Publications by authors named "Margaret Grey"

158 Publications

Expect the Unexpected: Adolescent and Pre-teens' Experience of Diabetes Technology Self-Management.

Pediatr Diabetes 2021 Jul 15. Epub 2021 Jul 15.

The Ohio State University College of Nursing, Columbus, OH.

Objective: Only 17% of adolescents with type 1 diabetes (T1D) are currently meeting their glycemic targets despite advances in diabetes technologies. Self-management behaviors and challenges specific to use of diabetes technologies are insufficiently studied in adolescents. We aimed to describe the experience of diabetes technology self-management, including facilitators and barriers, among preteens/adolescents with low and high A1C.

Research Design And Methods: Youth (10-18 years of age) with T1D who use insulin pump therapy were recruited from the larger quantitative cohort of a mixed methods study for participation in semi-structured qualitative interviews. Maximum variability sampling was used to recruit youth with A1C <7.5% (n=5) and A1C >9% (n=5). Participants' personal insulin pump and continuous glucose monitoring data were downloaded and served as a visual reference. Interviews were analyzed using a qualitative descriptive approach.

Results: Participants were 50% female with a median age of 14.9 years and 80% used CGM. The sample was predominantly white (90.0%). Analysis produced four major themes, Bad Day, Expect the Unexpected, Nighttime Dependence and Unpredictability, It's Really a Team and interconnecting subthemes. Youth characterized "Bad Days" as those requiring increased diabetes focus and self-management effort. The unpredictability ("Expect the Unexpected") of glucose outcomes despite attention to self-management behaviors was considerable frustration.

Conclusions: Diabetes devices such as insulin pumps are complex machines that rely heavily on individual proficiency, surveillance, and self-management behaviors to achieve clinical benefit. Our findings highlight the dynamic nature of self-management and the multitude of factors that feed youths' self-management behaviors. This article is protected by copyright. All rights reserved.
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http://dx.doi.org/10.1111/pedi.13249DOI Listing
July 2021

Use of the self- and family management framework and implications for further development.

Nurs Outlook 2021 Jun 25. Epub 2021 Jun 25.

Yale School of Nursing, West Haven, CT.

Background: The Self- and Family Management Framework (SFMF) was created in 2006 and revised in 2015 to guide research on self- and family management of chronic conditions. There has been no review of use of the SFMF.

Purpose: We reviewed articles citing the SFMF to identify the frequency and nature of use.

Method: We conducted a citation analysis, searching Web of Science, Scopus, and Google Scholar databases and extracted key data from identified articles.

Findings: Of 126 articles, 84(66%) cited the 2006 SFMF, 37(29%) cited the 2015 SFMF, and 6(5%) cited both. The SFMF was used most to inform study design. Users noted strengths (e.g., considers family context) and limitations (e.g., non-specification of patient- family caregiver synergies) of the framework.

Discussion: The SFMF has been used broadly to guide research on self- and family management of chronic conditions. Findings will inform development of a third version of the SFMF.
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http://dx.doi.org/10.1016/j.outlook.2021.05.009DOI Listing
June 2021

Circadian characteristics of the rest-activity rhythm, executive function, and glucose fluctuations in young adults with type 1 diabetes.

Chronobiol Int 2021 Jun 15:1-11. Epub 2021 Jun 15.

Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio, USA.

Circadian alignment is an important element in individual health, and one behavioral marker, rest-activity rhythm, could influence self-management in young adults with type 1 diabetes (T1D). Little is known about the rest-activity rhythms, executive function, and glycemia among young adults with type 1 diabetes (T1D). The purpose of this study was to evaluate parametric and nonparametric circadian characteristics of the rest-activity rhythm and the associations between these variables, sleep-wake behavior, executive function, and glycemia among young adults with T1D. Young adults with T1D, recruited from diabetes clinics, wore wrist actigraphs and a continuous glucose monitor (CGM) concurrently for 6-14 days. Participants completed a 3-minute Trail Making Test on paper and electronic questionnaires - 8-item PROMIS v1.0 Emotional Distress Scale, 17-item Diabetes Distress Scale, including twice-daily Pittsburgh sleep diaries. Cosinor and nonparametric analyses were used to compute the rest-activity rhythm parameters, and linear regression modeling procedures were performed to determine the associations among the study variables. The sample included 46 young adults (mean age 22.3 ± 3.2; 32.6% male; 84.8% non-Hispanic White, HbA1c mean 7.2 ± 1.1%, BMI mean 27.0 ± 4.4 kg/m). A number of parametric associations were observed between a stronger rhythm, better objective sleep-wake characteristics, and less daytime sleepiness. Nonparametric circadian parameters were significantly associated with several outcomes: a stronger rhythm adherence (higher inter-daily stability) with better objective sleep-wake characteristics, better executive function, lower diabetes distress, less hyperglycemia risk, and more time spent in hypoglycemia/hypoglycemia risk; and a more robust rhythm (higher relative amplitude) with better objective sleep-wake characteristics and more time spent in hypoglycemia/higher hypoglycemia risk. Future work should be directed at designs that test causality, such as interventions directed at the strength and stability of rest-activity rhythms, for the potential to improve glucoregulation and other diabetes outcomes.
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http://dx.doi.org/10.1080/07420528.2021.1932987DOI Listing
June 2021

Sleep-wake characteristics, daytime sleepiness, and glycemia in young adults with type 1 diabetes.

J Clin Sleep Med 2021 May 5. Epub 2021 May 5.

School of Nursing and School of Medicine, Yale University, West Haven, Connecticut.

