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CORRELATES OF EXECUTIVE FUNCTION IN ADOLESCENTS WITH
TYPE 1 DIABETES
Katia Perez, MEd; Niral Patel, MPH; Jade Lord, BA; Kim Savin, BA; Sarah Jaser, PhD
Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
INTRODUCTION
TYPE 1 DIABETES & ADOLESCENCE
• Type 1 Diabetes
• 18,000 new cases annually in the U.S.1
• Highest incidence among 10-14 year olds2
• Requires adhering to complex treatment regimens to achieve optimal glycemic control
• Long-term health complications include nerve damage
and kidney, eye, and heart disease3
• Adolescents with Type 1 Diabetes4-7
Glycemic control
Treatment adherence
Depressive symptoms
Quality of life
1 CDC National Diabetes Statistics Report, 2014; 2 SEARCH for Diabetes in Youth Group, 2007; 3 Wood et al., 2013; 4 Hilliard et al., 2013; 5 Clements et al., 2015; 6 Varni et al., 2003; 7 Grey, Whittemore & Tamborlane, 2002
EXECUTIVE FUNCTION
• Ability to plan, organize and monitor
goal-directed behavior
EXECUTIVE FUNCTION &DIABETES CARE
When did I last use my glucometer?
Where is that thing…
So if my blood sugar is high, and I eat 50g
of carbs, and I’m going for a run, and I feel a cold coming
on… How much insulin do I take right
now?
Sure, I can dine out! I just need to bring my
supplies, a snack for the wait, look up carbs, time
my insulin dose…
PREVIOUS STUDIES
• EF Impairment in youth with type 1 diabetes
• Brain changes as a result of glycemic dysregulation1,2
• Subtle cognitive differences compared to healthy youth3
• EF and adherence4-7
• Worse EF worse adherence
• Adherence measured through self-report
• Limited evidence in this age group
1 Ohmann et al., 2010; 2 Lin et al., 2010; 3 Duke & Harris, 2014;4 Bagner et al., 2007; 5 Berg et al., 2014; 6 Smith et al., 2014; 7 McNally et al., 2010
PREVIOUS STUDIES
• EF and glycemic control1-3
• Mixed findings
• Direct or indirect relationship?
• Limited evidence on sex differences4
• EF associated with adherence & glycemic control in males
1 Berg et al., 2014; 2 Smith et al., 2014; 3 Nylander et al., 2013;4 Graziano et al., 2010
STUDY AIMS
• Aim 1: Examine the relationships between EF &
several measures of adherence
• Parent-report, child-report, glucometer data
• Aim 2: Examine the relationship between EF &
diabetes-related outcomes
• Glycemic control (i.e., A1c)
• Psychosocial outcomes (i.e., depression, quality of life)
• Aim 3: Explore sex-related differences in these
associations
METHODS
STUDY DESIGN & PROCEDURES
• Design: cross-sectional analysis of
baseline data from intervention study
• Eligibility criteria:
• 13-17 years old
• > 6 months since diagnosis
• No other major health problems
• A1c between 8-12%
• Not currently in intervention studies
• Procedures:
• Electronic questionnaires
• 28-day glucometer data downloads
• A1c (%) from enrollment date from
medical record
Assessed for eligibility (n=361)
Approached (n=185)
Enrolled (n=120)
Declined to participate
(n=64)
Excluded (n=177)
MEASURES
Parent- Reported
• Sample characteristics
