Objective. Previous studies have suggested adolescents with type 1 diabtes who strive for good metabolic control are at risk for poorer metabolic control and quality of life in young adulthood. Unfortunately, the majority of these studies were retrospective and conducted prior to the release of the Diabetes Control and Complications Trial (DCCT) results. The DCCT was a large randomized clinical trial that demonstrated that intensive insulin treatment with maintenance of metabolic control of type 1 diabetes as close to normal as possible could delay or prevent the onset of the neuropathic and microvascular complications of diabetes. In response to these findings, intensive insulin treatment became the standard for type 1 diabetes care in adolescents, but little is known about the impact of intensive treatment in adolescence on metabolic control and quality of life as these youth transiton to young adulthood. This concern has led some clinicians not to promote good control before adulthood. The purpose of this prospective study was to determine if intensive treatment provided during adolescence was associated with poorer metabolic control and quality of life in a cohort of teens on intensive diabetes treatment.
Design. Prospective, longitudinal cohort study.
Population, Sample, Setting, Years. The population of interest is adolescents and young adults with type 1 diabetes on intensive insulin treatment. A total of 130 teens were recruited from a Regional Diabetes Center in the northeast. The youth ranged in age at baseline from 12 to 20 (mean=14.4+/-2.0 years); there were 71 females and 45 males; and their race/ethnicity was 106 white; 3 black, 4 Hispanic. Over the 5 years of follow-up, only 23 have been lost to follow-up for a total sample of 116. The study was conducted over 5 years (1995-2001).
Concepts or Variables Studied. Diabetes Quality of Life, Glycosylated hemoglobin.
Methods. Data were collected using the Diabetes Quality of Life for Youth scale with 3 subscales (disease impact, satisfaction, and worry), that has been used in a number of studies and has reliabilities ranging from 0.86 to 0.95. Metabolic control was indicated by glycosylated hemoglobin (HbA1c) assessed with the DCA 2000 (Bayer, Tarrytown, NY). Measurements were made at baseline, 3 months, and then at 6 month intervals for up to 5 years, representing youth from age 12 to age 24 years. To assess whether curvilinear models were improvements over flat lines, mixed models calculated and selected using Akaike's Information Criteria (AIC).
Findings. For metabolic control, a quadratic expected value was selected together with autoregressive moving average (ARMA) errors. Expected metabolic control increased in this model from 7.64+/-0.16% at age 12 to a peak of 8.69+/-0.12% at 18 years, and then decreased to 7.90+/-0.33%, almost the same level as at baseline, by age 24. A comparison of AIC scores indicates that this model provides a tangible improvement (3%) over a constant model. In other words, metabolic control worsened over the adolescent years, but there was no difference between HbA1c at age 12 and at age 24. There were no gender differences. Models of the 3 quality of life outcomes (impact, worry, satisfaction) with nonconstant expectation curves have lower AIC scores than the constant model, but the scores for the constant models were almost the same (<0.2%). These results indicate that quality of life is reasonably modeled as a constant, and hence, does not worsen over time. Thus, youth on intensive insulin treatment report generally good quality of life that does not worsen into young adulthood.
Conclusions. Our results indicate that metabolic control, while worsening over the adolescent years, does not vary as much as in studies conducted pre-intensive treatment. Further, quality of life appears to remain relatively stable in this group of intensively treated youth. In addition, the data suggest that striving for better metabolic control using intensive treatment does not worsen quality of life in young adulthood.
Implications. This is the first prospective study conducted after the release of the DCCT results to examine the transition from adolescence to young adulthood in youth on intensive insulin treatment. The data demonstrate that now that intensive treatment is the standard of care, negative effects in young adulthood, such as poorer metabolic control and quality of life in youth, appear not to be a problem. Therefore, clinicians need not be concerned that working toward good metabolic control of diabetes in adolescence will increase the risk for poorer outcomes during the transition to young adulthood.
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