Michael P. Golden

Cognitive maturity and self-management among adolescents with insulin-dependent diabetes mellitus

The ability of adolescents with insulin-dependent diabetes mellitus (IDDM) to assume responsibility for self-management is complicated by normal psychosocial developmental tasks, including establishing independence from authority. We evaluated self-managerial behavior and its relation to cognitive maturity. Forty-one adolescents with IDDM (age range 12 to 21 years) and their parents, who were trained to self-adjust insulin on compensatory and anticipatory bases, participated. The data indicated that parents withdrew from the insulin adjustment process as their adolescents grew older. Parental participation had virtually ceased by the time the child reached age 15 years. Parental withdrawal, however, was not always balanced by the adolescents assumption of responsibility for insulin adjustments. Older adolescents were statistically no more likely than younger adolescents to self-adjust insulin doses. Both self-adjustment and metabolic control (HbA1 values) among adolescents were, however, related to cognitive maturity. More cognitively mature adolescents were also more likely to perceive themselves as being in control of their illness. Thus, older adolescents who are less cognitively mature than their peers are sometimes given responsibility for self-managerial behaviors that they are unable to assume.

An approach to prevention of recurrent diabetic ketoacidosis in the pediatric population

In 1982 we introduced a program designed to prevent recurrent diabetic ketoacidosis (RDKA), based on the assumption that diabetes education in conjunction with appropriate use of and adherence to insulin therapy should eliminate all RDKA. A hierarchical set of medical, educational, and psychosocial interventions was used. The rate of RDKA was lower after initiation of the program even though patients seen during this period came from lower socioeconomic and more one-parent families (each independently associated with RDKA) than patients seen prior to intervention. In 44 patients with a history of RDKA, insulin omission was documented in 31, inadequate education in 13. Overall, the rate of RDKA decreased from a prereferral mean of 25.2 episodes to a postreferral mean of 2.6 episodes per 100 patient-months (P less than 0.0001). Metabolic control improved after intervention as documented by a decrease in mean hemoglobin A1 from 14.1% to 10.7% (P less than 0.0001). RDKA ceased whether or not psychotherapy was used. Although RDKA is causally related to a variety of social, economic, and family dysfunctions, its prevention requires recognition that its proximate cause is omission of insulin and assurance that a support system exists to ensure adherence.

Clinical evaluation of computer-assisted self-monitoring of blood glucose system.

The Glucometer M Diabetes Management System includes a glucose-reflectance meter with memory that can interface with a microcomputer for data manipulation and analysis. We evaluated the system in a short-term randomized control trial to determine its impact on metabolic control, self-monitoring of blood glucose (SMBG) testing behaviors, regimen selfadjustment, understanding of insulin-dependent diabetes mellitus (IDDM) treatment, attitudes about SMBG, and perceived quality of patient-physician interaction. Twenty-nine adolescent subjects (experimental) with IDDM were randomly assigned the Glucometer M system for 4 mo. Twenty-eight control subjects used meters without memory. All subjects returned twice to the clinic at 2-mo intervals during the study. At clinic visits, both groups reviewed their SMBG data with their physician. Reviews on experimental subjects were conducted with computer-generated data formats. Control subject reviews used traditional logbooks. Both groups showed a significant drop in glycosylated hemoglobin during the study period (P < .001); however, there were no between-group differences. There were also no differences in SMBG testing behavior or self-reported regimen selfadjustment between groups or within groups compared with baseline. Compared with control subjects, experimental subjects indicated a significant increase in self-reported understanding of IDDM treatment (P = .002), perceived importance of testing (P = .006), and the quality of interaction with their physician (P < .001). These data suggest that use of computer-assisted SMBG systems in the outpatient setting does not improve metabolic control over 4 mo. It may, however, contribute to improving communication between the patient and health-care providers.

