Psychosocial Aspects of Diabetes Management Across the Life Span

Diabetes is an incredibly challenging disease that not only affects those carrying the diagnosis, but also their family, friends, and others with whom they share close relationships. These psychosocial aspects of diabetes have the potential to dramatically influence the natural history of the disease throughout the lifespan, and yet the psychosocial factors that most strongly influence outcomes and the interventions most likely to improve these outcomes remain poorly understood.

To address these important and complex issues, UPMC endocrinologists have partnered with Vicki Helgeson, PhD, professor of psychology, and her team of investigators at Carnegie Mellon University (CMU). This collaboration arose almost two decades ago when the diabetes community recognized the multiple challenges facing youth with type 1 diabetes.  Adolescence is a particularly important time to study youth with diabetes, as self-care behaviors and glycemic control have been observed to decline during this period of time. The transition through emerging adulthood is an understudied but important period, as most youth experience multiple transitions during this developmental period, including changes in lifestyle (e.g., education, occupation, living situation), changes in health care, and shifting relationships with family members, friends, and intimate others. Clinicians and investigators at UPMC and CMU realized the need to establish working relationships with experts representing the medical and psychosocial aspects of care delivery to better understand how young adults with type 1 diabetes navigate these transitions while also assuming increasing responsibility for their diabetes care and overall health.

In order to study these transitions, youth with type 1 diabetes and their nondiabetic peers were recruited and followed until age 27 in the Teen Health study, Transition Times study, and Research on Emerging Adults Changing Health (REACH) study. These longitudinal studies revealed that parental involvement in diabetes was a critical determinant of self-care behavior and glycemic control during adolescence — especially for older adolescents. During emerging adulthood, the relationship with parents remained an important influence on health behaviors and psychological well-being. Higher parental support in the year after high school was associated with better adherence, fewer depressive symptoms, and lower risk behaviors among emerging adults with diabetes. In addition, parental support buffered the adverse association between peer conflict and poor glycemic control among young adults with diabetes.2 When compared to healthy controls, those with diabetes did not score higher on depressive symptoms, loneliness, or bulimic symptoms, but did report lower life satisfaction and lower life purpose over time.3 An analysis of the transition from the pediatric health care system to the adult health care system showed that an early transition is associated with worse glycemic control ,as well as a host of psychosocial variables (lower social status, nonwhite race, lower likelihood of pursuing college after high school graduation, and lower levels of parental involvement in their daily lives).4

Because individuals with diabetes are experiencing increasingly longer lifespans, it is imperative to understand how to use support resources to enhance diabetes management and quality of life in adult patients and their families. Self-management of diabetes during adulthood (involving good adherence to medication regimens and behaviors that foster good metabolic control) requires daily self-regulation of one’s emotions, behaviors, and cognitions in the face of daily stressful events dealing both with one’s diabetes (highs and lows in blood glucose) and other domains of life 
(child-rearing problems, marital conflicts, problems at work, managing other chronic illnesses). Managing daily stress occurs in the context of important social relationships, most importantly the romantic/marital relationship. Romantic partners are likely to be most strongly affected by the person’s diabetes and to most strongly influence how the person with diabetes manages his or her disease.

To study the impact of the social environ-ment on adults with type 1 diabetes, our collaborative team embarked upon the Diabetes Across Development In Couples (DiADIC) study, which adopted an adult life-span perspective to examine the stressors that are linked to diabetes management and distress during young, middle-aged, and older adulthood. The focus of this study was on the ways that romantic partners may facilitate diabetes management across time through communal coping. As opposed to the pediatric and adolescent population, few studies have been performed to address how couples cope with type 1 diabetes during adulthood. The focus on communal coping involves appraisals by the persons with diabetes that the illness is shared (i.e., use of relational language such as “it is our disease” rather than an individual’s disease) and collaborative coping efforts to manage the disease. The data collected through interviews, behavioral observations, and online diary assessments has allowed our investigative team to measure communal coping, diabetes management, distress, stress, and executive function. The study aim is to identify the daily stressors experienced by adults with type 1 diabetes that are linked to poorer diabetes self-management and distress, to examine the collaborative processes that are associated with better diabetes management and lower levels of distress, and to examine whether executive function abilities modulate the relation of collaborative processes to diabetes management and distress. A total of 199 couples have been recruited in this study in collaboration with the University of Utah. The investigators are currently in the midst of preparing manuscripts for publication.

