Factors Influencing Glycaemic Control in Adolescents with Type I Diabetes: Cross-Sectional Analysis of Individual and Parental Factors

By Fozia Memon, Muzna Arif, Maryam Haider, Muhammad Farrukh Qazi, Imran Nisar, Khadija Nuzhat Humayun

Affiliations

1. Department of Paediatrics, Endocrinology, and Child Health, The Aga Khan University Hospital, Karachi, Pakistan

doi: 10.29271/jcpsp.2025.07.908

ABSTRACT
Objective: To identify modifiable risk factors that influence glycaemic control in Type I Diabetic adolescents.
Study Design: A cross-sectional analytical study.
Place and Duration of the Study: Outpatient clinics, Department of Paediatric, Endocrinology, and Child Health, The Aga Khan University Hospital, Karachi, Pakistan, from January 2020 to December 2022.
Methodology: This study included 246 randomly selected adolescents aged 10-18 years with Type I Diabetes on multiple daily injections. Data were gathered through face-to-face interviews and scrutiny of medical records. The research employed multiple logistic regression analysis to identify and understand the factors associated with glycaemic control.
Results: Of the 246 adolescents (mean age 13.7 years, range 10-18 years), there were 56% females and 43% males. The average duration of Diabetes diagnosis was 5.1 years (range 1-15 years). HbA1c levels reflecting poor glycaemic control (HbA1c >7.5%) were found in 71% of the study population. Multivariate analysis showed poor compliance with diet (OR: 2.2, CI: 0.9, 4.6, p = 0.056), infrequent clinic visits (OR: 3.32, CI: 1.63, 6.79, p = 0.001), and number of insulin injections per day (OR: 0.12, CI: 0.02, 0.93, p = 0.043) were significantly associated with increased odds of suboptimal glycaemic control.
Conclusion: This study concluded that glycaemic control in the adolescent population was suboptimal. For optimal glycaemic control, treating physicians should concentrate on the modifiable factors responsible for glycaemic control.

Key Words: Type I Diabetes mellitus, Adolescents, Glycaemic control, Risk factors.

INTRODUCTION

Hyperglycaemia is a major risk factor for the development of long-term complications in Type I Diabetes (T1D). HbA1c is an index of metabolic control and a measure of long-term diabetic complications. Data from the DCCT and the U.K. Prospective Diabetes Study show that HbA1c is strongly correlated with adverse outcome risks.¹ In the T1D exchange clinic registry, which included 25,833 individuals with T1D in the USA, the poorest control was observed in the age group of 13–25 years.² Similarly, another study found that the highest percentage of people with an HbA1c level ≥58 mmol/mol (≥7.5%) was among individuals aged 15-24 years in Ireland, with a proportion of 91.1%.³
 

Adolescents with diabetes face various challenges that can make it difficult to adhere to their treatment plan. Pubertal physiology, developmental habits, changes in family dynamics, socioeconomic status, and perceived social pressure can all contribute to insulin resistance and exacerbate difficulties in managing diabetes.^4-6

Achieving good metabolic control is crucial for children with diabetes to avoid complications later in life. Despite advancements in diabetes technology, therapies, and more ambitious glycaemic targets, a recent study revealed that contemporary youth and young adults with T1D in the U.S. exhibit poorer glycaemic control compared to earlier cohorts.⁷ Moreover, the study on role of physical activity among youth proves that better glycaemic control is significantly associated with higher physical activity.⁸

Managing T1D is even more challenging in developing countries such as Pakistan, where the cost of medications and insulin pumps is a significant issue, and health insurance coverage and medical resources in rural as well as urban areas are limited. Despite these challenges, healthcare providers are responsible for ensuring that individuals with diabetes comply with treatment plans and address any modifiable risk factors that may lead to poor blood sugar control. This study aimed to identify factors that impact blood sugar regulation in adolescents with T1D, allowing healthcare providers to focus on addressing these underlying issues and improving care for adolescents with T1D.

