The increased incidence of type 1 diabetes mellitus (T1DM) among children is an important public health burden [
In recent years, empowerment has been proposed as a therapeutic process, aimed to increase the patient’s own ability to think critically and act autonomously [
Our experience shows that adolescents with T1DM frequently want to change their lifestyle with respect to diabetes, but they often do not achieve their long-term goals. We suggest that deficits in their executive functions may be responsible for that. Therefore, we hypothesised that the readiness to change of adolescent patients with T1DM is related to their clinical features and executive functions. Using the Diabetes Empowerment Scale (DES) and the Behavioural Rating Inventory of Executive Function (BRIEF), we evaluated adolescent patients from three Polish diabetes centres. We related the data to features associated with the disease and its treatment and compared the results to those obtained for adolescents without diabetes. We believe that the results might help better understand the difficulties in diabetes education in young patients, and how this education should be adapted to match their capabilities and meet their needs for an improved quality of life.
A cross-sectional study was conducted between October 2015 and June 2018 in three Polish diabetes centres of the PolPeDiab group. The criteria for inclusion in the study group were age ≥14 years to ≤18 years, diagnosis of T1DM, end of remission, possible coexistence and treatment for immunological diseases of the thyroid gland and/or gastrointestinal tract and hypertension/albuminuria. The comparison group consisted of adolescent patients without diabetes, admitted to one of our pediatric departments for check-up tests due to cardiac problems (clinically irrelevant heart defects or arrhythmias). Adolescents from the comparison group did not take any medications. Psychiatric abnormalities and evidence of chromosomal disorders in physical examination were excluded in both the study and comparison groups.
The study design was approved by the Ethics Committee at the Medical University of Bialystok in accordance with the Declaration of Helsinki (No. R-I-002/374/2014). Signed informed consent was obtained from patients and their parents/guardians. The rates of consent were 93.0% and 86.1% in the study and comparison groups, respectively.
The following parameters were evaluated in all adolescents: age, sex, and body mass index standardized deviation score (BMI-SDS). Body mass index (BMI) was calculated from the height and weight measured by appropriately trained members of the research group. The BMI-SD referred to the centile charts for gender, age, and BMI [
The empowerment of the participants was measured using the Diabetes Empowerment Scale [
Cognitive functions were assessed in all adolescents with the Behavioural Rating Inventory of Executive Functions® – Self Report Version (BRIEF®-SR) scale. BRIEF®-SR is an 80-item standardized self-report measure developed to capture older children’s and adolescents’ views of their own executive functions, or self-regulation, in their everyday environment [
Data are presented as means and standard deviation (SD) and rates of incidence of a given characteristic in the evaluated group. Univariate analysis was conducted using the
Anthropometric data of both groups and clinical data concerning the disease and treatment of adolescents with T1DM are presented in Table
Clinical features of the comparison group and adolescents with T1DM included in the study.
Comparison group | Adolescents with T1DM | |
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Number of patients | N=112 | N=147 |
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Sex Male / Female | 52 (46.4%) / 60 (53.6%) | 69 (47.0%) / 78 (53.0%) |
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Age in years (mean ±SD) | 15.8 ± 1.6 | 16.0 ± 1.4 |
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SDS-BMI (mean ±SD) | 0.78 ± 1.3 | 0.73 ± 1.2 |
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Age of diabetes onset (mean ±SD) | - | 8.7 ± 3.7 |
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Disease duration (mean ±SD) | - | 7.2 ± 3.7 |
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Therapy: pumps / pens |
- | 116 (78.9%) / 31 (21.1%) |
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HbA1c % (mean ±SD) | - | 8.5 ± 2.3% |
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Dose of insulin (mean U/kg/day) | - | 0.78 |
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Glycaemia measurements / day (mean ±SD) | - | 5.6 ± 2.2 |
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Celiac disease = gluten free diet | - | 14 (9.5%) |
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Hashimoto disease | - | 23 (15.6%) |
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Hypertension / nephropathy | - | 6 (4.0%) |
There were no statistically significant differences between adolescents treated with the pens and with the pump in the clinical parameters mentioned in Table
The rates of normal and deficient results in the executive function tests were compared between the groups. Significantly higher proportions of T1DM adolescents with impaired executive functions (score ≥65) were noted compared to those without diabetes in the “organization of materials” function (31 [21.0%] versus 9 [8.0%], respectively; p = 0.01) and in the Global Executive Composite (GEC), which summarizes all executive functions (42 [28.5%] versus 16 [14.2%], respectively; p = 0.01). No gender differences were found in these scores. The remaining rates of deficient results and mean values of executive functions in patients with T1DM did not differ significantly from those without T1DM (Table
Comparison of executive functions between adolescents with and without T1DM. All differences were not statistically significant (p > 0.05).
