Effects of Macronutrient Intake and Number of Meals on Glycemic Outcomes Over 1 Year in Youth with Type 1 Diabetes.

Objective: Insulin bolus doses derive from glucose levels and planned carbohydrate intake, although fat and protein impact glycemic excursions. We examined the impact of macronutrients and number of daily meals/snacks on glycemic outcomes in youth with type 1 diabetes. Methods: Youth (N = 136, ages 8-17) with type 1 diabetes completed 3-day food records, wore 3-day masked continuous glucose monitoring, and had A1c measurements every 3 months for 1 year. Diet data were analyzed using Nutrition Data System for Research. Longitudinal mixed models assessed effects of macronutrient intake and number of meals/snacks on glycemic outcomes. Results: At baseline, youth (48% male) had mean age of 12.8 ± 2.5 years and diabetes duration of 5.9 ± 3.1 years; 73% used insulin pumps. Baseline A1c was 8.1% ± 1.0%, percent time in range 70-180 mg/dL (%TIR) was 49% ± 17%, % time below range <70 mg/dL (%TBR) was 6% ± 8%, % time above range >180 mg/dL (%TAR) was 44% ± 20%, and glycemic variability as coefficient of variation (CV) was 41% ± 8%; macronutrient intake included 48% ± 5% carbohydrate, 36% ± 5% fat, and 16% ± 2% protein. Most youth (56%) reported 3-4 meals/snacks daily (range 1-9). Over 1 year, greater carbohydrate intake was associated with lower A1c (P = 0.0003), more %TBR (P = 0.0006), less %TAR (P = 0.002), and higher CV (P = 0.03). Greater fat intake was associated with higher A1c (P = 0.006), less %TBR (P = 0.002), and more %TAR (P = 0.005). Greater protein intake was associated with higher A1c (P = 0.01). More daily meals/snacks were associated with lower A1c (P = 0.001), higher %TIR (P = 0.0006), and less %TAR (P = 0.0001). Conclusions: Both fat and protein impact glycemic outcomes. Future automated insulin delivery systems should consider all macronutrients for timely insulin provision. The present research study derived from secondary analysis of the study registered under NCT00999375.

School Nurses' Comfort With Diabetes Management and Technology From 2012 to 2019.

Objective: School nurses are integral to optimizing diabetes management for students with type 1 diabetes. The aim of this study was to describe the use of diabetes technology in schools over time and assess school nurses' comfort level performing diabetes management tasks. Study design: From 2012 to 2019, school nurses who attended a diabetes education program completed a survey about their experience and comfort level with diabetes management. Results: A total of 1,796 school nurses completed the survey; 56% had at least 5 years of school nursing experience. Most (86%) had at least one student with type 1 diabetes. Among school nurses with at least one student with type 1 diabetes, 73% had at least one student using insulin pump therapy, and 48% had at least one student using continuous glucose monitoring (CGM). There was no change in pump use over time, but the percentage of nurses who had a student using CGM increased significantly from 24% in 2012 to 86% in 2019 (P <0.001). School nurses' comfort level using pumps remained stable over time. Overall, 47% reported being mostly/very comfortable giving boluses using a pump, and 17% reported being mostly/very comfortable troubleshooting problems with a pump. However, there was a significant increase in school nurses reporting feeling mostly/very comfortable working with CGM devices, increasing from 9% in 2012 to 44% in 2019 (P <0.001). Conclusion: School nurses are an important part of diabetes management for school-aged youth with type 1 diabetes. There is a need for additional diabetes education and support to build their confidence with diabetes management and technology, especially with further technological advancements in management.

Updated Psychosocial Surveys With Continuous Glucose Monitoring Items for Youth With Type 1 Diabetes and Their Caregivers.

