Glycemic control, depression, diabetes distress among adolescents with type 1 diabetes: effects of sex, race, insurance, and obesity

A trauma-informed approach to type 1 diabetes mellitus in adults

Suggested mechanisms for an association between early life adversity and worse glycaemic control.

Diabetes distress, depression, and future glycemic control among adolescents with type 1 diabetes

OBJECTIVES

Increased diabetes distress and depression in adolescents with type 1 diabetes (T1D) are associated with poor glycemic control but it is not known whether they predict future glycemic control.

METHODS

Patient Health Questionnaire (PHQ-9) and Problem Areas in Diabetes-Teen version (PAID-T) scores were given to 275 adolescents (age 13-17 years) with T1D. Robust rank order multivariate regression analysis was used to assess how age, duration of diabetes diagnosis, HbA1c at screen, PHQ-9 score, PAID-T screen, and insurance status predicted HbA1c at 1, 2, and 3 years after, and the changes in HbA1c over time.

RESULTS

HbA1c and changes in HbA1c after one year were related to baseline HbA1c. At 2 and 3 years HbA1c was related to the initial HbA1c [β: 0.64 (95 % CI 0.53-0.75) and β: 0.47 (95 % CI 0.33-0.61), respectively], and to PHQ9 at screening [β: 0.07 (95 % CI 0.01-0.14) and β: 0.11 (95% CI 0.03-0.18), respectively]. Relationships were also demonstrated between PHQ9 and changes HbA1c after 2 and 3 years [β: 0.07 (95% CI 0.01-0.14) and β: 0.11 (95 % CI 0.03-0.18), respectively]. PAID-T score was not related to future glycemic control or changes in glycemic control at any time. Insurance status (private 1, public 2) also predicted future glycemic control and changes in HbA1c at 1, 2, and 3 years too.

CONCLUSIONS

Higher PHQ9 scores and public insurance predict worsening glycemic control over 3 years in adolescents with T1D while increased diabetes distress does not.

The role of depression and diabetes distress in glycemic control: A meta-analysis

AIMS

This study evaluated the associations between depression, diabetes distress, glycemic control (HbA1c), and self-care behaviours in individuals with diabetes. Findings on these relationships have been inconsistent, highlighting the need for systematic evaluation.

METHODS

Data from 61 studies involving 19,537 participants conducted between 2001 and 2024 were analysed using random-effects models. Subgroup analyses examined variations by diabetes type, geographic location, and measurement tools. Heterogeneity was assessed using I2 statistics.

RESULTS

Depression and diabetes distress were significantly associated with poorer glycemic control (r = 0.23, 95 % CI [0.15 to 0.31], p < 0.001) and reduced self-care behaviours (r = -0.19, 95 % CI [-0.28 to -0.10], p < 0.001). Stronger correlations were observed in mixed diabetes populations (r = 0.35, 95 % CI [0.30 to 0.40], I2 = 0 %) and in studies conducted in Europe (r = 0.28) and North America (r = 0.34). High heterogeneity (I2 = 97.24 %) was identified.

CONCLUSIONS

Depression and diabetes distress are associated with poorer glycemic control and reduced self-care behaviours. Findings highlight the need for standardized measures and longitudinal studies to explore mechanisms underlying these associations.

Psychosocial factors correlating self-care management among Jordanian adolescents with type 1 diabetes

PURPOSE

Few studies were conducted to examine the correlation between the anxiety symptoms, depressive symptoms, self-efficacy, and social support variables and type 1 diabetes in developing countries, including Jordan. Thus, this study was conducted to assess the correlation between these psychosocial factors and self-care management among Jordanian adolescents with type 1 diabetes.

DESIGN & METHODS

A cross-sectional, descriptive correlational design was used to perform a study among adolescents with type 1 diabetes (N = 351) aged 14-18 years who attended primary healthcare centers clinics, and diabetic clinics related to hospitals in Amman Governorate, Jordan. A convenience sampling method was used to recruit participants. The data were collected using self-reported questionnaire during the period from June to December 2023.

FINDINGS

The results revealed that around 61.0 % of the sample were males and 39 % female, and 74.9 % of the participants experienced type 1 diabetes for more than one year. Only, 4.3 % of the participants had the recommended HbA1c (< 7.5 %). The participants had high percentage anxiety and depressive symptoms, poor self-efficacy, moderate social support, and low self-care management. There was a correlation between self-efficacy, social support, and self-care management. Also, social support mediated the relationship between self-efficacy and self-care management. However, no relationship existed between anxiety and depressive symptoms and self-care management.

CONCLUSION

Screening for anxiety and depressive symptoms should be a significant element of care for adolescents with type 1 diabetes in outpatient clinics. Policymakers and healthcare professionals including pediatric nurses should develop strategies and education programs on self-care management to enhance self-care practices and management for adolescents with type 1 diabetes.

Adaptation of the Problem Areas in Diabetes-Teen Scale into Turkish and examination of its psychometric properties: a validity and reliability study

OBJECTIVE

Management of type 1 diabetes (T1DM) is quite challenging for both adolescents and their families. In this study, we aimed to translate the 14-item Problem Areas in Diabetes-Teen (PAID-T) scale, which measures variables that influence diabetes distress, to Turkish and investigate the Turkish version's reliability and validity.

METHODS

One hundred and ninety-four adolescents with T1DM participated in the study. PAID-T and forms for sociodemographic and diabetes characteristics were used for data collection. The scale's content validity was checked using the Davis technique. Cronbach's α was used to analyze the scale's internal reliability and the test-retest for the scale's reliability. Exploratory factor analysis (EFA) was utilized to examine the factor structure. The fit of the scale was assessed using confirmatory factor analysis (CFA).

