Objective
The overall goal of our research is to understand how executive function skills impact diabetes outcomes, particularly looking at how the use of diabetes technologies (such as automated insulin delivery systems) might change this relationship. We want to learn more about which types of executive function skills are most important for diabetes management so that in the next stage of our research we can design an intervention that will be most helpful to people with type 1 diabetes trying to organize themselves to take care of their diabetes. Most of the research that has looked into how executive function relates to diabetes outcomes has looked at teens and young adults, who are still developing their executive function skills, and older adults, who may have declining executive function skills. Very little research has looked at how executive function relates to diabetes outcomes in middle-aged adults, who will likely have fairly stable executive function skills in the middle decades of life. Looking at these relationships in this age group might make things more clear because we aren’t looking at people whose executive function is improving or worsening. Because most of the work in this area so far has been in young adults and older adults, understanding the relationships in middle-aged adults will help us to link the data between these other groups and understand how things might change across the lifespan. Finally, by collecting information about people who have had diabetes for a longer period of time than we have done in the studies of young adults, we can learn more about how the age when someone was diagnosed or how long they’ve had diabetes might impact the relationship between executive function and diabetes outcomes.
Background Rationale
People who have diabetes may be more likely to have difficulties with executive function skills. Executive function skills are important to help people complete a task that they set out to complete. People with type 1 diabetes might be more likely to have difficulties with executive function skills because of how high and low blood sugars may impact the brain. There are some studies that show that even from a young age, children with type 1 diabetes have lower executive function skills than children without diabetes. But research has also shown that people with executive function difficulties have more trouble taking their insulin as prescribed and have a harder time managing their diabetes. So there may be a self-driven cycle where people with diabetes have more high and low blood sugars, which leads to difficulties in executive function skills, which then causes more challenges in managing diabetes, which then drives more high and low blood sugars. Our work focuses on the second half of this cycle, looking at how executive function impacts a person’s ability to complete the daily tasks to take care of diabetes. In our previous research, we have seen that teens with type 1 diabetes and executive function challenges are less ready to take care of their diabetes on their own. When looking at the role of technology in an earlier era (before automated insulin delivery systems), we found that teens with executive function difficulties do benefit from diabetes technology – those using insulin pumps had lower A1c than those not using pumps, without increasing risk of complications like diabetic ketoacidosis. Our more recent work in teens and young adults showed that people with executive function challenges had lower CGM time-in-range even when using automated insulin delivery systems. This may be because they give fewer boluses per day compared to those without executive function challenges. In summary, teens and young adults with type 1 diabetes and executive function difficulties are less likely to meet blood sugar targets, which may be because they are not using the technology as well as people without executive function challenges. Few studies have looked at how these relationships might be different for middle-aged adults, and none of them have looked at automated insulin delivery.
Description of Project
From giving insulin to dealing with unexpected continuous glucose monitor (CGM) site failures to keeping up with supply orders, people with type 1 diabetes have to complete dozens of tasks every day to take care of their diabetes. Executive function skills, like planning, organization, and problem-solving, are crucial for people to complete tasks. People who have difficulties with executive function skills – which can include people with a diagnosis of attention deficit-hyperactivity disorder (ADHD) or autism, but also people who have more minor difficulties – may have more difficulty completing tasks and taking care of their diabetes. We have shown in our previous studies that teens and young adults with type 1 diabetes are less ready to take care of diabetes on their own and that their A1cs tend to run higher, even when they use diabetes technology such as automated insulin delivery (AID) systems. In teens and young adults, executive function skills are still developing; people reach their highest level of executive function skills in their late 20s or early 30s. Very little research has looked into how executive function skills relate to diabetes outcomes among adults, in whom executive function skill development is complete. In this study, we plan to recruit 207 people with type 1 diabetes ages 36-65 years to complete a survey which will include a measure of executive function as well as details about how they manage their diabetes, their adherence to their insulin regimen, and questions related to diabetes distress, sleep quality, and support in managing their diabetes. We will also collect information about their diabetes outcomes from the medical record and download information from their CGMs and insulin pumps from the manufacturer’s portals. Our goal is to be very broad and to capture the full range of people with type 1 diabetes, so we have very few reasons why we would exclude someone from the study, including things like a recent organ transplant or a cancer that is being actively treated. Our primary goal is to look at how executive function skills relate to diabetes outcomes like time-in-range on CGM and A1c. This will help to provide the groundwork for our next step in this research, which will be to develop an intervention that will help people who have type 1 diabetes organize themselves to stay on top of their diabetes regardless of their baseline executive function skills. We believe that an intervention like this will help improve the lives of people with diabetes by lowering the mental load that it takes to manage diabetes.
Anticipated Outcome
We expect that when we look at executive function skills and glucose outcomes among middle-aged people with type 1 diabetes, we will find that executive function difficulties will be associated with lower CGM time-in-range and higher A1c. We also expect that people with executive function difficulties who use insulin pumps will bolus fewer times per day than those without executive function difficulties.
Relevance to T1D
While relationships between executive function and disease management tasks could apply to any person with a chronic disease, there are a few ways that this work is particularly relevant to people with type 1 diabetes. First of all, type 1 diabetes may make people more likely to have executive function challenges. Secondly, taking care of type 1 diabetes takes more focus and attention than almost any other chronic disease, and so executive function skills are particularly important in type 1 diabetes because there are so many things to keep track of and tasks to complete throughout the day. The type 1 diabetes-executive function cycle is where high and low blood sugars lead to executive function challenges, and difficulties with keeping up with diabetes tasks, which in turn causes more high and low blood sugars. We believe that this cycle can be stopped by creating an intervention which helps people manage their diabetes effectively regardless of their executive function skills at baseline.