of Bosnia-Herzegovina with limited access to specialized diabetes care.

Methods

This cross-sectional study, performed in February-March 2023, evaluated T1DM pediatric patients who used the Diabetes: M app in a 3-month mHealth-based T1DM management program, along with their parents and healthcare providers (HCPs). All participants completed self-administered online questionnaires at the end of the 3-month period. Data were analyzed by descriptive statistics.

Results

The study population included 50 T1DM patients (children/parents and adolescents) and nine HCPs. The mean ± SD age of the T1DM patients was 14 ± 4.54 years, with 26 (52%) being female. The mean ± SD age of the HCPs was 43.4 ± 7.76 years; all (100%) were women, with a mean ± SD professional experience of 17.8 ± 8.81 years. The app was reported usable in the domains of ease-of-use and satisfaction by the T1DM children/parents (5.82/7.0), T1DM adolescents/young adults (5.68/7.0), and HCPs (5.22/7.0). Various app features, as well as the overall app experience, were rated positively by the participants.

Conclusion

The results strongly support the usability of mHealth-based interventions in T1DM care, especially in overcoming care shortage and improving diabetes management and communications between HCPs and patients. Further studies are needed to compare the effectiveness of apps used to support T1DM management with routine care.

Sustained Effectiveness of an Advanced Hybrid Closed-Loop System in a Cohort of Children and Adolescents With Type 1 Diabetes: A 1-Year Real-World Study

OBJECTIVE

To investigate glucose metrics and identify potential predictors of the achievement of glycemic outcomes in children and adolescents during their first 12 months of MiniMed 780G use.

RESEARCH DESIGN AND METHODS

This multicenter, longitudinal, real-world study recruited 368 children and adolescents with type 1 diabetes (T1D) starting SmartGuard technology between June 2020 and June 2022. Ambulatory glucose profile data were collected during a 15-day run-in period (baseline), 2 weeks after automatic mode activation, and every 3 months. The influence of covariates on glycemic outcomes after 1 year of MiniMed 780G use was assessed.

RESULTS

After 15 days of automatic mode use, all glucose metrics improved compared with baseline (P < 0.001), except for time below range (P = 0.113) and coefficient of variation (P = 0.330). After 1 year, time in range (TIR) remained significantly higher than at baseline (75.3% vs. 62.8%, P < 0.001). The mean glycated hemoglobin (HbA1c) over the study duration was lower than the previous year (6.9 ± 0.6% vs. 7.4 ± 0.9%, P < 0.001). Time spent in tight range (70-140 mg/dL) was 51.1%, and the glycemia risk index was 27.6. Higher TIR levels were associated with a reduced number of automatic correction boluses (P < 0.001), fewer SmartGuard exits (P = 0.021), and longer time in automatic mode (P = 0.030). Individuals with baseline HbA1c >8% showed more relevant improvement in TIR levels (from 54.3% to 72.3%).

CONCLUSIONS

Our study highlights the sustained effectiveness of MiniMed 780G among youth with T1D. Findings suggest that even children and adolescents with low therapeutic engagement may benefit from SmartGuard technology.

Adolescents and type 1 diabetes: A grounded theory on adolescents' experiences of adaptation to type 1 diabetes

PURPOSE

Type 1 diabetes influences adolescents' health status and therapeutic management. Adaptation for adolescents with type 1 diabetes is considered a significant issue for this cohort group and is based on many factors, including availability of resources, and family and community support. Thus, this study aimed to explore Palestinian adolescents' experiences of adaptation to type 1 diabetes in the West Bank.

DESIGN AND METHODS

A qualitative grounded theory approach was adopted. The purposive sample consisted of fourteen adolescents aged from 12 to 18 years and diagnosed with type 1 diabetes. The data were collected using semi-structured and face-to-face individual interviews during the period from March to June 2023. A constant comparative method was used to analyze data.

FINDINGS

The core category had emerged with categories and subcategories. There were three categories and ten subcategories including difficulties in the management of type 1 diabetes, for example, "insulin injections, dietary management, and control of HbA1c levels", burdens of type1 diabetes, for example, "burden regarding follow-up treatment, the burden of interaction and communication, emotional burden, and economic burden", and fears and worries of unexpected future life, for example, "worries about disease complications, worries regarding social relationships, and worries about marriage and parenthood".

CONCLUSION

Adolescents diagnosed with type 1 diabetes suffer from difficult experiences influencing their adaptation to this disease.

PRACTICE IMPLICATIONS

Counseling programs concerning self-care management for those adolescents need to be developed in addition to support programs. Health education programs are needed to develop their adaptation and coping skills to these experiences.

