Race and sex differences in metabolic control of adolescents with IDDM: a function of psychosocial variables?

Race and sex differences have been reported in the prevalence of complications from insulin-dependent diabetes mellitus (IDDM). Because metabolic control is assumed to be associated with the probability of developing future complications, race and sex differences in metabolic control were assessed in a group of adolescents. Subjects were 27 Black and 27 White adolescents who were similar in age, age at diagnosis, and social class. Girls did not differ on number of days since their last menses. A 2-by-2 (race-by-sex) analysis of variance revealed that the Black female group had worse HbA1c than each of the other groups (P less than .012). Multivariate analyses of variance were conducted to determine whether the poor metabolic control of the Black girls was associated with pertinent psychosocial variables. The analyses revealed that their poor control was not associated with a deficiency in the girls' knowledge about IDDM, adherence to treatment, self-concept, coping patterns, family functioning, stress, social support, or involvement in the health-care system. If the poor control of the Black girls is not associated with psychosocial deficiencies, biological variables or psychosocial variables not assessed in this study are probably operative.     

Supportive and nonsupportive family behaviors: relationships to adherence and metabolic control in persons with type I diabetes

The Diabetes Family Behavior Checklist (DFBC) was administered to 54 adults and 18 adolescents (less than 19 yr of age) with insulin-dependent diabetes mellitus (IDDM). Subjects and family members completed parallel forms of the DFBC at initial and 6-mo follow-up home interviews. During each of these periods, adherence was assessed via self-report, 1 wk of self-monitoring, and 24-h dietary recalls. The results showed reliable differences between adolescents and adults. More negative interactions with family members were reported by adolescents and their family members, and adolescents were in poorer metabolic control. For adults but not adolescents, negative DFBC scores were prospectively predictive of poorer regimen adherence over the 6-mo interval for measures of glucose testing, insulin injection, and dietary adherence. In addition, higher negative DFBC scores for adults were marginally associated with higher HbA1 levels (P less than 0.10). We conclude that the DFBC is a promising measure of family interaction related specifically to the IDDM regimen and that, for adults, higher levels of nonsupportive family behaviors may be related to reduced regimen adherence and poor control.     

Adherence to IDDM regimens: relationship to psychosocial variables and metabolic control

Thirty-four adolescents (ages 12-14 yr) with IDDM completed a questionnaire assessing regimen adherence over the previous week and psychosocial measures potentially related to adherence. Four aspects of the IDDM regimen were studied: insulin injections, dietary patterns, glucose testing, and exercise. Psychosocial variables included (1) Social Learning Theory measures of diabetes-specific family behaviors and barriers to adherence and (2) more general measures of family interaction. Glycosylated hemoglobin levels were predicted accurately (R = 0.68) from a combination of three adherence measures. The psychosocial measures were not directly related to metabolic control, but they were associated with adherence. Degree of adherence to one aspect of the IDDM regimen was not related to adherence to other aspects of the regimen and different psychosocial variables predicted adherence to different regimen components. The diabetes-specific measures were generally more predictive of adherence than were the more global measures. Implications and limitations of this cross-sectional, correlational study were discussed.     

Coping and adaptation in children with diabetes

The purpose of this study was to investigate the influence of age, coping behavior, and self-care on psychological, social, and physiologic adaptation in preadolescents and adolescents with diabetes. Children (N = 103) with insulin-dependent diabetes mellitus (IDDM) between 8 and 18 years of age and their parents participated in the study. Findings indicated that preadolescent children were significantly less depressed, less anxious, coped in more positive ways, had fewer adjustment problems, and were in better metabolic control than their adolescent counterparts. Age and secondary sexual development were related to psychosocial adaptation and metabolic control of the diabetes. Further, those who coped by avoiding their problems and who were more depressed were the most likely to have problems in both adjustment and metabolic control with 56% of the variance in metabolic control explained by the variables studied. These findings indicate that preadolescents and adolescents cope differently with a chronic illness, and that interventions should be designed to identify and help those with inappropriate coping styles.     

