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The purpose of this study was to explore perceptions of the first dose of a cognitive behavioral sleep self-management intervention (CB-sleep) among young adults aged 18 to 25 years with type 1 diabetes (T1D). We used a qualitative descriptive approach to conduct in-depth semi-structured focused interviews with a purposive sample of 16 young adults with T1D, transitioning from adolescence to early adulthood. Interviews were audio-recorded, transcribed verbatim, and analyzed using qualitative content analysis. Participants described their sleep knowledge (previous, new, and additional), sleep health goals, along with barriers and facilitators of the CB-sleep intervention. Based on these results, we suggest CB-sleep is a useful modality with the potential to support sleep self-management in young adults with T1D during this complex life transition. Furthermore, CB-sleep could be incorporated into an existing diabetes self-management education and support program after pilot testing and determining efficacy to improve sleep and glycemic health.

Purpose: The primary purpose of this descriptive cross-sectional study was to examine the associations between sleep-wake characteristics (total sleep time, sleep variability, sleep onset latency, and sleep efficiency), distress symptoms (general and diabetes), and diabetes physical symptoms in young adults ages 18 to 30 years with type 1 diabetes (T1D). The secondary purpose was to determine whether biological sex, body mass index (BMI), and T1D duration (covariates) influence the relationships among the study variables. Methods: Forty-six young adults with T1D, recruited from diabetes clinics from December 2018 to February 2020, wore a wrist actigraph and continuous glucose monitor concurrently for 6 to 14 days and completed the PROMIS Emotional Distress Scale, Diabetes Distress Scale, and Diabetes Symptom Checklist-Revised. Results: Shorter total sleep time and poorer sleep efficiency were associated with higher diabetes emotional distress symptoms. Higher sleep variability was associated with higher neurological pain symptoms. A longer sleep onset latency was associated with higher symptoms of diabetes distress, including psychological, cognitive, hyperglycemia, and a higher total symptom burden. Associations remained statistically significant after adjusting for biological sex and BMI, with the exception of sleep onset latency and total symptom burden. Conclusions: Poorer objective sleep-wake characteristics were associated with higher diabetes symptoms even after considering biological sex and BMI among young adults with T1D.

Background The Self- and Family Management Framework (SFMF) was created in 2006 and revised in 2015 to guide research on self- and family management of chronic conditions. There has been no review of use of the SFMF. Purpose We reviewed articles citing the SFMF to identify the frequency and nature of use. Method We conducted a citation analysis, searching Web of Science, Scopus, and Google Scholar databases and extracted key data from identified articles. Findings Of 126 articles, 84(66%) cited the 2006 SFMF, 37(29%) cited the 2015 SFMF, and 6(5%) cited both. The SFMF was used most to inform study design. Users noted strengths (e.g., considers family context) and limitations (e.g., non-specification of patient- family caregiver synergies) of the framework. Discussion The SFMF has been used broadly to guide research on self- and family management of chronic conditions. Findings will inform development of a third version of the SFMF.

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.

AIMS To describe the specific domains of diabetes distress and factors associated with these domains. BACKGROUND Diabetes distress is a common problem but not well recognised in adolescents by healthcare providers or adolescents themselves. There is insufficient evidence on how specific domains of diabetes distress exist in adolescents, making it challenging to select precise components to alleviate diabetes stress. DESIGN A quantitative, descriptive and cross-sectional study. METHODS Data were collected on socio-demographic and clinical characteristics, diabetes distress, perceived stress, self-efficacy and diabetes self-management using established questionnaires. Multivariate linear regression was conducted to examine the associations between specific factors and four domains in diabetes distress. STROBE checklist was used as the guideline for this study. RESULTS A total of 100 adolescents with type 1 diabetes aged 12 to 18 years participated in this study. Adolescents experienced the highest levels of distress in the regimen-related distress [2.41 (SD =0.82)] and physician-related distress [2.40 (SD =0.80)] domains. Older age, female gender, more diabetes problem-solving and higher levels of perceived stress were associated with higher regimen-related distress (β = 0.21 ~ 0.45, p

