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Context Short sleep duration and sleep disruptions are associated with impaired glucoregulation in type 1 diabetes (T1D). However, the mechanistic pathways between sleep and glucose variability remain unclear. Objective To determine within- and between-person associations between objective sleep-wake characteristics and glucose variability indices. Methods Multilevel models were used to analyze concurrent sleep and glucose patterns over 7 days in 42 young adults with T1D in their natural home environment. Young adults with T1D (mean age 22.2 ± 3.0 years, HbA1c 7.2%, 32.6% male) for at least 6 months with no other medical or major psychiatric comorbidity were included. Sleep-wake characteristics were measured via wrist actigraphy and glucose variability indices via a continuous glucose monitor (CGM). Results Lower sleep efficiency predicted higher glucose variability (less time in range β = 0.011 and more time in hyperglycemia β = −0.011) within-person. A longer wake after sleep onset and more sleep disruptions were associated with higher glucose variability between persons (β = 0.28 and 0.31). Higher glucose variability predicted poorer sleep within-person (delayed bedtime, waketime, mid-sleep time, and lower sleep efficiency), while higher glucose variability was associated with poorer sleep and more sleep disruptions between persons (lower sleep efficiency, longer wake after sleep onset, and a higher sleep fragmentation index). Conclusion Clinicians can address the reciprocal nature of the sleep-glucose relationship by optimizing sleep and targeting efforts toward a euglycemic range overnight. Sleep habits are a modifiable personal target in diabetes care.

OBJECTIVE: We used multilevel models (MLMs) to determine person (between-persons) and day level (within-person) associations between glucose variability indices and sleep characteristics in adolescents with type 1 diabetes (T1D). METHODS: Adolescents with T1D (Mean age 13.4 ± 1.8 years; 37.8% male; mean HbA1c 8.2 ± 1.2%, 66 mmol/mol) monitored their sleep and glucose patterns concurrently for 3–7 days with a wrist actigraph on their nondominant wrist and a continuous glucose monitor (CGM) (their own or a provided, blinded CGM). Glucose variability indices included J index, coefficient of variation, low and high blood glucose risk indices (LBGI and HBGI), time in range, and sleep characteristics, including bedtime, wake time, total sleep time, sleep efficiency, wake after sleep onset, awakenings, and sleep fragmentation index. RESULTS: More overall glucose variability was associated within person, more sleep disruptions (more awakenings and more fragmentation) or poorer sleep in our study (earlier wake time or longer wake after sleep onset). Also, more time spent in hypoglycemia

Background The prevalence of adults with Type 1 diabetes (T1D) is increasing, and their risk of cardiovascular disease is high. Comorbid diabetes distress and depressive symptoms may affect their cardiovascular health. Objectives The purpose of this study was to describe the relationship between diabetes distress and depressive symptoms with cardiovascular health factors. Methods This was a cross-sectional survey of a sample of adults with T1D. Valid and reliable instruments were used to collect the data on sociodemographics, diabetes-related complications, psychological factors, and cardiovascular health factors. Independent-sample t tests, analysis of variance, chi-square analyses, and linear regression were used to compare the cardiovascular health factors among the three levels of diabetes distress scores and the two levels of depressive symptom scores. Results Our sample included 83 adults with a mean age of 45.2 years and a mean duration of T1D of 20 years. The majority scored low in the Diabetes Distress Scale, whereas 18% scored moderate and 18% scored high. Twenty-two percent had increased levels of depressive symptoms. There were significant correlations between diabetes distress and fear of hypoglycemia, depressive symptom scores, hemoglobin A1c, and total cholesterol. Depressive symptom scores were significantly correlated with hemoglobin A1c. Hemoglobin A1c and total cholesterol were significantly higher in those with higher levels of diabetes distress. There were no significant differences in cardiovascular health between those who scored below or above the cut point for depressive symptoms, but there was a finding toward higher mean body mass index, hemoglobin A1c, and a lower weekly step count in those who had elevated depressive symptoms. In the linear regression, only diabetes distress was significantly associated with hemoglobin A1c. Discussion This is a sample with elevated diabetes distress and depressive symptoms, both of which may affect their risk of cardiovascular disease.

Only 14% of young adults with Type 1 Diabetes (T1D) achieve targets for glycemic control (HbA1C < 7.0%), with deterioration over time. Complex cognitive processes required to manage glycemia are vulnerable to sleep deficiency. Using Whittemore and Knafl’s approach, we conducted an integrative review of research literature on sleep characteristics and glycemia in these young adults. Quality was assessed using the Mixed Methods Appraisal Tool (v. 2011). Multiple databases were searched for articles published in English in peer-reviewed journals from 2003 to 2018, using search terms ‘sleep’ and ‘T1D’ with age limiters 18–40. Of 218 studies initially retrieved, 17 original studies met the inclusion criteria. The following themes were identified in young adults with T1D: (1) They had poorer objective and subjective sleep quality, more variability, and impaired awakening response to hypoglycemia compared with controls; (2) They had poorer glycemic control that was associated with shorter sleep duration, poorer sleep quality, and less time in deep sleep; and (3) Hypoglycemia negatively impacted diabetes management, sleep quality, and next day functioning. Sleep deficiency, as indicated by short sleep duration is associated with a range of negative health outcomes for people with T1D; therefore, optimizing sleep should be a priority in practice and research.

Circadian alignment is an important element in individual health, and one behavioral marker, rest-activity rhythm, could influence self-management in young adults with type 1 diabetes (T1D). Little is known about the rest-activity rhythms, executive function, and glycemia among young adults with type 1 diabetes (T1D). The purpose of this study was to evaluate parametric and nonparametric circadian characteristics of the rest-activity rhythm and the associations between these variables, sleep-wake behavior, executive function, and glycemia among young adults with T1D. Young adults with T1D, recruited from diabetes clinics, wore wrist actigraphs and a continuous glucose monitor (CGM) concurrently for 6-14 days. Participants completed a 3-minute Trail Making Test on paper and electronic questionnaires - 8-item PROMIS v1.0 Emotional Distress Scale, 17-item Diabetes Distress Scale, including twice-daily Pittsburgh sleep diaries. Cosinor and nonparametric analyses were used to compute the rest-activity rhythm parameters, and linear regression modeling procedures were performed to determine the associations among the study variables. The sample included 46 young adults (mean age 22.3 ± 3.2; 32.6% male; 84.8% non-Hispanic White, HbA1c mean 7.2 ± 1.1%, BMI mean 27.0 ± 4.4 kg/m2). A number of parametric associations were observed between a stronger rhythm, better objective sleep-wake characteristics, and less daytime sleepiness. Nonparametric circadian parameters were significantly associated with several outcomes: a stronger rhythm adherence (higher inter-daily stability) with better objective sleep-wake characteristics, better executive function, lower diabetes distress, less hyperglycemia risk, and more time spent in hypoglycemia/hypoglycemia risk; and a more robust rhythm (higher relative amplitude) with better objective sleep-wake characteristics and more time spent in hypoglycemia/higher hypoglycemia risk. Future work should be directed at designs that test causality, such as interventions directed at the strength and stability of rest-activity rhythms, for the potential to improve glucoregulation and other diabetes outcomes.