Relationship of self-efficacy and binging to adherence to diabetes regimen among adolescents.

OBJECTIVE--To test the hypothesis that poorer adherence to diabetes care is related to four variables associated with self-concept in adolescents with diabetes: self-esteem, self-efficacy, depression, and binging behavior. In addition, we expected adolescent females to be less adherent to diabetes care. RESEARCH DESIGN AND METHODS--We recruited 193 consecutive patients (aged 13-18 yr) with insulin-dependent diabetes mellitus during their regular quarterly visit to a diabetes clinic in a large urban hospital. Participants completed the Rosenberg Self-Esteem Scale, the Children's Depression Inventory, an assessment of the frequency of binging in the past 3 mo, and parallel forms of an adherence scale and a self-efficacy scale that were developed for use in this study. RESULTS--Adolescents who reported lower adherence tended to report lower self-esteem (r = 0.45, P less than 0.001) and self-efficacy (r = 0.57, P less than 0.001), more depressive symptoms (r = -0.50, P less than 0.001), more binging (r = -0.36, P less than 0.001), and had higher HbA1c (r = -0.24, P less than 0.001) than those with higher adherence scores. Together, the psychological variables accounted for 50% of the variance in adherence. There was no sex difference in reported binging, but, as expected, adolescent females reported less adherence overall (F[7,184] = 2.5, P = 0.018). CONCLUSIONS--Treatment adherence in adolescents with insulin-dependent diabetes mellitus is associated with behavioral and psychological variables. These findings suggest that specific behavioral and cognitive interventions could be used to improve adherence in those individuals who lack confidence in their ability to perform diabetes-related tasks.     

Discordance between physician and adolescent assessments of adherence to treatment: influence of HbA1c level. The PEDIAB Collaborative Group.

OBJECTIVE: To compare the subjective assessments (perceptions) of physicians and adolescent diabetic patients on the adolescents' adherence to treatment and to test the hypothesis that the HbA1c level influences physicians' perceptions. RESEARCH DESIGN AND METHODS: In a multicenter cross-sectional survey, 143 adolescents with diabetes (mean age 14.6 years) auto-assessed, while their pediatricians independently assessed, the level of adherence to treatment on a four-point scale. Scores of adherence given by a validated scale and metabolic control (HbA1c) were compared according to those assessments. RESULTS: Agreement between the adherence perceptions from adolescents and physicians was low (kappa = 0.23), and adolescents scored significantly higher (P < 0.001). Mean adherence score to diabetes treatment was significantly higher when the adolescents' perception of their self-care behaviors was good than when it was poor (P = 0.01), but did not significantly differ according to physicians' perception. Mean HbA1c level was significantly lower when the self-care behavior perception was good than when it was poor, both for the adolescents (P = 0.02) and for the physicians (P < 0.001). Multivariate analyses showed that only the adherence scale score was significantly associated with the adolescents' perception (P = 0.015), whereas only HbA1c level was significantly associated with the physicians' perception (P = 0.0008). CONCLUSIONS: By identifying the possible discrepancy between their own assessment of adherence and that of adolescents, and by avoiding the systematic attribution of poor metabolic control to poor adherence, physicians could generate a more confident and collaborative relationship with diabetic adolescents and therefore facilitate adolescents' self-management.     

Good metabolic control is associated with better quality of life in 2,101 adolescents with type 1 diabetes.

