Diabetes in adolescence

Behandlungsverhalten und Wünsche an die Therapie aus Sicht von jungen Erwachsenen mit Diabetes mellitus Typ 1

Hintergrund Bei Jugendlichen und jungen Erwachsenen (JujE) mit Diabetes mellitus Typ 1 (DMT1) werden gehäuft Behandlungsverhaltensweisen beobachtet, die mit ungünstigen Gesundheitsoutcomes assoziiert sind. Darüber hinaus verläuft der in diesem Alter erforderliche Transitionsprozess oft problematisch. Insgesamt ist diese Altersspanne mit einem erhöhten Risiko für akute Komplikationen und langfristige Folgeschäden assoziiert. Ziel der Studie ist es, Gründe für Therapieunzufriedenheit und ungünstiges Behandlungsverhalten aus Sicht der JujE zu explorieren und den Bedarf sowie konkrete Empfehlungen für ein zusätzliches psychologisches Coaching abzuleiten.

Methode Insgesamt wurden 15 qualitative Interviews mit JujE (Alter M=20.2; SD=3.1 Jahre; 53.3% weiblich) geführt. Zudem wurden die Soziodemographie und depressive Symptomatik (PHQ-9; Patient Health Questionnaire) erhoben.

Ergebnisse Die Ergebnisse deuten darauf hin, dass Behandlungsunzufriedenheit und ungünstiges Behandlungsverhalten mit direktiven Kommunikationsmustern sowie einer fehlenden persönlichen Bindung zu den Behandler:innen assoziiert sind. Zudem werden psychische Belastungen aus Sicht der Befragten unzureichend thematisiert. Die JujE wünschten sich insbesondere Kontinuität im Behandlungsteam sowie einen empathischen Umgang. Die Idee eines zusätzlichen Coachings wurde positiv aufgenommen. Hierbei besteht der Wunsch nach bedürfnisorientierter Ausgestaltung.

Diskussion Mögliche Barrieren von Adhärenz und psychische Belastungen sollten offen erfragt und thematisiert werden. Insbesondere bei psychisch belasteten JujE könnte das Behandlungsverhalten möglicherweise durch zusätzliche niederschwellige Coachingangebote verbessert werden. Eine randomisiert-kontrollierte Studie ist noch ausstehend.

Impact of anxiety, depression and disease-related distress on long-term glycaemic variability among subjects with Type 1 diabetes mellitus

BACKGROUND

Anxiety, depression, and disease-related distress are linked to worse overall glycaemic control, in terms of HbA1c. This study was aimed to evaluate whether traits of these emotional disorders are associated with long-term glycaemic variability in subjects with Type 1 diabetes.

METHODS

Longitudinal retrospective study. Six-year HbA1c data (2014-2019) from 411 subjects with Type 1 diabetes who had participated in a previous study to design a diabetes-specific quality of life questionnaire in the year 2014 were included. Scores for Spanish versions of the Hospital Anxiety and Depression Scale (HADS) and Problem Areas in Diabetes (PAID) scale were obtained at baseline, along with sociodemographic and clinical data. Long-term glycaemic variability was measured as the coefficient of variation of HbA1c (HbA1c-CV). The association between HADS and PAID scores and HbA1c-CV was analysed with Spearman correlations and multiple regression models, both linear and additive, including other covariates (age, sex, diabetes duration time, type of treatment, baseline HbA1c, use of anxiolytic or antidepressant drugs, education level and employment status).

RESULTS

Scores of depression, anxiety and distress were positively and significantly correlated to HbA1c-CV in univariate analyses. Multiple regression study demonstrated an independent association only for diabetes distress score (p < 0.001). Age, diabetes duration time, baseline HbA1c, education level and employment status were also significantly associated with HbA1c-CV. However, when subjects were analyzed separately in two age groups, distress scores were associated with HbA1c-CV only among those aged 25 years or older, while anxiety scores, but not distress, were associated with HbA1c-CV among those younger than 25 years.

CONCLUSIONS

Psychological factors, particularly disease-related distress and anxiety, are associated with long-term glycaemic variability in subjects with Type 1 diabetes.

The natural history of emerging diabetic retinopathy and microalbuminuria from prepuberty to early adulthood in Type 1 diabetes: A 19-year prospective clinical follow-up study

OBJECTIVE

To evaluate the impact of long-term glycaemic control and glycaemic variability on microvascular complications in adolescents and young adults with childhood-onset Type 1 diabetes.

METHODS

Twenty-six participants took part in a prospective follow-up study. We used univariate generalised estimating equations (GEE) analysis with first-order autoregressive AR(1) covariance structure for repeated measurements to evaluate the relationship between emerging diabetic retinopathy (DR) and each single explanatory variable, namely age at developmental stages from late prepuberty until early adulthood, duration of diabetes and long-term HbA_1c . Thereafter, the simultaneous effect of these three explanatory variables to DR was analysed in a multivariate model.

RESULTS

Twenty-five participants developed DR by early adulthood after a median diabetes duration of 16.2 years (range 6.3-24.0). No participants had DR during prepuberty. Each of the three variables was independently associated with emerging DR: age (OR 1.47, 95% CI to 1.25 to 1.74, p < 0.001) stronger than diabetes duration (OR 1.42, 95% CI 1.23 to 1.63, p < 0.001) and HbA_1c (OR 1.02, 95% CI 1.001 to 1.05, p = 0.041) in this population. In the multivariate analysis of these three explanatory variables, only age was associated with DR (adjusted OR 1.52, 95% CI 1.10 to 2.10, p = 0.012).