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

Purpose The purpose was to investigate the effects of metabolic control, self-efficacy, and quality of life on emotional eating in the adolescents with type 1 diabetes mellitus. Methods This was a descriptive, cross-sectional, and correlational study. A total of 107 adolescents participated. Data were collected using the Pediatric Quality of Life Inventory (TM) 3.0 Diabetes Module, the Diabetes Management Self-Efficacy Scale, and the Emotional Eating Scale. The relationships among emotional eating, metabolic control, self-efficacy, and quality of life were assessed using bivariate correlation analyses. Multiple regression analysis was used to analyze the data. Results The adolescents with diabetes ranged in age from 11 to 18 years. The mean duration of diabetes was 5.42 +/- 3.35 years. Mean A1C levels were 9.29 +/- 1.38%, far above the recommended level. When the correlation between emotional eating and self-efficacy was studied in the adolescents, there was a significant positive moderate correlation of self-efficacy with emotional eating. There was a significant negative moderate correlation between quality of life and emotional eating, but no significant correlation between A1C and emotional eating. Conclusion As a result of the study, it was found that self-efficacy and quality of life of adolescents with type 1 diabetes have an effect on emotional eating, while A1C values of adolescents have no effect on emotional eating. In future studies, it is recommended to add other factors that may affect the emotional eating behaviors of adolescents with diabetes and also to make different studies with a higher number of samples.

PurposeThe purpose of this study was to explore the perceived facilitators and barriers for obtaining sufficient sleep in young adults with type 1 diabetes (T1D).MethodsA qualitative descriptive approach was used to generate data. In-depth semi-structured interviews with 30 young adults with T1D (66.7% female, mean age = 22.1 years) were conducted. Interviews were transcribed verbatim and coded using NVivo.ResultsYoung adults with T1D reported feeling challenged at bedtime and overnight by the demands of a complex disease management regimen. General and diabetes-specific barriers and facilitators to obtaining sufficient sleep were the overarching themes in the present study. Young adults perceived that electronic device use was a facilitator for relaxation before bed and a barrier to sleep by some participants. Delays in bedtime or disruptions in sleep were common diabetes-specific barriers.ConclusionsWhen designing sleep-promoting interventions for young adults with T1D, researchers should consider diabetes-specific challenges and solutions in addition to those present in the general young adult population.

The Self- and Family Management Framework (SFMF) identifies factors and outcomes of patient and family management of chronic illness. In a previous citation analysis, we reported the frequency and nature of use of the SFMF.We conducted a sub-analysis of quantitative articles in the citation analysis to examine testing of relationships depicted in the SFMF.We analyzed study purposes, independent and dependent variables, study implications, and text that referred to the SFMF in 40 articles.The SFMF has been used largely to explore factors affecting SFM behaviors, focusing on patient versus family self-management. Independent variables included all categories of facilitators/barriers specified in the SFMF. Dependent variables included all SFMF components (Facilitators/Barriers, Processes, Proximal and Distal Outcomes). Racial/ethnic diversity was limited among study participants. Study implications pertained mostly to psychosocial outcomes. Most studies referred to the SFMF generally.Findings will contribute to revision of the SFMF.

Purpose To examine youth and parent perspectives on the acceptability of Bright 1 Bodies, a group physical activity and coping intervention for adolescents with type 1 diabetes mellitus (T1DM). Methods Adolescents participated in 12 weekly sessions of moderate to vigorous physical activity and discussion with peers with T1DM. Adolescents completed an exit survey measuring satisfaction with the intervention on a 5-point Likert scale. Semistructured interviews were conducted with adolescents and at least one parent. Qualitative description was used to develop themes that summarize the acceptability of the intervention. Results Mean scores for survey subscales were: 4.5 (SD = 0.39) for program components and strategies, 4.4 (SD = 0.44) for comfort with the intervention, and 4.3 (SD = 0.62) for instructors. Themes included: (1) adolescents and parents valued being around others with T1DM and their families, (2) the intervention helped adolescents gain knowledge and reinforce diabetes self-management behaviors, (3) challenges included convenience and sustaining participant engagement, and (4) adolescents intended to sustain physical activity and diabetes self-management behaviors after the intervention. Conclusions Adolescents and parents viewed the intervention as acceptable across multiple domains. Participants valued the group aspect of the intervention, and future interventions would benefit from integrating social interactions with others with T1DM.