Study Objectives: The purpose of this study was to describe objective sleep-wake characteristics and glycemia over 7 - 14 days in young adults with type 1 diabetes (T1D). Additionally, person level associations among objective sleep-wake characteristics (total sleep time, sleep variability, and sleep fragmentation index), daytime sleepiness, and glycemia (glycemic control and glucose variability) were examined.

Methods: In this cross-sectional study, objective sleep-wake characteristics were measured via actigraphy and glucose variability via continuous glucose monitoring (CGM) over 6-14 days. At baseline, participants completed a psychomotor vigilance test (PVT), Trail Making Test, and questionnaires on daytime sleepiness, sleep quality, and sleep disturbance including sleep diaries.

Results: Forty-six participants (mean age 22.3 ± 3.2 years) wore a wrist actigraph and CGM concurrently for 6-14 days. Greater sleep variability was directly associated with greater glucose variability (mean of daily differences) (r = 0.33, p = .036). Higher daytime sleepiness was directly associated with greater glucose variability (mean of daily differences) (r = 0.50, p = .001). The association between sleep variability and glucose variability (mean of daily differences) was no longer significant when accounting for daytime sleepiness and controlling for T1D duration (p > .05). A higher sleep fragmentation index was associated with greater glucose variability (B = 1.27, p = .010, pr = .40) after controlling for T1D duration and accounting for higher daytime sleepiness.

Conclusions: Sleep-wake variability, sleep fragmentation, daytime sleepiness, and the associations with glycemia are new dimensions to consider in young adults with T1D. Sleep habits in this population may explain higher glucose variability and optimizing sleep may improve overall diabetes management.
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http://dx.doi.org/10.5664/jcsm.9402DOI Listing
May 2021

Factors associated with diabetes distress among adolescents with type 1 diabetes.

J Clin Nurs 2021 Jul 7;30(13-14):1893-1903. Epub 2021 Apr 7.

Xiangya School of Nursing, Central South University, Changsha, China.

Aims: To describe the specific domains of diabetes distress and factors associated with these domains.

Background: Diabetes distress is a common problem but not well recognised in adolescents by healthcare providers or adolescents themselves. There is insufficient evidence on how specific domains of diabetes distress exist in adolescents, making it challenging to select precise components to alleviate diabetes stress.

Design: A quantitative, descriptive and cross-sectional study.

Methods: Data were collected on socio-demographic and clinical characteristics, diabetes distress, perceived stress, self-efficacy and diabetes self-management using established questionnaires. Multivariate linear regression was conducted to examine the associations between specific factors and four domains in diabetes distress. STROBE checklist was used as the guideline for this study.

Results: A total of 100 adolescents with type 1 diabetes aged 12 to 18 years participated in this study. Adolescents experienced the highest levels of distress in the regimen-related distress [2.41 (SD =0.82)] and physician-related distress [2.40 (SD =0.80)] domains. Older age, female gender, more diabetes problem-solving and higher levels of perceived stress were associated with higher regimen-related distress (β = 0.21 ~ 0.45, p < 0.05). Older age, female gender, a lower degree of endorsement of relevant diabetes-related goals and higher levels of perceived stress were associated with higher physician-related distress (β = -0.29 ~ 0.34, p < 0.05).

Conclusions: Diabetes distress was reported more on regimen-related and physician-related domains among adolescents with type 1 diabetes in China, associating with older age, female, increased perceived stress and poor diabetes-related problem-solving.

Relevance To Clinical Practice: Nurses need to screen the specific domains of diabetes distress among adolescents with type 1 diabetes, especially for the older adolescents and girls. This study highlighted the importance of incorporating diabetes-related problem-solving support and stress management strategies into diabetes management for adolescents with type 1 diabetes, which could help relieve diabetes distress.
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http://dx.doi.org/10.1111/jocn.15742DOI Listing
July 2021

Parent-Child Relationship Quality as a Mediator of the Association between Perceived Stress and Diabetes Self-Management in Adolescents With Type 1 Diabetes.

J Fam Nurs 2021 02 1;27(1):73-82. Epub 2020 Dec 1.

Yale University, New Haven, CT, USA.

Diabetes self-management is suboptimal in adolescents with type 1 diabetes (T1D), including those in China. The aim of the study was to investigate the impact of parent-child relationship quality on diabetes self-management. Data were collected by a self-report survey among 122 Chinese adolescents from April to July 2017. The data were analyzed using a one-way analysis of variance, descriptive analyses, correlation analyses, and mediation analyses. The mean age was 13.8 (range, 10-18) years, and the mean diabetes duration was 4.1 (±3.1) years. About half of the adolescents with T1D experienced high levels of perceived stress. Parent-child relationship quality mediated the associations between perceived stress and collaboration with parents, diabetes care activities, and diabetes communication on aspects of diabetes self-management (s < 0.05). To reduce the negative impacts of perceived stress on diabetes self-management in this population, parent-child relationship quality should be considered an important element of family-based interventions and clinical practice.
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http://dx.doi.org/10.1177/1074840720971584DOI Listing
February 2021

Self-management among pre-teen and adolescent diabetes device users.

Pediatr Diabetes 2020 12 10;21(8):1525-1536. Epub 2020 Oct 10.

The Ohio State University College of Nursing, Columbus, Ohio, USA.

Objective: Despite increased diabetes device use, few adolescents with type 1 diabetes (T1D) meet glycemic targets. We examine associations between utilization of insulin pumps and continuous glucose monitoring (CGM) and glycemic control.

Research Design And Methods: This prospective cohort study included 80 youths (10-18 years of age) with T1D. Multiple linear regression and linear mixed models (LMM) were used to estimate the effects of device self-management on HbA1c and daily time in range (70-180 mg/dL), respectively.