AIM: We added items relevant to continuous glucose monitoring (CGM) to the Diabetes Family Conflict Scale (DFC), Diabetes Family Responsibility Questionnaire (DFR), and Blood Glucose Monitoring Communication Questionnaire (GMC) and evaluated the psychometric properties of the updated surveys. RESEARCH DESIGN AND METHODS: Youth with type 1 diabetes who recently started CGM and their parents completed the updated surveys and additional psychosocial surveys. Medical data were collected from self-reports and review of the medical record. RESULTS: Youth (N = 114, 49% adolescent girls) were aged 13.3 ± 2.7 years and had mean glycated hemoglobin (HbA1c) 7.9 ± 0.9%; 87% of them used pump therapy. The updated surveys demonstrated high internal consistency (DFC youth: α = .91, parent: α = .81; DFR youth: α = .88, parent: α = .93; and GMC youth: α = .88, parent: α = .86). Higher youth and parent DFC scores (more diabetes-specific family conflict) and GMC scores (more negative affect related to glucose monitoring) were associated with more youth and parent depressive symptoms (r = 0.28-0.60, P ≤ .003), more diabetes burden (r = 0.31-0.71, P ≤ .0009), more state anxiety (r = 0.24 to r = 0.46, P ≤ .01), and lower youth quality of life (r = -0.29 to -0.50, P ≤ .002). Higher youth and parent DFR scores (more parent involvement in diabetes management) were associated with younger youth age (youth: r = -0.76, P < .0001; parent: r = -0.81, P < .0001) and more frequent blood glucose monitoring (youth: r = 0.27, P = .003; parent: r = 0.35, P = .0002). CONCLUSIONS: The updated DFC, DFR, and GMC surveys maintain good psychometric properties. The addition of CGM items expands the relevance of these surveys for youth with type 1 diabetes who are using CGM and other diabetes technologies.

Associations of Executive Function With Diabetes Management and Glycemic Control in Adolescents With Type 1 Diabetes.

Aims: The aims of this study were to assess domains of executive function in relation to diabetes management and glycemic control in adolescents with type 1 diabetes and to compare adolescent self-report and parent proxy-report of adolescent executive function. Methods: Adolescents with type 1 diabetes (N = 169, 46% female, age 15.9 ± 1.3 years) and their parents completed self-report and parent proxy-report versions of the Behavior Rating Inventory of Executive Function (BRIEF). Results: Self-report and parent proxy-report BRIEF T scores were moderately to strongly correlated; parent proxy scores were significantly higher than self-report scores. Executive function problems (Global Executive Composite T score ≥60) occurred in 9% of adolescents by self-report and 26% by parent proxy-report. For almost all Metacognition Index scales, elevated (T score ≥60) parent proxy scores were associated with lower adherence, lower adolescent diabetes self-efficacy, and more parent involvement in diabetes management. Elevated scores on several Metacognition Index scales were associated with less pump use (Plan/Organize by self-report, Initiate by parent proxy-report, and Monitor by parent proxy-report) and higher A1C (Plan/Organize by self-report and parent proxy-report and Organization of Materials by parent proxy-report). The only significant associations for the Behavioral Regulation Index scales occurred for adherence (by parent proxy-report) and diabetes self-efficacy (by self-report and parent-report). Conclusion: Adolescents with type 1 diabetes who have problems with metacognition may need additional support for diabetes self-management.

Observed Characteristics Associated with Diabetes Device Use Among Teens with Type 1 Diabetes.

