Can-Do-Tude: an Online Intervention Using Principles of Motivational Interviewing and Tailored Diabetes Self-Management Education for Adolescents with Type 1 Diabetes

abstract: Type 1 diabetes (T1D) is one of the most common chronic diseases in youth and it has been shown that adolescents have the worst glycemic control of any age group. The objective of this study was to develop, test and evaluate the feasibility of an online intervention (Can-Do-Tude) that uses the principles of motivational interviewing (MI) to deliver tailored diabetes self-management education to adolescents with T1D. Bandura’s efficacy belief system was used to guide the design of this study. The study used a multi-phase, multi-method approach. The first phase (alpha) of this study was a qualitative descriptive design to examine the intervention’s fidelity. Evaluation of performance was conducted by experts in the fields of MI, T1D, adolescence and/or online education. The second phase (beta) was a quantitative descriptive design conducted in order to evaluate feasibility by examining the acceptability (recruitment, retention and satisfaction) and implementation (diabetes self-management self-efficacy) to determine whether the intervention was appropriate for further testing. First phase findings showed that the intervention passed all measures with the content experts (n = 6): it was functional, accurate, usable and secure. Improvements to the intervention were made based on reviewer recommendations. For the second phase 5 adolescents between 14 and 17 were enrolled. Three adolescents completed all 4 weeks of the intervention while 2 completed only 3 weeks. Participants (n = 3) rated satisfaction on a 5-point Likert-type scale ranging from “not at all” satisfied (1) to “very much” satisfied (5). There was a positive response to the intervention (M = 4.28, SD = 0.55). Implementation was measured by a pre- and post-test for diabetes self-management self-efficacy. Participants (n = 3) demonstrated overall improvements in diabetes self-management self-efficacy (Z = -2.952, p = .007). Implications for further Can-Do-Tude research are planned at a metropolitan diabetes center using updated technology including an application platform. Although the sample was small, findings indicate that the intervention can be conducted using a web-based format and there is initial evidence of improvement in self-efficacy for diabetes self-management.Dissertation/ThesisDoctoral Dissertation Nursing and Healthcare Innovation 201

Risks and Prevalence of Diabetic Retinopathy in Children and Young People with Type 1 Diabetes Mellitus

Diabetic retinopathy is a progressive ophthalmic microvascular complication of diabetes and is one of the commonest complications of Type 1 diabetes (T1D). The prevalence of diabetic eye disease varies within different population and age groups, and many risk factors are associated with the development and progression of diabetic retinopathy in T1D. This review discusses the current prevalence of diabetic retinopathy in children and young people (0-18 years) with T1D and the risk factors associated with the presence of diabetic eye disease in this population

Metabolic syndrome, dyslipidemia, hypertension and type 2 diabetes in youth: from diagnosis to treatment

Overweight and obesity in youth is a worldwide public health problem. Overweight and obesity in childhood and adolescents have a substantial effect upon many systems, resulting in clinical conditions such as metabolic syndrome, early atherosclerosis, dyslipidemia, hypertension and type 2 diabetes (T2D). Obesity and the type of body fat distribution are still the core aspects of insulin resistance and seem to be the physiopathologic links common to metabolic syndrome, cardiovascular disease and T2D. The earlier the appearance of the clustering of risk factors and the higher the time of exposure, the greater will be the chance of developing coronary disease with a more severe endpoint. The age when the event may occur seems to be related to the presence and aggregation of risk factors throughout life

Managing diabetes in preschool children

This article is a new chapter in the ISPAD Clinical Practice Consensus Guidelines Compendium. The complete set of guidelines can be found for free download at www.ispad.org. The evidence grading system used in the ISPAD Guidelines is the same as that used by the American Diabetes Association

Predictors of mortality and survival in type 1 diabetes: a retrospective cohort study of type 1 diabetes mellitus (T1D) in the Wirral Peninsula

