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Am Fam Physician. 2001;64(12):2002-2004

Almost 130,000 American children and adolescents have type 1 diabetes. Studies have demonstrated that intensive therapy and optimal glycemic control dramatically reduce the occurrence of complications in adolescents older than 13 years. At 12 months after initiation of a new intensive management program, Grey and colleagues studied the clinical and psychosocial factors associated with glycemic control and quality of life in adolescents with type 1 diabetes.

The study authors recruited patients aged 12 to 20 years who had used insulin therapy for at least one year. The patients had no health problems except for treated hypothyroidism, no history of hypoglycemic attacks within the previous six months, and were in the appropriate school grade according to their age within one year. Recent glycosylated hemoglobin (HbA1c) levels of 7.2 to 14.0 percent were required for inclusion in the study. The 35 male and 48 female volunteers were treated with intensive management. In addition, one half were randomly allocated to receive coping skills training (CST).

The CST program used role play, feedback, and repetition to increase a sense of competency and mastery, and to encourage problem solving, social skills, and positive attitudes. The CST groups met for six to eight sessions. Videotape review was used to monitor consistency between groups. The intensive diabetes management program required frequent blood sugar monitoring (at least four times per day, including once per week at 3 a.m.) and up to four injections of insulin daily, or the use of an insulin pump. The therapy goals were for blood glucose levels of 80 to 120 mg per dL (4.4 to 6.6 mmol per L) and normalization of HbA1c levels. Standardized questionnaires and scales were used to assess depression, aspects of family behavior, and quality of life.

In the entire group, HbA1c levels dropped to 7.8 percent from an average of more than 9.0 percent within a 12-month period. Approximately one third of the participants achieved target HbA1c levels of 7.2 percent or lower. On logistic regression analysis, the factors associated with achieving target HbA1c levels were better metabolic control at entry to the study, participation in CST, and parental participation in diabetes management. Depression and type of treatment (insulin pump or injections) were not significantly associated with achieving treatment goals when the other factors were taken into account. Attitudes on entry to the study and participation in CST were identified as important factors in the impact of diabetes on the quality of life of the adolescents.

The authors conclude that health care professionals should pay particular attention to adolescent diabetic patients with poor metabolic control and the significant impact of diabetes on their quality of life. Behavioral interventions such as CST and greater family support could help these vulnerable adolescents achieve control of their diabetes and minimize the impact of the disease on their quality of life.

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