Brief report: disordered eating and psychosocial factors in adolescent females with type 1 diabetes mellitus

OBJECTIVE: To evaluate whether insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] is associated with a lower frequency of disordered eating, better glycemic control, and improved quality of life and self-efficacy compared to multiple daily injections (MDI) in adolescent females with type 1 diabetes mellitus (T1DM). METHODS: This cross-sectional study included 22 adolescent females using CSII and 47 adolescent females using MDI who completed standardized questionnaires measuring disordered eating, quality of life, and self-efficacy. Most recent glycosylated hemoglobin (HbA1(c)) and measures of personal characteristics were drawn from medical records. RESULTS: The CSII group exhibited better glycemic control and reported higher quality of life and more self-efficacy. However, the groups did not differ significantly on disordered eating behaviors and attitudes. CONCLUSION: Insulin pump therapy may provide a means for improving glycemic control, quality of life, and self-efficacy in adolescent females with type 1 diabetes.     

Personality predictors of bulimic behavior and attitudes in males.

This study was an investigation of personality factors associated with bulimic behaviors and attitudes in males. Various measures that have been noted as predictors of female bulimia were tested on 96 college students. Chronic dietary restraint and interoceptive awareness were the strongest predictors of more maladaptive eating patterns. The results suggest that maladaptive eating patterns in males and females may share a common set of features.     

Child routines and youths' adherence to treatment for type 1 diabetes

OBJECTIVE: Type 1 diabetes (T1DM) is a chronic life-threatening disease that requires strict adherence to daily treatment tasks. Although necessary for survival, children who present with behavior problems tend to show problems complying with the treatment regimen, thereby increasing their risk for morbidity and premature mortality. The risk of poor treatment adherence is hypothesized to be lower for these children, however, if they engage in more routine behaviors. Given the potential clinical implications, this hypothesis and two theoretical models proposed to elucidate the underlying psychological process for the role of child routines in treatment adherence were evaluated empirically. The first model hypothesized that child routines protect (moderator variable) behaviorally problematic children from poor treatment adherence, whereas the alternative model hypothesized that child routines mediate the relation between childhood behavior problems and poor treatment adherence. METHODS: Parents of T1DM patients (N = 111) ranging from 6 to 16 years of age (M = 12 years) reported on their child's behavior problems, routine behaviors, and adherence to treatment for T1DM using standardized measures. Baron and Kenny's statistical procedures for testing moderation and mediation hypotheses were used to evaluate the proposed models. RESULTS: Regression analyses did not support the moderation hypothesis but did support the hypothesis that engaging in child routines mediates the relation between childhood behavior problems and poor treatment adherence. CONCLUSIONS: Parents of behaviorally problematic children diagnosed with T1DM might be advised to instill routines in their child's daily activities to increase the likelihood of treatment adherence, and thereby reduce the risk of morbidity and early mortality. Implications for clinical interventions are discussed.     

Challenges and Lessons Learned in the Development and Implementation of a Couples-Focused Telephone Intervention for Adults with Type 2 Diabetes: The Diabetes Support Project

BACKGROUND: Type 2 diabetes (T2DM) studies report that marital/family support relates to glycemic control, adherence and quality-of-life. Yet, there are few reports of couples-focused interventions. PURPOSE: To describe the challenges faced and lessons learned in the implementation of a theoretically-based, couples intervention. METHODS: 350 couples (one partner has T2DM in poor glycemic control) are randomized to a couples intervention, individual intervention, or enhanced usual care. All contacts are by telephone, to increase reach. OUTCOMES: medical (e.g. glycemic control), psychosocial (e.g. diabetes distress), and behavioral (e.g. regimen adherence). Challenges in recruitment, assessment and intervention with couples are described, with suggestions about how to address them. RESULTS: Findings concerning the efficacy and cost-effectiveness of the couples intervention, its effect on partners, and possible mechanisms of demonstrated changes, are anticipated in 2013. CONCLUSIONS: Interventionists need specific skills to work with couples to promote communal coping and increase the likelihood of an efficacious couples intervention.     