RESULTS

Of the participants, 54.6% (n=106) were girls. The content validity index values of the scale items ranged between 0.86 and 1.0. The PAID-T scores of girls and boys were similar. No significant difference was found between PAID-T scores with sociodemographic data and diabetes characteristics (p>0.05). The test-retest correlation coefficient of the scale was found to be 0.952. The three-factor (emotional burden, family and friend distress, and regimen-specific distress) model identified in EFA explained 61.8% of the common variance. Fit analysis was performed using CFA for the three-factor model, which did not show adequate fit (x2/df = 2.402, GFI = 0.822, CFI = 0.815, NFI = 0.727, NNFI = 0.772, RMSEA = 0.118). The Cronbach α value of the scale was 0.864.

CONCLUSION

The Turkish version of the 14-item PAID-T showed moderate validity and strong reliability. Accordingly, it can be used as a reliable measurement tool to assess diabetes stress in adolescents with T1DM.

Identifying depression, diabetes distress, and suicidality among adolescents with diabetes

This study explored the frequency of adolescents with diabetes who endorse suicidality on the Patient Health Questionnaire (PHQ-9) with varying degrees of depression scores. Additionally, compared whether diabetes distress levels from the Problem Areas in Diabetes-Teen (PAID-T) assessment tool is associated with and without suicidal ideation. Χ2 analysis was used to assess differences in subjects with or without suicidal ideation based on depression severity. Since all the data were nonparametrically distributed (Shapiro-Wilk test, p < .05), Kruskal-Wallis test assessed differences in continuous variables. Overall, 27 of 355 adolescents screened endorsed suicidal ideation. Both PHQ-9 [13 (9-17.8) vs 1 (0-4.5)] and PAID-T [88 (61.8-104.5) vs 40 (30-58.8)] scores were significantly higher in patients with suicidal ideation. The frequency of suicidal ideation increased with the severity of depression. The frequency of severe depression was higher in adolescents with type 2 diabetes (n = 48) than in type 1, but there was no difference in suicidality. Adolescents with no demonstrable or minimal depression can still have potential suicidal ideation. Suicidality is a separate construct that should be screened routinely and apart from any measures screening for distress or adjustment disorders associated with adolescents experiencing life-long chronic conditions in a healthcare follow-up setting.

The moderating role of diabetes distress on the effect of a randomized eHealth intervention on glycemic control in Black adolescents with type 1 diabetes

OBJECTIVE

Due to systemic inequities, Black adolescents with type 1 diabetes are more likely to have suboptimal glycemic control and high rates of diabetes distress, but tailored interventions for this population are lacking. In primary outcomes of a randomized clinical trial, a family-based eHealth intervention improved glycemic control in Black adolescents with type 1 diabetes and elevated depressive symptoms. The present study is a secondary analysis of these clinical trial data examining the moderating effect of diabetes distress on the efficacy of the intervention.

METHODS

Using secondary data from a multicenter randomized clinical trial (Clinicaltrials.gov [NCT03168867]), caregiver-adolescent dyads were randomly assigned to either up to three sessions of an eHealth parenting intervention (n = 75) or a standard medical care control group (n = 74). Black adolescents (10 years, 0 months to 14 years, 11 months old) with type 1 diabetes and a caregiver willing to participate were eligible. Adolescents reported their diabetes distress at baseline, and hemoglobin A1c (HbA1c) data were collected at baseline, 6-, 13-, and 18-month follow-up.

RESULTS

No between-group contrasts emerged in a linear mixed-effects regression (p's > .09). Within-group contrasts emerged such that adolescents assigned to the intervention who reported high diabetes distress had lower HbA1c at the 18-month follow-up relative to baseline (p = .004); the 18-month decrease in HbA1c was -1.03%.

CONCLUSIONS

Black adolescents with type 1 diabetes and high levels of diabetes distress showed significant decreases in HbA1c following a family-based eHealth intervention, suggesting diabetes distress may be a key moderator of intervention efficacy within this population.

Type 1 diabetes-related distress: Current implications in care

Type 1 diabetes (T1D) is a complex chronic disease associated with major health and economic consequences, also involving important issues in the psychosocial sphere. In this regard, T1D-related distress, defined as the emotional burden of living with T1D, has emerged as a specific entity related to the disease. Diabetes distress (DD) is an overlooked but prevalent condition in people living with T1D, and has significant implications in both glycemic control and mental health in this population. Although overlapping symptoms may be found between DD and mental health disorders, specific approaches should be performed for the diagnosis of this problem. In recent years, different DD-targeted interventions have been postulated, including behavioral and psychosocial strategies. Moreover, new technologies in this field may be helpful to address DD in people living with T1D. In this article, we summarize the current knowledge on T1D-related distress, and we also discuss the current approaches and future perspectives in its management.

Body mass index moderates the association between diabetes distress and objective self-management behaviours in adolescents with type 1 diabetes and elevated A1Cs

OBJECTIVE

To examine the cross-sectional associations between diabetes distress, BMI (zBMI; BMI z-score), objectively measured mean daily blood glucose readings and insulin boluses administered, and A1C in adolescents with type 1 diabetes (T1D) using insulin pumps.

METHODS

T1D self-management behaviour data were downloaded from adolescents' (N = 79) devices and mean daily frequency of blood glucose readings and insulin boluses were calculated. Diabetes distress was measured (Problem Areas in Diabetes-Teen questionnaire [PAID-T]), A1C collected, and zBMI calculated from height and weight. Three multiple linear regressions were performed with blood glucose readings, insulin boluses, and A1C as the three dependent variables and covariates (age, T1D duration), zBMI, diabetes distress, and the diabetes distress x zBMI interaction as independent variables.

