Korey K. Hood

Depressive Symptoms in Children and Adolescents With Type 1 Diabetes Association with diabetes-specific characteristics

Depression in children and adolescents with type 1 diabetes has been associated with negative diabetes-related health outcomes such as poorer glycemic control (1–5) and recurrent diabetic ketoacidosis (DKA) admissions (6,7). While mechanisms that link depression and suboptimal health outcomes are poorly understood (8), it is apparent that the chronicity of type 1 diabetes and the demands of management provide a fertile environment for adjustment problems. Our aim was to investigate depressive symptoms in children and adolescents with type 1 diabetes and their association with demographic, diabetes-specific, and family-functioning variables. Study participants were 145 youth and their parents (107 mothers, 35 fathers, and 3 guardians) who received care at a pediatric diabetes center from a multidisciplinary team. The sample of 145 youth (56% female) had a mean age of 14.9 ± 2.3 years (range 10–18). Duration of type 1 diabetes was 8.3 ± 3.5 years, and mean HbA1c (A1C) was 8.7 ± 1.4%. At the time of the participant’s clinic appointment, a trained research assistant obtained written informed consent and assent and then administered questionnaires. This sample of 145 parent-youth dyads represented 88% of the families approached. Insulin dose and frequency of insulin injections were documented by the youth’s medical provider. Frequency of blood glucose monitoring (BGM) was documented through meter downloads and parent report. Each participant provided a sample of blood for A1C, measured by high-performance liquid chromatography (reference range 4.0–6.0%, Tosoh 2.2; Tosoh Bioscience, South San Francisco, CA). Depressive symptoms in youth were assessed with the Children’s Depression Inventory (CDI) (9), a self-report questionnaire consisting of 27 …

Association Between Adherence and Glycemic Control in Pediatric Type 1 Diabetes: A Meta-analysis

CONTEXT: Although adherence has been identified in practice guidelines for youth with type 1 diabetes to promote optimal glycemic control, there has been no systematic integration of studies investigating the adherence-glycemic control link. This recommendation partly stemmed from the Diabetes Control and Complications Trial (DCCT); however, this trial did not comprehensively measure adherence and had only 195 adolescents. OBJECTIVE: Our goal was to determine the magnitude of the adherence-glycemic control link in pediatric type 1 diabetes and evaluate its correlates. METHODS: Our data sources were PubMed (1950–2008), Scopus (1950–2008), and references from reviews in pediatric type 1 diabetes. Studies that included youth under age 19 with type 1 diabetes and a reported association between adherence and glycemic control were eligible for inclusion. Articles were not included if they contained youth with type 2 diabetes, had study samples that overlapped with other studies, or the results came from intervention studies. Of the eligible 26 studies, 21 had sufficient statistical data. Two authors independently extracted information by using a standardized protocol. Agreement between coders was high. RESULTS: The mean effect size across 21 studies, including 2492 youth with type 1 diabetes, was −0.28 (95% confidence interval: −0.32 to −0.24). As adherence increases, A1c values decrease. No sample or disease characteristics were correlates of the adherence-glycemic control link. Pre-DCCT studies had a mean effect size of −0.32 (8 studies; 1169 participants) compared with −0.25 in post-DCCT studies (13 studies; 1323 participants). CONCLUSIONS: This meta-analysis supports the adherence-glycemic control link in pediatric type 1 diabetes. The weaker post-DCCT association suggests that the approach to intensive diabetes management has shortcomings. We conclude that this is because of a mismatch between what scientists and clinicians know is the best way to manage pediatric type 1 diabetes and the capabilities of youth and their families.

