Decision-making in diabetes mellitus type 1

Diabetes alters neuroeconomically dissociable forms of mental accounting

Those with diabetes mellitus are at high-risk of developing psychiatric disorders, yet the link between hyperglycemia and alterations in motivated behavior has not been explored in detail. We characterized value-based decision-making behavior of a streptozocin-induced diabetic mouse model on a naturalistic neuroeconomic foraging paradigm called Restaurant Row. Mice made self-paced choices while on a limited time-budget accepting or rejecting reward offers as a function of cost (delays cued by tone-pitch) and subjective value (flavors), tested daily in a closed-economy system across months. We found streptozocin-treated mice disproportionately undervalued less-preferred flavors and inverted their meal-consumption patterns shifted toward a more costly strategy that overprioritized high-value rewards. We discovered these foraging behaviors were driven by impairments in multiple decision-making systems, including the ability to deliberate when engaged in conflict and cache the value of the passage of time in the form of sunk costs. Surprisingly, diabetes-induced changes in behavior depended not only on the type of choice being made but also the salience of reward-scarcity in the environment. These findings suggest complex relationships between glycemic regulation and dissociable valuation algorithms underlying unique cognitive heuristics and sensitivity to opportunity costs can disrupt fundamentally distinct computational processes and could give rise to psychiatric vulnerabilities.

Usefulness of the Montreal Cognitive Assessment in Older Adults With Type 1 Diabetes

Objective

Older adults with type 1 diabetes are at high risk for cognitive impairment, yet the usefulness of common cognitive screening instruments has not been evaluated in this population.

Methods

A total of 201 adults ≥60 years of age with type 1 diabetes completed a battery of neuropsychological measures and the Montreal Cognitive Assessment (MoCA). Receiver operating characteristic (ROC) curves and Youden indices were used to evaluate overall screening test performance and to select an optimal MoCA cutoff score for detecting low cognitive performance, as defined as two or more neuropsychological test performances ≥1.5 SD below demographically corrected normative data.

Results

The ROC area under the curve (AUC) was 0.745 (P < 0.001). The publisher-recommended cutoff score of <26 resulted in sensitivity of 60.4% and specificity of 71.4%, whereas a cutoff score of <27 resulted in sensitivity of 75.0% and specificity of 61.0%. The Youden indices for these cutoff scores were 0.318 and 0.360, respectively. Minimally acceptable sensitivity (i.e., >0.80) was obtained when using a cutoff score of <28, whereas >0.80 specificity was obtained with a cutoff score of <25.

Conclusions

The MoCA has modest overall performance (AUC 0.745) as a cognitive screening instrument in older adults with type 1 diabetes. The standard cutoff score of <26/30 may not adequately detect individuals with neuropsychological testing-defined abnormal cognition. The optimal MoCA cutoff score (based on the Youden index) was <27/30. A score of <28 resulted in acceptable sensitivity but was accompanied by low specificity (42%). Future studies with a more diverse population are needed to confirm these findings.

Trust-Based Decision-Making in the Health Context Discriminates Biological Risk Profiles in Type 1 Diabetes

Theoretical accounts on social decision-making under uncertainty postulate that individual risk preferences are context dependent. Generalization of models of decision-making to dyadic interactions in the personal health context remain to be experimentally addressed. In economic utility-based models, interactive behavioral games provide a framework to investigate probabilistic learning of sequential reinforcement. Here, we model an economic trust game in the context of a chronic disease (Diabetes Type 1) which involves iterated daily decisions in complex social contexts. Ninety-one patients performed experimental trust games in both economic and health settings and were characterized by a multiple self-report set of questionnaires. We found that although our groups can correctly infer pay-off contingencies, they behave differently because patients with a biological profile of preserved glycemic control show adaptive choice behavior both in economic and health domains. On the other hand, patients with a biological profile of loss of glycemic control presented a contrasting behavior, showing non-adaptive choices on both contexts. These results provide a direct translation from neuroeconomics to decision-making in the health domain and biological risk profiles, in a behavioral setting that requires difficult and self-consequential decisions with health impact. Our findings also provide a contextual generalization of mechanisms underlying individual decision-making under uncertainty.

