November 21, 2019

Dr. Elizabeth Mayer Davis

Dr. Beth Mayer-Davis

When it comes to managing weight, challenges faced by adolescents with Type 1 diabetes (T1D) are compounded in young adulthood and influence the habits they form as they get older. This is according to new findings from a research team lead by Elizabeth Mayer-Davis, PhD, Cary C. Boshamer Distinguished Professor of nutrition and medicine at the UNC Gillings School of Global Public Health.

The study, “The interplay of type 1 diabetes and weight management: A qualitative study exploring thematic progression from adolescence to young adulthood,” was published in the November issue of Pediatric Diabetes.

Diabetes puts adolescents at risk of cardiovascular disease, among other complications. Being overweight or obese carries a similar risk of cardiovascular disease. This emerging problem was the inspiration for examining potential interventions around treatments for weight and diet.

Mayer-Davis and her team – which included doctoral scholars Daria Igudesman, Anna Kahkoska, Franklin Muntis and clinical research assistant Katherine Souris from the Gillings School – recognized that the dual burden of managing weight and blood sugar made it difficult for adolescents to adopt best practices for co-managing the two. Building off a prior study on weight and blood sugar co-management in children with T1D aged 12-17, Mayer-Davis and co-authors analyzed experiences of young adults with T1D aged 18-25 to identify themes that evolved between the two demographics.

Controlling blood sugar and weight can be an arduous task for adolescents with T1D. The level of sugar bound to hemoglobin in the blood (hemoglobin A1c) increases during this age range and remains elevated until around age 30. Adolescence is also the time when children establish habits for self-care and weight management that persist into adulthood.

“Being diabetic and then having the whole weight loss thing – it turns your life into numbers.”

Weight struggles for those with diabetes can be exacerbated by insulin intensification – a gradual increase in the amount of insulin needed to maintain glycemic control. “When insulin dosing is being pushed up in order to help people maintain their blood sugar, weight tends to go up,” Mayer-Davis explained. This might cause a person to take less insulin for fear of weight gain, which causes blood sugar to creep up.

Exercise and monitoring caloric intake are critical pieces of a weight management strategy. Those with T1D, however, can experience hypoglycemia after exercising, prompting them to consume more calories to increase blood sugar. Regular eating habits are important for diabetes management, and having to binge-eat to prevent hypoglycemia can make exercising feel like a discouraging and futile effort.

“Being diabetic and then having the whole weight loss thing – it turns your life into numbers, which can be really frustrating, because now you are watching your carbs and your calories,” one study participant stated.

Adolescents with diabetes encounter other struggles, including societal stigma around diabetes and weight, misinformation and lack of support from family and friends, and a need for better technology and support from health care providers to manage their condition.

Taking these themes into account, the study examined how youth with T1D adapted weight management to the challenges of adulthood: families, jobs, college and other responsibilities. Some themes remained persistent and unchanged, while others evolved with age.

Charting the theoretical framework of the thematic progression of the dual management of weight and T1D from youth to young adulthood

Theoretical framework of the thematic progression of the dual management of weight and T1D from youth to young adulthood (click to enlarge)

Participants reported prioritizing control of blood sugar over weight loss, sometimes taking on a mentorship role for children who encountered similar struggles.

While adolescents with T1D previously reported struggles with binge-eating for reasons that included exercise-induced hypoglycemia, the study found that young adults developed irregular eating habits related to new scheduling conflicts. These irregular changes resulted in binges occurring at any time of day.

The personal relationship young adults had to their condition also evolved as they recognized the need to put health before weight loss. “You will have to eat something when you don’t want to,” one participant said. “So just [don’t] be discouraged by that. Just keep on.”

New themes around weight management emerged unique to the responsibilities of adulthood, including financial considerations, romantic partnerships, work commitments and family planning. While some themes impacted participants positively – such as support gained from spouses and partners, or the drive to maintain healthy lifestyles for future pregnancies – added stressors came from financial burdens that T1D compounded onto rent, bills, tuition and other necessary costs. Aspects of employment environment, such as scheduling, activity level and work load, also created variations in eating habits.

These study findings underscore a need for comprehensive education around best practices that youth with T1D can adopt to promote physical activity and normal blood sugar. A critical piece of this education comes from pediatric and adult providers. However, many of the young adults in the study reported an adversarial relationship with providers when it comes to weight management.

“It is well established that a positive relationship with one’s provider is associated with improved glycemic control,” the Mayer-Davis team noted. This emphasizes a need for providers to take thoughtful approaches to managing blood sugar and weight that include supportive and patient-first language.

Informed by the findings of this study, Mayer-Davis is now principal investigator on a new pilot study funded by the National Institutes of Health (NIH) that will compare three distinct, evidence-based dietary approaches designed to address weight loss and glycemic control throughout the day for young adults with T1D. The study will allow participants to maintain other lifestyle patterns as normal. The diets include a low-fat-low-calorie diet, a low-carbohydrate-low calorie diet and a Mediterranean diet. While the primary outcomes measured will be weight, body composition and blood sugar, Mayer-Davis says it’s also important that participants in the study find the diet agreeable.

“If you dislike the diet, you’re not going to do it,” she explained. It’s a vital part of finding a solution that can lead to positive outcomes.

The pilot study is recruiting now and is estimated to be completed in December 2020.

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