A parallel study is also being conducted, titled Communal Health Interactions in Couples (CHOICE) study, and is looking at communal coping and diabetes management among adult couples, in which one person recently has been diagnosed with type 2 diabetes, also is being conducted. A total of 207 patients were recruited from the community who had been diagnosed with type 2 diabetes within the past five years, were married or living with a romantic partner, and whose partner did not have diabetes. The team interviewed couples in person, conducted a behavioral observation of their coping, and had them complete daily diaries for 14 consecutive days. Through all of these assessments, it was found that patients who engage in communal coping have better psychological and health behavior outcomes.5,6 In addition, patients who felt understood and cared for by their partners reported a better mood and were more likely to take care of themselves on a daily basis, whereas patients whose partners were identified as being more controlling on a daily basis reported poorer mood. Furthermore, patients characterized by unmitigated communion (focus on and involvement with others to the exclusion of the self) were most affected by partner supportive and unsupportive behavior.7 Given the increasing prevalence of type 2 diabetes in the United States and the critical role that self-care behavior plays in preventing complications, these results suggest that early intervention efforts aimed at people who are newly diagnosed with diabetes ought to target couples and families. Intervention efforts should focus on cultivating emotional support, optimizing more subtle forms of infor mational support that are acceptable to patients, and minimizing controlling behaviors.

From an endocrinologist’s perspective, interdisciplinary collaboration with Dr. Helgeson’s team to investigate the psychosocial aspects of diabetes across the lifespan has been very enlightening. It has given collaborating clinical endocrinologists a unique perspective regarding the psychosocial needs of our patient population. This is nicely illustrated by a favorite anecdote from a patient who returned for an office visit a few months after participating in the DiADIC study. His hemoglobin A1c had improved by over 1 percent, which he ascribed to the interviews conducted at Dr. Helgeson’s lab. He stated that the interview process made him and his wife realize that they are in this together and need to deal with his diabetes as a team. Insights gleaned from these studies will reveal novel insights into how addressing life stressors, improving coping skills, and recruiting others in key relationships with patients can improve glycemic control and diabetes outcomes among our patients.  Likewise, the academic environment at UPMC is a fertile environ-ment for multidisciplinary collaborative relationships between clinicians and researchers to create new knowledge that ultimately improves the health and well-being of our patients.

References

1 Helgeson VS, Reynolds KA, Siminerio L, Escobar O, Becker D. Parent and Adolescent Distribution of Responsibility for Diabetes Self-care: Links to Health Outcomes. J Pediatric Psych. 2008; 
33(5): 497-508.

2 Helgeson VS, Palladino DK, Reynolds KA, Becker D, Escobar O, Siminerio L. Relationships and health among emerging adults with and without Type 1 diabetes. Health Psychology. 2014; 33(10): 1125–1133.

3 Palladino DK, Helgeson VS, Reynolds KA, Becker DJ, Siminerio LM, Escobar O. Emerging adults with type 1 diabetes: A comparison to peers without diabetes. J Pediatric Psych. 2013; 38(5): 506–517.

4 Helgeson VS, Reynolds KA, Snyder PR, Palladino DK, Becker DJ, Siminerio L, Escobar O. Characterizing the transition from pediatric to adult care among emerging adults with Type 1 diabetes. Diabetic Medicine. 2013; 30: 610–615.

5 Van Vleet M, Helgeson VS, Seltman HJ, Korytkowski MT, Hausmann LRM. An examination of the communal coping process in couples coping with diabetes. J Soc Person Rel. 2018.

6 Zajdel M, Helgeson VS, Seltman HJ, Korytkowski MT, Hausmann LRM.  Daily communal coping in couples with type 2 diabetes: Links to mood and self-care. Ann Behavioral Med. 2018; 52: 228-238.

7 Helgeson VS, Mascatelli K, Seltman H, Korytkowski M, Hausmann LRM. Implications of Supportive and Unsupportive Behavior for Couples with Newly Diagnosed Diabetes. Health Psychology. 2016; 35(10): 1047-1058.

Hussain Mahmud, MD
Clinical Assistant Professor of Medicine
EDM Fellowship Associate
Program Director

Mary Korytkowski, MD
Professor of Medicine and Director of Quality Improvement

Vicki Helgeson, PhD
Director of Graduate Studies Professor of Psychology Carnegie Mellon University