BACKGROUND: Despite advancements in diabetes technologies, disparities remain with respect to diabetes device use in youth with type 1 diabetes (T1D). We compared sociodemographic, diabetes, and psychosocial characteristics associated with device (pump and continuous glucose monitor [CGM]) use in 13- to 17-year-old teens with T1D. MATERIALS/METHODS: Data were derived from a multicenter clinical trial to optimize self-care and glycemic control in teens with T1D. We categorized teens as pump users versus non-users and CGM users versus non-users based on their diabetes device usage. Chi-square and t-tests compared characteristics according to device use. RESULTS: The sample comprised 301 teens (50% female) with baseline mean ± SD age 15.0 ± 1.3 years, T1D duration 6.5 ± 3.7 years, and HbA1c 8.5 ± 1.1% (69 ± 12 mmol/mol). Two-thirds (65%) were pump users, and 27% were CGM users. Pump users and CGM users (vs. non-users) were more likely to have a family annual household income ≥$150,000, private health insurance, and a parent with a college education (all P < .001). Pump users and CGM users (vs. non-users) also performed more frequent daily blood glucose (BG) checks (both P < .001) and reported more diabetes self-care behaviors (both P < .05). Pump users were less likely to have baseline HbA1c ≥9% (75 mmol/mol) (P = .005) and to report fewer depressive symptoms (P = .02) than pump non-users. Parents of both CGM and pump users reported a higher quality of life in their youth (P < .05). CONCLUSION: There were many sociodemographic, diabetes-specific, and psychosocial factors associated with device use. Modifiable factors can serve as the target for clinical interventions; youth with non-modifiable factors can receive extra support to overcome potential barriers to device use.

Ecological Momentary Assessment of Positive and Negative Affect and Associations with Blood Glucose in Teens with Type 1 Diabetes.

BACKGROUND: Affect (i.e., emotions) can be associated with diabetes self-care and ambient glucose in teens with type 1 diabetes (T1D). We used momentary sampling to examine associations of daily affectwithblood glucose (BG) monitoring,BG levels,and BG variability in teens with T1D. METHOD: Over 2 weeks, 32 teens reported positive and negative affect (Positive and Negative Affect Scale) and BG levels on handheld computers 4x/day, coordinated with planned daily BG checks. BG values were classified as: in-range (70-180 mg/dL); low (<70 mg/dL); severe low (<54 mg/dL); high (>180 mg/dL); severe high (>250 mg/dL). Daily BG variability was derived from BG coefficient of variation (BGCV). To determine associations of positive and negative affect with BG checks, BG levels, and BGCV, separate generalized estimating equations were performed, adjusting for demographic and diabetes-related variables, for the overall sample and stratified by HbA1c (≤8%, >8%). RESULTS: Teens (44% male, ages 14-18, 63% pump-treated, HbA1c 8.8 ± 1.4%) reported 51% in-range, 6% low (2% severe low), and 44% high (19% severe high) BG. In teens with HbA1c ≤8%, positive affect was associated with in-range BG (OR = 1.08, 95% CI = 1.04-1.13, P = .0002), reduced odds of very low glucose (OR = 0.35, 95% CI = 0.16-0.74, P = .006), and less daily BGCV (ß = -0.9; 95% CI = -1.6, -0.2; P = .01). In teens with HbA1c >8%, negative affect was associated with less likelihood of checking BG (OR = 0.75, 95% CI = 0.64-0.87, P = .0003). CONCLUSIONS: Our findings shed light on individual differences in metabolic reactivity based on glycemic levels and the importance of incorporating affect into automated insulin delivery systems.

Assessing Incorporation of Type 1 Diabetes Into Identity: Validation of the Accepting Diabetes and Personal Treatment (ADAPT) Survey in Teens and Young Adults.

OBJECTIVES: Teens and young adults with type 1 diabetes (T1D) often demonstrate difficulty with diabetes management, as they struggle to navigate the impact of T1D on their identities---their self-concepts, bodies, social networks, life experiences and desired futures. Positively incorporating T1D into identity may benefit biomedical and psychosocial outcomes. We aimed to validate and assess psychometric properties of the Accepting Diabetes and Personal Treatment (ADAPT) survey, a new measure of incorporation of T1D into one's identity. METHODS: This cross-sectional study included 165 teens and young adults (13 to 25 years of age) with T1D (46% male, 87% Caucasian, 72% pump users, 67% on continuous glucose monitoring [CGM], age 18.5±3.2 years, diabetes duration 10.2±5.0 years, glycated hemoglobin [A1C] 8.5±1.3% [69±14 mmol/mol]). A1C was collected from medical records; participants completed the ADAPT survey and validated measures of fear of hypoglycemia, diabetes distress and quality of life. Internal consistency, reliability, validity and underlying factor structure were assessed. RESULTS: The 18-item ADAPT survey demonstrated excellent internal consistency (alpha=0.90) as well as criterion and construct validity. Greater incorporation of diabetes was associated with male sex, pump use, CGM use, lower A1C, less fear of hypoglycemia, less diabetes distress and improved quality of life (p<0.01 for all). Factor analysis identified 3 main contributors to incorporation: Stigma Management, Adjustment to Perceived Interference and Benefit-finding. CONCLUSIONS: The ADAPT survey is a valid and reliable measure of incorporation in teens and young adults with T1D that highlights the importance of identity in health outcomes. Diabetes device use and factors of incorporation (Stigma Management, Adjustment to Perceived Interference and Benefit-finding) offer targets for clinical intervention.