Determinants of adherence to insulin and blood glucose monitoring among adolescents and young adults with type 1 diabetes in Qatar: a qualitative study

Background

Adherence to insulin and blood glucose monitoring (BGM) is insufficient in adolescents and young adults (AYAs) with type 1 diabetes (T1D) worldwide and in Qatar. Little is known about the factors related to being aware of suboptimal adherence and the beliefs related to suboptimal adherence in this group. This qualitative study investigated factors related to awareness of, and beliefs about suboptimal adherence, as well as the existence of specific action plans to combat suboptimal adherence using the I-Change model.

Methods

The target group was comprised of 20 Arab AYAs (17-24 years of age) with T1D living in Qatar. Participants were interviewed via semi-structured, face-to-face individual interviews, which were audio-recorded, transcribed verbatim, and analyzed using the Framework Method.

Results

Suboptimal adherence to insulin, and particularly to BGM, in AYAs with T1D was identified. Some AYAs reported to have little awareness about the consequences of their suboptimal adherence and how this can adversely affect optimal diabetes management. Participants also associated various disadvantages to adherence ( e.g., hypoglycemia, pain, among others) and reported low self-efficacy in being adherent ( e.g., when outside home, in a bad mood, among others). Additionally, goal setting and action-planning often appeared to be lacking. Factors facilitating adherence were receiving support from family and healthcare providers, being motivated, and high self-efficacy.

Conclusions

Interventions that increase awareness concerning the risks of suboptimal adherence of AYAs with T1D are needed, that increase motivation to adhere by stressing the advantages, creating support and increasing self-efficacy, and that address action planning and goal parameters.

The associations between physical activity, health-related quality of life, regimen adherence, and glycemic control in adolescents with type 1 diabetes: A cross-sectional study

BACKGROUND

Adolescents with Type 1 Diabetes (T1D) display a greater than two-fold higher risk of developing diabetes-related complications compared with their healthy peers and the risk increases markedly as glycated hemoglobin (HbA1c) increases. The majority of the known factors associated with improved glycemic control in adolescents with T1D are geared toward Western populations. Therefore, this study examined the associations between Physical Activity (PA), Health-Related Quality of Life (HRQoL), and regimen adherence on glycemic control in a Middle Eastern population of adolescents with T1D METHODS: The study utilized a cross-sectional design of Jordanian adolescents (aged 12-18) with T1D (n = 74). Self-reported measures used were the Pediatric Quality of Life-Diabetes Module, the International Physical Activity Questionnaire, and the Summary of Diabetes Self-Care Activities. HbA1c values were obtained from the medical records. Correlation analyses were conducted using Pearson's and Spearman's correlation tests. Multiple regression analyses were conducted to determine if HRQoL, PA, and regimen adherence predict glycemic control.

RESULTS

Only 14.8 % of the participants demonstrated good glycemic control (HbA1c ≤ 7.5 %). Participants with poor control had a statistically significant lower mean PA of MET-minutes/week (3531.9 ± 1356.75 vs. 1619.81 ± 1481.95, p < .001) compared to those with good control. The total sample was found to demonstrate low HRQoL (47.70 ± 10.32). Participants were within the acceptable range of PA (1885.38 ± 1601.13) MET-minutes/week. HbA1c significantly inversely correlated with PA (r = -0.328, p = .010) and regimen adherence (r = -0.299, p = .018). The regression analysis revealed that PA significantly predicted glycemic control (β = -0.367, p < .01) as adherence (β = -0.409, p < .01) and disease duration did (β = 0.444, p < .01).

CONCLUSION

Better glycemic control was significantly associated with higher PA and regimen adherence levels. The correlation between PA and glycemic control depends highly on the level of regimen adherence or arguably, adherence acts as a buffer in the correlation between PA and glycemic control. There was no significant association between glycemic control and HRQoL.

Adherence as a Predictor of Glycemic Control Among Adolescents With Type 1 Diabetes: A Retrospective Study Using Real-World Evidence

PURPOSE

Metabolic control among adolescents with type 1 diabetes mellitus (T1DM) is generally poor. Nonadherence is a contributor to this poor glycemic control, leading to adverse outcomes. The findings of studies reporting the association between adherence and glycemic control are conflicting. This study aimed to assess the level of adherence among adolescents with T1DM and its relationship with glycemic control.

METHODS

This was a retrospective, cross-sectional study that was conducted at Sidra Medicine, a state-of-the-art tertiary health care facility for women and children in Qatar. Mean blood or interstitial glucose monitoring frequency (BGMF) was used to assess adherence level among adolescents with T1DM, whereas glycemic control was assessed via documented glycated hemoglobin A_1c (HbA_1c). Adolescents who had a mean BGMF of ≥4 checks per day were considered adherent, and those who had an HbA_1c level of <7% were considered as having controlled diabetes. Correlational and logistic regression analyses were performed to assess the relationship between adherence and glycemic control, incorporating other covariates into the model.

