Current State of the Science: The treatment of type 1 diabetes is complex, requiring daily insulin administration and monitoring of blood glucose levels, diet and exercise. In adolescents, the perceived level of stress arising from the daily hassles of managing this disease may influence treatment adherence and metabolic health outcome, especially when using more intensive regimens such as intensive insulin therapy (IIT).
Objective: The purpose of this secondary analysis was to investigate interrelationships among IIT use, diabetes-related stress, adherence and metabolic health outcome in female adolescents with type 1 diabetes.
Design: The primary study used a randomized, controlled design implemented in a single clinical site. For this secondary analysis, only data from the baseline assessment were used, more consistent with a correlation type design.
Population, Sample, Setting, Years: Subjects were sampled from the female patients with type 1 diabetes between the ages of 16 and 20 years attending a diabetic clinic located in a university-affiliated healthcare system in Southwestern Pennsylvania during 2000. The sample consisted of 47 young women, who were predominantly white (n=41, 83.7%), aged 16 to 20 years (mean=17.4, SD=1.0), and had type 1 diabetes on average 7.1 years (SD=3.9, range=1-17).
Variables Studied Together: Relationships among types of diabetes regimen (IIT vs. non IIT), self-reported stress and adherences, and metabolic control as measured by glycosylated hemoglobin will be investigated.
Method: All measures were compiled into one self-administered questionnaire, mailed to the subjects, completed at home and returned during a clinic visit. Regimen adherence was measured as a sum of 5 Likert scaled items addressing adherence to components of the diabetes regimen (i.e., following a diet plan, checking blood sugars, administering insulin as recommended, exercising regularly, and keeping scheduled clinic visits) during the past 3 months. Items ranged from 1 (=none of the time) to 5 (=all of the time) and high scores were suggestive of good adherence to the diabetes regimen. Diabetes-related stress was measured as a summative score of 6 Likert scaled items, ranging from 1 (=not at all) to 4 (=very much), which assessed stress over a various aspects of diabetes self-management during the past 3 months. High scores were indicative of greater levels of stress related to diabetes self-management. Metabolic control health outcome was measured as glycosylated hemoglobin (HbA1c) based on A1C At Home lab assays (normal HbA1c=4.6% to 6.4%). IIT was defined as checking blood sugar levels >4 times daily and >3 daily shots of insulin or use of insulin pump.
Findings: Most of the subjects were on IIT (n=29, 59.2%). Eight subjects (16.3%) were on insulin pumps. Of the remaining 39 subjects, most (n=23, 48.9%) were administering insulin shots 3 or 4 times per day. Subjects reported checking their blood sugar on average 3.9 times per day (SD=1.7, range=0-8). Metabolic control based on HbA1c lab values was on average 8.1 (SD=1.3, range=5-12). Subjects reported good adherence (Mean=19.7, SD=3.2, range=6-20) and moderate levels of diabetes-related stress (Mean=12.9, SD=3.7, range=8-25). IIT use was significantly related to adherence (t=-2.49, p=.02) and marginally related to HbA1c (t=1.90, p=.07) suggesting that diabetic adolescents on IIT have better regimen adherence and metabolic control than adolescents not on IIT. Correlational analyses revealed significant relationships between diabetes-related stress and adherence (r=-.31, p=.04) and adherence and HbA1c (r=-.39, p=.01). These findings indicate that as stress related to diabetes self-management increases adherence with the regimen decreases and that poor adherence is associated with poor metabolic control.
Conclusions: These results suggest that IIT is associated with improved treatment adherence and metabolic control health outcome in diabetic adolescents without increasing stress related to diabetes self-management.
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