Objective Despite increased diabetes device use, few adolescents with type 1 diabetes (T1D) meet glycemic targets. We examine associations between utilization of insulin pumps and continuous glucose monitoring (CGM) and glycemic control. Research design and methods This prospective cohort study included 80 youths (10-18 years of age) with T1D. Multiple linear regression and linear mixed models (LMM) were used to estimate the effects of device self-management on HbA1c and daily time in range (70-180 mg/dL), respectively. Results Every blood glucose (BG) input/day was associated with a 0.2% decrease in HbA1c (95% CI: -0.297, -0.013), each bolus/day was associated with a 0.2% decrease (-0.327, -0.057), and use of CGM was associated with a 0.5% decrease (-1.00, -0.075). Among CGM users (n = 45) every 10% increase in CGM use was associated with a 0.3% decrease in HbA1c (-0.390, -0.180). In LMM accounting for within subject and between subject variability, there was a negative association between BG input/day frequency (coefficient = -1.880, [-2.640, -1.117]) and time in range. Residual random effects for CGM users were large showing time in range varied between youth with a SD of 15.0% (3 hours and 36 minutes) (SE 2.029, [11.484, 19.530]). Time in range varied significantly from day-to-day with SD of 18.6% (4 hours and 40 minutes) (SE0.455, [17.690, 19.473]). Conclusions Device self-management behaviors among youth are significantly associated with both HbA1c and time in range. Our findings showing an association between reduced time in range and increased self-management behaviors is novel and deserves further investigation.

Background: Care management processes are meant to improve care quality, but there is little information about their effectiveness in socioeconomically disadvantaged individuals. This study was aimed to test if systematic care management processes are as effective in controlling diabetes among Medicaid as in non-Medicaid patients. Methods: This cross-sectional study used standardized performance measures (glycemic control, BP control, statin drug use, aspirin use, smoking cessation) matched to a 2017- clinic survey on the use of diabetes-related care management processes (62 items in Physician Practice Connections-Research Survey). A mixed effect multi-level regression model with fixed clinic- and patient-level independent variables and random clinic-level intercepts was used to test the association between clinic use of care management processes (index of 0-100%) and glycemic control of glycated hemoglobin (A1C) level while adjusting for patient covariates (age, sex, comorbid conditions, diabetes type 1 or 2, residence rurality) and clinic covariates (PCMH certification, medical group size, federally qualified health center). Results: The overall mean index of care-management processes usage was 86% (IQR of 76-97%). Every 10% increase in the use of care management processes was associated with a decrease of 0.57 in A1C (p Conclusions: Clinic utilization of PCMH care management processes had a larger effect on diabetes control for patients on Medicaid than for other patients. Improving and implementing these processes may be an important strategy for reducing disparities in diabetes outcomes. Disclosure H.N. Fu: None. J. Wolfson: None. L. Solberg: None. M. Grey: None. K.A. Peterson: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (R18DK110732)

Introduction The association between short sleep duration and poorer glycemic control in adolescents ages 10-16 with type 1 diabetes (T1D) is well established. Researchers have used cross-sectional, between-subjects’ methods, with limited focus on the potential intraindividual variation among these variables. The purpose of this analysis was to examine the within person associations between glucose variability indices (J index, low/high blood glucose index, time in range) and sleep characteristics (bedtime, waketime, total sleep time, sleep efficiency, wake after sleep onset [WASO], awakenings, and sleep fragmentation index) in adolescents with T1D. Methods Adolescents monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and either their own continuous glucose monitor (CGM) or a provided blinded CGM. General linear mixed models (GLMM) were used to determine within-person and day level associations. Results The sample included 38 adolescents (M age 13.4±1.8; 37.8% male; M A1C 8.2±1.2%). Average glucose levels were controlled in all GLMMs. Adolescents had earlier waketimes on days when more time was spent in hypoglycemia Conclusion Glucose variability was positively associated with poor sleep (e.g., WASO and awakenings) in adolescents with T1D both at the daily and intraindividual level. Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person associations between habitual short sleep duration and glucose variability. Support NINR T32NR0008346 & P20NR014126, Medtronic MiniMed provided CGMs at a discounted rate for the study.

Background and aims Diabetic foot ulcers are the leading cause of lower extremity amputations, which require more effective prevention. Even though previous nursing studies on diabetic foot ulcers have been well performed, programs implementing self- and family management are limited and even underexplored. Therefore, the purpose of the study was to investigate the effect of 3-month self- and family management support programs on clinical outcomes among Indonesians with diabetic foot ulcers. Method The randomized controlled trial design was used to answer the research question of the study. A total of 56 eligible participants were enrolled, with 27 in the experimental group and 29 in the control group. The experimental group received self- and family management support programs for three months. Meanwhile, the control group received usual care. Descriptive statistics, multivariate analysis of variance, and Generalized Estimating Equations were used to analyze the data. The significance level was considered at .05 for hypothesis testing. Results The study showed that there were statistically significant improvements in self-management, family supports, hemoglobin A1c, and wound size after implemented the programs for three months (p Conclusions With regard to the result of the study, implementing the 3-month self- and family management support programs improves the patients’ and families’ abilities to perform diabetic foot ulcer care at home.

Background/objective Many adolescents with type 1 diabetes do not achieve 60 minutes of daily moderate-to-vigorous intensity physical activity (MVPA). Recognizing the importance of peer influence during adolescence, we evaluated the feasibility and safety of a group MVPA intervention for this population. Methods Eighteen adolescents with type 1 diabetes (age 14.1 ± 2 .3 years, female 67%, black or Latino 67%, median body mass index 92%'ile, A1c 79.9 ± 25.1 mmol/mol, 9.5 ± 2.3%). Intervention sessions (35 minutes MVPA and 45 minutes discussion) occurred 1×/week for 12 weeks. Feasibility and safety metrics were enrollment, completion of intervention and assessments, cost, and hypoglycemia rates. Participants completed MVPA (accelerometry), and exploratory nutritional, psychosocial, clinical, and fitness variable assessments at baseline, 3 months, and 7 months. Hedges' effect sizes were calculated. Results Enrollment was 16%, and intervention completion was 56%. Assessment completion at 7 months was 67% for MVPA, nutrition, and fitness, 83% for psychosocial assessments, and 94% for clinical assessments. Cost was $1241 per completing participant. One episode of mild hypoglycemia occurred during the sessions (0.6%). Self-reported daily fruit/vegetable servings (d = -0.72) and diabetes self-management behaviors decreased over time (d = -0.40). In the 10 completers, endurance run score improved (d = 0.49) from low baseline levels, while systolic blood pressure decreased (d = -0.75) and low-density lipoprotein increased (d = 0.49) but stayed within normal ranges. Conclusions The protocol for the group MVPA intervention was safe and had some feasibility metrics meriting further investigation. MVPA levels and glycemic control remained suboptimal, suggesting the need for more intensive interventions for this population.

