**5. Discussion**

130 Type 1 Diabetes – Complications, Pathogenesis, and Alternative Treatments

Table 3. Predictors of Adherence, Metabolic Control and Quality of Life in Adolescents on Glycated Hemoglobin and Illness Representations (N=85 adolescents; N= 85 fam. members) In this study, adolescent's gender (i.e. being male) predicted lower adherence to diabetes self-care and higher quality of life. An association between gender and low adherence to diabetes, in adolescents girls, particularly regarding exercise, has been found in the literature (Patino et al., 2005). Girls with diabetes show lower quality of life than boys because they seemed to worry more regarding their illness (Grey et al., 1998; Rocha, 2010; Hoey et al., 2001). In fact, low quality of life, in girls, has been associated to more difficulties and worries regarding diabetes and less satisfaction with metabolic control. Girls enter puberty earlier than boys and a weak metabolic control may be associated to physiological changes, normal to adolescence, such as increased levels of hormones responsible for insulin resistance (Carroll & Shade, 2005).

In terms of predictors of **a**dherence, taking in consideration the final model, higher values of glycated hemoglobin (poor metabolic control) predicted lower adherence to diabetes selfcare and lower quality of life. These results are in accordance with the literature. Adolescents have more difficulties with metabolic control suggesting that hormonal changes, associated with puberty and the decline on adherence to self-care, were responsible for these results (Helgeson et al., 2009). In another study, glycated hemoglobin explained a small variance of quality of life in adolescents with diabetes suggesting that higher levels of glycated hemoglobin (poor metabolic control) had negative effects on the adolescent's perception of quality of life (Malik & Koot, 2009). In a study that addressed metabolic control and quality of life, good metabolic control (measured by glycated hemoglobin) was a predictor of better quality of life (Hoey et al.,2005).

Higher family support predicted higher adherence and better metabolic control (lower levels of glycated hemoglobin). These results are in accordance with the literature. Family support has been found to be a predictor of good metabolic control (Lewin et al., 2006). In fact, low family support was associated to low adherence to diabetes self-care and, indirectly, to a poor metabolic control. La Greca and Bearman, in 2002, suggested that family support predicts adolescents' adherence to diabetes self-care because family support is an important factor on the daily management of diabetes' self-care tasks in adolescents. Higher family support was found to be a predictor of higher adherence to self-care and good metabolic control suggesting the direct impact of parental support on diabetes' management tasks influencing , as a result, adherence and metabolic control, in the adolescent (Duke et al., 2008; Ellis et al., 2007). In a Portuguese sample of adolescents, family support was found to predict adherence in adolescents with type 1 diabetes (Pereira et al., 2008).

In the present study, a lower perception of personal control predicted lower adherence to diabetes self-care in adolescents. Beliefs in the effectiveness of treatment (control over the illness) were found to predict adherence to dietary self-care (Delamater, 2009). When the benefits, compared to costs of following the diabetes regimen were considered lower, diabetes was perceived as a less threatening disease and adherence to self care in diabetes , as a result, was poor (Patino et al., 2005).

Higher family perception of diabetes' duration, as an illness, predicted higher adherence of adolescents to diabetes self-care. In an attempt to understand if there were differences between illness representations in adults with type 2 diabetes and their partners, a relationship was found between partner's perceptions of the duration of diabetes (timeline) and treatment suggesting that partners' perceptions could influence positively patients' adherence to diabetes self-care (Searle et al., 2007). Based on these result, the same may be true for the dyads parent-adolescent. In fact, parent's perception as a long last condition in

Predictors of Adherence, Metabolic Control and Quality of Life in Adolescents with Type 1 Diabetes 133

future studies should address how peers, teachers and school environment may help or hinder adherence, metabolic control and quality of life. According to results, psychological interventions should be included in the treatment protocol of adolescents receiving medical