CONCLUSIONS

The emergence of DR during adolescence and early adulthood is not rare and increases with age in patients with deteriorating metabolic control during puberty and thereafter. This underpins the need to prevent deterioration of glycaemic control from taking place during puberty-seen again in this follow-up study-in children with diabetes.

Diminished school-based support for the management of type 1 diabetes in adolescents compared to younger children

AIMS

To evaluate diabetes management at school in a large cohort of adolescents with type 1 diabetes and to compare the level of support provided to adolescents with that provided to younger children.

METHODS

Questionnaires were distributed to adolescents with type 1 diabetes attending nine regional and tertiary paediatric diabetes services in the Republic of Ireland. The data collected included patient demographics, treatment regimen and support provided for self-care management. Results were compared with a similar cohort of primary school children with type 1 diabetes, studied using similar methodology.

RESULTS

The study cohort comprised 405 adolescents with a median age of 15 years, of whom 215 (54%) were on multiple daily injections and 128 (32%) were on pump therapy. Eighty-five percent of pump users administered their bolus insulin in classrooms, whereas 76% of those on a multiple daily injection regimen injected outside the classroom. Girls were less likely to administer bolus insulin in an office (10% vs 19%) and more likely to administer it in the bathroom (50% vs 34%; P=0.01). Twenty-five adolescents (12%) on multiple daily injection regimens did not administer bolus insulin at school. Compared to primary school children with type 1 diabetes, adolescents were less likely to use pump therapy, have an emergency treatment plan and have a designated staff member responsible for care needs.

CONCLUSIONS

Support provided to adolescents with type 1 diabetes is diminished compared with that provided to younger schoolchildren.

Association between physical activity and self-rated health in pediatric patients with type 1 diabetes mellitus

Patients with type 1 diabetes mellitus (T1DM) tend to experience poor self-rated health. However, few studies have examined the association between physical activity and self-rated health in pediatric patients with T1DM. The purpose of this study was to investigate the association between regular physical activity, regular muscle strength exercise, and self-rated health in pediatric patients with T1DM who lacked diabetes care. The eligible participants for this study were 37 pediatric patients with T1DM aged 9 to 17 years. Physical activity was divided into regular physical activity and regular muscle strength exercise to analyze the relationship with self-rated health using binomial logistic regression analysis. The results showed that self-rated health of pediatric patients with T1DM who did not engage in regular muscle strength exercise was significantly lower than those who did (odds ratio [OR], 0.100; 95% confidence interval [CI], 0.012-0.855; P<0.05). However, the association between regular physical activity and self-rated health was not statistically significant (OR, 0.211; 95% CI, 0.041-1.088; P=0.06). In conclusion, regular muscle strength exercise in pediatric patients with T1DM who lacked diabetes care was effective in contributing to optimal self-rated health. Future research is needed to collect physical activity data using objective assessment methods and to analyze the association between variables applying diverse factors for pediatric patients with T1DM, which might be able to effect on their health.

Usefulness of Image Theater Workshops for Exploring Dilemmas in Diabetes Self-Management Among Adolescents

Diabetes treatment involves a demanding self-management regime that is particularly challenging to adolescents. There is a need for qualitative research into the specific contexts in which adolescents attempt to balance self-management demands with the needs and desires of adolescent life. This study investigates the usefulness of image theater, a participatory form of theater using the body as an expressive tool, to articulate these dilemmas in daily life contexts. We performed a qualitative analysis of two image theater workshops with 12- to 18-year-old adolescents living with diabetes. Our results show three areas of application: (a) unraveling the contextual complexity of lived experience, (b) the articulation of implicit understandings and underlying motives, and (c) the playful exploration of new behavior. We conclude that image theater is a promising method, especially with respect to the opportunities of a more contextual and action-oriented understanding of the trade-offs made in self-management provide for diabetes education and counseling.

Guided self-determination-young versus standard care in the treatment of young females with type 1 diabetes: study protocol for a multicentre randomized controlled trial

Background

Female adolescents with type 1 diabetes mellitus (T1DM) have the most unsatisfactory glycaemic control of all age groups and report higher disease burden, poorer perceived health, and lower quality of life than their male counterparts. Females with T1DM face an excess risk of all-cause mortality compared with men with T1DM. New methods are needed to help and support young females with T1DM to manage their disease.

A prerequisite for successful diabetes management is to offer individualized, person-centred care and support the patient’s own motivation. Guided self-determination (GSD) is a person-centred reflection and problem-solving method intended to support the patient’s own motivation in the daily care of her diabetes and help develop skills to manage difficulties in diabetes self-management. GSD has been shown to improve glycaemic control and decrease psychosocial stress in young women with T1DM. The method has been adapted for adolescents and their parents, termed GSD-young (GSD-Y). The aim of this study was to evaluate whether an intervention with GSD-Y in female adolescents with T1DM leads to improved glycaemic control, self-management, treatment satisfaction, perceived health and quality of life, fewer diabetes-related family conflicts, and improved psychosocial self-efficacy.

Methods/design

This is a parallel-group randomized controlled superiority trial with an allocation ratio of 1:1. One hundred female adolescents with T1DM, 15–20 years of age, and their parents (if < 18 years of age), will be included. The intervention group will receive seven individual GSD-Y education visits over 3 to 6 months. The control group will receive standard care including regular visits to the diabetes clinic. The primary outcome is level of glycaemic control, measured as glycosylated haemoglobin (HbA1c). Secondary outcomes include diabetes self-management, treatment satisfaction, perceived health and quality of life, diabetes-related family conflicts, and psychosocial self-efficacy. Data will be collected before randomization and at 6 and 12 months.

