5. Facilitating Positive Health Behaviors and Well-being to Improve Health Outcomes: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Measuring Multimorbidity: Selecting the Right Instrument for the Purpose and the Data Source

BACKGROUND

Adults have a higher prevalence of multimorbidity-or having multiple chronic health conditions-than having a single condition in isolation. Researchers, health care providers, and health policymakers find it challenging to decide upon the most appropriate assessment tool from the many available multimorbidity measures.

OBJECTIVE

The objective of this study was to describe a broad range of instruments and data sources available to assess multimorbidity and offer guidance about selecting appropriate measures.

DESIGN

Instruments were reviewed and guidance developed during a special expert workshop sponsored by the National Institutes of Health on September 25-26, 2018.

RESULTS

Workshop participants identified 4 common purposes for multimorbidity measurement as well as the advantages and disadvantages of 5 major data sources: medical records/clinical assessments, administrative claims, public health surveys, patient reports, and electronic health records. Participants surveyed 15 instruments and 2 public health data systems and described characteristics of the measures, validity, and other features that inform tool selection. Guidance on instrument selection includes recommendations to match the purpose of multimorbidity measurement to the measurement approach and instrument, review available data sources, and consider contextual and other related constructs to enhance the overall measurement of multimorbidity.

CONCLUSIONS

The accuracy of multimorbidity measurement can be enhanced with appropriate measurement selection, combining data sources and special considerations for fully capturing multimorbidity burden in underrepresented racial/ethnic populations, children, individuals with multiple Adverse Childhood Events and older adults experiencing functional limitations, and other geriatric syndromes. The increased availability of comprehensive electronic health record systems offers new opportunities not available through other data sources.

Childhood Obesity Evidence Base Project: A Systematic Review and Meta-Analysis of a New Taxonomy of Intervention Components to Improve Weight Status in Children 2-5 Years of Age, 2005-2019

Objective: To evaluate the efficacy of childhood obesity interventions and conduct a taxonomy of intervention components that are most effective in changing obesity-related health outcomes in children 2-5 years of age. Methods: Comprehensive searches located 51 studies from 18,335 unique records. Eligible studies: (1) assessed children aged 2-5, living in the United States; (2) evaluated an intervention to improve weight status; (3) identified a same-aged comparison group; (4) measured BMI; and (5) were available between January 2005 and August 2019. Coders extracted study, sample, and intervention characteristics. Effect sizes [ESs; and 95% confidence intervals (CIs)] were calculated by using random-effects models. Meta-regression was used to determine which intervention components explain variability in ESs. Results: Included were 51 studies evaluating 58 interventions (N = 29,085; mean age = 4 years; 50% girls). Relative to controls, children receiving an intervention had a lower BMI at the end of the intervention (g = 0.10, 95% CI = 0.02-0.18; k = 55) and at the last follow-up (g = 0.17, 95% CI = 0.04-0.30; k = 14; range = 18-143 weeks). Three intervention components moderated efficacy: engage caregivers in praise/encouragement for positive health-related behavior; provide education about the importance of screen time reduction to caregivers; and engage pediatricians/health care providers. Conclusions: Early childhood obesity interventions are effective in reducing BMI in preschool children. Our findings suggest that facilitating caregiver education about the importance of screen time reduction may be an important strategy in reducing early childhood obesity.

Childhood Obesity Evidence Base Project: Methods for Taxonomy Development for Application in Taxonomic Meta-Analysis

Meta-analysis has been used to examine the effectiveness of childhood obesity prevention efforts, yet traditional conventional meta-analytic methods restrict the kinds of studies included, and either narrowly define mechanisms and agents of change, or examine the effectiveness of whole interventions as opposed to the specific actions that comprise interventions. Taxonomic meta-analytic methods widen the aperture of what can be included in a meta-analysis data set, allowing for inclusion of many types of interventions and study designs. The National Collaborative on Childhood Obesity Research Childhood Obesity Evidence Base (COEB) project focuses on interventions intended to prevent childhood obesity in children 2-5 years old who have an outcome measure of BMI. The COEB created taxonomies, anchored in the Social Ecological Model, which catalog specific outcomes, intervention components, intended recipients, and contexts of policies, initiatives, and interventions conducted at the individual, interpersonal, organizational, community, and societal level. Taxonomies were created by discovery from the literature itself using grounded theory. This article describes the process used for a novel taxonomic meta-analysis of childhood obesity prevention studies between the years 2010 and 2019. This method can be applied to other areas of research, including obesity prevention in additional populations.

Childhood Obesity Evidence Base Project: A Rationale for Taxonomic versus Conventional Meta-Analysis

Introduction: There is a great need for analytic techniques that allow for the synthesis of learning across seemingly idiosyncratic interventions. Objectives: The primary objective of this paper is to introduce taxonomic meta-analysis and explain how it is different from conventional meta-analysis. Results: Conventional meta-analysis has previously been used to examine the effectiveness of childhood obesity prevention interventions. However, these tend to examine narrowly defined sections of obesity prevention initiatives, and as such, do not allow the field to draw conclusions across settings, participants, or subjects. Compared with conventional meta-analysis, taxonomic meta-analysis widens the aperture of what can be examined to synthesize evidence across interventions with diverse topics, goals, research designs, and settings. A component approach is employed to examine interventions at the level of their essential features or activities to identify the concrete aspects of interventions that are used (intervention components), characteristics of the intended populations (target population or intended recipient characteristics), and facets of the environments in which they operate (contextual elements), and the relationship of these components to effect size. In addition, compared with conventional meta-analysis methods, taxonomic meta-analyses can include the results of natural experiments, policy initiatives, program implementation efforts and highly controlled experiments (as examples) regardless of the design of the report being analyzed as long as the intended outcome is the same. It also characterizes the domain of interventions that have been studied. Conclusion: Taxonomic meta-analysis can be a powerful tool for summarizing the evidence that exists and for generating hypotheses that are worthy of more rigorous testing.