Personality factors and disordered eating in young women with type 1 diabetes mellitus

The authors examined the association between the presence of personality variables implicated in the pathogenesis of eating disorders and the presence of eating disorder symptoms in 51 women with type 1 diabetes. Subjects were assessed with interview instruments and self-report questionnaires, including scales measuring eating disorder symptoms, borderline personality characteristics, and perfectionism. Fourteen subjects displayed moderate to severe eating disorder symptoms. Perfectionism was related to attitudinal aspects of eating disorders (e.g., weight preoccupation), and borderline personality characteristics were related to disordered behaviors (e.g., insulin omission) and poor glycemic control. The results suggest that personality factors are related to disordered eating and poor glycemic control in diabetic women.     

Eating disorder behaviors and depression: a minimal relationship beyond social comparison,self‐esteem,and body dissatisfaction

Existing literature fails to comprehensively identify factors contributing to the comorbid relationship between eating disorder (ED) behaviors and unipolar depression. Maladaptive social comparison, body dissatisfaction, and low self‐esteem are disruptive psychological patterns common to both constructs. It is unclear whether a unique relationship exists between depression and eating disorder behaviors beyond the effects exerted by this negative cognitive triad. The purpose of the present study is to examine whether a unique relationship exists between depression and ED behaviors after controlling for maladaptive social comparison, body dissatisfaction, and low self‐esteem. We predict minimal unique variance in ED behaviors will be explained by depression after controlling for this negative cognitive triad. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–11, 2009.     

Reducing risk factors for eating disorders: comparison of an Internet- and a classroom-delivered psychoeducational program

This controlled trial compared Internet- (Student Bodies [SB]) and classroom-delivered (Body Traps [BT]) psychoeducational interventions for the reduction of body dissatisfaction and disordered eating behaviors/attitudes with a control condition. Participants were 76 women at a private university who were randomly assigned to SB, BT, or a wait-list control (WLC) condition. Measures of body image and eating attitudes and behaviors were measured at baseline, posttreatment, and 4-month follow-up. At posttreatment, participants in SB had significant reductions in weight/shape concerns and disordered eating attitudes compared with those in the WLC condition. At follow-up, disordered behaviors were also reduced. No significant effects were found between the BT and WLC conditions. An Internet-delivered intervention had a significant impact on reducing risk factors for eating disorders.     

The MEssaging for Diabetes (MED) intervention improves short-term medication adherence among low-income adults with type 2 diabetes

Adults with type 2 diabetes (T2DM) and low socioeconomic status (SES) have high rates of medication nonadherence, and, in turn, suboptimal glycemic control (hemoglobin A1c [HbA1c]). We tested the initial efficacy of a short message service (SMS) text messaging and interactive voice response (IVR) intervention to promote adherence among this high-risk group. Eighty low SES, diverse adults with T2DM used the MEssaging for Diabetes (MED) SMS/IVR intervention for 3 months. We used a pre-post single group design to explore adherence changes over 3 months, and a quasi-experimental design to test the impact of MED on HbA1c among the intervention group relative to a matched, archival control group. Compared to baseline, adherence improved at one (AOR 3.88, 95 % CI 1.79, 10.86) and at 2 months (AOR 3.76, 95 % CI 1.75, 17.44), but not at 3 months. HbA1c remained stable, with no differences at 3 months between the intervention group and the control group. MED had a positive, short-term impact on adherence, which did not translate to improvements in HbA1c. Future research should explore the longer-term impact of SMS/IVR interventions on the medication adherence of high risk adults with T2DM.     

Predicting Self-Management Behaviors in Familial Hypercholesterolemia Using an Integrated Theoretical Model: the Impact of Beliefs About Illnesses and Beliefs About Behaviors

Purpose

Patients with familial hypercholesterolemia (FH) are at markedly increased risk of coronary artery disease. Regular participation in three self-management behaviors, physical activity, healthy eating, and adherence to medication, can significantly reduce this risk in FH patients. We aimed to predict intentions to engage in these self-management behaviors in FH patients using a multi-theory, integrated model that makes the distinction between beliefs about illness and beliefs about self-management behaviors.

