The emotional burden of type 1 diabetes: A cross-sectional study to understand associations between diabetes distress and glucose metrics in adulthood.

AIMS: Advancements in type 1 diabetes (T1D) management, such as continuous glucose monitoring (CGM), have helped people achieve narrower glucose ranges, but associations between CGM and diabetes distress are unclear. Although higher HbA1c is associated with higher distress, associations with other glucose metrics are unknown. To better understand this relationship, we characterized diabetes distress in a sample of CGM users and compared differences in glucose metrics (measured via CGM) between those with higher versus lower distress. METHODS: CGM users with T1D from the T1D Exchange Registry completed an online survey including diabetes distress (DDS-2) and shared CGM data (N = 199). CGM metrics were computed from all available data within 3 months prior to survey completion. Participants were grouped by distress level: lower (DDS-2 < 3, n = 120) or higher (DDS-2 ≥ 3, n = 79). Welch's t-tests were used to compare mean differences in CGM metrics between groups and MANCOVA was used to further probe mean differences. RESULTS: Approximately 39.7% participants reported higher diabetes distress. Welch's t-tests revealed participants with higher distress spent significantly more time in higher glucose ranges (above 180 mg/dL and above 250 mg/dL), less time in target glucose ranges (between 70 and 180 mg/dL and between 70 and 140 mg/dL) and had higher glucose management index values compared to those with lower distress (p < 0.01). MANCOVA models showed similar results. CONCLUSIONS: CGM users continue to experience diabetes distress. Moreover, higher distress appears to be associated with hyperglycaemia. These findings provide support for broader screening efforts for diabetes distress.

Emerging Adult and Caregiver Psychosocial Experiences with Severe Hypoglycemic Events and the Perceived Impact of Nasal Glucagon: A Cross-Sectional Study.

INTRODUCTION: Severe hypoglycemic events are distressing. Although past studies have shown that young adulthood is a potentially distressing time, few studies have explored distress about severe hypoglycemia in this age group. The real-world psychosocial experiences of potential severe hypoglycemic events and the perceived impact of glucagon treatments like nasal glucagon are currently unknown. We explored perceptions of severe hypoglycemic events and impact of nasal glucagon on psychosocial experiences with these events in emerging adults with type 1 diabetes and caregivers of emerging adults and children/teens. Further, we compared perceptions of preparedness and protection in handling severe hypoglycemic events with nasal glucagon versus the emergency glucagon kit that requires reconstitution (e-kit). METHODS: This observational, cross-sectional study enrolled emerging adults (aged 18-26; N = 364) with type 1 diabetes, caregivers of emerging adults (aged 18-26; N = 138) with type 1 diabetes, and caregivers of children/teens (aged 4-17; N = 315) with type 1 diabetes. Participants completed an online survey about their experiences with severe hypoglycemia, perceptions of nasal glucagon impact on psychosocial experiences, and perceptions of feeling prepared and protected with nasal glucagon and the e-kit. RESULTS: Many emerging adults (63.7%) agreed that the experience of severe hypoglycemic events was distressing; 33.3% and 46.7% of caregivers of emerging adults and children/teens, respectively, reported distress. Participants reported positive perceptions of nasal glucagon impact, particularly improved confidence in other people's ability to help during severe hypoglycemic events: emerging adults, 81.4%; caregivers of emerging adults, 77.6%; caregivers of children/teens, 75.5%. Participants demonstrated higher perceptions of preparedness and protection for nasal glucagon than for the e-kit (p < 0.001). CONCLUSIONS: Participants reported improved confidence in other people's ability to help during severe hypoglycemic events since having nasal glucagon available. This suggests that nasal glucagon may help broaden the support network for young people with type 1 diabetes and their caregivers.

Daily experiences of type 1 diabetes stress across adulthood.

AIMS: Daily diabetes stressful events take a toll on individuals with type 1 diabetes, and these experiences may look different across adulthood. The aims of the current study were to understand the nature of daily diabetes stress across adulthood and explore whether these experiences differed by age. METHODS: In this qualitative study, adults with T1D (N = 199, Mage  = 46.81 years) described the most stressful event related to their diabetes each evening as part of a 14-day diary. Using a grounded theory approach, diabetes stressful events were coded for where they occurred, the source of stress (i.e. interpersonal or not), and content (e.g. sleep; blood glucose checking; frustration). RESULTS: Participants reported having a diabetes-related stressful event on 58% (M = 0.58, SD = (0.25)) of days. Daily stressful events included issues of diabetes management, diabetes-related interference to or from other areas of life, and negative impact on psychological well-being, but rarely included a social component. Older adults were less likely to report having a diabetes-related stressful event, but were more likely to report that stressful events occurred at home, compared to younger adults. CONCLUSION: The lived experience of diabetes-related stress appears similar across ages, with individuals continuing to experience generally the same types of diabetes-related events in similar frequencies. Interventions to help improve diabetes outcomes or well-being may benefit from targeting the most commonly experienced areas of stress, which includes reducing the interference of daily activities to and by diabetes management.

