Barbara J. Anderson
Baylor College of Medicine
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The New England Journal of Medicine | 2008
William V. Tamborlane; Roy W. Beck; Bruce W. Bode; Bruce Buckingham; H. Peter Chase; Robert Clemons; Rosanna Fiallo-Scharer; Larry A. Fox; Lisa K. Gilliam; Irl B. Hirsch; Elbert S. Huang; Craig Kollman; Aaron J. Kowalski; Lori Laffel; Jean M. Lawrence; Joyce M. Lee; Nelly Mauras; Michael J. O'Grady; Katrina J. Ruedy; Michael Tansey; Eva Tsalikian; Stuart A. Weinzimer; Darrell M. Wilson; Howard Wolpert; Tim Wysocki; Dongyuan Xing; Laurel Messer; Victoria Gage; P. Burdick; K. Milaszewski
BACKGROUND The value of continuous glucose monitoring in the management of type 1 diabetes mellitus has not been determined. METHODS In a multicenter clinical trial, we randomly assigned 322 adults and children who were already receiving intensive therapy for type 1 diabetes to a group with continuous glucose monitoring or to a control group performing home monitoring with a blood glucose meter. All the patients were stratified into three groups according to age and had a glycated hemoglobin level of 7.0 to 10.0%. The primary outcome was the change in the glycated hemoglobin level at 26 weeks. RESULTS The changes in glycated hemoglobin levels in the two study groups varied markedly according to age group (P=0.003), with a significant difference among patients 25 years of age or older that favored the continuous-monitoring group (mean difference in change, -0.53%; 95% confidence interval [CI], -0.71 to -0.35; P<0.001). The between-group difference was not significant among those who were 15 to 24 years of age (mean difference, 0.08; 95% CI, -0.17 to 0.33; P=0.52) or among those who were 8 to 14 years of age (mean difference, -0.13; 95% CI, -0.38 to 0.11; P=0.29). Secondary glycated hemoglobin outcomes were better in the continuous-monitoring group than in the control group among the oldest and youngest patients but not among those who were 15 to 24 years of age. The use of continuous glucose monitoring averaged 6.0 or more days per week for 83% of patients 25 years of age or older, 30% of those 15 to 24 years of age, and 50% of those 8 to 14 years of age. The rate of severe hypoglycemia was low and did not differ between the two study groups; however, the trial was not powered to detect such a difference. CONCLUSIONS Continuous glucose monitoring can be associated with improved glycemic control in adults with type 1 diabetes. Further work is needed to identify barriers to effectiveness of continuous monitoring in children and adolescents. (ClinicalTrials.gov number, NCT00406133.)
Diabetes Care | 1995
William H. Polonsky; Barbara J. Anderson; Patricia A Lohrer; Garry Welch; Alan M. Jacobson; Jennifer E Aponte; Carolyn E. Schwartz
OBJECTIVE To describe a new measure of psychosocial adjustment specific to diabetes, the Problem Areas in Diabetes Survey (PAID), and to present initial information on its reliability and validity. RESEARCH DESIGN AND METHODS Before their routine clinic appointments, 451 female patients with type I and type II diabetes, all of whom required insulin, completed a self-report survey. Included in the survey was the PAID, a 20-item questionnaire in which each item represents a unique area of diabetes-related psychosocial distress. Each item is rated on a six-point Likert scale, reflecting the degree to which the item is perceived as currently problematic. A total scale score, hypothesized to reflect the overall level of diabetes-related emotional distress, is computed by summing the total item responses. To examine the concurrent validity of the PAID, the survey also included a series of standardized questionnaires assessing psychosocial functioning (general emotional distress, fear of hypoglycemia, and disordered eating), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for HbA1, within 30 days of survey completion and again ∼ 1–2 years later. Finally, long-term diabetic complications were determined through chart review. RESULTS Internal reliability of the PAID was high, with good item-to-total correlations. Approximately 60% of the subject sample reported at least