Type 1 diabetes affects the brain functional connectivity underlying working memory processing

Visuospatial working memory (VSWM) deficits have been demonstrated to occur during the development of type-1-diabetes (T1D). Despite confirming the early appearance of distinct task-related brain activation patterns in T1D patients compared to healthy controls, the effect of VSWM load on functional brain connectivity during task performance is still unknown. Using electroencephalographic methods, the present study evaluated this topic in clinically well-controlled T1D young patients and healthy individuals, while they performed a VSWM task with different memory load levels during two main VSWM processing phases: encoding and maintenance. The results showed a significantly lower number of correct responses and longer reaction times in T1D while performing the task. Besides, higher and progressively increasing functional connectivity indices were found for T1D patients in response to cumulative degrees of VSWM load, from the beginning of the VSWM encoding phase, without notably affecting the VSWM maintenance phase. In contrast, healthy controls managed to solve the task, showing lower functional brain connectivity during the initial VSWM processing steps with more gradual task-related adjustments. Present results suggest that T1D patients anticipate high VSWM load demands by early recruiting supplementary processing resources as the probable expression of a more inefficient, though paradoxically better adjusted to task demands cognitive strategy.

Advancing the Measurement of Executive Functioning in Pediatric Chronic Pain

Youth with chronic pain often report executive functioning difficulties, many of which have been linked to poor treatment adherence and health-related quality of life in adults with chronic pain, as well as in other pediatric chronic health populations. Despite the extensive implications for functional impairment, executive functioning remains understudied in pediatric chronic pain. Measurement approaches have lacked clear theoretical guidance, resulting in only some domains of executive functioning being investigated. To date, the methods used to measure executive functioning have been inconsistent, ranging from self-report measures of everyday executive functioning in home and school contexts to standardized neuropsychological tests. We argue for enhanced measure validation efforts and increased clarity in the approaches chosen to measure executive functioning in pediatric chronic pain to better guide research efforts in this area, thus yielding clearer clinical implications.

Personality Prototypes in People with Type 1 Diabetes and Their Relationship with Adherence

Type 1 diabetes (Dm1) is a chronic endocrine and metabolic disease that affects the whole person and requires active, decisive treatment. However, personality traits may influence a patient's adherence to treatment guidelines. The objective of this work is firstly to identify the 3 Asendorpf personality prototypes (resilient, undercontrolled and overcontrolled) in a sample of Dm1 individuals and determine whether there are any differences in comparison with a control sample; and, secondly, to study their association with adherence to self-care guidelines using both physiological indicators (HbA1C) and self-report measures. To achieve these objectives, a descriptive cross-sectional study was carried out. The sample comprised 294 participants, of whom 104 were people with Dm1 and 190 were controls. The participants, aged between 14 and 34 years, were classified by their scores in NEO-FFI-R, according to the personality characteristics inherent to Asendorpf's prototypes. Asendorpf's 3 prototypical personality patterns were found both in the group of people with Dm1 and in the control sample. These patterns showed different degrees of association with adherence to self-care guidelines for this disease and with psychological health factors. Importance should therefore be attached to the personality traits and Asendorpf prototypes of people with Dm1 when proposing interventions to address medical, psychological, and behavioral aspects.

Suicide and Self-inflicted Injury in Diabetes: A Balancing Act

Glycemic control in type 1 diabetes mellitus (T1DM) remains a challenge for many, despite the availability of modern diabetes technology. While technologies have proven glycemic benefits and may reduce excess mortality in some populations, both mortality and complication rates remain significantly higher in T1DM than the general population. Diabetes technology can reduce some burdens of diabetes self-management, however, it may also increase anxiety, stress, and diabetes-related distress. Additional workload associated with diabetes technologies and the dominant focus on metabolic control may be at the expense of quality-of-life. Diabetes is associated with significantly increased risk of suicidal ideation, self-harm, and suicide. The risk increases for those with diabetes and comorbid mood disorder. For example, the prevalence of depression is significantly higher in people with diabetes than the general population, and thus, people with diabetes are at even higher risk of suicide. The Center for Disease Control and Prevention reported a 24% rise in US national suicide rates between 1999 and 2014, the highest in 30 years. In the United Kingdom, 6000 suicides occur annually. Rates of preventable self-injury mortality stand at 29.1 per 100 000 population. Individuals with diabetes have an increased risk of suicide, being three to four times more likely to attempt suicide than the general population. Furthermore, adolescents aged 15 to 19 are most likely to present at emergency departments for self-inflicted injuries (9.6 per 1000 visits), with accidents, alcohol-related injuries, and self-harm being the strongest risk factors for suicide, the second leading cause of death among 10 to 24 year olds. While we have developed tools to improve glycemic control, we must be cognizant that the psychological burden of chronic disease is a significant problem for this vulnerable population. It is crucial to determine the psychosocial and behavioral predictors to uptake and continued use of technology in order to aid the identification of those individuals most likely to realize benefits of any intervention as well as those individuals who may require more support to succeed with technology.

