Adolescent Diabetic Control: Using the Process-Person-Context-Time Model

Diabetes is a serious, yet relatively common, chronic disease, affecting nearly 17 million Americans. There is no cure for diabetes. In fact, diabetes is the sixth-leading cause of death by disease in the United States. Estimates suggest that diabetes, with its related health complications and associated loss in human productivity, costs the U.S. health care system approximately $98 billion annually. Diabetic complications pose grave concerns for persons with diabetes. Annual reports indicate that diabetes causes blindness in 12,000 to 24,000 adults. Diabetes also is the leading cause of kidney disease, accounting for 40% of all new cases of kidney failure each year. A large number of people with diabetes (60%-70%) experience mild to severe forms of diabetic nerve damage, and persons with nerve damage are 15 to 40 times more likely to undergo lower leg amputation. Finally, diabetes is significantly associated with increased heart and circulatory disease. Heart disease is present in about 75% of diabetes-related deaths, and persons with diabetes are 2 to 4 times more likely to experience stroke (American Diabetes Association [ADA], 2007; Juvenile Diabetes Research Foundation International, 2007). Although the cause of diabetes is unknown, medical evidence suggests that both genetic and environmental factors play important roles (Juvenile Diabetes Research Foundation International, 2007). There are two types of diabetes: Type I and Type II. Of interest to the present study is Type I diabetes. Type I diabetes (sometimes referred to as juvenile diabetes) is a common chronic disease, typically diagnosed during childhood or adolescence. More than 1 million Americans live with Type I diabetes, and approximately 13,000 children and adolescents are diagnosed each year. Moreover, in the past 2 decades, the incidence of Type I diabetes among children and adolescents younger than 16 years of age has nearly doubled from 7.9 to 13.5 per 100,000 per year (Skinner & Hampson, 1998). Type I diabetes may be broadly defined as a lifelong metabolic disorder brought about by the failure of the human pancreas to produce insulin. Insulin is a hormone that "unlocks" the body's cells, allowing life-sustaining energy or blood glucose to enter (Juvenile Diabetes Research Foundation International, 2007). Conventional medical wisdom suggests that children and adolescents with Type I diabetes must comply with treatment regimen in order to maintain diabetic control. The medical community defines diabetic control as the ability to sustain blood glucose levels within near-normal ranges. Diabetic control is an important concept. In 1983, the National Institutes of Health launched a landmark study called the Diabetes Control and Complications Trial (DCCT; National Diabetes Information Clearinghouse, 2001). At the DCCT's conclusion in 1993, medical scientists reported a causal relationship between diabetic control and a reduction in related health complications and/or their severity (Brink, 1997; Tamborlane & Ahem, 1997). Furthermore, results from the DCCT suggested that strict compliance with a treatment regimen was related to improved diabetic control (Brink, 1997). Strict compliance is a complicated, multifaceted, and multidimensional construct, consisting of the ability to understand diabetes information, appraise and solve diabetes-related problems, and implement diabetes tasks on a consistent basis. Specific compliance tasks include daily insulin-replacement therapy either through injection or insulin pump, blood glucose monitoring, special attention to diet and exercise, and regular medical checkups. Optimal diabetic management through strict compliance has been described as "difficult, if not impossible" (Jacobsen, 1996, p. 1251). DCCT investigators acknowledged that adolescents with Type I diabetes who strictly comply with a treatment regimen may experience greater psychological, emotional, and sociological hardships than do healthy adolescents without diabetes (Grey, Boland, Yu, Sullivan-Bolyai, & Tamborlane, 1998). …