Adults with type 1 diabetes (T1D) are at risk for cardiovascular (CV) disease. Managing CV risk is an important prevention strategy. The American Heart Association has defined 7 factors for ideal CV health. The purpose of this 2016 secondary analysis was to assess the prevalence of 6 CV health factors in a sample of adults ≥ 18 (n = 7153) in the T1D Exchange Clinic registry. CV health factors include: hemoglobin A1c (HbA1c) The mean age was 37.14 ± 17 years. Mean HbA1c was 7.9 ± 1.5%, and duration was 19.5 ± 13.5 years. The majority (54%) were working full or part-time. Achievement of CV health factors in the whole sample ranged from 27% (HbA1c This young sample exhibited low levels of some CV health factors, especially HbA1c and physical activity. Providers need to routinely assess and advise on management of all CV risk factors to prevent this common diabetes complication.

Summary In the United States, more than two-thirds of adolescents and one-third of emerging adults report habitual short sleep duration, which is a known risk factor for psychological distress. The primary aim of this systematic review and meta-analysis was to evaluate the effect of behavioral sleep-promoting interventions on the sleep characteristics (e.g., total sleep time and sleep efficiency) of adolescents and emerging adults (aged 12 to 25 years) who do not have a sleep disorder. The secondary aim was to determine the effect of behavioral sleep-promoting interventions on psychological distress. Multiple electronic databases were searched for relevant randomized controlled trials (RCTs) published in English. Fourteen RCTs were included in the qualitative synthesis (N = 932), seven were included in the meta-analysis (n = 711) to address the primary aim, and three (n = 253) were included to address the secondary aim. The pooled standardized mean difference for sleep-promoting interventions after treatment for total sleep time was 34.92 minutes (95% CI: 8.70, 61.14). Sleep-promoting interventions had no significant effect on sleep efficiency. More RCTs that involve adolescents and emerging adults are needed to determine the effect of sleep-promoting interventions on reducing psychological distress in this high-risk age group.

Introduction Type 1 Diabetes (T1D) affects 1.25 million Americans, and only 14% of emerging adults (ages 18-30 years) achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, less than 6.5 hours total sleep time (TST), is associated with poorer glycemic control. Methods Emerging adults with T1D wore a wrist actigraph and their own or provided continuous glucose monitor (CGM) concurrently 24 hours/day for 6-8 days. Participants completed a 10-minute psychomotor vigilance test (PVT) on a device, 3-minute Trail Making Test on paper, and questionnaires including twice daily Pittsburgh sleep diaries in Research Electronic Data Capture (REDCap). TST, sleep onset latency (SOL), sleep efficiency (SE), wake after sleep onset (WASO), and sleep fragmentation index (SFI) were determined via actigraphy, glycemic control via A1C, and glucose variability via CGM. The purpose of this descriptive study was to explore associations between TST, sleep variability (SD of TST), neurocognitive function (psychomotor vigilance and executive function) and diabetes outcomes (glycemia and distress). Results The sample included 36 emerging adults (mean age 22.8±3.1; 30.6% male; 91.7% White, 86.1% non-Hispanic; A1C mean 7.1±1.0%, BMI 27.3±4.8 kg/m2). Mean TST was 7.1±1.2 hours, SOL was 19.7±13.5 minutes, SE was 85.5±4.6%, WASO was 34.7±18.2 minutes, and SFI was 17.7±6.2. Shorter TST was associated with more severe sleepiness (r=-0.48,p=0.004) and more diabetes distress (r=-0.37, p=0.03). More sleep variability was associated with more severe sleepiness (r=0.36, p=0.03), longer response times (RT) ≥ 500ms (rho=0.39, p=0.02) measured via PVT, more nocturnal glucose variability (r=0.38, p=0.04), greater mean daily differences in glucose levels (r=0.42, p=0.02). Shorter mean RT was associated with more time in glucose range (rho=-0.37, p=0.04). Conclusion Improving TST and sleep variability are potential therapeutic targets to improve glucoregulation in this high-risk population. Researchers should consider within-person multi-level modeling to inform our understanding of the true nature of the sleep-glucose association in emerging adults with T1D. Support T32 NR0008346, Sigma Theta Tau International, Dexcom provided continuous glucose monitors (G4) free of charge for participants who did not have their own device.

Nearly 70% of adolescents have chronic sleep problems (quality, quantity, and/or altered circadian rhythm). Adolescents with type 1 diabetes (T1D) are subject to nocturnal blood glucose fluctuations that may result in restless sleep and require self-care that disrupts sleep. Deficient sleep may also contribute to insulin resistance. Few studies of sleep characteristics and their association with glycemic control have been conducted. Our aim was to describe sleep characteristics in adolescents with T1D and its relationship with glycemic control. Adolescents with T1D (ages 10-16) were recruited from the Yale Program. For 7 days, participants wore a wrist actigraph, which was used to calculate sleep/wake cycles using 30-second epochs, and a continuous glucose monitor (CGM). The Pittsburgh Sleep Quality Index (PSQI) was used to assess subjective sleep reports. The sample included 30 participants age 13.4+1.9, 67.9% female, 29.2% minority, BMI percentile 75+25%, diabetes duration 7.4+ 4.5 years, and 97% on insulin pumps. Hemoglobin A1c (A1c) levels (8.29+1.38%) and CGM (46.3+14.9% time in hyperglycemia) indicated poor glycemic control. Actigraphy showed inadequate total sleep time (7.33+19 hours), but good sleep efficiency (80.0+20.3%). Higher MESOR (rhythm adjusted mean) (r=0.25) and lower circadian quotient (r=-0.31) were associated with higher A1c. Greater circadian quotient was associated with more glucose variability (r=0.41). Greater WASO (wake after sleep onset) was associated with higher glucose (r=0.26), HBGI (high blood glucose index) (r=0.27), and more hyperglycemia (r=0.25). Higher MESOR was associated with lower LBGI (low blood glucose index) (r=-0.39) and less hypoglycemia (r=-0.42). Higher amplitude was associated with lower LBGI (-0.35) and less hypoglycemia (r=-0.39). These results suggest that insufficient sleep is common among adolescents with T1D and is associated with poorer glycemic control. Further research is required to determine if improving sleep will improve glycemic control. Disclosure M. Grey: None. K. Rechenberg: None.

