Improving HbA1c in Teens with Type 1 Diabetes

The biological and psychological changes of adolescence are never easy, but youth with type 1 diabetes (T1DM) have a double cross to bear. Studies have shown that this age group has the poorest glycemic control of all. Biology partly explains the problem. The hormonal changes of adolescence can wreak havoc on glucose control. Emotional and behavioral difficulties-though sometimes overlooked-also play a vital role, given the increased risk for depression, anxiety, and eating disorders among teens.

Now a new study has looked at the complexities of this issue by zeroing in on contributing factors such as poor self-esteem and low self-efficacy. The study was published in the Journal of Diabetes Research.

“More problem behavior in adolescents with type 1 diabetes is associated with worsened glycemic control and this relationship is mediated by low confidence in diabetes self-care and poorer self-management of the diabetes,” wrote first author Minke Eilander, PhD, and colleagues at the VU University Medical Center, Amsterdam, Netherlands.

In particular, the study looked at internalizing behaviors such as depression, and externalizing behaviors like disruptive problems, hyperactivity, and impulsivity.  

The study included 88 youths (51% boys) aged 11-15 with T1DM. Participants were part of a larger study called Diabetes in Development (DINO) conducted in The Netherlands, which focused on biological and psychosocial development during adolescence. Participants completed an online survey that asked about several areas of emotional and behavioral functioning. Questions were adapted from the Strengths and Difficulties Questionnaire (which asks about peer problems, hyperactivity, social behavior, and provides an estimate of normal behavior), the Confidence in Diabetes Self-Care-Youth Questionnaire, and the Diabetes Mismanagement Questionnaire.

Researchers used HbA1c as a marker of glycemic control, with a target of <7.5%

Key Results:

• 14% of youth reported problem behavior outside the normal range

• 82.7% of youth had HbA1c that failed to reach target (mean HbA1c: 8.0%)

• Higher overall problem behavior scores were significantly linked to:

♦ Higher HbA1c (P=0.029)

♦ Worse diabetes self-care (P<0.01)

• Lower confidence in diabetes self-care was linked to higher HbA1c (P<0.01)

• Further analyses showed that low self-confidence in diabetes self-care and poor diabetes self-management mediated the relationship between overall problem behavior and higher HbA1c

Increased externalizing problem behavior was significantly linked to higher HbA1c (P=0.02), with lower confidence in diabetes self-care mediating the effect. While the association between higher internal problem behavior and increased HbA1c failed to reach significance (P=0.270), internal problem behavioral was significantly linked to low confidence in diabetes self-care (P=0.042), which in turn was linked to higher HbA1c (P<0.01).

The study confirms past results suggesting that problem behaviors can lead to higher HbA1c levels, while adding a layer of complexity concerning the role that self-confidence plays in self-management of diabetes among teens with T1DM. The authors suggested that screening for problem behaviors among teens-including questions about internalizing and externalizing behaviors-may help improve glycemic control.

“Our findings corroborate the clinical relevance of finding practical ways to ensure that assessment and management of behavioral problems in adolescents are in place,” the authors stressed “…To assist adolescents in achieving better glycemic control, it would seem imperative to help them build their confidence and reduce diabetes mismanagement, for example, [by] improving their self-care practices.”

Take-home Points

• A Dutch study found that higher overall problem behavior is significantly linked to higher HbA1c among adolescents with T1DM.

• Low self-confidence in diabetes self-care and poor diabetes self-management mediated the relationship between overall problem behavior and higher HbA1c.

• Screening for problem behavior, including internalizing and externalizing behaviors, as well as building self-confidence, may improve glycemic control in youth with T1DM.

Reference: Eilander MM, et al. Low self-confidence and diabetes mismanagement in youth with type 1 diabetes mediate the relationship between behavioral problems and elevated HbA1c. J Diabetes Res. 2016;2016:3159103.

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