Type 1 Diabetes Self-management Research Articles

Suicidal Ideation, Suicide Attempts, and Suicide Deaths in Adolescents and Young Adults With Type 1 Diabetes: A Systematic Review and Meta-analysis.

Evidence is lacking on the risk of suicide-related behaviors (suicidal ideation, suicide attempt, suicide death) in youth with type 1 diabetes (T1D). We aimed to 1) determine the prevalence of suicidal ideation, suicide attempts, and suicide deaths in adolescents and young adults (AYA) with T1D aged 10-24 years; 2) compare suicide-related behavior prevalence in youth with and without T1D; and 3) identify factors associated with suicide-related behaviors. A systematic search was conducted in MEDLINE, Embase, and PsycInfo up to 3 September 2023. We included observational studies where investigators reported the prevalence of suicide-related behaviors among AYA aged 10-24 years with T1D. We collected data on study characteristics, data on prevalence of suicide-related behaviors, and data on associated factors. We included 31 studies. In AYA with versus without T1D, pooled prevalence of suicidal ideation was 15.4% (95% CI 10.0-21.7; n = 18 studies) vs. 11.5% (0.4-33.3; n = 4), respectively, and suicide attempts 3.5% (1.3-6.7; n = 8) vs. 2.0% (0.0-6.4; n = 5). Prevalence of suicide deaths ranged from 0.04% to 4.4% among youth with T1D. Difficulties with T1D self-management were frequently reported to be associated with higher rates of suicide-related behaviors. However, findings on the association of glycemic levels and suicide-related behaviors were inconsistent. There was a considerable level of heterogeneity in meta-analysis of both suicidal ideation and suicide attempts. Suicidal ideation and suicide attempts are prevalent in AYA with T1D. Current evidence does not suggest that these rates are higher among AYA with T1D than rates among those without.

The Glycemia Risk Index Predicts Performance of Diabetes Self-Management Habits in Youth With Type 1 Diabetes Mellitus.

The Glycemia Risk Index (GRI) was developed in adults with diabetes and is a validated metric of quality of glycemia. Little is known about the relationship between GRI and type 1 diabetes (T1D) self-management habits, a validated assessment of youths' engagement in habits associated with glycemic outcomes. We retrospectively examined the relationship between GRI and T1D self-management habits in youth with T1D who received care from a Midwest pediatric diabetes clinic network. The GRI was calculated using seven days of continuous glucose monitor (CGM) data, and T1D self-management habits were assessed ±seven days from the GRI score. A mixed-effects Poisson regression model was used to evaluate the total number of habits youth engaged in with GRI, glycated hemoglobin A1c (HbA1c), age, race, ethnicity, and insurance type as fixed effects and participant ID as a random effect to account for multiple clinic visits per individual. The cohort included 1182 youth aged 2.5 to 18.0 years (mean = 13.8, SD = 3.5) comprising 50.8% male, 84.6% non-Hispanic White, and 64.8% commercial insurance users across a total of 6029 clinic visits. Glycemia Risk Index scores decreased as total number of habits performed increased, suggesting youth who performed more self-management habits achieved a higher quality of glycemia. In youth using CGMs, GRI may serve as an easily obtainable metric to help identify youth with above target glycemia, and engagement/disengagement in the T1D self-management habits may inform clinicians with suitable interventions for improving glycemic outcomes.

Body mass index moderates the association between diabetes distress and objective self-management behaviours in adolescents with type 1 diabetes and elevated A1Cs.