Daily stress spillover and crossover in couples coping with type 1 diabetes.

In the context of a chronic illness such as Type 1 diabetes (T1D), managing general stressors may be linked to diabetes-specific stressors for persons with T1D, an intraindividual contagion phenomenon (i.e., spillover). Among those with romantic partners, stress may also be associated with the partner's stress (i.e., crossover). These intraindividual and interpersonal processes may be further strengthened or weakened in the presence of individual (e.g., sleep satisfaction) and interpersonal (e.g., relationship satisfaction) factors. This study examined spillover and crossover effects between daily general and diabetes-specific stressors and whether sleep satisfaction and relationship satisfaction moderated spillover and crossover effects among couples in which one person had T1D. Persons with T1D (n = 199; Mage = 46.82, 52.3% female) and their romantic partners (n = 199; Mage = 46.41, 47.2% female) reported general stressors and sleep satisfaction, and persons with T1D reported diabetes-specific stressors on 14 consecutive days. Both couple members completed a survey that assessed relationship satisfaction. Multilevel models revealed significant within-person and between-person stress spillover and crossover effects. When examining the moderating role of sleep satisfaction, however, persons with T1D with better sleep satisfaction did not experience spillover between one domain and the other. Furthermore, partners with higher relationship satisfaction did not experience crossover between the persons with T1D-specific stressors and their general stressors. These findings support the conceptualization of the link between general and diabetes-specific stressors as both an intraindividual and a dyadic process among couples coping with T1D. In addition, better sleep satisfaction can prevent spillover effects, and relationship satisfaction can prevent stress crossover effects. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Close relationships and diabetes management across the lifespan: The good, the bad, and autonomy.

Relationships are linked with positive and negative self-management and illness outcomes for individuals with type 1 diabetes. Explanations for these mixed associations have remained separated in psychosocial research in type 1 diabetes by relationship type (e.g. parent vs spouse) and individual's age (e.g. adolescence vs older adulthood). In this conceptual review, we present a novel perspective that close relationships across the lifespan may be beneficial for illness self-management when they support individuals' sense of autonomy, defined from a Basic Psychological Needs perspective. Processes of autonomy support are crucial for promoting illness management across all ages and relationship types.

Shared illness appraisal and self-efficacy among adults with type 1 diabetes.

We examined the interaction between shared illness appraisal and self-efficacy among couples in which one partner was diagnosed with type 1 diabetes (n = 199). We hypothesized that the relation between self-efficacy and health would be weakened under conditions of shared rather than individual appraisal. Multiple regression analyses demonstrated that partner shared illness appraisal interacted with the self-efficacy of the person with type 1 diabetes to predict overall psychological distress and daily diabetes stressors in the predicted direction. Plots of the interactions suggest that partner appraisal of diabetes as shared buffers individuals with lower levels of self-efficacy from poorer health.

Age differences in reactivity to daily general and Type 1 diabetes stressors.

Older adults often report less exposure to and less affective reactions to daily stressors. However, older adults with a chronic illness such as Type 1 diabetes may experience more daily stressors due to the complications of diabetes and may be more affected by those stressors. The study examined (a) age differences in reported exposure to general and diabetes stressors, (b) whether daily general and diabetes stressors relate to daily positive and negative affect, self-care, and blood glucose, and (c) whether these daily associations are moderated by age and comorbidity. Individuals with Type 1 diabetes (n = 199; 52.3% female, average age 46.81 years) completed a checklist for 14 days reporting general and diabetes stressors. General diabetes distress was assessed with the Diabetes Distress Scale. Daily positive and negative affect and daily self-care behaviors were rated each day. Blood glucose was assessed via glucometers. Older adults reported fewer daily general and diabetes stressors and less diabetes distress compared to younger adults. Multilevel models indicated that both daily general and diabetes stressors (between- and within-person) were associated with lower positive and higher negative affect. Fewer diabetes stressors were associated with better self-care and lower (better) mean blood glucose. Neither age nor comorbidity interacted with general or diabetes stressors to predict any outcome (except one effect for comorbidity), indicating that older adults and those experiencing more comorbid conditions were similarly affected by stressors. Results suggest that older adults experience fewer stressors than younger adults but are similarly affected when stressors do occur. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Daily illness appraisal and collaboration in couples with type 1 diabetes.

