Failure to maintain the benefits of home-based intervention in adolescents with poorly controlled type 1 diabetes

OBJECTIVE: To determine whether a 6-month home-based intervention program in adolescents with poorly controlled diabetes improves metabolic control and whether benefits are maintained after the intervention. RESEARCH DESIGN AND METHODS: Adolescents with a mean HbA1c of > 9.0% over the preceding 12 months received either routine care in a diabetes clinic and an ambulatory intervention for 6 months (n = 37) or routine care only (n = 32). A diabetes educator provided monthly home visits and weekly phone contact to educate and support the adolescents in setting goals for insulin adjustment, blood glucose monitoring, and target blood glucose range. There was no systematic change in the frequency of insulin injections. After the intervention, there was a 12-month follow-up when the intervention and control groups both received only routine care. Outcome measures were HbA1c and Diabetes Knowledge Assessment (DKN). RESULTS: During the intervention, mean HbA1c fell (baseline: 11.1 +/- 1.3%, 6 months: 9.7 +/- 1.6%; P = 0.0001) and mean knowledge scores increased (P = 0.0001) in the intervention group but not in control subjects. However, this improvement in HbA1c and increase in knowledge was not maintained in the intervention group at 12- and 18-month follow-up assessments. Parents' knowledge scores also improved significantly from baseline levels in the intervention group at 6 and 12 months (P = 0.001, P = 0.005, respectively). CONCLUSIONS: An ambulatory program improves metabolic control and knowledge in adolescents with poorly controlled type 1 diabetes; however, it is effective only while the intervention is maintained.     

Parent-adolescent communication and support for diabetes management as reported by adolescents with type 1 diabetes

This study examined parental involvement in terms of communication and support and these variables in relationship to diabetes management responsibility and metabolic control from the perspective of adolescents. The sample consisted of 27 adolescents who were 12 to 19 years of age (M=15.0 years, SD=1.9) and had type 1 diabetes. Participants completed Independent Functioning, Independent Decision Making, Parent-Adolescent Communication, and Parental Support Checklists. Adolescents reported relatively high level of communication with parents and relatively low level of parental support. These adolescents reported more agreement than amount of communication with parents and reported more parental support received than sought. Although not significantly different, the means for amount of communication and agreement decreased from early to middle to late adolescence and the means for seeking and receiving support increased from early to middle and then decreased from middle to late adolescence. When working with parents and adolescents with type 1 diabetes, health care professionals need to be cognizant of adolescents' view of specific ways that parents are involved and the developmental influences on parent-adolescent relationships.     

Communication and coping intervention for mothers of adolescents with type 1 diabetes: Rationale and trial design

Mothers of adolescents with type 1 diabetes (T1D) experience high rates of depressive symptoms and diabetes distress, which are established risk factors for deteriorating glycemic control, problems with adherence, increased depressive symptoms, and poor quality of life in adolescents. Given that adolescents are a high-risk population for suboptimal glycemic control, novel interventions to improve outcomes in adolescents with T1D are needed. Building on effective interventions to treat depression in adults, and our own pilot work in this population, we developed a cognitive behavioral intervention, Communication & Coping, to target maternal depressive symptoms and parenting behaviors. The randomized controlled trial compares the telephone and Facebook-delivered Communication & Coping intervention, which promotes the use of adaptive coping strategies and positive parenting practices, to a diabetes education control condition on diabetes outcomes and psychosocial outcomes in adolescents with T1D. This paper describes the study rationale, trial design, and methodology.     

Adiponectin and leptin concentrations may aid in discriminating disease forms in children and adolescents with type 1 and type 2 diabetes

