OBJECTIVE -To assess the social-cognitive, behavioral, and physiological outcomes of a self-management intervention for youth with type 1 diabetes.RESEARCH DESIGN AND METHODS -A total of 81 youth with type 1 diabetes aged 11-16 years were randomized to usual care versus a "diabetes personal trainer" intervention, consisting of six self-monitoring, goal-setting, and problem-solving sessions with trained nonprofessionals. Assessments were completed at baseline and multiple follow-up intervals. A1C data were obtained from medical records. ANCOVA adjusting for age and baseline values were conducted for each outcome.RESULTS -At both short-term and 1-year follow-up, there was a trend for an overall intervention effect on A1C (short-term F ϭ 3.71, P ϭ 0.06; 1-year F ϭ 3.79, P ϭ 0.06) and a significant intervention-by-age interaction, indicating a great effect among older than younger youth (short-term F ϭ 4.78, P ϭ 0.03; 1-year F ϭ 4.53, P ϭ 0.04). Subgroup analyses demonstrated no treatment group difference among younger youth but a significant difference among the older youth. No treatment group differences in parent or youth report of adherence were observed. CONCLUSIONS It is well-established that a deterioration in glycemic control accompanies adolescence (1), in part due to hormonal changes associated with puberty (2) but also resulting from worsening adherence (3,4). Consequences include hospitalizations and even mortality from diabetic ketoacidosis (5) and physical damage leading to later complications (6). Because diabetes management during childhood is associated with adult behavior and health outcomes (7,8), intervention to enhance diabetes self-management skills may be critical in decreasing the rate of physical health problems throughout the lifespan.Optimal diabetes management is a formidable undertaking for youth, who are still maturing cognitively and socially. Typically, self-management skills are not well developed, and evaluation of behavioral options and consequences may be inadequate. Despite concerns regarding readiness for diabetes management responsibility, increased independence from parents often results in youth assuming additional responsibility at the cost of poorer adherence.The development of effective intervention models during this transitional period is critical and may be facilitated by predominant theoretical perspectives. Social cognitive theory (9) emphasizes the reciprocal relationship of beliefs and social/environmental factors. One's outcome expectations (expected positive and negative outcomes of behaviors) and selfefficacy (perceived ability to perform behaviors) develop from experience, are influenced by cognitive and behavioral skills, and affect subsequent behavior (10,11). These beliefs provide the underpinnings for motivation and selfmanagement processes, as emphasized by the self-regulation model (12), which explains health-related behavior as a function of appraisal of the situation, perceived choice of actions, and evaluation of the outcomes of those actions (13,14). ...

OBJECTIVE -The purpose of this study is to evaluate two updated measures of diabetes regimen adherence. The Diabetes Self-Management Profile (DSMP) is a widely used, structured interview. Limitations include a substantial interviewer and respondent time burden and the need for well-trained interviewers to use appropriate prompts and score the open-ended responses. The Diabetes Behavior Rating Scale (DBRS) is a self-administered, fixed-choice survey.RESEARCH DESIGN AND METHODS -Both measures were administered to 146 youth with type 1 diabetes (aged 11-18 years) and their parents. Items were added to the DBRS to allow for both flexible and conventional regimens, and the DSMP was modified to use standardized wording across items, accommodate flexible regimens, and permit administration by nonmedical interviewers.RESULTS -Both measures had good evidence of internal consistency (for the DSMP: parent 0.75 and youth 0.70; for the DBRS: parent 0.84 and youth 0.84). Scores on the DSMP and the DBRS were significantly related (r ϭ 0.72 for parents and 0.74 for youth). There was moderate agreement between parent and youth (DSMP, r ϭ 0.51; DBRS, r ϭ 0.48). The measures were correlated with HbA 1c for both parent (DSMP, r ϭ Ϫ0.35; DBRS, r ϭ Ϫ0.35) and youth (DSMP, r ϭ Ϫ0.36; DBRS, r ϭ Ϫ0.34) reports.CONCLUSIONS -Both measures exhibit good psychometric properties and good criterion validity but varied in terms of respondent and interviewer burden, issues that should be considered in selecting assessment procedures. Diabetes