OBJECTIVE: It is unclear whether the demands of good metabolic control or the consequences of poor control have a greater influence on quality of life (QOL) for adolescents with diabetes. This study aimed to assess these relations in a large international cohort of adolescents with diabetes and their families. RESEARCH DESIGN AND METHODS: The study involved 2,101 adolescents, aged 10-18 years, from 21 centers in 17 countries in Europe, Japan, and North America. Clinical and demographic data were collected from March through August 1998. HbA(1c) was analyzed centrally (normal range 4.4-6.3%; mean 5.4%). Adolescent QOL was assessed by a previously developed Diabetes Quality of Life (DQOL) questionnaire for adolescents, measuring the impact of diabetes, worries about diabetes, satisfaction with life, and health perception. Parents and health professionals assessed family burden using newly constructed questionnaires. RESULTS: Mean HbA(1c) was 8.7% (range 4.8-17.4). Lower HbA(1c) was associated with lower impact (P < 0.0001), fewer worries (P < 0.05), greater satisfaction (P < 0.0001), and better health perception (P < 0.0001) for adolescents. Girls showed increased worries (P < 0.01), less satisfaction, and poorer health perception (P < 0.01) earlier than boys. Parent and health professional perceptions of burden decreased with age of adolescent (P < 0.0001). Patients from ethnic minorities had poorer scores for impact (P < 0.0001), worries (P < 0.05), and health perception (P < 0.01). There was no correlation between adolescent and parent or between adolescent and professional scores. CONCLUSIONS: In a multiple regression model, lower HbA(1c) was significantly associated with better adolescent-rated QOL on all four subscales and with lower perceived family burden as assessed by parents and health professionals.     

Effects of peer-group intervention on metabolic control of adolescents with IDDM. Randomized outpatient study

In children with insulin-dependent diabetes mellitus (IDDM), deterioration in metabolic control frequently occurs during early adolescence. To prevent this predictable increase in blood glucose levels, we randomly assigned young adolescents with IDDM to an intervention based on problem solving with self-monitoring of blood glucose (SMBG) integrated into standard outpatient care or to standard care only for an 18-mo period. At follow-up, 50% of the standard-care adolescents exhibited greater than 1% increase in glycosylated hemoglobin (HbA1) levels over baseline values, indicating a deterioration in metabolic control, compared to only 23% of the intervention group. Follow-up HbA1 means +/- SD were 10.10 +/- 2.00% for intervention and 11.04 +/- 2.28% for standard-care adolescents, indicating a significantly lower value in the intervention group (P = .04). At follow-up, a greater percentage of intervention than standard-care adolescents reported using SMBG information when they exercised (60.0 vs. 33.3%, chi 2 = 4.29, P = .04). Our data suggest that clinic-based problem-solving groups can be more effective with young adolescents with IDDM than conventional treatment in preventing the expected deterioration in blood glucose.     

Relating familial stress to the psychosocial adjustment of adolescents with Duchenne muscular dystrophy.

Adolescence is a time that offers significant challenges to families dealing with Duchenne muscular dystrophy (DMD). A major developmental task in the adjustment process for the adolescent is the achievement of a sense of self-identity. Mastering stress in families of adolescents with DMD has also been shown to be a major task in the adjustment process for the family. In this study, the relationships between familial stress and psychosocial adjustment in adolescents with DMD were investigated. The study participants (36 caregivers and 32 adolescents) were all registered with the Muscular Dystrophy Association of Canada and all resided in the province of Ontario. The Offer Self-Image Questionnaire for Adolescents (Offer et al., 1982, 1989) was used to measure psychosocial adjustment of adolescents with DMD. Family stress was measured by the Questionnaire on Resources and Stress (Holroyd, 1987). All but a few of the participants were interviewed and completed self-report instruments in their own homes. The other families were interviewed in other settings (e.g., clinic, adolescent's school). The results indicate that, overall and in several specific areas, the adolescents demonstrate lower levels of psychosocial adjustment than their normal reference group. The results also indicate that familial stress is not related to sociodemographic variables, but is associated with psychosocial adjustment in the adolescent (P = 0.0004), and with intellectual function of the adolescent (P = 0.001). In fact, the results of a regression analysis show that the level of stress experienced by the family predicts the degree of psychosocial adjustment of the adolescent with DMD (R2 = 0.38, P = 0.0003). These findings underscore the importance of a holistic approach with these families. Limitations of the study, and implications of the results, are discussed in terms of clinical practice and future research.     