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

Background: There is gradual acquisition of type 1 diabetes self-care responsibility across childhood as youth mature and gain more independence from their family. Understanding the timing of diabetes self-care by youth can guide the tailoring of diabetes education and support programs. Objective: To investigate parent-perceived responsibility for diabetes self-care tasks across childhood. Methods: Parents/guardians of youth (ages 5-18 years) with type 1 diabetes reported parent involvement in diabetes management using the Diabetes Family Responsibility Questionnaire. Survey items were divided items into five domains: nutrition, monitoring, insulin dosing, communication, and health surveillance. Age-groups for analyses were 5-10 years (elementary school), 11-14 years (early adolescence), and 15-18 years (late adolescence). Demographic, diabetes management, and A1C data were collected at the time of survey completion. Results: Youth (n = 148, 50% male) were a mean age of 12.9 ± 3.3 years, with a mean type 1 diabetes duration of 6.2 ± 3.6 years; 66% used insulin pump therapy, and the mean A1C was 8.4 ± 1.3%. Of the parents (84% mothers, 91% White), 83% were married, and 52% were college educated. Per parent report, less parental involvement was associated with older youth age (P <0.001). Across all age-groups, more overall parental involvement was related to lower A1C (P = 0.02). Youth self-care in the nutrition domain began in elementary school, whereas self-care in monitoring and insulin dosing began in early adolescence, and self-care with regard to communication started in late adolescence. Responsibility for health surveillance remained mainly under parent care throughout childhood and adolescence. Conclusion: Providing education and support for youth during their acquisition of self-care tasks, especially those relating to nutrition, monitoring, and insulin dosing, may help to prevent glycemic deterioration later in childhood and adolescence.

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

PURPOSE: The COVID-19 pandemic led to rapid adoption of telemedicine for the care of youth with type 1 diabetes (T1D). We assessed the utility of a primarily virtual care model by comparing glucometrics from a pediatric sample with T1D using continuous glucose monitoring (CGM) both before and during the pandemic. METHODS: Pediatric patients aged 1 to 17 years with T1D duration ≥ 1 year if ≥ 6 years old or ≥ 6 months if < 6 years old, with ≥ 1 visit with recorded CGM data both prepandemic (April 1, 2019-March 15, 2020) and during the pandemic (April 1, 2020-March 15, 2021) were included. Data were extracted from the electronic health record. RESULTS: Our sample comprised 555 young people (46% male, 87% White, 79% pump-treated), mean age 12.3 ±â€…3.4 years, T1D duration 5.9 ±â€…3.5 years, baseline glycated hemoglobin A1c 8.0 ±â€…1.0% (64 ±â€…10.9 mmol/mol). Diabetes visit frequency increased from 3.8 ±â€…1.7 visits/prepandemic period to 4.3 ±â€…2.2 visits/pandemic period (P < 0.001); during pandemic period, 92% of visits were virtual. Glucose management indicator (GMI) improved slightly from 7.9% (63 mmol/mol) prepandemic to 7.8% (62 mmol/mol) during the pandemic (P < 0.001). Those with equal or greater visit frequency (n = 437 [79% of sample]) had significant improvement in GMI (8.0% to 7.8% [64 to 62 mmol/mol], P < 0.001), whereas those with lower visit frequency did not (7.8 [62 mmol/mol], P = 0.86). CONCLUSIONS: Children and adolescents with T1D using CGM before and during the pandemic showed an overall increase in visit frequency using primarily telemedicine-based care and improved CGM glucometrics. Further research is needed to understand factors associated with successful use of telemedicine for pediatric T1D.