Adolescents and parents' illness representations were predictors of adherence, metabolic control and quality of life, showing the importance of these constructs on diabetes outcomes and should, therefore, be included in intervention programs. Future studies should address how contradictory illness representations between parents and adolescents impact diabetes outcomes particularly if the adolescent perceives parents as intrusive trying to force their

It would be also interesting to assess family functioning from the adolescent point of view, besides parents' perspective (the only one addressed in the present study) and find out whether parents and adolescents' different perspectives, regarding family functioning, may

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Almeida, J. & Pereira, M.G. (2008). Questionário de Avaliação da Qualidade de Vida para

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Amillategui, B. , Calle, J. R. , Alvarez, M. A. Cardiel, M. A., & Barrio, R. (2007). Identifying

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Anderson, B.J., & Laffel, L.M.B. (1997). Behavioral and psychology research with school aged children with type 1 diabetes. *Diabetes Spectrum,* 10 (4), 277-284. Anderson, B.J., Miller, P., Auslander, W.F., & Santiago, J.V. (1981). Family Characteristics of Diabetic Adolescents: Relationship to Metabolic Control. *Diabetes Care*, 4, 586-594. Barros, L. (2003). *Psicologia Pediátrica: perspectiva desenvolvimentista*. 2ªEdição. Climepsi

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**7. References** 

adolescent's life may be associated to more parental support regarding diabetes' management tasks in order to decrease future complications in the adolescent.

In terms of predictors of metabolic control, higher adherence to diabetes self-care predicted better metabolic control (lower levels of glycated hemoglobin). In fact, higher adherence to diabetes self-care has been found to predict good metabolic control in adolescents with type 1 diabetes, and lower quality of life, on the other hand, to predict poor metabolic control (Lewin et al., 2009). Higher levels of glycated hemoglobin have been associated to more worries regarding diabetes having, therefore, a negative impact on quality of life (Guttmann-Bauman et al., 1998).

Parents' understanding of the medical situation (coping with diabetes) predicted lower levels of glycated hemoglobin (better metabolic control) in the adolescent. This is a very interesting result. Family environment is important in the complex mechanism of adaptation to diabetes self-care having also an impact on metabolic control (Grey & Berry, 2004). In a study about behavioral therapy with families of adolescents with diabetes, when the relationship between parents and adolescents with diabetes improved, parents´ coping with their adolescents' diabetes got better producing also better outcomes, such as good metabolic control in the adolescent (Wysocki et al., 2000).

Adolescent's emotional representation of diabetes (as a threatening disease) predicted higher levels of glycated haemoglobin (poor metabolic control). In a study about health beliefs in adolescents with type 1 diabetes, negative illness perception, like illness severity and susceptibility were predictors of poor metabolic control. On the other hand, lower family's comprehension (illness coherence) of diabetes predicted bad metabolic control in the adolescent. This result emphasizes the importance of parents' understanding of the impact of diabetes on their child suggesting that those parents who understand less the disease may exercise less parental supervision and provide less family support regarding diabetes's management and, as a consequence, metabolic control decreases.

In terms of quality of life, higher school support predicted higher quality of life. This result is in accordance with the literature. Peers relationships are paramount on the psychological well-being of adolescents with diabetes (Helgeson et al., 2009). In fact, relationships with peers can positively or negatively (e.g. conflict experiences) influence quality of life of adolescents with type 1 diabetes. Adolescents who have more positive attitudes with their school experience tended to experience lower problems and worries with diabetes's management (Lehmkuhl & Nabors, 2007).

Lower quality of life was predicted by higher perceptions of diabetes consequences and higher perceptions of emotional representation (more threatening). This result is in accordance with the literature. In fact, using the same illness perceptions questionnaire, with adults with type 2 diabetes, lower quality of life was found to be related to stronger beliefs of diabetes consequences and negative emotional representations (Edgar et al., 2003). Also, in another study, illness beliefs predicted quality of life i.e. consequences and emotional representations of diabetes were found to predict low quality of life in adolescents (Paddison et al., 2008).