To examine the cross-sectional associations between diabetes distress, BMI (zBMI; BMI z-score), objectively measured mean daily blood glucose readings and insulin boluses administered, and A1C in adolescents with type 1 diabetes (T1D) using insulin pumps. T1D self-management behaviour data were downloaded from adolescents' (N = 79) devices and mean daily frequency of blood glucose readings and insulin boluses were calculated. Diabetes distress was measured (Problem Areas in Diabetes-Teen questionnaire [PAID-T]), A1C collected, and zBMI calculated from height and weight. Three multiple linear regressions were performed with blood glucose readings, insulin boluses, and A1C as the three dependent variables and covariates (age, T1D duration), zBMI, diabetes distress, and the diabetes distress x zBMI interaction as independent variables. Participants (55.7% female) were 14.9 ± 1.9 years old with T1D for 6.6 ± 3.4 years. zBMI moderated the relationship between diabetes distress and mean daily insulin boluses administered (b = -0.02, p = 0.02); those with higher zBMI and higher diabetes distress administered fewer daily insulin boluses. zBMI was not a moderator of the association between diabetes distress and blood glucose readings (b = -0.01, p = 0.29) or A1C (b = 0.002, p = 0.81). Using objective behavioural data is useful for identifying how adolescent diabetes distress and zBMI affect daily bolusing behaviour amongst adolescent insulin pump users. Although distinct interventions exist to improve T1D self-management or diabetes distress, none addresses them together while considering zBMI. Decreasing diabetes distress could be especially important for youth with high zBMI.

Understanding Whether and How a Digital Health Intervention Improves Transition Care for Emerging Adults Living With Type 1 Diabetes: Protocol for a Mixed Methods Realist Evaluation.

Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals. This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process. We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory. For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power. Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences. PRR1-10.2196/46115.

Implementation and evaluation of a longitudinal diabetes educational programme for adolescents

IntroductionInternational guidelines recommend structured and continuous educational programmes to expand diabetes knowledge and self-efficacy in youth. To address these recommendations within a paediatric diabetes clinic, we conducted a three-phase quality...

1161-P: Patterns of Diabetes Distress (DD) and Glycemic Outcomes in Teens with Type 1 Diabetes (T1D)

Background: DD distracts from T1D self-management, contributing to suboptimal glycemia. Yet, DD can change day-to-day and over time. We compared A1c trends in teens with increasing vs. decreasing DD over time. Methods: At baseline, 6, 12, and 18 months, participants (N=301) ages 13-17 years completed the Problem Areas in Diabetes Survey—Pediatric scale; higher scores indicate more DD with ≥41 indicating elevated DD. We identified three trajectories: participants with low baseline DD, who then reported persistent high DD; participants with high baseline DD, who then had persistent low DD levels; all others. Mean A1c levels were compared at baseline and 18 months. Results: At baseline, participants (49% male, 78% white) were 15.0±1.3 years old with T1D duration 6.5±3.7 years; 59% used insulin pumps; 12% used CGM; A1c was 8.5±1.1%. Twenty-six participants (9%) had elevated DD at baseline and then low DD at subsequent time points; A1c did not change significantly from 0 to 18 months for these participants (p=.33). Thirty-five participants (12%) had low DD at baseline and then elevated DD at subsequent time points; A1c increased significantly from 0 to 18 months for these participants (p=.01). The remaining participants (n=240) had varying levels of DD with no significant change in A1C (p=.05). Conclusion: Adolescents who initially had low DD and reported increasing DD over time may be at risk for worsening glycemic outcomes. Disclosure K.Wentzell: None. L.J.Tinsley: None. L.K.Volkening: None. D.E.Mcgill: Employee; Vertex Pharmaceuticals Incorporated. B.J.Anderson-thomas: None. L.M.Laffel: Advisory Panel; Medtronic, Lilly Diabetes, Novo Nordisk, Vertex Pharmaceuticals Incorporated, Roche Diagnostics, Provention Bio, Inc., Consultant; Dexcom, Inc., Janssen Pharmaceuticals, Inc., Medscape. Funding National Institutes of Health (T32DK007260); National Institute of Diabetes and Digestive and Kidney Diseases (R01DK095273); JDRF (2-SRA-2014-253-M-B)

218-OR: Predictors of Young Adults’ (YAs) Engagement in a Type 1 Diabetes (T1D) Self-Management Intervention—The Resilient, Empowered, Active Living–Telehealth (REAL-T) Diabetes Study