one serious diabetes-related concern. As expected, the PAID was positively associated with relevant psychosocial measures of distress, including general emotional distress, disordered eating, and fear of hypoglycemia, short- and long-term diabetic complications, and HbA1, and negatively associated with reported self-care behaviors. The PAID accounted for ∼ 9% of the variance in HbA1. Diabetes-related emotional distress, as measured by the PAID, was found to be a unique contributor to adherence to self-care behaviors after adjustment for age, diabetes duration, and general emotional distress. In addition, the PAID was associated with HbA1 even after adjustment for age, diabetes duration, general emotional distress, and adherence to self-care behaviors. CONCLUSIONS These findings suggest that the PAID, a brief, easy-to-administer instrument, may be valuable in assessing psychosocial adjustment to diabetes. In addition to high internal reliability, the consistent pattern of correlational findings indicates that the PAID is tapping into relevant aspects of emotional distress and that its particular feature, the measurement of diabetes-related emotional distress, is uniquely associated with diabetes-relevant outcomes. These data are also consistent with the hypothesis that diabetes-related emotional distress, separate from general emotional distress, is an independent and major contributor to poor adherence. Given that the study was limited to female patients using insulin, further examination of the clinical usefulness of the PAID will need to focus on more heterogeneous samples.
The Journal of Pediatrics | 1997
Barbara J. Anderson; Joyce Ho; Julienne Brackett; Dianne M. Finkelstein; Lori Laffel
OBJECTIVES The goal of this study was to identify parental behaviors that relate to adherence and metabolic control in a population of young adolescents with insulin-dependent diabetes mellitus (IDDM), and to understand the interrelationships among the variables of parental involvement, adherence to blood glucose monitoring, and glycemic control. STUDY DESIGN A cross-sectional design was used to investigate parental involvement in diabetes regimen tasks in 89 youth, aged 10 to 15 years, with IDDM. Levels of parental involvement in blood glucose monitoring (BGM) and insulin administration were evaluated through interviews. Assessment of adherence was made by physicians or nurses, independent of patient or parent reports of adherence. Glycemic control was assessed with glycosylated hemoglobin (HbA1c) (reference range, 4% to 6%). RESULTS There were significant differences in the mean HbA1c values between the older (13 to 15 years of age) (HbA1c = 8.9% +/- 1.03%) and younger (10 to 12 years) patients (HbA1c = 8.4% +/- 1.06%) (p < 0.02). Parental involvement in BGM was significantly related to adherence to BGM (number of blood sugar concentrations checked daily) in both groups of adolescent patients. The younger patients monitored their blood glucose levels more frequently than did the older patients, 39% of the younger patients checked sugar concentrations four or more times daily compared with only 10% of the older group (p < 0.007). In a multivariate model controlling for age, gender, Tanner staging, and duration of diabetes, the frequency of BGM was a significant predictor of glycemic control (R2 = 0.19, p < 0.02). Increased frequency of BGM was associated with lower HbA1c levels. When the frequency of BGM was zero or once a day, the mean HbA1c level was 9.9% +/- 0.44 (SE); when the frequency of BGM was two or three times a day, the mean HbA1c level was 8.7% +/- 0.17; and when the frequency of BGM was four or more times daily, the mean HbA1c level was 8.3% +/- 0.22. CONCLUSIONS Parental involvement in BGM supports more frequent BGM in 10- to 15-year-old patients with IDDM. This increased adherence to BGM is associated with better metabolic control (i.e., lower HbA1c levels). These findings suggest that encouraging parental involvement in BGM with 10- to 15-year-old patients with IDDM may help to prevent the well-documented deterioration in glycemic control and adherence to treatment that often occurs in later adolescence.