Methods

Using a cross-sectional, correlational design, patients (N?=?110) diagnosed with FH from a clinic in Perth, Western Australia, self-completed a questionnaire that measured constructs from three health behavior theories: the common sense model of illness representations (serious consequences, timeline, personal control, treatment control, illness coherence, emotional representations); theory of planned behavior (attitudes, subjective norms, perceived behavioral control); and social cognitive theory (self-efficacy).

Results

Structural equation models for each self-management behavior revealed consistent and statistically significant effects of attitudes on intentions across the three behaviors. Subjective norms predicted intentions for health eating only and self-efficacy predicted intentions for physical activity only. There were no effects for the perceived behavioral control and common sense model constructs in any model.

Conclusions

Attitudes feature prominently in determining intentions to engage in self-management behaviors in FH patients. The prominence of these attitudinal beliefs about self-management behaviors, as opposed to illness beliefs, suggest that addressing these beliefs may be a priority in the management of FH.

     

Do adherence variables predict outcome in an online program for the prevention of eating disorders?

Unlike traditional interventions, Internet interventions allow for objective tracking and examination of the usage of program components. Student Bodies (SB), an online eating disorder (ED) prevention program, significantly reduced ED attitudes/behaviors in college-aged women with high body image concerns, and reduced the development of EDs in some higher risk subgroups. The authors investigated how adherence measures were associated with ED attitudes and behaviors after treatment. Female SB participants (n = 209) completed the Eating Disorders Examination-Questionnaire (EDE-Q; C. G. Fairburn & S. J. Beglin, 1994) at baseline, posttreatment, and 1-year follow-up. Total weeks participation and frequency of utilizing the online Web pages/journals predicted pre- to posttreatment changes in EDE-Q Restraint but not in other ED symptoms. In participants with some compensatory behaviors, discussion board and booster session use were associated with increased weight/shape concerns during follow-up. In overweight participants, higher online Web page/journal use was related to decreased EDE-Q Eating Concern scores during follow-up. This is the first study to investigate the relationship between adherence to specific program components and outcome in a successful Internet-based intervention. Results can be used to inform future development and tailoring of prevention interventions to maximize effectiveness and facilitate dissemination.     

Improving empowerment,motivation, and medical adherence in patients with poorly controlled type 2 diabetes: A randomized controlled trial of a patient-centered intervention

ObjectiveTo test whether an intervention consisting of four patient-centered consultations improves glycemic control and self-management skills in patients with poorly regulated type 2 diabetes (T2DM), compared to a control group receiving usual care.MethodsUnblinded parallel randomized controlled trial including 97 adults diagnosed with T2DM ≥ 1 year and hemoglobin A1c (HbA1c) levels ≥ 8.0% (64 mmol/mol). Consultations incorporated tools supporting self-reflection, learning processes, and goal setting. Primary outcome was HbA1c. Secondary outcomes were autonomy support, motivation, self-management skills, and well-being.ResultsAverage HbA1c decreased slightly in both groups. Autonomy support and frequency of healthy eating were significantly higher in the intervention group. Most participants in the intervention group chose to set goals related to diet and physical exercise. Implementation of the intervention was inconsistent.ConclusionDespite increased autonomy support and individual goal-setting, the intervention was not superior to usual care in terms of glycemic control. More research is needed on how individual preferences and goals can be supported in practice to achieve sustainable behavior changes.Practice ImplicationsThe intervention promoted participant engagement and supported exploration of participants’ challenges and preferences. Further exploration of more flexible use of tools adapted to individual contexts is recommended.     

Relation between sense of coherence and glycemic control in type 1 and type 2 diabetes

In this study, the authors examined the relation between glycemic control and sense of coherence (SOC) and the mediating role of psychological distress and of adherence to self-care behaviors in 67 people with type 1 and type 2 diabetes. In addition, 29 individuals without any chronic disease composed a control group. The authors determined glycemic control by glycosylated hemoglobin (HbA1c) measures. The participants answered a questionnaire that included questions about medical data, an adherence to self-care behaviors inventory, Derogatis' Brief Symptoms Inventory, and Antonovsky's SOC scale. People with diabetes showed higher levels of psychological distress than matched controls, but similar SOC scores. A path analysis revealed that SOC was indirectly related to glycemic control, through adherence to self-care behaviors and psychological distress. Adherence did not mediate the effect of psychological distress on glycemic control In addition, the type of diabetes of the subject was directly related to glycemic control. The model explained 38% of the variance of glycemic control. The results suggest a possible role of SOC in the psychological and physical wellbeing of people with diabetes. SOC should constitute a focus of further research, particularly studies of possible psychological intervention to enhance SOC in people with diabetes.     