Background: YAs with T1D have more complications and mental health challenges, and are less engaged in care, than other age groups. Few studies have examined factors predicting engagement in self-management interventions, which may support YAs’ T1D care and overall well-being. Methods: Using data from a T1D self-management RCT, we analyzed predictors of engagement among those randomized to the intervention who had reached the 6 month endpoint. Engagement was defined as the number of completed intervention sessions. Control variables were measured at baseline. Ordinary least-squares regression was used, entering categories of predictors in separate steps: 1) demographics: age, gender, race/ethnicity, insurance status, parental education; 2) clinical: A1c, duration of T1D, device use; 3) behavioral: medication adherence, diabetes self-management (DSMQ); 4) psychosocial: diabetes distress (DDS), self-efficacy (DES-SF), and autonomous motivation (TSRQ). Results: Participants (n=87) were 24 (±4) yrs old, 60% female, 49% Hispanic/Latinx and 43% White, and completed a mean of 9.5 intervention sessions (range: 0-24). In the final model (p=0.0003), engagement was associated with low parental education (parameter estimate -4.1 visits), being uninsured (+3.6 visits), and higher glucose monitoring (-1.1 visits) and physical activity (-0.6 visits) on the DSMQ. Discussion: Clinical and psychosocial variables were unrelated to OT visits; to an extent, poorer self-management predicted more visits. Indicators of SES were most predictive: low parental education decreased, and uninsured status increased, number of OT visits. Given that the factors most associated with engagement were indicators of SES, clinicians are encouraged to assess barriers and external factors that may impact access and participation as soon as possible in the therapeutic process, to facilitate engagement in services. Disclosure E.Pyatak: Research Support; Abbott Diabetes. J.Sideris: None. D.Fox: None. G.Granados: None. J.Diaz: None. J.Blanchard: None. A.R.Khurana: None. E.Salcedo-rodriguez: None. J.Raymond: None.

669-P: Factor Analysis of the Diabetes-Specific Risk-Taking Inventory

Introduction: Adolescence is marked by increased risk-taking behaviors and challenges engaging in optimal type 1 diabetes (T1D) treatment. We developed the Diabetes-Specific Risk-Taking Inventory (DSRI) to assess risky adolescent T1D self-management behaviors. In the current study, we conducted confirmatory factor analyses (CFAs) for the DSRI and examined model fit. Methods: We surveyed a national sample of 224 adolescents (age 15-18 years; M age 16.9 ± 1.1 years; 49% female, 11% identified as Black, Indigenous, or Persons of Color; 76.8% used insulin pumps; M HbA1c= 8.5% ± 1.3); from the T1D Exchange registry in a cross-sectional design. Participants completed the DSRI, and we collected the most recent HbA1c value from registry data. We performed CFAs in R using the Lavaan package to evaluate three models: 1) a one-factor structure, 2) a two-factor structure reflecting items higher and lower in risk (item level of risk assessed by surveying diabetes health care providers), and 3) another two-factor structure reflecting items that associate with higher HbA1c (>9%) and lower HbA1c (<9%). Results: The DSRI measure contains 31 items; however, one item was removed from CFA analyses due to a nonsignificant factor loading value. The one-factor CFA model demonstrated poor fit χ2(399, n=224) =1714.94, p<0.001, RMSEA=0.12, CFI=0.52, TLI=0.49, as did the two-factor structure differentiating between higher and lower HbA1c χ2(399, n=224) =1121.02, p<0.001, RMSEA=0.090, CFI=0.72, TLI=0.69. The two-factor CFA reflecting higher and lower risk items model demonstrated improved fit χ2(399, n=224) =896.19, p<0.001, RMSEA=0.085, CFI=0.77, TLI=0.75. Conclusions: The DSRI is a valuable self-report measure that providers may use to screen for high-risk behaviors not routinely assessed in T1D clinical care. The results suggest that the high-risk vs. low-risk two-factor model is slightly better fitting than the one-factor model; however, additional factor structures should be assessed to identify a more robust structural model. Disclosure A.Monzon: None. J.Pierce: None. R.M.Wasserman: None. Funding The Leona M. and Harry B. Helmsley Charitable Trust (2016PG-T1D053); National Institutes of Diabetes and Digestive and Kidney Diseases (1K12DK097696)

Adaptation of an Adult Web Application for Type 1 Diabetes Self-management to Youth Using the Behavior Change Wheel to Tailor the Needs of Health Care Transition: Qualitative Interview Study.