Diabetes regimen behaviors. Predicting adherence

In this study, Social Learning Theory was used to generate psychosocial predictors of regimen adherence among persons with insulin-dependent diabetes mellitus (IDDM). Four categories of predictors were formed: knowledge, expectancies, skills, and environmental support. Persons with IDDM (84 adults and 23 adolescents) completed measures within each predictor category on two occasions, separated by 6 months. Multimethod assessment procedures (self-monitoring, interviews, mechanical devices) were used to measure adherence to four aspects of the IDDM regimen: insulin injections, glucose testing, diet, and exercise. Bivariate analyses demonstrated that measures of expectancies and environmental support were reliably related to several adherence behaviours. In particular, self-efficacy expectations were related to adherence across almost all regimen areas for both adolescents and adults. Skills were also important, though only for adolescents, whereas regimen knowledge was unrelated to adherence for either adults or adolescents. Multivariate analyses showed that expectancies were consistently predictive of adherence and that, in general, psychosocial variables were better predictors of insulin administration and glucose testing than of diet or exercise. The implications of these findings for diabetes education programs are discussed.     

Adolescents with type 1 diabetes: family functioning and metabolic control

Families play central roles in the care of their adolescents with chronic illnesses. This study examined the relationship between family functioning and metabolic control in adolescents with Type 1 diabetes. The McMaster Family Assessment Device (FAD) measured family functioning; the Youth Self-Report Form (YSR) measured adolescent behavior. Older adolescents reported increased family dysfunction. Adolescents who reported family dysfunction on affective responsiveness had HbA(1c) levels greater than 9. Older adolescents, males, and adolescents who reported a greater number of behavior problems were significantly more likely to have HbA(1c) levels greater than 9. Considered together, older age and greater attention problems were most significantly associated with higher HbA(1c) levels. These findings suggest the importance of the relationship between the adolescent's perception of family functioning and metabolic control in the adolescents with Type 1 diabetes.     

Effect of temperament on metabolic control in children with diabetes mellitus

Fifty-one children with insulin-dependent diabetes mellitus (IDDM) and 24 healthy sibling controls were compared on one of two temperament questionnaires completed by parents. Children with IDDM did not provide a characteristic temperament profile or show any problem areas. A regression analysis to predict diabetic control as measured by most recent glycosylated hemoglobin (HbA1c) values revealed that five of the nine temperament scales accounted for a significant 42% of the variance in HbA1c (P less than .001). Children with higher activity levels, greater regularity in routines, milder reactions to external stimuli, distractibility, and negative moods were achieving better glycemic control. The results are discussed in terms of how individual differences in behavioral organization, energy consumption, and stress modulation may affect blood glucose levels.     

Attributions of adolescents with type 1 diabetes in social situations: relationship with expected adherence, diabetes stress, and metabolic control

OBJECTIVE: To examine the relationships among negative attributions of friend reactions (NAFRs) within a social context, anticipated adherence difficulties, diabetes stress, and metabolic control. RESEARCH DESIGN AND METHODS: A sample of 104 adolescents with type 1 diabetes completed instruments measuring demographics, attribution of friend reactions, anticipated adherence, and diabetes stress. Metabolic control was measured by HbA(1c) obtained during the clinic visit. RESULTS: Path analysis demonstrated an excellent fit of a model depicting an indirect relationship between NAFRs and metabolic control through the mechanisms of expected adherence difficulties and diabetes stress. CONCLUSIONS: Adolescents who make NAFRs are likely to find adherence difficult in social situations and have increased feelings of stress, with the latter associated with poorer metabolic control. Intervention efforts to address negative attributions may impact adherence behavior and feelings of stress, especially if specific contexts of self-care behavior are taken into account.     

Race-related differences in metabolic control among adults with diabetes.