Background: The prevalence of T1D is rising, despite improvements in the management of this condition. It presents a risk of premature and excess mortality, which impacts survival and life expectancy. Aim: The study aim was to assess mortality, identify predicting risk factors for mortality and survival in T1D in the Wirral. A systematic review was done to establish present current evidence of all-cause and cause-specific mortality amongst T1D patients. Methods: A retrospective cohort study design, 1786 patients diagnosed with T1D extracted from the Wirral Diabetes Register (WDR). The follow-up period was between 1st of January, 2000 to 31st December, 2012. The primary outcome measured was all-cause mortality. Results: 1458 participants with T1D meet the inclusion criteria, after a follow-up period of 12 years, 113(7.75%) deaths were recorded. While the incidence rate was steady over the study period, the prevalence rate continued to increase over the study period. Significant predictors of mortality in this cohort were age of diagnosis, duration of diabetes, HbA1c,systolic blood pressure (SBP), diastolic blood pressure (DBP), and triglyceride levels. The predicting risk gender, age at diagnosis, duration of T1D, BMI, serum creatinine levels, SBP, total cholesterol, LDL, HDL, TC\HDL, and LDL\HDL showed a linear increase in mortality risk. IMD and DBP followed a U-shaped relationship with relative and absolute mortality, while HbA1c levels reveal a sinusoidal pattern with the highest risk of mortality at the levels ≤ 5.9% (41 mmol/mol). The risk of mortality for the predicting risk factors for this study ranged between 5% and 9%. Maximal risk of mortality of 9% was recorded in the predicting risks of smoking, BMI, SBP, and DBP. The risk of mortality of 8% was recorded for IMD, serum creatinine, total cholesterol, TG, LDL\HDL ratio, and TSH. The risk of mortality of 7% was recorded for the predicting variables of HbA1c, HDL, LDL, and TC\HDL ratio. The minimum risk of mortality of 5% was recorded for the predictor variable of the duration of diabetes. The significant predictors of mortality were the age at diagnosis, duration of diagnosis, systolic and diastolic blood pressure, HbA1c. The burden of mortality rest disproportionately with females who had higher relative risk of mortality of 4 times that of their male counterparts, however, the burden of premature mortality as recorded by the years of potential life lost was slightly higher in males (1797[53.6%]) as compare to females (1553[46.4%]). Of the 113 deaths recorded for the cohort that indicated a proportion of 7.75% of the total T1D patients, records for only 37 participants were retrieved. The principal cause of death in this cohort was malignancy-related 8 deaths (21.6%), this was followed by cardiovascular disease and sepsis, each having 6 deaths (16.2%) respectively. Cerebrovascular disease accounted for 5 deaths (13.5%). Death from diabetes complications (hypoglycaemia) was recorded in 1 patient (2.7%). There were marked reductions in life expectancy for this cohort. Life expectancy at 40 years for females was to an average age mortality of 66.2 years as compared to males 78.3 years. There has been improved survival for T1D in this cohort, 77.185 years [95% CI: 75.191 – 79.179] in males and 76.011 years [95% CI: 73.169 – 78.000] in females. The systematic review highlighted increased mortality in those with T1D as compared to the general population, females showed greater risk of vascular complications as compared to the males with T1D. 35 studies were included. Results showed all-cause mortality RR 3.73 (95% CI 3.19, 4.36) compared to general population, with gender specific mortality RR 1.17 (95% CI 1.06, 1.29). For cause specific mortality risk (overall and gender specific): cardiovascular v disease RR 3.48 (95% CI 3.14, 3.86) and RR 1.41 (95% CI 0.92, 2.17); renal disease RR 1.06 (95% CI 0.89, 1.26) and RR 0.63 (95% CI 0.38, 1.04); neoplasms RR 1.03 (95% CI 0.92, 1.16) and RR 1.18 (95% CI 0.75, 1.86); cerebrovascular disease according to gender RR 0.99 (95% CI 0.66, 1.48), and accidents and suicides according to gender RR 2.30 (95% CI 1.31, 4.06). Conclusion In conclusion, the study highlighted significant mortality risk in females as compared to their male counterparts; there has been progress in the survival of patients with T1D. However, life expectancy remains reduced as compared to those without the condition. Prevalence of T1D continues to increase, and the complex interplay of the predictor variables support the need for an individualised approach to care

Understanding the Determinants of Sustained Beta Cell Function in Type 1 Diabetes