RESULTS

Participants (55.7% female) were 14.9 ± 1.9 years old with T1D for 6.6 ± 3.4 years. zBMI moderated the relationship between diabetes distress and mean daily insulin boluses administered (b = -0.02, p = 0.02); those with higher zBMI and higher diabetes distress administered fewer daily insulin boluses. zBMI was not a moderator of the association between diabetes distress and blood glucose readings (b = -0.01, p = 0.29) or A1C (b = 0.002, p = 0.81).

CONCLUSIONS

Using objective behavioural data is useful for identifying how adolescent diabetes distress and zBMI affect daily bolusing behaviour amongst adolescent insulin pump users. Although distinct interventions exist to improve T1D self-management or diabetes distress, none addresses them together while considering zBMI. Decreasing diabetes distress could be especially important for youth with high zBMI.

Diabetes distress in urban Black youth with type 1 diabetes and their caregivers: associations with glycemic control, depression, and health behaviors

OBJECTIVES

Adolescents with type 1 diabetes (T1D) and their caregivers endorse high diabetes distress (DD). Limited studies have documented the impact of DD on Black youth. The aims of the present study were to (1) describe DD among a sample of Black adolescents with T1D and their caregivers, (2) compare their DD levels with published normative samples, and (3) determine how DD relates to glycemic outcomes, diabetes self-management, parental monitoring of diabetes, and youth depressive symptoms.

METHODS

Baseline data from a multicenter clinical trial were used. Participants (N = 155) were recruited from 7 Midwestern pediatric diabetes clinics. Hemoglobin A1c (HbA1c) and measures of DD, parental monitoring of diabetes care, youth depression and diabetes management behaviors were obtained. The sample was split into (1) adolescents (ages 13-14; N = 95) and (2) preadolescents (ages 10-12; N = 60). Analyses utilized Cohen's d effect sizes, Pearson correlations, t-tests, and multiple regression.

RESULTS

DD levels in youth and caregivers were high, with 45%-58% exceeding either clinical cutoff scores or validation study sample means. Higher DD in youth and caregivers was associated with higher HbA1c, lower diabetes self-management, and elevated depressive symptoms, but not with parental monitoring of diabetes management.

CONCLUSIONS

Screening for DD in Black youth with T1D and caregivers is recommended, as are culturally informed interventions that can reduce distress levels and lead to improved health outcomes. More research is needed on how systemic inequities contribute to higher DD in Black youth and the strategies/policy changes needed to reduce these inequities.

Association of quality of life with medication adherence and glycemic control in patients with type 1 diabetes

Background and objectives

Psychological factors and patients' health-related quality of life (HRQOL) affect the outcome of patients with type 1 diabetes mellitus (T1DM). In this study, we aimed to determine the HRQOL status in patients with T1DM and its association with glycemic control and medication adherence.

Methods

In this cross-sectional study, 227 T1DM patients were selected from the diabetes clinic, Imam Ali Hospital, Alborz University of Medical Sciences, and the Gabric database registry from 2020 to 2022. Demographic and diabetes characteristic checklist, medication adherence questionnaire (8-item Morisky Medication Adherence Scale (MMAS)), and QOL questionnaires (Short-Form-12 and PedsQL) were filled. Independent sample T-test was used to assess mean of QOL subscales with glycemic control and medication adherence. A logistic regression model was used to evaluate the association between glycemic control and medication adherence with QOl.

Results

Overall QOL scores in adults and children were 33.4 ± 7.1 based on Short-Form-12 and 76.2 ± 17.8 based on PedsQL, respectively. It was demonstrated that adults with Moderate/High adherence had higher QOL (p-value = 0.007). Likewise, Children with good glycemic control had higher psychosocial health scores (0.048). Logistic regression analysis did not reveal a significant association between adherence and QOL or Glycemic control and QOL in both adjusted and crude models.

Conclusion

Better glycemic control and medication adherence in children and adults, respectively, are related to the psychological aspects of QOL. We suggest that emotional intelligence, which is replaced by other predictors during adulthood, may contribute to glycemic control in children in the early years following diagnosis.

The association between depressive symptoms and executive function in type 1 diabetes population: A scoping review

PURPOSE

The purpose of this study was to explore the existing literature on the relationship between depressive symptoms and executive function in patients with type 1 diabetes (T1DM) across the lifespan.

METHODS

The scoping review followed the PRISMA protocol by using three databases: PubMed, CINAHL, and PsycINFO on May 14, 2023. Primary research that included reported executive function and the association with depressive symptoms was included in the review.

RESULTS

Of 1470 de-duplicated publications identified, nine articles were included in the review. Five studies evaluated the T1DM population, while four studies evaluated T1DM and type 2 diabetes (T2DM) as an aggregate result. Three studies indicated an association between depressive symptoms and executive function in adults with T1DM, and four studies indicated an association between depressive symptoms and executive function in adults with either T1DM or T2DM. In general, participants who reported depressive symptoms also exhibited poor executive function. However, two studies did not find an association between depressive symptoms and executive function.

CONCLUSION

In summary, the seven studies in this review suggest that individuals with T1DM who report depressive symptoms are at a higher risk of poor executive function; a clear association between depressive symptoms and executive function in individuals with T1DM remains inconclusive. There is a need to explore this relationship in the future.

