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VOLUME 14 NUMBER 1 • JULY 2017
13
SA JOURNAL OF DIABETES & VASCULAR DISEASE
REVIEW
Process
Paediatric diabetes takes place in a progressive and complex
reciprocal interaction between an active, evolving child with
diabetes and the people, objects and symbols in its immediate
environment. Proximal processes are useful in clinical practice as
tools to understand required adjustments to diabetes care and in
understanding as well as adjusting the psychosocial well-being
of children with diabetes. For instance, parental warmth and
emotional availability are related to improved diabetes care and
diabetes-related quality of life (QoL).
12
The form, power, content and direction of proximal processes
will affect diabetes care and psychological well-being based on the
functions of the characteristics of the child.
6
For example, if the
child has low self-efficacy and the people surrounding the child are
not supportive of diabetes care, the child may have sub-optimal
glycaemic control, especially in the absence of critical objects such
as automatic insulin pumps.
An A
1c
goal of < 7.5% (58 mmol/mol) is recommended across all
paediatric age groups.
13
However, the increased use of basal–bolus
regimens, insulin pumps, frequent blood glucose monitoring, goal
setting and improved patient education in the youth from infancy
to adolescence have been associated with more children reaching
the blood glucose targets set by the American Diabetes Association
in developed countries.
13-15
In developing countries, both proximal
and distal processes make it difficult for children to reach the A
1c
target of < 7.5% (58 mmol/mol).
From a diabetes care and psychosocial well-being inquiry
perspective, examples of proximal processes, either protective or
preventative, can be phrased in questions such as: Does the child
get lessons about appropriate diabetes self-care activities? Does the
child receive social support useful for diabetes management? Does
the child get protection from physical and psychological harm, such
as discrimination from other children? Does the child get nutrition
suitable for diabetes management?
It is also important to note that children with diabetes are affected
by distal processes including the family’s own ability to support a
child with diabetes as well as interact with other environments,
of which the child is a part, for example, access to health centres
or pharmacies for medical essentials, and resources to enable
integration with people of different health status.
Person
The self of a child with diabetes is very important in determining
levels of diabetes care and psychological well-being. The biological
and genetic predisposition of the child have long been associated
with diabetes mellitus,
16,17
diabetes care
18
and psychological
well-being.
19
For the former, there are alleles or genetic variants
associated with type 1 diabetes mellitus (T1DM), which either
provide susceptibility or protection from acquiring the disease.
20
Further evidence for hereditary influence can be deduced from
twin studies. The concordance for T1DM is approximately 50%
for monozygotic twins and the risk to a first-degree relative is
approximately 5%.
21
Children with diabetes have personal characteristics that may
affect diabetes care and their psychological well-being, such as their
age, gender, weight and ethnicity. Firstly, insulin dose percentiles
(ID-Perc) have been found to significantly differ during various
periods of childhood and are influenced by gender, body weight
and insulin injection regimes.
22
For instance, the 50th ID-Perc (P50)
varied for insulin required for different ages: 0.67 IU/kg for age
three years, 0.93 IU/kg for 13 years, and 0.70 IU/kg for 23 years,
increasing from early childhood to adolescence and decreasing
towards adulthood. The highest P50 ID was found at 12 years in
females (0.94 IU/kg) and at 14 years in males (0.92 IU/kg).
In multivariate regression analysis, insulin dose was significantly
(
p
< 0.001) associated with age, gender and insulin-delivery
regime.
22
Moreover, one study found that children with diabetes
were shorter (128.3 ± 24.3 vs 133.6 ± 24.7 cm) and lighter (29.2 ±
15.3 vs 31.3 ± 15.4 kg) than their peers without diabetes.
23
Height
(−1.1 ± 1.2 vs −0.2 ± 0.8 m) and weight (−1.2 ± 1.3 vs −0.7 ±
1.3 kg) were also significantly lower in diabetic children compared
to healthy controls (
p
< 0.05).
23
Other studies indicate that the age of onset in South Africa and
Ethiopia was later than elsewhere in the world,
24,25
and the peak
age of onset of T1DM in sub-Saharan Africa was a decade later
than in the West.
24,26,27
Ethnic differences in the peak age of onset
have also been reported in some African countries. For instance, in
South Africa, it has been reported that the peak age of onset was
about 13 years in white South Africans (similar to Europeans) but
about 23 years in black South Africans.
24
These ethnic differences
may be due to socio-economic status and lifestyle differences
between white and black people. There is also evidence that young
people compared to adults have more challenges with diabetes
self-care.
28
Diabetes psychosocial issues tend to affect girls more than boys.
A longitudinal study including 910 T1DM and 241 type 2 mellitus
(T2DM) young people found that health-related quality of life (HRQL)
for girls remained stable or decreased over time, whereas boys’
HRQL increased.
29
Moreover, girls tended to report more depressive
symptoms compared to boys.
30,31
Girls also tended to face more
gender-specific discrimination and stigma related to diabetes than
boys. For instance, girls with diabetes tend to be more perceived
as reproductively unfit in romantic relationships than boys with
diabetes, and also tended to have more worries concerning finding
a romantic partner or the possibilities of giving birth.
32
These studies
suggest that the impacts of diabetes on HRQL differ by gender and
should be considered in clinical management.
Other personal characteristics useful for diabetes self-care are
self-efficacy,
33
motivation
34
and personality traits.
35
Self-efficacy
and motivation are useful in taking charge of one’s own diabetes
management. Personality can also be a barrier to or facilitator of
support from others. Extroverts compared to introverts tend to have
a wider social support network that may be useful for diabetes
care.
36
Physical maturity is one of the biggest challenges in diabetes
management. The majority of T1DM is diagnosed in individuals
younger than 18 years of age and this group requires unique
aspects of care and management, such as adjusting insulin intake
during this period of insulin sensitivity related to physical growth
and sexual maturation, ability to provide self-care, and neurological
vulnerability to hypo- and hyperglycaemia, as well as possible
adverse neurocognitive effects of diabetes ketoacidosis.
13,37,38
In
addition, some children with diabetes, especially in developing
counties, have co-morbid conditions such as malaria,
39
HIV and
AIDS,
40
and may also be undernourished due to high poverty levels,
all of which complicate diabetes care and contribute to psychosocial
problems.
Given the implications of the person with diabetes, considering
personal characteristics of a child with diabetes in treatment choices,
care and other interventions are crucial. Therefore, clinicians should