METHODOLOGY

A cross-sectional analytical study was carried out at the out- patient diabetes clinic of the Aga Khan University Hospital, Karachi, Pakistan, from January 2020 to December 2022. Adolescents aged between 10-18 years were included in the study.⁹ The children under 10 years, children with Type II diabetes (T2D), and other forms of secondary diabetes (e.g. Thalassaemia-associated diabetes and monogenic diabetes) were excluded from the study. The study involved interviewing the participants using a structured questionnaire to collect data on socio-demographic and risk factor variables, including age, gender, residence, household income, and socioeconomic status of the family. All participants had a documented diagnosis of T1D after six months of age. The criteria for diagnosis as per the International Society for Paediatric and Adolescent Diabetes (ISPAD) guidelines were HbA1C >6.5%, fasting glucose >126 mg/dl, and random glucose >200 mg/dl.¹⁰ Glycaemic control was further categorised into strict (HbA1c ≤7.5%) and poor control (HbA1c >7.5%) groups.

The study defined dietary compliance as adherence to a balanced diet recommended by a nutritionist, diabetic nurse, or paediatric endocrinologist following the ISPAD recommendations. Compliance with diet was further subcategorised into two categories: Strictly adhering to the recommended diet, and not or only occasionally adhering to it. The frequency of blood glucose monitoring was subcategorised into two categories: Monitoring less than or equal to two times per day, and monitoring more than or equal to three times per day. The number of clinic visits per year was categorised as less than or equal to two times per year and more than or equal to three times per year. Compliance with insulin administration with MDI was assessed by the number of insulin injections per day, subcategorised into one to three injections per day, and four injections per day. Daily physical activity, defined as moderate intensity for 20-25 minutes according to the Centres for Disease Control and Prevention (CDC) recommendation, was categorised as strictly adhering to the recommendation, and not or only occasionally adhering to it. Parental risk factors, including adherence to a balanced diet, involvement in glucose monitoring, and active participation, and encouragement in insulin insertion, were assessed by YES and NO.

The sample size was calculated using the following formula n = (Z² p (1–p)/ε², which resulted in an estimated minimum sample size of 246. Data analysis was conducted using the Stata software, quantitative variables were presented as mean and standard deviation, while qualitative variables were described using frequency and percentage. The differences in proportions of categorical variables between two or more groups were analysed using the Chi-square test. The prevalence odds ratio was calculated. Additionally, a multivariable logistic regression model was used to identify factors that affect glycaemic control. A statistical significance was set at a p-value of <0.05 for all analyses.

RESULTS

A total of 246 participants were enrolled, consisting of 108 (43.9%) males and 138 (56.1%) females. The median age at diagnosis was 13.7 years (range 10-18 years), and the median duration of diabetes was 5.1 years (range 1-15 years). The mean HbA1c of the study cohort was 8.6 ± 1.56%. Of the total participants, 70 (28.5%) had good glycaemic control (HbA1c ≤7.5%), while 176 (71.5%) had poor glycaemic control (HbA1c >7.5%) (Table I).

When analysing males and females separately based on their glycaemic control, it was found that 34 (48.6%) males and 36 (51.4%) females had good glycaemic control (HbA1c ≤7.5%). Conversely, 74 (42%) males and 102 (58%) females had poor glycaemic control (HbA1c >7.5%) (Table II). To investigate the factors that could be associated with better glycaemic control, individual characteristics were analysed among children with adequate (HbA1c ≤7.5%) and inadequate (HbA1c >7.5%) glycaemic control.

Table I: Demographic characteristics of adolescents with T1D by HbA1C levels.