Implementation of the Mind Youth Questionnaire (MY-Q) for routine health-related quality of life screening of adolescents with type 1 diabetes in a large tertiary care center

OBJECTIVES

Prevalence of diabetes distress and mental health comorbidities among adolescents with type 1 diabetes (T1D) is high. Despite recommendations for routine psychosocial risk assessment, there is little guidance for their implementation. This study aims to describe the implementation and baseline outcomes of the Mind Youth Questionnaire (MY-Q), a validated psychosocial screening tool for health-related quality of life (QoL) including mood, among adolescents living with T1D.

METHODS

Adolescents aged 13-18 years completed the MY-Q from October 1, 2019-April 1, 2023. Baseline characteristics, MY-Q results including categories flagged positive (noting possible areas of concern), debrief duration, and frequency of social work or mental health referral were collected and analyzed using descriptive statistics.

RESULTS

A total of 343 adolescents (mean age 15.3 years; 52 % female) completed a baseline MY-Q. Median overall MY-Q debrief time (IQR) was 10.0 min (6.0, 20.0). About 290 (84.5 %) adolescents had at least one of seven categories flagged, most commonly "Family" (61 %). About 30 % of adolescents had "Mood" flagged, and 2.9 % of adolescents were referred to mental health following debrief.

CONCLUSIONS

Without the need for additional resources, implementation of the MY-Q in a pediatric tertiary care diabetes clinic successfully identified QoL issues and mental health concerns among adolescents with T1D.

Screening for diabetes distress and depression in routine clinical care for youth with type 1 diabetes

OBJECTIVE

The purpose of this study is to examine diabetes distress as a potential mediator of the relationship between depression symptoms and diabetes outcomes, including hemoglobin A1c (hemoglobin A1c [HbA1c]) and diabetes management behaviors in a clinical sample of adolescents and young adults.

METHODS

In a pediatric diabetes clinic, 716 youth (ages 12-21 years) completed measures of diabetes distress (Problem Areas in Diabetes-Teen [PAID-T]), a single-item of diabetes distress, and depression (Patient Health Questionnaire [PHQ-9]) as part of standard care. Electronic health records were extracted for the "Six Habits" and glycemic management (HbA1c).

RESULTS

Overall, 3.6% (n = 26) of adolescents had clinically elevated diabetes distress and depression symptoms, 5.0% had diabetes distress alone, 8.7% had depression symptoms alone, and 82.7% had neither clinical elevation of diabetes distress nor depression symptoms. Results of mediation analysis demonstrated diabetes distress (both full and single-item measures) fully mediated the relationship between depression symptoms and HbA1c (p < .001). Also, mediation analysis results showcase incomplete mediation of the effect of the Six Habits score on HbA1c appears by PAID-T Diabetes Distress.

CONCLUSIONS

In a clinical sample of youth with type 1 diabetes, both depressive symptoms and diabetes distress are associated with HbA1c. Furthermore, diabetes distress fully mediates the relationship between depressive symptoms and HbA1c. As part of standard clinical care, the single-item screener for diabetes distress captured similar results as the full-scaled PAID-T. With limited clinical resources, providers may consider focusing assessment and interventions on the psychological factor of diabetes distress within the diabetes clinic to maximize the impact on glycemic control and consider the use of single-item screening to identify distress.

Observed collaborative and intrusive parenting behaviours associated with psychosocial outcomes of adolescents with type 1 diabetes and their maternal caregivers

AIMS

Maternal caregiver involvement is strongly associated with psychosocial and glycemic outcomes amongst adolescents with type 1 diabetes (T1D); however, previous studies have lacked detailed, objective examinations of caregiver involvement. We examined the relationship between observed parenting behaviors and psychosocial and glycemic outcomes amongst youth with T1D.

METHODS

Data collected from adolescents with T1D (age 11-17) and their female caregivers as a part of a randomized controlled trial were analyzed. These included structured, observation-based scores of adolescent-caregiver dyads engaged in videotaped interactions and selected psychosocial and glycemic outcome measures.

RESULTS

In adjusted analyses, higher levels of intrusive parenting behaviors during observed interactions were associated with higher diabetes distress in adolescents, but no difference in HbA1c. Associations between intrusive parenting behaviors and psychosocial outcomes were stronger for females compared to males for both diabetes distress and quality of life. Similarly, associations between collaborative parenting behaviors and quality of life were stronger for female adolescents than males. No associations were observed between collaborative parenting behaviors and glycemic outcomes. Consistent with previous work, we noted higher levels of adolescent-reported family conflict were associated with lower adolescent quality of life and higher diabetes distress with no significant difference between male and female adolescents.

CONCLUSION

These findings indicate that high levels of intrusive parenting behaviors, such as lecturing or over-controlling behaviors, are associated with lower levels of adolescent well-being, particularly among adolescent girls. This work suggests that interventions to reduce intrusive parenting by maternal caregivers could result in improved psychosocial outcomes for adolescents with T1D.

The role of peer social relationships in psychological distress and quality of life among adolescents with type 1 diabetes mellitus: a longitudinal study

BACKGROUND

Adolescents with type 1 diabetes mellitus suffer from diabetes distress and poor health-related quality of life (HRQOL) since living with the condition that differentiates them from their peers. The present study investigated the effects of peer support and stress on diabetes distress and HRQOL and whether positive coping mediated the effects.

METHODS

We used a prospective study design. A total of 201 adolescents with type 1 diabetes mellitus from 20 cities in 4 provinces were recruited.Participants complete two separate surveys at approximately 18-month intervals. The scales employed at both Time 1 and Time 2 included the Diabetes-Specific Peer Support Measure, Diabetes Stress Questionnaire for Youths, Simplified Coping Style Questionnaire, 5-item Problem Areas in Diabetes Scale, and the Diabetes Quality of Life for Youth scale.