Care 29:2263-2267, 2006L ong-term complications of insulindependent diabetes (type 1 diabetes) include higher morbidity and mortality from retinopathy, nephropathy, neuropathy, and cardiovascular disease (1-4). There may be no minimum glycemic threshold for the reduction of longterm complications; long-term risk continues to decrease with HbA 1c (A1C) Ͻ8% accompanied by a lessgradual increase in the risk of hypoglycemia (5). Successful management of type 1 diabetes has been shown to reduce the frequency and severity of these long-term consequences; however, although intensive therapy may improve glycemic control, few families are able to maintain metabolic control within the recommended guidelines (1-6), and control appears to decrease during the adolescent years (7-12). To reduce potential longterm health effects, Cefalu (13) argues for lowering the pediatric glycemic goal Ͻ8% but recognizes that until we can improve diabetes management during adolescence, such a goal is meaningless.Diabetes self-management includes a variety of skills that must be performed daily: monitoring blood glucose, administering insulin, regulating diet and physical activity, and calculating appropriate care based on the results of these activities (14,15). In addition, the process requires adaptation to changing adolescent physiology and shifting parent and youth responsibilities while recognizing that the goals of diabetes management may be changing at the same time (15). Reliable and valid measures of adherence are essential fo...

OBJECTIVE -Using a profile-based approach to the assessment of diabetes management, the purpose of this study was to identify and evaluate an empirically derived classification system of distinct self-management styles.RESEARCH DESIGN AND METHODS -Youth with type 1 diabetes (n ϭ 156) aged 10 -16 years and their parents were administered a modified version of the Diabetes SelfManagement Profile (DSMP). Cluster analyses were performed independently on parent and youth report forms to categorize patients based on their patterns of scores in five diabetes self-management areas.RESULTS -Cluster analyses revealed three self-management styles that emerged from both youth and parent report: a "methodical style" (33%) with an emphasis on careful meal planning and correct insulin administration; an "adaptive style" (46%), characterized by high rates of blood glucose testing, exercise, and self-care adjustments; and an "inadequate style" (21%) with moderate rates of self-care adjustments and otherwise low DSMP scores. Convergence between parent and youth report classifications was moderate (Cohen's ϭ 0.47, P Ͻ 0.0001). A1C was 1.6% higher in the inadequate style group than in both other groups (P Ͻ 0.0001), and the classification significantly accounted for differences in A1C above what was explained by an overall DSMP score.CONCLUSIONS -The findings provide support for recognizing subgroups of patients with unique multidimensional patterns of self-care behaviors. The assessment of self-management styles may prove useful for customized treatments that are targeted directly to the patients' needs. Diabetes Care 30:1107-1112, 2007S uccessful treatment of type 1 diabetes in adolescence rests heavily on the involvement of the young patients and their families. Evidence indicates that interventions that enhance adherence to the diabetes regimen improve adolescents' metabolic control (1,2). This in turn produces significant and long-lasting health benefits by reducing the risk of severe long-term complications and increasing life expectancy (3,4). Despite numerous technological advances, problems with adherence and metabolic control continue to be common and are exacerbated during the adolescent years (5-10). Thus, evaluating and improving diabetes self-management remains a critical issue in research and clinical practice.Many authors have noted that selfmanagement cannot be adequately defined as a static and unitary response to instructions given by health professionals. Instead it is multifaceted and involves sophisticated processes of day-to-day self-regulation (11-14). Optimal diabetes management requires a patient to maintain a delicate balancing act between insulin dose, food intake, and physical activity, guided by frequent blood glucose monitoring (14,15). Consistent with the notion of multidimensionality, adherence in different treatment areas has been found to be only weakly intercorrelated (11,12,16,17). Although parents and children might initially intend to follow the entire treatment protocol as recommended, eventu...