Objective The purpose of the study was to evaluate the participation and preliminary efficacy of an Internet psychoeducational program (Teens.Connect) shown to be efficacious under controlled conditions compared with an open-access diabetes website for youth (Planet D) on the primary outcomes of A1C and quality of life (QoL), and secondary outcomes of psychosocial and behavioral factors. Research Design and Methods Teens with type 1 diabetes (n = 124, 11–14 yr) from two clinical sites were randomly prescribed one of the programs and completed baseline, 3-month and 6-month data. A1C was obtained from clinic records. Participation data included number of log ins, posts to the discussion board, and lessons completed (Teens.Connect only). Descriptive and mixed model analyses were used. Results Eighty-five percent (85%) of consented teens registered for their prescribed program. Satisfaction and log ins were similar between groups (satisfaction ranged 3.3–3.5/5; mean log ins = 14/teen). Posts to the discussion forum were higher in Planet D (mean = 28 vs. 19). Participation in the Teens.Connect lessons was low, with only 69% of teens completing any lesson. After 6 months there were no significant differences in A1C, QoL or secondary outcomes between groups. Teens in the Teens.Connect group reported lower perceived stress over time (p

Purpose Drawn from one of the keynote addresses at the State of the Science Conference held by the Council for the Advancement of Nursing Science (CANS), the purpose of this paper is to review the evidence from clinical trials about the importance of lifestyle behaviors in human health. Methods Evidence from trials on the impact of lifestyle interventions on outcomes in diabetes and prediabetes are presented. Results These findings suggest that lifestyle behaviors are important to diabetes prevention and outcomes in youth and adults. Implications More research is needed on the factors that predict these outcomes, especially genetics and environment.

Healthy behaviors including limited screen time (ST), high physical activity (PA), and adequate fruits and vegetables consumption (FV) are recommended for adolescents, but it is unclear how gender, race/ethnicity, and weight status relate to these public health guidelines in diverse urban adolescents. Participants ( N = 384) were recruited from three public high schools in or near New Haven, Connecticut. Descriptive statistics and logistic regression analyses were conducted. Most adolescents exceeded recommended levels of ST (70.5%) and did not meet guidelines for PA (87.2%) and FV (72.6%). Only 3.5% of the sample met all three guidelines. Boys were more likely to meet guidelines for PA ( p < .01), while girls were engaged in less ST ( p < .001). Black, non-Latinos were less likely to meet PA guidelines ( p < .05). There were no significant differences in meeting ST, PA, or FV guidelines by weight status for the overall sample or when stratified by gender or race/ethnicity. We found alarmingly low levels of healthy behaviors in normal weight and overweight/obese adolescents.

Aims and objectives To describe the patterns of diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life over time in a cohort of Chinese youth with type 1 diabetes and to determine the relationships between these variables over time. Background Nurses have an important role in facilitating optimal self-management and health outcomes in youth with type 1 diabetes. Only a few studies have focused on patterns of diabetes adaptation over time in youth with type 1 diabetes, especially in China. Understanding changes in diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life can facilitate assessment and intervention. Design This is a multi-site longitudinal descriptive study. Data for this report were collected at baseline with 136 eligible Chinese youth and 86 of them were followed up for the second time, 6–12 months after baseline data collection. Methods Instruments to measure diabetes self-management, depressive symptoms, metabolic control and satisfaction with quality of life were collected at two time points. The data were collected from July 2009–October 2010. Linear mixed model analysis was used to analyse the longitudinal data. Results Self-management decreased over time; however, depressive symptoms, metabolic control and satisfaction with quality of life did not change from baseline to 6–12 months in this sample of Chinese youth with type 1 diabetes. A decrease in diabetes self-management over time was associated with worse metabolic control, while an increase in depressive symptoms over time was associated with poorer quality of life satisfaction in this sample. Conclusions Chinese youth faced difficulties with diabetes adaptation, especially with the deterioration of diabetes self-management. Improving self-management and decreasing depressive symptoms may enhance diabetes adaptation with respect to metabolic control and quality of life. Relevance to clinical practice The deterioration of diabetes self-management over time in youth with type 1 diabetes in China deserves nurses' careful surveillance. Clinical interventions appropriate to the Chinese culture and health care system are needed to improve self-management and depressive symptoms in Chinese youth with type 1 diabetes.

OBJECTIVE To evaluate the efficacy of two office-based treatments designed to prevent deterioration in glycemic control in young adolescents with type 1 diabetes in a randomized clinical trial. An individualized, more intensive family teamwork Coping skills program was compared with a diabetes Education treatment. RESEARCH DESIGN AND METHODS A baseline assessment was followed by four brief treatment sessions and immediate posttesting over the course of 1.5 years. Families of 226 early adolescents (ages 11–14) were randomized to receive either individualized coping skills education or diabetes education as adjunctive treatment to quarterly medical appointments. Continued follow-up occurred at 3.5-month intervals for a long-term follow-up of up to 3 years. A post hoc Usual Care group facilitated comparisons of glycemic control. RESULTS Growth curve analysis showed that both treatment groups successfully prevented deterioration in adolescent disease care and simultaneously improved adolescent and parent quality of life that included indicators of more effective communication and reduced adherence barriers—without a concomitant increase in diabetes-related or general family conflict. However, contrary to expectation, the Education group was more efficacious than the Coping group in improvement of disease adherence and glycemic control over a 3-year follow-up. CONCLUSIONS Low-intensity office-based quarterly treatment can maintain or improve disease care adherence in early adolescence when provided to adolescent/parent dyads. Better outcomes are achieved when treatment goals and techniques match the needs of the targeted population.

This study examined the relationship of family functioning and depressive symptoms with self-management, glycemic control, and quality of life in a sample of adolescents with type 1 diabetes. It also explored whether self-management mediates family functioning, depressive symptoms, and diabetes-related outcomes. Structural equation modeling was used to estimate parameters in the conceptual causal pathway and test mediation effects. Adolescents ( n = 320) were primarily female (55%), younger adolescents (58%), and self-identified as White (63%). Self-management mediated the relationship between family conflict, family warmth-caring, parent guidance-control, and youth depressive symptoms with glycosylated hemoglobin (A1C). In addition, self-management mediated the relationship between family conflict and youth depressive symptoms with quality of life. Supporting optimal family functioning and treating elevated depressive symptoms in adolescents with type 1 diabetes has the potential to improve self-management, glycemic control, and quality of life.

Overweight and obesity in youth with type 1 diabetes (T1D) is now prevalent and accounts for significant health consequences, including cardiovascular complications and dual diagnosis of type 2 diabetes. Physical activity and lifestyle are modifiable and play an important role in the prevention and management of excessive weight, but it is unclear how these factors relate to overweight and obese youth with T1D. Thus, a systematic review was conducted to examine how physical activity, sedentary behavior, sleep, and diet are related to overweight/obesity in youth with T1D. Seven observational and intervention studies published between 1990 and 2013 were included in the review. Prevalence of overweight ranged from 12.5% to 33.3%. Overweight in youth with T1D was associated with infrequent napping, increased screen time, and skipping breakfast and dinner but was not related to time engaged in physical activity. Weight-related interventions indicated modest weight loss along with improved glycemic control. In light of this review, there is a need for high quality research that examines all levels of activity in youth with T1D to identify lifestyle modification targets for weight prevention and management.