The effect of race on differences in metabolic control was examined in patients with non-insulin-dependent (NIDDM) and insulin-dependent (IDDM) diabetes mellitus. Data were collected on HbA1c, age, duration of diabetes, age at onset, family function, stress, body mass index, waist/hip ratio, total cholesterol, insulin dose, diet, and physical activity. Among those with NIDDM, black patients had significantly higher HbA1c levels than their white counterparts. This difference persisted after adjustment for covariates. Among patients with IDDM, black subjects were found to have higher HbA1c levels, body mass index, and total cholesterol levels than their white counterparts. After correction for diabetes duration, relative insulin dose, physical activity, body mass index, and cholesterol, black women had significantly higher HbA1c levels than black men, white men, or white women. We conclude that race and sex differences do affect the metabolic control of patients with diabetes mellitus.     

The association between diabetes metabolic control and drug adherence in an indigent population

OBJECTIVE: Studies of the association between diabetes metabolic control and adherence to drug therapy have yielded conflicting results. Because low socioeconomic and minority populations have poorer diabetes outcomes and greater barriers to adherence, we examined the relationship between adherence and diabetes metabolic control in a large indigent population. RESEARCH DESIGN AND METHODS: The study population consisted of patients receiving medical care from a university-based internal medicine clinic serving a low-income population in rural central Virginia. The sample comprised 810 patients with type 2 diabetes who received oral diabetes medications from the clinic pharmacy and had at least one HbA(1c) determination during the study period. Multiple linear regression was used to examine the association of HbA(1c) level as well as change in HbA(1c) level with medication adherence, demographic, and clinical characteristics. RESULTS: Better metabolic control was independently associated with greater medication adherence, increasing age, white (versus African-American) race, and lower intensity of drug therapy. For each 10% increment in drug adherence, HbA(1c) decreased by 0.16% (P < 0.0001). Controlling for other demographic and clinical variables, the mean HbA(1c) of African-Americans was 0.29% higher than that of whites (P = 0.04). Additionally, the intensity of diabetes drug therapy for African-Americans was lower, as was their measured adherence to it. There was no association between metabolic control and gender, income, encounter frequency, frequency of HbA(1c) testing, or continuity of care. CONCLUSIONS: Adherence to medication regimens for type 2 diabetes is strongly associated with metabolic control in an indigent population; African-Americans have lower adherence and worse metabolic control. Greater efforts are clearly needed to facilitate diabetes self-management behaviors of low-income populations and foster culturally sensitive and appropriate care for minority groups.     

Racial differences in metabolic control of children and adolescents with type I diabetes mellitus

OBJECTIVE: This study evaluated racial differences in the metabolic control of children and adolescents with insulin-dependent (type I) diabetes mellitus and examined the interactive effects of race with age and sex. RESEARCH DESIGN AND METHODS: Data on several demographic and clinical variables were obtained for 102 black and 108 white children, including the percentage of total HbA1, age, age at diagnosis, duration of diabetes, pubertal status, insulin dose (U.kg-1.day-1), body mass index, number of clinic visits kept and missed, number of hospitalizations for diabetic ketoacidosis (DKA) for the year, and socioeconomic status (SES). RESULTS: Black children had higher insulin dosages (P less than 0.05) and lower SESs (P less than 0.001) than white children. HbA1 was higher in black than white children (P less than 0.01) after statistically adjusting for the effects of insulin dose, diabetes duration, and SES. With HbA1-based criteria, more black than white children were in poor and fewer in good metabolic control (P less than 0.001). Older children (greater than or equal to 13 yr) had higher HbA1 levels than younger (less than 13 yr) children (P less than 0.002), but there were no differences in HbA1 between males and females nor were there interactive effects of race, sex, and age-group. Black children were hospitalized for DKA more frequently than white children (P less than 0.04). More black than white children missed clinic visits (P less than 0.01), but they did not differ in number of visits kept. CONCLUSIONS: Black youths with type I diabetes mellitus are in poorer metabolic control than white youths.     