Results: Every blood glucose (BG) input/day was associated with a 0.2% decrease in HbA1c (95% CI: -0.297, -0.013), each bolus/day was associated with a 0.2% decrease (-0.327, -0.057), and use of CGM was associated with a 0.5% decrease (-1.00, -0.075). Among CGM users (n = 45) every 10% increase in CGM use was associated with a 0.3% decrease in HbA1c (-0.390, -0.180). In LMM accounting for within subject and between subject variability, there was a negative association between BG input/day frequency (coefficient = -1.880, [-2.640, -1.117]) and time in range. Residual random effects for CGM users were large showing time in range varied between youth with a SD of 15.0% (3 hours and 36 minutes) (SE 2.029, [11.484, 19.530]). Time in range varied significantly from day-to-day with SD of 18.6% (4 hours and 40 minutes) (SE0.455, [17.690, 19.473]).

Conclusions: Device self-management behaviors among youth are significantly associated with both HbA1c and time in range. Our findings showing an association between reduced time in range and increased self-management behaviors is novel and deserves further investigation.
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http://dx.doi.org/10.1111/pedi.13131DOI Listing
December 2020

Daily variations in sleep and glucose in adolescents with type 1 diabetes.

Pediatr Diabetes 2020 12 28;21(8):1493-1501. Epub 2020 Sep 28.

Annie Goodrich Professor of Nursing and Professor of Pediatrics, Yale University, School of Nursing and School of Medicine, West Haven, Connecticut, 06477, USA.

Objective: We used multilevel models (MLMs) to determine person (between-persons) and day level (within-person) associations between glucose variability indices and sleep characteristics in adolescents with type 1 diabetes (T1D).

Methods: Adolescents with T1D (Mean age 13.4 ± 1.8 years; 37.8% male; mean HbA1c 8.2 ± 1.2%, 66 mmol/mol) monitored their sleep and glucose patterns concurrently for 3-7 days with a wrist actigraph on their non-dominant wrist and a continuous glucose monitor (CGM) (their own or a provided, blinded CGM). Glucose variability indices included J index, coefficient of variation, low and high blood glucose risk indices (LBGI and HBGI), time in range, and sleep characteristics, including bedtime, wake time, total sleep time, sleep efficiency, wake after sleep onset, awakenings, and sleep fragmentation index.

Results: More overall glucose variability was associated within person, more sleep disruptions (more awakenings and more fragmentation) or poorer sleep in our study (earlier wake time or longer wake after sleep onset). Also, more time spent in hypoglycemia <70 mg/dL and a higher LBGI was associated within person with earlier wake time indicating poorer sleep. However, a lower LBGI was associated with a later between-persons wake time.

Conclusions: Monitoring over a longer period of time in subsequent studies would allow researchers to determine the within person association between habitual short sleep duration and glucose variability. Providers should regularly assess sleep habits in adolescents as a way to improve glycemic control. Targeting a euglycemic range overnight is also important to promote better sleep and to decrease sleep disruptions.
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http://dx.doi.org/10.1111/pedi.13117DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642150PMC
December 2020

A systematic review and meta-analysis of behavioral sleep interventions for adolescents and emerging adults.

Sleep Med Rev 2020 12 8;54:101356. Epub 2020 Jul 8.

Yale School of Nursing, West Haven, Connecticut 06477, USA; Yale University, School of Nursing and School of Medicine, West Haven, CT 06477, USA. Electronic address:

In the United States, more than two-thirds of adolescents and one-third of emerging adults report habitual short sleep duration, which is a known risk factor for psychological distress. The primary aim of this systematic review and meta-analysis was to evaluate the effect of behavioral sleep-promoting interventions on the sleep characteristics (e.g., total sleep time and sleep efficiency) of adolescents and emerging adults (aged 12-25 y) who do not have a sleep disorder. The secondary aim was to determine the effect of behavioral sleep-promoting interventions on psychological distress. Multiple electronic databases were searched for relevant randomized controlled trials (RCTs) published in English. Fourteen RCTs were included in the qualitative synthesis (N = 932), seven were included in the meta-analysis (n = 711) to address the primary aim, and three (n = 253) were included to address the secondary aim. The pooled standardized mean difference for sleep-promoting interventions after treatment for total sleep time was 34.92 min (95% CI: 8.70, 61.14). Sleep-promoting interventions had no significant effect on sleep efficiency. More RCTs that involve adolescents and emerging adults are needed to determine the effect of sleep-promoting interventions on reducing psychological distress in this high-risk age group.
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http://dx.doi.org/10.1016/j.smrv.2020.101356DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7669566PMC
December 2020

Sleep, self-management, neurocognitive function, and glycemia in emerging adults with Type 1 diabetes mellitus: A research protocol.

Res Nurs Health 2020 08 8;43(4):317-328. Epub 2020 Jul 8.

School of Nursing and School of Medicine, Yale University, West Haven, Connecticut.

Type 1 Diabetes (T1D) affects 1.6 million Americans, and only 14% of emerging adults ages 18-25 years achieve targets for glycemic control (A1C < 7.0%). Sleep deficiency, including habitual short sleep duration (<6.5 hr total sleep time and high within-person variability in total sleep time), is associated with poorer glycemic control. Emerging adults with T1D have a more pronounced sleep extension on weekends compared with matched controls, consistent with sleep deficiency; however, associations among sleep variability and glycemic control have not been explored in this population. Sleep deficiency may affect the complex higher-order neurocognitive functioning needed for successful diabetes self-management (DSM). We report the protocol for an ongoing study designed to characterize sleep and the associations among sleep deficiency, neurocognitive function, DSM, diabetes quality of life, and glycemia among a sample of 40 emerging adults with T1D. We monitor sleep via wrist-worn actigraphy and glucose via continuous glucose monitoring concurrently over 14 days. We are collecting data on self-report and objective sleep, a 10-min psychomotor vigilance test on a PVT-192 device, a 3-min Trail Making Test on paper, and questionnaires, including twice-daily Pittsburgh sleep diaries using Research Electronic Data Capture (REDCap) . Results from this study will be used to support the development and testing of the efficacy of a tailored sleep self-management intervention that may improve total sleep time, sleep variability, neurocognitive function, DSM, glycemic control, and glucose variability among emerging adults with T1D.
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http://dx.doi.org/10.1002/nur.22051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7382362PMC
August 2020

Improving clinical outcomes of diabetic foot ulcers by the 3-month self- and family management support programs in Indonesia: A randomized controlled trial study.