The effect of type 1 diabetes on the developing brain

The effect of type 1 diabetes on the developing brain is a topic of primary research interest. A variety of potential dysglycaemic insults to the brain can cause cellular and structural injury and lead to altered neuropsychological outcomes. These outcomes might be subtle in terms of cognition but appear to persist into adult life. Age and circumstance at diagnosis appear to play a substantial role in potential CNS injury. A history of diabetic ketoacidosis and chronic hyperglycaemia appear to be more injurious than previously suspected, whereas a history of severe hypoglycaemia is perhaps less injurious. Neurocognitive deficits manifest across multiple cognitive domains, including executive function and speed of information processing. Some evidence suggests that subtle brain injury might directly contribute to psychological and mental health outcomes. Impaired executive function and mental health, in turn, could affect patients' adherence and the ability to make adaptive lifestyle choices. Impaired executive functioning creates a potential feedback loop of diabetic dysglycaemia leading to brain injury, further impaired executive function and mental health, which results in suboptimal adherence, and further dysglycaemia. Clinicians dealing with patients with suboptimal glycaemic outcomes should be aware of these potential issues.

Impact of General and Oral Complications of Diabetes Mellitus Type I on Lebanese Children's Quality of Life

Introduction

Diabetes mellitus type I (DM1) has been increasing at an alarming rate worldwide. Children suffering from this chronic disease are subject to a high risk of systemic and oral complications, due to their young age and the lack of awareness of the relation between diabetes and oral health.

Objective

The aim of this study is to evaluate the impact of oral and general complications of DM1 on the Lebanese children's quality of life. The goal was to assess the child's behavioral issues on the one hand and the oral issues on the other.

Materials and methods

About 37 diabetic Lebanese children aged between 6 and 12 years, recruited from the Chronic Care Center (CCC), answered two questionnaires, one related to the disease and the second related to the oral complications.

Results

A majority of the participants (81.1%) are aware of their disease, 73% know the importance of their treatment and 54.1% are able to control their glycemia; 45.9% are not annoyed with constantly carrying a monitor and 67.5% are bothered by their restricted diet. Only 5.4% of children isolate themselves.

Concerning the oral complications

About 83.8% of the children do not suffer from oral ulcers, 56.8% are caries-free, and 64.9% have completed their dental treatment; 89.2% do not complain while eating and 94.6% are not able to brush their teeth properly.

Conclusion

Diabetic patients are found to have good knowledge of the disease and its systemic complications but a little on their increased risk for oral diseases. In order to ensure a good quality of life for the diabetic children and their families, optimal control of diabetes, appropriate oral hygiene, and regular visits to the dentist must be respected.How to cite this article: Noueiri B, Nassif N, Ollek A. Impact of General and Oral Complications of Diabetes Mellitus Type I on Lebanese Children's Quality of Life. Int J Clin Pediatr Dent 2018;11(1):40-45.

Child and parental executive functioning in type 1 diabetes: Their unique and interactive role toward treatment adherence and glycemic control

OBJECTIVE

Managing type 1 diabetes (T1D) requires the ability to make complex and critical decisions regarding treatment, to execute complex tasks accurately, and to make adjustments when problems arise. This requires effective neuropsychological competences of patients and their families, especially in the domain of executive functioning (EF): the ability to self-monitor, plan, solve problems, and set priorities. Previous research focused mainly on child EF, neglecting the impact of parental EF. This study included both mothers and fathers and examined associations between child and parental EF and treatment adherence to T1D in a broad age range of patients.

METHODS

Parents of 270 patients (6-18 years) with T1D (mean age 12.7 years; 52.6% female) were included. Mothers (N = 232) and fathers (N = 168) completed questionnaires on child and parental EF and on treatment adherence. Analyses examined the associations linking child and parental EF to treatment adherence and glycemic control (and potential moderation effects in these associations) using hierarchical linear regression.