FINDINGS

The rate of adherence among adolescents with T1DM in Qatar was 40.9%. Adherent adolescents had significantly lower median HbA_1c levels compared with nonadherent adolescents (9.0% vs. 9.7%; P = 0.002). A significant negative correlation was found between BGMF and HbA_1c level (correlation coefficient r_s = -0.325; P < .001). Approximately 97% of nonadherent adolescents compared with 87% of adherent adolescents had suboptimal diabetes control (HbA_1c ≥7%) (P = .016). Furthermore, nonadherent adolescents were 78% less likely to have controlled diabetes compared with adherent adolescents (adjusted odds ratio = 0.221; 95% CI, 0.063-0.778; P = 0.019). The combined effect of the determinants of glycemic control among adolescents with T1DM that were included in the multiple regression model was able to explain approximately 9% of the variances in glycemic control (Cox and Snell R² = 0.092).

IMPLICATIONS

The current findings suggest that nonadherence was highly prevalent among adolescents with T1DM and was a significant independent predictor of glycemic control, explaining 9% of the variability. This finding warrants further exploration of other possible predictors of poor glycemic control among the adolescent population. Comprehensive interventions, including educational, technological, and health service delivery aspects, aimed at improving adherence and ultimately optimizing glycemic control are warranted in adolescents with T1DM.

Determinants of healthful eating and physical activity among adolescents and young adults with type 1 diabetes in Qatar: A qualitative study

BACKGROUND

In Qatar, as in the rest of the world, the sharp rise in the prevalence of type 1 diabetes (T1D) is a leading cause for concern, in terms associated with morbidity, mortality, and increasing health costs. Besides adhering to medication, the outcome of diabetes management is also dependent on patient adherence to the variable self-care behaviors including healthful eating (HE) and physical activity (PA). Yet, dietary intake and PA in adolescents and young adults (AYAs) with T1D are known to fall short of recommended guidelines. The aim of this study was to develop an in-depth understanding of the behavioral determinants of HE and PA adherence among Arab AYAs within the age range of 17-24 years with T1D attending Hamad General Hospital.

METHODS

Semi-structured, face-to-face individual interviews were conducted with 20 participants. Interviews were based on an integrative health behavior change model, the I-Change model (ICM). All interviews were audio-recorded, transcribed verbatim, and analyzed using the framework method.

RESULTS

More participants reported non-adherence than adherence. Several motivational determinants of adherence to HE and PA were identified. The majority of participants were cognizant of their own behaviors towards HE and PA. Yet, some did not link low adherence to HE and PA with increased risks of health problems resulting from T1D. Facilitators to adherence were identified as being convinced of the advantages of HE and PA, having support and high self-efficacy, a high level of intention, and a good health care system.

CONCLUSION

The suboptimal adherence in AYAs to HE and PA needs more attention. Supportive actions are needed to encourage adherence to a healthy lifestyle to achieve benefits in terms of glycemic control and overall health outcomes, with a special focus on adolescents. Interventions are needed to foster motivation by addressing the relevant determinants in order to promote adherence to these two behaviors in AYAs with T1D.

Goal-based measurement in paediatric settings: implications for practice

There is an observed link between physical illness and mental health difficulties and an increased likelihood of mental health difficulties in young people with chronic health conditions. The main outcome focus in paediatric settings is on physical health outcomes and functioning. In terms of functioning, the focus is on quality of life, measures of emotional well-being and perceptions of personal change, which are likely to be multifaceted and vary between patients. To complement standardised and diagnostically based measures, goal-based outcome measurement may be considered. The aim of this paper is to build on previous research, to provide a reflective commentary based on the authors' clinical and research experience in the use and interpretation of goal-based outcomes, to address what using goal-based measures for outcome purposes in these settings means practically. Examples are provided to demonstrate the importance of considering meaningful outcomes of importance to young people and how professionals may presume that physical 'recovery' is the goal of treatment, but what recovery means to that young person may be very nuanced. Further key considerations and suggested phrasing are given to introduce and work with young people's goals.

Socio-cognitive determinants affecting insulin adherence/non-adherence in late adolescents and young adults with type 1 diabetes: a systematic review protocol

Objective

This systematic review aims to investigate the key socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D.

