Type 1 diabetes is a chronic illness characterized by the body’s inability to produce insulin due to the destruction of the beta cells in the pancreas through autoimmune process, infection by viruses or idiopathic means. According to America Diabetes Association (2010) onset most often occurs in childhood at 10 -14 years of age, but the disease can also develop in adults in their late 30s and early 40s. Glycated hemoglobin (HbA1c) is the stable product of nonenzymatic irreversible glycation of the beta chain of hemoglobin by plasma glucose. Its rate of formation increases proportionately with plasma glucose levels. Since the half-life of an erythrocyte is typically 60 days, the level of glycosylated hemoglobin (HbA 1c) reflects the mean blood glucose level over the past 6–8 weeks, usually 1–3 months. Measurement of HbA1c therefore provides valuable information for management of diabetes mellitus (Murray, R. K. 2003). Treatment in control of the blood glucose is with a healthy diet, regular exercise and insulin injections.
The concentration of HbA1c can be affected by many factors that make it vary over a period. Therefore, this study aims to explore factors other than intensive insulin regimen, frequent monitoring of blood glucose, diet or exercise that affects the stability of HbA1c in type 1 diabetes. Some of these factors comprise of demographic factors, self-efficacy, self-control, family support, psychological conditions, socioeconomic state, and genetics/ethnicity.
Psychological factors and HbA1c stability
Researchers have studied a number of psychological factors with regard to HbA1c and the self. Self-variables like self-efficacy as well as self-worth have a significant impact on HbA1c and self-care among people who have type 1 diabetes mellitus in a number of ways (Snoek and Skinner, 2009). There is also a possibility that since self-esteem has indicated an emotional characteristic of the individual, it may prove to be an enhanced interpreter of more effective results such as quality of life, anxiety and depression instead of the physiological and behavioral outcomes that were studied (McCulley, 2009). Low self-esteem is related to a depressed mood that is related to poorer health and increased anxiety, which are related to poorer health. Poor self-esteem is linked with greater stress, which in turn leads to an elevated HbA1c level (McCulley, 2009).
A number of studies have looked at how self-esteem affects the stability of HbA1c. In one study, researchers made a comparison of fifty adolescents and children with type 1 diabetes. These researchers examined “self-percept” that defined how children felt of themselves. The results showed that participants who had enough self-percept indicated better diabetic control. In a different study of young adults with type 1 diabetes, researchers separated their sample to those who had better control of HbA1c and those with less control of HbA1c and discovered that children who had better control had relatively greater self- esteem (Miller, 2009).
Self-efficacy, self care and self control
Self-efficacy or the belief in an individual’s abilities of planning and implementing an action that is necessary to produce certain achievements has been associated with both diabetes and general behaviors. For instance, low self-efficiency has been related to behaviors that are more addictive, decline of smoking cessation, and increased physiological stress response. Additionally, the hypothesis that higher self-efficacy has been connected with adherence of self-report to their self-care regime, both longitudinally and section ally. There is also proof that suggests that the relationship between better HbA1c and greater self-efficacy was mediated. Cross-sectional analyses by McCulley (2009) showed that greater self-efficacy envisaged better testing and overall self-care that predicted better HbA1c measurement. Understanding the relationship between HbA1c level and greater efficacy assists clinicians, theorists, and researchers by offering insight into the means by which self-efficacy affects health outcomes. The findings of the study offer proof that among a young adult’s sample with type 1 diabetes, the belief of self-efficacy is stronger predictors of HbA1c level and behavior. The self-esteem of an individual is also critical in habits and outcomes of health. (Miller, 2009). In the clinical treatment of diabetes, these findings prove that strengthening the self-efficacy of an individual that can have a better prognosis and HbA1c measurements (Miller, 2009). This finding indicates that self-efficacy is critical in the prediction of HbA1c and self-care among children with type 1 diabetes.
Children with type 1 diabetes think they can chase their regimen of self-care. Even in children who had been suffering from diabetes for a while, self-efficacy sustained to be a critical task in their self-care activities and physiological performance (McCulley, 2009). Since the durations and severity of type 1 diabetes may vary, the psychosocial associate of the conditions may also vary. Additionally, no current study has stated self-efficacy is associated with better HbA1c in a sample of adults (Talley and Batey, 2012). The results implied that in the measurement of psychosocial variables that are associated with self, self-efficacy might be the most efficient, and expedient method for prediction of HbA1c and self-care among young people with type 1 diabetes (Child and Cypress, 2012).
Glycemic control and patient age
The ADA recommends using patient age as one consideration in the establishment of glycemic control goals, with different targets for pre-prandial, bedtime/overnight, and hemoglobin A1C (HbA1c) levels in patients aged 0-6, 6-12, and 13-19 years. Benefits of tight glycemic control include not only continued reductions in the rates of micro vascular complications but also significant differences in cardiovascular events and overall mortality. (Pilia et al, 2006)
Personal control and self-monitoring
Patients who are educated and empowered to self administer insulin, monitor blood glucose levels, and maintain appropriate diet and exercise attain highest level of control of the HbA1c levels. Optimal diabetic control requires frequent self-monitoring of blood glucose levels, which allows rational adjustments in insulin doses. All patients with type 1 diabetes should learn how to self-monitor and record their blood glucose levels with home analyzers and adjust their insulin doses accordingly. Real-time continuous monitoring of glucose—using continuous glucose monitors (CGMs) —can help patients improve glycemic control. CGMs contain subcutaneous sensors that measure interstitial glucose levels every 1-5 minutes, providing alarms when glucose levels are too high or too low or are rapidly rising or falling (Hillson, 2011).