Discussion

Poor glycaemic control is common in female adolescents and young adults with T1DM. Long-standing hyperglycaemia increases the risks for severe complications and may also have an adverse impact on the outcome of future pregnancies. In this study, we want to evaluate if the GSD-Y method can be a useful tool in the treatment of female adolescents with T1DM.

Trial registration

Current controlled trials, ISRCTN57528404. Registered on 18 February 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2296-6) contains supplementary material, which is available to authorized users.

Alcohol and cigarette use among adolescents with type 1 diabetes

In this study, we compare the prevalence of alcohol and cigarette use among Polish adolescents with type 1 diabetes mellitus (T1DM) (n = 209), aged 15-18 years, with that of a large cohort of their healthy peers, using standardized questionnaire used in the European School Survey Project on Alcohol and Drugs (ESPAD). The lifetime, previous year, and past 30-day prevalence of alcohol consumption was high among adolescents with T1DM but lower than in the controls (82.8 vs 92.0%, 71.7 vs 85.6%, and 47.5 vs 69.7%, respectively, p < 10^-5). The lifetime and 30-day prevalence of cigarette use was also lower among patients than the controls (54.6 vs 65.5%, p = 0.001 and 27.3 vs 35.9%, p = 0.012, respectively). Patients who admitted smoking exhibited worse metabolic control than non-smokers (p < 0.0001) and had a higher chance of developing diabetic ketoacidosis. The incidence of severe hypoglycemia was higher among those who reported getting drunk in the previous 30 days (p = 0.04) and lifetime smoking (p = 0.01).

CONCLUSIONS

Although alcohol and cigarette consumption is lower than in controls, it is common among teenagers with type 1 diabetes, effecting metabolic control and causing the risk of acute diabetes complications. Better prevention strategies should be implemented in this group of patients in their early teen years. What is Known: • Substance use remains a significant cause of morbidity and mortality among teenagers with type 1 diabetes. • Current medical literature contains inconsistent data on the prevalence of alcohol and cigarette use among adolescents with type 1 diabetes, mostly due to methodological problems with conducting such surveys. What is New: • Methodological approach: we used a validated questionnaire from the European School Survey Project on Alcohol and Other Drugs (ESPAD) and compared the results to a large national control group of 12,114 healthy students who took part in ESPAD in 2011.

The Use of Mobile Health to Deliver Self-Management Support to Young People With Type 1 Diabetes: A Cross-Sectional Survey

BACKGROUND

Young people living with type 1 diabetes face not only the challenges typical of adolescence, but also the challenges of daily management of their health and evolving understanding of the impact of their diagnosis on their future. Adolescence is a critical time for diabetes self-management, with a typical decline in glycemic control increasing risk for microvascular diabetes complications. To improve glycemic control, there is a need for evidence-based self-management support interventions that address the issues pertinent to this population, utilizing platforms that engage them. Increasingly, mobile health (mHealth) interventions are being developed and evaluated for this purpose with some evidence supporting improved glycemic control. A necessary step to enhance effectiveness of such approaches is to understand young people's preferences for this mode of delivery.

OBJECTIVE

A cross-sectional survey was conducted to investigate the current and perceived roles of mHealth in supporting young people to manage their diabetes.

METHODS

Young adults (16-24 years) with type 1 diabetes in Auckland, New Zealand, were invited to take part in a survey via letter from their diabetes specialist.

RESULTS

A total of 115 young adults completed the survey (mean age 19.5 years; male 52/115, 45%; European 89/115, 77%), with all reporting they owned a mobile phone and 96% (110/115) of those were smartphones. However, smartphone apps for diabetes management had been used by only 33% (38/115) of respondents. The most commonly reported reason for not using apps was a lack of awareness that they existed. Although the majority felt they managed their diabetes well, 63% (72/115) reported wanting to learn more about diabetes and how to manage it. A total of 64% (74/115) respondents reported that they would be interested in receiving diabetes self-management support via text message (short message service, SMS).

CONCLUSIONS

Current engagement with mHealth in this population appears low, although the findings from this study provide support for the use of mHealth in this group because of the ubiquity and convenience of mobile devices. mHealth has potential to provide information and support to this population, utilizing mediums commonplace for this group and with greater reach than traditional methods.

Isolated thoughts and feelings and unsolved concerns: adolescents' and parents' perspectives on living with type 1 diabetes - a qualitative study using visual storytelling

AIMS AND OBJECTIVES

To explore and describe the experiences of adolescents and their parents living with type 1 diabetes, to identify their needs for support to improve adolescents' self-management skills in the transition from child- to adulthood.

BACKGROUND

Adolescents with type 1 diabetes often experience deteriorating glycaemic control and distress. Parents are important in adolescents' ability to self-manage type 1 diabetes, but they report anxiety and frustrations. A better understanding of the challenges adolescents and parents face, in relation to the daily self-management of type 1 diabetes, is important to improve clinical practice.

DESIGN

A qualitative explorative study using visual storytelling as part of individual interviews.

METHODS

A purposive sample of nine adolescents and their parents (seven mothers, six fathers) took photographs illustrating their experiences living with type 1 diabetes. Subsequently, participants were interviewed individually guided by participants' photographs and a semistructured interview guide. Interviews were analysed using thematic analysis.