Childhood Obesity Evidence Base Project: Building Translational Capacity through Meta-Analytic Methods

Purpose: The purpose of this article is to demonstrate the need for and utility of using a taxonomic approach for evidence aggregation and meta-analyses, with focus on prevention and reduction of childhood obesity in very young children. As evidence has been generated through heterogeneous efforts, it is important that the field makes use of all available evidence to learn what works, for who, and in what circumstances. Methods: The Childhood Obesity Evidence Base (COEB) project conducted a taxonomic meta-analysis, using Grounded Theory to code elements present in reports of existing studies and initiatives, of diverse design and evaluation approaches, which were then mapped onto the levels of the socio-ecologic model. This article is the fourth in a series that describes the COEB project overall. It discusses both generally and specifically how taxonomies contribute to traditional meta-analytic methods, what questions can and cannot be answered, the method's contribution to translational (implementation) capacity, and ability to inform future efforts. Results: The COEB project illustrates how the taxonomic meta-analytic approach broadens the evidence base, increases translational capacity for effective intervention components, and evaluates the influence of contextual elements to inform future initiatives. How the method is used to establish associations between varying intervention components, contextual elements, and outcomes is discussed. Conclusions: Taxonomies generated through this process can be used for meta-analysis, serving to generate topic-specific questions associated with intervention approaches and outcomes in context, which is adjunctive to traditional meta-analytic methods and can inform public health approaches.

Weight-based teasing is associated with gain in BMI and fat mass among children and adolescents at-risk for obesity: A longitudinal study

BACKGROUND

Youths with overweight and obesity report frequent instances of weight-based teasing. However, little is known about the prospective associations between weight-based teasing and changes in body composition among youth.

OBJECTIVE

To assess associations between weight-based teasing and changes in body mass index (BMI) and fat mass in a longitudinal study of youths with, or at-risk for, overweight and obesity.

METHODS

One hundred ten youths with, or at-risk for, overweight participated in a longitudinal observational study. The Perception of Teasing Scale was administered at baseline. Height, weight, and body composition were obtained at baseline and at follow-ups (range: 1-15 years).

RESULTS

Mean age at baseline was 11.8 years; 53% had overweight/obesity; 36% were non-Hispanic Black; 55% were female; mean follow-up from baseline: 8.5 years. Adjusting for covariates and repeated measures of BMI or fat mass, linear mixed models revealed that weight-based teasing was associated with greater gain of BMI and fat mass across the follow-up period (ps ≤ .007). Adjusting for covariates, youths reporting high weight-based teasing (two standard deviations above the mean) experienced a 33% greater gain in BMI (an additional 0.20 kg/m² ) and a 91% greater gain in fat mass (an additional 0.65 kg) per year compared with peers who reported no weight-based teasing.

CONCLUSIONS

Among youths with, and at-risk for, overweight and obesity, weight-based teasing was associated with greater weight and fat gain.

Examination of Psychosocial and Physiological Risk for Bulimic Symptoms in Youth With Type 1 Diabetes Transitioning to an Insulin Pump: A Pilot Study

Objectives

This study tested hypotheses drawn from a risk model positing that psychosocial risk plus disease-related and treatment factors contribute to bulimic symptoms in youth with type 1 diabetes (T1D) transitioning to an insulin pump. The goal of this study was to examine whether disease-related factors, particularly disease- and treatment-based disruption in hunger and satiety, contribute to report of bulimic symptoms in youth with T1D after accounting for psychosocial risk factors.

Methods

43 youth (ages 10-17, 54% female) with established T1D were recruited before transition from multiple daily injections to insulin-pump therapy from three tertiary pediatric diabetes centers. Participants completed measures of bulimic symptoms, depressive symptoms dietary restraint, and the Diabetes Treatment and Satiety Scale, a diabetes-specific questionnaire assessing hunger and satiety cues and eating behavior in response to blood glucose levels and treatment.

Results

Hierarchical multiple regression was used to assess contributions of psychosocial and disease-based risk to report of bulimic symptoms. After assessing the contributions of body mass index, body image dissatisfaction, and dietary restraint, a significant 2-way interaction emerged between depression and diabetes-related uncontrollable hunger related to bulimic symptoms (β = 1.82, p < .01).

Conclusions

In addition to psychosocial risk, disease- and treatment-based hunger and satiety dysregulation appear to be important factors contributing to report of bulimic symptoms in youth with T1D. These preliminary findings have significant treatment implications for bulimic symptoms in youth with T1D.

The selection of comparators for randomized controlled trials of health-related behavioral interventions: recommendations of an NIH expert panel

OBJECTIVES

To provide recommendations for the selection of comparators for randomized controlled trials of health-related behavioral interventions.

STUDY DESIGN AND SETTING

The National Institutes of Health Office of Behavioral and Social Science Research convened an expert panel to critically review the literature on control or comparison groups for behavioral trials and to develop strategies for improving comparator choices and for resolving controversies and disagreements about comparators.

RESULTS

The panel developed a Pragmatic Model for Comparator Selection in Health-Related Behavioral Trials. The model indicates that the optimal comparator is the one that best serves the primary purpose of the trial but that the optimal comparator's limitations and barriers to its use must also be taken into account.

CONCLUSION

We developed best practice recommendations for the selection of comparators for health-related behavioral trials. Use of the Pragmatic Model for Comparator Selection in Health-Related Behavioral Trials can improve the comparator selection process and help resolve disagreements about comparator choices.

Childhood obesity research at the NIH: Efforts, gaps, and opportunities

Childhood obesity is a major public health challenge. This article describes an overview of the National Institutes of Health (NIH) behavioral and social sciences childhood obesity research efforts. The overview will highlight five areas of childhood obesity research supported by the NIH: (a) basic behavioral and social sciences; (b) early childhood; (c) policies, programs, and environmental strategies; (d) health disparities; and (e) transagency and public-private collaboration. The article also describes potential gaps and opportunities in the areas of childhood obesity and severe obesity, measurement, and sleep.

