Carol J. Howe

Increasing Incidence of Type 1 Diabetes in Youth: Twenty years of the Philadelphia Pediatric Diabetes Registry

OBJECTIVE The purpose of this study was to describe the incidence of type 1 diabetes in children in Philadelphia from 2000–2004, compare the epidemiology to the previous three cohorts in the Philadelphia Pediatric Diabetes Registry, and, for the first time, describe the incidence of type 2 diabetes. RESEARCH DESIGN AND METHODS Diabetes cases were obtained through a retrospective population-based registry. Hospital inpatient and outpatient records were reviewed for cases of type 1 and type 2 diabetes diagnosed from 1 January 2000 to 31 December 2004. The secondary source of validation was the School District of Philadelphia. Time series analysis was used to evaluate the changing pattern of incidence over the 20-year period. RESULTS The overall age-adjusted incidence rate in 2000–2004 of 17.0 per 100,000 per year was significantly higher than that of previous cohorts, with an average yearly increase of 1.5% and an average 5-year cohort increase of 7.8% (P = 0.025). The incidence in white children (19.2 per 100,000 per year) was 48% higher than in the previous cohort. Children aged 0–4 years had a 70% higher incidence (12.2 per 100,000 per year) than the original cohort; this increase was most marked in young black children. The overall age-adjusted incidence of type 2 diabetes was 5.8 per 100,000 per year and was significantly higher in black children. CONCLUSIONS The incidence of type 1 diabetes is rising among children in Philadelphia. The incidence rate has increased by 29% since the 1985–1989 cohort. The most marked increases were among white children ages 10–14 years and black children ages 0–4 years. The incidence of type 1 diabetes is 18 times higher than that of type 2 in white children but only 1.6 times higher in black children.

Disordered Eating Behaviors in Youth With Type 1 Diabetes

Eating disorders are a significant health problem for many adolescents and are described as occurring along a spectrum of symptoms including disordered eating behaviors and clinical eating disorders. Poor self-esteem and body image, intense fear of gaining weight or refusal to maintain weight, and purging unwanted calories are clinical features of some eating disorders. Type 1 diabetes is a chronic illness with marked insulin deficiency. Chronic hyperglycemia creates a state of glucosuria with subsequent weight loss. Diabetes treatment focuses on intensive daily management of blood glucose by balancing insulin, food intake, and physical activity. Insulin omission offers an easy method for the purging of unwanted calories. The combination of these 2 illnesses is potentially deadly and also leads to an increased risk of poor diabetes outcomes. This includes poor metabolic control (measured by elevated hemoglobin A1C), increased risk of diabetic ketoacidosis, and microvascular complications such as retinopathy and nephropathy. Diabetes clinicians should be aware of the potential warning signs in an adolescent with diabetes as well as assessment and treatment options for eating disorders with concomitant type 1 diabetes. This article reviews the available data on the prevalence, screening tools, assessment guidelines, and treatment options for eating disorders in youth with type 1 diabetes.

Parents' perceptions of factors that affect successful diabetes management for their children

Objective. To learn which factors parents perceive to be most influential in determining successful type 1 diabetes management. Methods. A 4-stage mixed qualitative-quantitative method that consists of a series of focus groups, a survey, and in-depth interviews was used to ensure that parents generated, prioritized, and explained their own ideas. In each stage, parents offered a new level of insight into their perception of how children achieve good metabolic control while living as normal a life as possible. The survey responses were divided into statistically different ranks, and the Kruskal-Wallis test was used to compare the results between subgroups. Results. A total of 149 parents participated in the formative qualitative phases, 799 families (66%) responded to the parent-generated survey, and 67 explanatory interviews were conducted. The families who responded to the survey had children of varied ages (mean: 11.9 years; SD: 4.44) and diabetes control (mean hemoglobin A1c: 8.22%; SD: 1.65); 84.1% of respondents were white, 12.3% were black, and 89% were privately insured. The 30 survey items were statistically discriminated into 8 ranks. The items cover a wide range of categories, including concrete ways of achieving better control, families’ or children’s traits that affect coping ability, actions of the health care team that support versus undermine families’ efforts, and the availability of community supports. No clear pattern emerged regarding 1 category that parents perceived to matter most. Conclusions. Clinicians can affect many of the factors that parents perceive to make a difference in whether they can successfully raise a resilient child in good diabetes control. Future research needs to determine whether health care teams that address the concerns that parents raised in this study are more effective in guiding children to cope well with diabetes, to incorporate healthier lifestyles, and ultimately to achieve better metabolic control.

Parental Expectations in the Care of Their Children and Adolescents With Diabetes

There is little research about what parents of children with diabetes want and need from their health-care providers as they negotiate life with diabetes. Sixty-three parents of children with type 1 diabetes were interviewed. Interviews were tape-recorded and transcribed verbatim, and a content analysis of text data was conducted. Three themes emerged describing what they wanted in their relationships with diabetes providers: laying the foundation, providing clinical care, and engaging families as partners. Collectively, these data provide vivid insights into the parents perspective regarding their needs from diabetes providers as well as their perceptions of interactions that were unhelpful or worse, hurtful or undermining.

Partnerships With Providers: Reflections From Parents of Children With Type 1 Diabetes

Sixty-three parents with a child or an adolescent with type 1 diabetes participated in this study that focused on what helped them “live well with diabetes.” Beyond medical expertise, parents described a partnering relationship with their provider as one of the factors that supported their efforts to live well with diabetes. Parents reported that a partnership was enhanced when the provider had the ability to understand the dynamic nature of the journey in living with diabetes, connect with their family and set the tone by inviting them to openly communicate about all aspects of family life impacting diabetes care, recognize when and how the provider may have to assume the role of Captain of the Ship in times of need, and empathize and respond therapeutically to intense emotions inherent in managing diabetes over time.