RESULTS

Four major themes were consistent across adolescents and their parents: (1) striving for safety, (2) striving for normality, (3) striving for independence and (4) worrying about future. Although adolescents and parents had same concerns and challenges living with type 1 diabetes, they were experienced differently. Their thoughts and feelings mostly remained isolated and their concerns and challenges unsolved.

CONCLUSIONS

The concerns and challenges adolescents and their parents face in the transition from child- to adulthood are still present despite new treatment modalities. Parents are fundamental in supporting the adolescents' self-management-work; however, the parties have unspoken concerns and challenges.

RELEVANCE TO CLINICAL PRACTICE

Healthcare providers should address the parties' challenges and concerns living with type 1 diabetes to diminish worries about future including fear of hypoglycaemia, the burden of type 1 diabetes and the feeling of being incompetent in diabetes self-management. It is important to focus on supporting both adolescents and their parents, and to provide a shared platform for communication.

Case Studies in Pediatric Endocrinology: An Interactive Learning Module

INTRODUCTION

Pediatrics is an exciting field because it requires having a background in physiology that evolves as the patient ages. As a subspecialty, pediatric endocrinology encompasses a wide range of disease processes both acute and chronic. This module was created to provide a review of endocrine physiology, promote understanding of the biopsychosocial model of children diagnosed with an endocrine disorder, and utilize simulated case studies to become familiar with patient management.

METHODS

The material and case studies presented are based on firsthand experiences in a pediatric clinic and diabetes camp, as well as an extensive literature review. The information in this resource teaches interview questions and problem-solving techniques and ensures that the learner understands the basic equipment used by the patients. Implementation of this module will advance students' and residents' efficacy in caring for this pediatric population. The approximate time to complete this module is 3 to 5 hours. To evaluate the effectiveness of this module, pre- and postmodule surveys were administered to medical students. Factors analyzed included overall user satisfaction, utility of the module, comfort in approaching pediatric endocrine patients, and suggestions for improvement.

RESULTS

A cohort of medical students (N = 26) completed both surveys and the module, with an equal distribution of first- and second-year students to third- and fourth-year students. The surveys showed a general trend of improvement in self-reported comfort with both basic science and clinical skills components.

DISCUSSION

This module would be most beneficial to a medical student who may rotate with a pediatric endocrinologist during the clinical years. The target audience can be broadened to include not only medical students but also physician assistant students, nursing/nurse practitioner students, pediatric residents, and pediatric endocrinology fellows.

Parent's perception of their children's health, quality of life and burden of diabetes: testing reliability and validity of 'Check your Health' by proxy

AIM

To test the validity and reliability of the 'Check your Health by proxy' instrument in parents to children with diabetes aged 8-17 years.

METHODS

One hundred and ninety-one caregivers and their children, aged 8-17 years, were included. All completed the 'Check your Health' questionnaire measuring quality of life and burden of diabetes, DISABKIDS self- or proxy version, and 45 completed the same questionnaires 2 weeks later.

RESULTS

Test-retest reliability on the 'Check your Health' questionnaire by proxy was moderate to strong (r = 0.48-0.74), p < 0.002). Convergent validity was weak to moderate (r = 0.15-0.49, p < 0.05). The instrument showed acceptable discriminant validity. Parents reported lower scores than the children on emotional health and social relations and higher scores on physical and emotional burden and higher burden on quality of life. Poorer social relationships and quality of life were associated with higher reported disease severity. The diabetes burden domain of the questionnaire correlated to perceived severity of diabetes and to perceived health. Discriminant validity showed that poorer social relationships and quality of life were associated with higher severity of the disease. The diabetes burden domain of 'Check your Health' by proxy showed discriminant validity on perceived severity of diabetes.

CONCLUSIONS

The instrument 'Check your Health' by proxy showed acceptable psychometric characteristics in parents to young people (8-17 years of age) with diabetes. We also concluded that parents reported that their children had lower health and higher burden of diabetes than the children did, and it correlated to reported disease severity.

Efficacy and safety of switching from insulin glargine to insulin degludec in young people with type 1 diabetes

We evaluated the efficacy and safety of switching to insulin degludec (IDeg) from insulin glargine (IGlar) as basal-bolus therapy in young people with type 1 diabetes. The subjects were 36 patients, 21.3±1.0 years of age, with type 1 diabetes. IGlar had previously been injected once daily in 25 patients and twice daily in 11. They were then switched from IGlar to once-daily injection of IDeg. Both fasting plasma glucose (FPG) and HbA1c levels decreased significantly from 134±3.9 mg/dL and 7.9±0.2% at baseline to 116±2.2 mg/dL and 7.4±0.2% at 12 months after starting IDeg (P<0.0001 and P≤0.001, respectively). Overall and nocturnal hypoglycemia (PG<70 mg/dL) frequencies also decreased significantly from 4.9±0.7 and 2.0±0.3 times/month to 2.4±0.3 and 0.4±0.1 times/month at 12 months after starting IDeg (P≤0.005 and P<0.0005, respectively). The daily basal insulin dose was significantly reduced from 0.48±0.04 units/kg/day at baseline to 0.38±0.03 units/kg/day at the end of the study period (P<0.0001), which corresponded to 79.2% of the baseline value. Trends were similar in patients receiving the once-daily injection and those given twice-daily injections, but basal-insulin value reductions from baseline were more marked in patients receiving twice-daily injections of basal insulin (76.0% vs. 82.6% of the baseline value). These results suggest that switching from IGlar to an appropriate dose of IDeg may effectively control hyperglycemia while reducing the frequency of hypoglycemia episodes in young Japanese people with type 1 diabetes.