Type 1 diabetes is a disease defined by the inexorable autoimmune destruction of pancreatic beta cells, leading to endogenous insulin deficiency. C-peptide, a 31 amino acid protein that joins the alpha and beta chains of insulin in the proinsulin molecule, is well established as a marker of endogenous insulin secretion. Circulating levels within people with type 1 diabetes demonstrate persistence of insulin secretion, in some cases, for many years after diagnosis. Additionally, histological analyses of donor pancreata have provided evidence for persistent immunoreactive insulin-positive beta cells. These findings have challenged the dogma that all beta cells are destroyed at, or soon after, onset of type 1 diabetes. Although it is clear there is some relationship between residual C-peptide and preserved beta cell mass, residual C-peptide alone cannot distinguish between loss of beta cell mass and reduced functionality. As such, C-peptide level remains a contested surrogate for the aetiopathological definition of type 1 diabetes, which is used across disease classification and as the end point in many intervention trials designed to preserve beta cell function. A fundamental difference between type 1 diabetes and type 2 diabetes is that the former is characterised by rapid progression to endogenous insulin deficiency due to autoimmune beta-cell destruction. Since histological classification is impossible in living humans with type 1 diabetes, C-peptide-defined type 1 and type 2 diabetes have been used as the endpoint in the development and validation of classification models which combine clinical features and biomarkers to improve classification of disease at diagnosis. In Chapter 2, I aimed to I validate a classification model that was previously developed on a C-peptide outcome in a clinical cohort, against a histological definition of type 1 diabetes. This classification model combined age, body mass index (BMI), autoantibody status and type 1 diabetes genetic risk score (T1D GRS), with its predictive performance tested on samples defined histologically as having type 1 diabetes and non-type 1 diabetes from the Network for Pancreatic Organ Donors with Diabetes (nPOD) biobank. Strong predictive performance of the model in this setting demonstrated that the C-peptide outcome, used in its development, is representative of histologically defined disease, confirming that C-peptide is a robust, appropriate surrogate outcome that can be used in large clinical studies where histological definition is impossible. In the 1970s it was crystallised that type 1 diabetes is a disease mediated by the autoimmune destruction of insulin producing beta cells. Since then, the centrepiece of many disease modifying intervention trials has been to augment the survival of functional beta cells, assessed via measures of preserved C-peptide secretion. However, there are clear differences in disease progression between children and adults with recent suggestions that, even within children, differences are driven by underlying endotypes. In Chapter 3, across disease duration, I compared the trends of decline of C-peptide in a cohort of living children from the UK Genetic Resource Investigating Diabetes, to the trends of decline of pancreatic beta cells in organ donors from the combined nPOD and Exeter Archival Diabetes Biobank (EADB), through stratifying by newly described age at diagnosis associated endotypes. I demonstrated that C-peptide loss and beta cell loss, in all age at diagnoses studied, mirror one another across duration of disease. I demonstrated that proportionally fewer children diagnosed <7 retained C-peptide after one year of diagnosis, with the levels of retained C-peptide being lower at diagnosis that those diagnosed at older ages. I showed these trends of loss are almost identical in pancreas donors, with proportionally fewer children retaining islets containing insulin positive beta cells after one year of diagnosis, with fewer insulin positive beta cells at diagnosis as compared to donors diagnosed at older ages. The results in this chapter are indicative of the differences in disease progression in children. The rapid depletion of C-peptide and beta cells in children diagnosed < 7 years is suggestive that early intervention close to or before diagnosis may be most time critical, and should additionally be considered in planning and interpretation of intervention trials. Preserving C-peptide is unequivocally beneficial to a person diagnosed with type 1 diabetes, associating with reduced frequency and severity of self-reported hypoglycaemia and fewer long term microvascular complications, as evidenced originally from DCCT. In Chapter 4, using insights from continuous glucose monitoring (CGM) technology, I demonstrated that higher levels of endogenous insulin secretion around the time of diagnosis impact glycaemic variability, but are not associated with hypoglycaemia. The work in this chapter adds to findings from previous studies of longer duration diabetes to offer a more complete picture of the impact that variation in C-peptide levels have on glucose control in people with type 1 diabetes. Increased use of flash and continuous glucose monitoring has enabled more detailed, daily insights into glycaemic control within type 1 diabetes, the relationships of such with C-peptide have been explored within this thesis. This technology however offers a wealth of opportunity for exploring the lived experience type 1 diabetes, in relation to daily glucose control. In Chapter 5 I developed upon the skills I had refined in CGM data analysis, exploring the impact that free-lived high and moderate intensity exercise have on glycaemic control in type 1 diabetes, as compared to an individual’s non-exercise “normal”. I compare monitored glucose traces from 10 adults with type 1 diabetes that each completed three, 14-day intervention periods of: home-based high intensity interval exercise, home-based moderate intensity continuous exercise and a free-living non-exercise control period. A key part of this analysis was the careful comparison of the glucose traces in each exercise intervention period to the glucose traces within the non-exercise of control period, in order to understand how much exercise perturbed an individual from their “normal” . In this analysis I found that the exercise modes assessed increase glycaemic variability and hypoglycaemia in the 4 hours after exercise, had a modest effect on glycaemic variability overnight, but increased glycaemic variability and hypoglycaemia the day after exercise. The findings in this chapter suggest that developing focused clinical guidance around time periods post-exercise, and accounting for “everyday life”, may improve the management of blood glucose in type 1 diabetes and ultimately reduce barriers to exercise. In the majority of endocrine conditions, the hormone in question is measured as part of routine usual care. In diabetes this is not yet the case. In this thesis I provide evidence that C-peptide is a robust surrogate marker of functional beta cells in clinical settings and demonstrate how an estimate of a patients C-peptide reserve could benefit clinical management. In addition to C-peptide level, I explore how exercise is another influential factor on glucose control in type 1 diabetes. Throughout this thesis I aim to place findings within the context of the lived experience of type 1 diabetes. After all, it is the people living with type 1 diabetes that are the reason we continue our research