RESULTS

Child EF problems were negatively associated with treatment adherence. As an indication of moderation, this effect was stronger in older children. Better treatment adherence and glycemic control were reported when both child and parent showed less EF problems. Effects were more pronounced in mothers than in fathers.

CONCLUSIONS

This study demonstrated a significant interplay between child and parental EF in the association with treatment adherence and glycemic control. Researchers and clinicians should remain attentive toward the role of neuropsychological concepts such as EF. Implementation in clinical practice seems meaningful.

A Systematic Review and Meta-analysis of Executive Function Performance in Type 1 Diabetes Mellitus

OBJECTIVE

The aims of the study were to examine the current evidence for executive function (EF) performance differences between groups with type 1 diabetes mellitus (T1DM) and nondiabetic control groups during adolescence and early adulthood and to explore the relationships between EF and diabetes-related risk factors.

METHODS

A systematic review of the literature examining EF performance in groups with T1DM was conducted according to the PRISMA guidelines. Electronic database searches for published and unpublished literature yielded a final set of 26 articles after application of inclusion and exclusion criteria. A meta-analysis was conducted on a subset of these articles (n = 17) comparing EF performance in T1DM and control groups, across a total sample size of 1619.

RESULTS

Sixteen of 26 studies found significantly lower EF on at least one task in groups with T1DM. Meta-analyses of the performance difference between T1DM groups and control groups without diabetes showed that inhibition (g = -0.28, p < .001), working memory (g = -0.34, p < .001), set-shifting (g = -0.31, p = .012), and overall EF performance across these domains (g = -0.42, p < .001) were all significantly lower in groups with T1DM. Performance on specific EF domains also seemed to be differentially associated with early age of diabetes onset, chronic hyperglycemia and its complications, and severe hypoglycemia.

CONCLUSIONS

T1DM and its associated risk factors are related to subtle impairments across the inhibition, working memory, and set-shifting domains of EF. Lower EF may be a key factor contributing to behavioral and clinical problems experienced by individuals with T1DM.

The Role of Authoritative Parenting in Adolescent Type 1 Diabetes Management

Objective

Adolescents with Type 1 diabetes are at risk for poorer adherence, lower quality of life (QOL), and poorer glycemic control (HbA1c). Authoritative parenting (AP) along with youth adherence and QOL was hypothesized to relate to better HbA1c.

Methods

Parent-youth dyads (N = 257) completed baseline measures of adherence and QOL. Youth completed an AP questionnaire, and HbA1c samples were evaluated. Structural equation modeling determined relations among AP, adherence, QOL, and glycemic control.

Results

AP indirectly linked to better HbA1c (β = -.15, p = .021) through both better adherence and higher QOL. AP also was associated directly with better adherence (β = .26, p = .001), which in turn was linked to better HbA1c (β = -.35, p = .021). In addition, adherence was associated directly with QOL (β = -.56, p = .001).

Conclusions

Together, better youth adherence and higher QOL are two mechanisms by which more AP indirectly relates to better glycemic control during the early adolescent years.

Decision-making in primary onset middle-age type 2 diabetes mellitus: a BOLD-fMRI study

Although type 2 diabetes mellitus (T2DM) is a well-recognized risk factor for dementia, the neural mechanisms that underlying cognitive impairment in T2DM remain unclear. We used functional magnetic resonance imaging (fMRI) during a computerized version of the Iowa Gambling Task to investigate the neural basis of decision making at the initial onset stage of T2DM. Eighteen newly diagnosed middle-aged T2DM patients, with no previous diabetic treatment history, and 18 matched controls were recruited. Results indicated that T2DM patients made more disadvantageous decisions than controls. Compared to healthy subjects, T2DM patients showed decreased activation in the ventral medial prefrontal cortex (VMPFC), orbitofrontal cortex (OFC) and anterior cingulate cortex, and increased activity in the dorsolateral prefrontal cortex, posterior cingulate cortex, insula and occipital lobes. IGT performance positively correlated with changes in brain activation in the VMPFC and OFC in both groups. Moreover, poor glycemic control was associated with decision-making function both in behavioral and brain activity in the VMPFC and OFC in patients. Conclusively, T2DM patients may suffer from weaknesses in their prefrontal cortex functions that lead to poorer decision-making under ambiguity, at least as assessed by the IGT.