Youth (aged 14-24 years) living with type 1 diabetes (T1D) encounter increased challenges in their diabetes self-management (DSM), especially during the transition to adult care. Although DSM education and support are imperative, there is insufficient information on how web-based digital tools tailored to their demands can be developed. On the basis of the Behavior Change Wheel, this study aims to identify, among youth living with T1D, the needs and factors influencing their DSM in the context of health care transition and to inform the adaptation (content and features) of an adult self-guided web application (Support). Internet-based semistructured individual interviews based on a phenomenological study design were conducted with 21 youths, and transcripts were analyzed using an inductive approach with concept mapping. Factors influencing T1D self-management were categorized into barriers and facilitators and then as external or internal. Features influencing the accessibility to information, increasing the sense of support, and use of the tool were positively accepted. Features unrelated to their expectations of digital tool use or difficulty navigating were viewed negatively. Participants expressed an interest in reliable, practical, and novel educational content. Although youth considered the information provided by medical professionals to be important, peer exchange was deemed necessary to obtain a practical perspective and real-life examples. Compared with the adult population, in addition to tailored content and a simplified information search process, when building a DSM education and support digital tool for youth, features should be selected to encourage supervised peer exchange.

Adolescent perspectives on negotiating self-management responsibilities for type 1 diabetes with their parents

ObjectiveThe overall purpose of this study was to explore adolescent perspectives on communicating about self-management of type 1 diabetes (T1D) and negotiating responsibilities for self-management with parents. MethodsSemi-structured interviews were conducted with 28 adolescents aged 11–17 years living with T1D. Interviews were audio-recorded, transcribed verbatim and thematically analysed. ResultsTwo themes and five subthemes were identified. The first theme, ‘changing levels of involvement in self-management’ describes the division of responsibility for self-management within the family and adolescents collaborating and sharing responsibilities with parents for self-management. The second theme, ‘talking about self-management with parents’ describes changes in patterns of parent-adolescent communication about T1D over time, adolescents’ seeking parental feedback and advice and the factors that contribute to the promotion of self-management communication between adolescents and parents. ConclusionThis study identified that how adolescents perceive communication with their parents contributes to negotiation of responsibilities for self-management during adolescence. The findings provide a nuanced understanding of adolescent perspectives on communication with parents about T1D self-management and how parent-adolescent communication can be framed in ways that promote positive adolescent engagement with T1D self-management. Practice implicationsTargeting parent-adolescent communication strategies may result in more optimal sharing of responsibilities and improved self-management.

Knowledge of young people living with type 1 diabetes and their caregivers about its management.