Diabetes Metab Syndr 2020 Sep - Oct;14(5):857-863. Epub 2020 May 21.

Ramathibodi School of Nursing, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Thailand.

Background And Aims: Diabetic foot ulcers are the leading cause of lower extremity amputations, which require more effective prevention. Even though previous nursing studies on diabetic foot ulcers have been well performed, programs implementing self- and family management are limited and even underexplored. Therefore, the purpose of the study was to investigate the effect of 3-month self- and family management support programs on clinical outcomes among Indonesians with diabetic foot ulcers.

Method: The randomized controlled trial design was used to answer the research question of the study. A total of 56 eligible participants were enrolled, with 27 in the experimental group and 29 in the control group. The experimental group received self- and family management support programs for three months. Meanwhile, the control group received usual care. Descriptive statistics, multivariate analysis of variance, and Generalized Estimating Equations were used to analyze the data. The significance level was considered at .05 for hypothesis testing.

Results: The study showed that there were statistically significant improvements in self-management, family supports, hemoglobin A1c, and wound size after implemented the programs for three months (p < .05).

Conclusions: With regard to the result of the study, implementing the 3-month self- and family management support programs improves the patients' and families' abilities to perform diabetic foot ulcer care at home.
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http://dx.doi.org/10.1016/j.dsx.2020.05.028DOI Listing
July 2021

Facilitators and Barriers of Sleep in Young Adults With Type 1 Diabetes.

Diabetes Educ 2020 06 8;46(3):242-251. Epub 2020 May 8.

Yale University.

Purpose: The purpose of this study was to explore the perceived facilitators and barriers for obtaining sufficient sleep in young adults with type 1 diabetes (T1D).

Methods: A qualitative descriptive approach was used to generate data. In-depth semi-structured interviews with 30 young adults with T1D (66.7% female, mean age = 22.1 years) were conducted. Interviews were transcribed verbatim and coded using NVivo.

Results: Young adults with T1D reported feeling challenged at bedtime and overnight by the demands of a complex disease management regimen. General and diabetes-specific barriers and facilitators to obtaining sufficient sleep were the overarching themes in the present study. Young adults perceived that electronic device use was a facilitator for relaxation before bed and a barrier to sleep by some participants. Delays in bedtime or disruptions in sleep were common diabetes-specific barriers.

Conclusions: When designing sleep-promoting interventions for young adults with T1D, researchers should consider diabetes-specific challenges and solutions in addition to those present in the general young adult population.
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http://dx.doi.org/10.1177/0145721720916179DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7329586PMC
June 2020

Perceptions and experiences of living with type 1 diabetes among Latino adolescents and parents with limited English proficiency.

Res Nurs Health 2020 Jun 12;43(3):263-273. Epub 2020 Apr 12.

School of Nursing, Yale University, Orange, Connecticut.

We explored perceptions and experiences of living with type 1 diabetes mellitus (T1DM) among U.S. Latino adolescents (age 12-19 years) with T1DM and parents with limited English proficiency. We used a qualitative descriptive approach with semi-structured interviews of adolescents together with their parents. Interview data were reviewed, coded, and combined into themes about participant experiences with T1DM. Twenty-four adolescents (mean age: 15.4 years) and 23 parents participated. Analysis resulted in three themes: (a) Understanding and adapting to T1DM (i.e., initial fear and misunderstandings of T1DM; adolescents' reflections on living with a chronic health condition); (b) Coming to terms with social and environmental influences on T1DM self-management (i.e., T1DM as disruptive to school and social activities; dealing with stigma and judgments related to diabetes); and, (c) Integrating T1DM self-management expectations with components of Latino cultures (i.e., orientation toward family well-being; parent concerns about cultural preferences that influence food choices, positive influence of spirituality and religiousness; parental views of their current health care in comparison to that available in their place of birth). Adolescents and their parents reported experiences that are universal to adolescents with T1DM in addition to challenges that are unique to Latinos. Efforts aimed at improving T1DM self-management during adolescence with this population need to be tailored to meet the unique social and cultural contexts and delivered in a culturally and linguistically congruent manner.
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http://dx.doi.org/10.1002/nur.22019DOI Listing
June 2020

Sleep and Glycemia in Youth With Type 1 Diabetes.

J Pediatr Health Care 2020 Jul - Aug;34(4):315-324. Epub 2020 Mar 11.

Introduction: Short sleep duration and quality are problems for many youth, and are associated with difficulties in executive function. Our purpose was to describe subjective and objective sleep characteristics and their associations with executive function, stress and coping, adjustment, and self-management in youth with type 1 diabetes (T1D).

Method: Youth with T1D (N = 40; mean age, 13.4 ± 1.9 years; 60% female; 77.1% non-Hispanic white; diabetes duration, 7.1 ± 4.6 years; and hemoglobin A1c, 8.2 ± 1.2%) wore an actigraph and a continuous glucose monitor for 3-7 days and completed questionnaires. Descriptive and bivariate analyses were conducted.