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.

Objective Only 17% of adolescents with type 1 diabetes (T1D) are currently meeting their glycemic targets despite advances in diabetes technologies. Self-management behaviors and challenges specific to use of diabetes technologies are insufficiently studied in adolescents. We aimed to describe the experience of diabetes technology self-management, including facilitators and barriers, among preteens/adolescents with low and high A1C. Research design and methods Youth (10-18 years of age) with T1D who use insulin pump therapy were recruited from the larger quantitative cohort of a mixed methods study for participation in semi-structured qualitative interviews. Maximum variability sampling was used to recruit youth with A1C 9% (n=5). Participants' personal insulin pump and continuous glucose monitoring data were downloaded and served as a visual reference. Interviews were analyzed using a qualitative descriptive approach. Results Participants were 50% female with a median age of 14.9 years and 80% used CGM. The sample was predominantly white (90.0%). Analysis produced four major themes, Bad Day, Expect the Unexpected, Nighttime Dependence and Unpredictability, It's Really a Team and interconnecting subthemes. Youth characterized "Bad Days" as those requiring increased diabetes focus and self-management effort. The unpredictability ("Expect the Unexpected") of glucose outcomes despite attention to self-management behaviors was considerable frustration. Conclusions Diabetes devices such as insulin pumps are complex machines that rely heavily on individual proficiency, surveillance, and self-management behaviors to achieve clinical benefit. Our findings highlight the dynamic nature of self-management and the multitude of factors that feed youths' self-management behaviors. This article is protected by copyright. All rights reserved.

The purpose of this qualitative descriptive study was to describe the sleep health goals in 35 young adults age 18–30 years with type 1 diabetes (T1D). We reviewed clinician sleep reports generated from wrist-worn actigraphs with participants during an in-depth semistructured telephone interview. Interviews were audio-recorded then transcribed verbatim. We performed a constant comparison method for content analysis using NVivoTM. The following two overarching health goals are identified: (a) promoting sleep (quantity, quality, hygiene, bedtime/waketime) and (b) improving diabetes self-management (time in range, sleep and glucose monitoring, and diet). Young adults in the study readily generated goals after visualizing their sleep reports. Sleep data visualization and debriefing is an effective strategy to elicit health goals for young adults with T1D. Supporting young adults with T1D to achieve their health goals for sleep promotion and diabetes self-management is a promising direction for improved sleep and consequently the attainment of glycemic targets.

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.

STUDY OBJECTIVES: The purpose of this study was to describe objective sleep-wake characteristics and glycemia over 7–14 days in young adults with type 1 diabetes. In addition, person-level associations among objective sleep-wake characteristics (total sleep time, sleep variability, and sleep fragmentation index), daytime sleepiness, and glycemia (glycemic control and glucose variability) were examined. METHODS: In this cross-sectional study, objective sleep-wake characteristics were measured via actigraphy and glucose variability via continuous glucose monitoring over 6–14 days. At baseline, participants completed the Psychomotor Vigilance Test, the Trail Making Test, and questionnaires on daytime sleepiness, sleep quality, and sleep disturbance including sleep diaries. RESULTS: Forty-six participants (mean age, 22.3 ± 3.2 years) wore a wrist actigraph and underwent continuous glucose monitoring concurrently for 6–14 days. Greater sleep variability was directly associated with greater glucose variability (mean of daily differences; r = .33, P = .036). Higher daytime sleepiness was directly associated with greater glucose variability (mean of daily differences; r = .50, P = .001). The association between sleep variability and glucose variability (mean of daily differences) was no longer significant when accounting for daytime sleepiness and controlling for type 1 diabetes duration (P > .05). A higher sleep fragmentation index was associated with greater glucose variability (B = 1.27, P = .010, pr2 = 0.40) after controlling for type 1 diabetes duration and accounting for higher daytime sleepiness. CONCLUSIONS: Sleep-wake variability, sleep fragmentation, daytime sleepiness, and the associations with glycemia are new dimensions to consider in young adults with type 1 diabetes. Sleep habits in this population may explain higher glucose variability, and optimizing sleep may improve overall diabetes management. CITATION: Griggs S, Hickman RL Jr, Strohl KP, Redeker NS, Crawford SL, Grey M. Sleep-wake characteristics, daytime sleepiness, and glycemia in young adults with type 1 diabetes. J Clin Sleep Med. 2021;17(9):1865–1874.