Accumulating Data to Optimally Predict Obesity Treatment (ADOPT) Core Measures: Psychosocial Domain

BACKGROUND

Within the Accumulating Data to Optimally Predict obesity Treatment (ADOPT) Core Measures Project, the psychosocial domain addresses how psychosocial processes underlie the influence of obesity treatment strategies on weight loss and weight maintenance. The subgroup for the psychosocial domain identified an initial list of high-priority constructs and measures that ranged from relatively stable characteristics about the person (cognitive function, personality) to dynamic characteristics that may change over time (motivation, affect).

OBJECTIVES

This paper describes (a) how the psychosocial domain fits into the broader model of weight loss and weight maintenance as conceptualized by ADOPT; (b) the guiding principles used to select constructs and measures for recommendation; (c) the high-priority constructs recommended for inclusion; (d) domain-specific issues for advancing the science; and (e) recommendations for future research.

SIGNIFICANCE

The inclusion of similar measures across trials will help to better identify how psychosocial factors mediate and moderate the weight loss and weight maintenance process, facilitate research into dynamic interactions with factors in the other ADOPT domains, and ultimately improve the design and delivery of effective interventions.

The Childhood Obesity Declines Project: A Review of Enacted Policies

BACKGROUND

State- and local-level policies can influence children's diet quality and physical activity (PA) behaviors. The goal of this article is to understand the enacted state and local policy landscape in four communities reporting declines in childhood obesity.

METHODS AND RESULTS

State-level policies were searched within the CDC's online Chronic Disease State Policy Tracking System. Local level policies were captured during key informant interviews in each of the sites. Policies were coded by setting [i.e., early care and education (ECE) also known as child care, school, community], jurisdictional level (i.e., state or local) and policy type (i.e., legislation or regulation). The time period for each site was unique, capturing enacted policies 5 years before the reported declines in childhood obesity in each of the communities. A total of 39 policies were captured across the 4 sites. The majority originated at the state level. Two policies pertaining to ECE, documented during key informant interviews, were found to be adopted at the local level.

CONCLUSION

Similarities were noted between the four communities in the types of polices enacted. All four communities had state- and/or local-level policies that aimed to improve the nutrition environment and increase opportunities for PA in both the ECE and K-12 school settings. This article is a step in the process of determining what may have contributed to obesity declines in the selected communities.

Childhood Obesity Declines Project: A Different Methodology

BACKGROUND

The evidence for and our understanding of community-level strategies such as policies, system, and environmental changes that support healthy eating and active living is growing. However, researchers and evaluation scientists alike are still not confident in what to recommend for preventing or sustaining declines in the prevalence of obesity.

METHODS

The Systematic Screening and Assessment (SSA) methodology was adapted as a retrospective process to confirm obesity declines and to better understand what and how policies and programs or interventions may contribute as drivers. The Childhood Obesity Declines (COBD) project's adaptation of the SSA methodology consisted of the following components: (1) establishing and convening an external expert advisory panel; (2) identification and selection of sites reporting obesity declines; (3) confirmation and review of what strategies occurred and contextual factors were present during the period of the obesity decline; and (4) reporting the findings to sites and the field.

RESULTS/DISCUSSION

The primary result of the COBD project is an in-depth examination of the question, "What happened and how did it happen in communities where the prevalence of obesity declined?" The primary aim of this article is to describe the project's methodology and present its limitations and strengths.

CONCLUSIONS

Exploration of the natural experiments such that occurred in Anchorage, Granville County, New York City, and Philadelphia is the beginning of our understanding of the drivers and contextual factors that may affect childhood obesity. This retrospective examination allows us to: (1) describe targeted interventions; (2) examine the timeline and summarize intervention implementation; (3) document national, state, local, and institutional policies; and (4) examine the influence of the reach and potential multisector layering of interventions.

Childhood Obesity Declines Project: Highlights of Community Strategies and Policies

BACKGROUND

The social ecological model (SEM) is a framework for understanding the interactive effects of personal and environmental factors that determine behavior. The SEM has been used to examine childhood obesity interventions and identify factors at each level that impact behaviors. However, little is known about how those factors interact both within and across levels of the SEM.

METHODS

The Childhood Obesity Declines (COBD) project was exploratory, attempting to capture retrospectively policies and programs that occurred in four communities that reported small declines in childhood obesity. It also examined contextual factors that may have influenced initiatives, programs, or policies. Data collection included policy and program assessments, key informant interviews, and document reviews. These data were aggregated by the COBD project team to form a site report for each community (available at www.nccor.org/projects/obesity-declines ). These reports were used to develop site summaries that illustrate how policies, programs, and activities worked to address childhood obesity in each study site.

RESULTS/CONCLUSIONS

Site summaries for Anchorage, AK; Granville County, NC; Philadelphia, PA; and New York City, NY, describe those policies and programs implemented across the levels of the SEM to address childhood obesity and examine interactions both across and within levels of the model to better understand what factors appear important for implementation success.

Childhood Obesity Declines Project: An Exploratory Study of Strategies Identified in Communities Reporting Declines

BACKGROUND

Although childhood obesity rates have been high in the last few decades, recent national reports indicate a stabilization of rates among some subpopulations of children. This study examines the implementation of initiatives, policies, and programs (referred to as strategies) in four communities that experienced declines in childhood obesity between 2003 and 2012.

METHODS AND RESULTS

The Childhood Obesity Decline project verified obesity declines and identified strategies that may have influenced and supported the decline in obesity. The project used an adaptation of the Systematic Screening and Assessment method to identify key informants in each site. Four settings were highlighted related to childhood: (1) communities, (2) schools, (3) early care and education, and (4) healthcare. The findings indicate that programs and policies were implemented across local settings (primarily in schools and early childhood settings) and at the state level, during a timeframe of supportive federal policies and initiatives.