Demographic characteristics	n (%)
	n = 246
Age, years (mean ± SD) (10-18 years)	13.77 ± 2.85
≤14 years	139 (56.5%)
>14 years	107 (43.5%)
Gender
Male	108 (43.9%)
Female	138 (56.1%)
Family structure
Single parent	32 (13.0%)
Two (both parents)	214 (87.0%)
Household income, PKR
<50,000	52 (21.1%)
≥50,000	194 (78.9%)
Caretaker
Mother	223 (90.7%)
Father or others	23 (9.3%)
Duration of diabetes
≤5 years	152 (61.8%)
>5 years	94 (38.2%)
HbA1c
≤7.5%	70 (28.5%)
>7.5%	176 (71.5%)
Compliance with diet
Strictly	184 (74.8%)
No or occasionally	62 (25.2%)
Insulin frequency/day
Not using	4 (1.63%)
1-3 per day	32 (13.01%)
4 per day	210 (85.37%)
Frequency of blood glucose monitoring/day
2 or less	50 (20.3%)
3 or more	196 (79.7%)
Hospital admission last year
Yes	34 (13.8%)
No	212 (86.2%)
No. of clinic visits/year
2 or less visits	99 (40.2%)
3 or more visits	147 (59.8%)
Physical activity
Yes	165 (67.1%)
No	81 (32.9%)
Parental adherence
Yes	202 (82.1%)
No	44 (17.9%)

Table II: Individual and parental characteristics with comparison to glycaemic control.

Baseline characteristics by HbA1c	HbA1c ≤7.5	HbA1c >7.5	POR (CI)	p-value	OR (CI)	p-value
	(n = 70)	(n = 176)
Age, years (mean ± SD)	13.4 ± 2.7	13.8 ± 2.9	1.06 (0.96, 1.16)	0.274	-
≤14 years	43 (61.4%)	96 (54.5%)	Reference
>14 years	27 (38.6%)	80 (45.5%)	1.33 (0.75, 2.33)	0.326	-
Gender
Male	34 (48.6%)	74 (42.0%)	0.77 (0.44, 1.34)	0.353	-
Female	36 (51.4%)	102 (58.0%)	Reference
Family structure
Single parent	10 (14.3%)	22 (12.5%)	0.86 (0.38, 1.92)	0.707	-
Two (both parents)	60 (85.7%)	154 (87.5%)	Reference
Household income, PKR
<50,000	9 (12.9%)	43 (24.4%)	2.19 (1.04, 4.78)	0.049	-
≥50,000	61 (87.1%)	133 (75.6%)	Reference
Caretaker
Mother	64 (91.4%)	159 (90.3%)	Reference
Father or others	6 (8.6%)	17 (9.7%)	1.14 (0.43, 3.02)	0.792	-
Duration of diabetes
≤5 years	48 (68.6%)	104 (59.1%)	Reference
>5 years	22 (31.4%)	72 (40.9%)	1.51 (0.84, 2.72)	0.169	-
Compliance with diet
Strictly	60 (85.7%)	124 (70.5%)	Reference		Reference
No. or occasionally	10 (14.3%)	52 (29.5%)	2.52 (1.20, 5.29)	0.015	2.21 (0.98, 4.65)	0.056
Insulin frequency/day, (n = 242)
1-3 per day	1 (1.5%)	31 (17.8%)	Reference		Reference
4 per day	67 (98.5%)	143 (82.2%)	0.07 (0.01, 0.51)	0.009	0.12 (0.02, 0.93)	0.043
Frequency of blood glucose monitoring/day
2 or less	6 (8.6%)	44 (25.0%)	3.56 (1.44, 8.78)	0.006	-
3 or more	64 (91.4%)	132 (75.0%)	Reference
Hospital admission last year
Yes	8 (11.4%)	26 (14.8%)	1.34 (0.58, 3.13)	0.494	-
No	62 (88.6%)	150 (85.2%)	Reference
No. of clinic visits/year
2 or less visits	13 (18.6%)	86 (48.9%)	4.19 (2.14, 8.19)	<0.001	3.32 (1.63, 6.79)	0.001
3 or more visits	57 (81.4%)	90 (51.1%)	Reference		Reference
Physical activity
Yes	51 (72.9%)	114 (64.8%)	Reference
No	19 (27.1%)	62 (35.2%)	1.46 (0.79, 2.70)	0.225	-
Parental adherence
Yes	65 (92.9%)	137 (77.8%)	Reference
No	5 (7.1%)	39 (22.2%)	3.70 (1.39, 9.82)	0.009	-

The percentage of glycaemic control was found to be higher in children who maintained strict diet control, with an adjusted odds ratio of 2.21, CI (0.98, 4.65) and a p-value of <0.056. Furthermore, it was higher among subjects who regularly used insulin compared to those who did not, with an adjusted odds ratio of 0.12, CI (0.02, 0.93) and a p-value of <0.043. Additionally, children who attended clinics regularly (at least four times per year) had better glycaemic control than those who did not, with an adjusted odds ratio of 3.6, CI (1.85, 7.28) and a p-value of <0.001.

