This review was motivated by the need to understand the barriers to achieving and maintaining good metabolic control among children and adolescents. From insulin pump (CSII) therapy to carbohydrate counting, technology has advanced rapidly since the Diabetes Control & Complications Trial. However, this has not been matched with efforts to understand the impact of human behaviour on the uptake and incorporation of new approaches into overall self-management.
Among children and adolescents with type 1 diabetes, what demographic and psychosocial variables are associated with metabolic control and self-care across treatment types?
Studies using a wide range of designs were included in this review, with a qualitative synthesis of their findings. Although a search for unpublished studies was not mentioned, a comprehensive search was carried out in MEDLINE, PsycINFO, EMBASE and CINAHL. Non-English language studies were not included. Three members of the review team performed the study selection.
The review’s qualitative synthesis was planned because the studies came from different samples and focused on different factors using a range of measurement tools.
A no-nonsense approach to the assessment of the quality of studies was taken by the team, excluding 38 studies. This left 70 studies involving 11,686 children and adolescents with type 1 diabetes. 15 of these were longitudinal studies, with the remainder being cross-sectional surveys.
The results of this review are presented in the form of a theoretical model of interacting pathways between factors.
What is clear from this review is the care taken by the authors to maximise the practical applications of the findings. Factors found to predict lower self-care or metabolic control are identified which may be easily screened for within a clinic context or highlight important areas for future research.
Prominent amongst these are:
- Belonging to an ethnic minority group is strongly associated with higher HbA1c. More research is required to understand the influence of factors like socioeconomic deprivation, self-management behaviour and language & cultural barriers.
- Metabolic control and self-care benefit in response to a ‘loving, but firm’ parenting style and a division of responsibility for diabetes care agreed upon by both parent and child or adolescent.
- Negative thoughts related to diabetes and diabetes-related stress are associated with high HbA1c. Positive beliefs, for example in relation to the effectiveness of treatment predicted better dietary self-care in one study.
- Decision-making and self-efficacy (confidence in ability to perform self-care tasks) have been associated with self-care. Interventions to increase these skills may impact metabolic control through better self-care over time.
- Factors associated with self-care and metabolic control among children and adolescents on insulin pump (CSII) therapy or continuous glucose monitoring are not widely researched. Identification of demographic and personal factors associated with successful use of these technologies is recommended. Awareness of the characteristics of children, adolescents and families most likely to benefit from new forms of monitoring and insulin administration may ensure resources are maximised and patients may be facilitated in achieving better self-care and metabolic control.
- Interventions to improve family conflict and division of diabetes responsibility had the most positive impact on metabolic control.
- Definitions of children and adolescents vary from study to study and the two groups are often studied together. However, the authors note that as adolescents move through the teen years, the risk of high HbA1c and less self-care grows.
- Younger adolescents respond differently to peers and in school settings as well as relying more on their parents. These are important differences and should be considered according to the authors in research as well as in decisions for care within paediatric and adolescent services.
- The authors were able to include a decent number of varied studies in this review so the findings may relate to many children, adolescents and their families.
- Paediatric and adolescent services providing diabetes care may be set up in a variety of ways and have access to more or less technology. Regardless of the number of pumps available in your clinic or service, the authors of this review provide valuable patient centred guidelines without making the assumption that all services are progressing at the same rate or in the same direction.
This comprehensive and timely review covers a topic which will remain important in the planning and implementation of diabetes care while human behaviour remains the key to successful self-management strategies.
Neylon OM, O’Connell MA, Skinner TC, Cameron FJ. Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review. Diabetes Metab Res Rev. 2013 May;29(4):257-72. doi: 10.1002/dmrr.2392. [PubMed abstract]