Methods

A pre-specified search strategy will be used to search for studies in the electronic databases and citation indexes: PubMed, EMBASE, Web of Science, and PsycINFO. Two researchers will screen the title and the abstract independently, then will read and critically appraise the full text of each included study. A third independent reviewer will resolve disagreements in data extraction until consensus. Data will be extracted using the Population, Exposure, Outcomes, Study characteristics framework. Study selection will follow the updated guideline for reporting systematic reviews (PRISMA 2020) and will take place from 15 October 2021 to 1 January 2022. The methodological quality and risk of bias of the observational studies will be assessed by the JBI Critical Appraisal Checklist for Cohort and JBI Critical Appraisal Checklist for Analytical Cross Sectional Studies.

Results

A qualitative narrative synthesis will present the characteristics and the quality of studies and the outcomes of concern.

Conclusion

Based on the contemporary literature, this review will synthesize the evidence on the socio-cognitive determinants associated with adherence/non-adherence to insulin treatment in late adolescents and young adults in the age range of 17–24 years with T1D. The findings will help design patient-centered interventions to promote adherence to insulin in this age group, guide patients’ consultations and diabetes self-management education (DSME) programs.

Protocol registration: PROSPERO ID: CRD42021233074.

Adherence to Diabetes Self-Management and Its Associated Factors Among Adolescents Living with Type 1 Diabetes at Public Hospitals in Addis Ababa, Ethiopia: A Cross-Sectional Study

Objective

The purpose of this study was to determine the level of adherence to diabetes self-management and associated factors among adolescents living with type 1 diabetes at Public Hospitals in Addis Ababa, Ethiopia.

Methods

An institutional-based cross-sectional study was carried out among 422 adolescents with type 1 diabetes attending outpatient diabetic clinics at public hospitals in Addis Ababa. The adolescents were interviewed using pretested questionnaires to give information on adherence to diabetes self-management. A variable that has a P-value of <0.2 in bi-variable logistic regression analysis was subjected to multivariable logistic regression analysis to control the confounding factors. The level of significance was pronounced at P-value <0.05.

Results

In this study, a total of 414 adolescents living with type 1 diabetes were interviewed making a 98.1% response rate. About 218 participants (52.7%) had poor adherence to overall diabetes self-management. Self-efficacy (AOR=8.7, 95% CI:1.9-14.1, P=0.005), social support (AOR=4.6, 95% CI:1.5-13.5, P=0.006), age (AOR=0.2, 95% CI:0.1-0.4, P=0.001), good knowledge of the disease (AOR=9.046, 95% CI:3.83-13.5, P=0.000), moderate knowledge (AOR=6.763, 95% CI:2.18-12.921, P=0.001), and time since diagnosis of type 1 diabetes (AOR=0.1, 95% CI:0.02-0.2, P=0.005) were significantly associated with adherence to diabetes self-management.

Conclusions and Recommendations

More than half of this population had poor adherence to diabetes self-management. The finding suggested that implementing a comprehensive guideline of adherence and expanding the recurrence of follow-up visits could be important for this population.

Liraglutide pharmacokinetics and exposure-response in adolescents with obesity

BACKGROUND

Obesity in adolescence presents a major public health challenge, often leading to obesity in adulthood with associated chronic disease.

OBJECTIVES

This study aimed to perform a population pharmacokinetic and exposure-response analysis of liraglutide by meta-analysis of data from trials conducted in children, adolescents and adults with obesity.

METHODS

The population pharmacokinetic analysis investigated the effect of covariates body weight, age group (children, adolescents and adults) and sex on liraglutide exposure in adolescents compared with previous results in adults. The exposure-response relationship of liraglutide for the change from baseline in body mass index standard deviation score (BMI SDS) was evaluated in adolescents and compared to that in adults.

RESULTS

Body weight was the main covariate affecting liraglutide exposure, with lower exposures at higher body weights, whereas age group was of no importance and sex was of little importance. An exposure-response relationship was demonstrated for liraglutide in both adolescents and adults as the decrease in BMI SDS from baseline increased in an exposure-dependent manner with increasing liraglutide exposure.

CONCLUSIONS

The population pharmacokinetic analysis supported similar liraglutide exposures in adolescents and adults; body weight was the most important covariate affecting exposure. An exposure-response relationship was established for liraglutide.

Quality of Life Differences in Pre- and Post-Educational Treatment in Type 1 Diabetes Mellitus During COVID-19

Purpose

The coronavirus-19 (COVID-19) pandemic requires the use of online media to ensure monitoring of type 1 diabetes mellitus (T1DM) in children. Thus, this study aims to determine whether online education effectively improves the quality of life (QoL) in children with T1DM during the coronavirus-19 pandemic.

