Type 1 diabetes in young women : aspects on person-centered care and BMI in risk assessment

Background and aims

Young women with type 1 diabetes (T1D) have higher relative risks of vascular complications and premature mortality than their male counterparts. Girls with T1D report higher disease burden, diabetes-related distress and lower health- related quality of life (HRQoL) than boys with T1D, and for many years, girls with T1D have had higher mean glycosylated hemoglobin (HbA1c). Targeted interventions for this patient group are lacking. Diabetes treatment is challenging, in particular in adolescence and young adulthood. It is important to find out which treatment the person with T1D prefers since treatment satisfaction can impact treatment burden and adherence. International guidelines recommend a person-centered approach in the care of young people with T1D, with individualized treatment and education. Guided Self-Determination-Young (GSD-Y) is a person-centered reflection and problem-solving model intended to guide the patient to become self-determined and to develop skills to deal with challenges in diabetes self-management. There is little data on time-trends in Body Mass Index (BMI) in young women with T1D, and it is unclear if overweight and obesity are independent risk factors for diabetes-related vascular disease in this population.

The overall aim of this thesis was to improve HbA1c, self-management of diabetes and HRQoL and to increase empowerment in young women with T1D. A further objective was to examine BMI time-trends in young women with T1D in comparison to a background population, and the potential impact of BMI on their risk of diabetes-related vascular complications.

Methods and results

Study I was a cross-sectional study of perceived treatment satisfaction in young individuals with T1D, 15-20 years, preceded by a translation and validation of a questionnaire for assessing treatment satisfaction in adolescents with T1D. A total of 138 adolescents with T1D participated in the cross-sectional study. We showed that treatment satisfaction was associated with both HbA1c and perceived burden of diabetes in adolescents with T1D but found no correlations with type of treatment, sex or age.

Study II was a randomized controlled trial to investigate the effects of an intervention with the GSD-Y in young women with T1D, 15-20 years. A total of 51 young women with T1D were included and randomized to intervention group (n=25) or control group (n=26). We demonstrated that the GSD-Y model may increase empowerment in young women with T1D but could not show a significant effect on HbA1c.

Study III was a qualitative interview study of a subset of participants from study II. 12 young women were interviewed. Inductive content analysis showed that the GSD-Y model initiated both an individual and a relational process including deep reflection and a mutual exchange of information beyond HbA1c. GSD-Y facilitated exploration and clarification of the young women's individual needs, leading to improved diabetes self-management and increased empowerment.

Study IV was a population-based cohort study with data from several Swedish registries. We identified 3,473 young women with T1D in the national diabetes registries and included 8,487 young women from the background population. We demonstrated a similar BMI increase over time in both populations but young women with T1D had a higher BMI at baseline. Furthermore, we showed that overweight and obesity independently increased the risk of diabetes-related vascular complications in young women with T1D.

Conclusions

In young persons with T1D, treatment satisfaction is important to assess since it is associated with both perceived disease burden and glycemic control. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) Teen is well-suited for use in clinical trials and in diabetes care. The finding of increased empowerment after the GSD-Y intervention is important since it may lead to improved diabetes self-management and glycemic control. The GSD-Y intervention encouraged young women to take an active role in their diabetes care, facilitating person- centered care. As a result, the GSD-Y model can be a valuable tool in the healthcare of young women with T1D. BMI is increasing in young women with T1D and overweight and obesity should be addressed as important modifiable risk factors for diabetes-related vascular complications in this population.

List of scientific papers

I. Haas J, Persson M, Toft EH, Rathsman B, Brorsson AL, Lindholm Olinder A. Treatment satisfaction correlated with glycaemic control and burden of diabetes in Swedish adolescents with type 1 diabetes. Acta Paediatr. 2020; 109 3:573-80. Epub 2019 Sep 16. https://doi.org/10.1111/apa.14991

II. Haas J, Persson M, Brorsson AL, Toft EH, Lindholm Olinder A. Person-centered care in in young women with type 1 diabetes - a Swedish multicenter randomized controlled trial with Guided Self Determination-Young (GSD-Y). [Manuscript]

III. Haas J, Persson M, Toft EH, Back-Nirs J, Lindström M, Lindholm Olinder A, Brorsson AL. Improved self-management of type 1 diabetes in young women: Experiences of Guided Self-Determination-Young: A qualitative interview study. Diabet Med. 2025 Mar 28:e70029. doi: 10.1111/dme.70029. Epub ahead of print. https://doi.org/10.1111/dme.70029

IV. Haas J, Andersson Franko M, Lindholm Olinder A, Nyström T, Persson M. Time-trends in body mass index, and overweight and obesity as independent risk factors for diabetes angiopathy in young females with type 1 diabetes - A nationwide study in Sweden. Diabetes Res Clin Pract. 2023 Sep 9;204:110899. https://doi.org/10.1016/j.diabres.2023.110899