To describe the prevalence of overweight and obesity in adolescents with type 1 diabetes (T1D) and to examine the associations among socio-demographic, clinical, and self-management factors by weight status.We analyzed baseline data obtained from 5529 adolescents with T1D (mean age=15.4±1.4years, 51.8% male, 77.9% white, mean HbA1c=8.7±1.8%; 72mmol/mol) from the T1D Exchange Clinic Registry. We examined correlates of weight status using multinomial logistic regression analyses.Overweight (22.9%) and obesity (13.1%) were prevalent in the overall sample and was highest among girls (40.8%) and adolescents of Hispanic/Latino race/ethnicity (46.1%). Female gender, older age, annual household income$35,000 (vs. ≥$200,000), high school parental educational attainment (vs. ≥graduate degree), lower HbA1c, longer duration of T1D, higher amount of insulin, and a recent visit with an allied healthcare provider were independently and significantly associated with higher odds of overweight or obesity. Adolescents who self-rated their health as fair/poor (vs. excellent) had the highest odds of obesity (OR 3.92, 95% CI 2.53-6.06).Overweight/obesity is prevalent among adolescents with T1D, especially among girls and those of diverse race/ethnicity. Some of these factors may be amenable to remediation and point to subgroups that can benefit from obesity prevention and management efforts.

Problem Mental health conditions are prevalent in youth with type 1 diabetes (T1D). Anxiety symptoms and depressive symptoms are highly correlated and are two of the most prevalent mental health conditions in youth in the general population. The detrimental effect of depressive symptoms in youth with T1D has been well documented, but the effects of anxiety symptoms are not well understood. Eligibility criteria Studies were included if they were published between 1990 and 2015, and evaluated anxiety symptoms in a population of youth with T1D. Sample A total of 20 studies were identified from a sample of 338 papers. Results Anxiety symptoms were prevalent in youth with T1D. Anxiety symptoms were associated with higher glycosylated hemoglobin (HbA1c) levels, poorer self-management and coping behaviors, depressive symptoms, fear of hypoglycemia, and lower blood glucose monitoring frequency. State anxiety and trait anxiety symptoms affected health outcomes differently. Girls were at a higher risk of anxiety symptoms than boys. Conclusions Anxiety symptoms in youth with T1D have detrimental effects on health outcomes, including self-management, quality of life, and HbA1c. Implications Future research should aim to improve our current screening and treatment practices.

Background Type 1 diabetes (T1D) is one of the most common chronic health conditions in adolescents in the United States. Adherence to the recommended treatment regimen has been reported as a source of stress for adolescents. Aim The purpose of this study was to examine the associations among general and diabetes-specific stress and glycemic control (HbA1c), self-management, and diabetes-specific quality of life (QOL) in adolescents with T1D. Methods A secondary analysis of baseline data (N = 320) from a randomized controlled trial was conducted. Adolescents completed validated measures of general and diabetes-specific stress, self-management, and diabetes-specific QOL. HbA1c levels were obtained from medical records. Results Over 50% of the sample scored at or above criteria for high general and diabetes-specific stress. Higher general and diabetes-specific stress was significantly associated with higher HbA1c, poorer self-management activities, and lower diabetes-specific QOL. Diabetes-specific stress accounted for a significant proportion of the variance in HbA1c, while general stress did not. General and diabetes-specific stress accounted for 40% of the variance in diabetes-specific QOL. Conclusions General and diabetes-specific stress are common in adolescents with T1D. Healthcare providers must be mindful of the sources of stress that adolescents with T1D face on a daily basis. General stress and diabetes-specific stress should be differentiated and may require different interventions to improve coping and outcomes.

Purpose The purpose of the study was to examine the differences in clinical, psychosocial, and demographic factors by sex and weight status. Methods Baseline data were analyzed from 318 adolescents (mean age = 12.3 ± 1.1 years, 55.0% female, 62.7% white) with type 1 diabetes (T1D) from a multisite clinical trial. Differences were examined between normal weight (body mass index ≥5th and Results Overweight/obesity was prevalent (39.0%) and common in girls (42.6%) and boys (33.1%). In bivariate analyses, overweight/obese girls had parents with lower educational attainment, longer diabetes duration, and significantly worse self-management and psychosocial health as compared with normal weight girls. There were no differences between overweight/obese and normal weight girls in A1C, therapy type, race/ethnicity, or household income. No significant differences were found between normal weight and overweight/obese boys. In multivariate analysis, parental educational attainment (master or higher vs high school diploma or less) and perceived stress were significantly associated with overweight/obesity in girls. Longer duration of T1D bordered statistical significance. Conclusions Overweight/obesity is prevalent among adolescents with T1D. Clinical, psychosocial, and demographic factors are associated with overweight/obesity in girls but not boys. Greater attention to weight status and aspects of health that are germane to adolescents with T1D is warranted.

Chronic illnesses, such as cardiovascular disease, cancer, and diabetes, are among the most prevalent and costly of all global health problems (World Health Organization, 2011). They are the primary reason adults seek health care and are the leading cause of death and disability in the United States (U.S. Centers for Disease Control and Prevention, 2011). Chronic illnesses are long term, uncertain, and can be very intrusive to individuals' everyday lives (Larsen, 2009). Often, chronic illnesses have a course that varies over time specific to the etiology and physiology of the particular illness. However, there are common challenges across chronic illnesses, which include recognizing symptoms and taking appropriate actions, using medications effectively, managing complex regimens, developing strategies to deal with the psychological consequences of the illness, and interacting with the healthcare system over time (Wagner et al., 2001; U.K. Department of Health, 2003). Chronic illness management has been recognized as an important component of health care, and there is increasing awareness that similar strategies can be effective across different types of chronic illnesses (Dowrick, Dixon-Woods, Holman, & Weinman, 2005; Harvey et al., 2008; Swendeman, Ingram, Rotheram-Borus, 2009).

Background TODAY (Treatment Options for type 2 Diabetes in Adolescents and Youth) is a federally-funded multi-center randomized clinical trial comparing three treatments of youth-onset type 2 diabetes.

Background—Although it is recognized that caring for a child with type 1 diabetes (T1D) is stressful for parents, few interventions have been developed and tested for this population. Objectives—To compare a group educational intervention for parents of children with T1D to a coping skills training intervention. Method—Parents of children with T1D were randomized to the group educational (n = 106) or coping skills training (n = 75) conditions. Parents completed measures of family conflict, responsibility for treatment, coping, and quality of life at baseline and 3 months, 6 months, and 12 months postintervention. Clinical data (i.e., HbA1c) were collected from children’s medical records pre- and postintervention. Results—There were no significant treatment effects 12 months postintervention, but parents in both groups reported improved coping (p < .001), less responsibility for treatment management (p < .001), and improved quality of life (p = .005). While children’s metabolic control worsened over time, mean values at 12 months were still within the recommended levels in this well-controlled sample (HbA1c < 8%). Discussion—Group-based interventions for parents of children with T1D may lessen the impact of treatment management, improving coping and quality of life.