Obesity and socioeconomic class in children and their mothers

An attempt was made to identify environmental (potentially modifiable) factors which might contribute to the excess risk for obesity existing in lower socioeconomic status (SES) populations. The relationships between relative weights of children and their mothers, SES, maternal nutritional knowledge, maternal weight locus of control (WLOC), and hours of television viewed daily by children (TV) were evaluated in 144 children (mean age 5.9 years, range 2 to 14) and their mothers. The degree of overweight in children was measured by percent weight for height and expressed as the percentile for age. Maternal weight was expressed as the percent ideal body weight. SES was assessed separately by a 9-point rating scale of paternal occupation and by years of parental education, nutritional knowledge using a newly developed 17-item questionnaire, and WLOC by a previously developed scale. Subjects were recruited from two clinic populations selected to differ in socioeconomic status. Mothers from the lower SES clinic were heavier, had less nutritional knowledge, and perceived themselves as having less control of their own weight (external) than their higher SES counterparts. Hours of daily TV viewing were similar in both groups. Children from a lower SES resembled their mothers with regard to weight, whereas the middle SES children did not. Using multiple regression analysis, nutritional knowledge, external locus of control, and child TV viewing predicted maternal weight with a correlation of 0.4 in the lower SES clinic, but less strongly in the middle SES clinic. These results suggest that the increased risk for the development of obesity in children from lower SES populations can be decreased in part by programs directed at maternal weight control, including nutritional education and behavioral efforts focused on increasing internal weight locus of control. This approach is less likely to be successful in middle class populations.

Maximum oxygen uptake determination in insulin-dependent diabetes mellitus

In brief: Four girls and six boys (mean age, 13.3 years; range, 12 to 14) with insulin-dependent diabetes mellitus (IDDM), who were not physically fit, performed a maximum-effort, continuous, progressive cycling test. The purpose was to document baseline aerobic capacity before prescribing exercise as part of the treatment plan for IDDM. Results showed that blood glucose levels did not change appreciably during the test. Maximum oxygen uptake (VO2) was 34 and 44 ml·kg-−1·min−1 for girls and boys, respectively (substandard values for the age of the subjects). These findings suggest that patients in fair to poor metabolic control (mean Hb A1, 11.42%; SD, 4.47; normal range, 5.0% to 7.5%) can indeed tolerate stress testing without experiencing a change in glucose level that would jeopardize their health.

Pediatrics Residents' Attitudes about Insulin-Dependent Diabetes Mellitus and Children with Diabetes.

Nationwide, pediatricians provide a substantial portion of the health care of children with diabetes. Their beliefs and attitudes about diabetes and children with the illness have an important influence on their treatment decisions. The attitudes and beliefs of a 1988 sample of pediatrics residents were compared with data from a 1987 national survey of practicing pediatricians beliefs and attitudes about children with insulin-dependent diabetes mellitus and about the disease itself. Pediatrics residents in their second and third years of training were considerably more negative about diabetes and diabetic children than were either the members of the national sample of practicing pediatricians or the residents first-year colleagues.

Computer-Generated Formats for SMBG Data

a prolonged period with little variation in HbA, levels, so that the correlation between HbA, and FPG is relatively poor (Fig. 2 top). The excellent agreement between FPG and HbA, in NIDDM patients suggests that FPG offers a reliable, simple, and adequate measure of glycemic control and leads us to question the need for routine testing of HbA, in such patients. Even in the unstructured setting of diabetic outpatients, the fasting blood sample has the advantage of some standardization, and fasting from the night before the test is no problem in outpatients. Theoretically, FPG measurements could indicate spuriously good control if patients dieted before a clinic visit. However, the excellent correlations we obtained over a wide range of glycemia suggest that such attempted deception is relatively rare. At a time of increasing concern about the cost of health-care provision, it behooves physicians to exercise the greatest efficiency possible in clinical investigation and management. We do not suggest that measurement of HDAT should be abandoned in NIDDM patients, but we believe its use could be rationed, perhaps to no more than one measurement per year in most patients, without compromising clinical care.

Betakid--lessons learned while developing a microcomputer pediatric case simulation.

An arcade-style game, Betakid, was developed to provide diabetic children an opportunity to practice and evaluate skills in food and insulin dose selection. The user participates in the events through displays of text and graphics, occasionally accompanied by music. Choices are made concerning insulin dose, diet, and exercise. A displayed score indicates the appropriateness of the users actions. Remediation is available after each decision. During the design and initial evaluation of Betakid, a number of lessons were learned about the application of computer-based simluations to diabetes education and care. The approach that was followed in developing Betakid, a summary of the characteristics of the simulation, and a list of suggestions for efficiently developing this type of project are presented.