Effects of adapted multi-dimensional family therapy on glycemic control, diabetes-related family conflict and distress in the families of adolescents with poorly controlled type 1 diabetes

Adolescents with type 1 diabetes (T1D) undergo psychological and physiological challenges that increase the risk for insulin sensitivity, diabetes-related distress, family-conflict, and diabetes-related complications. Glycemic control, the cornerstone of management, is influenced by individual and familial factors. Most adolescents with T1D don’t achieve glycemic targets. This purpose of this research proposal is to describe an RCT with repeated-measures design, that will assess multi-dimensional family therapy for T1D (MDFT-T1D), an intervention that was designed specifically for adolescents with uncontrolled T1D. Adolescents (n=110) and a parent will be randomized to standard-care or MDFT-T1D and enrolled for 30-months. MDFT-T1D will consist of 8 in-person sessions at scheduled diabetes care appointments and intermediate check-in calls. RMANOVA analyses will assess main outcomes of: Glycemic control, blood glucose monitoring, distress, and family conflictEducational Psycholog

The development and evaluation of a web-based diet and diabetes education programme for children with type 1 diabetes

PhD ThesisDiabetes education is one of the essential components of standard diabetes care. Rapid advances in technology have made the internet a viable mode for the delivery of educational interventions to young people with type 1 diabetes (T1D). The main purpose of this study was to develop a web-based education programme to assist in diabetes management and to provide support for children with T1D in Malaysia. The data were collected in three phases using a mix method approach. Participants were children with T1D living in Malaysia (n=64), their parents (n=12), the clinicians (n=3) and Malaysian‟ children living in Newcastle (n=12). In Phase one, the data were collected using both qualitative and quantitative methods to understand the experiences and challenges which children face living with diabetes and to identify regularly consumed carbohydrate-rich foods. In Phase two, data were gathered by a semi-structured interview and an open-ended questionnaire with healthy children in Newcastle to elicit views and general usability of the programme. In the final Phase, Phase three, children with T1D and their families were recruited and introduced to the programme and guided in its use at home. Semi-structured interviews were conducted with children, parents and clinicians, and the questionnaires were used with children in order to gain participants‟ views, experiences and acceptance of the system. Children used the programme for a period of six months. Most children reported using the programme to obtain information about carbohydrate content of the food and drink they consumed and adjusting their insulin accordingly. They also reported they had made changes in their food choices based on the information and knowledge they obtained from the programme. Most of them did not record their blood glucose regularly in the programme. The majority felt confident in managing their diet, insulin, and monitoring their blood glucose, however, a few reported lack of confidence and difficulty managing their diabetes. Clinicians indicated that the programme was feasible to use in the clinic setting to teach and review children‟ blood glucose and dietary intake, and to support children when they faced any problems related to their diabetes. The clinicians believed that the programme had the most application for children as a self-education and self-management system. Overall, participants described the programme as useful, accessible and beneficial for managing diet and diabetes. This study demonstrated feasibility of using the web-based education programme. Further research is required to determine the effectiveness of the programme in improving diabetes management of T1D by young people.Malaysian governmen