Quality of life of adolescents with type 1 diabetes

INTRODUCTION

Diabetes mellitus is a highly prevalent chronic disease. Type 1 diabetes mellitus usually develops during infancy and adolescence and may affect the quality of life of adolescents.

OBJECTIVE

To evaluate the quality of life of adolescents with type 1 diabetes mellitus in a metropolitan region of western central Brazil.

METHODS

Adolescents aged 10-19 years who had been diagnosed with type 1 diabetes mellitus at least 1 year previously were included. Patients with verbal communication difficulties, severe disease, and symptomatic hypo- or hyperglycemic crisis as well as those without an adult companion and who were <18 years of age were excluded. The self-administered Diabetes Quality of Life for Youths instrument was applied.

RESULTS

Among 96 adolescents (57% females; 47% white, and 53% nonwhite), 81% had an HbA1c level of >7%. In general, the adolescents consistently reported having a good quality of life. The median scores for the domains of the instrument were as follows: "satisfaction": 35; "impact": 51; and "worries": 26. The total score for all domains was 112. Bivariate analysis showed significant associations among a lower family income, public health assistance, and insulin type in the "satisfaction" domain; and a lower family income, public health assistance, public school attendance, and a low parental education level in the "worries" domain and for the total score. A longer time since diagnosis was associated with a worse total score. Multivariable analysis confirmed the association of a worse quality of life with public health assistance, time since diagnosis, and sedentary lifestyle in the "satisfaction" domain; female gender in the "worries" domain; and public health assistance for the total score.

CONCLUSIONS

Overall, the adolescents evaluated in this study viewed their quality of life as good. Specific factors that led to the deterioration of quality of life, including public assistance, time since diagnosis, sedentary lifestyle, and female gender, were identified. No potential conflict of interest was reported.

Challenges of emerging adulthood-transition from paediatric to adult diabetes

Diabetes mellitus is a complex condition with far reaching physical, psychological and psychosocial effects. These outcomes can be significant when considering the care of a youth transferring from paediatric through to adult diabetes services. The art of mastering a smooth care transfer is crucial if not pivotal to optimising overall diabetic control. Quite often the nature of consultation varies between the two service providers and the objectives and outcomes will mirror this. The purpose of this review is to analyse the particular challenges and barriers one might expect to encounter when transferring these services over to an adult care provider. Particular emphasis is paid towards the psychological aspects of this delicate period, which needs to be recognised and appreciated appropriately in order to understand the particular plights a young diabetic child will be challenged with. We explore the approaches that can be positively adopted in order to improve the experience for child, parents and also the multi- disciplinary team concerned with the overall delivery of this care. Finally we will close with reflection on the potential areas for future development that will ultimately aim to improve long-term outcomes and experiences of the young adolescent confronted with diabetes as well as the burden of disease and burden of cost of disease.

Effect of guided self-determination youth intervention integrated into outpatient visits versus treatment as usual on glycemic control and life skills: a randomized clinical trial in adolescents with type 1 diabetes

BACKGROUND

Providing care for adolescents with type 1 diabetes is complex, demanding, and often unsuccessful. Guided self-determination (GSD) is a life skills approach that has been proven effective in caring for adults with type 1 diabetes. To improve care, GSD was revised for adolescents, their parents, and interdisciplinary healthcare providers (HCP) to create GSD-Youth (GSD-Y). We evaluated the impact of GSD-Y after it was integrated into pediatric outpatient visits versus treatment-as-usual, focusing on glycemic control and the development of life skills in adolescents with type 1 diabetes.

METHODS

Seventy-one adolescents (mean age: 15 years, mean duration of diabetes: 5.7 years, mean HbA1c: 77 mmol/mol (9.1%), upon entering the study) from two pediatric departments were randomized into a GSD-Y group (n = 37, GSD-Y was provided during individual outpatient sessions) versus a treatment-as-usual group (n = 34). The primary outcome was the HbA1c measurement. The secondary outcomes were life skills development (assessed by self-reported psychometric scales), self-monitored blood glucose levels, and hypo- and hyperglycemic episodes. The analysis followed an intention-to-treat basis.

RESULTS

Fifty-seven adolescents (80%) completed the trial, and 53 (75%) completed a six-month post-treatment follow-up. No significant effect of GSD-Y on the HbA1c could be detected in a mixed-model analysis after adjusting for the baseline HbA1c levels and the identity of the HCP (P = 0.85). GSD-Y significantly reduced the amotivation for diabetes self-management after adjusting for the baseline value (P = 0.001). Compared with the control group, the trial completion was prolonged in the GSD-Y group (P <0.001), requiring more visits (P = 0.05) with a higher rate of non-attendance (P = 0.01). GSD-Y parents participated in fewer of the adolescents' visits (P = 0.05) compared with control parents.

CONCLUSIONS

Compared with treatment-as-usual, GSD-Y did not improve HbA1c levels, but it did decrease adolescents' amotivation for diabetes self-management.

TRIAL REGISTRATION

ISRCTN 54243636, registered on 10 January 2010. Life skills for adolescents with type 1 diabetes and their parents.

Balancing parental involvement with adolescent friendly health care in teenagers with diabetes: are we getting it right?

PURPOSE

Current guidance about adolescent-friendly health care emphasizes the benefits of seeing young people alone for confidential consultations. Yet in young people with Type 1 diabetes mellitus (T1DM), parental involvement has been shown to contribute to better diabetes control. This study aimed to better understand how these apparent tensions are reconciled in clinical practice by identifying how frequently adolescents with T1DM are seen alone and exploring parents' opinions about this.