Diabetes self-management is suboptimal in adolescents with type 1 diabetes (T1D), including those in China. The aim of the study was to investigate the impact of parent–child relationship quality on diabetes self-management. Data were collected by a self-report survey among 122 Chinese adolescents from April to July 2017. The data were analyzed using a one-way analysis of variance, descriptive analyses, correlation analyses, and mediation analyses. The mean age was 13.8 (range, 10–18) years, and the mean diabetes duration was 4.1 (±3.1) years. About half of the adolescents with T1D experienced high levels of perceived stress. Parent–child relationship quality mediated the associations between perceived stress and collaboration with parents, diabetes care activities, and diabetes communication on aspects of diabetes self-management ( ps < 0.05). To reduce the negative impacts of perceived stress on diabetes self-management in this population, parent–child relationship quality should be considered an important element of family-based interventions and clinical practice.

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)

AIMS AND OBJECTIVES To describe obesity-risk behaviours (diet, physical activity and sedentary behaviour) and examine the relationships of the obesity-risk behaviours with body mass index (BMI) in school-aged Korean American children. BACKGROUND Korean American children have a risk of becoming overweight or obese and developing obesity-related complications; however, there is limited research about obesity-risk behaviours in Korean American children. DESIGN A cross-sectional study. METHODS Obesity-risk behaviours of children were assessed with well-validated self-report questionnaires (i.e., Elementary-level School-based Nutrition Monitoring Questionnaire) from children and their mothers. Height and weight of children were measured. Data were analysed with bivariate and multivariate analyses using mixed effects models to incorporate the correlation within siblings. RESULTS A total of 170 Korean American children (mean age 10.9 [2.0] years; 52.4% girls; mean BMI 19.3 [3.2]; 28.7% ≥85 percentiles) participated in the study. Only 38.3% of Korean American children met established recommendations of five fruits/vegetables per day; 56.5% met recommendations for more than 3 days per week of vigorous physical activity; and 40.8% met recommendations for

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.

In this entry, the authors review the literature on peer support and coping skills training for children and adolescents with type 1 and type 2 diabetes to develop a comprehensive review and make recommendations for practice and research. The search was limited to articles published from 2000 to 2018. A total of ten studies met the inclusion criteria and were included in the review. Peer support was defined as the provision of emotional, appraisal, and informational assistance by a created social network member who possesses experiential knowledge of a specific behavior or stressor and similar characteristics as the target population, to address a health-related issue of a potentially or actually stressed focal person. Coping skills training is a psychosocial self-management support intervention focused on improving the coping skills of social problem-solving, communication skills, cognitive-behavioral modification, and stress management. The majority of the studies focused on adolescents. Recommendations for implementation and dissemination research are made.

We explored perceptions and experiences of living with type 1 diabetes mellitus (T1DM) among U.S. Latino adolescents (age 12-19 years) with T1DM and parents with limited English proficiency. We used a qualitative descriptive approach with semi-structured interviews of adolescents together with their parents. Interview data were reviewed, coded, and combined into themes about participant experiences with T1DM. Twenty-four adolescents (mean age: 15.4 years) and 23 parents participated. Analysis resulted in three themes: (a) Understanding and adapting to T1DM (i.e., initial fear and misunderstandings of T1DM; adolescents' reflections on living with a chronic health condition); (b) Coming to terms with social and environmental influences on T1DM self-management (i.e., T1DM as disruptive to school and social activities; dealing with stigma and judgments related to diabetes); and, (c) Integrating T1DM self-management expectations with components of Latino cultures (i.e., orientation toward family well-being; parent concerns about cultural preferences that influence food choices, positive influence of spirituality and religiousness; parental views of their current health care in comparison to that available in their place of birth). Adolescents and their parents reported experiences that are universal to adolescents with T1DM in addition to challenges that are unique to Latinos. Efforts aimed at improving T1DM self-management during adolescence with this population need to be tailored to meet the unique social and cultural contexts and delivered in a culturally and linguistically congruent manner.