CONCLUSIONS

Multilevel approaches were aimed to improve the nutrition and physical activity environments where children spend most of their time. We hypothesized that other, more distal strategies amplified and reinforced the impact of the efforts that more directly targeted children. The simultaneous public health messaging and multilayered initiatives, supported by cross-sector partnerships and active, high-level champions, were identified as likely important contributors to success in attaining declines in rates of childhood obesity.

The Childhood Obesity Declines Project: Implications for Research and Evaluation Approaches

BACKGROUND

Childhood obesity remains prevalent and is increasing in some disadvantaged populations. Numerous research, policy and community initiatives are undertaken to impact this pandemic. Understudied are natural experiments. The need to learn from these efforts is paramount. Resulting evidence may not be readily available to inform future research, community initiatives, and policy development/implementation.

METHODS

We discuss the implications of using an adaptation of the Systematic Screening and Assessment (SSA) method to evaluate the Childhood Obesity Declines (COBD) project. The project examined successful initiatives, programs and policies in four diverse communities which were concurrent with significant declines in child obesity. In the context of other research designs and evaluation schemas, rationale for use of SSA is presented. Evidence generated by this method is highlighted and guidance suggested for evaluation of future studies of community-based childhood obesity prevention initiatives. Support for the role of stakeholder collaboratives, in particular the National Collaborative on Childhood Obesity Research, as a synergistic vehicle to accelerate research on childhood obesity is discussed.

RESULTS/DISCUSSION

SSA mapped active processes and provided contextual understanding of multi-level/component simultaneous efforts to reduce rates of childhood obesity in community settings. Initiatives, programs and policies were not necessarily coordinated. And although direct attribution of intervention/initiative/policy components could not be made, the what, by who, how, to whom was temporally associated with statistically significant reductions in childhood obesity.

CONCLUSIONS

SSA provides evidence for context and processes which are not often evaluated in other data analytic methods. SSA provides an additional tool to layer with other evaluation approaches.

Childhood Obesity Declines Project: An Effort of the National Collaborative on Childhood Obesity Research to Explore Progress in Four Communities

BACKGROUND

Recent findings show that national childhood obesity prevalence overall is improving among some age groups, but that disparities continue to persist, particularly among populations that have historically been at higher risk of obesity and overweight. Over the past several years, many jurisdictions at the city or county level across the nation have also reported declines. Little evaluation has focused on understanding the factors that influence the implementation of efforts to reduce childhood obesity rates. This article summarizes the rationale, aims, and overall design of the Childhood Obesity Declines Project (COBD), which was the first of its kind to systematically study and document the what, how, when, and where of community-based obesity strategies in four distinct communities across the nation.

METHODS

COBD was initiated by the National Collaborative on Childhood Obesity Research (NCCOR), was led by a subset of NCCOR advisors and a research team at ICF, and was guided by external advisors made up of researchers, decision makers, and other key stakeholders. The research team used an adapted version of the Systematic Screening and Assessment method to review and collect retrospective implementation data in four communities.

RESULTS

COBD found that sites implemented strategies across the many levels and environments that impact children's well being (akin to the social-ecological framework), building a Culture of Health in their communities.

CONCLUSIONS

COBD demonstrates how collaboratives of major funders with the support of other experts and key stakeholders, can help to accelerate progress in identifying and disseminating strategies that promote healthy eating and physical activity.

Introduction to special issue: Self-regulation of appetite-it's complicated

OBJECTIVE

A meeting of multidisciplinary biobehavioral scientists and National Institutes of Health (NIH) program staff was convened by the Office of Behavioral and Social Sciences Research, Division of Program Coordination, Planning, and Strategic Initiatives, Office of the Director, NIH to examine mechanisms associated with humans' ability to self-regulate appetite and appetitive behavior.

METHODS

Based upon prior discussions of the NIH Obesity Research Task Force Behavioral Phenotyping Work Group, the premise was adopted that, in modern society, multiple factors on multiple levels interact to create circumstances wherein self-control of appetite is difficult, leading to overconsumption of unhealthy foods versus healthy eating patterns, contributing to our current levels of obesity. Through presentations and group discussions, the panel examined how foundational processes/mechanisms directly and indirectly affect appetitive behavior and how these processes can be manipulated to affect food intake and thereby weight. The meeting identified evidence-based mechanisms with the potential to impact self-regulation of appetite and appetitive states (hunger, satiety, food wanting, restraint, reward) and associated behaviors such as overconsumption, eating in the absence of hunger, food seeking, and decision-making that could inform novel weight intervention strategies in free-living, nonlaboratory settings.

CONCLUSION

The three summary papers contained in this issue represent the synthesis of the material presented at the meeting and the panel's recommendations on how existing evidence regarding mechanisms and pathways to appetitive behavior can be used to inform future research and novel prevention and intervention strategies to impact prevalence of obesity.

Maternal stress predicts postpartum weight retention

Postpartum weight retention (PPWR) is a significant contributor to the development of overweight and obesity in women of childbearing age. Stress may be a key mechanism making it more difficult for mothers to lose weight in the year following delivery. The aim of this study was to assess whether specific aspects of parenting stress and life stress influence postpartum weight retention in new mothers. Women in late pregnancy or up to 2 months postpartum (n = 123) were enrolled in the study and followed through the first year postpartum. Linear regression models evaluated the associations of parenting stress (isolation, attachment and depressive symptoms) as well as overall life stress at 2, 6, and 12 months postpartum with PPWR at 6 and 12 months. During the first year postpartum, higher depression and life stress were significantly associated with greater PPWR. As the effect of depression diminished, the effect of life stress became significant. Contrary to hypothesized relationships, fewer problems with attachment and less social isolation were significantly associated with greater PPWR. Higher gestational weight gain and African American race were also significantly associated with greater PPWR at both 6 and 12 months. Different types of stress predict weight retention in first time mothers during the first year postpartum. Understanding the relationships between parenting stress, concurrent life stress and PPWR can enhance the development of future interventions that specifically target self-identified stressors, leading to improved weight related outcomes.