METHODS

A convenience sample of consecutive parents of adolescents (aged 12-21 years) with T1DM was recruited from the outpatient clinic of a specialist diabetes service and asked to complete a 30-item written survey.

RESULTS

A total of 137 surveys were returned from 146 eligible parents (94%) of whom 106 had complete data. Thirteen percent of adolescents with T1DM had ever been seen alone for a confidential consultation with their doctor. The most common concern for parents about confidential care was not being informed about important information, not just about T1DM, but also about common adolescent risk behaviors and mental health states.

DISCUSSION

These findings suggest that young people with T1DM are not being routinely seen alone for confidential care. This could be attributed to: parents or adolescents declining confidential care; clinicians being time-poor and/or lacking the necessary skills; or a culture of uncertainty about the value of confidential care. A discussion is now required about how best to enact adolescent-friendly care in the chronic-illness outpatient setting, where parental involvement is understood to be important for effective chronic illness management.

Preparing adolescents with chronic disease for transition to adult care: a technology program

BACKGROUND

Adolescents with chronic disease (ACD) must develop independent disease self-management and learn to communicate effectively with their health care team to transition from pediatric to adult-oriented health care systems. Disease-specific interventions have been implemented to aid specific ACD groups through transition. A generic approach might be effective and cost-saving.

METHODS

Eighty-one ACD, aged 12 to 20 years, were recruited for a randomized clinical trial evaluating an 8-month transition intervention (MD2Me). MD2Me recipients received a 2-month intensive Web-based and text-delivered disease management and skill-based intervention followed by a 6-month review period. MD2Me recipients also had access to a texting algorithm for disease assessment and health care team contact. The intervention was applicable to adolescents with diverse chronic illnesses. Controls received mailed materials on general health topics. Disease management, health-related self-efficacy, and health assessments were performed at baseline and at 2 and 8 months. Frequency of patient-initiated communications was recorded over the study period. Outcomes were analyzed according to assigned treatment group over time.

RESULTS

MD2Me recipients demonstrated significant improvements in performance of disease management tasks, health-related self-efficacy, and patient-initiated communications compared with controls.

CONCLUSIONS

Outcomes in ACD improved significantly among recipients of a generic, technology-based intervention. Technology can deliver transition interventions to adolescents with diverse chronic illnesses, and a generic approach offers a cost-effective means of positively influencing transition outcomes. Further research is needed to determine whether improved short-term outcomes translate into an improved transition for ACD.

A multicentre randomized controlled trial of an empowerment-inspired intervention for adolescents starting continuous subcutaneous insulin infusion--a study protocol

Background

Continuous subcutaneous insulin infusion (CSII) treatment among children with type 1 diabetes is increasing in Sweden. However, studies evaluating glycaemic control in children using CSII show inconsistent results. The distribution of responsibility for diabetes self-management between children and parents is often unclear and needs clarification. There is much published support for continued parental involvement and shared diabetes management during adolescence. Guided Self-Determination (GSD) is an empowerment-based, person-centred, reflection and problem solving method intended to guide the patient to become self-sufficient and develop life skills for managing difficulties in diabetes self-management. This method has been adapted for adolescents and parents as Guided Self-Determination-Young (GSD-Y). This study aims to evaluate the effect of an intervention with GSD-Y in groups of adolescents starting on insulin pumps and their parents on diabetes-related family conflicts, perceived health and quality of life (QoL), and metabolic control. Here, we describe the protocol and plans for study enrolment.

Methods/design

This study is designed as a randomized, controlled, prospective, multicentre study. Eighty patients between 12–18 years of age who are planning to start CSII will be included. All adolescents and their parents will receive standard insulin pump training. The education intervention will be conducted when CSII is to be started and at four appointments in the first 4 months after starting CSII. The primary outcome is haemoglobin A1c levels. Secondary outcomes are perceived health and QoL, frequency of blood glucose self-monitoring and bolus doses, and usage of carbohydrate counting. The following instruments will be used: Disabkids, ‘Check your health’, the Diabetes Family Conflict Scale and the Swedish Diabetes Empowerment Scale. Outcomes will be evaluated within and between groups by comparing data at baseline, and at 6 and 12 months after starting treatment.

Discussion

In this study, we will assess the effect of starting an CSII together with the model of GSD to determine whether this approach leads to retention of improved glycaemic control, QoL, responsibility distribution and reduced diabetes-related conflicts in the family.

Trial registration

Current controlled trials: ISRCTN22444034

Clinical review: Diabetes in the adolescent: transitional issues

CONTENT

Orchestrating a seamless transition from pediatric to adult care can be a daunting task in caring for youth with diabetes mellitus. This clinical review focuses on physical and psychosocial aspects affecting the care of adolescents and young adults with diabetes, evaluates how these aspects can be barriers in the process of transitioning these patients to adult diabetes care, and provides clinical approaches to optimizing the transition process in order to improve diabetes care and outcomes.

EVIDENCE ACQUISITION AND SYNTHESIS

A PubMed search identified articles related to transition to adult diabetes care and physical and psychosocial assessment of adolescents with diabetes. An Internet search for transition of diabetes care identified online transition resources. The synthesis relied on the cumulative experience of the authors. We identify barriers to successful transition and provide a checklist for streamlining the process.