• Diabetes history
• Demographics
• Executive Function
• Behavior Rating Inventory
of Executive Function
(BRIEF) – Parent Form
• Adherence
• Self Care Inventory
Adolescent-Reported
• Adherence
• Self Care Inventory
• Quality of Life
• Pediatric Quality of Life Inventory (PedsQL) 3.0 –
Diabetes Module
• Depression
• Patient Health
Questionnaire (PHQ-9)
EXECUTIVE FUNCTION MEASURE
Global Executive Composite
Metacognition Index
InitiateWorking Memory
Plan/Organize
Organization
of MaterialsMonitor
Behavioral Regulation Index
Shift InhibitEmotional
Control
Behavior Rating Inventory of Executive Function (Parent Form)1
1 Gioia, Isquith, Guy & Kenworthy, 2000
RESULTS
SAMPLE CHARACTERISTICS
Range Mean (SD)
Age (years) 13-17 14.83 (1.44)
Duration of Diabetes (years) 1-16 5.84 (3.64)
N (%)
Sex
Male
Female
57 (47.5)
63 (52.5)
Race, % White, Non-Hispanic 105 (87.5)
Annual Family Income (USD)
<39,000 32 (26.7)
40,000-79,000 45 (37.5)
>80,000 43 (35.8)
Treatment type
Insulin pump
Injections
61 (50.8)
59 (49.2)
SAMPLE CHARACTERISTICS
Range Mean (SD)
A1c (%) 8-11.5 9.16 (0.90)
Mean Daily BGM 0.21-9.30 3.29 (1.75)
PHQ-9 0-24 4.14 (4.02)
P-SCI 1.29-5.0 3.53 (0.73)
C-SCI 1.71-4.86 3.50 (0.74)
PedsQL 26.85-97.22 70.87 (12.05)
EXECUTIVE FUNCTION IMPAIRMENT ACROSS BRIEF SCORES
N (%)1 Normative Sample2
GEC 16 (13.6) 7-11 %
MI 18 (15.3) 9-12 %
Initiate 22 (18.6) 7-10 %
WM 21 (17.8) 5-9 %
P/O 15 (12.7) 5-9 %
Org. of Materials 22 (18.6) 5-10 %
Monitor 9 (7.6) 4-7 %
BRI 13 (11.0) 7-11 %
Inhibit 13 (11.0) 7-9 %
Shift 19 (16.1) 4-9 %
EC 17 (14.4) 5-8 %1 Percentage of adolescents with BRIEF scoresat or above the clinical cutoff (T-scores of ≥ 65)2Gioia, Isquith, Guy & Kenworthy, 2000
GEC= Global Executive Composite, MI= Metacognition Index, WM= Working Memory, P/O= Planning and Organization, BRI= Behavioral Regulation Index, EC= Emotional Control
BIVARIATE ASSOCIATIONS BETWEEN EXECUTIVE FUNCTION, ADHERENCE, AND
OUTCOMES
GEC MI BRI
Age -.11 -.06 -.19*
Duration of Diabetes -.06 -.05 -.06
P-SCI -.32** -.29** -.29**
C-SCI -.10 -.09 -.10
Daily BGM .06 .08 .02
A1c .06 .04 .07
PHQ-9 .15 .14 .13
PedsQL -.31** -.26** -.33**
* p < 0.05
** p < 0.01
BIVARIATE ASSOCIATIONS BETWEEN EXECUTIVE FUNCTION, ADHERENCE, AND
OUTCOMES
GEC MI BRI
Age -.11 -.06 -.19*
Duration of Diabetes -.06 -.05 -.06
P-SCI -.32** -.29** -.29**
C-SCI -.10 -.09 -.10
Daily BGM .06 .08 .02
A1c .06 .04 .07
PHQ-9 .15 .14 .13
PedsQL -.31** -.26** -.33**
* p < 0.05
** p < 0.01
BIVARIATE ASSOCIATIONS BETWEEN EXECUTIVE FUNCTION, ADHERENCE, AND
OUTCOMES
GEC MI BRI
Age -.11 -.06 -.19*
Duration of Diabetes -.06 -.05 -.06
P-SCI -.32** -.29** -.29**
C-SCI -.10 -.09 -.10
Daily BGM .06 .08 .02
A1c .06 .04 .07
PHQ-9 .15 .14 .13
PedsQL -.31** -.26** -.33**
* p < 0.05
** p < 0.01
PREDICTORS OF PARENT-REPORTED ADHERENCE
Teen Age
P-SCI
GEC
Race/Ethnicity
*p < .05; **p<.01; ***p < .001
Teen Sex
Family Income
1.
2.
F (5, 113) = 3.99**
PREDICTORS OF QUALITY OF LIFE
Teen Age
PedsQL
GEC
Race/Ethnicity
*p < .05; ***p < .001
Teen Sex
Family Income
1.
2.