OBJECTIVE: Dyadic coping theories posit that spousal involvement may benefit illness management through collaborative and supportive (C&S) strategies and shared illness appraisals. Illness appraisals have only been examined as individual differences rather than fluctuating daily as individuals manage the difficult Type 1 diabetes regimen. The study examined how daily illness appraisals of individuals with Type 1 diabetes and their spouses were linked to spouses' daily C&S strategies and whether C&S strategies were most beneficial for daily diabetes outcomes when they occurred in the context of shared illness appraisals. METHOD: Couples (N = 199) in which one person had Type 1 diabetes (M age patients = 46.81; 52.3% female; spouses = 46.40, 47.5% female) completed a 14-day diary assessing illness appraisals (ranging from nonshared through shared) and spouses' C&S strategies. Patients reported daily self-regulation failures, self-care behaviors, and perceived coping effectiveness. Daily blood glucose was gathered from glucometers. RESULTS: Multilevel models indicated both within-person and between-person effects of patients' and spouses' illness appraisals on C&S strategies with higher shared illness appraisals associated with greater C&S strategies. Greater shared illness appraisals were associated with fewer self-regulation failures and better self-care. C&S strategies were associated with lower self-care and higher blood glucose levels. Appraisal interacted with C&S strategies such that C&S strategies were associated with more self-regulation failures, lower self-care, and lower perceived coping effectiveness when patients reported lower shared appraisals. CONCLUSIONS: Results suggest that C&S strategies may be more detrimental for diabetes management when individuals view diabetes as less shared. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

The separation in coordination between social- and self-regulation for emerging adults with type 1 diabetes.

To examine how self-regulation and social-regulation surrounding type 1 diabetes (T1D) management are coordinated during early emerging adulthood and whether classes of coordination relate to HbA1c and executive functioning (EF). Emerging adult participants (N = 212) with T1D (M age = 18.8 years, SD = .40) completed a 14-day diary to capture components of self-regulation and social-regulation. A mixture multi-level latent coordination model first determined the separate but coordinated factor structure of self- and social-regulation, then determined the number of distinct classes of coordination and how those classes linked to HbA1c and EF. The best-fitting model included three coordinative factors (self, mother, and father) of regulation and two distinct classes. The class with lower HbA1c and higher EF had more stable self- and social-regulation, more connections between self- and social-regulation and reflected more adaptive patterns, consistent with medical management goals. Social connection with parents may aid in regulation during this at-risk transitional time of emerging adulthood.

Yours, Mine, and Ours: A Qualitative Analysis of the Impact of Type 1 Diabetes Management in Older Adult Married Couples.

OBJECTIVE: The purpose of this study was to understand perceptions of diabetes management responsibilities and the impact of diabetes on day-to-day activities in older adulthood for individuals with type 1 diabetes and their spouses. DESIGN AND METHODS: This qualitative content analysis used a constant-compare approach to analyze individual interviews conducted with older adults and their spouses. People with type 1 diabetes (PWD) and their spouses were interviewed regarding how they coped or dealt with diabetes, what activities they carried out or avoided because of diabetes, and how they appraised diabetes as an individual or shared problem. RESULTS: Participants (n = 52) included 26 older adults with diabetes (mean age 69 years, SD 2.56 years; 38.5% female) and their spouses (mean age 68 years, SD 5.11 years; 61.5% female). Half of the PWD (50%) and the majority of spouses (76.9%) appraised diabetes as a shared issue. Five themes emerged from the interview data: 1) Perceptions pf PWD of spouse involvement in diabetes care, 2) PWD underestimated the impact of diabetes on their spouse's daily lives, 3) gendered nature of spouses supporting diabetes management, 4) evolution of diabetes and the relationship across developmental time, and 5) differences in diabetes management among couples. CONCLUSION: Older adults with type 1 diabetes and their spouses have different perspectives regarding diabetes support and responsibility and may not always realize what support is being provided or needed to optimize effective diabetes management. Advancing age with or without diabetes complications may necessitate that spouses provide diabetes support. Diabetes management training for spouses would likely be helpful.