Diabetes Care | 1981
Barbara J. Anderson; J Philip Miller; Wendy Auslander; Julio V. Santiago
This research compares the family environments of diabetic adolescents in good (HbA1c < 10), fair (10 ≥ HbA1c ≤ 14), and poor (HbA1c > 14) control. Fifty-eight adolescents diagnosed with type I diabetes and their parents (mothers) were independently assessed with structured interviews, the Moos Family Environment Scale, and adolescents also completed the Piers-Harris Childrens Self-Concept Scale. As compared with adolescents in poor control, those in good control reported fewer diabetes-related symptoms and had less anxiety and a more positive self-concept. Well-controlled youths also reported more cohesion and less conflict among family members. More parents of well-controlled youths stated that family members were encouraged to behave independently. In addition, more parents of poorly controlled adolescents believed that diabetes had negatively affected the childs personality, physical well-being, schooling, and participation in activities away from home. These findings suggest a complex interplay between the diabetic adolescents psychological and physical functioning, metabolic control, and the family environment.
Diabetic Medicine | 2002
Barbara J. Anderson; Laura Vangsness; Alexa Connell; Deborah A. Butler; Ann Goebel-Fabbri; Lori Laffel
Aims Behavioural support around diabetes management tasks is linked to glycaemic outcomes. In this study we investigated the relationship between diabetes‐related parental behaviours (conflict around and involvement in treatment tasks), adherence to blood glucose monitoring (BGM), and glycaemic control in youth with short duration Type 1 diabetes mellitus (DM).
Diabetes Care | 1994
William H. Polonsky; Barbara J. Anderson; Patricia A Lohrer; Jennifer E Aponte; Alan M. Jacobson; Cole Cf
OBJECTIVE To describe the extent of intentional insulin omission in an outpatient population of women with insulin-dependent diabetes mellitus (IDDM) and examine its relationship to disordered eating, attitudes toward diabetes, other psychosocial factors, long-term complications, and glycemic control. RESEARCH DESIGN AND METHODS Before their routinely scheduled clinic appointments, female IDDM patients who were 13–60 years of age completed a self-report survey (final n = 341). The survey included standardized questionnaires assessing disordered eating attitudes and behaviors, psychological functioning (general distress, diabetes-specific distress, and hypoglycemic fear), attitudes toward diabetes, and self-care behaviors. All subjects were assessed for glycosylated hemoglobin within 30 days of survey completion. Long-term complications were determined through chart review. RESULTS Approximately 31% of the subject sample, representing women of all ages, reported intentional insulin omission, but only 8.8% reported frequent omission. Compared with non-omitters, omitters reported more disordered eating, greater psychological distress (general and diabetes-specific), more hypoglycemic fear, poorer regimen adherence, and greater fears concerning improved diabetes management (which may lead to weight gain). Omitters evidenced poorer glycemic control, more diabetes-related hospitalizations, and higher rates of retinopathy and neuropathy. Multivariate examination revealed only two variables that independently predicted omission: diabetes-specific distress and fear of improved glycemic control (“because I will gain weight”). Of the omitters, approximately half reported omitting insulin for weight-management purposes (weight-related omitters). These subjects evidenced significantly greater psychological distress, poorer regimen adherence (including more frequent omission), poorer glycemic control, and higher rates of complications than did non-weight-related omitters as well as non-omitters. Non-weight-related omitters tended to fall between weight-related omitters and non-omitters on most measures of psychological functioning, adherence, and glycemic control. CONCLUSIONS These findings suggest that insulin omission is common, that it is not limited to younger women, and that the medical consequences of omission, especially frequent omission, may be severe. Although a strong association between omission and disordered eating was observed, these data suggest that this link may be complicated by important diabetes-specific factors. Patients preoccupied with eating and weight concerns may also become emotionally overwhelmed by diabetes and/or fearful of normoglycemia (and the associated weight-related consequences), thus reinforcing the desire to omit insulin and maintain elevated blood glucose levels.