Attitudes and cardiovascular disease

Psychological attitudes are prospectively related to cardiovascular disease (CVD), but a causal relationship has not been demonstrated. Trait optimism/pessimism (positive or negative future expectation, respectively), and cynical hostility (mistrust of people), are attitudes with features of personality traits. These attitudes may affect CVD risk in several ways, by influencing an individual's (1) adoption of health behaviors, (2) maladaptive stress responding resulting in direct alteration of physiology (i.e., autonomic dysfunction, thrombosis, arrhythmias), (3) development of traditional CVD risk factors, and (4) lack of adherence to therapy in both primary and secondary prevention. More adaptive attitudes may favorably influence CVD risk at each of these critical junctures. The genetic and environmental (i.e., social, economic, racial/ethnic) determinants of attitudes have not been extensively studied. In addition, it is important to understand how some of these environmental determinants may also moderate the association between attitudes and CVD. Clinical trials to modify attitudes for CVD risk reduction (either by reducing negative attitudes or by increasing positive attitudes) are difficult to conduct, but are necessary to determine whether attitudes can indeed be modified, and if, so, to quantify any CVD-related benefits. To address these questions we present a broad, multidisciplinary research agenda utilizing mixed methods and integrating principles of epidemiology, genetics, psychophysiology, and behavioral medicine over the lifecourse (first figure). This overview focuses on attitudes and CVD, but has broader implications for understanding how psychological factors relate to chronic diseases of adulthood.     

Immigrant patients with type 2 diabetes mellitus have poorer initial and on-going glycemic control than a matched population of Irish patients

We compared the glycemic and cardiovascular risk status of non-Caucasian patients with type 2 diabetes mellitus (T2DM) who recently emigrated to Ireland with a matched population of Irish patients. We identified 105 non-Caucasian patients with T2DM who recently emigrated to Ireland and compared them with 105 Irish patients with T2DM, who were matched for age, sex and duration of diabetes. Immigrants with T2DM had significantly worse initial (9.8% vs 9.1%, p<0.05) and on-going (8.3% vs 7.1, p<0.05) glycemic control and higher microalbumin to creatinine ratio compared to the Irish patients. A greater proportion of immigrants with T2DM were on insulin therapy for their diabetes. Irish patients had significantly higher fasting triglyceride concentrations compared to the immigrants (1.9+/-0.1 mmol/l vs 1.6+/-0.1 mmol/l, p<0.05). This vulnerable population of immigrants with T2DM is currently at higher risk of complications of diabetes and warrants greater attention to glycemic control and control of other risk factors.     

The Association between Cognitive Impairment and Diabetic Foot Care: Role of Neuropathy and Glycated Hemoglobin

Diabetes mellitus is associated with impairment in cognitive functions which can complicate adherence to self-care behaviors. We evaluated the incidence of cognitive impairment in patients with diabetes mellitus to determine the strength of the association between diabetic foot (a complication that occurs in about 10% of diabetic patients), adherence to the clinician’s recommendations, glycemic control, and cognitive function. A prospective study was carried out in a probabilistic sample of older patients with diabetic foot living in three nursing homes. Cognitive functions were evaluated by the MMSE (Mini-Mental State Examination), the Trail Making test (TMT), and the Michigan neuropathy screening instrument (MNSI). There were no significant associations between cognitive function and neuropathy or foot alterations, although glycated hemoglobin (HB1Ac > 7%) significantly (p < 0.05) associated with MMSE and adherence to treatment in the 1 month follow-up visit. Receiver operating characteristic curve analysis showed that both HB1Ac and the MNSI score significantly (p < 0.05) discriminate subsequent adherence to treatment for foot complication, with a sensitivity of 80.0–73.3% and specificity 70.6–64.7%, respectively. Proper control of foot complications in diabetic patients involves appropriate glycemic control and less severe neuropathy, and seems to be unrelated to cognitive dysfunction, and warrants further studies in order to tailor appropriate treatments to central and peripheral nervous system disorders. Poor glycemic control (Hb1Ac level > 7%) and a neuropathy score of 5.5 in the MNSI are the best-cut off points to discriminate poor adherence to the clinician’s recommendations for self-care behaviors in people with diabetic foot complication. In this study, we observed that foot disorders were associated with impaired global cognitive function in elderly patients (aged ≥ 65). Podiatrists and physicians should consider cognitive dysfunction as an important chronic complication in the management of diabetic foot.     