savage e., farrell d., mcmanus v. & grey m. (2010) The science of intervention development for type 1 diabetes in childhood: systematic review. Journal of Advanced Nursing 66(12), 2604–2613. Abstract Aim. This paper is a report of a review of the science of intervention development for type 1 diabetes in childhood and its implications for improving health outcomes in children, adolescents, and/or their families. Background. Previous reviewers have identified insufficient evidence to support the application of effective interventions for type 1 diabetes in clinical practice. The need for quality randomized controlled trials to address shortcomings in previous study designs has been highlighted as a priority for future intervention research. However, there is also a need to consider the scientific development of interventions, which to date has received little attention. Data source. A search for published randomized controlled trials over 5 years (2004–2008) was conducted in electronic databases (Medline, CINAHL, Cochrane Library, Psychinfo, ERIC). Reference lists of papers identified from electronic searches were examined for additional papers. Methods. A systematic review was conducted. Studies were included if (i) an intervention for managing any aspect of type 1 diabetes was implemented, (ii) children, adolescents and/or their families were sampled, (iii) a randomized controlled trial, (iv) published in English. Results. Fourteen randomized controlled trials were reviewed on education (n = 7), psychosocial (n = 5) and family therapy (n = 2) interventions. Compared to education interventions, family therapy and most psychosocial interventions were developed with greater scientific rigour, and demonstrated promising effects on more health outcomes measured. Conclusion. Interventions developed within clearly-defined scientific criteria offer potential for improving health outcomes in children and adolescents with type 1 diabetes and their families. Future reviews on interventions for type 1 diabetes in childhood need to include criteria for assessing the science of intervention development.

Children with type 1 diabetes are at risk for negative psychosocial and physiological outcomes, particularly as they enter adolescence. The purpose of this randomized trial (n = 82) was to determine the effects, mediators, and moderators of a coping skills training intervention (n = 53) for school-aged children compared to general diabetes education (n = 29). Both groups improved over time, reporting lower impact of diabetes, better coping with diabetes, better diabetes self-efficacy, fewer depressive symptoms, and less parental control. Treatment modality (pump vs. injections) moderated intervention efficacy on select outcomes. Findings suggest that group-based interventions may be beneficial for this age group.

Objective To evaluate the impact of a multifaceted, school-based intervention on inner city youth at high risk for type 2 diabetes mellitus (T2DM) and to determine whether the addition of coping skills training (CST) and health coaching improves outcomes. Method 198 students in New Haven, CT at risk for T2DM (BMI > 85th percentile and family history of diabetes) were randomized by school to an educational intervention with or without the addition of CST and health coaching. Students were enrolled from 2004 to 2007 and followed for 12 months. Results Students in both groups showed some improvement in anthropometric measures, lipids, and depressive symptoms over 12 months. BMI was not improved by the intervention. Students who received CST showed greater improvement on some indicators of metabolic risk than students who received education only. Conclusion A multifaceted, school-based intervention may hold promise for reducing metabolic risk in urban, minority youth.

This study examined symptoms of anxiety and depression in mothers of young children with type 1 diabetes (T1D) in relation to mothers’ fears of hypoglycemia, perceptions of coping, and children’s metabolic control. Sixty-seven mothers of children less than 8 years of age diagnosed with T1D completed self-report measures, and children’s metabolic control was measured with glycosolated hemoglobin (HbA1c). Twenty-one percent of mothers reported clinically significant levels of symptoms of anxiety, and twenty-four percent reported clinically significant levels of depression. Lower income level and finding it more upsetting to cope with diabetes-related stress accounted for higher symptoms of anxiety and depression in mothers. Mothers’ symptoms were not related to children’s metabolic control. Recommendations are made for screening mothers and providing supportive interventions to alleviate their distress.

Our purpose was to compare parental perceptions regarding children's analgesics in Finland and the USA. Data were collected from 315 Finnish and 110 American parents of children undergoing surgery using questionnaires. Cross-tabulation, and χ 2 were used in the analysis. Parents thought that analgesia should be given regularly, but more American than Finnish parents thought analgesics should be given to the child before the pain becomes severe. Additionally, more American than Finnish parents stated that children easily become dependent on analgesics and that analgesics for home use may be dangerous for children. Nurses should be aware of parents' incorrect perceptions which may be barriers to children's pain relief.

Purpose: The purpose of this study was to characterize nurse practitioners’ (NPs’) practice by using reports of patient encounters to more accurately reflect practice patterns than has been previously performed. This study was part of a larger primary care practice survey by a consortium of 20 practice-based research networks (PBRNs). Therefore, comparisons, when appropriate, were also made between this network of NPs (Advanced Practice Registered Nurse Network, APRNet) and the other 19 physician-run research networks. Data sources: A descriptive survey was developed by the 20 PBRN consortium under grants from the Agency for Healthcare Research and Quality. The consortium’s goal was to collect primary care data over a 6-month period and to document and compare primary care practice in the United States. The data were collected immediately following members’ encounters with patients rather than from billing spreadsheets. Nineteen PBRNs may have had NPs in the practices that comprised their networks. However, the data from these NPs were collected under the study ID numbers of the physician owners of each practice. APRNet, therefore, was the sole research network comprised exclusively of NPs who collected and reported data under their own study ID numbers. Conclusions: Acute health problems comprised 45% of all episodes treated by NPs compared to 30% of episodes for exacerbations of chronic conditions and 24.5% for nonillness and health promotion visits. In addition, our findings suggest that NPs provide counseling in 84% (vs. 61% for physicians) of their primary care visits, regardless of the reason for visit, and the type of counseling varies by the type of NP. Implications for practice: Despite many studies on the comparability and outcomes of NP practice, the need to identify, clarify, and document the practices of NPs in primary care settings remains. The present survey provides an important and useful first step in providing a systematic way to characterize these practices through a survey of APRNs immediately following their patient encounters.

BACKGROUND: We studied the relationship between children’s and parents’ sociodemographic and personality characteristics and parents’ perceptions of their children’s pain. METHODS: One-hundred-ten parents of children undergoing surgery completed measures of pain perception (e.g., Medication Attitude Questionnaire; MAQ) and parent and child personality characteristics (e.g., Neuroticism, Extraversion and Openness to experience Five-Factor Inventory; NEO-FFI). Factor analysis and logistic regression models were developed. RESULTS: In terms of pain medication perceptions (MAQ), descriptive analysis showed that more than 70% of parents feared side effects of analgesia, 43% thought analgesics were addictive, and 37% thought that the less often children receive analgesia, the better it worked. Factor analyses of the MAQ revealed a three factor solution explaining 52% of the variance in parental pain medication perceptions. Conceptually, these factors represented Appropriate Use Attitude of Analgesics, Concerns about Side Effects, and Avoidance of Analgesia. Stepwise regression models were used to identify predictors of parents’ scores on each of the three factors. Results indicated that less educated parents and parents of more sociable and more reactive children were more likely to indicate that they would avoid giving analgesia (Avoidance factor; P 0.001). Parents with higher conscientiousness scores (NEO-FFI) and those with more impulsive children were more likely to perceive that analgesia was appropriate to use for child pain (Appropriate Use Attitude factor; P 0.001). DISCUSSION: We conclude that many parents have misconceptions of pain and analgesics, and that child and parent personality characteristics can be used to identify parents at risk of these misconceptions. (Anesth Analg 2007;104:790‐8)