OBJECTIVE: The incidence of pediatric type 2 diabetes has recently seen an alarming increase. To improve our understanding of pediatric type 2 diabetes and identify markers that discriminate these subjects from those with type 1 diabetes, we performed a multivariant analysis associating serum adiponectin and leptin levels with anthropometrical parameters and disease state. RESEARCH DESIGN AND METHODS: Samples from children and adolescents with type 1 diabetes (n = 41) and type 2 diabetes (n = 17) and from nondiabetic individuals of similar age from the general population (n = 43) were investigated. An analysis included the parameters of matching for BMI and Tanner stage. Receiver-operator characteristic (ROC) curves were established to assess these analytes' association with disease. RESULTS: Contrary to studies of adult type 1 diabetes, adiponectin levels in our pediatric type 1 diabetic subjects (10.2 microg/ml [95% CI 8.6-11.7]) did not differ from those of healthy control subjects (10.6 microg/ml [9.2-12.0]; P = NS). Children with type 2 diabetes (5.5 microg/ml [4.8-6.2]) had significantly lower adiponectin levels than both of those groups. Conversely, type 2 diabetic subjects showed marked elevations in serum leptin concentrations (24.3 ng/ml [17.1-31.5]) compared with healthy control subjects (2.7 ng/ml [1.3-4.1]; P < 0.001) and type 1 diabetic subjects (5.1 ng/ml [3.5-6.7]; P < 0.001). Importantly, each of the properties ascribed to pediatric type 2 diabetes was present when the comparison was restricted to healthy children or type 1 diabetic patients whose BMI was >85th percentile or who had Tanner stage 4 and 5. The evaluation of adiponectin-to-leptin ratios revealed a striking difference between children with type 1 diabetes (6.3 [3.8-8.8]) and type 2 diabetes (0.3 [0.2-0.5]; P < 0.001). CONCLUSIONS: In pediatric diabetes, where diagnosis of disease is often difficult, these studies suggest that the adiponectin-to-leptin ratio may provide additional help in the discrimination between type 1 and type 2 diabetes.     

Prevalence of diabetes complications in adolescents with type 2 compared with type 1 diabetes

OBJECTIVE: To compare the prevalence of diabetes complications and their risk factors in youth with type 1 versus type 2 diabetes. RESEARCH DESIGN AND METHODS: We performed a comparative clinic-based study of 1,433 patients with type 1 diabetes and 68 patients with type 2 diabetes aged <18 years from New South Wales, Australia. Retinopathy was assessed by seven-field stereoscopic retinal photography; albumin excretion rate from three consecutive, timed, overnight urine collections; peripheral neuropathy by thermal and vibration threshold; and autonomic neuropathy by pupillometry. HbA(1c) (A1C) and lipids were measured in all patients and C-peptide in patients with type 2 diabetes. RESULTS: In patients with type 1 versus type 2 diabetes, median (interquartile range) age was 15.7 years (13.9-17.0) and 15.3 years (13.6-16.4), respectively (P = 0.2), whereas median diabetes duration was 6.8 years (4.7-9.6) and 1.3 years (0.6-3.1), respectively (P < 0.0001). Retinopathy was significantly more common in patients with type 1 diabetes (20 vs. 4%, P = 0.04), while microalbuminuria and hypertension were significantly less common (6 and 16% in type 1 diabetes vs. 28 and 36% in type 2 diabetes). Rates of peripheral and autonomic neuropathy were similar (27 and 61% in type 1 diabetes vs. 21 and 57% in type 2 diabetes). In multivariate analyses, microalbuminuria was significantly associated with older age (odds ratio 1.3 [95% CI 1.2-1.5], P < 0.001) and systolic hypertension (3.63 [2.0-6.3], P < 0.001) in type 1 diabetes, while only higher A1C (1.7 [1.3-2.9], P = 0.002) was significant in patients with type 2 diabetes. CONCLUSIONS: Youth with type 2 diabetes have significantly higher rates of microalbuminuria and hypertension than their peers with type 1 diabetes, despite shorter diabetes duration and lower A1C. The results of this study support recommendations for early complications screening and aggressive targeting of glycemic control in patients with type 2 diabetes.     