Evaluation of glycemic control in patients with type 2 diabetes mellitus in Chinese communities: a cross-sectional study

This study aimed to evaluate the glycemic levels in Chinese patients with type 2 diabetes mellitus (T2DM) and to explore the factors related to the results of glycemic control. A total of 2454 T2DM patients from 11 communities were examined for glycosylated hemoglobin levels and glycemic control options. Potential factors related to the results of glycemic control were analyzed using logistic regression. Of all the patients, 55.3 % achieved the glycemic control target of HbA1c < 7 %. Multivariate analysis showed that male sex (OR 1.345, 95 % CI 1.022–1.769; P = 0.034), higher levels of fasting blood glucose (OR 1.954, 95 % CI 1.778–2.147; P < 0.001), and low-density lipoprotein cholesterol (OR 1.181, 95 % CI 1.020–1.367; P = 0.026) were significantly associated with poor glycemic control. The complexity of antidiabetics was also associated with poor glycemic control (P < 0.05). Compared to diet and exercise, insulin injection was most strongly associated with poor glycemic control (OR 6.210, 95 % CI 4.054–9.514; P < 0.001). Male patients with higher levels of total cholesterol, lower levels of high-density lipoprotein cholesterol, or longer diabetic durations showed poor glycemic control, which was not found in female patients. Glycemic control was not satisfactory in T2DM patients of Nanjing communities. Various factors are associated with poor results of glycemic control.     

Lipid lowering with dietary supplements: focus on diabetes

Cardiovascular disease (CVD) is the predominant cause of mortality in type 2 diabetic (T2DM) patients. Dyslipidemia is a modifiable risk factor that should be treated early for CVD prevention. Further, dietary supplement intake is increasing in popularity worldwide. This review examines the recent meta-analyses and clinical studies on dietary supplements, specifically psyllium, garlic and green tea, on plasma lipids levels and glycemic control, as well as other potential CVD risk factors in T2DM patients. Generally, results demonstrate that psyllium supplements improve lipid profiles as well as glycemic control beyond a traditional diet in patients with T2DM. On the other hand, the results on the usefulness of garlic and green tea supplementation for dyslipidemia and hyperglycemia are uncertain. Overall, the addition of dietary supplements may be a therapeutic alternative to lower CVD risk factors in T2DM; however, more well-designed intervention studies are needed to assess the benefit of these dietary supplements.     

Pathways from emotional adjustment to glycemic control in youths with diabetes in Hong Kong

OBJECTIVE: To examine factors that influence emotional adjustment, adherence to diabetic care, and glycemic control in Hong Kong youths with insulin-dependent diabetes mellitus (IDDM). METHODS: Seventy youths, their mothers, and matched controls provided information on health beliefs, authoritarian parenting style, parent-child conflict, emotional adjustment, and adherence to medical regimen. Glycosylated hemoglobin levels were obtained to measure glycemic control. RESULTS: Predictors explained 34% of the variance in emotional adjustment and 39% of the variance in glycemic control. The data supported a pathway from emotional adjustment to self-efficacy to adherence behaviors to glycemic control. In contrast to Western culture and consistent with prediction, parenting style did not associate with negative outcomes, and even relatively low levels of parent-child conflict correlated negatively with emotional adjustment in this culture. CONCLUSIONS: Management of conflict and self-efficacy enhancing interactions are suggested interventions to enhance adherence to diabetic care in Hong Kong youths with IDDM.