PurposeThe purpose of this study was to examine sociodemographic, clinical, and psychological factors associated with engaging in regular physical activity (PA) in adults with type 1 diabetes.MethodsSecondary cross-sectional analysis based on data from the Type One Diabetes Exchange clinic registry was conducted. Adults ≥18 years old enrolled in the clinic registry who had completed PA self-report data (n = 7153) were included in this study.ResultsMean age was 37.14 ± 17 years, and 54% (n = 3840) were men. Type 1 diabetes duration was 19.5 ± 13.5 years, and mean A1C level was 7.9% ± 1.5% (62 mmol/mol). Twelve percent (n = 848) of the sample reported no PA; 55% (n = 3928) reported PA 1 to 4 days per week; and 33% (n = 2377) reported PA ≥5 days per week. Factors that were associated with increased odds of no PA were older age, less-than-excellent general health, increased body mass index, longer duration of diabetes, and increased depressive symptoms. More blood glucose meter checks per day decreased odds of no PA. Factors associated with lower odds of ≥5 days of PA included minority race/ethnicity, education, less-than-excellent general health, presence of a foot ulcer, increased body mass index, and depressive symptoms. Male sex, less-than-full-time employment, and being single increased the odds of ≥5 days of PA.ConclusionsSeveral demographic, clinical, diabetes-related, and psychosocial factors were related to PA. Potential interventions may target those with depressive symptoms or self-reported poor general health, or they may be tailored to working adults who may find it harder to be physically active.

Type 1 diabetes is a tremendously challenging and complex disease for children and families to manage. Advances in research are constantly bringing about changes in therapies and treatments with the hope of improving the quality of life for youth with type 1 diabetes and their families. Accurate diagnosis, education, treatment, and referral to a certified diabetes educator, endocrinologist, dietitian, social worker, and psychologist are needed to provide the child with the skills necessary to manage diabetes over a lifetime. Nurses and nurse practitioners must be informed of the most current treatments and research available for their patients so that they can encourage their patients to live full and healthy lives.

Purpose This study explores and compares the privacy concerns of primary care nurse practitioners (NPs) and their patients. Data sources Privacy concerns were identified in separate focus groups of NPs and patients, and then parallel survey instruments were designed and administered to 27 NPs and 185 of their patients. All subjects were recruited through APRNet, a regional practice-based research network of NPs in southern New England encompassing 58 practices. Conclusions Both groups demonstrated high levels of concern regarding privacy. While NPs and patients had similar levels of concern about most issues, there were some notable differences regarding breeches because of carelessness, disclosures for research, and which disorders require the most care in maintaining privacy. Implications for practice These results allow NPs to anticipate patient privacy concerns and to enhance trust in the clinical relationship. These results also indicate the need to educate patients regarding privacy rights and expectations.

During recent years, the American Diabetes Association (ADA) has published detailed guidelines and recommendations for the management of diabetes in the form of technical reviews, position statements, and consensus statements. Recommendations regarding children and adolescents have generally been included as only a minor portion of these documents. For example, the most recent ADA position statement on “Standards of Medical Care for Patients With Diabetes Mellitus” (last revised October 2003) included “special considerations” for children and adolescents (1). Other position statements included age-specific recommendations for screening for nephropathy (2) and retinopathy (3) in children with diabetes. In addition, the ADA has published guidelines pertaining to certain aspects of diabetes that apply exclusively to children and adolescents, including care of children with diabetes at school (4) and camp (5) and a consensus statement on type 2 diabetes in children and adolescents (6). The purpose of this document is to provide a single resource on current standards of care pertaining specifically to children and adolescents with type 1 diabetes. It is not meant to be an exhaustive compendium on all aspects of the management of pediatric diabetes. However, relevant references are provided and current works in progress are indicated as such. The information provided is based on evidence from published studies whenever possible and, when not, supported by expert opinion or consensus (7). Several excellent detailed guidelines and chapters on type 1 diabetes in pediatric endocrinology texts exist, including those by the International Society of Pediatric and Adolescent Diabetes (ISPAD) (8), by the Australian Pediatric Endocrine Group (www.chw.edu/au/prof/services/endocrinology/apeg), in Lifshitz’s Pediatric Endocrinology (9–11), and by Plotnick and colleagues (12,13). Children have characteristics and needs that dictate different standards of care. The management of diabetes in children must take the major differences between children of various ages and …

PURPOSE The purpose of this study was to examine the child, parent, and family factors associated with quality of life and metabolic control in school-aged children with type 1 diabetes on intensive treatment. METHODS A cross-sectional analysis was performed of child, parent, and family psychosocial variables with child quality of life and metabolic control. RESULTS Families of school-aged children were able to intensively manage type 1 diabetes, achieve good metabolic control ( CONCLUSIONS Most school-aged children and families in this sample coped well with the demands of intensive treatment. However, intensive psychosocial support may also be indicated because managing a complex chronic illness is stressful and potentially difficult for some families.

Adolescents with type 1 diabetes reported more clinically significant depressive symptoms in the spring/summer months (22% in April–September) than in the fall/winter months (11% in October–March) (χ2 = 5.67, p = .018). This seasonal pattern was stronger in low-income adolescents than in adolescents from higher-income families.

Purpose: To determine correlates of depression in adolescents with type 1 diabetes. Methods: Data on 117 adolescents participating in a longitudinal study (72 F, 45 M; 95 W; age = 14.3 ± 2.0 yr; duration = 6.3 ± 3.7) were collected with the Children's Depression Inventory (CDI), Diabetes Family Behavior Scale (DFBS), Family Adaptability and Cohesion Scale (FACES), and chart review at study entry and 2-year follow-up. Results: Fifteen per cent of adolescents in this sample demonstrated depressive symptoms (CDI > 13) at study entry and 10% at 2 yr follow-up. Adolescents aged 14.1–16 yr and those with diabetes > 10 yr demonstrated the highest rates. When demographic/clinical variables were controlled, the DFBS warmth-caring subscale (p = 0.001) and the FACES adaptability subscale (p = 0.005), but not DFBS guidance-control (p = 0.635), contributed significantly to the explained variance in depressive symptoms (R2 = 0.27) at study entry. At 2 yr follow-up, study entry CDI scores were the only significant predictor of depressive symptoms (R2 = 0.40). By 2 yr, adolescents with depressive symptoms had significantly higher HbA1c than those without (p = 0.03). Conclusion: The prevalence of depressive symptoms in adolescents with type 1 diabetes coupled with the potential impact of depressive symptoms on metabolic control suggest the need for early diagnosis and treatment. Greater attention to psychosocial outcomes of youth, family functioning, and the potential burden of diabetes over time to youth/families is indicated.