Results: Sleep variability was associated with stress and depressive symptoms, as well as more glucose variability. Consistent rest-activity rhythm timing was associated with fewer trait anxiety symptoms. Robust rhythms were associated with better diabetes self-management.

Discussion: Providers should routinely assess sleep habits in youth, especially those with T1D. Improving consistency in sleep timing and sleep duration may be a potential therapeutic target to improve diabetes clinical outcomes.
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http://dx.doi.org/10.1016/j.pedhc.2019.12.002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311270PMC
March 2020

Diabetes Distress, Depressive Symptoms, and Cardiovascular Health in Adults With Type 1 Diabetes.

Nurs Res 2019 Nov/Dec;68(6):445-452

Margaret M. McCarthy, PhD, RN, FNP-BC, is an Assistant Professor, the New York University Rory Meyers College of Nursing, New York. Robin Whittemore PhD, APRN, is Professor and Codirector, the National Clinician Scholars Program, Yale School of Nursing, West Haven, Connecticut. Margaret Grey, DrPH, RN, is Annie Goodrich Professor of Nursing, Yale School of Nursing, West Haven, Connecticut. Georica Gholson, PhD, is Psychologist, Walter Reed Medical Center, Bethesda, Maryland.

Background: The prevalence of adults with Type 1 diabetes (T1D) is increasing, and their risk of cardiovascular disease is high. Comorbid diabetes distress and depressive symptoms may affect their cardiovascular health.

Objectives: The purpose of this study was to describe the relationship between diabetes distress and depressive symptoms with cardiovascular health factors.

Methods: This was a cross-sectional survey of a sample of adults with T1D. Valid and reliable instruments were used to collect the data on sociodemographics, diabetes-related complications, psychological factors, and cardiovascular health factors. Independent-sample t tests, analysis of variance, chi-square analyses, and linear regression were used to compare the cardiovascular health factors among the three levels of diabetes distress scores and the two levels of depressive symptom scores.

Results: Our sample included 83 adults with a mean age of 45.2 years and a mean duration of T1D of 20 years. The majority scored low in the Diabetes Distress Scale, whereas 18% scored moderate and 18% scored high. Twenty-two percent had increased levels of depressive symptoms. There were significant correlations between diabetes distress and fear of hypoglycemia, depressive symptom scores, hemoglobin A1c, and total cholesterol. Depressive symptom scores were significantly correlated with hemoglobin A1c. Hemoglobin A1c and total cholesterol were significantly higher in those with higher levels of diabetes distress. There were no significant differences in cardiovascular health between those who scored below or above the cut point for depressive symptoms, but there was a finding toward higher mean body mass index, hemoglobin A1c, and a lower weekly step count in those who had elevated depressive symptoms. In the linear regression, only diabetes distress was significantly associated with hemoglobin A1c.

Discussion: This is a sample with elevated diabetes distress and depressive symptoms, both of which may affect their risk of cardiovascular disease.
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http://dx.doi.org/10.1097/NNR.0000000000000387DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6852792PMC
November 2019

State and Trait Anxiety and Diabetes Outcomes in Youth With Type 1 Diabetes.

Diabetes Educ 2019 10 31;45(5):477-483. Epub 2019 Jul 31.

Yale University, School of Nursing and School of Medicine, West Haven, Connecticut.

Purpose: The purpose of this exploratory pilot study was to examine the associations of state and trait anxiety with glycemic control, self-management, and diabetes-specific quality of life (QOL) in youth 10 to 16 years of age with type 1 diabetes (T1D).

Methods: Bivariate Pearson correlations and multiple linear regression modeling were conducted to examine the relationship among anxiety symptoms, hemoglobin A1C (A1C), self-management, QOL, and covariates.

Results: A sample of 67 adolescents was 50.7% female, and 87.1% were non-Hispanic white, with a mean ± SD age of 13.4 ± 1.85 years and an A1C of 8.3% ± 1.2% (67 mmol/mol). Higher state anxiety was correlated with older age. Better self-management was correlated with lower trait anxiety and lower state anxiety. Higher state and trait anxiety were associated with poorer self-management. Higher state anxiety was associated with higher A1C. Higher trait anxiety was associated with poorer diabetes-specific QOL.

Conclusions: State and trait anxiety may differentially affect diabetes outcomes. State anxiety may be a modifiable target for physiologic (A1C) and psychosocial (QOL) outcomes in youth with T1D, while trait anxiety may be a modifiable target for psychosocial outcomes (QOL). Anxiety symptoms should be assessed at regular clinic visits. Interventions to improve anxiety symptoms may in turn improve physiologic and psychosocial outcomes.
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http://dx.doi.org/10.1177/0145721719866146DOI Listing
October 2019

Feasibility and safety of a group physical activity program for youth with type 1 diabetes.

Pediatr Diabetes 2019 06 9;20(4):450-459. Epub 2019 Apr 9.

Yale University School of Nursing, West Haven, Connecticut.

Background/objective: Many adolescents with type 1 diabetes do not achieve 60 minutes of daily moderate-to-vigorous intensity physical activity (MVPA). Recognizing the importance of peer influence during adolescence, we evaluated the feasibility and safety of a group MVPA intervention for this population.

Methods: Eighteen adolescents with type 1 diabetes (age 14.1 ± 2 .3 years, female 67%, black or Latino 67%, median body mass index 92%'ile, A1c 79.9 ± 25.1 mmol/mol, 9.5 ± 2.3%). Intervention sessions (35 minutes MVPA and 45 minutes discussion) occurred 1×/week for 12 weeks. Feasibility and safety metrics were enrollment, completion of intervention and assessments, cost, and hypoglycemia rates. Participants completed MVPA (accelerometry), and exploratory nutritional, psychosocial, clinical, and fitness variable assessments at baseline, 3 months, and 7 months. Hedges' effect sizes were calculated.