We sought to investigate knowledge and skills of type 1 diabetes (T1D) management among young people living with the disease and their caregivers. Our aim is to provide baseline evidence to inform T1D self-management education for young people living with the disease and their caregivers. Both local and international guidelines recommend ongoing T1D self-management education for people living with the disease. This is because T1D often develops among young people who rarely have the competencies to adequately manage their condition. However, the extent to which young people living with T1D and their caregivers can self-manage this chronic disease in a low-resource country like Ghana is unknown. Using a phenomenological study design, semi-structured interviews were conducted with 28 young people living with type 1 diabetes, 12 caregivers and 6 healthcare providers in southern Ghana. Data were collected at homes, hospitals and support group centres of participants via face-to-face interviews, photovoice and video-conferencing. The data were analysed thematically using QSR NVivo 11. The young people living with T1D and their caregivers demonstrated knowledge and skills in the self-monitoring of blood glucose, and the treatment of hyperglycaemia. Areas of more marginal or lack of knowledge were concerning carbohydrate counting, severe hypoglycaemia and the management of intercurrent illnesses. Young persons living with T1D and their caregivers received their management information from healthcare and non-healthcare providers. Access to diabetes self-management education influenced T1D management knowledge and practices. Young people living with type 1 diabetes and their caregivers possessed limited scope of knowledge on type 1 diabetes self-management. Multiple sources of T1D knowledge were found, some of which may not be helpful to patients. The knowledge gaps identified compromises transitional independence and self-management capacity. It is important for clinicians and organizations that provide T1D education to provide diabetes self-management education also on managing hypoglycaemia, carbohydrate counting and managing T1D during intercurrent life events among young people living with T1D. Patients and their caregivers were interviewed as research participants. They did not conceptualize, analyse, interpret or prepare the manuscript.

Domesticating the condition: Design lessons gained from a marathon on how to cope with barriers imposed by type 1 diabetes.

Through analytical autoethnographic analysis of marathon preparation, this study examines challenges faced by people with Type 1 Diabetes (T1D) who engage in high-performance sports. Autoethnographer and second-person perspectives (T1D runners, family members, and health providers) were collected through introspective activities (autoethnographic diary and in-depth interviews) to understand the T1D runner's coping experience. Six insights involved in T1D self-management were identified and analyzed with reference to related design tools (prototyping, archetyping and journey mapping). Finally, we conclude with a discussion of how endurance physical activity (PA) such as running helps to "domesticate" T1D, a term coined to reflect the difficulties that T1D presents for PA accomplishment and how T1D runners' experiences give them an opportunity to overcome PA barriers promoting physical culture and enriching further health psychology studies.

Learning experience design of an mHealth self-management intervention for adolescents with type 1 diabetes.

Type 1 diabetes (T1D) is a lifelong and chronic condition that can cause severely compromised health. The T1D treatment regimen is complex, and is a particular challenge for adolescents, who frequently experience a number of treatment adherence barriers (e.g., forgetfulness, planning and organizational challenges, stress). Diabetes Journey is a gamified mHealth program designed to improve T1D self-management through a specific focus on decreasing adherence barriers and improving executive functioning skills for adolescents. Grounded in situativity theory and guided by a sociotechnical-pedagogical usability framework, Diabetes Journey was designed, developed, and evaluated using a learning experience design approach. This approach applied design thinking methods within a Successive Approximation Model design process. Iterative design and formative evaluation were conducted across three design phases, and improvements were implemented following each phase. Findings from the user testing phase indicate Diabetes Journey is a user-friendly mHealth program with high usability that holds promise for enhancing adolescents' T1D self-management. Implications for future designers and researchers are discussed regarding the social dimension of the sociotechnical-pedagogical usability framework. An extension to the framework is proposed to extend the social dimension to include socio-cultural and contextual considerations when designing mHealth applications. Consideration of the pedagogical and sociocultural dimensions of learning is imperative when developing psychoeducational interventions.

What nursing interventions and healthcare practices facilitate type 1 diabetes self-management in young adults? An integrative review.

This integrative review aimed to explore how current nursing and healthcare practices can be designed to facilitate effective type 1 diabetes (T1D) self-management in young adults aged 16-25 years. The review explored relevant quantitative and qualitative literature published between 2017 and 2021. Five electronic databases were searched: CINAHL, Medline, Scopus, PubMed and PsycINFO. PRISMA reporting was used to show the flow of information through the different phases of the review. Articles that met the inclusion/exclusion criteria were critically appraised using the Mixed Methods Appraisal Tool. Four main themes emerged through thematic analysis: digital information systems; glucose monitoring and insulin devices; group and peer education and peer support; and diabetes care delivery style. Findings from the review identified that 1) platforms for text messaging, social media, email, and smartphone apps were innovative communication strategies that worked for this age group; 2) the use of continuous glucose monitoring and insulin devices were found to improve self-management routines and psychological well-being of young adults; 3) health service support and education needs to be flexible, dynamic and young adults want to be treated as partners in their own care; and, 4) young adults prefer to be socially engaged, interacting either in group educational settings or with peers through social media. This integrative review highlights the importance of adopting age-appropriate interventions to improve young adults’ engagement in T1D self-management, requiring nurses and healthcare practitioners need to keep up to date with the rapid changes in digital technology and diabetes-related device technology. However, relational engagement remains an essential component integral to nurses supporting young adults living with T1D.