Understanding, measuring and treating eating disorders in those with type 1 diabetes

The purpose of this thesis was to explore the nature of Eating Disorders in Type 1 Diabetes. Whether or not Eating Disorders are more prevalent in this demographic is a topic of contention but regardless there is a consensus that those with comorbid Type 1 have considerably worse outcomes and are significantly more difficult to treat. It has been argued that this may be due to a feature unique to this population; insulin omission for weight control. The first aim of this thesis was to systematically review how Eating Disorders have been measured in Type 1 Diabetes, paying particular attention to whether researchers have taken the role of Diabetes regimen and insulin omission into account. Following this a comparison between two Eating Disorder scales, one Diabetes specific the other not, was made in order to compare prevalence rates, to explore which items may be potentially biased and to investigate what the effect of modification may be. The structure of the Diabetes specific scale (the Diabetes Eating Problem Scale Revised) was then explored. The second aim of this thesis was to replicate a pilot study that aimed to explore demographic, psychological and health seeking features of those with Type 1 Diabetes related Eating Disorders. This formed the basis of a structural model whereby psychological and Diabetes specific traits were hypothesised to predict Eating Disorder behaviour and elevated blood glucose levels. A questionnaire built for that study regarding patient attributions was also reanalysed using new data. The final aim was to investigate how Eating Disorders in Type 1 Diabetes have been treated by reviewing literature from the last 2 decades, paying particular attention as to how treatment providers have accommodated the unique needs of those with T1D and whether or not programmes have been successful in relation to both psychological and biological outcomes

The impact of type 1 diabetes on the psycho-social well-being of adolescents

The purpose of this study was to explore and describe the impact of type 1 diabetes (T1D) on the psycho-social well-being of adolescents in a resource-constrained community. Historical and contemporary literature on the psycho-social issues of adolescents with this disease draws attention to the complexity of individual’s experiences in this regard. This study contributes to a context-specific understanding of T1D, by exploring adolescents’ subjective personal, family, school and hospital lived experiences. The relational impact that T1D has on adolescents is further situated in the context of its importance to their psycho-social well-being. This research study adopted Engel’s Biopsychosocial Model, Systems Theory and Phenomenology for the theoretical framework. The researcher consulted relevant literature relating to diabetes, specific to T1D; the adolescent with T1D, defining adolescence and disease-related adjustment; epidemiology, diagnosis, treatment, glycaemic control, management and complications of adolescents with T1D; family centred care for T1D and health related quality of life. A qualitative research approach was applied, guided by an interpretive phenomenological paradigm. Five adolescents, between the ages of 15 and 18 years, described their lived experiences of having T1D during semi-structured interviews. The data was subsequently analysed using interpretative phenomenological analysis (IPA). Five main themes emerged from the transcripts, each of which is discussed separately as well as in relation to other prevalent literature. The critical investigation of the findings presented in this study revealed divergent aspects to those found in some of the current literature, as well as considerations comparable with earlier research. The meanings that emerged from these adolescents’ stories revealed complex cognitive, emotional, social and biological distress, all of which highlight the subjective experience of having T1D, the impact thereof, and the multi-faceted stress it has on their psycho-social well-being.Dissertation (MEd)--University of Pretoria, 2017.Educational PsychologyMEdUnrestricte