Living with type 1 diabetes: perceptions of children and their parents

Aim. To explore and describe the experiences of children and their parents living with type 1 diabetes mellitus from diagnosis onwards. Background. Type 1 diabetes mellitus is a psychologically and behaviourally demanding chronic condition that necessitates children and their parents taking extensive responsibility for managing the condition. Diabetes management involves maintaining a highly effective level of treatment to reduce the risks of short‐ and long‐term complications. Treatment is carried out in the context of daily life, but little research evidence is available about this experience. Design. A phenomenological study using conversational interview. Method. A purposive sample of 10 children, (aged 4–17) living with type 1 diabetes mellitus and their parents participated in this study. Participants were from different ethnic backgrounds and at differing lengths of time since diagnosis. Data were generated through conversational interviews and analysed using thematic analysis. Results. The central theme that was identified was ‘normal’. This was underpinned by four subthemes: transition, attachment, loss and meaning. The notion of ‘normal’ is dominant in the lives of these children and their parents because diabetes not only makes these families different, but also makes their pursuit of ‘normal’ more visible. Conclusion. These findings highlight that, despite different cultures, ages and lengths of time since diagnosis, families living with diabetes share very similar experiences. Understanding how children and parents create meaning and how this meaning influences their actual and potential health problems, is important if the provision of healthcare is to be effective in meeting their needs. Relevance to clinical practice. Conducting child‐ and parent‐centred qualitative research allows exploration of the perceptions and understanding of type 1 diabetes mellitus and the meaning ascribed by children and their parents who live with the condition. Diabetes is a lifelong, life‐threatening condition that has a significant impact on children’s and parents’ lives. Developing a deeper understanding of their lives and experiences will enable the delivery of nursing care to meet their specific needs.     

The development and psychometric testing of an instrument to measure diabetes management self-efficacy in adolescents with type 1 diabetes

Adherence to treatment is a major issue for people with diabetes mellitus, and attention has been given to improving self-management in persons with this chronic disease. Most studies show that knowledge alone will not improve self-management behavior. Self-efficacy, a concept introduced by Bandura, has been shown to be an important variable in improving health behaviors. In order to determine whether self-efficacy can influence self-management of diabetes, however, instruments to measure self-efficacy are needed in native languages at an appropriate developmental level, and with good psychometric properties. The study reported here was part of a larger project in the Netherlands, Belgium and the United States in which several instruments, measuring diabetes management self-efficacy, have been developed, both in English and Dutch, for different types of diabetes and different age groups. This article reports on the development and psychometric testing of an instrument measuring self-efficacy in adolescents with type 1 diabetes mellitus. Initially 30 items for the instrument were generated through focus group interviews and their relevance was judged by a team of 10 experts on self-management behavior in adolescents. The final instrument contained 26 items. The sample for psychometric testing consisted of 90 patients with type 1 diabetes who were between 12 and 18 years old. Cronbach's alpha of the instrument was 0.86. An exploratory factor analysis produced two factors which reflect general and more difficult diabetes self-management situations.     

Chronic sorrow in parents of children with type 1 diabetes

Title.  Chronic sorrow in parents of children with type 1 diabetes.
Aim.  This paper reports on a study exploring parents' longer-term experiences of having a child with type 1 diabetes.
Background.  Parents of children with type 1 diabetes may experience a grief reaction at diagnosis similar to that normally associated with bereavement, but little is known about their long-term emotional adaptation. Chronic sorrow, a sustained but intermittent grief reaction, is identified in adults with diabetes but has not previously been explored in relation to parents.
Methodology.  In-depth interviews were conducted in 2007 with a convenience sample of 17 parents of children with type 1 diabetes 7–10 years after diagnosis. Data were explored within a theoretical framework of grief, loss, adaptation, and change.
Findings.  Parents had adapted to the needs of diabetes management but most had not 'come to terms' with the diagnosis. They experienced a resurgence of grief at critical times during their child's development and some, particularly mothers, became upset during their interviews, even though these took place 7–10 years after their child's diagnosis. Mothers elaborated more on their emotions than fathers, but continuing feelings associated with grief, such as anger and guilt, were expressed by both fathers and mothers.
Conclusion.  Greater understanding of parents' long-term emotional responses and recognition that grief may never resolve in these parents may enable healthcare professionals to provide appropriate and timely support at critical times.     

Perceptions of psychosocial support groups by parents who have a child with diabetes: a needs analysis

Psychosocial support groups play an important role in assisting parents to understand and manage the demands of having a child with diabetes. Actual participation in such groups is marred by problems of poor uptake, irregular attendance and attrition. A survey was conducted with a convenience sample of parents to determine their knowledge needs about preferred program characteristics, the management of diabetes, perceived barriers to program participation, and factors facilitating group attendance. A response rate of 66% (n = 40) was achieved. Parents favoured a program that was only conducted monthly or three to six times a year, held during the evening or weekend and of two or three hours duration. Parents were keen to know more about new developments in the treatment of diabetes, and strategies to assist their child when they refuse medication or treatment. The most commonly reported barriers to group attendance were distance, timing of groups, and employment demands. Participants were more likely to attend a support group in order to learn new information or skills, keep up to date, as well as meet parents in the same situation. Support groups need to address both content and practical issues for enhanced support and empowerment of families.     