Topical review: a comprehensive risk model for disordered eating in youth with type 1 diabetes

OBJECTIVES

Provide an updated literature review on prevalence, measurement, and correlates of disordered eating in youth with Type 1 diabetes (T1D), present a novel theoretical risk model (i.e., The Modified Dual Pathway Model) for disordered eating in youth with T1D incorporating psychosocial and physiological risk factors, and discuss clinical implications.

METHODS

Literature review of prevalence, correlates, risk factors, and outcomes of disordered eating behavior (DEB) in youth with T1D.

RESULTS

Insulin treatment, subsequent weight gain, and disruptions to hunger and satiety regulation are hypothesized disease-related mechanisms through which the treatment of T1D may increase vulnerability to development of behavior characterized as DEB. The Modified Dual Pathway Model integrates these factors with a validated psychosocial risk (body dissatisfaction, depression, and abstinence violation) model for DEB in nondiabetic youth.

CONCLUSIONS

The Modified Dual Pathway model of DEB in youth with T1D is a comprehensive representation of both psychosocial and T1D-related risk factors with the potential to inform future interventions for this population.

Use of technology when assessing adherence to diabetes self-management behaviors

During the last several decades, a proliferation of sophisticated technology has taken place to facilitate diabetes self-management and improve health outcomes. Blood glucose monitors, insulin pumps, and continuous glucose monitors have significant data storage capacity, which can be used to summarize diabetes health management and outcomes. In the absence of technology errors or failures, and in the context of the multiple psychosocial factors associated with nonadherence, these data have the potential to elucidate diabetes care because they reflect actual patient behaviors. This review provides a summary of the diabetes adherence literature in the context of current American Diabetes Association Clinical Practice Recommendations with a focus on studies that have used objective methods (ie, data derived from technology) to assess diabetes care provider and patient adherence in the areas of glucose monitoring; insulin administration and antihyperglycemic medications; medical nutrition therapy; and physical activity.

Disordered eating behaviors in youth with type 1 diabetes: prospective pilot assessment following initiation of insulin pump therapy

BACKGROUND

There is risk for disordered eating behaviors in type 1 diabetes, especially related to insulin manipulation. Implementation of insulin pump therapy may encourage either normalization of eating behaviors or a greater focus on food intake due to renewed emphasis on carbohydrate counting. There is need for prospective studies to assess disordered eating behaviors upon implementation of pump therapy using diabetes-specific measurement tools.

SUBJECTS AND METHODS

In a multicenter pilot study, 43 youth with type 1 diabetes, 10-17 years old, were assessed prior to pump initiation and after 1 and 6 months of pump therapy. Youth completed the Diabetes-specific Eating Problems Survey-Revised (DEPS-R), a validated measure of risk for both diabetes-specific and general disordered eating behaviors.

RESULTS

Youth (45% female), 13.3 years old with diabetes for 2.1 years, had a mean hemoglobin A1c of 8.3±1.3% (68±14.5 mmol/mol) at baseline. DEPS-R scores decreased over time (P=0.01). Overall rate of high risk for eating disorders was low. Overweight/obese youth endorsed more disordered eating behaviors than normal-weight participants. DEPS-R scores were correlated with z-score for body mass index at all three time points and with hemoglobin A1c after 1 and 6 months. Hemoglobin A1c did not change significantly over the 6 months and was higher in overweight/obese compared with normal-weight participants.

CONCLUSIONS

Initiation of insulin pump therapy was associated with diminished endorsement of disordered eating behaviors in youth with type 1 diabetes. Longer follow-up studies are needed to assess the impact of insulin pump therapy on glycemic control, weight status, and disordered eating behaviors in this vulnerable population.

Monitoring in diabetes self-management: issues and recommendations for improvement

The American Association of Diabetes Educators hosted a Monitoring Symposium during which 18 invited participants considered pre-set questions regarding how diabetes education can more effectively address barriers to monitoring for people with diabetes and related conditions. This report provides a summary of the moderated discussion and highlights the key points that apply to diabetes educators and other providers involved with diabetes care. The participating thought leaders reviewed findings from published literature and participated in a moderated discussion with the aim of providing practical advice for health care practitioners regarding monitoring for people with diabetes so that the overall health of this population can be enhanced. The discussants also defined monitoring for diabetes as including that done by the clinician or laboratory, as well as self-monitoring. The discussion was distilled into key points that apply to diabetes educators and other providers involved with diabetes care. Participants developed specific recommendations for a self-monitoring behavior and monitoring framework. People with diabetes benefit from instruction and guidance about self-monitoring and decision making that is based on monitored results and informed interactions with providers. Importantly, collaboration among the entire diabetes care community is needed to ensure that monitoring is performed and utilized to its fullest advantage. Going forward, it will be critical to mitigate barriers to diabetes self-management and training and to identify linkages and partnerships to address barriers to self-monitoring.