RESULTS

Baseline peer stress directly predicted diabetes distress and HRQOL at 18 months, even controlling for age, gender, and peer support. However, the direct effect of baseline peer support on 18-month diabetes distress and HRQOL was insignificant. Baseline peer support indirectly affected diabetes distress and HRQOL at 18 months through positive coping, indicating that positive coping plays a mediating role.

CONCLUSION

The findings suggest that peer social relationships, especially peer stress, and positive coping are promising intervention targets for adolescents facing challenges in psychosocial adaptation.

Moderating Effect of Depression on Glycemic Control in an eHealth Intervention Among Black Youth With Type 1 Diabetes: Findings From a Multicenter Randomized Controlled Trial

BACKGROUND

Black adolescents with type 1 diabetes (T1D) are at increased risk for suboptimal diabetes health outcomes; however, evidence-based interventions for this population are lacking. Depression affects a high percentage of youth with T1D and increases the likelihood of health problems associated with diabetes.

OBJECTIVE

Our aim was to test whether baseline levels of depression moderate the effects of a brief eHealth parenting intervention delivered to caregivers of young Black adolescents with T1D on youths' glycemic control.

METHODS

We conducted a multicenter randomized controlled trial at 7 pediatric diabetes clinics located in 2 large US cities. Participants (N=149) were allocated to either the intervention group or a standard medical care control group. Up to 3 intervention sessions were delivered on a tablet computer during diabetes clinic visits over a 12-month period.

RESULTS

In a linear mixed effects regression model, planned contrasts did not show significant reductions in hemoglobin A1c (HbA1c) for intervention adolescents compared to controls. However, adolescents with higher baseline levels of depressive symptoms who received the intervention had significantly greater improvements in HbA1c levels at 6-month follow-up (0.94%; P=.01) and 18-month follow-up (1.42%; P=.002) than those with lower levels of depression. Within the intervention group, adolescents had a statistically significant reduction in HbA1c levels from baseline at 6-month and 18-month follow-up.

CONCLUSIONS

A brief, culturally tailored eHealth parenting intervention improved health outcomes among Black adolescents with T1D and depressive symptoms.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03168867; https://clinicaltrials.gov/study/NCT03168867.

Prevalence and predictors of diabetes distress and depression in people with type 1 diabetes

Background

People living with diabetes often encounter psychosocial challenges, including diabetes distress and depression. Despite this, little research has focused on the co-occurrence of these conditions. This study aimed to explore the prevalence of depressive symptoms and diabetes distress in people with type 1 diabetes in Kuwait and to identify clinical and demographic factors associated with these conditions.

Methods

A total of 832 people with type 1 diabetes (females: 54.1%, mean age: 29 ± 8.5 years), were invited to participate in Dose Adjustment for Normal Eating (DAFNE) course. Diabetes distress was measured using the Problem Areas in Diabetes (PAID) scale and depressive symptoms were measured using the Patient Health Questionnaire-9 (PHQ-9). Depressive symptoms were defined as PHQ-9 scores ≥10. Data on biomedical outcomes, lifestyle factors, and sociodemographic information were collected.

Results

The prevalence rates of diabetes distress and depressive symptoms were 27.8% and 38.3%, respectively. Notably, 19.6% of people experienced both conditions. In the regression analysis, PAID scale and PHQ-9 scores were significantly associated, patients with higher score on depressive symptoms scale were more likely to suffer diabetes distress (B= 2.65, p < 0.001). Female sex (odds ratio [OR]= 2.2, 95% CI= 1.5, 3.2), higher hemoglobin A1c levels (OR= 1.6, 95% CI= 1.0, 2.5), obesity (OR= 1.7, 95% CI= 1.1, 2.8), inactivity (OR= 2.4, 95% CI= 1.6, 3.6), microvascular complications (OR= 2.8, 95% CI= 1.5, 5.4), and lipohypertrophy (OR= 1.7, 95% CI= 1.1, 2.5) were associated with greater odds for the co-occurrence of diabetes distress and depressive symptoms (p< 0.05 for all).

Conclusion

The majority of people with type 1 diabetes in Kuwait experience both diabetes distress and depressive symptoms. The strong correlation between diabetes distress and depressive symptoms suggests mutual predictability. The co-occurrence of both symptoms is associated with many sociodemographic and clinical factors.

Outpatient screening for anxiety and depression symptoms in adolescents with type 1 diabetes - a cross-sectional survey

BACKGROUND

The daily demands of type 1 diabetes management may jeopardize adolescents' mental health. We aimed to assess anxiety and depression symptoms by broad-scale, tablet-based outpatient screening in adolescents with type 1 diabetes in Germany.

METHODS

Adolescent patients with type 1 diabetes mellitus (n = 2,394; mean age 15.4 y [SD 2.0]; 50.7% male) were screened for anxiety (GAD-7) and depression symptoms (PHQ-9) by self-report questionnaires and linked to clinical data from the DPV patient registry. Logistic regression was used to estimate the contribution of clinical parameters to positive screening results.

RESULTS

Altogether, 30.2% showed a positive screening (score ≥ 7 in either test), and 11.3% reported suicidal ideations or self-harm. Patients with anxiety and depression symptoms were older (15.7 y [CI 15.5-15.8] vs. 15.3 y [CI 15.2-15.4]; p < 0.0001), had higher HbA1c levels (7.9% [CI 7.8-8.0] (63 mmol/mol) vs. 7.5% [CI 7.4-7.5] (58 mmol/mol); p < 0.0001), and had higher hospitalization rates. Females (adjusted odds ratio (aOR) 2.66 [CI 2.21-3.19]; p < 0.0001), patients > 15 years (aOR 1.40 [1.16-1.68]; p < 0.001), who were overweight (aOR 1.40 [CI 1.14-1.71]; p = 0.001), with HbA1c > 9% (> 75 mmol/mol; aOR 2.58 [1.83-3.64]; each p < 0.0001), with a migration background (aOR 1.46 [CI 1.17-1.81]; p < 0.001), or smoking (aOR 2.72 [CI 1.41-5.23]; p = 0.003) had a higher risk. Regular exercise was a significant protective factor (aOR 0.65 [CI 0.51-0.82]; p < 0.001). Advanced diabetes technologies did not influence screening outcomes.