Results: Enrollment was 16%, and intervention completion was 56%. Assessment completion at 7 months was 67% for MVPA, nutrition, and fitness, 83% for psychosocial assessments, and 94% for clinical assessments. Cost was $1241 per completing participant. One episode of mild hypoglycemia occurred during the sessions (0.6%). Self-reported daily fruit/vegetable servings (d = -0.72) and diabetes self-management behaviors decreased over time (d = -0.40). In the 10 completers, endurance run score improved (d = 0.49) from low baseline levels, while systolic blood pressure decreased (d = -0.75) and low-density lipoprotein increased (d = 0.49) but stayed within normal ranges.

Conclusions: The protocol for the group MVPA intervention was safe and had some feasibility metrics meriting further investigation. MVPA levels and glycemic control remained suboptimal, suggesting the need for more intensive interventions for this population.
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http://dx.doi.org/10.1111/pedi.12841DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6508986PMC
June 2019

Sleep characteristics in young adults with type 1 diabetes.

Diabetes Res Clin Pract 2019 Apr 18;150:17-26. Epub 2019 Feb 18.

Yale University, School of Nursing, United States.

Only 14% of young adults with Type 1 Diabetes (T1D) achieve targets for glycemic control (HbA1C < 7.0%), with deterioration over time. Complex cognitive processes required to manage glycemia are vulnerable to sleep deficiency. Using Whittemore and Knafl's approach, we conducted an integrative review of research literature on sleep characteristics and glycemia in these young adults. Quality was assessed using the Mixed Methods Appraisal Tool (v. 2011). Multiple databases were searched for articles published in English in peer-reviewed journals from 2003 to 2018, using search terms 'sleep' and 'T1D' with age limiters 18-40. Of 218 studies initially retrieved, 17 original studies met the inclusion criteria. The following themes were identified in young adults with T1D: (1) They had poorer objective and subjective sleep quality, more variability, and impaired awakening response to hypoglycemia compared with controls; (2) They had poorer glycemic control that was associated with shorter sleep duration, poorer sleep quality, and less time in deep sleep; and (3) Hypoglycemia negatively impacted diabetes management, sleep quality, and next day functioning. Sleep deficiency, as indicated by short sleep duration is associated with a range of negative health outcomes for people with T1D; therefore, optimizing sleep should be a priority in practice and research.
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http://dx.doi.org/10.1016/j.diabres.2019.02.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6525057PMC
April 2019

"Anxiety and Type 1 diabetes are like cousins": The experience of anxiety symptoms in youth with Type 1 diabetes.

Res Nurs Health 2018 12 30;41(6):544-554. Epub 2018 Oct 30.

Yale University School of Nursing, West Haven, Connecticut.

Type 1 diabetes (T1D) is one of the most common chronic health conditions in youth in the United States, and its incidence is rising worldwide. Youth with T1D are at a high risk of psychological comorbidity, for example, anxiety, depression, and eating disorders. Psychological comorbidities, especially anxiety symptoms, have been correlated with poorer diabetes outcomes, but anxiety symptoms have not been well studied in these youth. The primary aim of this study was to describe the experience of anxiety symptoms in youth with T1D, especially as those symptoms relate to diabetes self-management tasks. We used a qualitative descriptive approach, consisting of an in-depth, semi-structured interview comprising 10 open-ended questions with follow-up probes. The analysis was guided by the principles of thematic analysis. Demographic data, Hemoglobin A1c levels, and the State-Trait Anxiety Inventory for Children survey data were also collected and analyzed. We identified four themes and seven sub-themes. Participants (n = 29, ages 10-16, 55% female) reported that T1D was an extra layer of responsibility that took time away from their ability to participate fully in other aspects of their lives. Some participants were able to integrate diabetes management into their lives, while others were not. Some participants were dependent on parents and the school nurse for diabetes management. Participants described two types of anxiety symptoms, general and diabetes-specific, and they noted that their experience of anxiety was associated with poor quality sleep, general lifestyle factors, and diabetes.
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http://dx.doi.org/10.1002/nur.21913DOI Listing
December 2018

Stressful Life Events in Young Adults With Type 1 Diabetes in the U.S. T1D Exchange Clinic Registry.

J Nurs Scholarsh 2018 11 24;50(6):676-686. Epub 2018 Sep 24.

Delta Mu , Annie Goodrich Professor of Nursing, Yale University School of Nursing, Orange, CT, USA.

Purpose: The purpose was to test associations among stressful life events, frequency of missed insulin doses, and glycemic control in young adults with type 1 diabetes (T1D).

Design: The study was a cross-sectional descriptive secondary analysis.

Methods: Data from 2,921 participants (ages 18-26 years) in the U.S. T1D Exchange Clinic Registry were analyzed. Report of a stressful life event was defined as one or more positive responses on a 17-item stressful life events index and defined as a dichotomous variable (yes or no). Frequency of missed insulin doses was measured using a single self-report item and collapsed into two levels (fewer than three times a week, three or more times a week). The glycosylated hemoglobin (A1c) level recorded at the time of enrollment was used to assess glycemic control.