An evaluation of an online intervention to provide social support and health education

Managing chronic illness in the isolation of rural environments is challenging for women who lack access to personal sources of social support and health information. The Women to Women project was designed to provide chronically ill rural women access to support and health information via electronic means. This article reports on the acquisition of computer skills, the perceptions of importance of various aspects of the intervention, and an assessment of women's overall satisfaction with participation in the research project. Findings indicate that the women's self-ratings of computer skills improved significantly over the 22-week intervention and that highly interactive features of the project were rated as most important by the participants. Overall, women found the program beneficial in assisting them to better manage their chronic illness.     

Early loss of the glucagon response to hypoglycemia in adolescents with type 1 diabetes

OBJECTIVE

To assess the glucagon response to hypoglycemia and identify influencing factors in patients with type 1 diabetes compared with nondiabetic control subjects.

RESEARCH DESIGN AND METHODS

Hyperinsulinemic hypoglycemic clamp studies were performed in all participants. The glucagon response to both hypoglycemia and arginine was measured, as well as epinephrine, cortisol, and growth hormone responses to hypoglycemia. Residual β-cell function was assessed using fasting and stimulated C-peptide.

RESULTS

Twenty-eight nonobese adolescents with type 1 diabetes (14 female, mean age 14.9 years [range 11.2–19.8]) and 12 healthy control subjects (6 female, 15.3 years [12.8–18.7]) participated in the study. Median duration of type 1 diabetes was 0.66 years (range 0.01–9.9). The glucagon peak to arginine stimulation was similar between groups (P = 0.27). In contrast, the glucagon peak to hypoglycemia was reduced in the group with diabetes (95% CI): 68 (62–74) vs. 96 (87–115) pg/mL (P < 0.001). This response was greater than 3 SDs from baseline for only 7% of subjects with type 1 diabetes in comparison with 83% of control subjects and was lost at a median duration of diabetes of 8 months and as early as 1 month after diagnosis (R = −0.41, P < 0.01). There was no correlation in response with height, weight, BMI, and HbA_1c. Epinephrine, cortisol, and growth hormone responses to hypoglycemia were present in both groups.

CONCLUSIONS

The glucagon response to hypoglycemia in adolescents with type 1 diabetes is influenced by the duration of diabetes and can be lost early in the course of the disease.Hypoglycemia is a complication of insulin therapy of type 1 diabetes that can cause significant morbidity and rarely, mortality; as a result, it proves a significant barrier to contemporary targets for glycemic control (1). Young people with type 1 diabetes are especially prone to hypoglycemia due to the nonphysiological nature of insulin therapy, as well as defective counterregulation (1–4). Impairment of the glucagon response to hypoglycemia is well documented in adult patients with long-standing diabetes (2,5); however, the natural history and underlying pathophysiology have not been well characterized in children and adolescents. Studies with small sample numbers suggested that the glucagon response to hypoglycemia is lost during the first months after diagnosis of type 1 diabetes (6,7), but this remains to be studied further.The purpose of this study was to 1) assess the glucagon response to both hypoglycemia and arginine as an independent stimulus in adolescents with type 1 diabetes with a range of diabetes duration, as well as in healthy control subjects, and 2) identify clinical and demographic factors that predict the glucagon response to hypoglycemia.     

