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Family Conflicts Influence Outcomes for  Children with Type 1 Diabetes

Aug 10, 2019
 
Editor: Steve Freed, R.PH., CDE

Author: Kassey  James, Pharm.D. Candidate, LECOM School of Pharmacy

SEARCH for Diabetes in Youth Study finds addressing risk factors and diabetes-related family conflict may significantly improve outcomes.

Achieving glycemic control is a struggle for most children with type 1 diabetes. The ADA recommends a target of <7.5% in this population, but 56% of children and >70% of adolescents with type 1 diabetes do not achieve this goal. Furthermore, the Type 1 Diabetes Exchange Clinic Network recently reported that only 17-23% of children meet the ADA goal of <7.5%. Since advances in treatment are not improving outcomes in this population, providers should screen and address other risk factors noted in this study.

The SEARCH for Diabetes in Youth Study investigated the link between sociodemographic, behavioral, and clinical barriers in relation to glycemic control in US children with type 1 diabetes. This is the largest multicenter population-based study to examine diabetes-related family conflict and outcomes in children with type 1 diabetes. Higher HbA1c levels are associated with lower socio-economic status, adolescent age, minority groups, single parent homes, diabetes-related family conflict, low parental involvement in treatment, treatment access issues, and lack of a regular diabetes provider. In addition, this trial highlighted the fact that socio-economic status was associated with the type of insulin regimen used. Insulin pumps are associated with better HbA1c values and were most often used in white children, higher income families, those with educated parents, and those with private insurance.

The objective of the SEARCH study was to examine glycemic control of children with type 1 diabetes based on the insulin regimen used, and the link between sociodemographic, behavioral, and clinical barriers in relation to glycemic control within each regiment group. Surveys were completed by parents and 1,095 children with type 1 diabetes aged 10-17 years old with a mean duration of diabetes of 7.5 years. These parent and self-reported surveys evaluated insulin regimen, self-management, socio-demographics, family conflict, and barriers to care. A multivariable logistic regression was used to correlate poor glycemic control within each group. The conflict survey consisted of 19 items with an emphasis on recent conflict around diabetes care, and a higher score suggested increased family conflict. 

Patient HbA1c was analyzed based on ADA guidelines as good [<58 mmol/mol (<7.5%)], intermediate [58 to <80 mmol/mol (7.5 to <9.5%)] and poor [≥ 80 mmol/mol (≥ 9.5%)]. Insulin treatment regiments were classified into three groups: insulin pump therapy, basal-bolus injections with glargine or detemir plus rapid acting insulin, and mixed insulin regimen of multiple daily injections. The study of 1,095 children had 694 on an insulin pump, 188 on basal bolus injections, and 213 on mixed insulin injections. The mixed insulin group, as defined by the study: “(a) multiple daily injections (≥3 injections) with glargine or detemir insulin plus NPH insulin plus regular or rapid-acting insulin, (b) multiple daily injections (≥3 injections) with any insulin types excluding basal insulin (glargine or detemir), or (c) one to two injections per day, excluding insulin glargine or detemir.”

Results show the children on the mixed insulin regimen had the worst glycemic control. Conversely, the children on insulin pumps had better glycemic control. Group poor glycemic control percentages were as follows: 28.5% insulin pump, 45.2% basal bolus, and 51.2% mixed regiment. Only a minority of each group met the ADA target HbA1c: 14.4% insulin pump, 8% basal bolus, and 3.8% on mixed insulin. 

The unadjusted factors associated with poor glycemic control in all groups were non-white race, living in multiple households, decreased adherence, family conflict, eating disorders, and lack of time with healthcare provider. In the adjusted multivariable model, parent reported diabetes related family conflict was the only factor significantly linked to poor glycemic control in all three groups.

Overall, the SEARCH study shows that most US children with type 1 diabetes have glycemic control issues, specifically those not on an insulin pump. The other main key factor associated with poor control in all groups was diabetes-related family conflict.

Practice Pearls:

  • In the adjusted multivariable model, parent reported diabetes-related family conflict was the only factor significantly linked to poor glycemic control in all three groups.
  • Children not on an insulin pump are at a higher risk of poor glycemic control.
  • Providers should use behavioral therapy to improve diabetes-related family conflict for better glycemic control in children with type 1 diabetes.

 

Snyder, L. L., et al. “Socio‐Economic, Demographic, and Clinical Correlates of Poor Glycaemic Control within Insulin Regimens among Children with Type 1 Diabetes: the SEARCH for Diabetes in Youth  Study.” Diabetic Medicine, vol. 36, no. 8, 2019, pp. 1028–1036., doi:10.1111/dme.13983.

Petitti DB, Klingensmith GJ, Bell RA, Andrews JS, Dabelea D, Imperatore G et al. Glycaemic control in youth with diabetes: the SEARCH for Diabetes in Youth Study. J Pediatr 2009; 155(668–672): e1–3.

 

Kassey James, Pharm.D.Candidate, LECOM School of Pharmacy