Findings: Nearly half (48.6%) of the participants reported having a stressful life event during the previous year. The most frequently reported stressful life events were problems at work or school (16.1%), serious arguments with family members or a close friend (15.2%), and financial problems in the family (13.8%). Compared to the participants not reporting stressful life events, those who reported stressful life events were more likely to be older, female, with a higher educational attainment level, and not working or unemployed. Those who reported a stressful life event were more likely than those who did not to say they typically missed insulin doses at least three times a week and less likely to say they typically missed insulin doses fewer than three times a week (p < .001 adjusted for age, sex, race or ethnicity, educational attainment level, duration of T1D diagnosis, and insulin delivery method). Mean A1c level was higher for the group who reported having a stressful life event in the past 12 months compared to the group who did not (8.7 ± 1.8% vs. 8.2 ± 1.6%; adjusted p < .001). The results of a mediation analysis suggest that the measure of frequency of missed insulin doses may be a mediator of the relationship between recent stressful life events and glycemic control (Sobel test: ab = .841, 95% confidence interval = 0.064-1.618).

Conclusions: These findings suggest that, for young adults with T1D, the experience of stressful life events may increase their risk for poorer glycemic control, possibly by disrupting adherence with insulin doses.

Clinical Relevance: Further exploration of these relationships may allow for the potential for identifying those at risk and assisting them with more positive approaches to managing stressful events.
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http://dx.doi.org/10.1111/jnu.12428DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6788928PMC
November 2018

Type 1 Diabetes Self-Management From Emerging Adulthood Through Older Adulthood.

Diabetes Care 2018 08 25;41(8):1608-1614. Epub 2018 May 25.

Yale School of Nursing, Orange, CT.

Objective: The purpose of this study of adults with type 1 diabetes was to analyze patterns of diabetes self-management behaviors and predictors of glycemic control across the adult life span.

Research Design And Methods: This study was a secondary cross-sectional analysis of data of 7,153 adults enrolled in the T1D Exchange Clinic Registry who were divided into four developmental stages (emerging, young, middle-aged, and older adults). Data were collected by questionnaire and medical record review at enrollment. Statistical analyses compared sociodemographic, clinical, and diabetes-related factors across groups. Logistic regressions were conducted for each group to identify factors associated with hemoglobin A ≥7%.

Results: The sample was divided according to adult developmental stage: emerging adults, age 18 to <25 years ( = 2,478 [35%]); young adults, age 25 to <45 years ( = 2,274 [32%]); middle-aged adults, age 45 to <65 years ( = 1,868 [26%]); and older adults, age ≥65 years ( = 533 [7%]). Emerging adults had the highest mean hemoglobin A level (8.4 ± 1.7% [68 mmol/mol]), whereas older adults had the lowest level (7.3 ± 0.97% [56 mmol/mol]; < 0.0001). Emerging adults were less likely to use an insulin pump (56%) or a continuous glucose monitor (7%) but were more likely to miss at least one insulin dose per day (3%) and to have had an episode of diabetic ketoacidosis in the past year (7%) (all < 0.0001). Different factors were associated with hemoglobin A ≥7% in each age-group, but two factors were noted across several groups: the frequency of blood glucose checks and missed insulin doses.

Conclusions: When discussing diabetes self-management, providers may consider a patient's developmental stage, with its competing demands (such as work and family), psychosocial adjustments, and the potential burden of comorbidities.
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http://dx.doi.org/10.2337/dc17-2597DOI Listing
August 2018

Development of an eHealth Program for Parents of Adolescents With Type 1 Diabetes.

Diabetes Educ 2018 02 20;44(1):72-82. Epub 2017 Dec 20.

New England Research Institutes, Watertown, MA.

Purpose The purpose of this study was to understand the experience of parenting an adolescent with type 1 diabetes (T1DM), to develop a prototype of an eHealth program for parents of adolescents with T1DM, and to evaluate the prototype content and acceptability from the perspective of parents and health care providers. Methods A multiphase method was used generating both qualitative and quantitative data at multiple time points. There were 27 parents of adolescents aged 12 to 18 years with T1DM and 16 health care providers who participated in semistructured interviews to identify parental challenges; 53 parents and 27 providers evaluated the prototype. Thematic content analysis was used to analyze interview transcripts, and descriptive statistics were used to summarize survey data. Results Challenges experienced by parents of adolescents with T1DM included understanding the developmental and hormonal changes of adolescence that affect diabetes care, feeling tension between adolescent independence and parent control, communicating without nagging or conflict, transferring diabetes care responsibility safely, dealing with feelings of stress and distress, and perceiving a lack of resources for T1DM care and insufficient personal time for self-care. In the prototype evaluation, both parents and providers found content to be relevant and provided feedback to guide the development of the full program. Conclusions Parents of adolescents with T1DM and providers expressed a need for parents to have more support in transitioning diabetes care from parent to adolescent. eHealth programs offer an ideal way to address these needs and ultimately can be linked to electronic medical records improving quality and efficiency of health care in this population.
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http://dx.doi.org/10.1177/0145721717748606DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330708PMC
February 2018

Stress and Posttraumatic Stress in Mothers of Children With Type 1 Diabetes.

J Fam Nurs 2017 May 10;23(2):201-225. Epub 2017 Jan 10.

1 Yale School of Nursing, Orange, CT, USA.

The onset of acute and chronic illness in children frequently triggers episodes of stress and posttraumatic stress symptoms (PTSS) in mothers. Mothers of children with type 1 diabetes (T1D) consistently report high levels of stress and PTSS. The purpose of this integrative review was to review and synthesize the published empirical research. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct this integrative literature review. A total of 19 studies were identified from a sample of 128. Stress and PTSS were prevalent in mothers of youth with T1D. While PTSS was most severe at disease onset, symptoms often persisted 1 to 5 years after diagnosis. The diagnosis of T1D in a child was traumatic for mothers. Stress and PTSS in mothers adversely affected children's health. Management of stress symptoms in mothers may lead to improved behavioral and metabolic outcomes in children.
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http://dx.doi.org/10.1177/1074840716687543DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5611825PMC
May 2017

Obesity-risk behaviours and their associations with body mass index (BMI) in Korean American children.