Maternal stress, physical activity, and body mass index during new mothers' first year postpartum

We evaluated associations of parenting stress, including depressive symptoms, with 51 first-time mothers' light and moderate physical activity and body mass index during the first year postpartum. The Parenting Stress Index and 24-hour physical activity recalls were completed during the first year postpartum (mean time elapsed since birth: 6 months). Direct relationships between identified variables were tested, and then hierarchical linear regression was used to assess hypothesized relationships among body mass index, physical activity, and parenting stress. Effects of parenting stress on the relationships between postpartum body mass index, light physical activity, and moderate physical activity were evaluated after controlling for factors known to be associated with overweight and low levels of physical activity in women. Mean postpartum body mass index = 27.4 kg/m² ± 7.7, range = 18-50 kg/m². Mean reported hours of light physical activity = 11.2 ± 3.0, and moderate physical activity = 4.5 ± 3.0 per day. Postpartum body mass index was not associated with parenting stress, but was positively related to higher pre-pregnancy body mass index (r = .89, p < .01) and light physical activity (r = .32, p < .05), and was negatively related to moderate physical activity (r = -25, p < .08). Higher postpartum body mass index (β = .27, p < .05), less concern regarding parenting competence (β = -.95, p < .001), and more depressive symptoms (β = .66, p < .01) were associated with more light physical activity (R² = .48, p < .001). More moderate physical activity (R² = .45, p < .001) was associated with lower postpartum body mass index (β = -.27, p < .05), more concern about parenting competence (β = 1.0, p < .001), and less depressive symptoms (β = -.68, p < .01). Higher postpartum body mass index (R² = .89, p < .001) was associated with higher pre-pregnancy body mass index (β = .99, p < .001), more pregnancy weight gain (β = .22, p < .001), less attachment (β = -.68, p < .01), and less social isolation (β = -.13, p < .02). These data suggest that interventions that target parenting stress and depressive symptoms in addition to physical activity are needed to prevent development of overweight in new mothers.

Psychological symptoms and insulin sensitivity in adolescents

PURPOSE

Symptoms of psychological distress have been linked to low insulin sensitivity in adults; however, little is known about this relationship in pediatric samples. We therefore examined symptoms of depression and anxiety in relation to insulin sensitivity in adolescents.

METHODS

Participants were 136 non-treatment-seeking, healthy adolescents (53.2% female) of all weight strata (BMI-z = 1.08 +/- 1.08) between the ages of 12 and 18 years (M = 15.16,SD = 1.55). Adolescents completed questionnaire measures assessing depression and anxiety symptoms. Fasting blood samples for serum insulin and plasma glucose were obtained to estimate insulin sensitivity with the quantitative insulin sensitivity check index. Fat mass and fat-free mass were measured with air displacement plethysmography or dual-energy X-ray absorptiometry.

RESULTS

Depressive symptoms were associated with higher fasting insulin and decreased insulin sensitivity even after controlling for fat mass, fat-free mass, height, age, pubertal status, race, and sex (p < 0.01).

CONCLUSIONS

As has been described for adults, depressive symptoms are associated with low insulin sensitivity among healthy adolescents. Further experimental and prospective studies are required to determine the directionality of this link.

Exercise effects on depressive symptoms and self-worth in overweight children: a randomized controlled trial

OBJECTIVE

To test the dose-response effects of an exercise program on depressive symptoms and self-worth in children.

METHOD

Overweight, sedentary children (N = 207, 7-11 years, 58% male, 59% Black) were randomly assigned to low or high dose (20 or 40 min/day) aerobic exercise programs (13 +/- 1.6 weeks), or control group. Children completed the Reynolds Child Depression Scale and Self-Perception Profile for Children at baseline and posttest.

RESULTS

A dose-response benefit of exercise was detected for depressive symptoms. A race x group interaction showed only White children's global self-worth (GSW) improved. There was some evidence that increased self-worth mediated the effect on depressive symptoms.

CONCLUSIONS

This study shows dose-response benefits of exercise on depressive symptoms and self-worth in children. However, Blacks did not show increased GSW in response to the intervention. Results provide some support for mediation of the effect of exercise on depressive symptoms via self-worth.

Aerobic exercise program reduces anger expression among overweight children

This study tested the effect of a structured aerobic exercise program on anger expression in healthy overweight children. Overweight sedentary children were randomly assigned to an aerobic exercise program or a no-exercise control condition. All children completed the Pediatric Anger Expression Scale at baseline and posttest. Anger Out and Anger Expression scores were lower for the exercise condition at posttest. Fitness improvements contributed significantly to final models, and points earned for adherence correlated negatively with posttest Anger Out. An aerobic exercise program might be an effective strategy to reduce anger expression, including reduction of aggressive behavior, in overweight children.

Psychological status and weight-related distress in overweight or at-risk-for-overweight children

OBJECTIVE

To associate psychological status, weight-related distress, and weight status during childhood in overweight or at-risk-for-overweight children.

RESEARCH METHODS AND PROCEDURES

We associated self-report of depression, trait anxiety, and weight-related distress (body size dissatisfaction and weight-related peer teasing after controlling for the effects of weight) in 164 children (black 35%; age 11.9 +/- 2.5 years; girls 51%) who were overweight or at-high-risk-for-overweight and were not seeking weight loss.

RESULTS

Overall, heavier children reported more psychological and weight-related distress. Black children reported more anxiety and body size dissatisfaction than white children, despite equivalent weights. However, psychological distress was not significantly associated with weight in white children. Girls reported more weight-related distress than boys. Depression was associated with weight-related teasing in all predictive models, except in the model using only black subjects. Trait anxiety was associated with report of peer teasing when using all subjects. Depression was also significantly associated with children's report of body size dissatisfaction in models using all subjects, only girls, or white subjects, but not in analyses using only boys or black subjects. For boys peer teasing was associated with body size dissatisfaction. In models including only black children, depression and trait anxiety were not significantly associated with either report of peer teasing or body size dissatisfaction.

DISCUSSION

Regardless of race or sex, increasing weight is associated with emotional and weight-related distress in children. However, associations of psychological status, weight, and weight-related distress differ for girls and boys, and for black and white children.

Health-related quality of life in overweight and nonoverweight black and white adolescents

OBJECTIVES

To assess the impact of obesity on quality of life (QOL) in black and white adolescents.

STUDY DESIGN

One hundred ten overweight (body mass index [BMI], 41.7 +/- 8.9 kg/m2) and 34 nonoverweight adolescents (BMI, 20.6 +/- 2.9 kg/m2) and their parents completed measures of QOL.