1型糖尿病患儿父母亲职压力影响因素及干预措施的研究进展

阐述亲职压力的概念,综述1型糖尿病患儿父母亲职压力的现状、影响因素及干预措施。指出临床医护工作者可借鉴国外研究成果,从疾病管理、自我效能及应对方式等可控性因素入手,通过评估父母照顾问题及需求,为其提供疾病管理支持与协调服务,通过心理干预加强父母疾病管理自我效能和积极应对方式。同时探讨1型糖尿病患儿父母亲职压力的根源,制定针对性的干预措施。     

Nondipping and its relation to glomerulopathy and hyperfiltration in adolescents with type 1 diabetes

OBJECTIVE: To determine whether there is a relation between dipping/nondipping status and end-organ damage (measured as renal glomerulopathy) and long-term renal function in order to predict the development of nephropathy in normoalbuminuric patients with type 1 diabetes. RESEARCH DESIGN AND METHODS: Analysis of renal biopsy and ambulatory blood pressure measurements was done in relation to renal function tests performed during a 10-year period. Forty unselected patients (16 girls), with a mean age of 17.7 years and a mean duration of 10.7 years, were studied. The renal biopsies were examined by electron microscopy. Ambulatory blood pressure was monitored (Space Labs 90 207). Systolic nondippers were defined as a <7%, diastolic nondippers as a <14%, and mean arterial blood pressure (MAP) nondippers as a <12% fall in blood pressure during the night. Renal function was evaluated every other year by clearances of inulin (glomerular filtration rate [GFR]) and para-amino hippurate (effective renal plasma flow [ERPF]), and filtration fraction (GFR/ERPF) was calculated. Overnight urinary albumin excretion rate and long-term mean HbA(1c) were measured. RESULTS: MAP (27% of the patients) and diastolic nondippers (12%) had a significantly thicker basement membrane; larger mesangial matrix volume fraction; and higher long-term GFR, nighttime heart rate, and mean HbA(1c) than dippers. CONCLUSIONS: Nondipping status was related to more renal morphological changes and long-term hyperfiltration in normoalbuminuric adolescents and young adults, despite a short duration of type 1 diabetes. Nondipping status may be an early predictor of later nephropathy.     

What adolescents with type I diabetes and their parents want from testing technology: a qualitative study

The presence of diabetes in an adolescent can significantly affect his/her normal development. Mobile technology may offer the ability to lessen this negative impact. We wished to learn from adolescents with diabetes and their parents how monitoring systems that incorporated mobile communication technology could potentially help to reduce hassles associated with testing, improve compliance, and ease adolescent-parent conflict about testing behavior. We recruited adolescents between the ages of 13 and 18 years, living with type 1 diabetes mellitus and their parents for focus groups. Qualitative analysis of the focus group data followed a set procedure. From the discussions, the following themes were identified: issues with blood glucose monitoring and desired technology. Elements of desired technology included hardware requirements, software requirements, communication, and miscellaneous requirements. The reported needs of this end-user group can help others to leverage maximally the capabilities of new and existing technology to care for children managing chronic disease.     

Heart rate variability in adolescents and adults with type 1 diabetes

BACKGROUND: Limited data are available regarding the onset or trajectory of cardiovascular autonomic deterioration in persons with type 1 diabetes. OBJECTIVE: To describe differences in heart rate variability among adolescents with type 1 diabetes, adults with type 1 diabetes who have coexisting renal failure, and adolescent and adult controls. RESEARCH DESIGN AND METHODS: A correlational design was used to compare the status of heart rate variability in adults with type 1 diabetes and renal failure (n = 62); healthy adult controls (n = 67); adolescents with type 1 diabetes (n = 55); and healthy adolescent controls (n = 28). Convenience samples of adult patients with diabetes awaiting kidney or pancreas and kidney transplantation, and adolescents with diabetes were recruited from local university-based clinics. Volunteers served as healthy controls. The short-term R-R variability measures included in this study were changes in heart rate with deep breathing and with the Valsalva maneuver. Twenty-four hour ambulatory heart rate monitoring with power spectral analysis was also obtained to assess longterm R-R variability. RESULTS: Adult patients with type 1 diabetes awaiting transplantation had significantly poorer heart rate variability measures than any of the other three populations studied (p < .0001). Adult control values also were significantly lower than either teenage controls or youths with diabetes (p < .05). Although most long-term R-R variability measures were lower in adolescents with diabetes versus controls, only one measure of parasympathetic modulation (i.e., pNN50) was significantly lower (p = .042). There were significant negative associations between HbA1c and sympathetic modulation (i.e., low hertz) in both the adult group (r= -.406, p = .029) and the adolescent group (r= -.324, p = .025) with diabetes. CONCLUSIONS: Type 1 diabetes is associated with decreased heart rate variability, with the extent of the decrease related to the age of the individual and the severity of the disease.