CONCLUSIONS

Electronic mental health screening was implemented in 42 centers in parallel, and outcomes showed an association with clinical parameters from sociodemographic, lifestyle, and diabetes-related data. It should be integrated into holistic patient counseling, enabling early recognition of mild mental health symptoms for preventive measures. Females were disproportionally adversely affected. The use of advanced diabetes technologies did not yet reduce the odds of anxiety and depression symptoms in this cross-sectional assessment.

Sedentary Behavior and Physical Activity Associated with Psychosocial Outcomes in Adolescents with Type 1 Diabetes

Background

Adolescents with type 1 diabetes (T1D) are particularly vulnerable to poor psychosocial outcomes-high rates of diabetes distress and poor quality of life are common among this cohort. Previous work in the general population demonstrated positive associations between quality of life and increases in moderate-to-vigorous physical activity (MVPA), as well as decreased sedentary behavior. While survey-based assessments of young adults with T1D observed similar trends, these studies were limited by their use of subjective assessments of MVPA and sedentary behavior. The use of direct activity monitoring is needed to establish the association between psychosocial outcomes and MVPA and sedentary behavior among adolescents with T1D.

Objective

To explore the association between objectively measured MVPA and sedentary behavior on psychosocial outcomes among adolescents with T1D.

Subjects and Methods

The current study is a secondary analysis of baseline data collected for a pilot trial of sleep-promoting intervention for adolescents with T1D. Participants (n = 29, with a mean age of 15.9 ± 1.3 years) completed baseline surveys and wore an actigraph for a week following the baseline visit. We examined minutes per week of MVPA and proportion of awake time spent sedentary in relation to adolescents' diabetes distress, depressive symptoms, and diabetes-related quality of life.

Results

Participants engaged in a mean of 19.6 ± 22.4 minutes of MVPA per day and spent 68.6 ± 9.9% of their awake time sedentary. MVPA was associated with lower diabetes distress in unadjusted (-3.6; 95% CI: -6.4 to -0.8) and adjusted (-2.6; 95% CI: -5.0--0.3) analyses. Sedentary time was associated with higher diabetes distress in adjusted (6.3; 95% CI: 1.3-11.2) but not unadjusted (6.0; 95% CI: -5.6-12.6) analyses. In secondary analyses, we did not observe significant associations between quality of life or depressive symptoms with either MVPA or sedentary behavior.

Discussion

Our findings extend previous survey-based work demonstrating an association between decreased diabetes distress with greater weekly MVPA and lower sedentary time. The current study highlights the multifaceted benefits of physical activity in this population and provides preliminary evidence for developing interventions to reduce sedentary time as an alternative method to improve psychosocial outcomes in this at-risk population.

Type 1 diabetes mellitus - Population characterization and metabolic control outcomes in a Portuguese patient sample

AIMS

To characterize a cohort of T1D patients and to compare diabetes control between patients using different regimen of insulin therapy and glucose monitoring.

METHODS

Were included all T1D patients followed at the Pediatric Endocrinology Unit, between April 1st and June 30th, 2021. Several clinical and demographic variables were analyzed.

RESULTS

Our sample included 208 patients, 56.7 % males, mean age of 12.7 ± 4.6 years. The median HbA1c was 7.3 %. Most patients, 78.8% were treated with continuous subcutaneous insulin infusion (CSII) and 81.3 % used continuous glucose monitoring (CGM). CSII had a lower HbAc compared with multiple daily injections (MDI) users (7.1vs 8.1 %, p < 0.01). In the CSII group, those who used CGM had a lower HbAc (7.1 vs 7.5 %,p = 0.02). Analyzing the data of the ambulatory glucose report, the CSII users had a lower glucose management indicator, (7.2 % vs 7.6 %, p < 0.01), more time in range (58.0 % vs 52.4 %;p < 0.01) and less time above range > 250 mg/dL (12.4 % vs 20.5 %;p < 0.01) than MDI users.

CONCLUSIONS

The median HbA1c was 7.3% very close to the recommended target. In Portugal, pediatric patients can access a CSII provided by the national health service and a CGM system due to an elevated reimbursement of their cost. This healthy policy allows us to achieve better goals without the risk of hypoglycemia.

Insulin and fluoxetine produce opposite actions on lateral septal nucleus-infralimbic region connection responsivity

Some diabetes patients develop depression, the main treatment for which is antidepressants. Pharmacological interactions between insulin and antidepressants (e.g., fluoxetine) are controversial in the literature. Some authors reported hypoglycemic actions of fluoxetine, whereas others reported antidepressant-like actions. In healthy rats, insulin produces an antidespair-like action in rats through an increase in locomotor and exploratory activity, but differences in actions of insulin and fluoxetine on neuronal activity are unknown. The present study evaluated Wistar healthy rats that were treated with saline, insulin, fluoxetine, or fluoxetine + insulin for 3 days (short-term) or 21 days (long-term). The model consisted of electrical stimulation of the lateral septal nucleus (LSN) while we performed single-unit extracellular response recordings in the prelimbic cortex (PL) and infralimbic cortex (IL) subregions of the medial prefrontal cortex (mPFC). Stimulation of the LSN produced an initial brief excitatory paucisynaptic response and then a long-lasting inhibitory afterdischarge in the PL and IL. Treatment with saline and fluoxetine, but not insulin, minimally affected the paucisynaptic response. Differences were found in LSN-IL responsivity. The inhibitory afterdischarge was clearly enhanced in the long-term fluoxetine group but not by insulin alone or fluoxetine + insulin. These findings suggest that insulin produces some actions that are opposite to fluoxetine on LSN-mPFC connection responsivity, with no synergistic actions between the actions of insulin and fluoxetine.

Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine During 1 Year of COVID-19

PURPOSE

The COVID-19 pandemic led to rapid adoption of telemedicine for the care of youth with type 1 diabetes (T1D). We assessed the utility of a primarily virtual care model by comparing glucometrics from a pediatric sample with T1D using continuous glucose monitoring (CGM) both before and during the pandemic.

METHODS

Pediatric patients aged 1 to 17 years with T1D duration ≥ 1 year if ≥ 6 years old or ≥ 6 months if < 6 years old, with ≥ 1 visit with recorded CGM data both prepandemic (April 1, 2019-March 15, 2020) and during the pandemic (April 1, 2020-March 15, 2021) were included. Data were extracted from the electronic health record.

RESULTS

Our sample comprised 555 young people (46% male, 87% White, 79% pump-treated), mean age 12.3 ± 3.4 years, T1D duration 5.9 ± 3.5 years, baseline glycated hemoglobin A1c 8.0 ± 1.0% (64 ± 10.9 mmol/mol). Diabetes visit frequency increased from 3.8 ± 1.7 visits/prepandemic period to 4.3 ± 2.2 visits/pandemic period (P < 0.001); during pandemic period, 92% of visits were virtual. Glucose management indicator (GMI) improved slightly from 7.9% (63 mmol/mol) prepandemic to 7.8% (62 mmol/mol) during the pandemic (P < 0.001). Those with equal or greater visit frequency (n = 437 [79% of sample]) had significant improvement in GMI (8.0% to 7.8% [64 to 62 mmol/mol], P < 0.001), whereas those with lower visit frequency did not (7.8 [62 mmol/mol], P = 0.86).

CONCLUSIONS

Children and adolescents with T1D using CGM before and during the pandemic showed an overall increase in visit frequency using primarily telemedicine-based care and improved CGM glucometrics. Further research is needed to understand factors associated with successful use of telemedicine for pediatric T1D.

Prevalence and predictors of diabetes-related distress in adults with type 1 diabetes

Type 1 diabetes (T1DM) is a chronic disease requiring lifelong insulin therapy and rigorous self-management. As it negatively impacts the affected individuals’ quality of life, it may eventually lead to diabetes-related distress. This study evaluated the prevalence and identified the predictors of diabetes-related distress in a representative sample of adults with T1DM treated at secondary and tertiary levels in Croatia. A multicenter, cross-sectional study was conducted in adults with T1DM in Croatia (N = 100). Data were collected between January 2018 and December 2018 from medical records and interviews during a single clinical visit, when participants completed a 20-item Problem Area in Diabetes (PAID) Questionnaire. The proportion of participants with a total PAID score ≥ 40 indicating high diabetes-related distress was calculated, and binary logistic regression was run to determine predictors. High diabetes-related distress was found in 36% of participants, with a mean PAID total score of 31.9 (21.1). The predictors of diabetes-related distress were higher HbA1c level (OR = 1.491, p = 0.037, CI = 1.025–2.169) and the presence of microvascular complications (OR = 4.611, p = 0.005; 95%CI 1.546–13.754). Worrying about the future and chronic complications and feeling guilty when off-track with diabetes management were identified as items that contribute the most to distress. Diabetes-related distress is a frequent condition in adults with T1DM in Croatia. Special attention should be given to patients with suboptimal glycemic control and microvascular complications. Given the high prevalence and impact of psychosocial problems in diabetes, psychological care should be integrated into routine care for adults with type 1 diabetes.

Glycemic control, depression, diabetes distress among adolescents with type 2 diabetes: effects of sex, race, insurance, and obesity

AIMS

To determine (1) differences in depression and distress scores between adolescents with type 1 (T1D) and type 2 diabetes (T2D), (2) how socioeconomic factors, obesity, race, and treatment regimen affect depression and diabetes distress in adolescent T2D, (3) the relationships between depression and diabetes distress scores in adolescents with T2D, and (4) how depression and diabetes distress scores relate to current and future glycemic control in adolescents with T2D.

BACKGROUND

Diabetes distress is a negative emotional reaction to diabetes complications, self-management demands, unresponsive providers, poor interpersonal relationships, and to diabetes itself. It is frequently mistaken for depression and the two are interrelated. Increases in both predict poor glycemic control in adolescents with T1D.

METHOD

Depression (PHQ-9) and diabetes distress (PAID-T) scores from self-administered tests were studied in 364 patients with diabetes between the ages of 13-17. Kruskal-Wallis test was used to assess differences between types of diabetes, sexes, races, and insurance status. Spearman correlations, and robust rank order multivariable regression analysis were used to assess relationships. Medical records were reviewed for follow-up hemoglobin A1c (HbA1c) levels over 3 years.

RESULTS

HbA1c was significantly lower in females with T2D than with T1D (p  =  0.019) but not in males. It, also, did not differ between females and males with T2D. Median PHQ-9 score in females with T2D was significantly greater than in females with T1D (p = 0.007) but did not differ between females and males with T2D. PHQ-9 scores did not differ between males with T2D and T1D. PAID-T scores, however, were higher in males with T2D than in males with T1D but did not differ between females. PHQ-9 scores and PAID-T scores were significantly related in T2D (r_s = 0.65, p < 0.001). Neither was related to HbA1c in T2D.