Improvement in Mean CGM Glucose in Young People with Type 1 Diabetes During 1 Year of the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic likely affected youth with type 1 diabetes (T1D). We used electronic health record-extracted data to compare continuous glucose monitoring (CGM) metrics during 1 year of the pandemic with those of the previous year. The sample comprised CGM users, aged 1 to <18 years, with T1D duration ≥6 months (age <6 years) or ≥1 year (age ≥6 years). The prepandemic sample comprised 641 youth (52% female, aged 12.3 ± 3.5, T1D duration 6.0 ± 3.5 years). The pandemic sample comprised 648 youth (52% female, age 13.3 ± 3.5, duration 6.7 ± 3.8 years), with care delivered primarily through telemedicine. Mean CGM glucose was 6.3 mg/dL lower during the pandemic (187.3 ± 35.6) versus prepandemic (193.6 ± 33.0) (P < 0.001). A higher percentage of youth achieved glucose management indicator <7% during the pandemic than the prior year (P < 0.001). Lower CGM glucose values were observed during the COVID-19 pandemic. Future studies are needed to assess how changes in health care delivery, including telemedicine, and lifestyle during this time may have supported this improvement.

Association of executive function problems and disordered eating behaviours in teens with type 1 diabetes.

AIM: To explore cross-sectional associations between executive function problems and disordered eating behaviours in teens with type 1 diabetes. METHODS: Executive function was assessed by the Behavior Rating Inventory of Executive Function (BRIEF), self-report and parent proxy-report versions. Scores ≥60 (on Global Executive Composite, Behavioral Regulation Index, Metacognition Index or clinical scales) indicated problems with executive function. Disordered eating behaviour was assessed by the Diabetes Eating Problem Survey Revised (DEPS-R) and categorized as follows: <10 low, 10-19 moderate and ≥20 high. RESULTS: In the 169 teens (46% girls, median age 16.0 years [range 13.7-18.7], median diabetes duration 8.9 years [range 1.4-16.6]), 29% had moderate and 12% had high level of disordered eating behaviours. Executive function problems were present in 9% by self report and 26% by parent proxy-report. Among teens with moderate/high level of disordered eating behaviours, 19% had executive function problems by self report (vs. 2% of teens with low level of disordered eating behaviours, p < 0.001) and 33% had executive function problems by parent proxy-report (vs. 20% of teens with low level of disordered eating behaviours, p = 0.056). A greater level of disordered eating behaviours was associated with executive function problems by teen self report on the General Executive Composite (p < 0.001), Behavioral Regulation Index (p < 0.001), emotional control clinical scale (p < 0.001), shift clinical scale (p < 0.001) and by parent proxy-report on the task initiation clinical scale (p = 0.008). CONCLUSIONS: Assessing executive function and screening for disordered eating behaviours in teens with type 1 diabetes could help identify a subset of teens at high risk for adverse outcomes and need for intervention.

Youth and parent preferences for an ideal AP system: It is all about reducing burden.