Risky self-management behaviors in adolescents with type 1 diabetes: Measurement validation for the Diabetes-Specific Risk-Taking Inventory.

Among persons with type 1 diabetes (T1D), adolescents often experience the greatest challenge achieving optimal treatment engagement and glycemic targets. Risk-taking behaviors often increase during adolescence and may interfere with engagement in T1D care. We developed the Diabetes-Specific Risk-Taking Inventory (DSRI) to assess risky T1D self-management behaviors in adolescents with T1D. In the current study, we aimed to examine the DSRI's psychometric properties. We surveyed a national sample of 224 adolescents from the T1D Exchange registry (M age=16.9 ± 1.1, 49% female, M A1c=8.5% ± 1.3, 76.8% on insulin pumps) in a cross-sectional design. Participants completed the DSRI and measures of engagement, general risk-taking, and executive functioning and reported on incidence of severe hypoglycemia and diabetic ketoacidosis over the past year. The DSRI demonstrated reliability (internal consistency: α=0.89; test-retest reliability: r=0.86, p < 0.01). Concurrent validity was demonstrated through significant associations between the DSRI and T1D engagement (r=-0.75), general risk-taking (r=0.57), executive dysfunction (r=0.34), and report of severe hypoglycemia over the past year (r=0.22). The DSRI accounted for unique variance in adolescents' most recent glycated hemoglobin, above and beyond other variables, indicating its incremental validity. Overall, initial psychometrics suggest the DSRI is a reliable and valid measure of risks that adolescents may take with their T1D care. This innovative self-report measure has potential to be an actionable clinical tool to screen for high-risk behaviors not routinely assessed in T1D clinical care.

Enhancing self-management in type 1 diabetes with wearables and deep learning

People living with type 1 diabetes (T1D) require lifelong self-management to maintain glucose levels in a safe range. Failure to do so can lead to adverse glycemic events with short and long-term complications. Continuous glucose monitoring (CGM) is widely used in T1D self-management for real-time glucose measurements, while smartphone apps are adopted as basic electronic diaries, data visualization tools, and simple decision support tools for insulin dosing. Applying a mixed effects logistic regression analysis to the outcomes of a six-week longitudinal study in 12 T1D adults using CGM and a clinically validated wearable sensor wristband (NCT ID: NCT03643692), we identified several significant associations between physiological measurements and hypo- and hyperglycemic events measured an hour later. We proceeded to develop a new smartphone-based platform, ARISES (Adaptive, Real-time, and Intelligent System to Enhance Self-care), with an embedded deep learning algorithm utilizing multi-modal data from CGM, daily entries of meal and bolus insulin, and the sensor wristband to predict glucose levels and hypo- and hyperglycemia. For a 60-minute prediction horizon, the proposed algorithm achieved the average root mean square error (RMSE) of 35.28 ± 5.77 mg/dL with the Matthews correlation coefficients for detecting hypoglycemia and hyperglycemia of 0.56 ± 0.07 and 0.70 ± 0.05, respectively. The use of wristband data significantly reduced the RMSE by 2.25 mg/dL (p < 0.01). The well-trained model is implemented on the ARISES app to provide real-time decision support. These results indicate that the ARISES has great potential to mitigate the risk of severe complications and enhance self-management for people with T1D.