DISCUSSION

The current study found that adolescents with T1D had high levels of HbA1c, with a mean level of 8.6%, ranging from 6-13.5%. This is comparable to the findings from Scotland (DIABAUD2) and Thailand, which reported mean HbA1C levels of 9.1% and 9.2%, respectively.^11,12 However, studies in deve-loping countries such as Kenya and Tanzania reported even higher mean HbA1c levels, suggesting that differences in access to healthcare and specialists may play a role in glycae-mic control.¹³

Dietary compliance is an essential factor in glycaemic management, especially for adolescents with T1D who may be vulnerable to disordered eating habits. This study found that poor glycaemic control was more common among adolescents with poor dietary compliance, which is consistent with findings from other studies.¹⁴ In addition to poor dietary habits, teenagers with T1D often face psychosocial hurdles such as low mood, anxiety, and depression, which can lead to skipping doses of insulin. This study found that skipping doses of insulin was a significant contributor to poor glycaemic control. Previous studies have also reported similar findings, with evidence suggesting that a regimen of three or more daily injections is more effective than a two-daily injection regi-men.¹⁵ Resolving psychological issues and tailoring treatment to the adolescents’ lifestyle can help improve adherence to insulin.

Another key-study finding is the significant association bet-ween the frequency of clinic visits and glycaemic control, which is consistent with previous research by Kaufman et al. They recommend that quarterly clinic visits should be ensured for adequate glycaemic control in adolescents with T1D.¹⁶

Although the development of pumps and CGM in recent years has certainly improved the management of T1D, particularly in children.¹⁷ However, the authors still believe that treatment compliance and adherence are still critical factors for success-ful diabetes control. Therefore, the focus is on identifying and addressing modifiable factors that can improve glycaemic control in resource-limited settings. By prioritising these factors, the authors hope to promote better treatment comp-liance and help patients achieve better diabetes outcomes despite resource constraints.

This was a single-centre study, catering to the higher socio-economic class, and therefore not truly representative of the actual Pakistani community, which is composed of people from the lower and lower-middle classes. The second biggest weakness is the study's cross-sectional design, which prevents inferences about direct causal relations. Recall bias may exist in data that parents and teenagers self-reported. The relation of a few variables that influence glycaemic control, including income, parental adherence, frequency of blood glucose monitoring, and physical activity, is still not clear in this study. Further prospective research is required to establish the causal link between these parameters and glycaemic control.

CONCLUSION

This study concluded that glycaemic control in this adolescent population is poor. For optimal glycaemic control, treating physicians should concentrate on the risk factors associated with poor glycaemic control in every clinic visit. Overall, these results underscore the importance of a comprehensive approach to diabetes care that considers not only medical treatment but also patient education, support, and follow-up care.

ETHICAL  APPROVAL:
Ethical approval for this study was obtained from the Institutional Review Board and Ethical Committee of the Aga Khan University Hospital, Karachi, Pakistan (ERC# 2019- 1967-5864).

PATIENTS’  CONSENT:
All patients provided written informed consent, while child participants above 16 years of age provided their assent.

COMPETING  INTEREST:
The authors declared no conflict of interest.

AUTHORS’  CONTRIBUTION:
FM: Conception or design of the work and interpretation of the data.
MA, MH: Conception or design of the work.
MFQ: Analysis and interpretation of the data.
IN, KNH: Drafting of the work and critically revising the manuscript for important intellectual content.
All authors approved the final version of the manuscript to be published.

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