Iowa Gambling Task Performance Prospectively Predicts Changes in Glycemic Control among Adolescents with Type 1 Diabetes

OBJECTIVES

Good glycemic control is an important goal of diabetes management. Late adolescents with type 1 diabetes (T1D) are at risk for poor glycemic control as they move into young adulthood. For a subset of these patients, this dysregulation is extreme, placing them at risk for life-threatening health complications and permanent cognitive declines. The present study examined whether deficiency in emotional decision making (as measured by the Iowa Gambling Task; IGT) among teens with T1D may represent a neurocognitive risk factor for subsequent glycemic dysregulation.

METHODS

As part of a larger longitudinal study, a total of 241 high-school seniors (147 females, 94 males) diagnosed with T1D underwent baseline assessment that included the IGT. Glycated hemoglobin (HbA1c), which reflects glycemic control over the course of the past 2 to 3 months, was also assessed at baseline. Of the 241,189 (127 females, 62 males, mean age=17.76, mean HbA1c=8.11) completed HbA1c measurement 1 year later.

RESULTS

Baseline IGT performance in the impaired range (per norms) was associated with greater dysregulation in glycemic control 1 year later, as evidenced by an average increase in HbA1c of 2%. Those with normal IGT scores (per norms) exhibited a more moderate increase in glycemic control, with an HbA1c increase of 0.7%. Several IGT scoring approaches were compared, showing that the total scores collapsed across all trials was most sensitive to change in glycemic control.

CONCLUSIONS

IGT assessment offers promise as a tool for identifying late adolescents at increased risk for glycemic dysregulation. (JINS, 2017, 23, 204-213).

Health-Related Decision-Making in HIV Disease

Individuals living with HIV show moderate decision-making deficits, though no prior studies have evaluated the ability to make optimal health-related decisions across the HIV healthcare continuum. Forty-three HIV+ individuals with HIV-associated neurocognitive disorders (HAND+), 50 HIV+ individuals without HAND (HAND-), and 42 HIV- participants were administered two measures of health-related decision-making as part of a comprehensive neuropsychological battery: (1) The Decisional Conflict Scale (DCS), and (2) The Modified UCSD Brief Assessment for Capacity to Consent (UBACC-T). Multiple regression analyses revealed that HAND was an independent predictor of both the DCS and the UBACC-T, such that the HAND+ sample evidenced significantly poorer scores relative to comparison groups. Within the HIV+ sample, poorer health-related decision-making was associated with worse performance on tests of episodic memory, risky decision-making, and health literacy. Findings indicate that individuals with HAND evidence moderate deficits in effectively comprehending and evaluating various health-related choices.

Short and long term neuro-behavioral alterations in type 1 diabetes mellitus pediatric population

Type 1 diabetes mellitus (T1DM) is one of the most prevalent chronic conditions affecting individuals under the age of 18 years, with increasing incidence worldwide, especially among very young age groups, younger than 5. There is still no cure for the disease, and therapeutic goals and guidelines are a challenge. Currently, despite T1DM intensive management and technological interventions in therapy, the majority of pediatric patients do not achieve glycemic control goals. This leads to a potential prognosis of long term diabetic complications, nephrological, cardiac, ophthalmological and neurological. Unfortunately, the neurological manifestations, including neurocognitive and behavioral complications, may present soon after disease onset, during childhood and adolescence. These manifestations may be prominent, but at times subtle, thus they are often not reported by patients or physicians as related to the diabetes. Furthermore, the metabolic mechanism for such manifestations has been inconsistent and difficult to interpret in practical clinical care, as reported in several reviews on the topic of brain and T1DM. However, new technological methods for brain assessment, as well as the introduction of continuous glucose monitoring, provide new insights and information regarding brain related manifestations and glycemic variability and control parameters, which may impact the clinical care of children and youth with T1DM. This paper provides a comprehensive review of the most recently reported behavioral, cognitive domains, sleep related, electrophysiological, and structural alterations in children and adolescences from a novel point of view. The review focuses on reported impairments based on duration of T1DM, its timeline, and modifiable disease related risk parameters. These findings are not without controversy, and limitations of data are presented in addition to recommendations for future research direction.