Elizabeth A. Boland

Personal and family factors associated with quality of life in adolescents with diabetes.

OBJECTIVE Quality of life is an important criterion for assessing outcomes of treatment in chronic illness related to psychosocial well-being. The purpose of this study was to evaluate the factors that influence quality of life in adolescents with IDDM. RESEARCH DESIGN AND METHODS Self-reports were obtained from 52 adolescents (age 13-20 years, mean 16.1 ± 1.9 [mean ± SD], diabetes duration 8.2 ± 3.4 years, 49% female) using the following scales: Diabetes Quality of Life for Youths, Childrens Depression Inventory, Issues in Coping with Diabetes, Diabetes Family Behavior Scale, Family Adaptability and Cohesion, Self-Efficacy for Diabetes, and the Adolescent Coping Orientation. Metabolic control was measured by HbA1c. RESULTS Teenagers whose diabetes had the greater impact (R2 = 0.48) and were less satisfied (R2 = 0.45) felt that management was more difficult (r = 0.56) and that diabetes was more upsetting (r = 0.63). They also used fewer rebellion strategies for coping (r = −0.44), had lower diabetes self-efficacy (r = −0.36), and had more depressive symptoms (r = 0.61). Higher impact was also associated with higher family warmth and caring (r = −0.54) and lower family adaptability (r = −0.42). Teenagers who were more worried (R2 = 0.37) about their diabetes felt that management was more difficult (r = 0.40) and that diabetes was more upsetting (r = 0.58), and they used less rebellion (r = −0.49) and more ventilation (r = 0.42) to cope, had lower diabetes (r = −0.40) and medical (r = −0.30) self-efficacy, were more depressed (r = 0.55), and their families were less warm and caring (r = −0.33). HbA1c levels were not associated with quality of life or any other psychosocial factors except in teenagers who perceived their families as providing more guidance and control. These teenagers had lower HbA1c values than those whose families were less involved. CONCLUSIONS Even teenagers who are successfully achieving HbA1c goals of therapy may perceive diabetes as having a negative impact on their lives, be depressed, and find diabetes difficult to manage. Diabetes treatment teams need to pay equal attention to the psychosocial needs to the quiet, nonrebellious teen with well-controlled diabetes from a supportive family as they do to the rebellious adolescent with poorly controlled diabetes.

Short-term Effects of Coping Skills Training as Adjunct to Intensive Therapy in Adolescents

OBJECTIVE Given the urgent need to develop effective programs that improve the ability for adolescents to achieve metabolic control equivalent to programs studied in the Diabetes. Control and Complications Trial, we have undertaken a clinical trial to determine if a behavioral intervention (coping skills training [CST]) combined with intensive diabetes management can improve metabolic control and quality of life in adolescents implementing intensive therapy regimens. RESEARCH DESIGN AND METHODS A total of 65 youths between the ages of 13 and 20 years, who elected to initiate intensive insulin therapy, were randomly assigned to one of two groups: the intensive management with CST group and the intensive management without CST group. CST consists of a series of small group efforts designed to teach adolescents the coping skills of social problem-solving, social skills training, cognitive behavior modification, and conflict resolution. Data were collected at pre-intervention and at 3 months following the use of the Self-Efficacy for Diabetes scale, Childrens Depression Inventory, Issues in Coping with IDDM scale, and the Diabetes Quality of Life: Youth scale. Clinical data (HbA1c, adverse effects) were collected monthly. RESULTS The experimental and control groups were comparable on all measures at baseline. Results show that adolescents who received CST had lower HbA1c and better diabetes self-efficacy and were less upset about coping with diabetes than adolescents receiving intensive management alone. In addition, adolescents who received the CST found it easier to cope with diabetes and experienced less of a negative impact of diabetes on quality of life than those who did not receive CST. CONCLUSIONS CST is useful in improving not only an adolescents metabolic control, but also their quality of life. As more pediatric providers aim for improved control, in adolescents with diabetes, the addition of this behavioral intervention may be helpful in achieving metabolic and life goals.

Insulin pump therapy in pediatrics: a therapeutic alternative to safely lower HbA1c levels across all age groups

Abstract: Objective: To examine the efficacy and safety of using continuous subcutaneous insulin infusion (CSII) therapy in a large group of patients 18 months to 18 yr from a single pediatric diabetes program.