Keeping parents connected in early emerging adulthood: Diabetes-related disclosure and solicitation.

Emerging adults with Type 1 diabetes benefit when parents remain knowledgeable of their self-management. Yet how early emerging adults remain connected with parents while they experience normative declines in involvement and move out of the parental home is unclear. The present study examined how disclosure to, and solicitation from, parents may (a) be a way that emerging adults and parents remain connected, (b) occur with different methods of contact (i.e., face-to-face; non-face-to-face), and (c) associate with diabetes management differently for those living in versus outside of the parental home. Early emerging adults with Type 1 diabetes (N = 202; Mage = 18.81 years; 66% female) completed measures of their methods of contact with parents; diabetes-related disclosure to, and solicitation from, parents; and diabetes management as part of a 14-day daily diary. General linear models found that face-to-face contact was associated with greater disclosure to parents, for both those living in and out of the parental home. Individuals who lived outside the parental home used more non-face-to-face contact (e.g., texting) than those in the parental home. Multilevel models revealed that higher disclosure to mothers on a daily basis (within-persons) and to mothers and fathers overall (between-persons) was associated with better diabetes management similarly for those living in versus out of the parental home. Results suggest that face-to-face contact may be most effective for keeping parents "in the know" about diabetes management. Moreover, disclosure and solicitation continue to support diabetes management even as individuals move out of the parental home. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Parental Involvement and Executive Function in Emerging Adults with Type 1 Diabetes.

OBJECTIVE: To examine (a) changes in parental involvement across early emerging adulthood, (b) whether yearly fluctuations in parental involvement were associated with adherence and glycated hemoglobin (HbA1c) over time, and (c) whether higher involvement was more beneficial for those with poorer executive function (EF). METHODS: A total of 228 high school seniors (M age = 17.76) with type 1 diabetes reported on mothers' and fathers' acceptance, knowledge of diabetes activities, disclosure to mothers and fathers regarding diabetes, and adherence at four yearly time points. At baseline, participants completed performance-based measures of EF. HbA1c was collected from assay kits. RESULTS: Growth curve models revealed significant declines in disclosure to fathers and mothers' and fathers' knowledge of diabetes activities; no changes were found in mothers' or fathers' acceptance nor disclosure to mothers. Multilevel models indicated significant between-person effects for nearly all aspects of parental involvement with more acceptance, knowledge, and disclosure associated with better HbA1c and adherence. Within-person effects for disclosure to fathers, and mothers' and fathers' knowledge indicated that in years when emerging adults perceived higher amounts of these types of involvement (compared with their own average), HbA1c was lower. Within-person effects were found for acceptance to mothers, disclosure to mothers and fathers, and mothers' diabetes knowledge for adherence. Disclosure to fathers and mothers' knowledge of diabetes activities were especially beneficial for HbA1c for those with poorer EF performance. CONCLUSIONS: Parental involvement in diabetes management remains important during the high-risk time of emerging adulthood, especially for those with poorer EF.

Structural model of patient-centered communication and diabetes management in early emerging adults at the transfer to adult care.

Early emerging adulthood (ages 18-25) is a time of risk for type 1 diabetes (T1D) when relationships with parents and providers are changing. We examined whether individuals' high-quality relationships with mothers are associated with greater perceptions of patient-centered communication (PCC) with their doctor and whether PCC is associated with better adherence and glycemic control through diabetes-related self-efficacy. Additionally, we tested whether associations of PCC with self-efficacy and diabetes outcomes are stronger among those who had transferred to adult care. One-year post-high school, 217 individuals with T1D (60% women, 53% in adult care) reported perceptions of maternal relationship quality, PCC, self-efficacy, and adherence. Glycemic control was measured via HbA1c assay kits. Structural equation modeling indicated good model fit and revealed indirect paths linking higher maternal relationship quality to better adherence through higher PCC, and higher PCC to better HbA1c through adherence. Transfer status moderated the link between PCC and self-efficacy, suggesting PCC may be especially important when emerging adults transfer to adult care.

Patient and partner illness appraisals and health among adults with type 1 diabetes.