Diabetes Care | 2007
Jill Weissberg-Benchell; Howard Wolpert; Barbara J. Anderson
Diabetes research and health care have traditionally been divided into two distinct areas for receiving medical care: pediatric and adult. We propose a fresh approach to providing care in which we consider the period of development after high school as a period of “emerging adulthood” for youth with diabetes. We argue that the traditional conceptualization of only two distinct groups of patients misses the unique personal needs of individuals immediately post–high school. We frame this discussion about the needs of these post–high school patients (∼18–30 years of age) within the context of a contemporary theory of post-adolescent development. With this developmental context in hand, we then review psychosocial research on youth with type 1 diabetes. Next we discuss current clinical perspectives and knowledge about the natural course of diabetes during these years. Armed with an understanding of development, psychosocial functioning, and overall health, we then consider the literature regarding transition programs for youth with chronic diseases—both diabetes and other illnesses. We conclude by presenting specific strategies and recommendations to help both pediatric and adult providers care for the transition needs of this vulnerable population of individuals with diabetes. Over the past century, traditional developmental psychology defined the time immediately after adolescence as the “young adult period” (3,4). In contrast, a leading contemporary developmental theorist (1,2) has argued that young adulthood does not begin until youth are in their late twenties or thirties and that the developmental stage between ∼l8 and 25 years defines a period called “emerging adulthood.” Recent cultural trends in America for young people in their twenties lead to delays in assuming adult roles with respect to marriage, parenting, and work. Arnett (2) suggests that todays young people “explore the possibilities available to them in love and work, and move gradually toward making enduring …
Diabetes Care | 1989
Barbara J. Anderson; Fredric M Wolf; Mary T Burkhart; Richard G Cornell; George E Bacon
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 > 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%, X2 = 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.
BMJ | 2001
Howard Wolpert; Barbara J. Anderson
Several large intervention studies have shown that intensive glucose management in diabetic patients can prevent microvascular complications. 1 2 Furthermore, analysis of cost effectiveness in these studies indicates that the lifetime improvement in quality of life and longevity derived from intensive management would outweigh the increased costs of such treatment. 3 4 Nevertheless, tight glycaemic control has proved difficult to achieve in clinical practice. Even patients who have received comprehensive diabetes education and are skilled in self management have difficulty maintaining optimal glycaemic control in the long term. During the four years after completion of the diabetes control and complications trial, the median glycated haemoglobin concentrations of the intensive treatment cohort rose to 7.9% (up from a median value of 7.0-7.2% during the trial).5 Other studies have shown that education on self management of diabetes without interventions to reinforce behavioural change does not lead to sustained improvements in glucose control.6 Many factors can directly and indirectly influence disease management behaviour and metabolic control of people with diabetes. In addition to individual variables (biological and psychological factors), patient behaviour is influenced by transactions within the family system, the broader social and cultural community, and socioeconomic and healthcare system factors.7 In this article we focus on the influence from within the healthcare system—that is, the healthcare providers message about the benefits of optimal glycaemic control—and argue that the message needs to be framed from the perspective of the patient. #### Summary points Because diabetes is a self managed condition, successful models of care must focus on strategies that promote and maintain improved selfcare behaviour New treatment frameworks are needed to enhance the effectiveness of clinicians in promoting behavioural change The message about the benefits of tight glycaemic control needs to be refocused from the perspective of the patient The benefits of intensive …
Diabetes Care | 1980
Barbara J. Anderson; Wendy Auslander
Research on diabetes management and the family has been traditionally viewed within a linear model, in which parental attitudes toward diabetes are seen as the principal influence on the childs adjustment and metabolic control. Recently the focus of research has shifted to the broader family milieu, with an emphasis on patterns of cooperation and conflict among all family members in implementing the treatment regimen. As investigators have begun to study the entire family, the linear model of parental influences has been overshadowed by a systems model of family interaction, based on the concept of mutual influences among all individuals in the family. Several methodological problems have characterized research in this area, such as inadequate assessments of family functioning, unreliable indices of metabolic control, and insensitivity to differences in age and disease variables. Future studies of diabetes management will have much to gain from consideration of the role of the father and siblings in treatment, attention to the diabetic childs impact on family functioning, and recognition of sources of support and stress outside the family that affect adaptation to diabetes.