OBJECTIVE -To describe a 2-year follow-up of A1C outcomes of a self-regulation intervention for youth with type 1 diabetes.RESEARCH DESIGN AND METHODS -A total of 81 youths with type 1 diabetes ages 11-16 years were randomized to usual care versus a diabetes personal trainer intervention consisting of six self-monitoring, goal-setting, and problem-solving sessions with trained nonprofessionals. A1C data were obtained from medical records 2 years postintervention, and ANCOVA adjusting for age and baseline A1C was conducted.RESULTS -An overall intervention effect on A1C (8.93% control vs. 8.43% intervention; F ϭ 8.24, P ϭ 0.05) and a significant intervention-by-age interaction (F ϭ 9.88; P ϭ 0.002) were observed, indicating a greater effect among older than younger youths. Subgroup analyses demonstrated no treatment group differences among pre-/early adolescents but a significant difference in A1C among middle adolescents (9.61% control vs. 8.46% intervention; F ϭ 7.20, P ϭ 0.011).CONCLUSIONS -Findings indicate maintenance of intervention effects on A1C observed at 1-year follow-up. Diabetes Care 32:807-809, 2009E ffective behavioral programs designed to counter the deterioration in glycemic control that typically accompanies adolescence (1) could contribute substantially to improving diabetes management in this population, with the potential of impacting long-term management trajectories and health outcomes (2,3). The objective of this study was to assess 2-year A1C outcomes of a selfregulation intervention, delivered by nonprofessionals, for youth with type 1 diabetes. Short-term and 1-year outcomes have previously been reported; these showed a significant A1C effect and a treatment-by-age interaction, indicating a greater intervention effect among older than younger youths (4). The current analyses assessed whether these effects were maintained at 2-year follow-up. RESEARCH DESIGN AND METHODS -The study design and methods have previously been reported (4). Youth ages 11-16 years diagnosed with type 1 diabetes for at least 1 year and having no other major chronic illnesses or psychiatric diagnoses were recruited during routine visits at two pediatric endocrinology clinics serving a multistate area with urban, suburban, and rural populations. Of 113 eligible youth, 81 (72%) consented to participate. Data were collected by medical record review and inhome assessments with the youth and parents. Random assignment was stratified by age (11-13 vs. 14 -16 years) and A1C (Ͻ8.0 vs. Ն8.0%) for a total of four strata. The study protocol was approved by the National Institute of Child Health and Human Development institutional review board and the Western institutional review board (for participating clinical sites).The intervention consisted of six inperson semistructured sessions, supplemented with telephone calls, conducted over ϳ2 months by trained nonprofessionals (4). The approach was guided by principles of motivational interviewing, applied behavior analysis, and problem solving. Youth were assisted to identify are...

Objective-To determine the acceptability of lower glycemic index (GI) foods served at diabetes camp.Design-Crossover design of standard and lower GI menus. Setting-Three consecutive 5-day diabetes camp sessions.Participants-140 youth, age 7-16, with type 1 or 2 diabetes.Intervention-A standard camp cycle menu was reformulated to include 2½ days of standard foods and 2½ days of lower GI foods.Main Outcome Measures-Youth provided satisfaction ratings after meals and snacks using measures designed for this study. Observations of food consumption were conducted on a random sample of youth for each meal.Analysis-Descriptive analyses and t-tests were conducted to assess differences in satisfaction with and consumption of standard and lower GI foods.Results-Lower GI foods served at dinner and for snacks received satisfaction ratings equal to standard foods (dinner: 3.68 lower GI versus 3.79 standard, P = .30; snacks: 3.74 lower GI versus 3.79 standard, P = .60). Lower GI foods served at breakfast and lunch received lower, though very acceptable, ratings (breakfast: 3.76 lower GI versus 4.04 standard, P < .01; lunch: 3.64 lower GI versus 3.88 standard, P < .01). Consumption of all meals was acceptable. No differences occurred in the frequency of high or low blood sugars between standard and lower GI days.Conclusions and Implications-Higher quality carbohydrates may be provided to youth in institutional settings while maintaining sufficient levels of acceptability; specific findings are instructive for designing efforts to increase their consumption.