605-P: Self-Management Behaviors Mediate the Relationship between Diabetes Burden in Caregivers and A1C

Type 1 Diabetes (T1D) treatment involves engaging in multiple complex and burdensome self-management behaviors daily. The purpose of this study was to examine the relationship between diabetes burden, self-management behaviors, and A1C. Caregivers of 77 adolescents with T1D (age=14.9±1.9 years, A1C=9.8±1.6%, T1D duration=6.8±3.5 years, 45.5% male) participating in a RCT that provided integrated behavioral intervention to improve A1C completed a short version of Problem Areas in Diabetes-Parent Revised (PAID-PR) at the baseline visit prior to beginning intervention. The Immediate Burden subscale of PAID-PR was used to assess diabetes burden. Objective self-management behaviors were calculated using data downloaded from adolescents’ T1D devices. As caregiver burden increased, so did the frequency of self-management behaviors of carbohydrate entries per day (r=0.365, p&amp;lt;0.01) and insulin boluses per day (r=0.273, p&amp;lt;0.05) , but not blood glucose readings. Caregiver burden increased as A1C decreased (r=-0.224, p&amp;lt;0.05) . There was a significant indirect effect of diabetes burden on A1C through the self-management behaviors for carbohydrate entries per day (b=-0.023, 95% bias-corrected and accelerated bootstrap (BCa) CI [-0.056, -0.002] and insulin boluses per day (b=-0.016, 95% BCa CI [-0.041, 0.001]) . Higher T1D self-management is associated with lower A1C, but this may come with a cost- greater feelings of burden due to T1D management. Family interventions to promote teamwork and assist caregivers and adolescents to appropriately distribute responsibility for T1D management may allow for continued high engagement while reducing burden. Disclosure H.K.O'donnell: None. A.C.Himelhoch: None. T.B.Vigers: None. G.T.Alonso: None. S.Majidi: None. L.Pyle: None. J.K.Snell-bergeon: Stock/Shareholder; GlaxoSmithKline plc. R.Wadwa: Advisory Panel; Dompé, Consultant; Beta Bionics, Inc., Other Relationship; Tandem Diabetes Care, Inc., Research Support; Dexcom, Inc., Eli Lilly and Company, Tandem Diabetes Care, Inc. K.A.Driscoll: None. Funding National Institute of Diabetes and Digestive and Kidney Diseases (DP3DK113363)

Bring Blood Glucose Down! An intervention to reduce fear of hypoglycemia in caregivers of adolescents with type 1 diabetes: Study design and participant characteristics

Fear of hypoglycemia (FOH) is anxiety or extreme worry about having a low blood glucose and its consequences. FOH is common in individuals with type 1 diabetes (T1D) of all ages, as well as their caregivers, and can lead to inappropriate T1D self-management and suboptimal health outcomes. Despite its prevalence and serious health consequences, there has been very little attention focused on developing interventions to reduce FOH and its associated maladaptive T1D management behaviors. The primary aim of the present study, Bring BG Down!, was to implement a pilot intervention targeting FOH in mothers of adolescents with T1D. Exploratory aims included determining if the intervention had an impact on the adolescent's FOH, glycemia, as well as other generalized anxiety symptoms or symptoms of obsessive-compulsive disorder in both the mother and adolescent. Caregiver participants and their adolescents with T1D were randomized to either the Bring BG Down! group or the Control group. Individuals in the Bring BG Down! group participated in intervention sessions for 6 months via telehealth and they completed questionnaires, whereas those in the Control group only completed questionnaires. Follow-up occurred at 7-months and 10-months. The purpose of this paper is to describe the Bring BG Down! study design and rationale, and participant characteristics at the start of the study.

The Impact of Racial and Ethnic Health Disparities in Diabetes Management on Clinical Outcomes: A Reinforcement Learning Analysis of Health Inequity Among Youth and Young Adults in the SEARCH for Diabetes in Youth Study.