Patients and Methods

The study, conducted from March to October 2020, utilized the paired t-test before and after online education. Moreover, it adopts the recommended Pediatric Quality of Life Inventory (PedsQL) 3.2 diabetes module for the 33 patients registered in the Pediatric Endocrine Outpatient Clinic of Dr. Soetomo Hospital, Surabaya, Indonesia.

Results

The QoL of all children (p = 0.011), parents (p = 0.001), and both children and parents (overall; p = 0.002) have shown significant improvement after the treatment. The QoL of parents, as a subcriterion, improved after the treatment. However, the improvement in the children in subcriterion treatment II (p = 0.186) was not significant.

Conclusion

Online education has proven to create a better QoL almost in all children with T1DM during the coronavirus-19 pandemic.

Efficacy of a glucose meter connected to a mobile app on glycemic control and adherence to self-care tasks in patients with T1DM and LADA: a parallel-group, open-label, clinical treatment trial

Objective

The main aim of the study was to evaluate the patients' glycemic control and adherence to self-care tasks.

Methods

Patients with type 1 diabetes mellitus (T1DM) or latent autoimmune diabetes of the adult (LADA) using a multiple daily injection (MDI) regimen with carbohydrate counting (n = 25, Subgroup B) or fixed insulin dose (n = 25, Subgroup C) were allocated to use the application (app) for 12 weeks. Both subgroups were compared with each other and against a control group (n = 25, Group A) comprising patients with T1DM or LADA treated with continuous subcutaneous insulin infusion (CSII) in a parallel-group, open-label, clinical treatment trial. All patients had glycated hemoglobin (A1C) levels measured and were asked to fill out the Diabetes Self-Management Profile (DSMP) questionnaire at study start and end. The patients were instructed to measure capillary glucose six times daily in study weeks 4, 8, and 12.

Results

Mean A1C levels decreased 0.725% in Subgroup C in intragroup analysis (p = 0.0063), and had a mean variation of 0.834% compared with Group A (p = 0.003). Mean DSMP scores increased 5.77 points in Subgroup B in intragroup analysis (p = 0.0004) and increased by a mean of 6.815 points in relation to Group A (p = 0.002).

Conclusion

OneTouch Reveal improved both A1C levels and DSMP scores in patients with T1DM or LADA compared with standard treatment (CSII).

Assessment of Selected Aspects of the Quality of Life of Children with Type 1 Diabetes Mellitus in Poland

Type 1 diabetes mellitus (T1D) is, next to obesity and asthma, the most common chronic disease in children in Poland. T1D is not only a medical challenge, but it also affects all areas of a sick child's life and family functionality. New forms of therapy facilitate the daily management of the disease, but their availability is limited and partly dependent on socioeconomic status. This study aimed to assess the incidence and interrelationships between the child's health condition and the applied therapy model, and selected aspects of the child's family functionality and access to health and care services. The survey involved 206 child and youth caregivers with T1D who are members of Facebook support groups. The analysis of the obtained results revealed the existence of links between family income level and the type of insulin therapy applied. Children from families with a better financial situation (subjective and objective) were more likely to have additional medical consultations and make more frequent control visits. In families with a higher level of income, the T1D-induced restriction of child activity was less frequent. Living outside of urban centers was associated with a reduced availability of care or educational facilities adapted to take care of a child with T1D. No statistically significant correlations were observed between demographic and economic factors and the child's health status expressed by the occurrence of complications. The incidence of the latter, however, affected the child's family situation.

Barriers to Diabetes Adherence: Translation and Cultural Adaptation of the Instrument Into Arabic Context

OBJECTIVES

Barriers to Diabetes Adherence (BDA) instrument is a measure developed in English to assess barriers to adherence in adolescents with type 1 diabetes (T1DM). The main objectives of the present study were to translate and culturally adapt the BDA tool into Arabic for the assessment of barriers to adherence in adolescents with T1DM in Arabic-speaking populations.

METHODS

The International Society for Pharmacoeconomics and Outcomes Research guidelines for the translation and cultural adaptation of patient-reported outcome measures were used for the process. Permission to use the instrument was obtained from the developers. This was followed by 2 forward translations of the tool into Arabic. The 2 Arabic versions were combined into a reconciled Arabic version that was then back-translated into English. This was then tested against the original tool. The resultant Arabic version underwent a cognitive debriefing process to assess its comprehension and appropriateness among potential users, and this resulted in further refinements, leading to the final Arabic version of the tool.