Clinical and psychosocial factors associated with achievement of treatment goals in adolescents with diabetes mellitus

PURPOSE To examine the following questions with regard to the initiation of a new intensive management program for adolescents with Type 1 diabetes mellitus: (a) What clinical and psychosocial factors are associated with achievement of metabolic control treatment goals after 1 year? and (b) What baseline clinical and psychosocial factors are associated with improvement in the quality of life after 12 months? METHODS Eighty-one subjects (of 83 who began; aged 14.3 +/- 2.0 years at entry; 48 females, 33 males; 95% white; diabetes duration 8.9 +/- 3.9 years) with Type 1 diabetes completed 12 months of follow-up in a study of intensified treatment of diabetes. Assessments at baseline and at 12 months used the Diabetes Quality of Life for Youth scale, the Self-efficacy for Diabetes Scale, the Childrens Depression Inventory, the Issues in Coping with Diabetes Scale, and the Diabetes Family Behavior Scale. Data were analyzed using multiple and logistic regression. RESULTS From a baseline of >9%, HbA1c levels decreased to a mean of 7.8 +/- 0.7%, with 30% of the subjects achieving our treatment goal of <or=7.2%. Logistic regression demonstrated that achievement of goal levels of HbA1c were associated with better metabolic control at study entry (p = .05), participation in coping skills training (p = .003), and more parental participation in guidance and control (p = .05). Multiple regression analysis demonstrated that participation in coping skills training with lower impact of diabetes on quality of life at baseline and less depression at baseline contributed significantly to the variance (0.57) in quality of life at 12 months. CONCLUSIONS Providers need to pay particular attention to adolescents with poorer metabolic control and impact of diabetes on quality of life when they intensify their treatment because they are less likely to reach treatment goals. Furthermore, behavioral interventions such as coping skills training may help teens achieve their goals.

Coping skills training for youths with diabetes on intensive therapy.

The purpose of this study was to determine if a behavioral intervention (coping skills training [CST]) combined with intensive diabetes management can improve the metabolic control and quality of life in adolescents who are implementing intensive therapy. A total of 77 youths (age range, 12.5-20 years) who were beginning intensive insulin therapy were randomly assigned to one of two groups: intensive management with CST or without CST. CST consists of a series of small group efforts designed to teach problem solving skills and communication. Data were collected preintervention and at 3 and 6 months post-intervention by using established clinical and psychosocial indicators. Randomization produced equivalent groups. After 6 months, subjects who received CST had better metabolic control (F = 3.89, p = .02) and better general self-efficacy (F = 4.54, p = 0.01). They reported less negative impact of diabetes on their quality of life (F = 4.55, p = .01) and had fewer worries about diabetes (F = 3.82, p = .02). Thus, nurses may find CST useful in assisting youths with diabetes to achieve metabolic and quality of life goals.

Analysis of Continuous Glucose Monitoring Data from Non-Diabetic and Diabetic Children: A Tale of Two Algorithms

Use of the Medtronic MiniMed Continuous Glucose Monitoring System (CGMS) in non-diabetic children has revealed many low and high sensor glucose (SG) values, suggesting that the original analytical algorithm (Solutions 2.0) might be overreading glycemic excursions. A revised algorithm (Solutions 3.0) was introduced in 2001. Our aim was to compare analyses of the same sensor profiles using both programs. Twenty-five lean, non-diabetic subjects (mean age 14 +/- 4 years) underwent continuous glucose monitoring with CGMS for up to 72 h. Sensor tracings were analyzed with both algorithms and compared. Separate analyses were performed for nocturnal readings (12-6 a.m.). Mean SG values were similar (103 +/- 24 mg/dL for version 2.0 vs. 100 +/- 14 for version 3.0), but the distribution was significantly different: 13.8% of total SG were <70 mg/dL by version 2.0 versus 8.2% by version 3.0 (p < 0.001), and 7.7% of total SG were >150 mg/dL by version 2.0 versus 4.7% by version 3.0 (p = 0.02). Of nocturnal SG values, 25.8% were <70 mg/dL by version 2.0 compared with 17.9% by version 3.0, and 9.4% were >150 mg/dL by version 2.0 compared with 4.0% by version 3.0. In lean non-diabetic children, Solutions 2.0 identified significantly more hypoglycemia and hyperglycemia than Solutions 3.0. Similar analyses in 40 children with type 1 diabetes revealed no significant differences. Solutions 3.0 may be a more useful algorithm for preventing over-reading of low and high SG readings in non-diabetic children, whereas both algorithms give similar results in children with diabetes.

Use of lispro insulin and quality of life in adolescents on intensive therapy.