To estimate difference in population-level glycemic control and the emergence of diabetes complications given a theoretical scenario in which non-White youth and young adults (YYA) with type 1 diabetes (T1D) receive and follow an equivalent distribution of diabetes treatment regimens as non-Hispanic White YYA. Longitudinal data from YYA diagnosed 2002-2005 in the SEARCH for Diabetes in Youth Study were analyzed. Based on self-reported race/ethnicity, YYA were classified as non-White race or Hispanic ethnicity (non-White subgroup) versus non-Hispanic White race (White subgroup). In the White versus non-White subgroups, the propensity score models estimated treatment regimens, including patterns of insulin modality, self-monitored glucose frequency, and continuous glucose monitoring use. An analysis based on policy evaluation techniques in reinforcement learning estimated the effect of each treatment regimen on mean hemoglobin A1c (HbA1c) and the prevalence of diabetes complications for non-White YYA. The study included 978 YYA. The sample was 47.5% female and 77.5% non-Hispanic White, with a mean age of 12.8 ± 2.4 years at diagnosis. The estimated population mean of longitudinal average HbA1c over visits was 9.2% and 8.2% for the non-White and White subgroup, respectively (difference of 0.9%). Within the non-White subgroup, mean HbA1c across visits was estimated to decrease by 0.33% (95% CI -0.45, -0.21) if these YYA received the distribution of diabetes treatment regimens of the White subgroup, explaining ∼35% of the estimated difference between the two subgroups. The non-White subgroup was also estimated to have a lower risk of developing diabetic retinopathy, diabetic kidney disease, and peripheral neuropathy with the White youth treatment regimen distribution (P < 0.05), although the low proportion of YYA who developed complications limited statistical power for risk estimations. Mathematically modeling an equalized distribution of T1D self-management tools and technology accounted for part of but not all disparities in glycemic control between non-White and White YYA, underscoring the complexity of race and ethnicity-based health inequity.

21-LB: Development and Validation of the Barriers and Supports Evaluation for Working-Age Adults with Type 1 Diabetes

Objective: To optimize type 1 diabetes (T1D) self-management, experts recommend tailoring care to meet people’s needs and preferences. To facilitate this tailoring, we developed and validated the Barriers and Supports Evaluation (BASES) tool to identify working-age adults’ T1D self-management barriers and supports. Methods: Participants were 25-64 year old adults with T1D recruited from clinics and a community-based registry. Guided by Social Cognitive Theory, content analysis of 33 semi-structured interviews was used to create a comprehensive item pool of 136 items, further refined to 70 candidate items on a 5-point Likert scale through cognitive interviewing and pilot testing. To develop and validate the tool, exploratory and confirmatory factor analyses were applied to 392 participants’ survey responses to the candidate barrier and support items. Additional survey data included demographics and the Diabetes-Specific Quality of Life Scale-Revised. To evaluate concurrent validity, A1c values from medical records and quality of life (QoL) scores were regressed on domain scores. Results: Factor analyses yielded 5 domains with a total of 30 items: (1) Cognitive Processes, (2) Costs and Insurance, (3) Learning Opportunities, (4) Family and Friend Support, and (5) Diabetes Provider Interactions. Models exhibited good to adequate fit, with Comparative Fit Index (CFI)&amp;gt;0.88 and Root Mean Squared Error of Approximation (RMSEA)&amp;lt;0.06. All domains demonstrated significant associations with A1c and QoL in the expected direction, with the exception of the Family and Friend Support domain. The Cognitive Processes domain exhibited the strongest associations with both A1c (β=0.7; 0.4-0.9) and QoL (β=-19; -21 to -17). Conclusions: The BASES tool is brief, patient-centered, and demonstrates construct and concurrent validity. The tool could be used in clinical practice to tailor diabetes support and education to individual’s needs, improving effectiveness of services. Disclosure E. D. Cox: None. E. M. Planalp: None. H. Kliems: None. M. Palta: n/a. T. J. Lecaire: None. B. A. Chewning: None. Funding American Diabetes Association (1-18-ICTS-026 to E.D.C.)