RESULTS

The translation and cognitive debriefing processes revealed issues related to the cultural or conceptual equivalence of the tool that were addressed and resolved by rewording, restructuring, or addition or elimination of words or phrases that in certain circumstances necessitated communications with the developers for further clarifications of the intended meaning of relevant items. This process generated an easy, comprehensive, clear, and culturally acceptable tool as proven by the cognitive debriefing and clinical review processes.

CONCLUSION

A culturally acceptable Arabic translation of the BDA tool was developed to be used in adolescent Arabic population with T1DM.

Adolescent Interventions to Manage Self-Regulation in Type 1 Diabetes (AIMS-T1D): randomized control trial study protocol

BACKGROUND

Self-regulation (SR), or the capacity to control one's thoughts, emotions, and behaviors in order to achieve a desired goal, shapes health outcomes through many pathways, including supporting adherence to medical treatment regimens. Type 1 Diabetes (T1D) is one specific condition that requires SR to ensure adherence to daily treatment regimens that can be arduous and effortful (e.g., monitoring blood glucose). Adolescents, in particular, have poor adherence to T1D treatment regimens, yet it is essential that they assume increased responsibility for managing their T1D as they approach young adulthood. Adolescence is also a time of rapid changes in SR capacity and thus a compelling period for intervention. Promoting SR among adolescents with T1D may thus be a novel method to improve treatment regimen adherence. The current study tests a behavioral intervention to enhance SR among adolescents with T1D. SR and T1D medical regimen adherence will be examined as primary and secondary outcomes, respectively.

METHODS

We will use a randomized control trial design to test the impact of a behavioral intervention on three SR targets: Executive Functioning (EF), Emotion Regulation (ER), and Future Orientation (FO); and T1D medical regimen adherence. Adolescents with T1D (n = 94) will be recruited from pediatric endocrinology clinics and randomly assigned to treatment or control group. The behavioral intervention consists of working memory training (to enhance EF), biofeedback and relaxation training (to enhance ER), and episodic future thinking training (to enhance FO) across an 8-week period. SR and treatment regimen adherence will be assessed at pre- and post-test using multiple methods (behavioral tasks, diabetes device downloads, self- and parent-report). We will use an intent-to-treat framework using generalized linear mixed models to test our hypotheses that: 1) the treatment group will demonstrate greater improvements in SR than the control group, and 2) the treatment group will demonstrate better treatment regimen adherence outcomes than the control group.

DISCUSSION

If successful, SR-focused behavioral interventions could improve health outcomes among adolescents with T1D and have transdiagnostic implications across multiple chronic conditions requiring treatment regimen adherence.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03688919; registered September 28, 2018.

Self-Management Behaviors of Patients with Type 1 Diabetes: Comparing Two Sources of Patient-Generated Data

OBJECTIVES

This article aims to evaluate adult type 1 diabetes mellitus (T1DM) self-management behaviors (SMBs) related to exercise and alcohol on a survey versus a smartphone app to compare self-reported and self-tracked SMBs, and examine inter- and intrapatient variability.

METHODS

Adults with T1DM on insulin pump therapy were surveyed about their alcohol, meal, and exercise SMBs. For 4 weeks, participants self-tracked their alcohol, meal, and exercise events, and their SMBs corresponding with these events via an investigator-developed app. Descriptive statistics and generalized linear mixed-effect models were used to analyze the data RESULTS:  Thirty-five participants self-tracked over 5,000 interactions using the app. Variability in how participants perceived the effects of exercise and alcohol on their blood glucose was observed. The congruity between SMBs self-reported on the survey and those self-tracked with the app was measured as mean (SD). The lowest congruity was for alcohol and exercise with 61.9% (22.7) and 66.4% (20.2), respectively. Congruity was higher for meals with 80.9% (21.0). There was significant daily intra- and interpatient variability in SMBs related to preprandial bolusing: recommended bolus, p < 0.05; own bolus choice, p < 0.01; and recommended basal adjustment, p < 0.01.

CONCLUSION

This study highlights the variability in intra- and interpatient SMBs obtained through the use of a survey and app. The outcomes of this study indicate that clinicians could use both one-time and every-day assessment tools to assess SMBs related to meals. For alcohol and exercise, further research is needed to understand the best assessment method for SMBs. Given this degree of patient variability, there is a need for an educational intervention that goes beyond the traditional "one-size-fits-all" approach of diabetes management to target individualized treatment barriers.

Data-Driven Diabetes Education Guided by a Personalized Report for Patients on Insulin Pump Therapy

Objective

It is difficult to assess self-management behaviors (SMBs) and incorporate them into a personalized self-care plan. We aimed to develop and apply SMB phenotyping algorithms from data collected by diabetes devices and a mobile health (mHealth) application to create patient-specific SMBs reports to guide individualized interventions. Follow-up interventions aimed to understand patient's reasoning behind discovered SMB choices.

