Diabetes-Specific Distress and Glycemic Control in Children and Adolescents with Type 1 Diabetes: A Longitudinal Analysis of the Moderating Effect of Social Support

This thesis examines the roles diabetes-specific distress and social support play in impacting glycemic control trajectories in youth with type 1 diabetes. Due to the increase in responsibilities and stressors occurring during pre-adolescence and adolescence, it is particularly important to consider the impact of diabetes-specific distress on glycemic control trajectories during this time, in order to determine best practices for screening and treating this population. It is also important to consider how social support may serve as a buffer against negative diabetes outcomes. In order to determine how diabetes-specific distress and social support impact glycemic control trajectories in this population, scores on the Problem Areas in Diabetes Scale (PAID-5), Multidimensional Scale of Social Support (MSPSS), and hemoglobin A1c values over three time points were collected from 121 youth (55.4% male) between the ages of 8 and 18 years visiting a diabetes clinic at a large academic medical center in an urban city in the Midwestern United States. Multilevel modeling was used to test for the effects of diabetes-specific distress and social support on glycemic control trajectories. Results found that diabetes-specific distress significantly predicted glycemic control trajectories over time, when moderated by the significant other subscale of the MSPSS (β = -0.799, p = 0.007). A trend toward a significant interaction between diabetes-specific distress and the total social support score in predicting glycemic control trajectories was also found (β = -0.572, p = 0.053). Simple slopes analyses found that the trajectory for youth with higher levels of distress and lower levels of support (both total and for significant others) was significantly different from zero and increasing (i.e., becoming poorer) over time (Total support: β = 1.42, p = 0.033; Significant other support: β = 1.93, p = 0.007). Results suggest that diabetes-specific distress and social support may be important areas of screening and intervention for youth with type 1 diabetes. 2 STRESS AND GLYCEMIC CONTROL IN ADOLESCENTS Diabetes-Specific Distress and Glycemic Control in Children and Adolescents with Type 1 Diabetes: A Longitudinal Analysis of the Moderating Effect of Social Support Insulin-dependent diabetes mellitus (more commonly known as type 1 diabetes) is the most common chronic medical condition diagnosed in children and adolescents, and it is estimated that over 18,000 people under the age of 20 are diagnosed with type 1 diabetes in the United States each year (Centers for Disease Control and Prevention, 2014; Shulman & Daneman, 2010). Due to the increasing prevalence of type 1 diabetes, it is important to understand factors that are associated with both positive and negative diabetes control outcomes, in order to explore ways medical professionals can increase positive and reduce negative outcomes in as many youth as possible. Therefore, the current study aims to determine how two factors related to diabetes care and coping, diabetes-specific distress and social support, influence glycemic control trajectories, either positively or negatively, in youth with type 1 diabetes. The current study hypothesizes that (1) higher levels of diabetes-specific distress at time point 1 will predict poorer glycemic control trajectories across three time points, and (2) social support will moderate the relation between diabetes-specific distress and glycemic control trajectories, such that youth who report experiencing greater social support (overall, from friends, from family, and from significant others) will show better glycemic control trajectories than youth who report experiencing less social support. It is predicted that social support will serve as a buffer in this relationship, reducing the negative effect of diabetes-specific distress on glycemic control trajectories. In order to test these hypotheses, youth were administered measures of diabetes-specific distress (Problem Areas in Diabetes Scale; PAID-5) and social 3 STRESS AND GLYCEMIC CONTROL IN ADOLESCENTS support (Multidimensional Scale of Social Support; MSPSS), and their glycemic control (hemoglobin A1c; HbA1c) values were measured across three time points. Type 1 diabetes is a lifelong autoimmune illness characterized by the body’s inability to produce insulin. Consequently, individuals with type 1 diabetes must regulate blood glucose levels artificially, through the use of multiple daily injections (MDI) of insulin or through continuous subcutaneous insulin infusion (CSII) using an insulin pump. In order to maintain their health, individuals with diabetes must check their blood glucose levels multiple times a day, and monitor and regulate food intake, insulin dosages, and exercise levels. The maintenance of diabetes, especially for youth, may seem stressful and overwhelming; in fact, stressors have been