CONCLUSIONS

Key points in the transition to adult diabetes care include: 1) starting the process at least 1 year before the anticipated transition; 2) assessing individual patients' readiness and preparedness for adult care; 3) providing guidance and education to the patient and family; 4) utilizing transition guides and resources; and 5) maintaining open lines of communication between the pediatric and adult providers. No current single approach is effective for all patients. Challenges remain in successful transition to avoid short- and long-term complications of diabetes mellitus.

Multicentre randomized controlled trial of structured transition on diabetes care management compared to standard diabetes care in adolescents and young adults with type 1 diabetes (Transition Trial)

BACKGROUND

Transition from pediatric to adult diabetes care is a high risk period during which there is an increased rate of disengagement from care. Suboptimal transition has been associated with higher risks for acute and chronic diabetes-related complications. The period of emerging adulthood challenges current systems of healthcare delivery as many young adults with type 1 diabetes (T1D) default from diabetes care and are at risk for diabetes complications which are undetected and therefore untreated. Despite the importance of minimizing loss to follow-up there are no randomized control trials evaluating models of transition from pediatric to adult diabetes care.

METHODS/DESIGN

This is a multicentre randomized controlled trial. A minimum of 188 subjects with T1D aged between 17 and 20 years will be evaluated. Eligible subjects will be recruited from three pediatric care centres and randomly assigned in a 1:1 ratio to a structured transition program that will span 18 months or to receive standard diabetes care. The structured transition program is a multidisciplinary, complex intervention aiming to provide additional support in the transition period. A Transition Coordinator will provide transition support and will provide the link between pediatric and adult diabetes care. The Transition Coordinator is central to the intervention to facilitate ongoing contact with the medical system as well as education and clinical support where appropriate. Subjects will be seen in the pediatric care setting for 6 months and will then be transferred to the adult care setting where they will be seen for one year. There will then be a one-year follow-up period for outcome assessment. The primary outcome is the proportion of subjects who fail to attend at least one outpatient adult diabetes specialist visit during the second year after transition to adult diabetes care. Secondary outcome measures include A1C frequency measurement and levels, diabetes related emergency room visits and hospital admissions, frequency of complication screening, and subject perception and satisfaction with care.

DISCUSSION

This trial will determine if the support of a Transition Coordinator improves health outcomes for this at-risk population of young adults.

TRIAL REGISTRATION

TRIAL REGISTRATION NUMBER

NCT01351857.

Transitions in care: support group for young adults with Type 1 diabetes

AIMS

Young adulthood is a challenging period for patients with Type 1 diabetes as developmental changes complicate Type 1 diabetes management and gaps in care may arise as patients transition from paediatric to adult providers. This period has been associated with worsening diabetes outcomes. One approach to aid young adults during this transition period could entail professionally led support groups to enhance self-motivation and facilitate peer-to-peer interactions. We implemented and evaluated a support group for young adults with Type 1 diabetes as a pilot project.

METHODS

Young adults with Type 1 diabetes (18-30 years) participated in monthly, professionally led support groups for 5 months. Questionnaires were completed pre- and post-group and chart review data were collected regarding glycaemic control and visit frequency in the year before and after group participation.

RESULTS

Participation in the group was associated with improvement in HbA(1c) and decreased self-reported diabetes burden, along with a trend for an increase in diabetes-related self-care behaviours. Frequency of visits did not vary from pre- to post-group. Discussion topics identified by participants included managing diabetes in day-to-day life, experiences and interactions with others who do not have diabetes and emotions related to diabetes. Participants identified that they sought a diabetes care team that offers knowledge, support and a multidisciplinary team.

CONCLUSIONS

Professionally led support groups may have utility for increasing social support and optimizing diabetes outcomes in young adults with Type 1 diabetes.

Transition to adult care: systematic assessment of adolescents with chronic illnesses and their medical teams

OBJECTIVE

To examine the process of transition from pediatric to adult health care services from the perspectives of young adults with chronic disease and both pediatric and adult health care providers.

STUDY DESIGN

A qualitative approach using focus-group interviews was performed to investigate transition experiences. Novel games were also used to generate data. Content and narrative analyses of interview transcripts were performed.

RESULTS

We conducted 6 focus groups with 10 young adults who had chronic disease and with 24 health care providers. Content analysis yielded 3 content domains: (1) transition experiences in the context of relationships among patients, parents, and health care providers; (2) differences between pediatric and adult-oriented medicine and how these differences inhibit or facilitate transition; and (3) identification of transition services that should be provided to young patients who have chronic disease.

CONCLUSION

This study demonstrates the need for gradual transfer of disease management from parent to child and the need for better communication between adult and pediatric services during the transition process. Pediatric medicine and adult medicine represent different subcultures; acknowledging these differences may improve cooperation during transition from pediatric to adult providers. Young-adult patients with chronic disease embrace the use of technology for specific interventions to improve the transition experience.

Attained education and self-assessed health later in life when diagnosed with diabetes in childhood: a population-based study

BACKGROUND

Previous studies have reported conflicting findings on academic achievement in children with type 1 diabetes, and generally lower self-assessed health status among respondents with diabetes.

OBJECTIVE

Thus, in this study, using the theoretical framework of the human-capital model, a population-based survey data set for Sweden, and explanatory variables following predictions from theory and previous empirical human-capital studies, individuals diagnosed with diabetes before the age of 19 were examined whether they differ from the general population at the same age concerning (i) educational level attained and (ii) self-assessed health later in life. Special attention was devoted to the association between education and health.