Pediatric Self-management: A Framework for Research, Practice, and Policy

Self-management of chronic pediatric conditions is a formidable challenge for patients, families, and clinicians, with research demonstrating a high prevalence of poor self-management and nonadherence across pediatric conditions. Nevertheless, effective self-management is necessary to maximize treatment efficacy and clinical outcomes and to reduce unnecessary health care utilization and costs. However, this complex behavior is poorly understood as a result of insufficient definitions, reliance on condition-specific and/or adult models of self-management, failure to consider the multitude of factors that influence patient self-management behavior, and lack of synthesis of research, clinical practice, and policy implications. To address this need, we present a comprehensive conceptual model of pediatric self-management that articulates the individual, family, community, and health care system level influences that impact self-management behavior through cognitive, emotional, and social processes. This model further describes the relationship among self-management, adherence, and outcomes at both the patient and system level. Implications for research, clinical practice, and health care policy concerning pediatric chronic care are emphasized with a particular focus on modifiable influences, evidence-based targets for intervention, and the role of clinicians in the provision of self-management support. We anticipate that this unified conceptual approach will equip stakeholders in pediatric health care to (1) develop evidence-based interventions to improve self-management, (2) design programs aimed at preventing the development of poor self-management behaviors, and (3) inform health care policy that will ultimately improve the health and psychosocial outcomes of children with chronic conditions.

Psychosocial Care for People With Diabetes: A Position Statement of the American Diabetes Association

Complex environmental, social, behavioral, and emotional factors, known as psychosocial factors, influence living with diabetes, both type 1 and type 2, and achieving satisfactory medical outcomes and psychological well-being. Thus, individuals with diabetes and their families are challenged with complex, multifaceted issues when integrating diabetes care into daily life. To promote optimal medical outcomes and psychological well-being, patient-centered care is essential, defined as “providing care that is respectful of and responsive to individual patient preferences, needs, and values and ensuring that patient values guide all clinical decisions” (1). Practicing personalized, patient-centered psychosocial care requires that communications and interactions, problem identification, psychosocial screening, diagnostic evaluation, and intervention services take into account the context of the person with diabetes (PWD) and the values and preferences of the PWD. This article provides diabetes care providers with evidence-based guidelines for psychosocial assessment and care of PWD and their families. Recommendations are based on commonly used clinical models, expert consensus, and tested interventions, taking into account available resources, practice patterns, and practitioner burden. Consideration of life span and disease course factors (Fig. 1) is critical in the psychosocial care of PWD. This Position Statement focuses on the most common psychological factors affecting PWD, including diabetes distress and psychological comorbidities, while also considering the needs of special populations and the context of care. Figure 1 Psychosocial care for PWD: life and disease course perspectives. *With depressed mood, anxiety, or emotion and conduct disturbance. **Personality traits, coping style, maladaptive health behaviors, or stress-related physiological response. \***|Examples include changing schools, moving, job/occupational changes, marriage or divorce, or experiencing loss. #### Recommendations

Depressive Symptoms and Glycemic Control in Adolescents With Type 1 Diabetes: Mediational role of blood glucose monitoring

OBJECTIVE To determine whether the association between depressive symptoms and glycemic control is mediated by blood glucose monitoring (BGM). RESEARCH DESIGN AND METHODS A total of 276 adolescents with type 1 diabetes (mean age ± SD, 15.6 ± 1.4 years) completed a measure of depressive symptoms. Sociodemographic and family characteristics were obtained from caregivers. BGM frequency and glycemic control were obtained at a clinic visit. RESULTS Separate regression analyses revealed that depressive symptoms were associated with lower BGM frequency (B = −0.03; P = 0.04) and higher A1C (B = 0.03; P = 0.05) and that lower BGM frequency was associated with higher A1C (B = −0.39; P < 0.001). With depressive symptoms and BGM frequency included together, only BGM frequency was associated with A1C and depressive symptoms became nonsignificant (B = 0.02; P = 0.19). The Sobel test was significant (Z = 1.96; P < 0.05) and showed that 38% of the depression-A1C link can be explained by BGM. CONCLUSIONS BGM is a mediator between depressive symptoms and glycemic control in adolescents with type 1 diabetes.