Scale / Index | Comparison group | Adolescents with type 1 diabetes |
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Inhibit | 56.4 ± 10.1 | 58.0 ± 10.5 |
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Shift | 54.6 ± 10.5 | 54.5 ± 11.0 |
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Emotional control | 58.4 ± 10.9 | 60.5 ± 11.9 |
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Monitor | 53.3 ± 9.9 | 53.9 ± 10.4 |
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Behaviour regulation index BRI | 57.4 ± 10.5 | 58.9 ± 10.8 |
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Working memory | 54.5 ± 9.4 | 56.3 ± 10.8 |
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Plan organize | 51.9 ± 9.8 | 53.4 ± 11.7 |
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Organisation of materials | 50.7 ± 9.5 | 53.8 ± 11.2 |
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Task completion | 53.0 ± 10.0 | 55.1 ± 9.9 |
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Metacognition index MI | 53.1 ± 9.1 | 55.5 ± 10.7 |
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GEC (BRI+MI) | 55.7 ± 9.5 | 57.7 ± 10.8 |
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Subscale | ||
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Behavioural shift | 55.9 ± 10.8 | 55.0 ± 11.3 |
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Cognitive shift | 52.3 ± 10.8 | 53.6 ± 11.5 |
No correlation was observed between the executive functions among adolescents with diabetes and age, sex, disease duration, number of daily glycaemic measurements, glycaemic control, insulin delivery tool (pens versus pump), BMI, or comorbidities (p > 0.05 in all cases).
The mean values obtained were 2.21±0.5 for DES I, 2.15±0.37 for DES II, and 2.21±0.45 for DES III. The mean total DES score was 2.19±0.37. DES scores in the group of adolescents with T1DM did not show correlations with: sex, age, standardized BMI, insulin regimen (pumps versus pens), or accompanying diseases. Diabetes empowerment was also not associated with the number of daily glucose assessments in the study group (p > 0.05).
The results for DES I (“managing the psychosocial aspects of diabetes”) were related to disease duration (r = -0.25, p = 0.006): the shorter the duration of the disease, the higher the diabetes empowerment. Diabetes duration was associated with the DES total score (r = -0.23, p = 0.01). In addition, DES I and DES total scores were correlated with the HbA1c value as follows: the poorer the metabolic control, the higher the empowerment (r = 0.25, p = 0.006). Furthermore, the DES total score was related to the daily insulin use calculated per day and per patient body weight, i.e., the lower the insulin dose, the higher the diabetes empowerment (DES score; r = -0.22, p = 0.01).
In the correlation analysis, numerous relationships were noted between the executive functions (BRIEF-SR scale) and the readiness to change as assessed in the DES scale (Table
Correlations between executive functions and readiness to change in T1DM adolescents. DES I – managing the psychosocial aspects of diabetes, DES II – assessing dissatisfaction and readiness to change, DES III – setting and achieving diabetes goals.