F(5, 113) = 4.40***
BIVARIATE ASSOCIATIONS BY SEX
1 2 3 4 5 6 7 8 9
1. Age - .30* -.18 -.11 -.12 -.10 .10 .31* -.16
2. Duration of Diabetes .09 - -.17 -.40** -.13 -.19 .09 .07 -.09
3. GEC -.09 .07 - -.18 -.27* .04 .16 .02 -.35**
4. P-SCI -.07 .06 -.56** - .47** .18 -.44** -.09 .27*
5. C-SCI -.15 .00 .13 .20 - .26* -.66** -.37** .43**
6. Daily BGM -.43** -.21 .14 .11 .30* - -.33** -.01 -.03
7. A1C .14 .13 -.10 .25 .00 -.13 - .22 -.39**
8. PHQ-9 .20 -.12 .30* -.30* -.20 -.07 -.12 - -.30*
9. PedsQL -.15 -.10 -.30* .25 .04 .16 -.09 -.53** -
Note. Correlations for male sex are presented below and correlations for female sex are
presented above the diagonal line.
* p < 0.05
** p < 0.01
BIVARIATE ASSOCIATIONS BY SEX
1 2 3 4 5 6 7 8 9
1. Age - .30* -.18 -.11 -.12 -.10 .10 .31* -.16
2. Duration of Diabetes .09 - -.17 -.40** -.13 -.19 .09 .07 -.09
3. GEC -.09 .07 - -.18 -.27* .04 .16 .02 -.35**
4. P-SCI -.07 .06 -.56** - .47** .18 -.44** -.09 .27*
5. C-SCI -.15 .00 .13 .20 - .26* -.66** -.37** .43**
6. Daily BGM -.43** -.21 .14 .11 .30* - -.33** -.01 -.03
7. A1C .14 .13 -.10 .25 .00 -.13 - .22 -.39**
8. PHQ-9 .20 -.12 .30* -.30* -.20 -.07 -.12 - -.30*
9. PedsQL -.15 -.10 -.30* .25 .04 .16 -.09 -.53** -
Note. Correlations for male sex are presented below and correlations for female sex are
presented above the diagonal line.
* p < 0.05
** p < 0.01
DISCUSSION
EXECUTIVE FUNCTION AND ADHERENCE
• Greater EF deficits associated with poorer parent-
reported adherence, but not child-reported
adherence
• EF not significantly related to meter download data
• Other diabetes tasks on the SCI may carry higher cognitive
demands
• Tasks requiring more skill/planning may be more sensitive to
EF deficits
EXECUTIVE FUNCTION AND DIABETES-RELATED OUTCOMES
• Executive function was associated with health-
related quality of life
• Adolescents with deficits in EF may struggle to face
stressors related to their diabetes, negatively impacting
quality of life
EF deficitsLower
adherence
Poor glycemic control
• A significant direct relationship between EF and
glycemic control did not emerge in this sample
• Proposed indirect relationship1
1 Smith et al., 2014
A CLOSER LOOK AT EXECUTIVE FUNCTIONING
• Evidence for greater than normal impairment in
working memory, and ability to initiate and shift
behavior
• Consistent with neurocognitive studies in T1D youth1
• Evidence of sex differences in correlates of
executive function
• Working memory and inhibition develop slower in males2
1 Naguib, Kulinskaya, Lomax & Garralda, 2008; 2 Boelema et al., 2014
LIMITATIONS & FUTURE DIRECTIONS
• Participants targeted
for poor glycemic
control (A1c > 8.0%)
• Longitudinal models
could not be tested
• EF measured through
questionnaire data
• Expand use of
objective measures of
adherence (e.g., insulin
pump data)
• Measure EF through
neuropsychological
assessments
• Investigate whether
specific EF skills are
stronger predictors of
adherence and
diabetes outcomes
CONCLUSION
• Current study demonstrates that EF is related to
adherence and certain diabetes outcomes
• May be further influenced by adolescent sex
• Adolescents with T1D should be studied
comprehensively, with the focus expanding beyond
traditional outcome measures (e.g., complications,
A1c)
• Consider maturity of EF skills and which aspects of diabetes
care are problematic for adolescents
ACKNOWLEDGEMENTS
Collaborators:
• Sarah Jaser, PhD
• Robin Whittemore,
PhD
• Jadienne Lord, BA
• Niral Patel, MPH
• Kimberly Savin, BA
• Bill Russell, MD
Funding:
• This research was
supported by grants from
the National Institute of
Diabetes and Digestive
and Kidney Diseases
[DP3DK097678-01]