The Mediating Role of Glycemic Control on Physical Activity and Internalizing and Externalizing Behaviors in Youth With Type 1 Diabetes Mellitus

Abstract

Research has documented a higher prevalence of psychiatric conditions and emotional difficulties in youth with Type 1 Diabetes Mellitus (T1DM). Routine screening across a range of social-emotional and behavioral symptoms is recommended by the American Diabetes Association (ADA) Standards of Care. Despite these documented behavioral challenges in youth with T1DM, there is a lack of research about how teachers view these behaviors manifesting in school. Further, more research is needed to understand possible links between glycemic control and school behavior. The purpose of this study was to examine the mediating role of glycemic control on physical activity and teacher-reported internalizing and externalizing behaviors. There were three research questions with the first focusing on the relative contribution of different metrics of glycemic control in predicting two internalizing (anxiety and depression) and three externalizing (hyperactivity, aggressivity, and conduct problems) behaviors. Additionally, questions two and three examined the relations between physical activity and teacher-reported behaviors along with the mediating role of glucose in that relationship. The findings showed that glycemic regulation measured via continuous glucose monitoring (CGM) contributed greater variance than HbA1c. Certain glucose metrics shared a significant relation with anxiety and depression symptoms but did not relate to externalizing behaviors. CGM averages across a week were most predictive of teacher-reported behaviors, as they showed significant bivariate relations with multiple Behavior Assessment System for Children, Second Edition, Teacher Rating Scales (BASC-2 TRS) scores, meaning that difficulties with disease management and behavioral functioning in school co-occur. Although the effects were small, glycemic control was also related to students’ internalizing symptoms, learning challenges, study habits, and attention. Physical activity did not relate to teacher-reported behaviors, and although high glucose levels positively related to more internalizing symptoms, there seemed to be direct associations rather than these subscales serving as mediators. Future research is also suggested, including the exploration of how real-time momentary changes in glucose levels are associated with behaviors in the classroom.