Interventions With Adherence-Promoting Components in Pediatric Type 1 Diabetes: Meta-analysis of their impact on glycemic control

OBJECTIVE To review interventions with adherence-promoting components and document their impact on glycemic control via meta-analysis. RESEARCH DESIGN AND METHODS Data from 15 studies that met the following criteria were subjected to meta-analysis: 1) randomized, controlled trial, 2) study sample included youth aged <19 years, 3) youth had type 1 diabetes, 4) study reported results on glycemic control; and 5) study reported use of adherence- or self-management–promoting components. RESULTS The 15 studies included 997 youth with type 1 diabetes. The mean effect size for pre- to posttreatment change for the intervention versus control group comparison was 0.11 (95% CI −0.01 to 0.23). This is a small effect, demonstrating very modest improvements in glycemic control. However, analysis for the pre- to posttreatment effects for the intervention group alone did show significant variability [Q(14) = 33.11; P < 0.05]. Multicomponent interventions, those that targeted emotional, social, or family processes that facilitate diabetes management, were more potent than interventions just targeting a direct, behavioral process (e.g., increase in blood glucose monitoring frequency). CONCLUSIONS Interventions that focus on direct, behavioral processes and neglect emotional, social, and family processes are unlikely to have an impact on glycemic control; multicomponent interventions showed more robust effects on A1C. Future clinical research should focus on refining interventions and gathering more efficacy and effectiveness data on health outcomes of the pediatric patients treated with these interventions.

Prediction of Adolescents' Glycemic Control 1 Year After Diabetes-Specific Family Conflict The Mediating Role of Blood Glucose Monitoring Adherence

OBJECTIVE To test adherence to blood glucose monitoring (BGM) as a mediator between diabetes-specific family conflict and glycemic control (hemoglobin A(1c) [HbA(1c)] levels) for 1 year. DESIGN Three waves of prospective data spanning 1 year. SETTING Diabetes clinic in a large tertiary care childrens hospital in the Midwestern United States. PARTICIPANTS One hundred forty-five dyads composed of an adolescent (aged 13-18 years) with type 1 diabetes mellitus and a parent. MAIN EXPOSURES Adolescent- and parent-rated diabetes-specific family conflict and mean daily BGM frequency obtained through meter downloads. MAIN OUTCOME MEASURE Levels of HbA(1c), abstracted from the medical record. RESULTS In separate general linear models, higher adolescent-rated family conflict scores at baseline predicted less frequent BGM at 6 months (β = -0.08 [P = .01]) and higher HbA(1c) levels at 12 months (β = 0.08 [P = .02]). In the multivariate model including baseline conflict and BGM as predictors of HbA(1c) levels, BGM was a significant predictor (β = -0.24 [P = .007]) and conflict was no longer significant (β = 0.05 [P = .11]), supporting the mediation hypothesis. Post hoc probing showed that BGM explained 24% of the variance in the conflict-HbA(1c) link. The mediation between parent-reported conflict and HbA(1c) levels via BGM adherence was partially supported (conflict predicting HbA(1c) in the zero-order equation, β = -0.24 [P = .004]; multivariate equation, β = 0.06 [P = .02]), and BGM frequency explained 16% of the conflict-HbA(1c) link. CONCLUSIONS Diabetes-specific family conflict in adolescence predicts deteriorations in BGM and subsequent glycemic control for at least 1 year. Results support ongoing intervention research designed to reduce family conflict and thus prevent a trajectory of declining adherence and glycemic control across adolescence.