J Clin Nurs 2018 Sep 26;27(17-18):3408-3417. Epub 2018 Mar 26.

Yale University School of Nursing, Orange, CT, USA.

Aims And Objectives: To describe obesity-risk behaviours (diet, physical activity and sedentary behaviour) and examine the relationships of the obesity-risk behaviours with body mass index (BMI) in school-aged Korean American children.

Background: Korean American children have a risk of becoming overweight or obese and developing obesity-related complications; however, there is limited research about obesity-risk behaviours in Korean American children.

Design: A cross-sectional study.

Methods: Obesity-risk behaviours of children were assessed with well-validated self-report questionnaires (i.e., Elementary-level School-based Nutrition Monitoring Questionnaire) from children and their mothers. Height and weight of children were measured. Data were analysed with bivariate and multivariate analyses using mixed effects models to incorporate the correlation within siblings.

Results: A total of 170 Korean American children (mean age 10.9 [2.0] years; 52.4% girls; mean BMI 19.3 [3.2]; 28.7% ≥85 percentiles) participated in the study. Only 38.3% of Korean American children met established recommendations of five fruits/vegetables per day; 56.5% met recommendations for more than 3 days per week of vigorous physical activity; and 40.8% met recommendations for <2 hr of recreational screen time per day. Sixty per cent and 88.8% of children met the recommendation of sleep on a weekday and weekend, respectively. Only screen time was positively associated with child BMI z-score (β = 0.08; p < .03).

Conclusion: Healthcare providers need to be aware of the increased rate of overweight and obesity in Korean American children and initiate clinical interventions to improve obesity-risk behaviours, especially sedentary behaviour, in Korean American children.

Relevance To Clinical Practice: Clinical assessment and management of the risk of developing overweight and obesity as well as obesity-related behaviours are important to improve obesity-related complications in overall Korean Americans.
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http://dx.doi.org/10.1111/jocn.13982DOI Listing
September 2018

Lifestyle determinants of health: Isn't it all about genetics and environment?

Authors:
Margaret Grey

Nurs Outlook 2017 Sep - Oct;65(5):501-505. Epub 2017 May 10.

Yale University School of Nursing, West Haven, CT. Electronic address:

Purpose: Drawn from one of the keynote addresses at the State of the Science Conference held by the Council for the Advancement of Nursing Science (CANS), the purpose of this paper is to review the evidence from clinical trials about the importance of lifestyle behaviors in human health.

Methods: Evidence from trials on the impact of lifestyle interventions on outcomes in diabetes and prediabetes are presented.

Results: These findings suggest that lifestyle behaviors are important to diabetes prevention and outcomes in youth and adults.

Implications: More research is needed on the factors that predict these outcomes, especially genetics and environment.
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http://dx.doi.org/10.1016/j.outlook.2017.04.011DOI Listing
October 2017

General and diabetes-specific stress in adolescents with type 1 diabetes.

Diabetes Res Clin Pract 2017 Aug 16;130:1-8. Epub 2017 May 16.

Yale University School of Nursing, 400 West Campus Drive, Orange, CT 06577, United States. Electronic address:

Background: Type 1 diabetes (T1D) is one of the most common chronic health conditions in adolescents in the United States. Adherence to the recommended treatment regimen has been reported as a source of stress for adolescents.

Aim: The purpose of this study was to examine the associations among general and diabetes-specific stress and glycemic control (HbA1c), self-management, and diabetes-specific quality of life (QOL) in adolescents with T1D.

Methods: A secondary analysis of baseline data (N=320) from a randomized controlled trial was conducted. Adolescents completed validated measures of general and diabetes-specific stress, self-management, and diabetes-specific QOL. HbA1c levels were obtained from medical records.

Results: Over 50% of the sample scored at or above criteria for high general and diabetes-specific stress. Higher general and diabetes-specific stress was significantly associated with higher HbA1c, poorer self-management activities, and lower diabetes-specific QOL. Diabetes-specific stress accounted for a significant proportion of the variance in HbA1c, while general stress did not. General and diabetes-specific stress accounted for 40% of the variance in diabetes-specific QOL.

Conclusions: General and diabetes-specific stress are common in adolescents with T1D. Healthcare providers must be mindful of the sources of stress that adolescents with T1D face on a daily basis. General stress and diabetes-specific stress should be differentiated and may require different interventions to improve coping and outcomes.
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http://dx.doi.org/10.1016/j.diabres.2017.05.003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608607PMC
August 2017

Church-Based Recruitment to Reach Korean Immigrants: An Integrative Review.

West J Nurs Res 2018 09 19;40(9):1396-1421. Epub 2017 Apr 19.

3 Yale University, Orange, CT, USA.

Although the Korean church has been frequently used to recruit Korean immigrants in research, little is known about the specific strategies and process. The purpose of this integrative review was to describe recruitment strategies in studies of Korean immigrants and to identify the process of Korean church-based recruitment. Thirty-three studies met inclusion criteria. Four stages of church-based recruitment were identified: initiation, endorsement, advertisement, and implementation. This review identified aspects of the church-based recruitment process in Korean immigrants, which are different from the Black and Hispanic literature, due to their hierarchical culture and language barriers. Getting permission from pastors and announcing the study by pastors at Sunday services were identified as the key components of the process. Using the church newsletter to advertise the study was the most effective strategy for the advertisement stage. Despite several limitations, church-based recruitment is a very feasible and effective way to recruit Korean immigrants.
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http://dx.doi.org/10.1177/0193945917703938DOI Listing
September 2018
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