The purpose of this mixed method study was to describe family management challenges for parents who have sons with Klinefelter Syndrome (KS). Standardized survey results showed that stress, quality of life and family management struggles varied by parent age. When interviewed, parents described feeling uninformed and without support to make decisions about managing their sons' KS. Parents reported that a lack of guidance and case coordination created barriers in caring for their sons throughout childhood. Given the prevalence of KS, health care providers need to be prepared to provide comprehensive evaluation and anticipatory guidance for KS boys and families.

Purpose: To examine the following questions with regard to the initiation of a new intensive management program for adolescents with Type 1 diabetes mellitus: (a) What clinical and psychosocial factors are associated with achievement of metabolic control treatment goals after 1 year? and (b) What baseline clinical and psychosocial factors are associated with improvement in the quality of life after 12 months? Methods: Eighty-one subjects (of 83 who began; aged 14.3 ± 2.0 years at entry; 48 females, 33 males; 95% white; diabetes duration 8.9 ± 3.9 years) with Type 1 diabetes completed 12 months of follow-up in a study of intensified treatment of diabetes. Assessments at baseline and at 12 months used the Diabetes Quality of Life for Youth scale, the Self-efficacy for Diabetes Scale, the Children's Depression Inventory, the Issues in Coping with Diabetes Scale, and the Diabetes Family Behavior Scale. Data were analyzed using multiple and logistic regression. Results: From a baseline of >9%, HbA1c levels decreased to a mean of 7.8 ± 0.7%, with 30% of the subjects achieving our treatment goal of ≤7.2%. Logistic regression demonstrated that achievement of goal levels of HbA1c were associated with better metabolic control at study entry ( p = .05), participation in coping skills training ( p = .003), and more parental participation in guidance and control ( p = .05). Multiple regression analysis demonstrated that participation in coping skills training with lower impact of diabetes on quality of life at baseline and less depression at baseline contributed significantly to the variance (0.57) in quality of life at 12 months. Conclusions: Providers need to pay particular attention to adolescents with poorer metabolic control and impact of diabetes on quality of life when they intensify their treatment because they are less likely to reach treatment goals. Furthermore, behavioral interventions such as coping skills training may help teens achieve their goals.

Objective: To determine whether initial effects on metabolic control and quality of life associated with a behavioral intervention combined with intensive diabetes management (IDM) can be sustained over 1 year in youth implementing intensive therapy regimens. Study design: Seventy-seven patients (43 females, 95% white) 12 to 20 years (mean = 14.2 ± 1.9; duration, 8.7 ± 3.9) electing to initiate IDM were randomly assigned to one of two groups: with or without coping skills training (CST), which consists of 6 small group sessions and monthly follow-up to help youth cope with their lives in the context of diabetes management; skills included social problem solving, cognitive behavior modification, and conflict resolution. Data were collected before the intervention and at 3, 6, and 12 months after the intervention by using the Self-Efficacy for Diabetes Scale, Children's Depression Inventory, Issues in Coping with IDDM, and the Diabetes Quality of Life: Youth scales. Clinical data (glycosylated hemoglobin level, height, weight, adverse effects) were collected monthly. Results: The CST and IDM groups were comparable at baseline. CST subjects had lower glycosylated hemoglobin ( P =.001) and better diabetes ( P =.002) and medical ( P =.04) self-efficacy, and less impact of diabetes on their quality of life ( P =.005) than youth receiving IDM alone after 1 year. In males, CST did not affect adverse outcomes of IDM hypoglycemia, diabetic ketoacidosis, and weight gain, but CST decreased the incidence of weight gain ( P =.05) and hypoglycemia in females ( P =.03). Conclusions: The addition of behavioral intervention to IDM in adolescence results in improved metabolic control and quality of life over 1 year. (J Pediatr 2000;137:107-13)

Issues and controversies in chronic illness research are discussed, with data and examples from a program of research dealing with children and adolescents with diabetes. The key differences that demand consideration include prevalence, developmental issues, measurement, cultural issues, the lack of viable models, use of controls, the importance of the family, and ethical concerns.

OBJECTIVE: Recommendations from the Diabetes Control and Complications Trial (DCCT) indicate that adolescents with type 1 diabetes should be treated with intensive therapy involving multiple daily injections (MDI) of insulin or insulin pump therapy (continuous subcutaneous insulin infusion [CSII] to help obtain better metabolic control and prevent later complications. Interest has thus focused on insulin pump therapy to help adolescents meet this challenge. The purpose of this study was to examine responses to CSII and MDI in a large group of adolescents with established type 1 diabetes during a 12-month period and to determine whether either treatment regimen more favorably affected clinical and psychosocial outcomes. RESEARCH DESIGN AND METHODS: One-third of 75 youths aged 12-20 years who were candidates for intensive therapy chose CSII as their mode of treatment. Patients received intensive treatment and education as described by the DCCT investigators. Psychosocial data (e.g., quality of life, depression, self-efficacy, and coping) were collected at baseline and at 6-month intervals, and clinical data (e.g., HbA1c levels, adverse events) were collected every 4-6 weeks. RESULTS: Although both MDI- and CSII-treated adolescents initially exhibited improved metabolic control, this level of control was more difficult to sustain for 12 months in the MDI group (at 6 months HbA1c = 8.1, at 12 months HbA1c = 8.3), whereas average HbA1c levels in the CSII group continued to decrease during the 12 months of treatment (at 6 months HbA1c = 7.7, at 12 months HbA1c = 7.5). Despite lower HbA1c levels in CSII-versus MDI-treated patients, the rate of severe hypoglycemic events was reduced by almost 50% in the CSII group (P = 0.01). Self-reported questionnaires demonstrated that there was improvement in self-efficacy, depression, and quality of life in both MDI- and CSII-treated patients. Finally, adolescents using CSII found coping with diabetes to be less difficult than adolescents using MDI did. CONCLUSIONS: CSII is an alternative means to lower HbA1c levels and reduce the risk of hypoglycemia without adversely affecting psychosocial outcomes in adolescents with type 1 diabetes.

The purpose of this study was to determine if a behavioral intervention (coping skills training ZCST]) combined with intensive diabetes management can improve the metabolic control and quality of life in adolescents who are implementing intensive therapy. A total of 77 youths (age range, 12.5–20 years) who were beginning intensive insulin therapy were randomly assigned to one of two groups: intensive management with CST or without CST. CST consists of a series of small group efforts designed to teach problem solving skills and communication. Data were collected preintervention and at 3 and 6 months post-intervention by using established clinical and psychosocial indicators. Randomization produced equivalent groups. After 6 months, subjects who received CST had better metabolic control ( F = 3.89, p = .02) and better general self-efficacy ( F = 4.54, p = 0.01). They reported less negative impact of diabetes on their quality of life ( F = 4.55, p = .01) and had fewer worries about diabetes ( F = 3.82, p = .02). Thus, nurses may find CST useful in assisting youths with diabetes to achieve metabolic and quality of life goals.