Methods

This study deals with adults on continuous subcutaneous insulin infusion using a continuous glucose monitor (CGM) who self-tracked SMBs with an mHealth application for 1 month. Patient-generated data were quantified and an SMB report was designed and populated for each participant. A diabetes educator used the report to conduct personalized, data-driven educational interventions. Thematic analysis of the intervention was conducted.

Results

Twenty-two participants recorded 118 alcohol, 251 exercise, 2,661 meal events, and 1,900 photos. A patient-specific SMB report was created from this data and used to conduct the educational intervention. High variability of SMB was observed between patients. There was variability in the percentage of alcohol events accompanied by a blood glucose check, median 79% (38-100% range), and frequency of changing the bolus waveform, median 11 (7-95 range). Interventions confirmed variability of SMBs. Main emerging themes from thematic analysis were: challenges and barriers, motivators, current SMB techniques, and future plans to improve glycemic control.

Conclusion

The ability to quantify SMBs and understand patients' rationale may help improve diabetes self-care and related outcomes. This study describes our first steps in piloting a patient-specific diabetes educational intervention, as opposed to the current "one size fits all" approach.

Shared Responsibility for Type 1 Diabetes Care Is Associated With Glycemic Variability and Risk of Glycemic Excursions in Youth

Objective

We examined how parent and youth responsibility for type 1 diabetes (T1D) care is related to adherence and glycemic outcomes, namely, glycemic variability and risk of glycemic excursions.

Methods

One hundred thirty-five parent-youth dyads (10-16 years old; diagnosed with T1D for at least 6 months) participated in this study. Percent responsibility of T1D care attributed to the youth, parent, or shared was measured using the Diabetes Family Responsibility Questionnaire. We collected youth's hemoglobin A1c (HbA1c) and glucometer downloads to examine relationships between responsibility and HbA1c, frequency of blood glucose monitoring (self-monitoring blood glucose, SMBG), risk of glycemic excursions, and actual glycemic variability using bivariate correlations and path analysis.

Results

Participants reported shared responsibility for almost half of T1D self-care tasks. Bivariate correlations showed shared responsibility was associated with less variability, whereas parent responsibility was associated with greater glycemic variability and risk for glycemic excursions. Youth responsibility was associated with lower frequency of SMBG. The path analyses confirmed our correlational findings (ps<.05) and better characterized interactions with age for youth-reported responsibility.

Conclusions

Our results support the hypothesis that shared T1D responsibility is associated with better diabetes outcomes in youth.

Adherence to metformin is reduced during school holidays and weekends in children with type 1 diabetes participating in a randomised controlled trial

BACKGROUND

Non-adherence to treatment in childhood chronic illness has serious consequences for health and healthcare costs. Accurate detailed objective data on adherence are minimal in this age group.

OBJECTIVE

To evaluate medication adherence using electronic monitoring systems in children with type 1 diabetes (T1D).

DESIGN

A cohort study of 90 T1D children (aged 13.6±2.5 years, 41 males) from two paediatric diabetes clinics, participated in a 12-month double-blind, randomised, placebo-controlled trial (1:1 allocation). This cohort provided 28 336 days of study observations; 7138 school holiday and 8875 weekend/public holiday days.

METHOD

Adherence to intervention (metformin (n=45) or placebo (n=45)) was measured objectively by Medication Event Monitoring Systems (MEMS) including proportion of medication doses taken and daily adherence patterns and by tablet count at 3, 6 and 12 months. The trial was completed in June 2015.

RESULTS

There was an average (SD) of 363.3 (42) days of MEMS observations available for each study participant (94.1 (12.6) school holiday days and 117.1 (13.4) weekend/public holiday days). Adherence reduced during school holidays (adjusted OR (aOR) 0.81; 95% CI 0.72 to 0.91; p<0.001) and during weekends/public holidays (aOR 0.74; 95% CI 0.69 to 0.80; p<0.001). Adverse effects to the intervention did not affect overall adherence (aOR 0.77; 95% CI 0.3 to 2.01; p=0.6). Age, gender, body mass index, diabetes duration, insulin dose, HbA1c (Haemoglobin A1c) or socioeconomic status did not predict adherence.

CONCLUSION

Medication adherence was reduced during school holidays and on weekends in children with T1D. Clinical characteristics including socioeconomic status and the presence of adverse effects did not predict adherence.

TRIAL REGISTRATION NUMBER

ACTRN12611000148976.