Diabetes empowerment | ||||
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Executive function | DES I | DES II | DES III | DES total score |
Inhibit | 0.27 |
-0.04 | 0.18 |
0.22 |
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Shift | 0.36 |
0.06 | 0.33 |
0.36 |
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Emotional control | 0.30 |
-0.16 | 0.20 |
0.22 |
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Monitor | 0.30 |
0.18 | 0.28 |
0.33 |
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Working memory | 0.32 |
0.11 | 0.31 |
0.33 |
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Plan organize | 0.46 |
0.14 | 0.49 |
0.50 |
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Organisation of materials | 0.32 |
0.21 |
0.28 |
0.34 |
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Task completion | 0.41 |
0.09 | 0.42 |
0.41 |
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BRI | 0.38 |
-0.02 | 0.28 |
0.33 |
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MI | 0.45 |
0.16 | 0.46 |
0.48 |
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GEC (BRI+MI) | 0.46 |
0.08 | 0.41 |
0.45 |
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Behavioural shift | 0.26 |
0.01 | 0.20 |
0.23 |
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Cognitive shift | 0.32 |
0.04 | 0.34 |
0.34 |
1 correlation significant in boys (r=0.3, p<0.01), but not in girls (r=0.1, p>0.05); other correlations mentioned in this table are statistically significant in both sexes.
Finally, using the regression model, we tested our primary hypothesis that executive functions and clinical factors (age, sex, metabolic control, self-management, treatment regimen, insulin dose) are related to the readiness to change in adolescents with diabetes. The variability of DES I, III, and DES total score was explained by all executive functions as well as disease duration, metabolic control, and insulin dose (R = 0.59, R∧2 = 0.35, p < 0.001). These associations were maintained when patients were grouped by sex.
In contrast, the variability of DES II (“assessing dissatisfaction and readiness to change”) was explained only by the executive function “organization of materials” and the dose of insulin/kg/day (R = 0.42, R∧2 = 0.18, p < 0.01). When the patients were grouped by sex, readiness to change in boys was solely associated with the “organization of materials” function, while in girls DES II was correlated only with the insulin dose per day.
In our experience, reeducation (including that based on empowerment) produces desired results in some adolescents with diabetes, while in others its effect is only temporary or none. To determine ways to increase the effectiveness of educational programs in diabetes, we investigated the factors that influence the readiness to change among adolescents with T1DM. We observed a higher rate of abnormal executive functioning among adolescents with T1DM compared to their peers without diabetes. At the same time, diabetes empowerment was associated with executive functions, disease duration, metabolic control, and insulin doses. We also observed gender-related differences in some of these relationships.
While the influence of executive functioning on the adherence to medical recommendations or metabolic control has been previously evaluated (reviewed in [
It is difficult to evaluate the effect of executive functions on diabetes care and thus a patient’s ability to count calories and insulin doses and adjust insulin to effort, and so on. Indirectly, this effect is assessed by the relationship with metabolic control. The authors of one study have stated that larger deficits in the executive functions of adolescents with T1DM lead to worse adherence to recommendations and lower quality of life [
What is the probable cause of executive function deficit in patients with T1DM? Whether hyperglycaemia in the course of diabetes impairs executive functions and subsequently weakens adherence to therapy recommendations, or the initial impairment of executive functions leads to not following care guidelines and the deterioration of metabolic control, remains unclear [
The association between executive functioning and empowerment can be mediated by adherence. One study showed better metabolic control in patients with better executive functioning, but only in adolescents reporting good adherence [
We also observed interesting gender-related differences in the relationships between executive functions and diabetes empowerment. “Assessing dissatisfaction and readiness to change” was related to the executive function “organization of materials” exclusively in boys, with poorer executive functioning correlating with higher diabetes empowerment. Similarly, a previous study showed that poorer executive function in boys correlated with better self-reported adherence [
The results of studies on the readiness to change and its relationship with age, duration of the disease, and metabolic control are diverse. In a study conducted on adult patients with T2DM, “assessing dissatisfaction and readiness to change” and “setting and achieving diabetes goals” decreased with the patient’s age; the first parameter also decreased with the disease duration [
Some data in this field refer to type 2 diabetes. In a large group of Chinese patients with T2DM, empowerment was predictive of metabolic control and self-management of patients in a manner that was independent of age, sex, marital status, education level, and disease duration [
One of the advantages of our study is the large number of patients and participants in the comparison group. Other advantages include the evaluation of the relationship between readiness to change and executive functions, which was performed for the first time, and the building of a regression model to explain factors that influence the diabetes empowerment of adolescents with T1DM. Nonetheless, our research also has several limitations, which should be considered when interpreting the results. First, since this is a cross-sectional study, a causal relationship in the studied associations cannot be proved. Such a relationship can be proved only in a prospective study. It also seems that the assessment of executive functions should be performed at the time of the disease onset, as the effect of fluctuations in glucose levels (characteristic of T1DM) on the results of executive function tests is unknown. Furthermore, we used the Polish version of DES, which has not been validated. Another limitation is the lack of data from parents about the executive functions of their children (adolescents). It is also difficult to assess whether accompanying diseases affect DES or executive functions, because the group with comorbidities was small and disease stabilization was a qualification criterion. However, thanks to good diabetes care, only a few adolescents with T1DM had unstable accompanying diseases.