PURPOSE this study examined the metabolic and quality-of-life effects of using lispro insulin in teenagers. METHODS Teenagers on multiple daily injections who had not reached metabolic treatment goals were offered the opportunity to use lispro insulin as part of a larger ongoing study of intensive management in youth. Of the 51 who were eligible, 35 used lispro and were followed for 12 months; the remaining 16 had reached treatment goals, were not offered lispro, and comprised the control group. RESULTS After 12 months, the teens who received lispro insulin achieved equivalent levels of metabolic control to those achieved by teens in the control group, without differences in total daily dose, insulin regimen, or adverse events. Those who received lispro found coping with diabetes less difficult than those who continued on regular insulin, and they reported less negative impact of diabetes on quality of life and fewer worries about diabetes. Both groups were equally satisfied with their diabetes treatment. CONCLUSIONS Lispro insulin is a safe alternative for youth on intensive regimens, may assist youth in coping with diabetes, and may improve their quality of life.

Continuous Glucose Monitoring in Youth with Type 2 Diabetes: Overcoming Barriers to Successful Treatment

S-53 IMMUNE-MEDIATED TYPE 1 DIABETES MELLITUS has traditionally been the only form of diabetes considered prevalent among children, while type 2 diabetes mellitus is commonly thought of as a disease of adulthood. Recently, however, there has been an alarming rise in the incidence of type 2 diabetes in children and adolescents, particularly among American children of non-European ancestry.1 At a consensus conference convened by the American Diabetes Association (ADA), it was reported that, depending on race/ethnicity and sampling strategy, 8–45% of newly diagnosed children have non-immune-mediated diabetes (Table 1).2,3 The majority of these children have type 2 diabetes, although an increase in idiopathic or non-immune-mediated type 1 diabetes also has been reported. In the past, only 1% to 2% of children were considered to have type 2 diabetes or other rare forms of non-immune-mediated diabetes. The importance of this phenomenon is underscored by a study of glucose abnormalities conducted among inner-city Mexican American middle school children (aged 11–14 years) in San Antonio, Texas. A report of preliminary data from this survey indicated that 8% of these children had impaired fasting glucose as defined by the ADA (i.e., fasting glucose levels of 110–125 mg/dL).4 Significant numbers had marked cardiovascular and metabolic risks, including family history of diabetes (54%), obesity (27% females, 40% males), acanthosis nigricans (19%), hypertension (15% males), and elevated insulin concentrations (26%). The rise in type 2 diabetes in children is not confined to North America. The incidence of type 2 diabetes among school children in Japan increased from 0.2/100,000 in 1976 to 7.3/ 100,000 in 1995.5,6 The incidence was greatest among children between the ages of 13 and 15, who had an incidence of 13.9/100,000. As in the United States, the problem has been attributed, at least in part, to changes in diet and an increased prevalence of obesity.

A Summer Vacation From Diabetes: Evidence From a Clinical Trial

PURPOSE This study examined the metabolic trend and factors associated with an unexpected rise in HbA1c levels during the summer, with a return to baseline when school resumed, in 40 intensively treated adolescents with type 1 diabetes. METHODS Psychosocial data were collected using a variety of diabetes evaluation instruments. HbA1c was measured monthly. RESULTS HbA1C values increased by a mean of .73% from May to July and decreased by a mean of .75% from August to October. Lack of consistency in summer routines compared with school days was associated with a worsening in metabolic control during the summer months. Other factors associated with the summer increase in HbA1c included lower guidance scores on the Diabetes Family Behavior Scale, and higher impact and worry scores on the Diabetes Quality of Life for Youth Scale. CONCLUSIONS Interviews suggested that teenagers need to take a vacation from intensive diabetes care during the summer.

A Primer on the Use of Insulin Pumps in Adolescents

Optimal metabolic control to minimize long-term complications is a major treatment goal for adolescents with diabetes mellitus. Reaching this goal is extremely challenging in this population due to unique physiological changes and psychosocial variables that affect metabolic control. Continuous subcutaneous insulin infusion (CSII) may be an excellent treatment alternative for selected adolescents to help overcome some of these challenges. CSII allows for minute insulin changes at variable times throughout the day, providing greater lifestyle flexibility. The purpose of this paper is to review the use of insulin pump therapy in adolescents. Specific strategies regarding screening, initiation, and maintenance of this therapy are described, and case examples are used for illustration. Implications for nursing practice and diabetes education are discussed.