Helping Teens With Type 1 Diabetes Reduce Heart Disease Risks

Kristin Jenkins

October 25, 2018

For many clinicians, motivating teens with type 1 diabetes to reduce their risk of heart disease by eating better and exercising more can seem like an uphill battle.

Now, strategies based on insights from an interview study of patients and their parents could help physicians guide teens around the obstacles to making heart-healthy choices, so that these youngsters can meet their blood pressure and lipid-lowering targets, say diabetes education experts.

The study, led by Michelle L. Katz, MD, of the Joslin Diabetes Center in Boston, Massachusetts, was published online in Pediatric Diabetes.

The qualitative study in 22 teens with type 1 diabetes showed that many adolescents had limited knowledge about hypertension and dyslipidemia, and did not fully understand the implications of current lifestyle behaviors on future health.

Separate interviews with 25 of their parents revealed that many sabotaged their child's diabetes management by maintaining a home environment that promoted obesity and by letting their distrust of medication delay the initiation of lipid-lowering therapy.

"Providers should consider teen and parent perspectives when managing cardiovascular disease (CVD) risk factors in order to enhance engagement with CVD risk management," the researchers say.

Study Employed One-on-One Interviews With Teens and Parents

The authors note that aggressive management of heart disease risk using diet, exercise, and medication is recommended for teens with type 1 diabetes. Despite this, studies show many adolescent patients don't meet targets for lowering blood pressure or lipids. This is probably because current strategies are ineffective, Katz and colleagues say.

"Our study findings may be generalizable to other teens with dyslipidemia or hypertension in the absence of diabetes," they write.

"Interventional studies incorporating the strategies and addressing [these] barriers...may be useful to validate these approaches to CVD risk factor management."

For the study, the researchers reviewed patient charts for lipid-lowering medication use, education level, and family history of hypertension, dyslipidemia, or heart disease. Two thirds of the teens were female, 82% were non-Hispanic white, and the median age was 17 years. Although none had been diagnosed with hypertension, 45% had dyslipidemia.

Then, using semi-structured one-on-one interviews, the researchers asked patients and parents to talk about heart health and risk factors such as hypertension and dyslipidemia.

Parents (84% of whom were mothers) were between 41 to 60 years of age, 88% were non-Hispanic white, and 63% had a college or graduate degree.

In a statement by the Joslin Diabetes Center, Katz said physicians should be prepared to offer realistic and specific guidance. She noted that when teens were asked about the risks of high blood pressure, for instance, some said it could "make you feel antsy" or "give you a headache."

Many hoped that high blood pressure could simply be "fixed" rather than have to be continually managed.

"We recognize that teens may not have a lot of knowledge, so we start our discussions at a pretty basic level, going over what blood pressure and cholesterol are," said Katz, who is associate director of the Pediatric, Adolescent and Young Adult Section at Joslin, and assistant professor of pediatrics at Harvard Medical School, Boston, Massachusetts.

"We encourage really specific goal-setting, drilling down on that with them. We're also putting teens on an exercise app with virtual exercise buddies to help give them some motivation."

The study feedback showed that teens wanted to know about their own risk of heart disease and get personalized advice about what they should do, including what foods to eat and even meal plans.

Strategies to Reduce Heart Disease Risk in Teens With Type 1 Diabetes
1. Exploit healthcare provider authority and recognize the value of peer motivation.
2. Enlist family support.
3. Provide guidance that addresses teens' knowledge gaps, focuses on the short-term benefits of lifestyle change, and deals with parental misconceptions about risk management.
4. Help identify preferred exercise activities and workout buddies.
5. Emphasize the contribution of genetic rather than lifestyle factors when a teen is diagnosed with high blood pressure or dyslipidemia.

Talk to the Teen First, Focus on Short-Term Gains

Katz and colleagues emphasize that clinicians should talk directly to the teen, not the parent.

And the focus should be on the short-term gains of lifestyle change such as weight loss, more energy, and clearer skin — not long-term cardiovascular risk reduction.

"Developmentally, teens value the present and discount the future, which limits their motivation to act in the present to protect themselves from future CVD," they note.

Physicians will also need to assess which situations or persons — at home, at school, friends' houses, fast food restaurants, and convenience stores — get in the way of teens making healthy food choices.

And the key to helping an impulse control-challenged teen successfully navigate dietary changes that last? Making sure that mom and dad get with the program.

"As parents typically buy the groceries and do the cooking, making better choices calls for a team effort," Katz points out.

The study also revealed that many parents felt heart-healthy advice would be more effective if it came from a health expert rather than from them.

While parents may hope provider authority would motivate behavior change, they "seem to underestimate the influence of peers rather than authority figures in impacting teen behavior," the researchers note.

Clinicians should encourage teens to choose an exercise activity that they like and to recruit regular exercise partners, said Katz.

Ask about their favorite exercise activity and have them name at least one friend they could work out with, and find out whether they would go to a community center or the local YMCA, she advises.

"Sometimes you have to get down into the details with them to coax them along," Katz explained.

Although teens readily accepted the need to take medication, often focusing on the mechanics of taking a pill every day, parents expressed concern about the side effects of drug therapy and the need for lifelong medication. Many preferred an initial trial of diet and exercise, leaving medication as "a last resort."

Importantly, clinicians should frame drug therapy as an important addition to the overall heart-healthy treatment plan, and not as a failing on the part of the patient or parents, the researchers say.

"Emphasizing genetic as well as environmental contributions to hypertension and dyslipidemia when there is a positive family history of these risk factors may help to alleviate teen and parental guilt and increase acceptance of medications."

A pilot study is now underway to determine the effectiveness of these strategies in teens with type 1 diabetes and additional cardiovascular risk factors.

This study was funded by the National Heart, Lung, and Blood Institute, National Institute of Diabetes and Digestive and Kidney Diseases, Katherine Adler Astrove Youth Education Fund, Maria Griffin Drury Pediatric Fund, and Eleanor Chesterman Beatson Fund. Katz has disclosed a relationship with Lexicon Pharmaceuticals.

Pediatr Diabetes. Published online on September 12, 2018. Abstract

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