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Abstract
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INTRODUCTION
Type 1 diabetes mellitus (T1D) is a common chronic condition in the U.S and worldwide. T1D is one of the most prevalent and highest in incidence of all childhood chronic diseases.1 The SEARCH for Diabetes in Youth Study, funded by the CDC and NIH, estimated 15,000 new cases of T1D in youth under age 20 in 2003, which increased to 18,436 new diagnoses in 2009.2,3 Although there are racial and ethnic variations in prevalence, incidence of T1D has been increasing worldwide.4,5 In the U.S, between 1.25 and 3 million children and adults are currently diagnosed with T1D.6,7
Advances in insulin therapy have improved diabetes management.
Individuals with T1D do not produce sufficient levels of endogenous insulin to use blood glucose efficiently. The standard of care for T1D is exogenous insulin administration. Advances in intensive insulin therapy over the past decades have improved glycemic control and reduced incidences of long-term complications.8 Continuous subcutaneous insulin infusion, commonly referred to as insulin pump therapy, was introduced in the late 1970s and delivers a continuous dose (basal) and manual dose (bolus) for meals and hyperglycemic events. allows for and continuous glucose monitors were developed in the late 1970s and early 1980s, respectively, to (Pickup 2015). To properly manage glucose levels, people with T1D must maintain awareness of how factors such as food intake and physical exertions will affect their glucose levels.
Despite advances in insulin therapy, lack of transitional support between pediatric and adult diabetes care leads to consequent issues with glycemic control. The need for an efficient transition in care from providers that understand the specific needs of this population has been emphasized.9,10 The abruptness of the transition often leads to delayed initial adult care visits, or losses to follow up altogether.9,11,12 Inconsistent follow-up care in children has been associated with more frequent acute complications (hypoglycemia, hyperglycemia, diabetic ketoacidosis) as well as long-term complications (retinopathy, nephropathy).13
Emerging adults with T1D face challenges with self-management that are specific to their phase of life. Emerging adulthood is the developmental stage after adolescence, which involves new responsibilities, independent decision-making, and advancement towards self-sufficiency.14 Emerging adults wrestle with life decisions about career and financial responsibilities and manage life without established routines or stable living situations, which are complex enough for those without a chronic disease.14 Emerging adults with T1D must balance these developmental challenges with the requirements of diabetes management, including more unfamiliar tasks such as making medical appointments and financing healthcare once they are no longer covered under parental insurance.15
Emerging adults with T1D are generally characterized by poor adherence, sub-optimal glycemic control, and increased risk of complications and death. From childhood to adolescence and early emerging adulthood, there is a trend of declining regimen adherence and poorer glycemic control.16–18 A Virginia study found that 80% of emerging adults do not meet hemoglobin A1c levels recommended by the American Diabetes Association.18 Cardiovascular disease is more prevalent at a younger age in people with T1D compared to the non-diabetic population.19 The risk of mortality is three to six times higher in young adults with T1D compared to their age-matched counterparts.20,21 Death in these patients occurs mostly from acute complications such as hypoglycemia, hyperglycemia, and DKA, as well as from chronic complications such as cardiac, renal, and cerebrovascular disease.21
There are limited studies on emerging adults with T1D.(Hannah et al 2013) Previous research has emphasized the importance of more data on this population regarding their transition in diabetes management. The ADA (standard diabetes care). One study focused on emerging adults
Because diabetes affects every organ system in the body, supporting the whole body through a holistic perspective on health is as important as maintaining proper glycemic control. Glycemic control affects all tissues of the body, because every cell utilizes glucose. Thus, diabetes is a systemic disease that affects all organs. Neuronal, renal, and retinal cells are more sensitive to fluctuations in glucose levels; hence chronic complications such as retinopathy, nephropathy, and neuropathy are common in diabetic patients.22 Prolonged hyperglycemia also contributes to oxidative stress, inflammation, and accumulation of advanced glycated end-products, which can lead to neurodegeneration and microvascular complications.23 Oxidative stress has been associated with cardiovascular disease and peripheral neuropathy in adults with type 2 diabetes.24 Nutritional supplementation with anti-oxidants such as vitamin E and flavonoids may not directly affect blood glucose levels, but Vitamin E has been shown to lower lipid peroxidation (reduced oxidative stress) in children with type 1 diabetes and a flavonoid rich diet has been correlated with lower hsCRP (reduced inflammation) and reduced odds of retinopathy in adults with diabetes.25,26
Glycemic control is affected by multiple factors, and each person may respond differently to each situation. Therefore, individualized care is necessary to allow
Although CIH usage has been evaluated in pediatric and older adults with T1D, it has not been evaluated in emerging adults with T1D.
Several studies have assessed the use of CIH modalities and their perceived effect in pediatric patients with T1D.27–32 In surveys and interviews of parents who implement CIH approaches to their child’s diabetes management, 54% were satisfied with CIH use, 30-67% found them to be beneficial, and 52% would recommend its use to others. 27–29,32 However, when children are asked about their own perceptions of CIH use, they may report different results than what their parents report.30 Parental use of CIH therapies is significantly associated with implementing them into their child’s diabetes management.31 Therefore, knowing the perspectives of the T1D patients themselves about their openness towards CIH approaches and beliefs on CIH effectiveness would be beneficial. CIH use is commonly reported in adults with T1D, but patient perceptions of its effectiveness are usually not evaluated.33–35 To our knowledge, there are no studies that report the attitudes toward CIH approaches to diabetes management specifically in emerging adults with T1D. Further, studies have mentioned that while pediatric diabetes care centers around finding holistic management strategies that fit into the family’s lifestyle, adult care is more focused on medical problems, where visits are shorter, and involve less input from the physician to find an individualized treatment plan that fits into the patient’s lifestyle. (peters 2011) Adult patients are thus expected to make their own choices and figure out management methods on their own.
Emerging adulthood is a time for developing lifelong behaviors, and may serve as a critical window of time for implementing CIH approaches that promote overall health in T1D patients. The initial years of emerging adulthood may be filled with anxiety over uncertainties of the future and new challenges of independent living. In light of such demanding changes, expecting emerging adults with T1D to accept new diabetes management strategies may seem unrealistic, as some studies have hypothesized. (Peters 2011, Hanna et al 2013) However, these changes do not necessarily result in worsened diabetes management for the entire emerging adult population. A longitudinal study found that their sample of emerging adults did not exhibit worsened diabetes management post-high school, even if they were living independently of their parents. (hanna et al 2013). Some emerging adults with T1D actually show increased motivation to take control of their diabetes. (Citation) Some become more receptive to changes in behavior to improve glycemic control, and recognize the importance of proper diabetes self-management.36 Many people with chronic diseases do not implement CIH approaches as a rejection of or disappointment with conventional medicine, but rather for the potential of these therapies to promote the highest possible state of overall health despite their chronic illness.37 Emerging adulthood may serve as a critical time period to introduce CIH approaches to diabetes management, where individuals are focused on establishing life habits and improving their overall health.

METHODS