RESULTS

Overweight was associated with poorer adolescent-reported QOL and parent reports of their children's QOL. Examining groups by weight status and race, overweight whites reported the greatest impairment on Social/Interpersonal, Self-Esteem, and Physical Appearance QOL (all P < .01), whereas parents of overweight blacks reported the poorest General Health Perceptions scores regarding their children. Interactions between BMI z-score and race were detected for Social/Interpersonal, Self-esteem, Daily Living, Self-Efficacy, Self-regard, and Physical Appearance QOL (all P < .05): Higher BMI in whites was associated with greater impairments in QOL than in blacks. Parents reported similar relations for their children.

CONCLUSIONS

According to adolescent and parent reports, overweight is associated with poorer QOL in adolescence, regardless of race; however, compared with overweight white adolescents, blacks report less impairment in QOL. Future research is required to determine whether differences in QOL are predictive of treatment success.

Weight and its relationship to adolescent perceptions of their providers (WRAP): a qualitative and quantitative assessment of teen weight-related preferences and concerns

PURPOSE

To examine the relationship of body weight to satisfaction with care in adolescents, and to obtain qualitative data on preferences for general and weight-related medical care in normal weight and overweight adolescents.

METHODS

The Weight and its Relationship to Adolescent Perceptions of their Providers survey, a 4-page questionnaire containing previously validated satisfaction scales and open-ended qualitative questions regarding health care preferences, was administered to 62 severely overweight (body mass index [BMI] 38.9 +/- 8.4 kg/m2) and 29 normal weight (BMI 22.5 +/- 4.0 kg/m2) adolescents (age 13.9 +/- 1.7 years; 57% female; 50% Caucasian, 47% African-American, 3% Hispanic).

RESULTS

The affective subscale of the medical satisfaction scale was negatively correlated with BMI standard deviation score (r = -.22, p < .05). Multiple regression models predicting affective satisfaction with medical care included BMI standard deviation score; however, continuity with provider appeared to be the strongest independent predictor of affective satisfaction. Fifty-five percent of participants identified their mother as the person they felt most comfortable talking with about weight, although 68% believed their provider knew the most about healthy eating. "Overweight" was identified by 47% of participants as the preferred term for heavy teens. Seventy-nine percent of overweight adolescents stated their health care provider discussed their weight with them; however, only 41% of overweight adolescents desired to discuss their weight. Compared to normal-weight adolescents, overweight teens were more likely to report that their provider raised topics of weight (p < .001), diet (p < .01), and exercise (p < .01) at their last physical, and were more likely to report that they would have liked their provider to discuss diet and exercise (both p < .05). Ten percent of overweight teens expressed concerns regarding the public location of their provider's office scale.

CONCLUSIONS

Satisfaction with affective aspects of the provider-patient relationship is negatively correlated with BMI standard deviation score. Length of experience with one's provider is also a strong predictor of teen satisfaction with their medical care. Teens prefer the term "overweight" for those with high body weight. Sensitivity to confidentiality, privacy, and embarrassment regarding physical examination and weight are important for teen satisfaction.

Obesity, appearance, and psychosocial adaptation in young African American children

OBJECTIVE

To evaluate the contributions of weight status, skin tone, peer teasing, and parental appraisals of child's size to self-esteem and psychosocial adjustment in overweight African American children.

METHOD

Overweight to very obese 5- to 10-year-old African American children (N = 117) completed measures of self-esteem, skin tone satisfaction, peer teasing, and body size perception. Caregivers completed the Child Behavior Checklist and rated their child's body size.

RESULTS

Overweight was associated with low appearance self-esteem, and body size dissatisfaction with low global self-worth and low appearance self-esteem in children 8 and older. Appearance self-esteem but not global self-worth was lower in girls than boys. Parental perception of child's size as heavier than average was associated with low child appearance self-esteem. Heavier children also had more parental report of behavior and psychosocial problems, but their scores were in the nonclinical range. Child skin tone dissatisfaction was associated with low global self-worth. Weight-related peer teasing was associated with low self-esteem.

CONCLUSIONS

The relationship between obesity and self-esteem in African American children depends upon age, gender, and children's experiences with teasing and parental evaluation of their size. Other factors, like skin tone satisfaction, contribute to a child's sense of self-worth.

Evaluation of the insulin resistance syndrome in 5- to 10-year-old overweight/obese African-American children

OBJECTIVE

To characterize the insulin sensitivity of overweight and obese 5- to 10-year-old (Tanner stage 1-3) African-American children screened for participation in a diabetes prevention study and to identify the association of insulin sensitivity with obesity, hyperlipidemia, and hypertension.

RESEARCH DESIGN AND METHODS

Measures of insulin resistance (homeostasis model assessment) and insulin sensitivity (Matsuda and DeFronzo's whole-body insulin sensitivity) were calculated from a 2-h oral glucose tolerance test in 137 African-American children recruited into a diabetes prevention study. Measures of lipids (LDL, HDL, total cholesterol, and triglycerides), blood pressure, and body composition were obtained for a subset of the children.

RESULTS

In response to a glucose challenge, girls and older and heavier children produced significantly more insulin. As BMI increased, there was a statistically significant decrease in insulin sensitivity, particularly in girls. Insulin sensitivity was inversely correlated with increases in blood pressure, triglycerides, subcutaneous fat, the percentage of total body fat, and Tanner stage, but it was not correlated with LDL and HDL.

CONCLUSIONS

Reduced insulin sensitivity and the cluster of risk factors known as the insulin resistance syndrome (IRS) are already apparent in these overweight African-American children. Young African-American girls, in particular, already show evidence of hyperinsulinemia in response to a glucose load, suggesting that the early stages of metabolic decompensation that lead to type 2 diabetes are already occurring. Monitoring of those risk factors known to be part of IRS should become part of routine medical care for overweight or obese African-American children.

Care giver perception of children's obesity-related health risk: a study of African American families

OBJECTIVE

To examine care giver perception of children's weight-related health risk in African American families.