Diabetes Device Use in Adults With Type 1 Diabetes: Barriers to Uptake and Potential Intervention Targets

OBJECTIVE Diabetes devices (insulin pumps, continuous glucose monitors [CGMs]) are associated with benefits for glycemic control, yet uptake of these devices continues to be low. Some barriers to device uptake may be modifiable through psychosocial intervention, but little is known about which barriers and which patients to target. RESEARCH DESIGN AND METHODS We surveyed 1,503 adult T1D Exchange participants (mean age 35.3 [SD 14.8] years, mean diagnosis duration 20.4 [SD 12.5] years) to investigate barriers to device uptake, understand profiles of device users versus nonusers, and explore differences by age and sex. Scales used were the Diabetes Distress Scale, Technology Use Attitudes (General and Diabetes-Specific), and Barriers to Device Use and Reasons for Discontinuing Devices. RESULTS Most commonly endorsed modifiable barriers were related to the hassle of wearing devices (47%) and disliking devices on one’s body (35%). CGM users (37%) were older than nonusers (mean 38.3 vs. 33.5 years), had diabetes for longer (22.9 vs. 18.8 years), had more positive technology attitudes (22.6–26.0 vs. 21.4–24.8), and reported fewer barriers to using diabetes technology than nonusers (3.3 vs. 4.3). The youngest age-group (18–25 years) had the lowest CGM (26% vs. 40–48%) and insulin pump (64% vs. 69–77%) uptake, highest diabetes distress (2.2 vs. 1.8–2.1), and highest HbA1c levels (8.3% [67 mmol/mol] vs. 7.2–7.4% [55–57 mmol/mol]). CONCLUSIONS Efforts to increase device use need to target physical barriers to wearing devices. Because young adults had the lowest device uptake rates, highest distress, and highest HbA1c compared with older age-groups, they should be the focus of future interventions to increase device use.

Psychosocial assessment of artificial pancreas (AP): commentary and review of existing measures and their applicability in AP research.

AIM This study aimed to systematically review the evidence base for the use of existing psychological and psychosocial measures suitable for use in artificial pancreas (AP) research. MATERIALS AND METHODS This systematic review of published literature, gray literature, previous systematic reviews, and qualitative and economic studies was conducted using terms and abbreviations synonymous with diabetes, AP, and quality of life (QoL). RESULTS Two hundred ninety-two abstracts were identified that reported psychosocial assessment of diabetes-related technologies. Of these, nine met the inclusion criteria and were included. Only four of 103 ongoing trials evaluated psychosocial aspects as an outcome in the trial. Of these, treatment satisfaction, acceptance and use intention of AP, fear of hypoglycemia episodes, satisfaction with AP, and an unspecified QoL measure were used. CONCLUSIONS A better understanding of the psychosocial side of AP systems and the extent to which human factors play a role in the uptake and efficient use of these systems will ultimately lead to the most benefit for people with diabetes.

The emerging diabetes online community.

Abstract: Background Diabetes self-management is complex and demanding, and isolation and burnout are common experiences. The Internet provides opportunities for people with diabetes to connect with one another to address these challenges. The aims of this paper are to introduce readers to the platforms on which Diabetes Online Community (DOC) participants interact, to discuss reasons for and risks associated with diabetes-related online activity, and to review research related to the potential impact of DOC participation on diabetes outcomes. Methods Research and online content related to diabetes online activity is reviewed, and DOC writing excerpts are used to illustrate key themes. Guidelines for meaningful participation in DOC activities for people with diabetes, families, health care providers, and industry are provided. Results Common themes around DOC participation include peer support, advocacy, self-expression, seeking and sharing diabetes information, improving approaches to diabetes data management, and humor. Potential risks include access to misinformation and threats to individuals’ privacy, though there are limited data on negative outcomes resulting from such activities. Likewise, few data are available regarding the impact of DOC involvement on glycemic outcomes, but initial research suggests a positive impact on emotional experiences, attitudes toward diabetes, and engagement in diabetes management behaviors. Conclusion The range of DOC participants, activities, and platforms is growing rapidly. The Internet provides opportunities to strengthen communication and support among individuals with diabetes, their families, health care providers, the health care industry, policy makers, and the general public. Research is needed to investigate the impact of DOC participation on self-management, quality of life, and glycemic control, and to design and evaluate strategies to maximize its positive impact.