BACKGROUND: As new diabetes technologies improve to better manage glucose levels, users' priorities for future technologies may shift to prioritize burden reduction and ease of use. We used qualitative methods to explore youth and parent desired features of an "ideal" artificial pancreas (AP) system. METHODS: We conducted semi-structured interviews with 39 youth, ages 10-25 years, and 44 parents. Interviews were audio-recorded, transcribed, and coded using thematic analysis. RESULTS: Youth (79% female, 82% non-Hispanic white) were (M ± SD) ages 17.0 ± 4.7 years, with diabetes for 9.4 ± 4.9 years, and HbA1c of 8.4 ± 1.1%; 79% were pump-treated and 82% used CGM. Of parents, 91% were mothers and 86% were non-Hispanic white. Participants suggested various ways in which an ideal AP system could reduce physical and emotional burdens of diabetes. Physical burdens could be reduced by lessening user responsibilities to manage glucose for food and exercise, and wear or carry devices. Emotional burden could be reduced by mitigating negative emotional reactions to sound and frequency of alerts, while increasing feelings of normalcy. Youth and parents differed in their suggestions to reduce emotional burden. Participants suggested features that would improve glycemia, but nearly always in the context of how the feature would directly reduce their diabetes-specific burden. CONCLUSIONS: Although participants expressed interest in improving glucose levels, the pervasive desire among suggested features of an ideal AP system was to minimize the burden of diabetes. Understanding and addressing users' priorities to reduce physical and emotional burden will be necessary to enhance uptake and maintain use of future AP systems.

Health-related quality of life in youth with type 1 diabetes: Associations with multiple comorbidities and mental health conditions.

AIM: This cross-sectional study examined the associations of comorbid conditions on health-related quality of life (HRQOL) in 601 youth with type 1 diabetes. We evaluated associations between number of comorbid conditions (0, 1, ≥2) and particular comorbid conditions and youth HRQOL by self-report and parent proxy-report. RESEARCH DESIGN AND METHODS: Youth with type 1 diabetes, aged 5-18 years, and their parents completed the PedsQL 4.0 Generic Core Scales self-report and parent proxy-report, respectively; they also reported youths' comorbid medical and mental health conditions. Separate linear regression models tested the relationship between number of comorbid conditions and specific comorbid conditions with youth-reported and parent proxy-reported HRQOL. RESULTS: Youth with ≥2 comorbid conditions had significantly lower HRQOL by both self- and parent proxy-reports compared with youth with 0 or 1 comorbid condition (youth self-report: 0: 85 ± 12, 1: 85 ± 13, 2+: 78 ± 16, p = <0.0001; parent proxy-report: 0: 83 ± 12, 1: 81 ± 13, 2+: 74 ± 15, p = <0.0001). Amongst the comorbid conditions, only a mental health comorbidity was associated with lower HRQOL. For youth and parent proxy-reports, both the number of comorbidities (≥2) and the presence of a mental health comorbidity were significantly associated with lower HRQOL. CONCLUSIONS: Health-related quality of life seems to be preserved in youth with type 1 diabetes unless confronted by multiple comorbidities as reported by youth and their parents. Our findings highlight the importance of tracking the presence of multiple comorbid conditions, possibly by reviewing problem and medication lists in the medical record, as well as screening for and addressing mental health conditions in routine diabetes care.

Blood glucose monitoring (BGM) still matters for many: Associations of BGM frequency and glycemic control in youth with type 1 diabetes.

AIMS: This study aimed to compare three approaches of blood glucose monitoring (BGM) frequency attainment and to examine their associations with glycemic control in youth with type 1 diabetes (T1D). METHODS: Cross-sectional data was derived from the baseline assessment in three clinical trials. Clinical and demographic characteristics of youth with T1D was obtained by chart review. BGM frequency was assessed by parent-youth interview, chart review, and meter downloads. To examine the relationship between A1c and frequency of BGM we performed analysis of variance. RESULTS: In youth with T1D (N = 385, 50% female, age 13.6 ± 2.5 years, 74% pump users), the 3 methods of assessing BGM frequency were significantly correlated. Frequency by self-report (6.4 ± 2.3 times/day) was significantly higher than both meter download (5.6 ± 2.4 times/day, p < 0.0001) and clinician report (5.7 ± 2.4 times/day, p < 0.0001). For all methods, more frequent BGM was associated with lower A1c and lower mean glucose (p < 0.0001). For each additional daily blood glucose check, there was a 0.2% decrease in A1c (p < 0.0001). CONCLUSION: BGM remains a potent predictor of glycemic control, warranting continued targeting in clinical efforts to improve glycemic management in youth with T1D.