Parent Health Literacy and Communication With Diabetes Educators in a Pediatric Diabetes Clinic: A Mixed Methods Approach

Low health literacy is associated with poor communication between adults and providers, but little is known about how parents’ health literacy influences communication in pediatric encounters. We examined how parent health literacy affected communication between parents and diabetes educators in a pediatric diabetes clinic. A mixed methods study was conducted including a cross-sectional survey of 162 parents and semi-structured interviews with a subsample of 24 parents of a child with Type 1 diabetes. Parent and child characteristics, parents’ report of quality of communication, and parent health literacy were assessed. Logistic regression was performed to determine associations between health literacy and 4 subscales of the Interpersonal Processes of Care (IPC) survey; directed content analyses of interview data were completed. Although health literacy was not significantly associated with the IPC subscales, results from directed content analyses revealed different communication experiences for parents by health literacy classification. Low health literate parents were confused by diabetes jargon, preferred hands-on teaching, and wished for information to be communicated in simple language, broken down into key points, and repeated. Parents with adequate health literacy wanted comprehensive information communicated through ongoing dialogue. Findings indicate that learner-driven curricula may be most appropriate for diabetes education.

Readability and Suitability of Spanish Language Hypertension and Diabetes Patient Education Materials

ABSTRACT Hispanics who speak Spanish are at risk for low health literacy. We evaluated Spanish language hypertension (HTN) and diabetes mellitus (DM) patient education materials from U.S. federal agency public sector sources using the Suitability of Assessment (SAM) instrument. Mean readability for HTN materials was grade 7.9 and for DM materials was grade 6.6. Mean SAM score for HTN materials was 43.9 and for DM materials was 63.2. SAM scores were significantly better for DM than for HTN materials in overall score, content, graphics, layout, stimulation/motivation, and cultural appropriateness (p < .05). Clinicians should evaluate suitability of Spanish language HTN and DM materials that they use in patient teaching.

Comment on 'Simultaneous interview technique for patients with persistent pain' by L. Jacobson, A.J. Mariano, C. Chabal and E.F. Chaney in Pain, 45 (1991) 105-106.

We wish to comment on the Ietter from the Clinical Pain Service of the University of Washington [6], discussing the development of a simultaneous interview technique (SIT) for the treatment of persistent pain patients. We were prompted to respond because as members of a pediatric pain management program, we independently evolved a similar interview structure. It too is our view that the biomedical model as applied to chronic pain is flawed, both theoretically and clinically. Therefore, we have moved toward a more integrated evaluation and treatment approach to pain management an approach that is emphasized and reinforced by the stimultaneous interview. We wholeheartedly support the overall direction of the Seattle group’s comments, but we would like to point out some differences in our pediatric experience and discuss their clinical implications. In our pain management program ‘. which began three years ago [S], we instituted an assessment and treatment model in which physicians, mental health clinicians (psychologist or psychiatrist) and clinical nurse specialist as a unit interview all patients and their families, beginning with the initial visit. This is a

Parents' Underestimations of Child Weight: Implications for Obesity Prevention

Purpose Obesity prevention efforts may be ineffective if parents lack awareness of their childrens overweight status. This study examined the factors that predicted parents’ underestimation of child weight status. Design and Methods Using a cross sectional design, researchers recruited children and parents in a local childrens museum. Parents completed a demographic questionnaire, the Newest Vital Sign, and the Child Body Image Scale. Childrens height and weight were measured to calculate child BMI. Random effects modeling examined the association between predictor variables (parent race/ethnicity, income, education, and health literacy, and child BMI percentile, gender, and age) and the dependent variable, parent underestimation of child weight status. Results Participants included 160 parents (213 children aged 7–12 years) representing a racially and ethnically diverse sample who were affluent, educated, and with 36.6% of parents assessed with limited health literacy. Although 45.1% of children were overweight/obese, only 7.5% of parents chose this weight status; 80% of parents underestimated the weight of their normal weight children, 96% underestimated their overweight children, and 72% underestimated their obese children. Parents were more likely to underestimate weight of older children and those under 81st percentile of BMI. No other predictors were significant. Conclusions Parent underestimation of child weight status appears to be a widespread phenomenon in this sample, regardless of race, ethnicity, income, education, and health literacy. Practice Implications The consistent underestimation of child weight suggests that parents’ misperception of weight status represents a critical pathway for intervention. Methods to improve parents’ perception of child weight need be developed and tested. HighlightsOver one third of parents in this sample had limited health literacy.The majority of parents underestimated the weight of their children.96% of parents underestimated their overweight children.72% of parents underestimated their obese children.Parent underestimation was not associated with social determinants of health.

Use of Continuous Glucose Monitoring Systems in Children with Type 1 Diabetes

Continuous glucose monitoring systems (CGMS) offer a recent technological solution to fear of hypoglycemia and reduction in hyperglycemia. With glucose readings every 5 minutes, and the alarm capabilities to signal rapid increases or decreases in blood glucose, they afford a sense of security for both children and parents. Although children and parents must continue to be vigilant in the treatment of diabetes, CGMS may effectively allow tight diabetes control with earlier detection of hypoglycemia onset. This article provides an overview of CGMS available at the time of publication; new generations of systems have been introduced annually with improvements in sensitivity and user friendliness.