Jeanne Bubb

Randomized Prospective Study of Self-Management Training With Newly Diagnosed Diabetic Children

This study was designed to evaluate the effects of a self-management training (SMT) program on metabolic control of children with insulin-dependent diabetes mellitus (IDDM) in the first 2 yr after diagnosis. After standard in-hospital diabetes education, 36 children (mean age 9.3 yr, range 3–16 yr) were randomized to conventional follow-up, conventional and supportive counseling (SC), or conventional and SMT, which emphasized use of data obtained from self-monitoring of blood glucose. SC and SMT interventions consisted of seven outpatient sessions with a medical social worker during the first 4 mo after diagnosis and booster sessions at 6 and 12 mo postdiagnosis. Groups were similar with respect to age, sex, body mass index, socioeconomic status, C-peptide, and severity of illness at diagnosis. Metabolic control, measured quarterly by glycosylated hemoglobin (HbA1), improved substantially in all three treatment groups during the first 6 mo. SMT patients had significantly lower HbA1 levels than conventional patients at 1 yr (P < 0.01) and 2 yr (P < 0.05) postdiagnosis. SMT patients also had lower HbA1 levels than SC patients, but this did not reach statistical significance. The lower HbA1 levels of SMT patients were not explained by severity of illness at diagnosis, or insulin dose, body mass index, and C-peptide levels at 2 yr. These results suggest that an SMT program during the first few months after diagnosis helps avoid the deterioration in metabolic control often seen in children with IDDM between 6 and 24 mo after diagnosis.

Stress and coping in relation to metabolic control of adolescents with type 1 diabetes.

The purpose of this study was to determine whether measures of anxiety, stress, and means of coping with stress differ in diabetic adolescents in good, fair, and poor metabolic control. Trait anxiety, perceived daily stress, and coping responses to a recent stressful event were assessed in 27 adolescents with Type 1 diabetes mellitus. Information also was obtained regarding the type of stressful events that subjects referred to in completing the coping measure, as well as their appraisals of the events. Hemoglobin A1 (HbA1) obtained at the time of the study was used as a measure of antecedent metabolic control. Based upon their HbA1, patients were divided into three metabolic control subgroups: good control (M = 8.4%; n = 8), fair control (M = 10.9%; n = 9), and poor control (M = 13.3%; n = 10). Patients in these subgroups were similar with regard to age, disease duration, and socioeconomic status. Results indicated that the subgroups did not differ on the anxiety and stress measures; however, analyses of the coping data indicated that patients in poor control employed significantly more wishful thinking and avoidance/help-seeking than did patients in good metabolic control. Furthermore, the metabolic control subgroups differed in the type of stressful events reported and their appraisals of the stressful events. These results support the hypothesis that the ways in which individuals with diabetes appraise and cope with stress is related to their metabolic control. The findings are discussed in relation to methodological issues and treatment implications. J Dev Behav Pediatr 8:136–140, 1987. Index terms: diabetes, stress, coping, adolescents.

Changing Behavior: Practical lessons from the Diabetes Control and Complications Trial

The recently completed Diabetes Control and Complications Trial (DCCT) has elicited renewed interest in behavior change strategies, because intensive therapy of 1DDM in the DCCT was a comprehensive behavioral change program with unequivocal health benefits (1,2). Intensive therapy lowered blood glucose levels and slowed the appearance and progression of microvascular and neuropathic complications because participants changed many behaviors, including testing blood glucose and administering insulin more frequently, quantifying and regulating dietary intake, and modifying diet, insulin, and physical activity to balance their effects on blood glucose levels. It is natural to ask what can be learned from the DCCT about changing behavior that is pertinent to diabetes management in clinical practice. The DCCT compared two treatment programs that differed in many ways. Among the differences between the two treatments was the more frequent use of behavioral change strategies in the intensive therapy group. Use of specific behavior change strategies depended on the needs of individual patients. In addition, while the framework of intensive therapy was dictated by the study protocol, the detailed application of behavioral change strategies is presumed to have varied with the skills and preferences of each Clinical Center staff, as was also true of other elements of treatment such as insulin management and the choice of pump or multiple injection therapy. Consequently, there were uncontrolled differences across clinics and individuals in the use of behavioral interventions. Therefore, the DCCT Study Group has not attempted to draw systematic conclusions about the effectiveness of specific behavioral change strategies or other elements of the intensive therapy program. Nevertheless, it is possible to offer opinions on the behavioral strategies that seemed most helpful. To generate a broad synthesis of practical lessons from the DCCT, the first author recruited collaborators from several DCCT Clinics and disciplines, including nursing, nutrition, clinical psychology, psychiatry, and social work. The practical lessons we offer here were not discovered or used for the first time in the DCCT, but are well grounded in a large body of literature, examples of which we cite. A short list of additional reading is also included. The point emphasized here is that the DCCT has demonstrated that these strategies are truly effective in achieving longterm behavioral changes and health benefits in subjects with IDDM. Before discussing specific behavioral change strategies, we wish to articulate a general principle suggested by the DCCT: ordinary people can adopt and maintain substantial behavioral changes. Because of the extraordinary adherence of the DCCT volunteers to the protocol, it has been implied that they were so well

Measurement of diabetes stress in older children and adolescents with type 1 diabetes mellitus

Studies indicate general psychological stress plays a role in the glycemic control of individuals with type 1 diabetes mellitus (T1DM). Disease‐specific rather than general measures may be more closely related to measures of health outcomes. Therefore, measurement of diabetes‐related stress is needed to advance knowledge of significant relationships between stress and glycemic control. The objective of this study was to evaluate the psychometric properties of a measure of diabetes‐related stress for youth with T1DM.

Self-Monitoring of Blood Glucose by Adolescents With Diabetes: Technical Skills and Utilization of Data

Two studies of adolescent patients were conducted to determine their technical skills and utilization of data obtained by self-monitoring of blood glucose (SMBG). In Study 1, direct observations of 58 adolescents revealed an overall SMBG technical accuracy score of 82 %. Most frequent errors were not cleaning fingers (45 %), not placing blood on strips correctly (21 %), and wiping strip at wrong time (14%). Technical performance was inversely correlated with blood glucose concentration, but was unrelated to other variables. In Study 2, a questionnaire was used to determine SMBG practices among 64 adolescents. Although the majority of patients reported doing daily SMBG, most did not record results in logbooks every time or utilize such data for self- management. No significant relationships were found between SMBG behaviors and other variables. We conclude that periodic evaluation and retraining are required for maintenance of SMBG skills and that methods to enhance utilization of SMBG data be developed for this patient population.

Weight loss from inappropriate insulin manipulation: an eating disorder variant in an adolescent with insulin-dependent diabetes mellitus.

This is the first in a series ofpapers being sponsored by the Psychosocial Committee ofAADE that will highlight psychosocial issues encountered in the treatment of diabetes. The present case describes the assessment, diagnosis, and treatment of a young woman with IDDM who inappropriately manipulated her insulin to lose weight. The discussion focuses on the role of the diabetes treatment team in the early detection and prevention of maladaptive weight-loss behaviors. This is achieved through routine assessment, diabetes-specific dietary counseling, and the education of young patients and their parents on the serious health and financial consequences of inappropriate insulin a adjustment.