Positive Well-Being in Youth With Type 1 Diabetes During Early Adolescence

Developmental shifts during early adolescence relate to type 1 diabetes (T1D) self-management, increased risk of emotional distress, and worsening health status. Less is known about positive experiences related to T1D. This study evaluated associations of positive well-being (PWB) with diabetes burden, self-management, and glycemic control. Youth (N = 55, age = 12-13 years; X̄ age = 12.75 + 0.56 years, 50.9% male, 38.2% non-Caucasian) reported PWB, depressive symptoms, and diabetes burden. Parents reported on overall T1D adherence. Adherence behaviors and glycemic control were assessed objectively. Higher PWB correlated with lower depressive symptoms (r s = -.45), less diabetes burden (r s = -.48), and better glycemic control (r s = -.43), all p < .01. When controlling for diabetes duration, higher PWB correlated with lower depressive symptoms and better glycemic control. PWB was not related to demographics or adherence. Initial exploration suggests PWB is related to key diabetes constructs, and maybe valuable to consider along with efforts to support youth with T1D during a vulnerable developmental period.

Hope and mealtime insulin boluses are associated with depressive symptoms and glycemic control in youth with type 1 diabetes mellitus

Adherence to treatment regimen is associated with improved glycemic control and is particularly problematic during adolescence for those with type 1 diabetes mellitus (T1DM). Both glycemic control and adherence may be negatively impacted by poor psychological outcomes in adolescence, such as depressive symptoms and low hopefulness. The purpose of this study was to examine associations between the mealtime insulin bolus score (BOLUS), a more robust proxy measure of adherence than frequency of blood glucose monitoring or self-report, with depressive symptoms, hope, and hemoglobin A1c (HbA1c). Ninety adolescents completed measures of hope (Children's Hope Scale) and depressive symptoms (Center for Epidemiologic Studies-Depression Scale), as well as lab-based measures of HbA1c and mealtime insulin bolus scores (BOLUS). Higher levels of hope were associated with lower levels of depressive symptoms, more frequent mealtime insulin boluses, and better glycemic control. Higher levels of BOLUS behavior were associated with lower depressive symptoms and better glycemic control. Both BOLUS behavior and hope independently and significantly impacted the relationship between depressive symptoms and HbA1c, suggesting a possible mediation. Since hope and BOLUS were each associated with the relationship between depressive symptoms and glycemic control, following confirmation of this relationship in a longitudinal study, clinics may consider measuring hope and BOLUS among youth with high depressive symptoms and further investigating BOLUS behavior and hope as potential intervention targets to improve glycemic control.

Factors associated with adherence to diabetes care recommendations among children and adolescents with type 1 diabetes: a facility-based study in two urban diabetes clinics in Uganda

PURPOSE

The purpose of this study was to determine the level of adherence and the factors associated with adherence to diabetes care recommendations among type 1 diabetic children and adolescents at two urban diabetes clinics in Kampala, Uganda.

RESEARCH DESIGN AND METHODS

A facility-based cross-sectional study was carried out among 200 children and adolescents with type 1 diabetes at two major diabetes clinics in Kampala. Caretakers of the children and adolescents were interviewed using pretested questionnaires to provide information on sociodemographic characteristics, diabetes care, knowledge, attitudes, and adherence to diabetes care recommendations in type 1 diabetes. Prevalence rate ratios (PRRs) at the 95% confidence interval (CI) were used to establish the factors associated with adherence using modified Poisson regression, with robust standard errors. The data were analyzed by using STATA Version 13.0.

RESULTS

The overall prevalence of adherence to diabetes care recommendations was at 37%. However, evaluating adherence to specific treatment parameters showed that 52%, 76.5%, and 29.5% of the children and adolescents adhered to insulin, blood glucose monitoring, and dietary recommendations, respectively. In the final adjusted model, active diet monitoring (adjusted PRR [APRR]: 1.95; 95% CI: 1.01, 3.78), being under care of a sibling (APRR: 1.66; 95% CI: 1.61, 1.71), being under care of a married caretaker (APRR: 1.10; 95% CI: 1.05, 1.14) and a separated or divorced caretaker (APRR: 1.60; 95% CI: 1.12, 2.27), taking three or less tests of blood glucose per day (APRR: 0.63; 95% CI: 0.42, 0.95), and having a caretaker with poor knowledge about diabetes (APRR: 0.49; 95% CI: 0.43, 0.57) and who is inactive in supervision of insulin injections (APRR: 0.58; 95% CI: 0.56, 0.60) were associated with adherence to type 1 diabetes care recommendations.

CONCLUSION

Adherence to type 1 diabetes care recommendations is still low among this population. The results suggest that reinforcing caretaker involvement could be vital in improving adherence to diabetes care recommendations in this population.