implicated in both the onset and exacerbation of diabetes (Lloyd, Smith, & Weinger, 2005). Additionally, failure to carefully regulate diabetes can result in a variety of physiological and psychological complications, such as kidney disease, retinopathy, eating disorders, anxiety, and depression (Bernstein, Stockwell, Gallagher, Rosenthal, & Soren, 2013; Edgren & Odle, 2006). Due to the importance of successfully managing diabetes in order to avoid complications, and due to the inherently stressful nature of managing a chronic illness, it is important to explore the relationship between diabetes-specific stress and glycemic control. It is also important to consider factors, such as social support from friends, family, and significant others, which may serve to influence the impact of stress on glycemic control in youth. Type 1 Diabetes Type 1 diabetes is characterized by the body’s failure to produce insulin. Insulin plays an important role in processing glucose from foods in order to convert it to energy. Failure of the body to appropriately process glucose results in a dangerous build-up of glucose in the blood 4 STRESS AND GLYCEMIC CONTROL IN ADOLESCENTS stream. Consequently, an individual whose body no longer produces insulin must closely monitor and regulate his or her blood glucose levels and food intake. In order to manage blood glucose levels and remain healthy, individuals with type 1 diabetes must take multiple daily insulin injections or use an insulin pump, which delivers insulin subcutaneously. In order to appropriately adjust insulin dosages based on the caloric or carbohydrate content of foods and one’s blood glucose levels, individuals must check their blood glucose levels multiple times a day and they must keep track of the foods they eat. Managing type 1 diabetes requires that an individual invest a great deal of time and attention into his or her daily diabetes management routine in order to prevent complications due to unmanaged or poorly managed diabetes. Due to the lifelong nature and persistent course of type 1 diabetes, constant and close management of the disease is required in order to prevent a variety of serious complications from occurring. Unmanaged or poorly managed diabetes can lead to many physical complications, such as those relating to the kidneys, eyes, and liver (Edgren & Odle, 2006). Persistently high blood glucose levels (a condition called hyperglycemia) can lead to ketoacidosis. Ketoacidosis is a dangerous and potentially life-threatening condition in which ketones (acids) build up in the blood (Edgren & Odle, 2006). If left untreated, ketoacidosis may lead to coma or death. In order to avoid complications, such as those mentioned above, and maintain good control of one’s diabetes, individuals must monitor and regulate blood glucose levels and insulin dosages, and they must carefully attend to food intake and participation in exercise. The responsibilities of managing diabetes are persistent and unceasing. Type 1 diabetes not only poses risks for physical complications, but for psychosocial complications, as well. Psychological conditions such as depression, anxiety, and eating disorders frequently co-occur with diabetes in young people; one study found rates of these 5 STRESS AND GLYCEMIC CONTROL IN ADOLESCENTS disorders to be as high as 11.3%, 21.3%, and 20.7%, respectively (Bernstein et al., 2013). It has been suggested that co-occurrence of mental health disorders and type 1 diabetes in adolescents might make the acquisition of strong diabetes management skills difficult (Bernstein et al., 2013). It is also possible that the stressors and worries related to diabetes management might contribute to the occurrence and exacerbation of psychological disorders. The comorbidity of type 1 diabetes and psychological disorders tends to impact glycemic control, in that adolescents with type 1 diabetes and a psychological disorder tend to have poorer glycemic control and diabetes management than their counterparts without psychological disorders. One study found that higher rates of state anxiety (anxiety occurring at the immediate time of testing) were associated with infrequent blood glucose monitoring habits and suboptimal glycemic control (Herzer & Hood, 2010). Depressive symptoms in youth with diabetes have been shown to related to poor glycemic control, as well (Grey, Whittemore, & Tamborlane, 2002; Johnson, Eiser, Young, Brierley, & Heller, 2013; Reynolds & Helgeson, 2011). Finally, many adolescent females with diabetes will manipulate their insulin dosages in such a way as to lose weight. This is a dangerous practice which can cause severe complications and even death. It has been found that increased symptoms of bulimia in adolescents with diabetes is associated with poorer glycemic control, as compared to those with fewer symptoms of bulimia (Meltzer et al., 2001). Due to the demanding nature of managing a chronic illness, such as diabetes, and the many possible complications related to its management, it is important to consider how individuals ad