INTRODUCTION: Short sleep duration and quality are problems with many youth, and these are associated with difficulties in executive function which may interfere with self-management behaviors. Thus, our purpose was to describe subjective and objective sleep characteristics and their associations with executive function, stress and coping, adjustment, and diabetes self-management in youth with Type 1 Diabetes (T1D). METHOD: Youth with T1D (N=40, M age 13.4±1.9 years, 60% female, 77.1% non-Hispanic white, diabetes duration 7.1±4.6 years, HbA1c 8.2±1.2%) wore an actigraph and a continuous glucose monitor concurrently for 3–7 days and completed questionnaires. Descriptive and bivariate analyses were conducted. RESULTS: Sleep variability was associated with higher stress, higher depressive symptoms, and more glucose variability. More consistent rest-activity rhythm timing was associated with fewer trait anxiety symptoms. More robust rhythms were associated with better diabetes self-management. DISCUSSION: Providers should routinely assess sleep habits in youth, especially those with T1D. Improving consistency in sleep timing and sleep duration may be a potential therapeutic target to improve diabetes clinical outcomes.

Purpose The purpose of this exploratory pilot study was to examine the associations of state and trait anxiety with glycemic control, self-management, and diabetes-specific quality of life (QOL) in youth 10 to 16 years of age with type 1 diabetes (T1D). Methods Bivariate Pearson correlations and multiple linear regression modeling were conducted to examine the relationship among anxiety symptoms, hemoglobin A1C (A1C), self-management, QOL, and covariates. Results A sample of 67 adolescents was 50.7% female, and 87.1% were non-Hispanic white, with a mean ± SD age of 13.4 ± 1.85 years and an A1C of 8.3% ± 1.2% (67 mmol/mol). Higher state anxiety was correlated with older age. Better self-management was correlated with lower trait anxiety and lower state anxiety. Higher state and trait anxiety were associated with poorer self-management. Higher state anxiety was associated with higher A1C. Higher trait anxiety was associated with poorer diabetes-specific QOL. Conclusions State and trait anxiety may differentially affect diabetes outcomes. State anxiety may be a modifiable target for physiologic (A1C) and psychosocial (QOL) outcomes in youth with T1D, while trait anxiety may be a modifiable target for psychosocial outcomes (QOL). Anxiety symptoms should be assessed at regular clinic visits. Interventions to improve anxiety symptoms may in turn improve physiologic and psychosocial outcomes.

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.

Adolescents with type 1 diabetes (T1D) are at a high risk of psychosocial comorbidity, e.g., anxiety, depression, and eating disorders. Anxiety symptoms have been associated with poorer glycemic control. Anxiety symptoms have not been well studied in these youth. Our aim was to describe the experience of anxiety symptoms in adolescents with T1D, especially related to diabetes self-management and sleep patterns. We used qualitative description, consisting of 10 open-ended questions, the State-Trait Anxiety Inventory for Children (STAIC), and Hemoglobin A1c (A1c). The analysis was guided by the principles of thematic analysis. Demographic data, A1c, and STAIC scores were used to stratify the qualitative data. Adolescents with T1D (ages 10-16) were recruited from the Yale Program. Twenty-nine participants were interviewed. Participants were mean age 13.6+1.9 years, 32% minority, 31% lower socioeconomic status (SES), A1c 8.3+1.3%, mean disease duration 5.6+3.7 years, mean state anxiety 47.1+4.5, and mean trait anxiety 32.8+8.2. Four themes and 7 sub-themes emerged. Participants reported that T1D was an extra layer of responsibility that took time away from their ability to participate fully in other aspects of their lives. Some participants were able to integrate diabetes management into their lives, while others were not. Participants noted that their experience of anxiety was associated with poor quality sleep, general lifestyle factors, diabetes, or all of these. Exploratory stratified analyses based on levels of STAIC findings revealed that: adolescents with high state anxiety were from lower SES single-parent families and all reported poor sleep and high A1c levels (≥9.5%); those with low state anxiety were from higher SES families with two parents, all had low A1c levels (≤7.5%), and all were still managed by their parents. Associations between anxiety symptoms and poorer self-management should be confirmed with further data. Increased screening and interventions for anxiety symptoms might be warranted. Disclosure K. Rechenberg: None. L.S. Sadler: None. M. Grey: None.