Patients with type 1 diabetes require two or more injections of insulin daily, with doses adjusted based on self-monitoring of blood glucose levels. Insulin replacement is accomplished by giving basal insulin and a pre-prandial (pre-meal) insulin. The basal insulin is either long acting (glargine or detemir) or intermediate-acting (Nph). The pre-prandial insulin is either rapid acting (lispro, aspart, or glulisine) or short-acting (Guyton & Hall, 2006).
Nutrition and dietary habits
All patients on insulin should have a comprehensive diet plan, created with the help of a professional dietitian. It is then expected that the patient will adhere to the dietary regime. Studies have shown that individuals who maintain a stable diet with the appropriate amount of calories, proteins, and vitamins like D achieve better glycemic controls and prevent development of coronary artery calcification among other complications (Simpson et al, Edelman, S. V., 2002, 2009). However, patients with eating disorders may either deny themselves of vital calories and lead to a very low plasma glucose level or eat too many calories and develop an extremely high HbA1C level.
Exposure to cow’s milk in early infancy period predisposes the individual to higher levels of HbA1c. Hillson (2011) found that signs of an enterovirus infection by 12 months of age were associated with the appearance of type 1 DM–related autoimmunity among children who were exposed to cow's milk before 3 months of age (Hillson 2011).
Activity and resilience
Exercise is also an important aspect of diabetes management. Patients should be encouraged to exercise regularly. Patients who regulate between exercise and adequate rest achieve glucose mobilization into cells and tissues and eventual expenditure and hence reduced level of HbA1c (Graber & Brown, 2010).
Genetics and ethnicity
Genetic variants like HBS trait, HBC trait can affect the accuracy of HbA1c measurements. For the child of a parent with type 1 DM, the risk varies according to whether the mother or the father has diabetes. Children whose mother has type 1 DM had a 2-3% risk of developing the disease, whereas those whose father has the disease have a 5-6% risk. When both parents are diabetic, the risk rises to almost 30%. In addition, the risk for children of parents with type 1 DM is slightly higher if the onset of the disease occurred before age 11 years and slightly lower if the onset occurred after the parent’s 11th birthday (Pilia et al, 2006).
Currently, autoimmunity is considered the major factor in the pathophysiology of type 1 DM. In a genetically susceptible individual, viral infection like enterovirus, mumps, rubella, and coxackie virus may stimulate the production of antibodies against a viral protein that trigger an autoimmune response against antigenically similar beta cell molecules. The prevalence of type 1 DM is also increased in patients with other autoimmune diseases, such as Graves disease, Hashimoto thyroiditis, and Addison disease that have a hereditary tendency (Pilia et al 2006). Moreover, genetic factors influence the development of diabetic nephropathy and neuropathy.
In areas where rates of type 2 DM and obesity are high, individuals with type 1 DM may share genetic and environmental factors that lead to their exhibiting features of type 2 diabetes such as reduced insulin sensitivity and consequent high HbA1c level (Pilia et al, 2006).
Diabetic programs and clinics
It is possible to predict development of type 1 diabetes through identification of genetic, immunologic, and metabolic markers in persons without symptoms. This involves screening of persons at high risk, such as relatives of persons with type 1 diabetes. Persons destined to have type 1 diabetes have a progressive metabolic defect, which is detected by a high measurement of HbA1c level and failure in a glucose tolerance test. Therefore, diabetic screening programs identify individuals among relatives of persons with type 1 diabetes, because the observed risk of type 1 diabetes (about 3% to 6% among first-degree relatives) is 10- to 20-fold that in the general population. For this reason, all populations at risk should adopt diabetic clinics and programs since it is a strategy aimed at prevention or delay of disease among susceptible persons before clinical manifestation of type 1 diabetes (Watkins, p. J. 2008). Education of patients is essential to successful therapy, and the treatment program must be sufficiently flexible and dynamic to allow for highly varied and changing lifestyles without sacrificing careful metabolic control.
Stress conditions and family support
Successful treatment of diabetes, also, involves attaining a stress free state of emotional and physical wellbeing. Stressing factors alter the state of wellbeing and glucose control mechanisms by stimulating secretion of ‘stress hormones’ like catecholamine, glucagon, and cortisol which again stimulate increased concentration of plasma glucose levels. This suggests that continued exposure to stress conditions like lead to progressive secretion of hormones like catecholamine and glycogen which in turn increase the plasma glucose level and hence a high HbA1c level (Childs & Cypress, 2012).
Family support also plays a role in HbA1c level. Availability of support from friends, family and relatives improves adherence to the anti diabetic regime including insulin therapy, glucose monitoring, activity and stress management. This leads to effective coping and improved state of well being. Thus, an acceptable level of HbA1c is measured when there is family support while this may increase beyond the acceptable level of 6.5% (American Diabetes Association, 2010) when there is no support from friends and families. This is because the individual becomes stressed and ‘stress hormones’ are release leading to an eventual increase in plasma glucose level.
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