SUBJECTS

A set of pooled cross-sectional population survey data complemented with register data, comprising 20 670 individuals (of whom 106 individuals were diagnosed with diabetes), aged 19-38 yr, from 1988 to 2000, was created from the Swedish Biennial Survey of Living Conditions.

METHOD

The influence of childhood diabetes was analyzed using multiple regression analysis, controlling for educational level, wage, sex, age, marital status, and parental ethnicity.

RESULTS

Childhood diabetes was associated with lower levels of attained education and self-assessed health in comparison with the general population. More educated individuals reported better health, though.

CONCLUSIONS

In terms of the rapid increase in the incidence of diabetes in many countries, it is important to bear in mind that investments made both in education and in health, early in life, may facilitate the capability of the individual to experience healthy time later in life.

Implementing a transition pathway in diabetes: a qualitative study of the experiences and suggestions of young people with diabetes

BACKGROUND

The prevalence of Type 1 diabetes is increasing with more children and adolescents being diagnosed with this chronic condition. There has been an increasing focus in recent years on the transition through adolescence and supporting young people who have chronic health conditions, with the recognition that young people are at risk of dropping out of healthcare services following transfer from paediatric to adult services. To date, there have been limited evaluations of transition models. The purpose of this study is to evaluate one such model in diabetes, the 'Transition Pathway' via interviews with young people who have experienced it first-hand. The results are discussed in terms of understanding the unique needs of adolescents with regard to psychosocial developmental theory, and what this means for healthcare providers of transition/adolescent services.

METHODS

Semi-structured interviews were carried out with 11 young people, two of whom returned a year later for a second interview. Qualitative analysis of these interviews using a 'Framework' approach enabled the data to be sorted according to initial themes. Following this, further analysis enabled the identification of 'super-ordinate' or overall themes.

RESULTS

Six initial themes emerged from the data. These concerned the transition pathway process, the experience and organization of transfer, organization of services, information and education, the healthcare consultation and the need for services to be inclusive of all young people's needs. From these initial themes, two overall/super-ordinate themes were identified: the need for transition services to be developmentally appropriate and to be based around individual needs. The consultation experience was central to keeping young people engaged with adolescent healthcare services.

CONCLUSION

Several key elements of adolescent/transition healthcare services have been proposed, one of which is training for professionals delivering the service. This study suggests that communication skills form a vital component of such training.

Risky business: risk behaviors in adolescents with type 1 diabetes

PURPOSE

The purpose of this article is to review risk behaviors and their health consequences in adolescents with type 1 diabetes. The existing literature on common risk behaviors in adolescents is examined, with a focus on illicit drug use, alcohol use, smoking, unprotected sexual activity, and disordered eating behaviors.

CONCLUSIONS

A review of the literature highlights the lack of studies of risk behaviors in this population. Much of what is known comes from studies with adolescents in the general population or from studies of adults with type 1 diabetes. Known risk and protective factors for risk behaviors and health outcomes are noted. Based on these findings, suggestions are provided for diabetes educators and health care providers to assess for and prevent risk behaviors in adolescents with type 1 diabetes. Directions for future research in this population are indicated, including the need to develop and test standardized prevention programs.

Improving glycaemic control and life skills in adolescents with type 1 diabetes: a randomised, controlled intervention study using the Guided Self-Determination-Young method in triads of adolescents, parents and health care providers integrated into routine paediatric outpatient clinics

BACKGROUND

Adolescents with type 1 diabetes face demanding challenges due to conflicting priorities between psychosocial needs and diabetes management. This conflict often results in poor glycaemic control and discord between adolescents and parents. Adolescent-parent conflicts are thus a barrier for health care providers (HCPs) to overcome in their attempts to involve both adolescents and parents in improvement of glycaemic control. Evidence-based interventions that involve all three parties (i.e., adolescents, parents and HCPs) and are integrated into routine outpatient clinic visits are lacking. The Guided Self-Determination method is proven effective in adult care and has been adapted to adolescents and parents (Guided Self-Determination-Young (GSD-Y)) for use in paediatric diabetes outpatient clinics. Our objective is to test whether GSD-Y used in routine paediatric outpatient clinic visits will reduce haemoglobin A1c (HbA1c) concentrations and improve adolescents' life skills compared with a control group.

METHODS/DESIGN

Using a mixed methods design comprising a randomised controlled trial and a nested qualitative evaluation, we will recruit 68 adolescents age 13-18 years with type 1 diabetes (HbA1c > 8.0%) and their parents from 2 Danish hospitals and randomise into GSD-Y or control groups. During an 8-12 month period, the GSD-Y group will complete 8 outpatient GSD-Y visits, and the control group will completes an equal number of standard visits. The primary outcome is HbA1c. Secondary outcomes include the following: number of self-monitored blood glucose values and levels of autonomous motivation, involvement and autonomy support from parents, autonomy support from HCPs, perceived competence in managing diabetes, well-being, and diabetes-related problems. Primary and secondary outcomes will be evaluated within and between groups by comparing data from baseline, after completion of the visits, and again after a 6-month follow-up. To illustrate how GSD-Y influences glycaemic control and the development of life skills, 10-12 GSD-Y visits will be recorded during the intervention and analysed qualitatively together with individual interviews carried out after follow-up.

DISCUSSION

This study will provide evidence of the effectiveness of using a GSD-Y intervention with three parties on HbA1c and life skills and the feasibility of integrating the intervention into routine outpatient clinic visits. Danish Data Association ref nr. 2008-41-2322.

TRIAL REGISTRATION

ISRCTN54243636.