CONCLUSIONS

As in adolescents with T1D, depression and diabetes distress screening scores are closely related in adolescent T2D. However, unlike T1D, they are not related to glycemic control in T2D. Depression and diabetes distress may be more closely related to weight and lifestyle concerns.

Demographic and Glycemic Factors Linked With Diabetes Distress in Teens With Type 1 Diabetes

OBJECTIVE

Diabetes distress (DD) is a negative emotional response related to the burdens of living with type 1 diabetes (T1D) and is linked with diabetes outcomes, such as hemoglobin A1c (A1c). Yet, less is known about how other glycemic indicators, average blood glucose and time in range, relate to DD, and which demographic characteristics are associated with higher DD.

METHODS

In total, 369 teens (Mage 15.6 ± 1.4, 51% female, MT1D duration 6.7 ± 3.8 years) screened for DD using The Problem Areas in Diabetes-Teen Version to determine eligibility for an ongoing multi-site behavioral trial. The associations of DD, demographic factors, and glycemic indicators (A1c, average blood glucose, and time in range) were analyzed.

RESULTS

Twenty-nine percent of teens (n = 95) scored above the clinical cutoff (≥44) for DD. Females scored significantly higher on average than males. Black/African American, non-Hispanic youth screened significantly higher compared to youth from other racial/ethnic groups. Higher DD scores were related to higher A1c and average blood glucose, and lower time in range. Logistic regression models revealed that females were significantly more likely to report clinically elevated DD than males, and teens with higher A1c were 1.3 times more likely to report DD. Age and diabetes duration were not significantly associated with clinically elevated DD scores.

CONCLUSIONS

Results demonstrated that DD is most prevalent in Black, non-Hispanic and female teens, and DD is associated with higher average blood glucose and lower time in range. Further investigation into these disparities is warranted to promote optimal health outcomes for teens with T1D.

Regional Comparison of Diabetes Psychosocial Comorbidities Among Americans With Type 1 Diabetes During the COVID-19 Pandemic

PURPOSE

The purpose of this study was to compare diabetes psychosocial comorbidities among adults with type 1 diabetes (T1D) across the United States during the onset of COVID-19 pandemic.

METHODS

Adults with T1D from 4 main US geographic regions including South (n = 367), West (n = 234), Northeast (n = 250), and Midwest (n = 247) completed a cross-sectional online survey between April and June 2020. Data collection was done on psychosocial measures, glycemic variability, sociodemographic characteristics, and various challenges related to the COVID-19 pandemic. Chi-square, Fisher's exact, Kruskal-Wallis tests, ordinary least squares, proportional odds, and ordinal logistic regression methods were used for data analysis.

RESULTS

In the South, 51.2% of participants had moderate to high levels of diabetes distress, and this was significantly (P = .03) higher than other regions. Northeast region had the lowest prevalence of moderate to severe diabetes burnout (19.8%), but this was not significantly different compared to the other regions. Participants in the South had also the highest mean score on the 8-item Patient Health Questionnaire, with 30.3% of them reporting moderate to severe depressive symptoms. However, there were no significant differences in depressive symptoms among the regions. Glycemic control, demographic characteristics, and COVID-19-related challenges were associated with different psychosocial comorbidities in different regions.

CONCLUSIONS

When providing information and support to individuals with diabetes in time of crisis like the COVID pandemic, providers should consider psychosocial aspects of diabetes care. Diabetes disparities and contextual factors vary geographically in the United States; these factors may impact the psychosocial comorbidities of diabetes in each region.

Acquisition of Self-Care Responsibility in Youth With Type 1 Diabetes: Opportunities for Improving Tailored Diabetes Education and Support Programs

BACKGROUND

There is gradual acquisition of type 1 diabetes self-care responsibility across childhood as youth mature and gain more independence from their family. Understanding the timing of diabetes self-care by youth can guide the tailoring of diabetes education and support programs.

OBJECTIVE

To investigate parent-perceived responsibility for diabetes self-care tasks across childhood.

METHODS

Parents/guardians of youth (ages 5-18 years) with type 1 diabetes reported parent involvement in diabetes management using the Diabetes Family Responsibility Questionnaire. Survey items were divided items into five domains: nutrition, monitoring, insulin dosing, communication, and health surveillance. Age-groups for analyses were 5-10 years (elementary school), 11-14 years (early adolescence), and 15-18 years (late adolescence). Demographic, diabetes management, and A1C data were collected at the time of survey completion.

RESULTS

Youth (n = 148, 50% male) were a mean age of 12.9 ± 3.3 years, with a mean type 1 diabetes duration of 6.2 ± 3.6 years; 66% used insulin pump therapy, and the mean A1C was 8.4 ± 1.3%. Of the parents (84% mothers, 91% White), 83% were married, and 52% were college educated. Per parent report, less parental involvement was associated with older youth age (P <0.001). Across all age-groups, more overall parental involvement was related to lower A1C (P = 0.02). Youth self-care in the nutrition domain began in elementary school, whereas self-care in monitoring and insulin dosing began in early adolescence, and self-care with regard to communication started in late adolescence. Responsibility for health surveillance remained mainly under parent care throughout childhood and adolescence.

CONCLUSION

Providing education and support for youth during their acquisition of self-care tasks, especially those relating to nutrition, monitoring, and insulin dosing, may help to prevent glycemic deterioration later in childhood and adolescence.