The management of diabetes is complicated. It requires accurate insulin dosing with personal insulin pumps, counting carbohydrate and protein-fat exchanges, obtaining multiple blood glucose measurements, and adjusting insulin doses to physical effort. Considering the complexity of this system, it is not surprising that some adolescents have difficulty complying with the rules, which leads to fluctuations in blood glucose and poor metabolic control. Whether empowerment therapy leads to a better quality of life and reduces the risk of diabetes-related complications in adolescents remains unclear. It could be that adolescents with executive function deficits require a simpler approach to diabetes therapy and greater parental support. Perhaps the use of a bolus calculator function could be a simple solution for patients treated with a personal insulin pump and that have impaired executive functions. In some rare cases (very poor metabolic control and/or self-control and/or cooperation with diabetes team, etc.) insulin pump therapy does not improve quality of life and metabolic control and should be replaced by pen therapy with fixed doses of insulin. In spite of that, the results of our study indicate that the poorer the executive function, the greater the diabetes empowerment. This surprising observation may indicate the need to evaluate the executive functions prior to implementing complicated diabetes therapies and to personalize diabetes education. All adolescents with diabetes should receive care adjusted to their needs and capabilities and obtain support from an experienced integrated therapy team that is sensitive to the specific nature of this chronic disease and the problems of adolescence. It seems that to improve the quality of life and metabolic control in this group of patients the latest technologies should be implemented, and more time devoted to adolescents with diabetes and their families. Therefore, implementing a guided self-determination approach (e.g., based on empowerment) that supports problem-solving and decision-making related to insulin therapy in adolescents with T1DM may improve their motivation to manage their diabetes care [
The results of our research indicate that adolescents with T1DM are characterized by a higher rate of abnormal results in executive function tests compared to their peers without diabetes. Diabetes empowerment in this group of patients depends on the duration of the disease, metabolic control, and executive functions, and the relationships are partially gender-differentiated. We recommend assessment of readiness to change and executive functions in order to individualize and adapt therapy to the needs and abilities of adolescents with T1DM. The impact of such measures on the quality of life and metabolic control in this group of patients requires further research.
The data used to support the findings of this study are available from the corresponding author upon request.
The study design was approved by the Ethics Committee at the Medical University of Bialystok in accordance with the Declaration of Helsinki (No. R-I-002/374/2014).
Signed informed consent was obtained from patients and their parents/guardians.
The authors declare that they have no conflicts of interest.
Włodzimierz Łuczyński designed the study, analysed and interpreted the patients’ data, and was a major contributor in writing the manuscript. Izabela Łazarczyk, Artur Bossowski, and Barbara Głowińska-Olszewska designed the study; Ilona Szlachcikowska, Żaneta Kiernozek, Anna Kaczmarek, Oliwia Szylaj, Agnieszka Szadkowska, and Przemysława Jarosz-Chobot collected and analysed the data. All authors read and approved the final manuscript.
The study was fully funded by Medical University of Bialystok, Poland, grant number N/ST/ZB/18/002/1206.