Effects of a physical activity program on metabolic control and cardiovascular fitness in children with insulin-dependent diabetes mellitus

The purpose of this investigation was to determine the effects of a regular vigorous physical activity program on children aged 5-11 yr with insulin-dependent diabetes mellitus (IDDM). The experimental group of children (N = 9) took part in a 30-min vigorous exercise program three times a week for 12 wk; the control group (N = 10) did not. Hemoglobin A1 (HbA1) and fasting blood glucose (FBG) were used to determine metabolic control. Oxygen consumption was evaluated by treadmill testing and analyses of expired air. The experimental group significantly (P less than 0.05) decreased their HbA1 and FBG while the control group showed no change. The experimental group significantly (P less than 0.05) increased their peak aerobic capacity (ml/kg . min) when compared with baseline values (47.14 +/- 1.94 versus 50.69 +/- 1.30). It was concluded that a carefully applied program of regular vigorous physical activity can beneficially influence metabolic control and cardiovascular fitness in young children with IDDM.     

Continuous subcutaneous insulin infusion. A new way to lower risk of severe hypoglycemia, improve metabolic control, and enhance coping in adolescents with type 1 diabetes.

OBJECTIVE: Recommendations from the Diabetes Control and Complications Trial (DCCT) indicate that adolescents with type 1 diabetes should be treated with intensive therapy involving multiple daily injections (MDI) of insulin or insulin pump therapy (continuous subcutaneous insulin infusion [CSII] to help obtain better metabolic control and prevent later complications. Interest has thus focused on insulin pump therapy to help adolescents meet this challenge. The purpose of this study was to examine responses to CSII and MDI in a large group of adolescents with established type 1 diabetes during a 12-month period and to determine whether either treatment regimen more favorably affected clinical and psychosocial outcomes. RESEARCH DESIGN AND METHODS: One-third of 75 youths aged 12-20 years who were candidates for intensive therapy chose CSII as their mode of treatment. Patients received intensive treatment and education as described by the DCCT investigators. Psychosocial data (e.g., quality of life, depression, self-efficacy, and coping) were collected at baseline and at 6-month intervals, and clinical data (e.g., HbA1c levels, adverse events) were collected every 4-6 weeks. RESULTS: Although both MDI- and CSII-treated adolescents initially exhibited improved metabolic control, this level of control was more difficult to sustain for 12 months in the MDI group (at 6 months HbA1c = 8.1, at 12 months HbA1c = 8.3), whereas average HbA1c levels in the CSII group continued to decrease during the 12 months of treatment (at 6 months HbA1c = 7.7, at 12 months HbA1c = 7.5). Despite lower HbA1c levels in CSII-versus MDI-treated patients, the rate of severe hypoglycemic events was reduced by almost 50% in the CSII group (P = 0.01). Self-reported questionnaires demonstrated that there was improvement in self-efficacy, depression, and quality of life in both MDI- and CSII-treated patients. Finally, adolescents using CSII found coping with diabetes to be less difficult than adolescents using MDI did. CONCLUSIONS: CSII is an alternative means to lower HbA1c levels and reduce the risk of hypoglycemia without adversely affecting psychosocial outcomes in adolescents with type 1 diabetes.     

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

OBJECTIVE: To understand the impact of family structure on the metabolic control of children with diabetes, we posed two research questions: 1) what are the differences in sociodemographic, family, and community factors between single-mother and two-parent families of diabetic children? and 2) to what extent do these psychosocial factors predict metabolic control among diabetic children from single-mother and two-parent families? RESEARCH DESIGN AND METHODS: This cross-sectional study included 155 diabetic children and their mothers or other female caregivers. The children were recruited if they had been diagnosed with diabetes for at least 1 year, had no other comorbid chronic illnesses, and were younger than 18 years of age. Interviews and self-report questionnaires were used to assess individual, family, and community variables. RESULTS: The findings indicate that diabetic children from single-mother families have poorer metabolic control than do children from two-parent families. Regression models of children's metabolic control from single-mother families indicate that age and missed clinic appointments predicted HbA1c levels; however, among two-parent families, children's ethnicity and adherence to their medication regimen significantly predicted metabolic control. CONCLUSIONS: This study suggests that children from single-mother families are at risk of poorer metabolic control and that these families have more challenges to face when raising a child with a chronic illness. Implications point to a need for developing strategies sensitive to the challenges of single mothers.