Associations of diabetes self-management characteristics, HbA1c, and psychosocial outcomes with depressive symptoms in a contemporary sample of adolescents with type 1 diabetes.

AIMS: We sought to examine the associations between diabetes self-management, HbA1c, and psychosocial outcomes with the frequency of depressive symptoms. METHODS: We surveyed 301 teens (50% male, 22% non-white), mean age of 15.0±1.3 years, diabetes duration of 6.5±3.7 years. Biomedical variables: daily frequency of blood glucose monitoring of 4.5±1.9, 63% insulin pump use, mean HbA1c 8.5±1.1% (69±12 mmol/mol); 15% of the sample achieved the target HbA1c of <7.5% (<58 mmol/mol). RESULTS: Nearly 1 in 5 (18%, n=54) adolescents reported significant depressive symptoms and, of those participants, slightly under half reported moderate/severe depressive symptoms. Teens with moderate/severe depressive symptoms (CES-D scores ≥24) were more likely to be female, have parents without a college education, and not utilize insulin pumps. Teens with more depressive symptoms reported higher diabetes family conflict, higher diabetes burden, and lower quality of life. In the group reporting no depressive symptoms (10%), scores on psychosocial variables and diabetes treatment variables were the most favorable. CONCLUSION: In our sample, the presence of depressive symptoms appears to relate to both diabetes treatment and quality of life. In addition, studying teens without depressive symptoms can help us learn more about protective factors that potentially buffer against depressive symptoms and that are associated with better outcomes.

Executive dysfunction is associated with poorer health-related quality of life in adolescents with type 1 diabetes: differences by sex.

PURPOSE: Type 1 diabetes (T1D) is one of the most complex and demanding chronic diseases in adolescents. Given the detrimental impact of problems with executive function (EF; the ability to initiate, plan, and monitor behavior) on health outcomes in adolescents with T1D, most studies have examined common diabetes-specific outcomes related to self-management and glycemic control. This study aims to investigate the impact of executive dysfunction on health-related quality of life (HRQoL; an individual's perceived impact of illness and treatment on daily functioning) in adolescents with T1D from a multi-informant perspective. METHODS: In this cross-sectional study, 169 adolescents (mean ± SD age 15.9 ± 1.3 years) and their parents reported on adolescent EF and HRQoL (assessed by the BRIEF and PedsQL, respectively). Parent-youth interview and chart review provided demographic and clinical characteristics. Statistical analyses encompassed bivariate correlations, t-tests, chi-squared tests, and multivariable analyses. RESULTS: Adolescent self-reports and parent proxy-reports identified 13% and 32% of adolescents, respectively, as having executive dysfunction. Poorer adolescent EF was associated with poorer adolescent HRQoL by both adolescent self-report and parent proxy-report, respectively. In significant multivariable models, adjusted for adolescent age, sex, diabetes duration, and glycemic control, 21% and 24% of the variance in adolescent self-reported and parent proxy-reported HRQoL were explained by adolescent self-reported and parent proxy-reported executive dysfunction. A significant interaction of sex with adolescent self-report of executive dysfunction indicated that executive dysfunction had a greater negative impact on HRQoL in females than males (p < .01). CONCLUSIONS: Findings suggest that the impact of EF problems in adolescents with T1D goes beyond diabetes-specific outcomes and focuses attention on the need to evaluate and preserve HRQoL.

Mental Health Providers' Assessment of Parents' Reactions to their Children's Elevated Depressive Symptoms.