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.

Type 1 diabetes (T1D) is one of the most common chronic health conditions in youth in the United States, and its incidence is rising worldwide. Youth with T1D are at a high risk of psychological comorbidity, for example, anxiety, depression, and eating disorders. Psychological comorbidities, especially anxiety symptoms, have been correlated with poorer diabetes outcomes, but anxiety symptoms have not been well studied in these youth. The primary aim of this study was to describe the experience of anxiety symptoms in youth with T1D, especially as those symptoms relate to diabetes self-management tasks. We used a qualitative descriptive approach, consisting of an in-depth, semi-structured interview comprising 10 open-ended questions with follow-up probes. The analysis was guided by the principles of thematic analysis. Demographic data, Hemoglobin A1c levels, and the State-Trait Anxiety Inventory for Children survey data were also collected and analyzed. We identified four themes and seven sub-themes. Participants (n = 29, ages 10-16, 55% female) reported that T1D was an extra layer of responsibility that took time away from their ability to participate fully in other aspects of their lives. Some participants were able to integrate diabetes management into their lives, while others were not. Some participants were dependent on parents and the school nurse for diabetes management. Participants described two types of anxiety symptoms, general and diabetes-specific, and they noted that their experience of anxiety was associated with poor quality sleep, general lifestyle factors, and diabetes.

To test whether binge eating and emotional eating mediate the relationships between self-reported stress, morning cortisol and the homeostatic model of insulin resistance and waist circumference. We also explored the moderators of gender and age. Data were from 249 adults (mean BMI = 26.9 ± 5.1 kg/m2; mean age = 28.3 ± 8.3 years; 54.2 % male; 69.5 % white) recruited from the community who were enrolled in a cross-sectional study. Participants completed a comprehensive assessment panel of psychological and physiological assessments including a morning blood draw for plasma cortisol. We found negative relationships between stress and morning cortisol (r = −0.15 to −0.21; p < 0.05), and cortisol and the homeostatic model of insulin resistance and waist circumference (r = −0.16, −0.25, respectively; p < 0.05). There was not statistical support for binge eating or emotional eating as mediators and no support for moderated mediation for either gender or age; however, gender moderated several paths in the model. These include the paths between perceived stress and emotional eating (B = 0.009, p < 0.001), perceived stress and binge eating (B = 0.01, p = 0.003), and binge eating and increased HOMA-IR (B = 0.149, p = 0.018), which were higher among females. Among women, perceived stress may be an important target to decrease binge and emotional eating. It remains to be determined what physiological and psychological mechanisms underlie the relationships between stress and metabolic abnormalities.

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

Background: Physical inactivity continues to be a major risk factor for cardiovascular disease, and only one half of adults in the United States meet physical activity (PA) goals. PA data are often collected for surveillance or for measuring change after an intervention. One of the challenges in PA research is quantifying exactly how much and what type of PA is taking place—especially because self-report instruments have inconsistent validity. Objective: The purpose is to review the elements to consider when collecting PA data via motion sensors, including the difference between PA and exercise, type of data to collect, choosing the device, length of time to monitor PA, instructions to the participants, and interpretation of the data. Methods: The current literature on motion sensor research was reviewed and synthesized to summarize relevant considerations when using a motion sensor to collect PA data. Results: Exercise is a division of PA that is structured, planned, and repetitive. Pedometer data include steps taken and calculated distance and energy expenditure. Accelerometer data include activity counts and intensity. The device chosen depends on desired data, cost, validity, and ease of use. Reactivity to the device may influence the duration of data collection. Instructions to participants may vary depending on the purpose of the study. Experts suggest pedometer data be reported as steps—because that is the direct output—and distance traveled and energy expenditure are estimated values. Accelerometer count data may be analyzed to provide information on time spent in moderate or vigorous activity. Discussion: Thoughtful decision making about PA data collection using motion sensor devices is needed to advance nursing science.