RESEARCH METHODS AND PROCEDURES

One-hundred and eleven families (representing 48 boys and 63 girls) screened for participation in a diabetes prevention study participated. Care givers completed a health awareness questionnaire that assessed their perception of the child's weight, eating habits, appearance, exercise habits, and health risk. The care givers also reported each subject's family history of obesity, diabetes, and other chronic diseases. After a physical examination, height and weight were used to compute an age- and sex-adjusted body mass index for each child.

RESULTS

Despite the fact that a substantial number of children were obese (57%) and super-obese (12%), only 44% of the care givers perceived the child's weight to be a potential health problem. Regression analysis showed that 21% of the variance in parental perception of obesity-related health risk could be predicted by child age, body mass index, perception of frame size, and perception of exercise habits.

DISCUSSION

A number of reasons for the apparent minimization of child health risk are discussed, including cultural differences in the acceptance of a large body habitus, lack of knowledge about the connection between childhood obesity and future health risk, and an optimistic bias in the perception of personal health risk.

Provider impact in diabetes education. What we know, what we would like to know, paradigms for asking

PURPOSE

A literature search from 1985 to the present was performed using Web-based search engines to identify evidence-based studies of diabetes education.

METHODS

Twelve studies were identified in which a provider characteristic was defined as a discriminate variable associated with impact or efficacy of the education intervention. Provider was defined as all those participating in diabetes care and education (e.g., patient, education and care teams, funding and policy agencies). The Certified Diabetes Educator credential also was described.

RESULTS

Specialty or discipline of the provider/care team, technology when used to assist providers, and physician practice patterns have been assessed. There is a paucity of research that assesses provider impact or the specific impact of provider characteristics on diabetes outcomes in a controlled and scientifically rigorous fashion.

CONCLUSIONS

Suggestions for evaluating provider impact based on literature concerning psychotherapy and healthcare education outcomes are: identify provider characteristics/attitudes/skills and link them to outcomes, define therapeutic alliance in diabetes care/education and assess its contribution to outcomes; and use performance measures as provider characteristics.

Biopsychobehavioral model of risk of severe hypoglycemia. Self-management behaviors

OBJECTIVE

To identify self-management antecedents of low blood glucose (BG) (< 3.9 mmol/l) that might be easily recognized, treated, or avoided altogether.

RESEARCH DESIGN AND METHODS

Ninety-three adults with type 1 diabetes (age, 35.8 +/- 8 years [mean +/- SD]; duration of diabetes, 17.0 +/- 11 years; daily insulin dose, 0.58 +/- 0.18 U/kg; and HbAlc, 8.6 +/- 1.8%) were recruited to participate in the study. Of the 93 subjects, 42 had a history of severe hypoglycemia (SH), defined as two or more hypoglycemic episodes in the preceding 12 months, and 51 subjects had no history of SH (No-SH) in the same time period. Before each of 70 BG measurements obtained over a 3-week period, subjects used a handheld computer to record whether their most recent insulin, food, and exercise was more than, less than, or the same as usual. Associations among self-management behaviors preceding BG readings < 3.9 mmol/l versus those preceding BG readings of 5.6-7.8 mmol/l were determined using chi 2 tests, analyses of variance, and logistic regression analyses.

RESULTS

Analysis of 6,425 self-management/self-monitoring of BG events revealed that the usual amounts of insulin, food, and exercise preceded the events 58.3% of the time. No significant differences were observed for changes in insulin before readings of BG < 3.9 mmol/l versus 7.8 < BG > 5.6 mmol/l, but significantly less food (P < 0.01) was eaten and more exercise (P < 0.001) was performed before the low BG measurement. No interactions between SH and No-SH groups and management behaviors were observed. However, each of the three management variables entered significantly in a logistic model that predicted 61% of all readings of BG < 3.9 mmol/l.

CONCLUSIONS

Subjects with a history of SH did not report managing their diabetes differently from those with no such history. Specifically, when low BG occurred, the preceding management behaviors, although predictive of low BG, were not different in SH and No-SH subjects. Overall, self-management behaviors did not distinguish SH from No-SH subjects. Thus, even though it might be beneficial for all patients to review their food and exercise management decisions to reduce their frequency of low BG, an educational intervention whose content stresses insulin, food, and exercise would be unlikely by itself to be sufficient to reduce the frequency of SH.

Assessment of risk for severe hypoglycemia among adults with IDDM: validation of the low blood glucose index

OBJECTIVE

To evaluate the clinical/research utility of the low blood glucose index (LBGI), a measure of the risk of severe hypoglycemia (SH), based on self-monitoring of blood glucose (SMBG).

RESEARCH DESIGN AND METHODS

There were 96 adults with IDDM (mean age 35+/-8 years, duration of diabetes 16+/-10 years, HbA1 8.6+/-1.8%), 43 of whom had a recent history of SH (53 did not), who used memory meters for 135+/-53 SMBG readings over a month, and then for the next 6 months recorded occurrence of SH. The SMBG data were mathematically transformed, and an LBGI was computed for each patient.

RESULTS

The two patient groups did not differ with respect to HbA1, insulin units per day, average blood glucose (BG) and BG variability. Patients with history of SH demonstrated a higher LBGI (P < 0.0005) and a trend to be older with longer diabetes duration. Analysis of odds for future SH classified patients into low- (LBGI <2.5), moderate- (LBGI 2.5-5), and high- (LBGI >5) risk groups. Over the following 6 months low-, moderate-, and high-risk patients reported 0.4, 2.3, and 5.2 SH episodes, respectively (P = 0.001). The frequency of future SH was predicted by the LBGI and history of SH (R2 = 40%), while HbA1, age, duration of diabetes, and BG variability were not significant predictors.

CONCLUSIONS

LBGI provides an accurate assessment of risk of SH. In the traditional relationship history of SH-to-future SH, LBGI may be the missing link that reflects present risk. Because it is based on SMBG records automatically stored by many reflectance meters, the LBGI is an effective and clinically useful on-line indicator for SH risk.