This study assessed parental reactions to the report of elevated depressive symptoms in a sample of 29 youth with type 1 diabetes (ages 8-17 years; 48% female) who scored ≥15 on the Center for Epidemiologic Studies Depression Scale for Children (CES-DC). We also assessed parental depressive symptoms and how the presence of such symptoms was linked to parental reactions to the report of a positive screening score in their children and subsequent acceptance of a mental health referral. Mental health professionals contacted parents to discuss elevated scores and offer a mental health referral. Two coders reviewed the documentation of phone contacts made by mental health professionals and categorized parental responses to their child's elevated CES-DC score and the disposition plan. Youth and parent depressive symptoms were modestly correlated (r = 0.21, P = .01). About half (55%, 16/29) of parents were unaware of their child's depressive symptoms. Only 14% (4/29) of youth were already receiving mental health care while 28% (8/29) of parents accepted a referral. Parents with depressive symptoms were frequently unaware of their child's symptoms. Findings provide insight into parental reactions to learning of their child's depressive symptoms and highlight the need for more research on parental mood and reactions to their child's positive screen for depressive symptoms, as a potential barrier to mental health referral acceptance.

Therapeutic play to teach children with type 1 diabetes insulin self-injection: A pilot trial in a developing country.

PURPOSE: Child participation in type 1 diabetes (T1D) self-care is needed in developing countries due to a lack of resources, especially during the school day. This pilot study evaluated the feasibility of a therapeutic play intervention (ITP) versus standard education (SE) on the ability of children with T1D to correctly perform insulin injection technique. DESIGN AND METHODS: Children with T1D (7-12 years) were recruited at two diabetes clinics in Brazil and randomized to ITP or SE. Registered nurses received protocol training to deliver the intervention and perform data collection. ITP group received an education that included a story about a child with T1D who self-injects insulin at school; SE group received routine clinic-based education. Preintervention, children were video-recorded giving insulin injections to a doll; postintervention, children were rerecorded giving the doll an injection. The research team reviewed the videos and assessed the injection technique using validated checklists. Parents reported children's self-injection practices at baseline and 30 days. RESULTS: Children (N = 20, 40% male) were 9.6 ± 1.3 years old and had T1D for 3.6 ± 2.3 years; HbA1c was 9.1 ± 2.0%; 20% of ITP and 50% of SE children used syringes (vs. pens) for injections. At baseline, 80% of both groups knew how to self-inject; most were taught by a parent/relative. Injection technique scores were low in both groups; ITP group increased their scores significantly postintervention. Practices of self-injection did not change in either group after 30 days. PRACTICE IMPLICATIONS: The play-based intervention appeared to improve the injection technique in the short-term. Pilot findings support the development of a larger trial to evaluate the effectiveness of ITP on educating children on insulin injections.

Ready or not? Greater readiness for independent self-care predicts better self-management but not HbA1c in teens with type 1 diabetes.

OBJECTIVE: Prior to the transfer from paediatric to adult health care transition, teens with type 1 diabetes seek increasing independence in diabetes self-care while parent involvement in care decreases. Yet, few teens attain glycaemic targets. This study aimed to assess changes in perceived readiness for independent self-care in teens with type 1 diabetes over 18 months, from both teens' and parents' perspectives, and to evaluate its predictive value for diabetes self-management and haemoglobin A1c (HbA1c ). RESEARCH DESIGN AND METHODS: At baseline, 6, 12 and 18 months, 178 teens with type 1 diabetes (mean ± SD age 14.9±1.3 years; HbA1c 8.5 ± 1.0% (69 ± 11 mmol/mol); 48% female) and their parents completed the Readiness for Independent Self-Care Questionnaire (RISQ-T and RISQ-P, respectively) and a measure of self-management. Chart review provided HbA1c values. Statistical analyses encompassed bivariate correlations, paired t-tests and multivariable longitudinal mixed models. RESULTS: Teens perceived greater self-care readiness than their parents at baseline and over 18 months of follow-up. Both teen and parent perceptions of teen readiness for independent self-care increased over time, and significantly predicted higher teen self- and parent proxy-reported teen diabetes self-management, respectively, but not improved HbA1c . CONCLUSIONS: The current findings may point to a disconnect between how increased readiness for independent self-care may translate into better perceived diabetes self-management, but not into better HbA1c . In an effort to optimize HbA1c in teens with type 1 diabetes, future research is needed to design interventions that align perceived readiness for independent self-care with self-care behaviours that improve HbA1c .