In a study of 199 couples in which one person had type 1 diabetes, we examined how patient appraisal of the diabetes as shared versus individual was associated with collaborative, supportive and unsupportive behavior and whether patient shared illness appraisal was most beneficial for health when it occurred in the context of supportive behavior. We assessed illness appraisal among patients with type 1 diabetes and their partners and had patients complete relationship and health measures. Results showed partners were more likely than patients to hold shared illness appraisals. Patients' shared appraisals were associated with more collaborative and instrumental support, more emotional support, less protective buffering, and more overprotective behavior. When patients and partners were consistent in their shared appraisals, support was highest. Regression analysis showed collaborative and instrumental support, as well as emotional support, was related to better psychological and physical health when patients held shared compared to individual illness appraisals.

Daily sleep quality and daily stressors in couples coping with type 1 diabetes.

OBJECTIVE: To examine the influence of daily sleep quality in patients with Type 1 diabetes (T1D) on that of their spouses and to investigate the influence of couples' sleep quality on patients' diabetes-specific stressors and couples' general stressors the following day. METHODS: 199 patients with Type 1 diabetes (Mage = 46.82) and their spouses (Mage = 46.41) completed a 14-day diary where they reported on their own sleep quality, and the presence of general stressors. Patients reported the presence of diabetes-specific stressors. Multilevel modeling examined the effects of daily variability in (within-person effects) and average levels of (between-person effects) sleep quality on the number of next-day diabetes-specific stressors (controlling for prior day stressors). Furthermore, the actor-partner interdependence model was used to examine the effect of sleep quality on general stressors. RESULTS: Greater patients' daily sleep quality was related to their spouses' greater sleep quality. Increases in the patients' own daily- and average sleep quality were uniquely associated with fewer next day diabetes-specific stressors. Better own daily- and average sleep quality were associated with fewer general stressors for both partners. Spouses' increased daily sleep quality was associated with fewer general stressors of patients. CONCLUSIONS: The results support that sleep quality is a dyadic phenomenon among couples and suggest that better sleep quality may buffer diabetes specific and general stress in couples coping with T1D. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Self- and Social-Regulation in Type 1 Diabetes Management During Late Adolescence and Emerging Adulthood.

PURPOSE OF REVIEW: This paper aims to examine how self-regulation (i.e., cognition, emotion) and social-regulation (i.e., parents, friends, romantic partners) are interrelated risk and protective factors for type 1 diabetes management during late adolescence and emerging adulthood. RECENT FINDINGS: Problems in cognitive (e.g., executive function) and emotional (e.g., depressive symptoms) self-regulation are associated with poorer management, both at the between- and within-person levels. Better management occurs when parents are supportive and when individuals actively regulate the involvement of others (e.g., seek help, minimize interference). Friends both help and hinder self-regulation, while research on romantic partners is limited. Facets of self- and social-regulation are important risk and protective factors for diabetes management during emerging adulthood. At this time when relationships are changing, the social context of diabetes may need to be regulated to support diabetes management. Interventions targeting those with self-regulation problems and facilitating self- and social-regulation in daily life may be useful.

Relationships and the development of transition readiness skills into early emerging adulthood for individuals with type 1 diabetes.

The study examined how 'transition readiness' skills develop from relationship processes with parents, friends, and healthcare providers. During their senior year of high school and one year later, participants (N = 217) with type 1 diabetes completed measures of transition readiness skills (Self-Management; Self-Advocacy), adherence, HbA1c, and relationships with providers (patient-centered communication), parents (monitoring/knowledge), and friends (knowledge/helpfulness) surrounding diabetes. Self-Management skills increased across time. Higher friend knowledge/helpfulness during emerging adulthood was associated with increased Self-Management skills. Adherence improved when relationships with providers and friends matched transition readiness skills, indicating that these relationships may facilitate transition skills in early emerging adulthood.

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).

Brief report: Benefit finding and identity processes in type 1 diabetes: Prospective associations throughout adolescence.

Identity formation constitutes a core developmental task during adolescence, but may be challenged when having a chronic illness such as type 1 diabetes. The present study examined whether viewing positive benefits to one's diabetes across adolescence was related to greater identity exploration and commitment later in time. A total of 55 adolescents (10-14 years; 47% female) with type 1 diabetes participated in a six-wave study spanning 3 years (with six-month measurement intervals). Through latent growth curve modeling, Time 6 identity scores were regressed on intercept and slope terms of benefit finding through Times 1-4, simultaneously controlling for demographic and clinical variables. Identity exploration (but not commitment) at Time 6 was positively predicted by the intercept and slope of benefit finding: adolescents who find benefits in diabetes are more inclined to explore different alternatives later on in adolescence. Benefit finding may constitute a resource facilitating identity formation in adolescents with diabetes.